Pancreaticoduodenal artery aneurysm associated with coeliac trunk occlusion treated with aorto-hepatic bypass and aneurysm resection.

Pancreaticoduodenal artery aneurysms are rare visceral artery aneurysms that may be associated with stenosis of the coeliac trunk. We present a case of a 48-year-old woman with a symptomatic aneurysm of the inferior pancreaticoduodenal artery caused by occlusion of the coeliac trunk due to median arcuate ligament syndrome. The patient was treated with an aorto-hepatic bypass and excision of the aneurysm. We discuss the case and the complexities and controversies in the treatment of this disease.

VariClose® vein sealing system is inferior to endovenous laser ablation for the treatment of varicose veins.

BACKGROUND: One of the three commercially available cyanoacrylate venous glues used for the treatment of saphenous vein insufficiency is the VariClose® vein sealing system. Previous studies have documented a high rate of occlusion and minimal postoperative complications. The aim of this study was to compare occlusion rates and clinical outcomes of endovenous laser treatment with the VariClose® vein sealing system in the treatment of truncal vein insufficiency. PATIENTS AND METHODS: Retrospective non-randomized single center study with prospectively collected data comparing endovenous laser treatment and VariClose® procedures between April 2018 and November 2019. RESULTS: VariClose® was used in 27 patients (30 veins) and endovenous laser treatment in 42 patients (51 veins). The occlusion rate at one, three, and six months were 96%, 85%, and 65% for VariClose® procedures and 100%, 100%, and 97% for endovenous laser treatment procedures (p = 0.01), respectively. Reduction of VCSS scores before treatment and at the last postoperative follow-up visit in the VariClose® group dropped by an average of 1.8 ± 1.6 and in the endovenous laser treatment by an average of 3.3 ± 2.9 (p = 0.01). CONCLUSION: VariClose® vein sealing system is inferior to endovenous laser treatment as a treatment option for varicose veins as it has a higher recanalization rate.

Repair of Aneurysmal Arteriovenous Fistulae: A Systematic Review and Meta-analysis.

OBJECTIVE: Aneurysms arising from arteriovenous fistulae are a common finding among dialysed patients and pose a risk of acute bleeding. The aim of this study was to perform a systematic review and meta-analysis evaluating the surgical options for the treatment of aneurysmal arteriovenous fistulae. METHODS: A systematic review and meta-analysis of articles published between January 1973 and March 2019 describing the surgical treatment of arteriovenous fistulae aneurysms. RESULTS: A total of 794 records were identified. After duplicate and low quality studies were removed, 72 full text articles were reviewed and from these 13 were included in the meta-analysis. The total number of patients was 597. Aneurysms were located in the upper arm in 289 (59%) cases and the smallest diameter of a treated aneurysm was 15 mm. The most frequent indication for treatment was bleeding prevention in 513 (86%) cases. Aneurysmorrhaphy was the surgical method of choice in all 13 studies. The pooled primary patency at 12 months was 82% (95% CI 69%-90%, 12 studies, I2 = 84%, p < .01). The 12 month primary patency rates were similar for aneurysmorrhaphy with external prosthetic reinforcement (85%, 95% CI 71%-93%, two studies, I2 = 0%, p = .33) and aneurysmorrhaphy performed using a stapler (74%, 95% CI 61%-83%, four studies, I2 = 0%, p = .48) and without a stapler (82%, 95% CI 60%-94%, six studies, I2 = 92%, p < .01). CONCLUSION: Aneurysmorraphy of arteriovenous fistulae is a procedure with acceptable short and long term results, with a low complication and aneurysm recurrence rate.

Early and late outcomes of hybrid endovascular and open repair procedures in patients with peripheral arterial disease.

BACKGROUND: Hybrid endovascular and open reconstructions are used increasingly often for multilevel revascularization for lower limb ischaemia. The aim was to evaluate outcomes after such procedures in a single-center non-randomized retrospective study. PATIENTS AND METHODS: Consecutive patients with multilevel arterial disease who underwent single session hybrid procedures were analyzed depending on the type of ischaemia and the type of revascularization. RESULTS: 164 patients were included with a median follow up time of 14 months (range: 0 - 70). Indication was claudication (group 1, 47 %), critical limb ischaemia (group 2, 33 %) and acute limb ischaemia (group 3, 20 %). Technical success rate was 99.3 %, perioperative mortality 2 %. Primary, assisted-primary and secondary patency rates at one year were 60 %, 61 % and 64 %, respectively. Primary, primary assisted and secondary patency were lower in group 2 and 3 compared to group 1 (all p < 0.05). Results were better when endovascular repairs were performed above compared to below the open repair site (all p < 0.05). Limb salvage at 1 year in groups 1 - 3 were 98 %, 92 % and 90 %, respectively. The risk of major amputation was highest in group 3 compared to group 1 (p = 0.001) or group 2 (p < 0.04). CONCLUSIONS: The results depend on the type of ischaemia and the localization of endovascular procedures.

