The anesthetic management and the specific features of perioperative management in cases of nephrectomy with thrombectomy from the inferior vena cava in patients with renal cell cancer

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INTRODUCTION

Renal cell cancer takes the second place by the incidence rate among the malignant neoplasms of the urogenital system, being in the top ten (4.9%) of the most commonly diagnosed malignant neoplasms in Russia. In 2023, there were 21,548 newly diagnosed cases of malignant kidney neoplasms, and the standardized morbidity rate for renal cell cancer was 10.14 per 100.000 of population [1]. Up to 25–30% of the cases of renal cell cancer are complicated by the tumor thrombosis of the renal vein and of the inferior vena cava, which in 1% of the cases reaches the right atrium [2].

The choice of surgical intervention in the treatment of renal cell cancer with tumor thrombosis of the inferior vena cava (TT IVC) depends mostly on the thrombus location level and, generally, includes the radical nephrectomy with the thrombectomy from the inferior vena cava (IVC) [3].

According to the classification by the Mayo Clinic, four levels of TT IVC are taken into account: level 0, in which the thrombus is limited by the renal vein; level I — the thrombus is spreading to the IVC by not more than 2 cm above the level of the renal vein; level II — the thrombus is spreading to the IVC by more than 2 cm above the level of the renal vein, but not reaching the level of hepatic veins; level III — the thrombus is at the level of the hepatic veins or higher, but below the diaphragm; level IV — the thrombus is spreading into the supradiaphragmatic IVC or into the right atrium.

Surgical interventions, especially in cases of level III or IV tumor thrombosis according to the Mayo classification, are technically complex and accompanied by the high risk of complications at all the stages of examination and therapy [4, 5]. In recent years, thanks to the constant enhancements of surgical approaches and of the instrumental basis, as well as due to the usage of artificial intelligence technologies, the radical methods of nephrectomy with IVC thrombectomy become more accessible and safer, however, the levels of complications and hospital mortality rates still remain high [6–8].

In the modern literature, the experience of anesthetic management and perioperative management for this cohort of patients is represented by predominantly single case reports or case series. Currently, there is no unified and commonly accepted algorithm for managing such patients [5, 9–17]. Systemizing the modern knowledge on the anesthetic approaches, the peri- and intraoperative risks, the methods of prevention, the timely diagnostics and treatment is necessary for increasing the survival rate and for improving the quality of the patients’ lives [18].

PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS OF TUMOR THROMBOSIS

Tumor invasion into the venous lumen occurs via the enzymatic destruction of the components of the IVC wall, mediated mainly by metalloproteinases, produced by the tumor cells, by fibroblasts and macrophages, participating in the immune response to the tumor presence. The basis of the active growth of tumor thrombosis is the presence of proprietary blood supply in the intraluminal tumor masses. The surface of the intraluminal tumor is covered in fibrin, which often promotes to the formation of blood clots [19].

Generally, the disease manifests with macrohematuria and pain in the lumbar area. Often, the tumor thrombosis has a long-term asymptomatic course, manifesting in some cases with symptoms of venous hyperemia, such as the swelling of the lower limbs, varicocele, dilation of the veins in the anterior wall of the abdominal cavity and the Budd-Chiari syndrome. The clinical signs of IVC obstruction are found quite rarely due to the development of collateral circulation. TT IVC levels III–IV may induce a short-term loss of consciousness, shortness of breath (upon the flotation in the right atrioventricular foramen) and the impairment of the cardiac rhythm. Some patients develop signs of chronic cardiac failure: tachycardia, shortness of breath, congestive signs in the lungs; the edematic syndrome can manifest as the cavity edemas, pastosity and swelling in the soft tissues. The relatively rare (0.9–2.4%) complication of TT IVC, related to the spontaneous fragmentation of the thrombus apex, is the pulmonary artery thromboembolism [20, 21].

