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Yaroustovsky et al. Vessel Plus 2019;3:9 I http://dx.doi.org/10.20517/2574-1209.2019.02 Page 3 of 11

immunoadsorption of lipoproteins, dextran sulfate adsorption, and all these procedures alter the
physicochemical and biochemical properties of lipoproteins.

Greater efficiency and selectivity have been gained with the implementation of new synthetic membranes
for rheofilters [Cascadeflow-EC50, Lipidfilter EC-50, Evaflux 4A, 5A (Japan)] in the treatment of lipid
[28]
metabolism disorders. This type of blood purification procedures was named cascade lipid-filtration .
[28]
Klingel et al. (2004) observed the decrease of total cholesterol, LDL, Lp(a) and fibrinogen after treatment
of more than 3300mL plasma; no significant changes of levels of high density lipoprotein (HDL), proteins,
immunoglobulin were detected, so it is a safe and effective method.

Another LDL-apheresis method based on the precipitation of atherogenic lipids in the acid buffer and with
high doses of heparin is called H.E.L.P.-apheresis (Heparin-induced extracorporeal LDL-precipitation). This
method aimed at lipids reduction and correction of rheological parameters, hemostasis, immunological
homeostasis) [29,30] .

The aim of this study is to evaluate safety and efficiency of H.E.L.P.-apheresis and cascade lipid-filtration in
the treatment with severe disorder of lipid metabolism in high-risk patients.

METHODS
From 2016 to 2018 we observed 6 patients with multifocal atherosclerosis before and after sessions of
myocardial revascularization, arteries of lower limbs (CABG, angioplasty and stenting). The study was
approved by the Local Ethical Committee of the Center. Patients included in the study signed an informed
consent for extracorporeal therapy. Patients were chosen by the decision of doctors’ consilium (cardiologists,
cardiac surgeons, specialists of blood purification).

The patients had severe dyslipidemia (type IIa), heart and vessels diseases. All the patients showed
hyperLDLemia combined with high Lp(a)emia (> 60 mg/dL), and the level of Lp(a) of 5 patients was higher
than 90 mg/dL. The conventional therapy included antiplatelet medications (Clopidogrel, acetylsalicylic
acid), lipid-lowering drugs (statins, Ezetrol), if necessary according to the indications - calcium antagonists,
ACE/ARA inhibitors, β-blockers [Tables 1 and 2].

The decision to initiate the selective lipid apheresis - treatment was made considering the anamnesis and
laboratory data. The first group with H.E.L.P.-apheresis (n = 74 sessions) included 3 patients with multifocal
atherosclerosis, who had undergone revascularization (coronary arteries, femoral artery) [Table 1]. In the
second group with cascade lipid-filtration (n = 92 sessions) one patients underwent revascularization surgery,
two patients received conventional therapy [Table 2]. Despite the lipid-lowering conventional therapy, no
targeted LDL was obtained. Atherogenic indexes remained moderate: in the 1st group on average 3 (2.35-4.5)
and in the second group 3.8 (3-6.15).

The main effect of H.E.L.P.-apheresis is the elimination of atherogenic lipoproteins due to precipitation.
During H.E.L.P.-apheresis, atherogenic lipoproteins and plasma fibrinogen precipitate on-line in the presence
of high heparin doses and acetate buffer. Primarily, blood passes through the plasma filter (surface area
2
0.3-0.5 m , rate 60-80 mL/min). Red blood cells are returned to the patient, and plasma is mixed with acetate
buffer (pH = 4.85) in the ratio 1:1 and with heparin solution (100 U/mL). This acidic mixture (pH = 5.12)
reaches the precipitating filter with the rate 20-30 mL/min (25%-30% of blood flow) and precipitates there
with further deposition of insoluble sediments of LDL, Lp(a), triglycerides and fibrinogen. Heparin excess is
eliminated from plasma on heparin adsorber (DEAE of cellulose). Bicarbonate dialysis is used for restoration
of plasma pH. After that plasma is returned to the patient in combination with red blood cells. If necessary,