The review discusses current approaches to the composition and duration of antiplatelet therapy in patients with acute coronary syndromes. The “standard” therapy has been known to include aspirin and active platelet P2Y12 receptor blocker for 12 months. This approach effectively prevents the development of thrombotic complications, but is predictably associated with an increased risk of bleeding. Understanding the issue of bleeding contributed to the arrangement of studies specifically aimed at assessing the efficacy and safety of early (after 1–3 months) discontinuation of aspirin while maintaining P2Y12 receptor blocker monotherapy. Serial meta-analyses of studies conducted over the past few years have shown typically similar results. Decreased frequency of bleeding and no “comprometation” in terms of thrombotic complications was observed in patients for whom the abbreviated therapy strategy was chosen. Among all P2Y12 platelet receptor blockers, the best evidence base has been collected for ticagrelor. The monotherapy with this drug resulted in not only expected reduction in the number of bleedings, but also in a positive effect on mortality, which risk decreased by almost 15%. Until recently, ticagrelor monotherapy was allowed for patients who were not at high bleeding risk, but today the optimal balance between effectiveness and safety has been also demonstrated in patients at high haemorrhagic risk. Thus, the existing evidence base supports a new alternative strategy to minimize bleeding, which suggests switching to P2Y12 blocker monotherapy in revascularized patients 3–6 months after an acute coronary syndrome (ACS) event. It therefore appears logical to use such approach to individuals without a high risk of ischemic events and in the absence of such during the initial treatment with two antiplatelet agents.

Introduction. Patients undergoing elective myocardial revascularization require 6 months of dual antiplatelet therapy (DAPT), including aspirin and clopidogrel. In patients with multifocal atherosclerotic lesion (MFA), it may be reasonable to extend the DAPT. Additional consideration of laboratory parameters, which reflect sensitivity to clopidogrel, may be useful in assessing the effectiveness and safety of prolongation DAPT.
Aim. To determine the significance of laboratory parameters reflecting sensitivity to clopidogrel in assessing the prognosis of patients with MFA receiving long-term DAPT after myocardial revascularization.
Materials and methods. 128 patients with coronary artery disease (CAD) and MFA were included from the prospective register of antithrombotic therapy (REGATTA-1), ClinicalTrials NCT04347200. Inclusion criteria were elective myocardial revascularization, the use of DAPT planned for at least one year and additional determination sensitivity to clopidogrel – residual platelet reactivity and polymorphisms of the CYP2C19* gene. Thrombotic events (TO) in any vascular beds and hemorrhagic complications(GO) (BARC 2–5).
Results. The median of DAPT was 380 days, IQR (346. 447). The total incidence of thrombotic events and hemorrhagic complications (the majority – BARC 2) were 9.9 and 4.4 cases per 100 patient-years. The frequency of bleeding events was 4.4 cases per 100 patient-years. There was no association of TO with the PRU and pharmacogenetic parameters. CYP2C19*17 allele carriers tended to have a higher frequency of GO rates compared compared to wild genotype carriers (63% versus 29%, p = 0.05). The frequency of GO in patients with PRU 147 (two lower quintiles) was higher compared with the frequency of GO in the three upper quintiles of the distribution: 12% vs. 3%, p = 0.041. PRU lost significance in multivariate analysis and an independent laboratory predictor of GO was the carriage of CYP2C19*17 alleles (HR 4.8).
Conclusion. In patients with MFA who are candidates for long-term DATT after myocardial revascularization, an additional pharmacogenetic assessment of the effect of clopidogrel (allelic variants of CYP2C19*17) can be discussed in order to predict bleeding

Pulmonary embolism (PE) is a common and potentially fatal cardiovascular disease that must be promptly diagnosed and treated. The diagnosis, risk assessment, and treatment of PE have evolved with better understanding of the effective use of diagnostic and therapeutic options. Diagnostic testing includes sequential application of clinical decision rules using Wells, Geneva scores, and D-dimer testing. Patients with a high likelihood of having venous thromboembolism (VTE) should undergo ultrasonography if deep vein thrombosis (DVT) is suspected and CT if PE is suspected. Direct oral anticoagulants (DOAC) are a safe, effective, and convenient treatment for most patients with VTE and have a lower risk of bleeding than vitamin K antagonists. Treatment of PE in frail patients, including the elderly (≥75 years) and/or with low body weight (≤50 kg) and/or impaired renal function (GFR ≤ 50 ml/min) remains quite problematic due to the increased risk of hemorrhagic complications compared to the risk of recurrent VTE. Available data indicate that DOAC therapy is not inferior in efficacy and safety to conventional anticoagulant therapy and these drugs can be successfully used in “fragile” patients. The presented review can be used to help in choosing the most rational method of treating pulmonary embolism in “fragile” patients.

Intimate sarcoma is a rare malignant tumor with a very poor prognosis. The incidence rate among all sarcomas is less than 1%. The primary localization of the tumor is most often the aorta and pulmonary artery. Other localizations account for about 10% of all observations. This tumor has an extremely nonspecific picture, is characterized by difficult diagnosis and poor prognosis. The main method of treatment is surgical – excision of the affected vessel and surrounding tissues with an interoperative histological examination, arterial reconstruction. About 140 cases of intimate sarcoma have been described in the literature. We present our own observation of intimate sarcoma. In the presented clinical case, the primary localization of the tumor was the common femoral artery. The patient was admitted with a clinical picture of a false femoral artery aneurysm, which was regarded as post-traumatic, without thrombosis or embolism of the distal bed and signs of limb ischemia. Repeated reconstructive surgical interventions were performed for a diagnosed false aneurysm. The intraoperative picture did not indicate any oncological process. After discharge, within six months there were two repeated requests for emergency indications in connection with erosive bleeding in the area of surgery. There were no signs of paraprosthetic infection. The oncological process was suspected with the appearance and growth of a voluminous formation of the inguinal region, which became the reason for performing a histological examination. The final diagnosis was made in the late stage of the disease, when radical surgical treatment was not feasible. The ongoing chemotherapeutic treatment did not have a significant effect, which led to an unfavorable outcome.

The article describes an example of successful surgical treatment of an elderly patient with an arterio-ureteral fistula in the presence of an infected vascular graft after numerous arterial reconstructions on the aortoiliac segment with the multidisciplinary team support. Restoration of the magistral blood flow in the aortoiliac region using bypass surgery or graft implantation relates to a technically sophisticated surgeries, especially in patients with severe concomitant diseases and previously implanted graft infection. This is associated with the high incidence of complications, which varies from 19.2 to 45% according to different sources. In such cases, extra-anatomic reconstructive interventions that are low-traumatic may be the method of choice for relieving critical ischemia. This approach in most cases becomes the only opportunity to save a limb in such clinical situation. A pronounced cicatrical adhesion process in the abdomen and retroperitoneum caused by numerous reconstructive surgeries on the infrarenal aorta in some cases can be the cause of ureteral strictures, which requires the involvement of a urologist in the treatment of such patients. Arterio-ureteral fistula (AUF) is an uncommon but potentially lethal complication. Despite increased number of reported cases and clinical awareness, AUF is not always detected in a timely manner. The prognosis in such cases can vary depending on the time interval from onset of clinical symptoms to the start of treatment. In the vast majority of cases, the AUF is located at the site where the ureter crosses over the bifurcation of the common iliac artery. Angiography is deemed the most effective procedure to diagnose AUF, although its sensitivity is only 62%. According to most authors, implantation of an endovascular stent graft for AUF is preferred over open surgery (mortality rate is 4 and 11%, respectively). However, an individual treatment strategy is developed in each specific case