Experience with VariClose® vein sealing system in the Czech Republic.

OBJECTIVES: The aim of this study was to assess occlusion rates of saphenous veins treated with the VariClose vein sealing system. METHODS: A retrospective analysis including a total of 64 patients from four centres from the Czech Republic. Occlusion was defined as a non-compressible vein with absence of flow with exception to the first 3 cm from the saphenofemoral or saphenopopliteal junction on duplex ultrasound. RESULTS: In 64 patients a total of 79 veins were treated. Technical success of the procedure was achieved in 74 (94%) of cases. The mean follow-up was 5.5 months. The closure rates calculated by the Kaplan-Meier method at 1, 3, 6 and 12 months were 94%, 85%, 69% and 36%, respectively, and there were no significant differences between centers. The average difference in VCSS score before and after the procedure was 1.8. CONCLUSIONS: The present study demonstrated surprisingly worse occlusion rates than the current literature.

[The influence of surgical complications on renal graft function]. / Vliv chirurgických komplikací na funkci transplantované ledviny.

BACKGROUND: Kidney transplantation is the method of choice for patients with end stage kidney disease. Surgical complications remain a serious clinical problem and can lead to loss of graft function. AIM: Analysis of surgical complications in patients after single kidney transplant from cadaver donors and their influence on the function of the transplanted graft. METHODS: Patients after a single kidney transplant from a cadaver donor (n = 566) between 1/2006-4/2009 in the Institute of Clinical and Experimental Medicine. RESULTS: Individual surgical complications did not affect the delayed onset of graft function. A significantly higher serum creatinine in the 3rd month was observed in the group of patients with urinary leak (p = 0.02) compared with a group of patients without complications. The serum creatinine at 6th month was not affected by any surgical complication. Serum creatinine at 12th month was statistically significantly higher in the group of patients with lymphocele (p = 0.028) compared with a group of patients without complications. The surgical complications which had a significant effect on one year graft survival were infectious wound complications in the recipient (p < 0.05), renal artery stenosis (p < 0.05) and renal vein thrombosis (p < 0.01). CONCLUSIONS: The onset of graft function was not affected by surgical complications. The group of patients with urinary leak had higher serum creatinine in 3rd month and patients with lymphocele in 12th month. Infectious wound complications, renal artery stenosis and renal vein thrombosis decrease the 1-year graft survival.

[Eversion carotid endarterectomy: evaluation of results after changing the operation technique]. / Everzní endarterektomie arterie carotis interna: hodnocení výsledku po zmene operacní techniky.

BACKGROUND: Stroke is the third most common cause of mortality, and carotid artery stenosis causes up to 30% of all ischemic strokes. Eversion CEA (ECEA) has been proposed as an acceptable alternative to the standard bifurcation endarterectomy in many patients. This study was designed to analyze the long-term durability of ECEA in symptomatic and asymptomatic patients. Data were retrospectively reviewed to determine the incidence of major adverse cardiovascular events (MACEs) within 30 days of surgery, late survival, and the incidence of restenosis. METHODS AND RESULTS: From January 1999 to June 2010, 344 ECEAs were performed on 324 patients (34% female, 38% symptomatic). The mean follow-up period was 30 months. CONCLUSIONS: MACEs occurred in 28 patients (8.6%). The overall incidence of stroke or death after ECEA was 1.7% and 0.9% at discharge. The overall incidence of stoke or death after CEA was 4.3% and 21% (14 strokes, 69 deaths, 8 of which were stroke-related). The overall occurrence of any restenosis (> 50%) after CEA was 4.3% (14 of 324 procedures).

Oncovascular Resection of a Ganglioneuroma Involving the Coeliac Trunk and Hepatic Artery-A Case Report.

A large tumorous mass completely surrounding and compressing the coeliac trunk was identified on computed tomography in a young woman with a six-month history of progressive abdominal pain. The tumor was excised along with the coeliac trunk and the proximal parts of its branches. The hepatic artery was reconstructed with an aorto-hepatic autogenous bypass. Postoperatively the patient had neurogenic diarrhea, which subsided on medical treatment. Seven months after surgery the patient is in a good state of health and living a normal life.

