Therapeutic angiogenesis is a method of inducing neovascularization in ischemized tissues. The consensus of Russian experts presents the relevant information on the history and state of the art of using the method of therapeutic angiogenesis in vascular surgery, particularly the possibilities of gene engineering on the example of the only registered in the Russian Federation drug containing in its composition plasmid supercoiled deoxyribonucleic acid carrying the gene encoding vascular endothelial growth factor under control of promoter pCMV‑VEGF165. The current consensus determines the place of gene therapeutic angioge­nesis in treatment of patients with occlusive lesions of lower-limb vessels from the position of evidence-based medicine.

This work is controversial. It addresses only one question: is there a convincing evidence base at this stage of development on the positive effect of the already registered drug Neovasculgen^® on the course of chronic lower limb ischemia in atherosclerotic lesions of the main vessels.

Conclusion. At the present stage, the evidence base on the benefits of using Neovasculgen^® is insufficient to include this drug as a recommended therapeutic agent in the National Clinical Guidelines.

Background. According to the periodical press of the 19^th century, there were very few studies devoted to the history of the origin of vascular surgery (operations of venous suture, arterial suture and cardiorrhaphy) in Russia.

Objective. This study was aimed at determining the precedence of first operations of venous suture, arterial suture and heart suturing in Russia based on publications in the periodical press in the 19^th century.

Materials and methods. Presented herein are reports of Russian surgeons regarding operations of vascular suture, arterial suture and cardiorrhaphy published in the periodical press in the 19^th century. These publications were analyzed using historical, evolutionary-chronological and comparative methods.

Design: retrospective study.

Results and discussion. We performed a comparative content analysis of 3 articles by Russian surgeon I.F. Sabaneev published in the periodical press (journal “Medical Review”, 1890, 1894; journal “Russian Surgical Archives”, 1895). A conclusion was made that I.F. Sabaneev should be considered a pioneer of not only restorative vascular surgery in Russia (venous suture operation and the first arterial suture operation) but also one of the world leaders performing cardiorrhaphy in experiment (third in the world operation of heart suturing in a rabbit).

Objective. To evaluate the effectiveness of conservative therapy supplemented by administration of plasma-free autologous platelet lysate in treatment of patients with chronic critical lower-limb ischemia if it was impossible to perform a reconstructive operation.

Patients and methods. This study is a continuation of our previously initiated research in the field of therapeutic angiogenesis using plasma-free autologous platelet lysate. Analyzed herein are the results of treating a total of 96 patients with critical ischemia of the lower extremities. The patients were divided into two groups: Group I included 49 patients who received standard conservative therapy supplemented by administration of plasma-free autologous platelet lysate and Group II consisted of 47 patients who underwent standard conservative therapy. We assessed such alterations as relief of rest pain, limitation of the necrosis zone, and epithelization of trophic ulcers. Besides, we analyzed the findings of three-phase scintigraphy assessing changes of microcirculation accompanied by an increase in the radiopharmaceutical elimination index because namely this parameter is most sensitive in critical ischemia. The duration of the follow-up period was 12 months, with interim examinations carried out at 6 months.

Results. The groups had no statistically significant differences in the main clinical and demographic indicators (p>0.05). A decrease in trophic ulcers was noted in 32 (65.3%) Group I patients and in 23 (48.9%) Group II patients, p=0.031; rest pain relief was noted in 25 (51.0%) Group I patients and in 17 (36.2%) Group II patients, p=0.024. In a number of Group I patients, three-phase scintigraphy performed again at 12 months showed improvement in tissue blood flow and an increase in the radiopharmaceutical elimination index. The amputation rate was higher in Group II (4.1%) than in Group I (2.0%), p=0.031, with no lethal outcomes observed.

Conclusion. In inoperable patients with chronic critical ischemia of the lower extremities, complex conservative therapy supplemented by administration of plasma-free autologous platelet lysate demonstrated better results than standard therapy over a 12-month follow-up period.

Objective. This study aimed to assess the remote results of endovascular radiofrequency denervation (ERD) of renal arteries in patients with resistant arterial hypertension (AH).