ANESTHETIC MANAGEMENT

Preoperative preparation

For selecting the treatment tactics, a detailed information is needed on the spreading of the tumor process and on the functional reserves of the organism. For this purpose, before surgery, a pre-determined set of examinations is needed, requiring the involvement of the specialists of various profiles. TT IVC patients are characterized by an especially high risk of hemorrhages, hemodynamic instability with the development of hemodynamical complications in somatically compromised patients (classes III and IV of the Goldman scale), in which one can expect the development of myocardial infarction types 1 and 2 [22], with this, it is expected that, the higher is the thrombosis level, the higher are these risks. In the patients of this cohort, clinically significant anemia is especially often diagnosed, requiring the preoperative correction and preparation of the reserves for intraoperative compensating the blood loss (donor erythrocyte suspension and fresh-frozen blood plasma, albumin solutions, the application of the equipment for the intraoperative blood re-infusion). Taking into consideration the high probability of intraoperative myocardial ischemia related to the hemodynamic instability and significant blood loss in the settings of possible coronary abnormalities, in such patients, it is practical to conduct the coronary angiography (CAG) for the purpose identifying or evaluating the dynamic changes of the stenoses in the coronary arteries. In case of detecting the significant lesions in the coronary circulation, re-vascularisation of the myocardium is to be performed [6, 23].

The risk of thromboembolic complications in TT IVC patients is especially high not only due to the fragmentation of the tumor thrombosis itself, but also due to the secondary thrombosis in the system of deep veins of the lower limbs. Before surgery and in the absence of contraindications, low molecular mass heparins are prescribed at the therapeutic dose. Due to the high risk of thrombus in-growth, routine installation of the cava-filter (a trap for the thrombi) should be avoided: the installation can be suggested in case of continuous episodes of pulmonary embolism, despite the use of anticoagulants, or in case of absolute contraindications to anticoagulant therapy. Other procedures include the ultrasound examination of the veins in the lower limbs for the purpose of diagnostics and evaluating the deep vein thrombosis [24–26].

All the patients with “high” (levels III and IV acc. to the Mayo classification) IVC thromboses, within the framework of the preoperative preparation, must obligatorily undergo echocardiography: such an examination allows for visualizing the thrombus head, for the dynamic detection of its mobility relative to the walls of the supradiaphragmatic segment of the IVC and the endocardium, the spreading of the thrombus from the right atrium into the ventricle, for evaluating the structure of the thrombus, as well as for non-invasively evaluating the pressure in the pulmonary artery [27].

One should also keep in mind the paraneoplastic toxic-anemic syndrome, related to the active oncology process, the hypovolemia and the impaired functions of the kidneys and of the liver. In particular, the depression of the renal functions can be caused by the decrease in the volume of the functioning parenchyma in cases of renal cell cancer (the course with signs of tubulointerstitial nephritis and canalicular necrosis) or tumor-associated blockage of the vein in the contralateral kidney. The tumor masses blocking the orifices of the main hepatic veins, lead to the increase of the venous pressure within the hepatic parenchyma, to the compression and stasis in the intrahepatic bile ducts and, as a result, to the impaired functions of hepatocytes [6]. The damage of hepatocytes resulting from the specific features of the liver blood supply, has the manifestations typical for hepatitis with signs of intoxication, decreased synthetic functions of the liver and coagulopathy, which aggravates the course of the oncological process.

According to clinical recommendations, patients with kidney cancer are advised to undergo laboratory examination at the extent of the clinical hematology panel (extended), the general clinical blood biochemistry panel, the extended panel of coagulation tests, the determination of the concentration of electrolytes (with paying attention to the levels of ionized and total calcium).

The patients, in which the use of intraoperative artificial circulation is planned, are recommended to undergo magnetic resonance tomography of the brain for the purpose of detecting the metastases that can lead to the intracerebral hemorrhage during the complete heparinization [27].

In case of chronic diseases, the preoperative period should include a consultation by the dedicated specialist with the determination of further follow-up tactics for the patient.

Intraoperative management of the patient

Combined and coupled anesthesia is used during the nephrectomy with IVC thrombectomy regardless of the thrombus location level. In case of level I–III thrombi, epidural anesthesia is also used at the level of Th7–Th8 as a component of multimodal analgesia, both in the intra- and in the postoperative period.

In case of level IV thromboses, the practicability of using epidural anesthesia remains disputable due to the high risk of developing the epidural hematoma caused by the necessity of complete heparinization during the artificial circulation. The role and the efficiency of high-level epidural anesthesia (Th2–Th5) for such interventions is not disclosed neither in the national nor in the foreign literature and it requires further research [28, 29], however, beyond question are its positive sides within the framework of improving the coronary circulation, the respiratory functions and the early rehabilitation after conducting the sternotomy. The technically correct conduction of this component of anesthetic support is considered safe [30, 31]. The reviews of the scientific literature on the problem of high epidural anesthesia in the settings of surgical interventions with using artificial circulation were not found in the accessible literature.

