On May 21–23, 2017, the Russian New University (RosNOU) took part in the XXI Annual Session of the National Scientific and Practical Center for Cardiovascular Surgery (NNPCSS) named after A. N. Bakulev of the Ministry of Health of the Russian Federation.

The session included a meeting “Sociology and jurisprudence in healthcare” and a scientific and practical seminar “Criminal legal risks of medical practice in cardiovascular surgery: prevention and prevention of negative legal consequences”, organized jointly by RosNOU, NNPCSSKh named after A. N. Bakulev, the association “Right in Health Care” and the Chamber of Lawyers of the Moscow Region.

The chairmen of the meeting “Sociology and jurisprudence in healthcare” were the dean of the Faculty of Law of RosNOU Alexey Tyrtyshny and the head of the Center for Medical and Legal Support of Medical Workers, senior researcher at the Department of Modern Sociology of Moscow State University. M. V. Lomonosova Tatyana Semina.

Tatyana Vasilyevna made a report “Trends in modern healthcare: burnout of a cardiovascular surgeon,” saying that one of the reasons for emotional burnout is the unsettled legal relations in conflicts between doctors and patients.

The following also made presentations at the meeting:

– Georgy Borisovich Romanovsky, head of the Department of Criminal Law, Penza State University, report “Legal basis of telemedicine”;

– Elena Vladimirovna Kunz, Head of the Department of Criminal Law and Criminology, Chelyabinsk State University, report “Current state of defects in the provision of medical care”;

– Leo Antonovich Bokeria, director of the A. N. Bakulev National Research Center for Agricultural Surgery, Vladimir Yuryevich Semenov, chief physician of the Institute of Agriculture and Agricultural Sciences of the A. N. Bakulev Scientific Center for Agricultural Surgery, Igor Nikolaevich Stupakov, deputy director of the A. N. Bakulev National Research Center for Agricultural Agricultural Sciences for general issues, Ivan Aleksandrovich Yurlov , surgeon at the A. N. Bakulev National Research Center for Cardiovascular Surgery, Aleksandr Vladimirovich Vinokurov, leading researcher at the Department of Training and Continuing Education at the A. N. Bakulev National Research Center for Cardiovascular Surgery with reports on the topic “The concept of professional development and the professional standard “doctor - cardiovascular surgeon” ";

– Nadezhda Gennadievna Osipova, Dean of the Faculty of Sociology, Moscow State University named after M.V. Lomonosov with the report “Sociology, jurisprudence and healthcare: the formation of an interdisciplinary categorical apparatus”;

– Goloshchapov-Aksenov Roman Sergeevich, head of the department of X-ray endosurgical diagnosis and treatment of the Central City Clinical Hospital of the city of Reutov, Lakunin Konstantin Yurievich, chief physician of the Central City Clinical Hospital of the city of Reutov, Pigolkin Yuri Ivanovich, head of the Department of Forensic Medicine of the I.M. Sechenov Moscow State Medical University with reports on the topic “Forensic medical criteria for assessing adverse outcomes of X-ray endovascular operations on the arteries of the lower extremities”;

– Alexey Aleksandrovich Tyrtyshny, Dean of the Law Faculty of RosNOU, Svetlana Ivanovna Pomazkova, Head of the Department of Civil Law Disciplines of RosNOU with reports on the topic “Conciliation procedures for resolving disputes between doctors and patients.”

In his report, Alexey Alexandrovich focused on the need to introduce into the practice of providing medical care the institution of pre-trial dispute resolution, based on the experience of foreign countries, but reflecting the realities of modern Russian healthcare.

The dean of the Faculty of Law of RosNOU spoke about the essence of the concept of conciliation (mediation) procedures and the experience of their application. According to him, in Russia, mediation procedures for resolving disputes apply only to private law relations, and public law relations are prohibited by mediation of dispute resolution.

Examples of judicial practice indicate the possible settlement of disputes in an administrative manner, which is a powerful argument in the issue of introducing the institution of pre-trial dispute resolution. The nature of some cases makes it possible in the future to allow such an alternative method of resolving disputes as mediation. For example, in the issue of reimbursement of the cost of technical rehabilitation equipment purchased independently by the patient at his own expense.