Patients and methods. The study lasted 10 years. At the first stage, from a total of 284 patients with resistant AH we selected 13 patients to undergo ERD of renal arteries. These were patients who had: 1) all possible “surgical” causes of AH ruled out; 2) clearly defined AH resistant to 4-component therapy; 3) resistance of AH confirmed only by means of 24-hour ambulatory blood pressure monitoring (ABPM).

ERD was carried out using a high-frequency generator. Ablation was achieved by a Symplicity catheter with energy power supply not exceeding 8 W. The remote results of ERD of renal arteries were assessed during a period of up to 120 months. Assessment criteria: a possibility of achieving the target level of BP and pressure decrease gradient in the postoperative period.

Results and discussion. Over a 5-year follow-up, we registered reliable persistence of decreased levels of the average 24-hour systolic BP (from 217.9±24.7 to 144±8.76 mm Hg, p<0.05) and diastolic BP (from 108.2±8.7 to 91.4±13.8 mm Hg, p<0.05), as well as the time index of elevated systolic BP (from 78.2±14.6 to 49.8±29.6%, p<0.05). During 10 years of follow-up, nine (70%) patients were found to have stage 1 AH and the target level of BP on the background of minimal doses of antihypertensive drugs, as confirmed by the findings of 24-hour ambulatory blood pressure monitoring. None of the operated patients during the follow-up period after ERD demonstrated episodes of progression of heart failure.

Conclusion. With strictly defined indications for endovascular radiofrequency denervation of renal arteries, this procedure is followed by a decrease in BP and stabilization of AH for up to 10 years of the postoperative period.

Background. Carotid artery stenosis, especially hemodynamically significant, is a major risk factor for ischemic stroke. While symptomatic carotid stenosis (SCS) clearly requires surgical intervention, the treatment of asymptomatic carotid stenosis (ACS) remains controversial. Current guidelines emphasize the importance of identifying unstable or “vulnerable” plaques prone to rupture and subsequent thromboembolic complications.

Objective. The aim of this study was to investigate morphological and biochemical differences between stable and unstable atherosclerotic plaques in patients with SCS and ACS, paying special attention to the role of extracellular matrix (ECM) components, glycocalyx molecules, and matrix metalloproteinases (MMPs) in plaque destabilization.

Patients and methods. The study enrolled a total of 28 patients who underwent carotid endarterectomy. They were divided into symptomatic (n=11) and asymptomatic (n=17) groups. Plaque samples were obtained intraoperatively and analyzed using histopathological and biochemical methods. Morphological assessment included the presence of neovascularization, inflammation, and the integrity of the fibrous cap. Biochemical analysis focused on the expression of ECM components (versican, syndecan, decorin) and MMP activity (MMP-1, MMP-2, MMP-9, MMP-12) using Western blotting and zymography. Preoperative ultrasound was used to evaluate plaques based on their echogenicity and structural features. Statistical analysis was performed to compare plaque characteristics between groups and identify correlations between ECM components and MMP activity.

Results. Unstable plaques, regardless of the presence of symptoms, exhibited neovascularization and a significant decrease in the levels of syndecan and decorin (p<0.05), which play a key role in maintaining vascular integrity and regulating inflammation. Increased MMP activity, particularly that of MMP-9, was observed in symptomatic plaques, indicating its role in plaque destabilization and, as a result, an increased risk of stroke. Interestingly, isolated symptomatic plaques did not have signs of neovascularization, but were characterized by pronounced calcification and low MMP-1 activity, which may indicate heterogeneity of plaque phenotypes. A positive correlation was found between the content of versican in plaques and the activity of MMP-9 and MMP-12 (r=0.809 and r=0.625, respectively). The obtained findings suggest that plaque stability is determined by a complex interaction of ECM remodeling, inflammation and angiogenesis.

Conclusion. This retrospective study demonstrated that morphological and biochemical markers such as neovascularization, ECM composition, and MMP activity provide important information about plaque stability and stroke risk in patients with carotid stenosis. The results confirm the feasibility of using these markers, along with the degree of stenosis, to make decisions about surgical treatment and improve stroke prevention strategies.