The optimal body temperature of the patient during nephrectomy with thrombectomy from the IVC still remains a discussible issue. Maintaining normothermia is necessary for the normal physiological functioning of the organs and for maintaining the function of blood clotting. It was proven that hypothermia and hypoperfusion increase the risk of perioperative hemorrhages and of the need for blood transfusions [17, 31] and, together with high risk of perioperative hemorrhages, induce the development of metabolic acidosis, which increases the coagulopathy and can become the reason of disseminated intravascular coagulation (DIC) syndrome. Maintaining the body temperature within the range of 36.5–37.4°С as the most comfortable is safe from the point of view of the possible development of complications related to unintended hypothermia. Intraoperative normothermia is assured by the use of convectional heating systems, of the flow-through thermostats with the constant control of the patient body temperature in the projection area of the lower third of the esophagus [28, 32]. A number of authors recommend maintaining the patient’s temperature within the range of mild hypothermia, which, on their opinion, decreases the blood loss, for it decreases the aggregation of platelets and the activity of enzymes in the cascade reactions of blood clotting [33, 34].

As the intraoperative monitoring, the invasive/non-invasive measurement of blood pressure is used; as well as the electrocardiography, pulse oximetry, capnography and thermometry; other methods include the control of gases in the arterial blood and intraoperative thromboelastography, transesophageal echo-cardiography, intraoperative ultrasound examination, cerebral oximetry (INVOS technology) and the control of diuresis rate [6, 23, 28, 35].

Within the structure of the complications, the predominant one is the massive blood loss (up to 60%), which can induce hemorrhagic shock (0.9%) and acute coronary syndrome (0.3%) [6]. In case of massive blood loss, a practicability remains for the mechanical methods for auto-blood transfusions (Сell-Saver device) for the purpose of decreasing the transfusion burden with donor blood components and the complications related to it. Thrombectomy is often accompanied by significant variations of hemodynamics, which requires the active vasopressor support and infusion therapy [23].

One of the methods of conducting the surgical intervention in the settings of complete vascular isolation without the impaired hemodynamics is the artificial circulation, providing the hemodynamic stability and bloodless surgical field, and, hence, wider possibilities for revising and for the safety of surgical manipulations. The artificial circulation system also provides the possibility of compensating the intraoperative blood loss, of decreasing the need for allogenic blood transfusions [36, 37]. However, the method is accompanied by certain risks: systemic anticoagulation, coagulopathy, neurological complications and impaired functions of the kidneys affect the survival, the prognosis and the costs of hospitalization [4].

The traumaticity of the artificial circulation prompts to extremely selective choosing the candidates for conducting the procedure. Currently, a number of methods was suggested that allow for withdrawing from artificial circulation: the technique of venous-venous stenting, the milking (pressing out), the dislocation of thrombus using the Foley catheter etc. [5, 9, 13, 38–40], however, the fixated thrombi of levels III–IV, the predicted massive hemorrhage, the hemodynamic instability, the floating thrombi with high risk of fragmentation remain, according to the opinion of many investigators, an indication for implementing the artificial circulation [36, 37].

For preventing the formation of thrombi within the pipelines of the artificial circulation equipment, it is necessary to constantly control the time of active blood clotting, the minimal safe value for which is 400 seconds. The other “side of the coin” — the massive hemorrhage caused by the total heparinization of the organism — is also a life-threatening complication of artificial circulation. The contact of blood with air and tissues, the foaming and the introduction of foreign particles promote the activation of systemic inflammatory response, the coagulation cascade and the fibrinolysis, which also hampers the hemostasis [41].

The aspiration of the large volume of blood from the IVC into the pipelines of the artificial circulation equipment and the unintended hemodilution create the opportunities for developing the organ dysfunctions. The damaging of the blood cells upon the aspiration and upon the passage along the pipelines of the artificial circulation equipment may lead to the post-perfusion hemolysis, which in turn, can induce the acute kidney damage and the acute respiratory distress-syndrome. It was proven that the blood pressure decrease to less than 80 mm.Hg. is less traumatic for the blood cells, hence, maintaining the proper level of pressure drop decreases the probability of damaging the blood corpuscles [42]. Besides, it is possible to intraoperatively use the hemofiltration column and to administer the donor erythrocyte-containing medications into the pipelines of the artificial circulation equipment for the purpose of correcting the hypervolemia and severe anemia resulting from the hemodilution [43, 44].

