АНГИОЛОГИЯ И СОСУДИСТАЯ ХИРУРГИЯ № 4, 2022

JOURNAL «ANGIOLOGY AND VASCULAR SURGERY»

A quarterly bi-lingual journal acknowledged by the world medical community, publishing original articles of Russian and foreign specialists on current problems of diagnosis and treatment of cardiovascular diseases, ultrasonographic, radiation and non-invasive studies of arterial and venous system diseases.


Topic number
№ 4 . 2022
Anniversaries

Yuri Mikhailovich Stoiko (to the 75th anniversary of the birth)

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Alexander Ivanovich Kirienko (to the 75th anniversary of the birth)

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History

48-year result of surgical treatment of arteriovenous malformation of the submandibular region

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Dedicated to 92nd anniversary of A.V. Pokrovsky

A description is given of a radical surgical intervention for arteriovenous malformation of the submandibular region, performed 48 years ago with a stable beneficial clinical result in the form of a complete cure for the patient. Literature information on the issue under discussion is considered.

Angiology

Progression of atherosclerotic process in the common carotid artery after carotid endarterectomy

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This study was undertaken to evaluate laboratory and instrumental parameters of progression of the atherosclerotic process in the common carotid artery after eversion carotid endarterectomy in 56 patients operated on for hemodynamically significant stenosis of the ostium of the internal carotid artery. All patients had concomitant prolonged (from 35 to 70 mm), non-ostial, low-grade (35.7±0.7%) stenosis of the common carotid artery. 41% of the patients in the remote postoperative period were found to have a statistically significant correlation between the increased degree of stenosis of the common carotid artery according to the findings of ultrasound duplex angioscanning and elevated levels of biochemical markers of the endothelial functional state (hs-CRP, MMP-9, sE-selectin, sVCAM-1, sPecam-1), thus suggesting progression of the atherosclerotic process in the previously unoperated proximal segment of the common carotid artery. Given the presence of a hemodynamically significant stenosis of the common carotid artery, the patients were subjected to repeat operations, i. e., angioplasty and stenting of the common carotid artery.

An elevated level of biochemical markers (hs-CRP, MMP-9, sE-selectin, sVCAM-1, sPecam-1) in blood serum is an unfavorable prognostic sign of progression of the atherosclerotic process and increasing degree of stenosis of the common carotid artery after carotid reconstruction. Guided by the mentioned predictors of progression of the atherosclerotic process, it is possible to timely change therapeutic policy and, if necessary, to perform surgical correction in such patients.

Clinical anatomy of intrapelvic anastomoses of the obturator artery

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Background. One of the main principles of contemporary endovascular surgery is that interventions should be as selective as possible. During treatment of prostatic hyperplasia when there is a need for endovascular occlusion of the rami prostatici, an operation of choice will be selective exclusion from blood flow of namely these peripheral branches. However, a series of recent studies have demonstrated that the presence of well-developed intrapelvic anastomoses in arteries, which are formed from the internal iliac artery may result in destruction or early recanalization (within 2–3 weeks) of endovascular emboli previously placed inside the branches of these arteries.

The lack of information in specialized literature concerning the location of intrapelvic anastomotic branches of the obturator artery makes it difficult to develop surgical methods of treatment.

Objective. The purpose of this study was to investigate the anatomy of collaterals of the obturator artery (OA) in the pelvic cavity.

Material and methods. The study was carried out on 206 cadavers of men (aged from 22 to 82 years) and 113 cadavers of women (from 32 to 93 years of age) who had died of accidental causes not related to pathology of pelvic organs. Our aim was achieved by means of cadaveric dissection followed by intravascular injection and statistical processing of the obtained findings.

Results. It was found that in men, the OA formed anastomotic branches in the pelvic cavity in 10.2% of cases on the right and in 8.3% of cases on the left. In women, the OA anastomosed on the right half of the pelvis in 5.3% of cases and in 4.4% of cases on the left half. Two thirds of all exposed anastomoses in men and women were located in the proximal third of the intrapelvic part of the OA. The anastomotic branches of the OA met with both parietal and visceral branches of the internal iliac artery. We revealed no gender-related statistically significant differences between the average diameters of the OA and the average diameters of its anastomoses. It was determined that large arterial anastomoses were formed from the obturator artery in both genders irrespective of its diameter.