Objective. To develop a safe technique of visualizing the abdominal aorta during endovascular aortic aneurysm repair (EVAR) using an alternative contrast agent – medical carbon dioxide (CO₂).

Patients and methods. In 2023–2024, a total of nine 58-to-74-year-old male patients underwent EVAR under the guidance of medical carbon dioxide (CO₂). Six patients were preoperatively diagnosed as having chronic kidney disease (CKD).

Results. The technical success of EVAR using medical carbon dioxide (CO₂) alone was achieved in 7 patients (77.8%). In 2 patients (22.3%), due to insufficient imaging, we were forced to use combined angiography (CO₂ + iohexol). The average amount of injected carbon dioxide in the first group per patient was 350±50 cm³, with the average amount of injected iohexol in the second group of patients equaling 20±5 ml. None of the patients in both groups with CKD required hemodialysis or additional hydration therapy. The parameters of renal markers before and after carboxygraphy did not change.

Conclusion. Medical carbon dioxide (CO₂) can be safely and effectively used as a contrast agent during EVAR in patients with CKD.

Background. Critical lower limb ischemia (CLLI) is an unfavorable prognostic factor in patients from the point of view of both limb loss and mortality. Endovascular operations for this pathology have gained wide acceptance. However, these operations are associated with administration of a liquid iodine-containing contrast agent (ICA) for visualization of arteries. Many such patients have accompanying pathology (chronic kidney disease, diabetes mellitus, etc.) and during angiography with a high dose of ICA there is a risk of developing contrast-induced nephropathy. That is why working with patients having many concomitant diseases and a high risk of nephropathy it is important to use “gaseous” contrast media: carbon dioxide can be used as a contrast agent. Medical carbon dioxide does not possesses nephrotoxicity, causes no allergic reactions and is excreted naturally through the alveoli of pulmonary tissues. Using automatic injector Angiodroid for administration of carbon dioxide makes it possible to decrease the degree of patient’s discomfort, because owing to smoothness of injections and pressure control the pain syndrome disappears almost completely.

Objective. To assess efficacy of using CO₂-angiography in treatment of a patient with CLLI, diabetic foot syndrome and stage IV chronic kidney disease.

Patients and methods. Presented herein is a clinical case report of successful endovascular treatment of a male patient with CLLI, diabetic foot syndrome and stage IV chronic kidney disease using carboxyangiography.

Results and discussion. CO₂-angiography exhibited good quality during endovascular balloon angioplasty in the patient with CLLI, diabetic foot syndrome and stage IV chronic kidney disease.

Introduction. Currently, there is a significant arsenal of means for restoring blood flow in occlusive lesions of limb arteries. The great saphenous vein is recognized to be an optimal material. Traditionally during computed tomography angiography, we perform visualization of only the arterial bed, leaving the venous subcutaneous system unexamined. In our work, we demonstrated the use of volumetric 3D multislice spiral computed tomography (SCT) imaging as an objective and minimally time-consuming method of preoperative assessment of the great saphenous vein as a would-be conduit. It was shown that this method of diagnosis is of particular value in difficult situations such as formation of arteriovenous anastomoses while creating an access for hemodialysis, distal reconstructions of lower-limb arteries, repeat reconstructions of limb arteries.

Objective. To propose and substantiate the use of the method of volumetric 3D MSCT for verifying the state of lower-extremity subcutaneous veins in preliminary planning of the course of reconstruction of major arteries using limb saphenous veins.

Patients and methods. The standard SCT-angiography in the framework of a single study was supplemented by extended slice-by-slice visualization of soft tissues and examination of the subcutaneous venous network. Such an approach made it possible to preoperatively measure the diameter and length of the vein, to determine the dimensions and number of its tributaries. The obtained diagnostic information allows it to more reliably assess the possibility of using the great saphenous vein for reconstructive operation or reject it as a conduit. When planning in situ bypass, we applied this method of diagnosis to assess localization of large tributaries. This method was used in a total of 55 patients: 36 reconstructions on lower limbs, 4 – on upper limbs, 12 – in patients on hemodialysis and 3 – in reconstructions of visceral arteries.

