ARTHERIOPATHY
Diseases and the damages causing an involvements of
vessels (arteriopathy)
1. Involvements of an arterial wall
· An
atherosclerosis
· Autoimmune angiopathy
o Group nodular
polyarteritis (illness of Kawasaki,
syndrome of Cogan, syndrome of Bekchet)
o Group hypersensitive angiitises (mixed cryoglobulinemia, malignant arteritis, arteritis of collagen diseases: nodular periarteritis,
dermatomyositis, system scleroderma)
o Group of giant-cell arteritis (arteritis Takayashi, temporal arteritis)
· Endocrine angiopathy
o A diabetes
· Obliterating
endarteritis (obliterating thrombangitis, illness of the Burgher)
· Vascular
hypotonias (congenital, evoked)
· Congenital
involvements of an arterial wall
o Pseudoxanthoma elasticum
o Syndrome of Egers-Danlos
o A syndrome of the big artery
o Syndrome of Marfan
o Cystous illness of adventitia
o Cystous illness of media
2. Involvements of a wall of a vessel owing to a trauma
· A sharp
and blunt trauma with a thrombosis of an artery
· Iatrogenic damages (catheterization of heart and vessels, arteriography)
· Chronic
traumatic arteritis
· Chronic
postradiating arteritis
· An allergic
syndrome
3. Involvements of a wall of a vessel owing to compression
· Congenital
(fibromuscular dysplasia)
· Evoked -
Neurovascular syndromes of compression of the top limbs (an anterior scalene, a cervical rib,
costoclavicular, a lesser pectoral muscle, hyperabducent, "shoulder - hand")
4. Involvements owing to the intravascular factor, metabolic disorders
· Dislipidemia
· Hypercoagulation
· Cold agglutination
· Polycythemia
vera
· Uremic arteriopathy
· Hemodialysis shunt
· A syndrome of
hyperviscosity
o Myeloproliferative disorders
o Myeloma
o Macroglobulinemia
o Cryoglobulinemia
o Neoplasia
o Benign monoclonal gammapathy
o Homocysteinemia
5. Involvements and dysfunction of capillaries (angiorigosis or trophoangioneurosis)
· Acrocyanosis
· Erythrocyanosis
· Acroparesthesias
· Livedo
· Erythromelalgia
· Ischemic
syndrome of Martorell
· Local
hypertensive syndrome of arteries of the inferior limbs
· Cold
erythrocyanosis (chillblains, or pernions,
cold neurovasculitis, trench
foot)
· Illness of Reino
o Illness of Reil
o Vibrating illness
But if to consider the reasons by the rate of
occurrence
Structure of the diseases causing the CAPI:
· An
obliterating atherosclerosis - 81,6 %;
· Nonspecific
aorto-arteritis - 9,0 %;
· Diabetic
angiopathy- 6,0 %;
· Obliterating
thrombangitis - 1,4 %;
· Illness of Reino - 1,4 %;
· Other diseases -
0,6 %
The table. Risk factors of occurrence of an ischemia
of the limbs
Professional damages:
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Vibrating illness (the pneumatic tool, an electric saw, a grindstone)
the Electric burn Hammer syndrome of antithenar (a lathe, mechanical work, repair work, first
fixings, electric works) Professional acroosteolysis Supercooling
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Doing by professional sports:
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Compression syndrome of the top aperture (a
weight-lifting, swimming by a
butterfly, a golf, rowing, a baseball throw) Traumas of the top limbs
(karate, a handball)
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Pharmacological damages:
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beta-blockers Drug abuse especially containing cocaine Cytostatic
medicine Dopamine
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The principal cause of chronic arterial insufficiency (CAI) considers obliterating atherosclerosis which meets
basically in age group of 55-65 years (man) and 60-80 years (women). The reason
of development CAI second by rate is the peripheral form of aorto-arteritis (at 9 % of patients). It meets among patients in the
age of 45-50 years.
Involving basically of men than 40 years are more
senior, it quite often causes heavy insufficiency of blood circulation of limbs,
dooms patients to painful sufferings and deprives with work capacity. Process
is located mainly in large vessels (an aorta, iliac arteries) or
arteries of mean calibre (femoral, popliteal).