Tissue reaction to three different types of tissue glues in an experimental aorta dissection model: a quantitative approach.

Tissue glues are used during surgical treatment of acute aorta dissection although some glues release toxic products and thus alter the histological structure of the vessel wall. The aim of our study was to use a porcine experimental model of infrarenal aorta dissection to compare histological changes of the vessel wall 1, 6 and 12 months after application of BioGlue, Gelatin-resorcin-formaldehyde (GRF) glue and Tissucol. For quantification, stereological methods were used. All types of glue caused stenosis, GRF most and Tissucol least severely. With increasing postoperative survival time, stenosis was again reduced. Elastine length density decreased with increasing survival time in Control as well as in all Experimental groups. The immunohistochemical phenotype of vascular smooth muscle cells was similar in Tissucol and Control samples. In GRF samples, actin, desmin and vimentin expression changed most severely. Similarly, number and distribution of vasa vasorum in the aortic wall was altered most severely in GRF samples. They tended to return to normal with increasing postoperative survival time, but at a slow rate in the GRF samples. It can be concluded that GRF causes the most severe histopathological changes within the treated aorta, which could be a reason for late failures of dissection surgery. However, glue handling and adhesive properties have to be taken into account, too, when certain glue is chosen for surgical intervention. Increased inflammation and vascularisation might even stabilise the aortic wall. Long-term experimental studies would be helpful to assess healing processes after initial disorganisation of the aortic wall structure.

Long-term outcomes of surgical radiofrequency ablation for atrial fibrillation in 3 groups of patients.

BACKGROUND: Left atrial surgical radiofrequency ablation represents an applicable and technically less demanding method for treating paroxysmal or permanent atrial fibrillation (AF) as a concomitant procedure. The aim of this study was to review the long-term outcomes of radiofrequency linear ablation for the treatment of AF limited to the left atrium in 3 groups of patients undergoing cardiac surgery. METHODS: The study population consisted of 357 consecutive patients, who were divided into 3 groups on the basis of the underlying disease: group I, 126 patients with nonischemic mitral valve disease; group II, 164 patients with coronary artery disease and aortic and/or ischemic mitral valve disease or who underwent other concomitant procedures; and group III, 67 patients with coronary artery disease only. RESULTS: Follow-up times were between 6 and 48 months (mean, 28.3 + 9.4 months). The 30-day hospital mortality rate was 2.80% (10 patients). Total mortality during the follow-up period reached 4.48% (16 patients). At discharge, 66% of group I patients, 64% of group II patients, and 69% of group in patients were in sinus rhythm. After 24 months, 60% of group I patients, 75% of group II patients, and 67% of group III patients were in sinus rhythm. A subgroup analysis of the patients with permanent AF showed that only 54% of these patients in group I, 52% in group II, and 67% in group III had a restored sinus rhythm at 24 months. Subgroup analysis also revealed that only 6 (27%) of 22 patients with a left atrium diameter >60 mm maintained a sinus rhythm during long-term follow-up. Biatrial contraction was restored in 75% of the patients with a stable sinus rhythm after 6 months of follow-up. Seven patients (2%) with symptomatic postoperative recurrent atrial arrhythmias underwent subsequent catheter ablation. CONCLUSION: Left atrial surgical radiofrequency ablation represents an applicable and technically less demanding method for treating paroxysmal or permanent AF as a concomitant procedure. Our results demonstrate the feasibility of this procedure for paroxysmal and persistent AF, with minimal risks to the patient. For permanent AF, further investigation and extensive intervention are essential.

Cardiac remodeling after reduction of high-flow arteriovenous fistulas in end-stage renal disease.