Results. In all patients included into the study, the planning of the operation was adequate, comfortable and reliable.

Conclusion. The proposed method of visualizing subcutaneous veins based on layer-by-layer comparison of limb vessels turned out to be highly valuable from the point of view of precise planning of reconstructive operations using the great saphenous vein, especially in repeat reconstructions.

Objective. To comparatively analyze early results of surgical treatment of patients with aneurysms of the ascending aorta in normal and variant anatomy of the brachiocephalic trunk.

Patients and methods. Our retrospective study included a total of 259 patients operated on for ascending aortic aneurysms. Depending on the anatomy of the brachiocephalic trunk (BCT), the patients were divided into two groups. Group I consisted of 202 patients with normal anatomy of the BCT and Group II comprised 57 patients having variant anatomy of the BCT, with the BCT and left common carotid artery originating from the aorta in a solitary-ostium manner. We analyzed both intra- and postoperative data.

Results. The duration of artificial circulation and circulatory arrest with antegrade cerebral perfusion was comparable in patients of both groups. Analyzing the course of the postoperative period revealed 11 (5.4%) neurological events in Group I patients and 2 (3.5%) neurological events in Group II patients (p=0.542). Prolonged pulmonary ventilation was required in 14 (6.9%) Group I patients and in 1 (1.7%) Group II patient (p=0.142); resternotomy for hemorrhagic complications was required in 6 (2.9%) and 4 (7.01%) Group I and Group II patients, respectively (p=0.170). Hospital mortality in Group I amounted to 7 (3.4%) patients, with no lethality in Group II (p=0.152).

Conclusion. The anatomical structure of the brachiocephalic trunk is not a factor influencing the result of prosthetic repair of the ascending aorta (“hemiarch”).

Background. High-flow arteriovenous malformations (AVMs) have long been considered by neuroradiologists as a target for embolization with adhesive embolizing materials based on N-butyl-cyanoacrylates (Glubran, Histoacryl).

Objective. The aim of this study was to evaluate the prospects of using adenosine triphosphate-induced cardioplegia during embolization of high-flow malformations or AVMs containing a hypertrophic shunt in the structure with non-adhesive embolizing materials.

Patients and methods. The study included 100 patients presenting with high-flow AVMs and operated on in 2018–2023. Of these, 83 patients had malformations corresponding to Spetzler–Martin grade III–V. The epileptic type of the course was dominant in 45% of patients, and among SM grade V AVMs, 10 patients out of 19 suffered hemorrhage. A total of 100 operations on embolization of high-flow malformations were performed. The key condition for the success of the operation was the provision by the anesthesiology team of prolonged (10–20 seconds) adenosine triphosphate-induced cardioplegia at the initial stage of AVM embolization. Not only the risk of embolizate migration directly through the high-flow shunt into the drainage veins and cerebral sinuses was minimized, but also the effect of “hemodynamic calm” appeared, when non-adhesive embolizing material encountering no resistance filled the shunt and all compartments of the malformation as evenly and completely as possible. After that, with the heart rhythm restored, embolization was continued according to the operation plan.

Results. We operated on a total of 100 patients (58 men, 42 women, mean age 41.2 years), performing 100 procedures on the background of adenosine triphosphate-induced cardioplegia (1 mg/kg body weight). In 89 patients, we managed to attain complete asystole lasting from 5 to 35 seconds. In nine patients, we achieved pronounced bradycardia and arterial hypotension, in which the conditions of embolization of high-flow malformations practically corresponded to those on the background of complete asystole. No migration to cerebral veins and sinuses was noted. If necessary, adenosine triphosphate-induced cardioplegia was used more than one time. In 86 patients – once, in 11 patients – twice, in 2 patients – thrice and in 1 patient – four times. No events of tachyphylaxis, pronounced arrhythmia and cardiac dysfunction were observed during either surgery or 24-hour postoperative monitoring.