Conclusion. The number of intrapelvic anastomoses of the obturator artery in men and women decreased in the direction from the place of the origin of this artery to that part of it located immediately at the entrance to the obturator canal.

Diagnosis

Assessment of peak systolic velocity in various-degree isolated stenoses of the internal carotid artery using triplex scanning

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The purpose of this study was to compare the values of the peak systolic velocity in various-degree stenoses of the internal carotid artery, measured by means of triplex scanning with the values revealed by multislice computed tomography. The obtained findings were compared with the data of the Society of Radiologists in Ultrasound Consensus (2003). Significant differences were revealed in the values of velocity for 50–69% stenoses and 70–89% stenoses.

Based on the results obtained, we proposed a table with the indication of the peak systolic velocity for various-degree stenoses of the internal carotid artery.

Discussion

Pathological tortuosity of the internal carotid artery: current problems and interesting facts

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This article is a review of the literature concerning the development and progression of pathological tortuosity of the internal carotid artery, also analyzing the parameters of measuring the severity of the pathology involved.

The materials were collected using the PubMed platform. The inclusion criteria were as follows: article age not exceeding 5 years, review articles or clinical trials concerning pathological tortuosity of carotid arteries.

Results. There was a correlation found between pathological tortuosity of the internal carotid artery and arterial hypertension, connective tissue disease, body mass index, cerebral small vessel disease and the risk of developing internal carotid artery dissection, with no relationship of atherosclerosis and pathological tortuosity of the internal carotid artery. It was revealed that hemodynamic significance of pathological tortuosity is determined by different diagnostic methods, with neither unequivocal parameters nor pathognomonic symptoms.

Conclusion. The only objective method of determining the degree of severity of pathological tortuosity is the tortuosity index. This parameter requires further study. Probably, early diagnosis and modification of risk factors contributing to the development and progression of pathological tortuosity of the internal carotid artery would decrease the likelihood of cerebrovascular complications.

Pathological tortuosity of extracranial arteries: a problem long known, but not yet solve

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This article describes the historical data concerning elongated and tortuous brachiocephalic arteries, the first diagnostic methods for confirming tortuosity of carotid arteries, and analyzes the modern approach to the treatment of pathological tortuosity, particularly that of the internal carotid artery. A critical interpretation of the very term “pathological tortuosity” (PT) is given, with the classification and causes of the disease also touched upon. A number of sporadic publications putting forward rather controversial theories of the mechanisms of the development of pathological tortuosity are questioned. Enumerated are the indications for surgery for PT, that correspond to the National Clinical Guidelines. They reflect inconsistency of approaches in the treatment of pathological tortuosity of internal carotid arteries. The main thesis of the authors is that tortuosity of internal carotid arteries, undoubtedly being a common phenomenon, nevertheless requires active surgical tactics only in a very limited number of patients with symptoms of cerebrovascular insufficiency.

Practical medicine

Peculiarities of clinical course and rendering surgical care in acute arterial thromboses and spontaneous hematomas on the background of COVID-19

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Presented in the article is a retrospective analysis of treating a total of 36 patients in whom the course of the novel coronavirus infection (COVID-19) was complicated by the development of acute arterial thromboses (23 subjects) and spontaneous hematomas (13 subjects). The course of COVID-19 infection in these patients was regarded as moderate, severe and extremely severe.

Twenty patients with acute thrombosis and six patients with spontaneous hematomas were operated on. The interventions performed were as follows: thrombectomy from arterial segments of lower limbs at various levels, endovascular thromboaspiration, aortic endoprosthetic repair, limb amputation, hematoma drainage. Three patients with acute thrombosis and seven patients with spontaneous hematomas underwent only conservative treatment.

Conclusion. Aggressive surgical policy in acute arterial thrombosis or spontaneous hematoma on the background of a severe course of the novel coronavirus infection is associated with a high but justified risk and a chance for a favorable outcome.

Case report

Retrograde assisted catheter thromboaspiration from arteries of the talocrural segment in acute ischemia (case report)

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The problem of surgical treatment of acute thrombosis of arteries of the talocrural region has turned out to be an especially challenging issue in the period of the COVID-19 pandemic, with more attention paid to endovascular techniques due to their minimal traumaticity.