The report examined the legal risks of introducing the institution of conciliation procedures, analyzed factors that can reduce risks, as well as directions for implementing the institution of a social ombudsman and mandatory pre-trial dispute resolution. According to the dean of the Faculty of Law of RosNOU, such areas include the resolution of medical disputes using online platforms, cooperation between insurance organizations, medical, patient and legal communities, and the professionalization of the institution of reconciliation.

Alexey Aleksandrovich Tyrtyshny paid special attention to the creation, at the Association of Cardiovascular Surgeons and the National Health League, of a Council for professional qualifications of non-medical personnel - lawyers, personnel officers, IT specialists for the direct implementation of the institution of pre-trial settlement of disputes in the provision of medical care in cardiovascular surgery.

Head of the Department of Civil Law Disciplines of RosNOU Svetlana Pomazkova made a report “Reasonable risk and the limits of its legality. Medical risk." According to Svetlana Ivanovna, one of the most important conditions for the legitimacy of a risk is the focus of the risker’s actions on achieving a socially useful goal - improving the patient’s health. The report noted that the patient has the right to receive information about the diagnosis, methods of care and the associated risks. The head of the department of civil law disciplines of RosNOU also spoke about the assessment of harm caused to the life and health of a patient, as well as cases when causing harm is not unlawful.

Civil law enshrines the so-called “principle of general tort,” according to which any harm caused is unlawful. The exceptions are infliction of harm by lawful actions, infliction of harm with the consent of the victim, and infliction of harm in a state of extreme necessity.

Text - Daria Rozhkova

Owners of patent RU 2289415:

The invention relates to medicine, in particular to gynecology, and concerns the treatment of uterine fibroids. To do this, after selective catheterization, 100 mg of Actovegin in 2.5 ml is injected into both uterine arteries and then the embolisate is immediately administered. The method ensures a painless course of the post-embolization period and reduces the manifestations of post-embolization syndrome.

The invention relates to medicine, in particular to gynecology, and concerns the treatment of uterine fibroids, mainly nodular forms, using the technique of uterine artery embolization (UAE).

Uterine fibroids are among the most common benign tumors of the female genital organs, often detected in women of reproductive age. According to average statistical data, its frequency after 30 years reaches 25-50%. In approximately 1/3 of all visits to gynecological clinics, this tumor is diagnosed (Kulakov V.I., Adamyan L.V., 2000). In 53.3-63.5%, uterine fibroids are diagnosed at the age of 40-50 years; more common among women engaged in mental labor - 60.1%, in contrast to women engaged in physical labor - 9.4% (Gilyazutdinova Z.Sh., 2004). According to the literature, the incidence of uterine fibroids in young women is currently increasing. The problem of treating patients with uterine fibroids is relevant in modern gynecology due to the high frequency of this pathology, as well as its negative impact on the reproductive system and the general health of women.

Currently, treatment of uterine fibroids is carried out using conservative, surgical and combined methods. Conservative therapy consists of prescribing medications (neuroleptics, immunomodulators, general somatic and hormonal), physiotherapeutic, balneological treatment methods. Modern hormone therapy has a large arsenal of medications, the use of which inhibits the growth and reduces the size of uterine fibroids, but after cessation of treatment, relapses of the disease are usually observed. The main treatment method for uterine fibroids remains surgical. The significance of the problem is emphasized by the fact that hysterectomy remains the most common gynecological operation worldwide (52-94% of patients). The scope of surgical intervention can be radical: hysterectomy, or conservative: myomectomy. However, removal of the uterus leads to the development of posthysterectomy syndrome, and removal of myomatous nodes in 30% of cases leads to relapse.

As mentioned earlier, in recent years there has been a “rejuvenation” of uterine fibroids, which creates a need to preserve a woman’s generative function.

Modern diagnostics, selection of an adequate treatment method for uterine fibroids, as well as evaluation of results are relevant at the present time.

In recent years, with the development of endovascular surgery, the method of uterine artery embolization (UAE) has found widespread use in the treatment of uterine fibroids. UAE is a minimally invasive, non-surgical organ-preserving procedure that is a sufficient alternative to surgical treatment.

