ЦЕЛЬ ИССЛЕДОВАНИЯ Провести анализ частоты, структуры, особенностей течения и исходов венозных тромбоэмболических осложнений (ВТЭО) у пациентов с новой коронавирусной инфекцией (COVID-19) во время первой и второй волны пандемии COVID-19, выявить и оценить особенности лабораторных показателей. МАТЕРИАЛ И МЕТОДЫ Проведена оценка инструментальных и лабораторных данных пациентов с COVID-19 в период первой (1839 больных) и второй (840 больных) волн пандемии. Выполнен анализ летальности, локализации тромбозов, вариантов антикоагулянтной терапии, лабораторных показателей (уровень лейкоцитов, С-реактивного белка, фибриногена, ферритина). РЕЗУЛЬТАТЫ ВТЭО были зарегистрированы в 27 (1,5%) и 13 (1,5%) случаях у пациентов с новой коронавирусной инфекцией во время первой и второй волны пандемии соответственно. Структура ВТЭО у пациентов первой волны новой коронавирусной инфекции была представлена следующим образом: тромбоз глубоких вен (ТГВ) — 16 (59%) случаев, тромбоэмболия легочной артерии (ТЭЛА) — 6 (22%), ТГВ+ТЭЛА — 2 (8%), тромбофлебит подкожных вен — 3 (11%) случая. Во время второй волны COVID-19 ТГВ выявили у 5 (38,5%) больных, ТГВ+ТЭЛА — у 5 (38,5%), ТЭЛА без ТГВ — у 2 (15,4%), тромбоз правой почечной вены — у 1 (7,6%) пациента. Средние величины лабораторных показателей у пациентов с ВТЭО во время первой волны COVID-19 были следующими: лейкоциты крови — 9,2∙10⁹/л (6,9—14,3); С-реактивный белок — 77,5 мг/л (26—159); фибриноген — 593,5 мг/мл (500—700); ферритин — 1132,6 мкг/л (165—1753). Для пациентов с ВТЭО во время второй волны пандемии были характерны: умеренный лейкоцитоз — 12,2∙10⁹/л (7—19), повышение уровня фибриногена — 544 мг/дл (405—781), а также высокие уровни С-реактивного белка — 102,75 мг/мл (80—163) и ферритина — 510 мкг/л (230—566). ЗАКЛЮЧЕНИЕ У пациентов с новой коронавирусной инфекцией при развитии ВТЭО отмечена высокая летальность. Во время второй волны пандемии летальность среди пациентов с ВТЭО увеличилась, что может быть связано как с тромботическими осложнениями, так и с сопутствующей сердечно-сосудистой патологией.

INTRODUCTION: A new coronavirus infection (NCI) is characterized by catastrophic coagulopathy with development of thrombotic and hemorrhagic complications. The choice of an optimal anticoagulant in these patients remains an important issue. AIM: To evaluate risk factors for venous thromboembolic complications (VTEC), effectiveness and safety of different variants of anticoagulant therapy (ACT) in patients with NCI. MATERIALS AND METHODS: A prospective study was conducted that involved 370 patients with NCI: group 1 patients who received low molecular weight heparin (LMWH) 190 people, group 2 patients who received unfractionated heparin (UFH) 123 people, group 3 patients who took direct oral anticoagulants (DOAC) 57 individuals. Clinical and anamnestic data, frequency of thrombotic and hemorrhagic complications were evaluated. The study was approved by the Local Ethics Committee and was registered on ClinicalTrials.gov. platform. RESULTS: The existence of chronic venous diseases increases the risk of development of venous thromboembolism (VTE) in patients with NCI 6.433 times (95% confidence interval (CI) 2.16719.093)) (р = 0.001), use of UFH instead of LMWH or DOAC 3.542 times (95% CI 1.14910.916) (р = 0.028), use of artificial lung ventilation (ALV) 5.925 times (95% CI 2.03417.26) (р = 0.001), high D-dimer level 2.024 times (95% CI 1.2313.33) (р = 0.005). The level of C-reactive protein and ferritin decreased in all patients in the course of treatment for NCI, with the lowest levels in patients receiving LMWH (С-reactive protein 5.8 (1.715.0) mg/l, р = 0.004; ferritin 364 (324497) g/l, р = 0.001). Lower fibrinogen levels were recorded in patients of group 1 compared to groups 2 and 3 (2.43 (1.93.52) g/l versus 3.37 (2.84.92) g/l and 4.1 (2.85.25) g/l, respectively, р = 0.002). A high frequency of pulmonary embolism with unspecified source was recorded in patients receiving UFH 11.4% of cases, with this, the frequency of using ALV in the group with UFH was evaluated as high 21% of cases. CONCLUSION: Risk factors of VTEC in patients with NCI are both factors typical of VTEC in general (obesity, chronic vein diseases, elevated D-dimer level), and factors specific of NCI (ALV, hypoventilation). Effective and safe anticoagulants in this group of patients are LMWH that demonstrated low frequency of development of VTEC and of hemorrhagic complications.