Conclusion. Adenosine triphosphate-induced cardioplegia is an effective, repeatable and safe technique allowing it to perform controlled embolization of high-flow arteriovenous malformations, requiring neither additional devices nor special skills, with no need to form a combination of various-viscosity embolizates to disconnect high-flow shunts.

Funding. The study had no financial support.

Conflict of interest. The authors declare no conflict of interest.

Authors’ contribution. Study conception and design – Fokin A.A., Fomin V.S., Maslyanyuk O.V.; data collection and handling – Fomin V.S., Kudryavtsev O.I., Oleksyk I.B.; statistical processing – Tishkov A.V.; draft manuscript preparation – Fomin V.S.; manuscript revision – Fokin A.A., Laptev K.V.

For citation: Fomin V.S., Maslyanyuk O.V., Oleksyk I.B., Kudryavtsev O.I., Tishkov A.V., Laptev K.V., Fokin A.A. Lower extremity revascularization for long occlusive lesions of femoral and crural arteries. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2025; 31 (3): 93–101. DOI: https://doi.org/10.33029/1027-6661-2025-31-3-93-101

Objective. The purpose of the study was to compare safety and efficacy of endovascular treatment (EVT) and hybrid repair (HR) using “Supera” stents in patients with combined lesions of the iliac arteries and common femoral artery.

Patients and methods. This pilot randomized study was registered on ClinicalTrials.gov (identifier: NCT03315884). The patients in the EVT group after recanalization and balloon angioplasty of the iliac arteries and common femoral artery underwent throughout stenting. The HR-group patients were subjected to recanalization and stenting of the iliac arteries in combination with endarterectomy from the common femoral artery and angioplasty with a xenopericardial patch. We compared short-term (30-day) and one-year results, including complications and patency rates.

Results. A total of 62 patients were randomized into two equal groups (31 EVT and 31 HR). The average length of the hospital stay in the EVT-group patients amounted to 3.9±1.2 days vs 7.9±2.7 days in the HR group, p=0.001. 30-day complication rates were 9.7% and 22.6% in the EVT and HR groups, respectively, p=0.17. Primary patency was 81% in the EVT group and 94% in the HR group, p=0.12. There were no statistically significant differences in secondary and primary assisted patency during 12 months, with no myocardial infarction, lethal outcomes, nor amputation.

Conclusion. The findings of this pilot randomized trial demonstrated safety and one-year efficacy of EVT in patients with tandem lesions of the iliac and common femoral arteries. The EVT-group patients showed a shorter length of hospital stay, a tendency toward a decrease in perioperative complications, and comparable to HR parameters of primary patency within 12 months.

Objective. To study perioperative results of minimally invasive direct coronary artery bypass grafting (MIDCAB) off-pump in treatment of patients with ischemic heart disease (IHD).

Patients and methods. Our retrospective single-center study included a total of 1366 patients operated on during the period from September 2012 to September 2024 at the Federal State Budgetary Institution “Federal Center for High Medical Technologies” (Kaliningrad). All patients underwent coronary bypass grafting (CBG) of the anterior descending artery (ADA) according to the MISCAB technique. There were 1054 (77.1%) men and 312 (22.9%) women. The mean age of the patients amounted to 66.1±16.4 years. Prior to surgery, functional class II angina of effort was diagnosed in 422 (30.9%) patients and FC III angina in 811 (59.4%) patients. 865 (63.3%) patients had a history of myocardial infarction. Lesions of the brachiocephalic arteries were detected in 194 (14.2%) patients and lesions of the low-limb arteries in 188 (13.7%) patients. 701 (51.3%) patients underwent hybrid interventions and 14 (1%) were subjected to subclavian coronary artery bypass grafting. Risk stratification was assessed by the EuroSCORE scale, amounting to 2.2±1.1%. We analyzed such perioperative parameters as early mortality, postoperative complications, and the immediate results.