UAE has been used since 1979 to stop severe postpartum and post-traumatic uterine bleeding. In 1990, Jacques Ravina, using uterine artery embolization for the preoperative preparation of women with uterine fibroids in the presence of hypervascularized tumors, noted that in some patients, as a result of the manipulation, the main symptoms were relieved and did not require surgical treatment. In September 1995, Jacques Ravina published an article for the first time in The Lancet on the treatment of uterine fibroids using UAE. Currently, the UAE method is widely used in medical institutions in the USA, Europe, Asia and the Middle East. In 1996, EMA received FDA approval in the USA, and in 1998, by order of the Ministry of Health of the Russian Federation, it was included in the list of approved endovascular interventions. More than 300,000 UAE procedures have been performed in Europe and the USA. Currently, around the world, including leading clinics in our country, more than 100,000 embolizations are performed annually.

In the pathogenesis of uterine fibroids, as is known, neoangiogenesis, which is activated during tumor growth, plays an important role. As the myometrium hypertrophies and the tumor mass grows in the capillary network of the myometrium adjacent to the myomatous nodes, the architectonics of the capillary network characteristic of normal myometrium - its loop-cellular pattern - completely disappears, the capillary network becomes shapeless, chaotic, uneven filling of blood vessels appears in them, stasis, capillaries often acquire a tortuous course. The angioarchitecture of the capillary network of the “intact” myometrium in some cases retains its normal appearance (Savitsky G.A., Savitsky A.G., 2003).

The vessels of the perifibroid plexus - a chaotic vascular network surrounding the fibroid at the periphery, are represented by arcuate and radial arteries that go around the node and give off a weakly expressed feeding capillary network into the tumor. Myoma vessels have a diameter of up to 0.5 mm, which is several times larger than the diameter of the arteries of normal myometrium. During UAE, injected polyvinyl alcohol (PVA) particles of a certain size (300-700 microns) migrate with the bloodstream only to the peripheral branches of the uterine arteries of the corresponding diameter and accumulate in them, causing segmental blockage of blood vessels. In this case, the distal parts of the vascular bed of the unchanged myometrium remain passable and after a short period of time begin to be supplied with blood through collateral vessels, which helps to gradually eliminate ischemia of the organ tissue. Of great importance in this mechanism are the anastomoses between the ovarian branches of the uterine artery and the ovarian arteries themselves, extending from the aorta. The capillary branches of the myomatous nodes themselves do not have anastomoses at the end sections, so PVA particles entering them lead to persistent blockage of the feeding vessels, which determines the selective effect of endovascular intervention and its effect only on the fibroid itself (Dobrokhotova Yu.E., Kapranov S.A. ., Bobrov B.Yu., Alieva A.A., Grishin I.I.). After the introduction of embolization particles, the fibroid loses its blood supply and is replaced by connective tissue - fibrosis, which leads to a significant reduction and/or disappearance of the fibroid and its manifestations.

The closest analogue of the proposed method is the method of treating uterine fibroids by selective embolization of the uterine arteries, proposed by Jacques Ravina (Ravina J.H., Arterial embolization to treat uterine myomata. Lanset 1995; 346: 671-672). Under local anesthesia of the skin in the upper third of the thigh, a transfemoral approach under X-ray television control is used to perform alternate catheterization of the uterine arteries, after which an angiogram is performed, followed by the introduction of embolic particles of polyvinyl alcohol (PVA) into the fibroid vessels, which leads to complete occlusion of the vascular bed and the main artery.

Catheterization of the uterine arteries is always carried out from both sides, since the blood supply to even one node can be carried out from different vessels, utero-ovarian anastomoses of different types (B.Yu. Bobrov, S.A. Kapranov, Yu.E. Dobrokhotova, I.A. Krasnova, N.A. Shevchenko, D.D. Alieva, V.B. Aksenova. Endovascular surgery of the heart and blood vessels, p. 198).

UAE causes ischemia of the fibroid, resulting in acute hypoxia and necrotic changes in the tissue. This leads to pain of varying intensity, bloody discharge from the vagina, increased body temperature, weakness, malaise, dysfunction of the bladder and intestines, changes in blood counts, that is, to the development of “post-embolization syndrome” (Yu.E. Dobrokhotova, S. A. Kapranov, B. Yu. Bobrov, A. A. Alieva, I. I. Grishin, Russian Bulletin of Obstetrician-Gynecologist, 2, 2005, 44-49). Depending on the severity of its symptoms, analgesic, infusion, anti-inflammatory, and antibacterial therapy is carried out.

