This article contains information on the possibilities of using rivaroxaban and other non-vitamin K-associated oral anticoagulants (novel oral anticoagulant (NOAC)) in patients with pulmonary embolism (PE) in both acute and later stages of the disease. In 2019, the European Cardiology Society released updated clinical guidelines, which slightly changed the rules of treatment. The rules state that if the anticoagulant therapy is planned to be started with oral drugs, it is recommended to use one of NOACs. The results of the Einstein-PE randomized clinical study proved the efficacy and safety of rivaroxaban in acute pulmonary embolism. In this study, rivaroxaban showed efficacy for prevention cases of repeated pulmonary embolism that was noninferior to the standard therapy. On top of that, the use of rivaroxaban was associated with fewer large bleeding. The recommended regimen for the use of rivaroxaban in acute pulmonary embolism is 15 mg twice daily for 21 days, then 20 mg once daily for at least 3 months.
The article outlines issues related to the need to extend anticoagulant treatment beyond the established standard terms (3-6 months) and issues of choosing a drug for extended treatment. Among other NOACs, rivaroxaban has the most comprehensive evidence base for extended treatment after PE, as its efficacy has been proven in several studies. It is important to note that rivaroxaban is the only NOAC, which was superior not only to placebo (in the EINSTEIN-Extension study), but also to the active drug (more precisely, aspirin in the EINSTEIN-CHOICE study) in preventing the development of re-thromboembolism. At the same time, the safety profile of rivaroxaban was comparable with both placebo and aspirin.
The possibility to use NOACs in patients with active oncological disease is one of the new positions in modern clinical guidelines for the treatment of PE. As for rivaroxaban, the reason for this was the results of the SELECT-D study, in which rivaroxaban proved to be more efficient in preventing recurrence compared to the standard treatment with dalteparin, having comparable safety indicators in patients with cancer and PE.
Thus, the available data from several clinical studies in patients with PE (in the acute and long-term periods) confirm the possibility of active use of rivaroxaban in this clinical situation.

Oncological disease is one of the most important risk factors for venous thromboembolic complications (VTEC). The treatment of an already confirmed VTEC in an oncological patient is always associated with additional difficulties, which are related to drug interactions, which may affect the efficacy of chemotherapy or the efficacy and safety of anticoagulant therapy. VTEC prophylaxis for oncological patients could take the lead. However, it remains unclear whether medication-based thromboprophylaxis should be given to patients with oncological diseases, as thrombotic risks and risks of hemorrhagic complications vary widely and depend on the type of cancer, the stage of the process and the anticancer treatment provided. The criteria for thromboprophylaxis are clearly defined for hospitalized patients and patients undergoing surgical treatment. However, long-term cancer therapy is mainly carried out in outpatient conditions. Chemotherapy increases the risk of developing VTEC. The new targeted therapy, which is performed independently or in combination with traditional chemotherapy, does not reduce the risk of developing VTEC. Low-molecular
heparins are the «gold standard» for the treatment and prevention of VTEC in cancer patients.
When using LMWH, especially in groups of oncological patients with high thrombotic risk, a reliable decrease in thrombotic events was shown, but bleeding remains the main adverse effect, leveling out the benefit of medical thromboprophylaxis. Another attempt to increase the safety of thromboprophylaxis is the use of direct oral anticoagulants (DOACs). The article deals with modern provisions of medical thromboprophylaxis in patients with cancer, as well as the possibility of using DOACs, in particular apixaban, for the prevention of cancer-associated VTEC.