For the prevention of acute kidney damage caused by using the artificial circulation equipment, it is important to maintain an adequate cardiac output, to suppress the spasm of kidney vessels, to decrease the need for oxygen by means of moderate cooling and to use diuretics according to indications [45, 46].

Also, the importance of intra-operative ultrasound examination should be noted, which provides the possibility of not only evaluating the length and the structure of the thrombus, but also of reflecting the changes upon the compression of the renal hilum, the presence/absence of thrombus fixation to the venous wall, as well as of evaluating the non-tumor vascular component of the thrombus.

Intraoperative transesophageal echocardiography right after the induction of anesthesia allows for actualizing the data on the location of the tumor thrombosis; for evaluating its fragility and adhesion, as well as the degree of contraction; for detailing the level of IVC compression and the volemic status of the patient [35, 47]. Besides, the method allows for correcting the tactics of anesthetic support, for defining the functional status of the myocardium, the presence of abnormalities and the degree of perfusion at the real-time mode, which is especially important for critical conditions in severe patients, also helping to select the optimal volemic load, to evaluate the pre- and the afterload, the status of the valvular structures in the heart at the real time mode, to adjust the anesthetic medications and to predict the possible complications [35, 47].

Postoperative management of the patient

In case of adequate hemostasis within the first hours after surgery, anticoagulation is initiated with low molecular mass heparins at the therapeutic dosage with taking into consideration the glomerular filtration rate. Low molecular mass heparins are the drug of choice with the recommended gradual transition to the oral anticoagulants and with the duration of anticoagulant therapy being 3–6 months. It is practicable to use the unfractionated heparins due to the more comfortable control of therapeutic anticoagulation using the active clotting time and the activated partial thromboplastin time at the early post-surgery period with further transition to oral anticoagulants [48].

Taking into consideration the severity of the conducted surgery, during the postoperative period a multicomponent intensive therapy is implemented for the main disease and for the occurring complications, as well as for the concomitant diseases: multi-modal analgesia (epidural anesthesia, blockades of nerve trunks and plexuses, small dosages of narcotic analgesics in combination with non-steroid anti-inflammatory drugs of predominantly central action), the rational antibacterial therapy, the correction of anemic syndrome and the symptomatic therapy.

The necessary procedures also include the echocardiography (especially in case of “high” tumor thromboses), the ultrasound duplex scanning of the veins in the lower limbs, the ultrasound examination of the abdominal cavity organs and of the retroperitoneal space (with detecting the circulation in the contralateral kidney, in the renal vein and in the IVC; with the evaluation of free fluid presence) not less frequent than 1 time a week after surgery.

COMPLICATIONS OF THE POSTOPERATIVE PERIOD

The rates of developing complications at the early post-surgery period after nephrectomy with IVC thrombectomy reach 93%. Surgical complications grade I according to the classification by Clavien-Dindo were reported in 6.8–10% of the patients, grade II — in 10–75%, grade III–V — in 11–22.3%. The mortality at the early post-surgery period is, generally, caused by the multi-organ insufficiency, by venous thromboembolic complications, by the myocardial infarction and infectious complications. The hospital mortality rates, according to the data from various authors, vary within the values of 3.3–10% [6–8].

The significant predictors of perioperative complications and of the postoperative mortality are acknowledged to be the age of the patient, the high degree of comorbidity, the preoperative intoxication syndrome and the high spreading degree of tumor thrombosis [6, 8, 49, 50]. The extent of surgical blood loss, the rates of transfusions, the rates of developing complications during the early postoperative period and the duration of hospitalization increase with the length of the thrombi [49].

Within the structure of the complications developing in the early postoperative period, the coagulopathies and the hemorrhages prevail (10.0–66.0%), followed by the complications on the side of the cardiovascular system (37.8–57.0%), by the functional organ insufficiency (0.7–53.9%), infectious complications (3.7–23.0%) and the pulmonary artery thromboembolism (3.0–6.8%) [6, 49, 51–54].