The purpose of the invention: to reduce these complications by preliminary increasing the parenchymal blood flow of the myomatously changed uterus before UAE, which promotes better embolization due to the penetration of PVA particles into the previously spasmed capillaries of the fibroids and, accordingly, reducing ischemic areas in it and improving blood supply in healthy myometrial tissues, which prevents the development of gross morphological changes in the uterus, leading to post-embolization complications. To achieve the effect of increasing parenchymal blood flow, we used Actovegin in an injection solution of 200 mg/5 ml, which was divided into equal parts and injected 100 mg/2.5 ml into each uterine artery, while counting on the improvement in blood circulation that Actovegin provides , as well as on its metabolic effect in the myometrium, namely activation of aerobic oxidation processes, increased utilization of oxygen by tissues, activation of enzymes of the antioxidant defense system, increased tissue tolerance to hypoxia.

Modified EMA technique.

The method is carried out as follows:

Under local anesthesia, a puncture of the femoral artery is performed in the upper third of the right thigh;

A pig-tail catheter is advanced to a level slightly below the renal arteries and pelvic angiography is performed to clarify the anatomy of the uterine arteries;

A Roberts (COOK) or Cobra catheter is inserted into the contralateral uterine artery and selective catheterization of the uterine artery is performed under radiotelevision control;

A contrast agent is administered and subsequent angiography is performed to visualize the uterine vessels;

100 mg (2.5 ml) of Actovegin is injected into the uterine artery;

An embolisate is introduced, for example, polyvinyl alcohol (PVA 500 from COOK: 500-710 microns) mixed with a contrast agent in the amount necessary to completely stop antegrade blood flow through the artery;

The Roberts catheter is placed in the ipsilateral artery and the above manipulation is performed on the opposite side.

This technique: administration of Actovegin 2.5 ml/100 mg on each side was effective regardless of the size and location of the fibroids.

Since 2004, we have been carrying out embolization of the uterine arteries for the treatment of uterine fibroids; since 2005, UAE has been carried out in our modification using Actovegin.

Treatment with UAE using our modified method using Actovegin was carried out in 11 patients; 20 patients formed the control group, who underwent standard UAE. UAE was performed in patients with the following types of uterine fibroids:

General increase from 6 to 15 weeks of the pregnant uterus;

The presence of one node and with multiple nodes;

In combination with adenomyosis;

Intermuscular location of nodes and nodes with centripital and subserous growth;

The presence of a node with a power failure in it.

The course of the post-embolization period after standard UAE was characterized by a variety of post-embolization symptoms: abdominal pain, hyperthermia up to 38°C and above; disruption of the gastrointestinal tract; symptoms of acute abdomen; menorrhagia; leukocytosis.

When performing UAE using a modified method with Actovegin, a favorable course of the post-embolization period was achieved: pain was insignificant or absent; increase in body temperature no higher than 37.0-37.5°C; no gastrointestinal dysfunction was noted; discharge from the genital tract is scanty and noted only in 2 patients; the number of leukocytes was up to 8.0 to 11.5*10^9/l, the patients' hospital stay after UAE was 1-2 days.

Patients, both experimental and control groups, were under dynamic observation: examination and ultrasound of the pelvic organs were carried out after 1, 3, 6, 9 months. The reduction in the size of uterine fibroids occurred equally in both groups.

Thus, when using a new modified UAE technique using Actovegin, a practically painless course of the post-embolization period was noted. The use of the above technique ensured a significant reduction in the manifestations of post-embolization syndrome while maintaining the effectiveness of this manipulation in terms of reducing the size of fibroids and its manifestations.

Clinical examples.

Patient 3., 47 years old. Case history No. 919. DS: Uterine fibroids, enlargement of the pregnant uterus up to 8 weeks with centripital growth of the node (node ​​size up to 5.0 cm in d).

02/01/05: UAE was carried out in this way: selective catheterization of the uterine arteries was carried out using a transfemoral approach, followed by the introduction of 2.5 ml/100 mg of Actovegin under fluoroscopic control and immediately the introduction of PVA-500 (COOK). In the post-operative period, there was no pain symptom, body temperature remained at normal levels, blood test showed L - 5.3*10^9/l, fibrinogen was normal. Ultrasound monitoring on the day of discharge on the 3rd day - reduction in the size of the node from 5.0 cm to 3.2*3.0 cm. Observation for 9 months: size of the node 2.5*2.2 cm, normalization of the menstrual cycle, improvement in general well-being.