AIM. Within the framework of outpatient and hospital registers of REGION (REGIster of patients who have undergone acute cerebrovascular accident) to carry out a comparative assessment of demographic and clinical-anamnestical characteristics, medical treatment and outcomes in clinical practice in patients with a combination of undergone acute cerebrovascular accident (ACVA) and atrial fibrillation (AF) in the presence or absence of myocardial infarction (MI) in the medical history.
MATERIAL AND METHODS. Outpatient registers REGION (Ryazan) and hospital register REGION (Moscow) included 1886 patients who have undergone ACVA (age 70.6 ± 12.5 years, 41.9% of men), of them 516 (27.4%) people with AF. Comparison groups included 152 (8.1%) patients with a combination of ACVA, AF and MI in medical history (ACVA + AF + MI group) and 364 (19.3%) patients with ACVA, AF without MI (ACVA + AF without MI group). The presence of cardiovascular diseases (CVD), concomitant diseases, drug therapy and outcomes were analyzed.
RESULTS. In the group of ACVA + AF + MI patients, compared to the ACVA + AF without MI group, the share of patients with AH (100% and 97.2%), IHD (100% and 87.1%), CHD (68.4% and 57.1%), repeated ACVA (36.9% and 23.9%), diabetes mellitus in women (39.5% and 20.4%) was statistically significantly higher. In the comparison groups, the share of smokers (13.3% and 15.5%), patients with burdened heredity of early development of CVDs (2.1% and 1.1%) and hypercholesterolemia (41.1% and 50.0%) did not differ significantly, however, in the group of ACVA + AF + MI, in comparison with the group of ACVA + AF without MI, there was a higher risk on the CHA2DS2-VASc scale (5.26 ± 1.32 and 4.09 ± 1.44; p < 0.001) and HAS-BLED scale (1.91 ± 0.76 and 1.62 ± 0.79; p < 0.01). Patients with AF of REGION register, both with and without MI, had insufficient frequency of proper medical prescriptions for CVDs (46.6% and 38.9% on average), especially prescription of anticoagulants (19.1% and 21.4%), statins in case of IHD (33.6% and 27.4%) and beta-adrenoblockers in case of CHD (39.4% and 35.6%).  During the four-year period of observation, in comparison with post-stroke patients without a history of MI, the mortality rate for all causes was 1.5 times higher (56.6% and 37.6%, p = 0.0001), the incidence of non-fatal MI was higher (2.0% and 0.3%,
p = 0.04). 
CONCLUSION. Patients with a combination of ACVA, AF and MI history are a very high risk group for adverse outcomes observed on an outpatient stage. For these patients it is very important to improve the quality of drug therapy and the effectiveness of secondary prophylaxis.

The review presents data on the frequency of thrombosis detection in the left atrium (LA and/or its appendage (LAA) in patients with non-valvular atrial fibrillation (NVAF), characterizes their connection with antithrombotic therapy and the presence of cardiovascular risk factors. It was demonstrated that thrombosis in LA/LAA is detected in 4-19% of cases. At the same time, data on thrombus frequency in LA/LAA were obtained by examination of small cohorts of patients with AF, who were subjected to transesophageal echocardiography before catheter isolation of pulmonary vein ostia, cardioversion, installation of occluders in LAA. Information about thrombosis frequency in the LA/LAA without these procedures is extremely limited. The frequency of thrombus detection in LA/LAA varies depending on the population studied, the presence of cardiovascular risk factors (diabetes mellitus, metabolic syndrome, arterial hypertension, chronic kidney disease, chronic heart failure) and peculiarities of anticoagulant therapy. CHADS2 and CHA2DS2-VASc scales do not sufficiently predict the presence of thrombus in LA/LAA. For example, at least 50% of patients with LA/LAA thrombus may have a low score on these scales and therefore the risk of heart thromboembolism will be underestimated. According to the facts, adequate anticoagulant therapy does not guarantee the absence of a thrombus in the LA/LAA. Approximately 40% of thrombotic formation cases in LA/LAA do not disappear after 1 year of antithrombotic treatment. 

Left atrial Intramural hematoma (LAIH) is rare complication cardiac invasive procedures. The article analyses the mechanism of formation of this pathology. The case of the LAIH after percutaneous coronary intervention (PCI) is presented. The patient complained of intensive chest pain. When performing ECHO, LAIH was found. LAIH occupied a large part of the cavity left atrium. The conservative supervision of the patient was chosen despite the compession of the left inferior pulmonary vein and symptoms of the acute heart failure. The successful symptomatic treatment was conducted. Taking into consideration the recent PCI dual antiplatelet therapy was not interrupted. LAIH gradually regressed. Five weeks after the desease began, the patient was discharged from the hospital. Nine months after almost full lysis of LAIH was observed. The discussion section is devoted to the issues of diagnosis, the choice of medical tactics, the necessity of surgical treatment and the stop of antitrombotic theatment.