Complications caused by the impaired blood clotting

Coagulopathies, hypocoagulation or disseminated intravascular clotting syndrome, generally, develop in patients having a history of massive blood loss and they can become complicated by clinically significant anemia, by the development of hematomas and their further infecting, as well as by the acute cerebrovascular events of the hemorrhagic type. The control of hemostasis and hemodynamics, of the red blood parameters along with the competent and timely prescription of anticoagulant therapy allow for preventing the development of these conditions. Oftentimes, non-complicated coagulopathies may resolve in a conservative manner (hemostatic therapy), however, in a number of cases (up to 3%), repeated surgical intervention is required. In cases of acute impairment of the cerebral circulation, intensive therapy is arranged, according to the indications — followed by the craniotomy with draining the intracranial hematoma [6].

Venous thromboembolic complications, including the phlebothromboses, re-thrombosis of the IVC and pulmonary artery thromboembolism can be caused both by the local (for example, incomplete removal of tumor masses from the IVC, damaging the vascular wall) and the systemic (hypercoagulation, associated with impaired rheologic properties of the blood, slowed circulation with a background of limited mobility at the early post-surgery period) factors. The proven risk factors of developing the pulmonary embolism are the cardiac rhythm disorders, which emphasizes the significance of cardiac monitoring and of the correction of arrythmias.

Myocardial infarction at the early post-surgery period after nephrectomy with IVC thrombectomy is more characteristic for patients with atherosclerotic lesions in the coronary vessels, which determines the necessity of arranging the coronary angiography and, according to the indications, re-vascularization of the myocardium within the framework of the preoperative preparation [45].

Organ insufficiency

Nephrectomy with IVC thrombectomy, especially in cases of level III–IV thromboses, bear the high risk of developing the functional insufficiency in separate organs and systems, as well as the risk of multi-organ insufficiency syndrome at the early post-surgery period. Within the structure of such complications, the expectably predominant is the acute kidney damage (up to 53.9%), which, generally, with a greater or lesser severity degree develops during the first 24 hours after surgery. The acute kidney damage is far from always becoming an indication to the renal replacement therapy (according to the data from various authors, only in 1.0–3.9% of the cases). The pathogenesis of these complication is, most probably, based on the decreased volume of circulating blood, on the changes in the renal hemodynamics and on the decreased volume of the functioning renal parenchyma. Based on the this, intraoperatively and during the postoperative period, it is necessary to thoroughly control the urine color, the diuresis, the blood levels of creatinine, urea and electrolytes, as well as to timely and justifiably employ the necessary measures (increasing the volume of circulating blood, controlling and normalizing the hemodynamic parameters, arranging the diuretic therapy and, according to indications — renal replacement therapy) [6, 45, 52].

Cardiac insufficiency develops in an average of 7.1% of the patients, approximately in three (0–12) days after surgery. Generally, cardiac insufficiency is a component of the multi-organ insufficiency syndrome, with this, up to 1/4 of the patients having this component as a part of multi-organ insufficiency syndrome, decease within the In-Patient Department. The main measure of preventing this complication is the control of hemodynamic parameters, the correction of the volume of circulating blood and the adequate anticoagulant therapy [6].

The development of respiratory insufficiency, reported in 4.7–10% of the patients, is associated with postoperative pneumonia, sepsis, progressive cardiovascular insufficiency, in single cases with fulminant progression of pulmonary metastases [6].

Hepatic failure is being diagnosed in an average of 5.3% of all the observations. The impaired functions of the liver can become the residual event, caused by the long-term impaired hepatic circulation. The laboratory parameters of hepatic dysfunction related to the obstruction of the IVC, persists for up to half a year after re-canalizing the hepatic veins and the IVC [54, 55]. In part, the impairment of the liver functions can be resulting from the intraoperative ischemia. Besides, oftentimes hepatic failure is accompanied by the acute kidney damage. The main approach to the correction of this condition is the infusion therapy [6].

Nephrectomy with IVC thrombectomy, being a long-term and complex surgical intervention, oftentimes (up to 10% of the cases) is characterized by the dynamic acute intestinal obstruction during the postoperative period. The diagnostics of this condition requires ruling out the mechanical reasons. In cases of confirmed functional etiology of the dynamic acute intestinal obstruction, the sufficient positive effect can be provided by the early mobilization of the patient, by pro-kinetic therapy, as well as by the treatment aimed at adequate analgesia, at restoring the volume of circulating blood and the hemodynamic balance, at decreasing the inflammation, at the decompression of the gastrointestinal tract and tube feeding [56].