Atherosclerotic involvements of arteries are represent
a manifestation of the general atherosclerosis. The basic changes at an
atherosclerosis develop in an intima (an internal coat) of arteries. Here cholesterol and adipose
inclusions (lipids) -
forming yellowish stains on an internal wall of a vessel start to be postponed.
In a circle of these centers there is a young connective tissue which maturing
leads to formation of the sclerous
plaques. On the plaques settles
platelets and
clots of fibrin, salt of calcium. At abundant accumulation of lipids and calcium
there is a disorder of blood circulation in plaques, necrosis of which causes
the occurrence of the atherom-cavities thick with a disintegrating masses . The wall of an
artery in the area of such plaque
has stone hardness, is easily crumbled.
Crumbleshaped masses are torn away in a lumen of a vessel. Getting
with a blood flow in underlying blood vessels, slices of crumbled
atherosclerotic plaque
can become the reason of occlusion (embolism) and lead to a thrombosis of arteries of a limb with
development of a gangrene (necrosis). Besides luminal narrowing of a vessel by large plaque leads to the major disorder of a blood flow that
reduces delivery of oxygen in a tissues.
Young French student - veterinary G. Bouley (1831)
once observed the old horse forced at run to pass to the slow walking and
beginning to limp. He has correctly established the reason of this lameness –
the occlusion of a femoral artery and has applied for the first time the term "claudication" from
Latin a claudicare-lameness. From this time doctors have started to attach
significance to involvement of arterial vessels and to connect with it a spontaneous
gangrene of a limb.
The basic symptom of the obliterating atherosclerosis
of the inferior limbs is the intermittent claudication shown by pains in calf muscles which
appear at walking and disappear after short-term rest. At atherosclerotic
involvement of the abdominal aorta and iliac
arteries (syndrome of Lerish) pains are
located not only in shins, but also in cluneal muscles, lumbar area and muscles of
hips. The intermittent claudication becoming stronger at the rise on a ladder
or uphill. The increased sensitivity of the inferior limbs to a cold, sometimes
feeling of numbness in
foots and usually chill. Consequently changes the stain of cutaneous covering
of legs which in initial stages of the
disease becoming pale , have at patients with syndrome of Lerish color of an
elephant ivory.
In later stages a skin of foots and fingers gets
crimson cyanotic
stain (trophic disorders). Development of trophic disorder conducts to loss of
hair, disorder of growth of nails. At corking (occlusion) of femoro-popliteal segment
pilosis usually
is absent on a shin, at involvement of aorto-iliac area the zone of alopecia is distributed
and on a distal third
of hip. One of manofestations of an atherosclerosis of aorto-iliac segment is the impotence caused by disorder of
blood circulation in system of internal iliac arteries. The indicated symptom meets at 50 % of
patients.
The relevant information about the character of
pathological process gives a palpation of
vessels of a leg. At an obliterating
atherosclerosis of the inferior limbs most involved the femoro-popliteal segment,
therefore, beginning from a place of origin of a deep artery of thigh , the pulsation
at the overwhelming majority of patients is not defined neither on a popliteal
artery, nor on arteries of foot.
Constant pain in the rest, demanding anesthesia within
2 weeks and more, the trophic ulcer or a gangrene of fingers or the foots which
have arisen on a background of chronic arterial insufficiency of the inferior
limbs are an attribute of a critical ischemia of the limb . In the name of this
condition crisis is mentioned. If to not undertake steps on improvement of
arterial blood supply amputation is inevitable at overwhelming majority of
patients. And often not the doctor persuades the patient on amputation, and on
the contrary, the patient, having exhausted from a pain and sleeplessness begs the
surgeon to take away a sick leg.
Depending on clinic define the following stages of disease
Depending on clinic define the following stages of disease
Stages of
disease (by Pokrovskiy)
· 1
stage -
the pain in the inferior limbs appears only at the big physical loading, for
example, at walking more than 1 km;
· 2
stage -
a pain in legs at walking on smaller distance. If the patient passes usual step
without a pain of 200 m, it is 2А
st. and if the pain arises earlier - 2B st;
· 3
stage -
occurrence of pain in legs at rest, sleeplessness;
· 4
stage -
to the previous complaints joins the rough trophic disorder of a tissues of the
inferior limb (a ulcer, necrosis, a gangrene) .
According to the European consensus, III and IV stages
are attributed to the conditions named a critical ischemia.