Presented in the article is a clinical case report describing successful retrograde assisted catheter thromboaspiration from crural arteries for treatment of acute ischemia in a patient with COVID-19.

Mechanochemical endovenous obliteration of the gonadal vein (case report)

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Presented herein is a clinical case report regarding mechanochemical obliteration of the gonadal vein in a 42-year-old female patient suffering from manifestations of pelvic venous plethora for 6 previous years. The examination revealed a primary form of pelvic varicose disease with dilatation of the left ovarian and uterine veins, bilateral veins of the pampiniform plexus.

In conditions of the X-ray operating room, inserted into the lumen of the left ovarian vein was the Flebogrif device for mechanical ablation. Appropriate application of the device with simultaneous administration of a sclerosing agent resulted in mechanical and chemical damage of the venous wall. The outcome thus obtained was cessation of intraluminal blood flow. The woman was examined at 3, 6, 12 and 24 months postoperatively. Reduction of venous reflux was accompanied by normalization of pelvic phlebohemodynamics and regression of clinical symptomatology, confirmed by clinical and instrumental methods of examination.

This case report demonstrates feasibility, efficacy and safety of the procedure performed. The developed mechanochemical method makes it possible to improve outcomes of surgical treatment of women with pelvic varicose veins, since it is devoid of a series of disadvantages intrinsic to the traditional type of endovascular treatment involving implantation of foreign material in the form of embolizing microcoils. To confirm this hypothesis, it is necessary to carry out randomized comparative trials with participation of a sufficient number of patients.

Closure of a large arteriovenous malformation of the left lung in a patient after Fontan procedure (case report)

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The development of arteriovenous pulmonary malformations quite often (up to 25% of all cases) occurs when applying a cavopulmonary anastomosis (Glenn procedure) and performing the Fontan procedure. This can be directly related to both the restructuring of hemodynamics in the hepatic segment of the venous system, with subsequent changes in the liver function against this background and the non-entry of hepatic enzymes – antiangiogenic factors into the pulmonary circulation, and the formation of a “non-pulsating” pulmonary blood flow. Endovascular treatment in this case is minimally traumatic and demonstrates high immediate efficiency, however, the long-term outcomes of these interventions have been poorly investigated, with the studied groups of patients being extremely small.

Today, embolization therapy is one of the main treatment options in patients with an arteriovenous malformation, especially when a vascular anomaly is located deep in the lung parenchyma. The proposed method is minimally invasive, relatively easy to perform and yields good results.

New technology of endovascular occlusion of renal artery aneurysm (case report)

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Background. Renal artery aneurysms are treated using roentgen endovascular methods, open and hybrid operative interventions. Therapeutic decision-making depends on hospital’s equipment, vascular anatomy, patient’s age, further prognosis of the disease, and concomitant pathology. However, there are situations being serious challenges for both endovascular and open reconstructive surgery of renal arteries. In some cases, nephrectomy is considered to be the only option of preventing life-threatening bleeding in a ruptured aneurysm.

Objective. The study was aimed at demonstrating possibilities of endovascular surgery in treatment of a renal artery aneurysm, previously recognized as inoperable.

Patients and methods. A 61-year-old male patient was admitted to our Clinic presenting with events of acute intestinal obstruction. The examination revealed a large intestine tumor, as well as a renal artery aneurysm measuring 34 cm in diameter with a non-differentiated neck and second-order arteries originating from the aneurysmal cavity. The first stage was double-barreled loop sigmoidostomy was urgently performed because of acute intestinal obstruction, with the second stage being embolization of the aneurysm according to an original technique: after filling the aneurysmal cavity with spirals, coronary stents were inserted and expanded to create tunnels in the spiral-filled cavities.

Results. The kidney was preserved, with no data on of renal infarction in either early or medium-term period.

Conclusion. Stent-assisted endovascular embolization with preservation of branches is an effective organ-sparing minimally invasive method of treatment of a renal artery aneurysm of complex localization.