INTRODUCTION: Pathological communications between the arterial and venous systems have been in the center of attention of surgeons since XVIII century. Despite the achievements of the modern medicine, the diagnosis and treatment of arteriovenous fistulas (AVF) is still quite a difficult problem. The most common location of AVF is the lower limbs ― 17% of cases. Because of the peculiarities of structure and clinical manifestations of posttraumatic AVF, they are diagnosed several years after the injury. Diagnostic errors reach 30%, and unsatisfactory results of surgical treatment are observed in 30% to 70% of cases. The article describes a clinical case of a patient with a rare posttraumatic AVF in the lower third of thigh identified 2 years after fracture of a lower limb. Initially, the patient was delivered to hospital for surgical treatment for varicose vein disease of the left lower limb (C5 in CEAP classification). In the follow-up examination at the department of vascular surgery, a posttraumatic AVF of femoral vessels in the lower third of thigh was found with alterations of central hemodynamics (according to the heart ultrasound data). An attempt of open disconnection of the AVF was undertaken, however, morphological alterations of the walls of femoral vessels caused by a long-existing fistula did not permit this to be done. In result, for effective disconnection of AVF two stages of endovascular treatment were required. CONCLUSION: This medical case is given by the authors because of the rarity of pathology, atypical clinical manifestations and diagnostic difficulties. This case is also interesting from the point of view of the fact that effective disconnection of AVF required several stages of endovascular treatment.

Эффективность компрессионной терапии в профилактике венозных тромбоэмболических осложнений у пациентов с COVID-19

INTRODUCTION: The physical inactivity, hypoventilation, as well as chronic inflammation in obese patients aggravates their condition in various diseases. These features have become important with the advent of the COVID-19 pandemic, in which inflammation and platelet-activated coagulopathy are closely linked. AIM: To study laboratory parameters of inflammation and platelet apoptosis in obese patients using various types of anticoagulant prophylaxis of venous thromboembolic complications with the underlying COVID-19. MATERIALS AND METHODS: The study included 370 patients with COVID-19. Depending on the presence or absence of obesity and the type of parenteral anticoagulant, patients in our study were divided into groups: group 1 — non-obese + low molecular weight heparin (LMWH) (n = 114), group 2 — non-obese + unfractionated heparin (UFH) (n = 58), group 3 — obesity + LMWH (n = 76), group 4 — obesity + UFH (n = 66). The incidence of venous thromboembolic complications (VTEC), bleeding, general markers of the acute phase of inflammation, and specific markers of platelet apoptosis (phosphatidylserine and calreticulin) have been analyzed. RESULTS: At the end of hospital treatment, a decrease in ferritin levels was noted in patients both with and without obesity receiving LMWH. The concentration of calreticulin was higher in patients taking LMWH (groups 1 and 3). Phosphatidylserine levels were high in patients receiving LMWH only if they were obese. In patients taking UFH compared to LMWH, a high incidence of pulmonary embolism (PE) without a source (13.6% of cases versus 2.6%, respectively, p = 0.029) and PE with a source in the lower extremities (9.1% of cases versus 0%, respectively, p = 0.018) was found. When using LMWH, a lower incidence of bleeding was observed compared to using UFH (5.3% of cases versus 16.7%, respectively, p = 0.056). CONCLUSION: The levels of phosphatidylserine and calreticulin are higher in obese patients receiving LMWH. At the same time, patients in this group have a low incidence of VTEC and hemorrhagic complications compared to the group of patients taking UFH.

INTRODUCTION: Anticoagulation prophylaxis of venous thromboembolism (VTE) is obligatory for hospitalized patients with coronavirus infection, unless contraindicated. Various clinical studies reported a high incidence of thrombotic complications in patients with COVID-19 despite application of anticoagulant therapy (ACT). Therefore, the guidelines from several scientific societies recommend the use of higher doses of anticoagulants for the prevention of VTE in patients with COVID-19 with additional risk factors. Subsequent retrospective studies showed contradictory results in terms of efficiency and safety of prophylactic doses. Currently, there exist prophylactic, intermediate and therapeutic doses of anticoagulant therapy. Of special interest is the choice of an anticoagulant. Today, a clinician may choose from low molecular weight heparin (LMWH), non-fractionated heparin (NFH) and direct oral anticoagulants (DOACs). Even before the coronavirus pandemic it was noted that heparins also have anticoagulant properties, which can favorably affect the outcome of COVID-19. This hypothesis served as the basis for numerous randomized clinical trials to compare various types of ACT and search for effective pharmacological alternatives for VTE prophylaxis in patients with coronavirus infection. CONCLUSION: The article presents a literature review based on the analysis of current Russian and foreign scientific works on investigation of various doses, kinds of anticoagulant prophylaxis of thrombotic complications in patients with coronavirus infection, and their effect on the incidence of venous thrombosis, bleeding and mortality. It also provides data on alternative pharmacological variants for prevention of venous thrombotic complications in patients with coronavirus infection.