Attributes of a critical ischemia
Constant pain in the rest, demanding anesthesia within
2 weeks and more, the trophic ulcer or a gangrene of fingers or the foots which
have arisen on a background of chronic arterial insufficiency of the inferior
limbs, are an attribute of a critical ischemia. To the patient with a critical
ischemia the skilled doctor can put the diagnosis in the distance. As a rule,
the sick person sits with the lowered leg, constantly rub it. The face takes a
suffering form. To force the patient to lie hour on a bed it is practically
impossible, he all the same will lower a leg. Stagnation of venous blood in the
lowered limb increases a degree of oxygen efficiency from blood to tissues and
reduces a pain. However , formed hypostasis squeezes and without that poorly -
replete arterial vessels and worsens the
blood circulation, leading to occurrence
of necrosis sites of a
skin and tissues, to formation of not healing ulcers even more. From for lack
of oxygen and a feeding , sensitive nerves inflame and there is an intolerable
burning pain. All measures directed on anesthesia bring only time pain relief.
Sooner or later for such sufferer there is a question to continue feel
an excruciating pain or to get
rid of their source. Only such choice earlier was. But in vascular surgery and
pharmacology lately there was a certain progress which has opened prospects in
treatment of a critical ischemia. To establish the diagnosis of a critical
ischemia will help the modern methods of imaging (ultrasonic diagnostics,
magnetic-resonant angiography) and methods of an estimation of tissue blood circulation .
Tool methods of diagnostics
1.
Ultrasonic research enables to define a level
of atherosclerotic occlusion and a degree of blood supply of distal departments of
the affected limb.
2. For specification of the diagnosis before the
reconstructive operation to a number of patients it is carried out x-ray
angiography. It allows to define the localization and extension of pathological
process, a degree of involvement of arteries (occlusion, a stenosis).
3. Modern magnetic-resonant contrast angiography does not
concede the x-ray information on quality, but does not demand hospitalization
and differs by high safety for patients as contrast is entered intravenously.
Technology of treatment of an
atherosclerosis
· Treatment
of lipidic disorders.
First of all the diet is necessary for decrease of a level of cholesterol. At a
high level of cholesterol and lipids
low density appointed special
preparations statins, promoting decrease of a level of those adipose fractions
which forward to an atherosclerosis (it is preparations zakor, lovastatin,
pravastatin, etc.) , braking biosynthesis of cholesterol in a liver) Treatment
is carried out under the control of laboratory researches.
· Obligatory
refusal of smoking. Smoking is the proved risk factor of progressing of an
atherosclerosis and its complications. If up to attributes of an
atherosclerosis with smoking it was possible to make advances, after the first signal
it is necessary to stop immediately. Nicotine causes an angiospasm and worsens
conditions of blood supply, thus forward to thromboses.
· Application
of preparations lowering risk of a thrombosis. It is known, that the main
complication of an atherosclerosis is a thrombosis of changed by plaques artery.
The thrombosis of a large artery causes vascular accident in basin of its blood
supply (an insult, myocardial infarction, a gangrene ).
· At
presence atherosclerotic plaques that threaten to normal blood supply of organs
are applied surgical
methods of treatment - reconstructive vascular operations.
The preparations dilated vessels (verapamil,
cylostasol), improving fluidity of blood and reducing risk formation of blood
clots (penthoxiphyllin, rheopolyglucin, aspirin, Vessel Due F, kurantil) are
used. At considerably expressed insufficiency of blood supply with success
preparations of prostaglandins (alprostan, vasaprostan) are applied.
Surgical treatment
Indications to fulfilment of reconstructive operations on vessels of limbs are by way of the importance:
1.
Attributes of a menacing gangrene of limbs
(necrosis of fingers,
a ulcer on foots);
2. Constant pains in foots in a condition of
rest. The pain relief is possible at constantly lowered leg. Patients can sleep
months at sitting;
Reduction of distance of painless walking less than 200 meters if the course of
conservative treatment do not increase the passing distance, and this distance
does not suit the patient.