CONCLUSION

The key tasks for the anesthesiologist-intensivist are the preoperative evaluation of the surgery and the anesthesiology risks, the intra- and postoperative risk of cardiovascular complications defined with the participation of specialists from the adjacent specialties, the treatment of anemic syndrome using various correction methods, the evaluation and correction of the nutritive status, the preparation of the patients, in which surgical treatment is planned, with the minimization of the possible complications for the safest course of surgery and for the maximally comfortable early rehabilitation.

At the present moment, the criteria for selecting the patients for carrying out this extremely traumatic surgical intervention — the nephrectomy with IVC thrombectomy — are not established, there are no standardized algorithms for preoperative preparation, for the intra- and postoperative managing the patients with renal cell cancer, complicated with tumor thrombosis of the inferior vena cava. Summarizing the experience of anesthetic management and intensive therapy with further standardization of the diagnostics, follow-up and conservative therapy protocols will allow for increasing the survival and the quality of life for this complex cohort of patients.

ADDITIONAL INFORMATION

Author contributions: O.V. Strunin, A.A. Gritskevich, T.P. Baitman, M.B. Shainyan, development of the study concept and design; T.P. Baitman, M.B. Shainyan, V.V. Malik, D.A. Parkhomenko, collection, analysis and interpretation of data; M.B. Shainyan, T.P. Baitman, V.V. Malik, D.A. Parkhomenko, O.V. Strunin, D.M. Monakov, A.A. Gritskevich, preparation and editing of the text; A.A. Gritskevich, O.V. Strunin, A.Sh. Revishvili, approval of the published version of the manuscript. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding sources: The article was prepared without attracting external funding.

Disclosure of interests: The authors declare no conflict of interests.

Statement of originality: The authors did not utilize previously published information (text, illustrations, data) in conducting the research and creating this paper.

Data availability statement: The editorial policy regarding data sharing does not apply to this work.

Generative AI: Generative AI technologies were not used for this article creation.

About the authors

Oleg V. Strunin

A.V. Vishnevsky National Medical Research Center of Surgery; Peoples’ Friendship University of Russia

Email: struninov@mail.ru
ORCID iD: 0000-0003-2537-954X
SPIN-code: 4734-0837

MD, PhD, Professor

Russian Federation, Moscow; Moscow

Tatiana P. Baitman

A.V. Vishnevsky National Medical Research Center of Surgery; Peoples’ Friendship University of Russia

Author for correspondence.
Email: bit.t@mail.ru
ORCID iD: 0000-0002-3646-1664
SPIN-code: 4684-3230

MD, PhD

Russian Federation, 27 Bolshaya Serpukhovskaya st, Moscow, 115093; Moscow

Maximilyan B. Shainyan

A.V. Vishnevsky National Medical Research Center of Surgery

Email: shnyanmax@gmail.com
ORCID iD: 0000-0002-6226-3573
Russian Federation, Moscow

Vasilii V. Malik

A.V. Vishnevsky National Medical Research Center of Surgery

Email: icefog899@mail.ru
ORCID iD: 0009-0003-6370-3248
Russian Federation, Moscow

Daniil A. Parkhomenko

A.V. Vishnevsky National Medical Research Center of Surgery

Email: parkhomenkod@yandex.ru
ORCID iD: 0009-0008-6460-239X
Russian Federation, Moscow

Dmitry M. Monakov

A.V. Vishnevsky National Medical Research Center of Surgery; Peoples’ Friendship University of Russia

Email: gvkg-monakov@mail.ru
ORCID iD: 0000-0002-9676-1802
Russian Federation, Moscow; Moscow

Alexander A. Gritskevich

A.V. Vishnevsky National Medical Research Center of Surgery; Peoples’ Friendship University of Russia

Email: grek@mail.ru
ORCID iD: 0000-0002-5160-925X
SPIN-code: 2128-7536

MD, PhD

Russian Federation, Moscow; Moscow

Amiran Sh. Revishvili

A.V. Vishnevsky National Medical Research Center of Surgery

Email: amirev@mail.ru
ORCID iD: 0000-0003-1791-9163
SPIN-code: 8181-0826

MD, PhD, Professor, academician of the Russian Academy of Sciences

Russian Federation, Moscow

References

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