PURPOSE. To evaluate the effectiveness and safety of warfarin therapy using a clinical laboratory model of centralized monitoring of international normalized relationships, and direct oral anticoagulants in patients with atrial fibrillation in real clinical practice.
MATERIAL AND METHODS. In a non-interactive prospective study, 661 atrial fibrillation patients were prescribed oral anticoagulants to prevent cardioembolic complications. The study included patients older than 18 years of age, with creatinine clearance at least 50 ml/min. Рatients were divided into 4 groups: 1 group of 120 people who took warfarin was observed in the conditions of centralized monitoring the international normalized ratio (INR), group 2 – 112 people– was taking Rivaroxaban, group 3 – 106 people– was taking Dabigatran, group 4 – 98 people took Apixaban. Formed 4 groups of patients were comparable in age, concomitant diseases, risks of thromboembolic and hemorrhagic complications.The follow-up period was 2 years from the date of prescribing.
RESULTS. In patients who were observed in the clinical laboratory model of centralized monitoring of INR, the TTR was 69.4%. The groups did not differ in the number of thromboembolic complications (p>0.05). Warfarin had an advantage in the amount of large bleeding - 0.9% versus 3.6% taking rivaroxaban and 3.8% taking dabigatran (p = 0.044 and p = 0.035, respectively) without statistical significance for apixaban.
CONCLUSION. The ratio of efficacy and safety of warfarin therapy can be successfully maintained at a satisfactory level using a centralized monitoring system of international normalized relationships. It allows you to get comparable treatment results with warfarin and direct inhibitors of blood coagulation factors in real clinical practice.

One of the factors determining the frequency of intra- and postoperative complications during operations on the abdominal part of the aorta is anatomical variations and abnormalities of renal arteries and veins. Among the renal structure anomalies the most common is a fused kidney. This anomaly is of great interest in patients with abdominal aortic aneurysm. The article highlights the historical aspects of the study of this group of patients, presents the classification, the features of surgical access, the advantages and disadvantages of each of them, the experience presented in the world literature, as well as the authors’ own experience in carrying out such operations for 30 years in the walls of the A.V. Vishnevsky National Medical Research Institute of Surgery. Peculiarities of surgical tactics in this group of patients were discussed: prevention of such complications as urinary leakage, addition of infection, bleeding, kidney ischemia and postoperative acute renal failure arising after routine intersection of the isthmus of the fused kidney, features in the placement of the prosthesis, data of CT, 3D reconstruction, CT-angiography, intraoperative photos were presented. The main issues that the surgeon faces during surgeries are considered: the choice of surgical access, the choice of the method of renal parenchyma protection, the choice of the method of reconstruction of the renal artery, the decision to preserve or intersect the isthmus of the fused kidney. The aspects of tactics definition in case of both planned and emergency operative interventions are considered. The authors also considered not only the possibility of performing open surgeries, but also X-ray endovascular operations, with a discussion of the advantages and disadvantages of each type of intervention.

The article deals with some aspects of surgical treatment of giant atherosclerotic abdominal aortic aneurysms. Giant aneurysms measuring more than 10 cm in diameter are an extremely rare disorder. A total of 33 observations of surgical treatment of patients with this disorder are described in the English language literature. This article provides epidemiology data based on the publications we studied. Clinical cases described in both domestic and foreign literature are presented and reviewed. A summary table has been created on the basis of the data, which provides comprehensive information on the experience accumulated over the given time in the treatment of gigantic aortic aneurysms. Over 600 surgeries for abdominal aortic aneurysms, of which nine interventions for gigantic aneurysms, have been performed in A.V.Vishnevsky National Medical Research Institute of Surgery. So far, this is the largest experience in surgery of gigantic aortic aneurysms accumulated in one institution. The article presents an analysis of literature data in the context of the results of our own observations. The aspects of choosing the surgical treatment method, the advantages and disadvantages of both open interventions and endovascular operations were considered in detail. The authors described in detail the features of the choice of surgical access, the technique for isolating the aneurysm neck with a detailed analysis of the further course of the operation. Extensive visual material is presented such as CT-, CT angiography scans, intraoperative photographs. The outcomes of interventions are analysed, the mortality rate of post-surgical treatment of giant aneurysms is 0%, there is no significant difference in morbidity in comparison with surgery of smaller aneurysms.

The article describes the clinical observation of LAA thrombosis in a 46-year-old patient with atrial fibrillation that first occurred during taking warfarin; discusses further management of the patient. Due to inefficacy of medical cardioversion (CV) and the need to restore sinus rhythm, electric CV was planned. Before the planned restoration of the rhythm, transesophageal echocardiography was performed and a thrombus in the LAA was detected. Given that the patient had been on adequate warfarin therapy for a long time, it was decided to prescribe a drug from the direct oral anticoagulants group dabigatran etexilate at a dose of 150 mg BID for 8 weeks. The control transesophageal echocardiographic examination showed evidence of complete lysis of thrombus.