Etiological treatment
(influence on causal factors)
Well-known, that smoking of nicotine promotes
development of vascular diseases. It is proved, that refusal of smoking at the
first attributes of vascular diseases reduces probability of complications and
promotes reduction speed of disease progression . The diet for patients with
obliterating diseases should solve the important problem - to normalize weight,
and for this purpose it is necessary to lower quantity of easy-to-digestible carbohydrates and fats and as a whole to reduce
caloric content of food on 10-15 %, it is especial at concomitent adiposity. A
useful product for treatment of an atherosclerosis is the fat fish (a salmon, a
cod) as in it to contain fat acids increasing quantity of useful lipoproteins
of high
density. At a high level of cholesterol and lipids of low density
are appointed special preparations statins, promoting decrease of a level of
those adipose fractions which promote an atherosclerosis (it is preparations
zakor, lovastatin, pravastatin, etc.) , Braking biosynthesis of cholesterol in
a liver) Treatment is carried out under the control of laboratory researches.
At endarteritis
(thrombangitis) anti-inflammatory
therapy as at an aggravation of disease there is evident inflammatory
autoimmune reaction
has great value. For these purposes hormones of adrenal glands are appointed in
the big dozes due to what the inflammation is stoped . The further treatment is
like at an atherosclerosis. At diabetic angiopathy has great value the full
compensation of a diabetes , prescription of insulin in difficult cases. The
common moment for treatment of obliterating diseases is thromboprophylaxis. It
should be lifelong and sufficient. Most preparations of aspirin (thromboass,
aspirin - cardio) or more modern and expensive preparations: tiklid and plavix are often
applied.
These preparations reduce aggregation of platelets and block the
formation of blood clots in the arteries changed by illness. Remarkable Italian
preparation Vessel Due F which unites in itself medical properties of the set
above forth groups now has appeared and improves also fluidity of blood,
reduces risk of thromboses and promotes restoration of the vascular epithelium.
Obliterating endarteritis
(thrombangitis)
System chronic inflammatory disease at which there is
a involvement of fine arteries of limbs. This is rather widespread disease
which meets worldwide though and with unequal rate. Men are ill in 10 times
more often than women. Middle age at which there is an illness of 30-40 years.
The definite reason of obliterating endarteritis is not
established till now. Now the following hypotheses are accepted:
1.
Infectious - toxic (including a fungal
infection);
2. Allergic (the increased reaction to tobacco
products);
3. A pathology of coagulant system of
blood;
4. Atherosclerotic (an atherosclerosis of young
age).
Now the majority of researchers is trended in favour of the autoimmune nature of disease. In these patients are often
found out changes in immune system that expressed in occurrence of antivascular
antibodies, increase of concentration of circulating antibodies, decrease in a
level of lymphocytes.
Development of disease can be presented as follows:
under influence of various factors (smoking, an infection, a feeding, etc.)
occurs accumulation of antibodies in a vascular wall and formation of immune
complexes. As a result of it develops the inflammation of all layers of an
artery which in the subsequent results to a sclerosis of a wall and occlusion
(obliteration) of a lumen . This process in a result leads to development of insufficiency of blood
circulation.
Clinical course differs by undulating at which the
periods of an aggravation are replaced more or less permanent improvement.
Symptoms of disease are connected to chronic arterial insufficiency of the inferior limbs. Patients complain of the
increased sensitivity to low temperature, weariness in legs, numbness, spasms,
a pain at walking or in rest, trophic disorders as ulcers in the area of
fingers and foots, necrosis or gangrenes. Differential diagnostics should be
carried out, first of all, with an obliterating atherosclerosis, involvement of
vessels at a diabetes.
It is necessary to carry out the following researches:
· Definition
of circulating immune complexes (Central Electoral Committee) in peripheral
blood.
· Definition
of quantity and a ratio of
various lymphocytes.
· Definition
of blood coagulation (coagulogram
and thromboelastogram). • Ultrasonic
researches of vessels.
· Measurement
of the contents of oxygen in tissues (Transcutaneous definition of
pressure РО2).
· Magnetic-resonant and
X-ray contrast angiography.
Treatment of endarteritis
Therapeutic treatment
1.
Exception of unfavourable factors, first of
all smoking, supercooling, vibration, psychoemotional stimulus.
2. Anti-inflammatory therapy and suppression of
the increased immune reactions during an aggravation (hormones of adrenal
glands and immunosuppressive agents in the big dozes
are applied).
3. Decrease of the raised coagulability of blood
(modern preparations of heparin).
4. Preparations improving blood supply (alprostan or
vasaprostan).