Surgery

Results of endovascular revascularization of combined lesions of aortic bifurcation and iliac arteries in immediate and remote periods of follow up

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Background. The use of endovascular methods of treatment for steno-occlusive lesions of the aortic bifurcation and common iliac arteries is the subject of discussions. The “gold standard” of surgical treatment in Leriche syndrome is aortofemoral bypass grafting, however, it is associated with a risk for developing surgical complications up to 25%.

Objective. The purpose of this study was to evaluate the immediate and remote results of patency of the aortic bifurcation and iliac arteries after endovascular reconstruction.

Patients and methods. We retrospectively analyzed outcomes of treatment of patients operated on between January 2012 and December 2018 using the kissing-stenting of the aortic bifurcation for TASC-II C and D atherosclerotic lesions, assessing the parameters in the early postoperative period (clinical success, procedure-related complications, revascularization, in-hospital MACE and MALE) and in the remote period (primary patency, secondary patency, survival, limb salvage).

Results. Lower primary patency of the reconstruction zone was statistically significantly associated with such factors as “exit” of proximal portions of the stents above the aortic bifurcation, their diameter being less than 7 mm, and the presence of thrombotic masses in the infrarenal portion of the aorta (according to the findings of computed tomography). In elderly patients, the risk for amputation after surgery turned out to be significantly higher.

Conclusion. The use of kissing-stenting of the aorta and iliac arteries yielded satisfactory results both from the technical point of view in the early period and in preservation of late patency. However, the revealed predictors of primary patency loss suggest the necessity of more thorough planning of the procedure.

Simultaneous and staged surgical treatment of carotid artery stenosis in patients with coronary artery disease: remote results

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Background. The systemic nature of vascular lesions in atherosclerosis leads in 2.4–14% of patients to hemodynamically significant combined lesions of the coronary and carotid basins. For these patients, recommendations on surgical treatment remain uncertain, with the discussions concerning advantages of various surgical techniques still going on.

Objective. This study was aimed at assessing the results of simultaneous and staged treatment of patients with combined lesions of brachiocephalic arteries and coronary artery disease.

Patients and methods. Patients were recruited into the study retrospectively according to the “continuous observation”. Between September 2012 and March 2022, we performed surgical treatment of a total of 5,340 patients with coronary artery disease. Significant concomitant lesions of coronary arteries and brachiocephalic arteries were diagnosed in 852 (16%) patients. The mean age of patients amounted to 65.9±14.2 years (form 38 to 84 years). Staged surgical treatment (with the first stage consisting in carotid endarterectomy and the second stage being coronary artery bypass grafting) was performed in 693 (81.3%) patients and simultaneous treatment in 159 (18.7%) patients. Risk stratification according to the EuroSCORE II scale amounted to 2.2±1.2%.

Results. In-hospital mortality in the groups of staged and simultaneous treatment amounted to 1 (0.1%) and 2 (1.3%), respectively. Patients of both groups underwent predominantly eversion carotid endarterectomy (97.8%). The frequency of complications such as postoperative bleeding, postoperative wound infection, stroke and acute myocardial infarction did not differ between groups and amounted to: 14 (2%) and 4 (2.5%) (p=0.410); 5 (0.7%) and 2 (1.2%) (p=0.41); 1 (0.1%) and 1 (0.6%) (р=0.339); 1 (0.1%) and 1 (0.6%) (p=0.339), respectively. In the remote follow-up period (65.1 months) after simultaneous (carotid endarterectomy + coronary artery bypass grafting) and staged (carotid endarterectomy followed by CABG) operations, there were no significant differences in long-term survival – 92.7% vs 89.2% (p=0.437), recurrent myocardial infarction – 8.7% vs 7.7% (p=0.51), and acute ischemic stroke – 5.5% vs 8.2% (p=0.959), respectively.

Conclusion. Simultaneous interventions are indicated for patients presenting with coronary artery disease and significant stenosis of brachiocephalic arteries in unstable angina pectoris, as well as in lesion of the left coronary artery trunk. Staged surgical treatment (first carotid endarterectomy then CABG) is indicated for stable patients with coronary artery disease.

Such differentiated approach makes it possible to perform oeprations for these patients relatively safely and with good efficacy in both the immediate and remote postoperative periods.