Patient U., 26 years old. Case history No. 11099. DS: Multiple uterine fibroids enlarged to 15 weeks of the pregnant uterus. Chronic anemia stage II. An ultrasound examination and gynecological examination revealed many nodes located in all layers and on all surfaces of the uterus. 10.20.05: UAE using a modified method with Actovegin: selective catheterization of the uterine arteries was performed through transfemoral access, followed by the introduction of 2.5 ml/100 mg of Actovegin under fluoroscopic control and immediately the introduction of PVA-500 (COOK). P/o period with minor pain syndrome (relief with a single injection of tramadol and no-shpa), t up to 37.3°C, on the first day - weakness, dizziness against the background of normal blood pressure, in the blood test L - 11.5 * 10^ 9/l, fibrinogen - 2.68. Ultrasound after 3 days: reduction in the size of the uterus up to 13 weeks.

Patient 77., 37 years old. Case history No. 11427. DS: Uterine fibroids 8 weeks, malnutrition of the node. She was admitted on October 25, 2005 with complaints of nagging pain in the lower abdomen. According to ultrasound and examination, the patient was diagnosed with a malnutrition of the myomatous node (interstitial node 4.3*3.5 cm along the left uterine rib). On day 1, the patient received 200 mg of Actovegin intravenously in 200.0 saline. solution; 2.0 2% papaverine; 400.0 5% glucose solution; 100.0 metrogil; 0.1 doxycycline per 200.0 sa. solution. A day later, on October 27, 2005, against the background of the disappearance of pain, UAE was performed using a modified method with Actovegin: selective catheterization of the uterine arteries was performed through transfemoral access, followed by the introduction of 2.5 ml/100 mg of Actovegin under fluoroscopic control and immediately the introduction of PVA-500 (COOK). In the post-operative period, the therapy was continued. Pain syndrome is insignificant, diclofenac suppositories were used rectally once a day, body temperature is normal, blood test shows L - 7.1*10^9/l, fibrinogen - 3.26. Ultrasound 10.29.05: nodule 3.5*2.8 cm, clear contours. Discharge 10/29/05 - 2 days after UAE.

Conclusion.

For the first time, an original modification of uterine artery embolization in the treatment of uterine fibroids was proposed, developed and used in clinical practice. The method of embolization of the uterine arteries with the preliminary administration of Actovegin allows one to achieve a more favorable course of the post-embolization period: painless or with minor pain; reduction of postoperative bed days; reducing the number of medications used without compromising the effectiveness of the manipulation and its immediate and long-term treatment results.

A method of treating uterine fibroids by embolization of the uterine arteries, characterized in that after selective catheterization, 100 mg of Actovegin in 2.5 ml is injected into both uterine arteries, and then the embolisate is immediately administered.

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At the end of last year, a department of x-ray endovascular diagnostic and treatment methods was opened in Reutov (a set of intravascular interventions performed on blood vessels through percutaneous access under the control of radiation imaging methods). And now it has been created on the basis of the department - for the first time in the Moscow region! — a unique operation with a name that is difficult for non-medics: endoprosthesis replacement of a saccular aneurysm of the aortic arch with a special stent graft. We talked about the new opportunities for Reutov healthcare with the head of the department of x-ray surgical methods of diagnosis and treatment of the Reutov Central Clinical Hospital, the chief specialist of the Ministry of Health of the Moscow Region for x-ray endovascular diagnostics and treatment, Roman Goloshchapov-Aksenov.

— Roman Sergeevich, on December 27 last year, an X-ray endovascular diagnostics department was opened at the Central City Clinical Hospital. How do you, one of the leading experts in this field, assess the significance of the event?

“It is impossible to imagine a modern multidisciplinary clinic today without such a department. This is a fundamentally new, actively developing area of ​​medicine, expanding the capabilities of diagnostic techniques to the active implementation of therapeutic operations that significantly improve the quality of life of patients. Such departments need to be replicated, and X-ray surgery should be brought as close as possible to the patient, so that the period of time from the onset of a life-threatening disease to the performance of the only possible effective operation is minimal.

— What are the main advantages of this method?

— Minimal surgical intervention under local anesthesia, easy repeatability of procedures without much additional risk for the patient, reducing the time patients spend in hospital, and therefore reducing the cost of treatment, improving the quality of life of patients and high cost-effectiveness of medical care. In addition, surgery may be offered to patients at high risk.