5. Oxygen therapy (hyperbaric oxygenation).
6. Anesthesia.
At endarteritis (thrombangitis) anti-inflammatory
therapy as at an aggravation of disease there is expressed inflammatory
autoimmune reaction has great value. For these purposes
hormones of adrenal glands in the big dozes due to what the inflammation is
stoped are appointed. The further treatment as at an atherosclerosis. At
diabetic angiopathy full
compensation of a diabetes, prescription of insulin in difficult cases has
great value. The common moment for treatment of obliterating diseases is the
thromboprophylaxis. It should be lifelong and sufficient. Most preparations of
aspirin (thromboass, aspirin - cardio) or more modern and expensive
preparations tiklid and
plavix are
often applied.
These preparations reduce aggregation of
platelets and
block the formation of blood clots in the arteries changed by illness.
Remarkable Italian preparation Vessel Due F which unites in itself medical
properties of the set above forth groups
now has appeared and improves also fluidity of blood, reduces risk of
thromboses and promotes restoration of the vascular epithelium.
Surgical treatment
1. In initial stages of disease it can be applied
lumbar or chest sympathectomy which removes a peripheral spasm of arteries and
promotes development of roundabout blood circulation.
2. At presence of conditions, reconstructive operations on vessels are carried
out. The combination of reconstructive operations to vascular therapy improves
results of operative treatment a little.
3. From indirect methods is applied free
transplantation of the greater omentum on a limb with the help of microvascular
anastomoses .
It is figure on formation of a new vascular network in muscles of the shin
sprouting from vessels of an omentum.
4. Amputation is indicated to patients with a
gangrene of a limb and absence of conditions for accomplishment of regenerative
vascular operation. It is important to execute amputation with preservation of
a knee joint as it, allows the patient will return to a full-fledged life after
prosthetics.
Technology of treatment of patients with a critical
ischemia
1. Anesthesia
· The
rational regimen of introduction of anesthetizing preparations;
· Epidural
prolonged anesthesia. It is applied at all patients with a pain of
"rest" at an inefficiency of usual anesthesia. Allows carry out
preoperative examination and conservative treatment.
2. Correction of system disorders of metabolism and
inflammatory reaction
· Correction
of a diabetes and insulinotherapy
at " diabetic stop ";
· Anti-inflammatory
pulse - therapy at patients with endarteritis (thrombangitis) is carried out
by the big dozes of methylprednisolone
and cyclophosphan by a short course of
treatment. Allows to interrupt an aggravation of process and to improve results
of conservative treatment of this disease.
3. Improvement of blood circulation in the affected
limbs
· Preparations
of prostaglandines (alprostan or
vasaprostan). Long 5-hour injections, sometimes twice day are carried out. For
today this is most effective conservative treatment.
· Intravenous
infusions of preparations (albumin, etc.). Fluidity improves and viscosity of
blood decreases;
· Correction
of the increased coagulability of blood (low-molecular heparins). The risk of
the continued thromboses in arteries of the affected limbs decreases;
· Surgical
treatment. Depending on a clinical situation all spectrum of the surgical
interventions which have proved the efficiency in leading European and domestic
clinics is applied.
Surgical ways of treatment of obliterating diseases
Operations on arteries are higher than
inguinal ligament
· Aorto-bifemoral shunting
and prosthetics
It is applied at involvements of an aorta and iliac arteries, as
the most effective intervention at patients with an obliterating
atherosclerosis.
Extraanatomical
interventions (femoro-femoral and
axillary-femoral shunting).
Are applied at the elderly, weakened patients as
effective and rather safe way to rescue a leg from amputation, are frequently
combined with X-ray endovascular
interventions...
Operations on arteries are lower than
inguinal ligament
· Profundoplasty,
femoro-popliteal shunting
Are applied at occlusions of arteries at a level of a
thigh, is more often at a critical ischemia of the inferior limbs
· Femoro-distal shunting
at a critical ischemia
Indications and technology of performance of this
delicate operation are in details worked through by vascular surgeons. Frequently
this operation allows rescue the limb even in the most hopeless cases.
· Indirect
methods of improvement of a blood-groove
To them concern lumbar sympathectomy, revasculizatory osteotrepanation,
microsurgical transplantation
of the greater omentum. Operations are carried out at impossibility to carry
out direct restoration of a blood-groove...