Simultaneous and staged surgical treatment of carotid artery stenosis in patients with coronary artery disease: remote results

Резюме

Background. The systemic nature of vascular lesions in atherosclerosis leads in 2.4–14% of patients to hemodynamically significant combined lesions of the coronary and carotid basins. For these patients, recommendations on surgical treatment remain uncertain, with the discussions concerning advantages of various surgical techniques still going on.

Objective. This study was aimed at assessing the results of simultaneous and staged treatment of patients with combined lesions of brachiocephalic arteries and coronary artery disease.

Patients and methods. Patients were recruited into the study retrospectively according to the “continuous observation”. Between September 2012 and March 2022, we performed surgical treatment of a total of 5,340 patients with coronary artery disease. Significant concomitant lesions of coronary arteries and brachiocephalic arteries were diagnosed in 852 (16%) patients. The mean age of patients amounted to 65.9±14.2 years (form 38 to 84 years). Staged surgical treatment (with the first stage consisting in carotid endarterectomy and the second stage being coronary artery bypass grafting) was performed in 693 (81.3%) patients and simultaneous treatment in 159 (18.7%) patients. Risk stratification according to the EuroSCORE II scale amounted to 2.2±1.2%.

Results. In-hospital mortality in the groups of staged and simultaneous treatment amounted to 1 (0.1%) and 2 (1.3%), respectively. Patients of both groups underwent predominantly eversion carotid endarterectomy (97.8%). The frequency of complications such as postoperative bleeding, postoperative wound infection, stroke and acute myocardial infarction did not differ between groups and amounted to: 14 (2%) and 4 (2.5%) (p=0.410); 5 (0.7%) and 2 (1.2%) (p=0.41); 1 (0.1%) and 1 (0.6%) (р=0.339); 1 (0.1%) and 1 (0.6%) (p=0.339), respectively. In the remote follow-up period (65.1 months) after simultaneous (carotid endarterectomy + coronary artery bypass grafting) and staged (carotid endarterectomy followed by CABG) operations, there were no significant differences in long-term survival – 92.7% vs 89.2% (p=0.437), recurrent myocardial infarction – 8.7% vs 7.7% (p=0.51), and acute ischemic stroke – 5.5% vs 8.2% (p=0.959), respectively.

Conclusion. Simultaneous interventions are indicated for patients presenting with coronary artery disease and significant stenosis of brachiocephalic arteries in unstable angina pectoris, as well as in lesion of the left coronary artery trunk. Staged surgical treatment (first carotid endarterectomy then CABG) is indicated for stable patients with coronary artery disease.

Such differentiated approach makes it possible to perform oeprations for these patients relatively safely and with good efficacy in both the immediate and remote postoperative periods.

Literature review

Contemporary approach to surgical treatment of retroperitoneal sarcomas involving major vessels (a literature review)

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Currently, radical removal of retroperitoneal sarcoma is the only method of treatment, making it possible to increase survival of oncological patients. Operative interventions for retroperitoneal tumors frequently require widening of the scope of surgery at the expense of resection of cancer-involved organs and structures, including major vessels.

The article is a review of literature searched in the PubMed database. Publications were retrieved using various combinations of terms: «retroperitoneal tumor», «retroperitoneal sarcoma», «vascular resection», «vein resection». The analysis included articles over the last 20 years, based on original studies demonstrating the results of surgical treatment of malignant retroperitoneal tumors involving major vessels.

We analysed 19 contemporary studies including a total of 472 patients with retroperitoneal tumors and lesions of major vessels. In retroperitoneal sarcomas, prosthetic repair using a synthetic graft is considered to be the most common method of vascular reconstruction. Widening the scope of the operative intervention at the expense of resection of major vessels made it possible to perform microscopically complete removal of the tumor in approximately 60% of patients, with the frequency of macroscopically incomplete resection amounting to 16%. The postoperative complication and mortality rates averagely amounted to 32.4% and 2.5%, respectively. The remote oncological results reliably did not differ in patients with and without lesions of major vessels. In removing retroperitoneal tumors with resection of major vessels, the overall 5-year survival rate varied from 21 to 66%, with the median overall survival ranging from 29 to 120 months.