The main feature of X-ray endovascular surgery is that all operations, regardless of the disease, are performed inside the vascular bed, without incisions and under the control of X-rays, and surgical access is carried out using a special needle. The length of hospitalization of patients during planned intravascular operations often does not exceed one day. Thus, the quality of life of patients is maintained at a high level. The methods of X-ray endovascular surgery are universal and have found application in almost all areas of medicine: cardiovascular surgery, cardiology, neurology, neurosurgery, urology, gynecology, oncology, liver and gastrointestinal surgery. X-ray endovascular surgeons restore the patency of the vessel, as in the treatment of acute myocardial infarction or ischemic stroke.

— Roman Sergeevich, on October 2, at the Reutov Central Clinical Hospital, an operation was performed to replace a saccular aneurysm of the aortic arch with a special stent-graft. What is unique?

— Firstly, until recently, performing such operations was impossible in any of the hospitals in the Moscow region, both at the municipal and federal levels. In the Moscow region there are well-equipped military hospitals, large federal centers, a regional institute named after. Vladimirsky - MONIKI, however, to perform a hybrid operation on the aorta, you need not only modern equipment, but also a team of highly qualified specialists - cardiovascular surgeons, specialists in X-ray endovascular diagnostics and treatment, as well as resuscitators.

— Please explain what a “hybrid” operation is?

— Hybrid surgery combines the capabilities of traditional surgery and X-ray endovascular surgery. It is performed by a cardiovascular surgeon and a specialist in X-ray endovascular diagnostics and treatment. This modern technology is used for stenting an aortic aneurysm, the largest arterial vessel in the human body, and for implanting an artificial aortic valve without the use of artificial circulation. The technology for installing endoprostheses is no different from traditional stenting of arteries, only to insert the prosthesis into the vascular bed, it is not a point access to the arteries that is required, but a minimal surgical incision. To install a special stent in the aortic arch, from which the arteries supplying blood to the brain arise, it is necessary to first perform a bypass operation of these arteries. The danger of an aortic aneurysm lies in its rupture with a high risk of fatal outcome. The difference between a stent-graft and a conventional stent is that its cell is covered with a special vascular prosthesis, which, after implantation of the stent, covers the aneurysm and turns it off from the blood circulation. The peculiarity of the localization of an aneurysm in the aortic arch is that arteries supplying blood to the head and upper extremities arise from this segment of the aorta, and blocking the lumen of the latter together with the aneurysm can lead to stroke and ischemia of the upper extremities.

- A little uneasy. Tell me, was the operation successful?

— Yes, the very next day the 64-year-old patient could get up. Currently, the patient's condition is satisfactory and he is preparing for discharge. As for the operation itself, the first stage was bypassing the arteries of the aortic arch, it was performed by Doctor of Medical Sciences, Professor Roman Komarov, an employee of the Clinic of Aortic and Cardiovascular Surgery of the First Moscow State Medical University. THEM. Sechenov. I performed stenting of the aortic arch.

— Will similar operations be carried out at the Reutov Central Clinical Hospital in the future?

— Hybrid technologies are expensive. In Russia, to date, only about 50 transcatheter aortic valves have been implanted, stenting of the aortic arch is rare, and somewhat more operations have been performed to stent an abdominal aortic aneurysm. In Europe and the USA, every patient diagnosed with an aortic aneurysm is considered a candidate for aortic stenting or a hybrid surgical treatment option. In the European Union, this technology is financially supported by the state, and in Germany and France there are also special federal programs. I hope that our clinic will be included in such a program.

Some statistics
Myocardial infarction: in 98.5% of cases, it is possible to stop the pathological process of the necrocardiac muscle with the timely use of X-ray surgery methods.
Ischemic stroke: mortality is reduced from 40% to 27.2% with timely administration of a thrombolytic drug into a thrombosed intracerebral artery.
Critical ischemia of the lower extremities: in 91% of cases, amputation can be avoided thanks to X-ray endovascular restoration of blood flow through the arteries of the leg.
Uterine fibroids: 99% of cases can be cured by blocking blood flow through the uterine arteries and avoiding removal of the uterus or fibroids.

You can watch the RTV video about the first aortic stenting operation in the history of the Moscow region, which was carried out in Reutov.