Results. All 1366 patients underwent CABG via left anterolateral thoracotomy off-pump (MIDCAB). Of these, in 701 patients CABG was performed as a stage of hybrid intervention. The average length of stay in intensive care unit and that of hospital stay amounted to 1.1 and 6.1 days, respectively. The early postoperative period in 17 (1.2%) patients was complicated by hemorrhage, requiring wound revision. 32 (2.3%) patients developed cardiac arrhythmia as atrial fibrillation relieved medicamentally. Surface suppuration of the postoperative wound occurred in 9 (0.7%) patients. The in-hospital mortality rate amounted to 0.7% (9 patients).

Conclusion. The MIDCAB technique is feasible “on stream” and is associated with satisfactory immediate results in treatment of CAD patients of various age categories, with severe accompanying pathology, as well as in repeat patients. MIDCAB can be used in both an isolated lesion of the ADA and in a multi-vessel lesion as a stage of hybrid intervention. For further study of the technique, it is necessary to conduct prospective randomized trials and to examine long-term results.

Objective. To evaluate the possibility of using distal transradial access in routine practice for emergency and elective non-coronary endovascular interventions.

Patients and methods. The results of the use of distal transradial access were studied in patients who underwent endovascular interventions for gastrointestinal bleeding, renal bleeding in a complicated course of angiomyolipoma, traumatic injury to the spleen accompanied by bleeding, uterine leiomyomas, abnormal uterine bleeding, ectopic pregnancy, bleeding in cancer process in the pelvic organs. The study included 78 patients.

Results. The use of distal transradial access demonstrated the results comparable to those of the access to the radial artery in the classical form.

Conclusion. The distal transradial approach is a reliable and safe site of arterial access in patients who require strict control of hemostasis in combination with minimal risk of bleeding, also making it possible to maintain patency of the radial artery for future use as an arterial conduit.

Despite good results of using retrograde recanalization techniques (retrograde access, transcollateral technique) in a failed antegrade endovascular intervention, in some cases their use is impossible or associated with certain risks. Therefore, in rare instances it is feasible to use “exotic” techniques. Presented herein is a clinical case report of successful use of antegrade pedal access in the situation of failed antegrade endovascular revascularization of the foot in a patient with chronic limb-threatening ischemia.

False aneurysms of upper-limb arteries are rare pathological conditions in vascular surgery. They are typically caused by various injuries, more often iatrogenic, after endovascular interventions. These pseudoaneurysms can be complicated by ruptures, compression of nerves and nerve plexuses, as well as embolization of the distal arterial bed with the development of limb ischemia. In this article, we summarize the experience of surgical treatment of false aneurysms of upper-limb arteries and describe two clinical case reports of successful surgical management of giant pseudoaneurysms of the brachial and axillary arteries.

Presented herein is a clinical case concerning endovascular surgical treatment of a male patient having developed a paraprosthetic pseudoaneurysm of the proximal anastomosis 2 years after previously performed aortofemoral bifurcation repair for an infrarenal abdominal aortic aneurysm.

The preoperative preparation was followed by endovascular prosthetic repair of the false aneurysm of the proximal anastomosis in the juxtarenal portion of the aorta. The postoperative period was uneventful with no complications, and the patient was discharged in a satisfactory condition on POD 9. During the period of follow-up in the hospital and at the outpatient stage 20 months, he reported no complaints, leading an active lifestyle. The control contrast-enhanced multislice computed tomography at 12 months after stent graft implantation revealed that the pseudoaneurysm was excluded from the circulation, with the visceral arteries contrasted satisfactorily. This clinical case demonstrates a significant progress in relation to minimally invasive treatment of complications of open surgical interventions on the abdominal aorta.