At impossibility of performance of direct vascular operation
at patients with involvements of arteries it is applied lumbar sympathectomy.
Essence of this intervention
1. Operations at the weakened and elderly
patients with high risk
2. At patients with high risk of the big
operation, at syndrome of Lerish, we carry out safe interventions which refer
to extraanatomical. If it is occlusion of one iliac artery we
remove blood from other leg. If the passable (donor) artery is narrowed, we
carry out its inflating by a cylinder and we install stent, thus improving a
blood-groove and in rather healthy leg.
3. If both arteries of legs are closed then at
the weakened patients is carried out the shunting from iliac arteries on a
shoulder in femoral arteries . Advantage of extraanatomical operations
that they are carried out easily and quickly with the minimal risk. For
anesthesia is suitable even local anesthesia . But lack is smaller passableness
of shunts. Within 5 years at 80 %, within 10 years at 70 %. However in case of
a critical ischemia at the patients elderly and weakened by other illnesses
these operations help to rescue a leg and to avoid heavy complications.
Alternative to classical operations recently became X-ray endovascular bladder dilation and stentation
of iliac arteries
which are carried out through a puncture in an artery and without open
intervention, but results of these operations while considerably concede to
open surgery and are not always feasible because of volume of involvements.
However the combination of these operations to small open operations allows make
vascular surgery effective and safe.
Endovascular methods of treatment
Percutaneous angioplasty of atherosclerotic narrow spots by various localization
takes the important place in treatment of patients with the disorders of blood
supply. The general principle of such interventions is selective influence on a
symptom - connected disorder, and characteristic features - paracentetic approach and transportation of tools by vessels.
Bladder angioplasty, offered by Charles Dotter (1964),
in modern invasive radiology is the most
investigated procedure of revasculization. However the big clinical experience
which has been saved up by present time, has sharply defined the limits and
potentialities of a method. Correction of extended narrow spots of vessels and
occlusion is possible, however in
these cases frequency of complications and limitation on time of medical effect
appeared obviously unacceptable.
The original idea of application of stent for modeling geometry of an arterial lumen belongs to
Charles Dotter (1969). For preservation of a vessel lumen have been design
the tubular open work which are
delivered in a vessel in a compact kind and, increasing in size till diameter of the
damaged artery, create a skeleton for maintenance of a lumen and delimit of the damaged surface of an artery from a stream of
blood.
Messages on the first cases of clinical application
have been published by Sigwart (1987) and
Palmaz (1988). " Johnson and Johnson (Cordis) " became the first the
company – producer of stents Palmaz.
The term "stent"
has appeared at the end of XIX century and has taken
place on behalf of English dentist Charles Stent who used supporting designs
for artificial limbs. Further this term began the common for all devices
assigned for mechanical support of living tissues.
Bladder
angioplasty
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Angioplasty represents the less invasive not surgical procedure which is applied for dilation (expansions) of a lumen of the narrowed or corked
peripheral arteries. Specially prepared doctor inflates a tiny medical cylinder
inside an artery, pressing plaque to a wall of a vessel. Then the cylinder is emptied and taken. All this
procedure is carried out inside an artery through a small aperture in one of
vessels in inguinal area.
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Stentation
Installation of stents is carried out in conditions of the clinic equipped with the
radiological equipment of imaging (laboratory of catheterization) which allows
the doctor to check the process of installation and a site of stent inside an artery.
In the same or next day after installation of stent patients frequently let off home as procedure is not
invasive manipulation as, for
example, the surgical operation demanding the long period of restoration.
At aneurysms or chronic dissection of a thoracic or
abdominal aorta recently due to application of intravascular stents has appeared the opportunity in most cases to avoid heavy and long abdominal operation. Such stents are entered in the combined position through a small section of a
femoral artery and finish in a place of aneurysms or dissection. Stent is fixed
inside a vessel and switches off to an aneurysm from a blood-groove. Thus the
risk of break of an aorta in this place is excluded. Operation is carried out
under the general narcosis and lasts on the average about one hour against
several hours at abdominal operation on replacement of a part of an aorta with an artificial limb.
Unfortunately, at a small part of patients in connection with anatomic features
not always it is possible to apply stent and in this case we resort to abdominal operation. The decision on carrying out of operation and manufacturing
of individual stent is carried out only on the
basis of special examinations, and the final decision is accepted only during
operation.