In patients with end-stage renal disease, excessive blood flow through an arteriovenous fistula (AVF) may lead to volume overload-induced cardiac remodeling and heart failure. It is unclear which patients with hyperfunctional AVF may benefit from AVF reduction or ligation. The indication for the procedure is often based on AVF flow. Because cardiac remodeling is driven by increased venous return, which is equivalent to cardiac output, we hypothesized that an elevated cardiac index (CI) might better identify subjects with reverse remodeling after AVF reduction. Thirty patients (age 52±12 years, 73% male) with AVF flow ⩾1.5 l min(-1) underwent comprehensive echocardiographic evaluations before and after AVF reduction. At baseline, 16 patients had a normal CI (2.5-3.8 l min(-1) m(-2)) and 14 had a high CI (4.0-6.0 l min(-1) m(-2)). A left ventricular end-diastolic diameter decrease after operation was predicted by elevated baseline CI (P<0.01), but not elevated AVF flow (P=0.07). There was a significant decrease in CI, left ventricular mass, left atrial and right ventricular diameter and pulmonary systolic pressure in the high CI group but not in the normal CI group. After AVF reduction, systemic vascular resistance decreased in the normal CI group, whereas it did not change in the high CI group. In conclusion, reduction of high-flow AVF leads to reverse cardiac remodeling but only in patients with elevated CI. The variability of the response of systemic vascular resistance to AVF flow may explain this observation. Increased CI but not increased AVF flow may better determine candidates for AVF reduction.

Identification of expanded-criteria donor kidney grafts at lower risk of delayed graft function.

BACKGROUND: Organ shortage leads to the increased use of expanded-criteria donor (ECD) kidneys, which contribute to a higher risk of delayed graft function (DGF) after transplantation. The aim of this study was to determine factors that may better predict the risk of DGF. METHODS: Histologic assessments of donor renal biopsy were used with other clinical variables to predict the risk of DGF after kidney transplantation. The total Banff score equaled the sum of interstitial fibrosis (CI), tubular atrophy, arteriolar hyaline thickening, fibrous intimal thickening (CV), and fraction of sclerotized glomeruli. RESULTS: In total, 126 of 344 patients developed DGF after kidney transplantation. The histologic score for CI, tubular atrophy, and CV and the total Banff score were increased in patients with DGF. Only CI and CV were independent predictors of DGF (P<0.01). A CIV score (CI+CV; odds ratio, 2.68; 95% confidence interval, 1.55-4.66; P<0.001) was superior to the combination of the total Banff score (odds ratio, 1.48; 95% confidence interval, 0.85-2.55; P=NS). A CIV score≥1, donor age more than 51 years, and anoxia donor brain injury were associated with the highest risk of DGF. A CIV<1 identified a subgroup of ECDs at a lower risk of DGF comparable with standard-criteria donors (29.3% vs. 28.4%). CONCLUSIONS: Composite CIV score better identifies ECD kidneys with a lower risk of developing DGF. Morphologic evaluation of ECD kidneys and donor characteristics may improve kidney allocation.

Dual kidney transplant: a single-center experience and review of the literature.

OBJECTIVES: Adult dual kidney transplant is a strategy to overcome the imbalance between limited nephron mass supplied from an older donor and a recipient with a metabolic request. MATERIALS AND METHODS: In our report, we review the literature and present our single-center experience. From June 2007 until July 2012, nine hundred twenty-eight single and seventeen dual kidney transplants from deceased donors were performed. RESULTS: The average donor was 71.5 ± 3.6 years of age with an average serum creatinine, creatinine clearance, and an average number of sclerotic glomeruli, 106.1 ± 44.2 µmol/L, 0.97 ± 0.37 mL/s, and 22.4 ± 14.2. Immediate graft function and acute rejection episodes were observed in 75% and 6% of patients. The overall patient survival rates at 1 and 2 years after transplant were 93%. The overall graft survival rates at 1 and 2 years were 88%. CONCLUSIONS: Previous studies and our single-center experience suggest that the dual transplant procedure may help improve results of kidney transplants from expanded criteria donors and extend the donor pool by using kidneys that would be discarded otherwise.

Combined infrainguinal reconstruction and infrapopliteal intraluminal angioplasty for limb salvage in critical limb ischemia.

The aim of this retrospective study was to assess the success rates of limb salvage, and the primary and secondary patency rates of reconstructions of critical limb ischemia (CLI) patients undergoing combined infrainguinal reconstruction and intraluminal angioplasty of crural arteries. In 2000-2005, infrainguinal reconstruction with concomitant intraluminal angioplasty of crural arteries was performed in 30 patients with CLI, mean age was 63 years (S.D.=10); according to the Fontaine classification, 28 (93%) patients had stage IV and 2 (7%) stage III ischemia. During mean follow-up of 12.9 (S.D.=16.9) months, primary 1-year patency of vascular reconstruction was seen in 16 (52.6%) patients of our group. Secondary 1-year patency over the same follow-up period was documented in 17 (56.2%) patients and 1-year limb salvage was obtained in 25 (82.6%) patients. Based on this finding, we consider a combined surgical and endovascular procedure to be the method of choice in limb salvage in patients with CLI not allowing for an isolated endovascular procedure.