The incidence of aortic dissection varies from 3 to 10 cases per 100.000 people. According to the International Registry of Acute Aortic Dissection (IRAD), type B aortic dissection accounts for 33%. The mean age of these patients is 63 years, with two thirds of them being males. The past two decades have witnessed an increase in the use of thoracic endovascular aortic repair (TEVAR) and hybrid methods of treatment from 7 to 31%, with a decrease in the proportion of open operations from 17 to 8%. In the current guidelines of the European Association for Cardio-Thoracic Surgery (EACTS) and the Society of Thoracic Surgeons (STS) as of 2024, TEVAR is considered a first-choice treatment procedure in patients with complications (class IB) in the acute phase and in high-risk patients (class IIa C) in the subacute phase. The main task of TEVAR is to close the proximal primary tear of the aortic intima, to exclude the false channel from blood flow, to initiate thrombosis of the false channel and dilatation of the true one. During TEVAR, there is a possibility of developing a specific complication, i. e., the formation of distal stent-graft induced new entry (dSINE). The mechanism of its development is multifactorial, with an important role given to fragility of the damaged aortic wall, rigidity of the stent graft, as well as the tendency of the graft to return to its original straight shape. The publications devoted to this subject in the literature are scarce. This complication occurs in 9.72–36.6% of patients. Mortality can reach 25%. Most authors make a choice in favor of repeat endovascular intervention.

In this clinical case report, we describe surgical treatment of a 35-year-old male patient with acute type B aortic dissection after the development of dDINE within 1 month after emergency TEVAR. After TEVAR, the proximal fenestration was closed, with the development of thrombosis of the false lumen. However, the patient on the background of poorly controlled arterial hypertension developed a series of life-threatening complications. Performing an open operation on the thoracoabdominal aorta resulted in regression of spinal disorders and sustained clinical improvement.

Transjugular Intrahepatic Portosystemic Shunting (TIPS) is a minimally invasive interventional radiology procedure that demonstrates high efficacy in reducing the portocaval pressure gradient. However, despite the effectiveness of this technique, clinical practice reveals cases of shunt dysfunction manifesting as stenosis or thrombosis due to various causes (leakage of thrombogenic bile into the stent lumen, intimal hyperplasia, prolapse of loose liver tissue, etc.). This may lead to recurrence of portal hypertension. In such cases, repeat endovascular intervention becomes both feasible and necessary to restore shunt patency.

The article presents two clinical cases describing various endovascular techniques for correcting dysfunction of previously established portocaval shunts, aimed at reducing the portosystemic gradient.

Background. Arteriovenous malformations (AVMs) are the most aggressive type of vascular malformations. They are characterized by a progressive and relapsing course, as well as by a high number of clinically significant complications.

Over the past two decades, endovascular treatment of AVMs has advanced rapidly, thanks to improvements in angiographic classification, treatment approaches, and embolization materials and tools. However, due to the rarity of the condition, large-scale studies reporting clinical outcomes of embolization for AVMs remain limited. Besides, the contemporary literature lacks uniformity in defining the outcomes that should be analyzed to evaluate treatment efficacy. For this reason, results from various clinical trials cannot be consolidated, complicating the development of evidence-based recommendations.

Objective. To analyze literature data and review recent studies describing treatment outcomes of peripheral AVMs.

Materials and methods. This study analyzed over 170 full-text English- and Russian-language publications from the past 10 years, sourced from PubMed, Google Scholar (English-language databases), eLibrary and the Russian Science Citation Index (RSCI, Russian-language databases). The publications cover various aspects of the management, diagnosis, and treatment of patients with peripheral AVMs.

Results. The currently available data on the definition, prevalence, and treatment of AVMs were systematized and presented herein. A structured table summarizing the findings of recent studies on endovascular treatment of peripheral AVMs is provided. This is followed by discussing the key trends and challenges in the research and management of this pathology.

Conclusion. Most of recent domestic and foreign publications on endovascular treatment of peripheral AVMs are case reports or case series. The high recurrence rates and need for multi-stage treatment underscore the importance of advancing embolization methods and technologies. International literature increasingly includes studies with larger patient cohorts, though most remain retrospective and single-center. Research focuses on outcomes of using various embolic agents and combining endovascular with surgical approaches. The universal use of transarterial, transvenous and percutaneous embolization methods or their combinations has proven its usefulness and effectiveness. Advanced surgical experience, technical tools and a wider range of embolic agents now allow previously impossible interventions to be performed, improving quality of life or achieving complete cure even in extensive, severe cases.