Conclusion. A present-day method of treatment for retroperitoneal sarcomas with lesions of major vessels still remains radical removal of the tumor. Widening the scope of the operation at the expense of vascular resection has admissible incidence of postoperative complications and mortality rates. Despite the locally disseminated process, complexity of the surgical procedure, total en bloc removal of the tumor makes it possible to obtain the relapse-free and overall survival rates comparable to those in patients without lesions of major vessels.

Risk factors for developing thromboembolic complications in oncological patients (a literature review)

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Oncological patients are typically prone to the development of thromboembolic complications significantly worsening the general prognosis of the disease. Therefore, determining the probability of the onset and prevention of these complications remains an important practical task.

This literature review presents the data of foreign and Russian authors on the major risk factors for developing venous thromboembolic complications in oncological patients, also giving characteristics of the main biochemical markers of the ongoing processes and intrinsic thereto alterations. This is followed by reflecting the incidence of thromboembolic events depending on the type, localization, incidence, degree of differentiation of malignant neoplasms, the presence or absence of concomitant diseases in patients, as well as the main demographic criteria associated with this pathology, Also analyzed herein is the effect of some chemotherapeutic drugs used as adjuvant and neoadjuvant therapy on the onset of thrombotic events. Next comes the information on the effect of radiation methods of treatment on the development of thromboses and thromboembolisms in oncological patients. Additionally demonstrated is the relationship of thromboembolic processes in patients suffering from malignant neoplasms with surgical interventions and placement of central venous catheters.

Rivaroxaban in comparison with low molecular weight heparin for the treatment of cancer-associated thrombosis: a systematic review and meta-analysis

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Background. Apixaban, edoxaban, and rivaroxaban are now recommended over low-molecular-weight heparins (LMWH) for long-term treatment of cancer-associated thrombosis (CAT).

Objective. Our study was aimed at comparing efficacy, safety and effect of rivaroxaban and LMWH on all-cause mortality in patients with cancer-associated thrombosis.

Methods. A systematic literature search was performed through the Medline and Cochrane libraries according to the previously developed in compliance with the PRISMA guidelines protocol (CRD42022310908). Randomized controlled trials comparing full-therapeutic dose of rivaroxaban with full-therapeutic and/or the intermediate dose of LMWH in patients with verified CAT were included. The main outcomes were: VTE recurrence, major bleeding, and all-cause mortality. Individual study events were converted into rates per patient-years of follow-up and combined using a pooled proportion meta-analysis with a random-effect model or fixed effect model according to the heterogeneity. The final results are reported as per 100 patient-years.

Results. The systematic search was performed in March 2022 and revealed 715 records. Of these, 16 full-text papers were screened for eligibility and two RCTs (SELECT-D and CASTA DIVA) combining the data on 564 patients were included into the analysis. The pooled event rate of VTE recurrence in those who received rivaroxaban and dalteparin was estimated as 10.0 and 19.6 per 100 patient-years, respectively. The pooled event rate for major bleeding and all-cause mortality amounted to 10.0 vs. 7.3 and 55.8 vs. 62.0 per 100 patient-years for those treated with rivaroxaban vs. dalteparin, respectively. The odds ratio (OR) for VTE recurrence was in favor of rivaroxaban (OR 0.45; 95% CI 0.22–0.96; p=0.04; I2=0.0%), with no differences in the risk of major bleeding (OR 1.12; 95% CI 0.23–5.53; p=0.136; I2=44.5%) and all-cause mortality (OR 0.77; 95% CI 0.45–1.31; p=0.330; I2=0.0%) observed.

Conclusion. In patients with cancer-associated thrombosis, the use of rivaroxaban in comparison with LMWH is associated with a reduced risk of VTE recurrence without an increase in the risk of major bleeding and does not affect all-cause mortality.
Memories of the colleague

Vasiliy Nutsovich Dan (28.12.1941–03.09.2022)

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CHIEF EDITOR
Akchurin Renat Suleymanovich
Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Sciences, Deputy General Director for Surgery, Head of the Department of Cardiovascular Surgery, National Medical Research Center for Cardiology named after Academician E.I. Chazov, President of the Russian Society of Angiologists and Vascular Surgeons

 

In accordance with the decision of the Presidium of the Russian Society of Angiologists and Vascular Surgeons, the journal "Angiology and Vascular Surgery" will be named after Academician A.V. Pokrovsky starting from No. 2/2022.

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