Rupture of a large aneurysm of common hepatic artery - case report.

Visceral artery aneurysms are rare findings in the practice of vascular surgeons. Their inaccessibility to physical examination, asymptomatic nature in many cases, but also an inherent risk of rupture that can be life threatening, make them a complex diagnostic and therapeutic problem. By presenting a case report of a ruptured common hepatic artery aneurysm the authors summarize basic characteristics of these aneurysms, as well as diagnostic and treatment options.

Infections associated with vascular reconstruction procedures at the Department of Surgery in Pilsen in retrospect.

INTRODUCTION: Vascular graft infection is a rare but serious complication in vascular surgery, associated with high morbidity and mortality. Early diagnosis of vascular graft infection is important for proper and timely surgical and antibiotic treatment that improves the outcome. The tactic and techniques of surgical treatment of vascular graft infection have changed over the last two decades, and this trend can also be observed in our retrospective study. METHODS: We evaluated a group of patients with prosthetic vascular reconstructions performed at the Department of Surgery, University Hospital in Pilsen in the period of 2003-2021 using retrospective analysis. In the analyzed 19-year period, 23 infected vascular grafts were managed out of a total of 2090 performed peripheral bypasses, and 27 infected vascular grafts were managed out of a total set of 1940 central reconstructions. RESULTS: The incidence of peripheral vascular graft infections at our Department of Surgery in the period of 2003-2021 reached 1.1% with the early mortality rate of 8.7%; 1.4% central vascular graft infections occurred in the same time period with 33% early mortality. CONCLUSION: The results of our retrospective study are comparable virtually in all parameters with the experience of other departments. Consistently, our department switched to in situ replacements for explanted vascular grafts and we can confirm good experience with silver impregnated grafts.

Perioperative acute internal carotid thrombosis after general surgery.

INTRODUCTION: The average incidence of perioperative stroke during major non-cardiac surgery is less than 1%, suggesting that it is rarely a major problem for the vast majority of patients. METHODS: In our paper we present a 46-year-old patient undergoing acute right hemicolectomy who developed right-sided hemiparesis in the perioperative setting. Immediate CTAg examination showed an ischemic stroke in the left hemisphere as a result of left internal carotid thrombosis. A surgical procedure to recanalize the left carotid artery was performed 14 hours from the onset of neurological symptomatology and the neurological deficit gradually recovered fully. CONCLUSION: Our case report supports studies showing that a thorough diagnostic assessment allows the selection of patients who may benefit from urgent revascularization of acute internal carotid occlusion during the phase of acute brain ischemia.

[Our experience with left-sided retroperitoneal approach to resection of abdominal aortic aneurysm]. / Nase zkusenosti s levostranným retroperitoneálním prístupem pri resení výdutí brisní aorty.

INTRODUCTION: At most vascular surgery departments, transperitoneal approach predominates in resections of the aortic aneurysms. For difficult reconstructions of the aorta in the visceral segment, a left flank retroperitoneal approach is used most frequently. METHOD: The authors retrospectively evaluate the left retroperitoneal approach in the management of abdominal aortic aneurysms during a 10-year period. From the total number of 445 operated patients, the left-sided retroperitoneal approach was used in 23 cases. RESULT: All operated patients survived. Average hospital stay was 10 days in the case of elective operations. CONCLUSION: Based on favorable results, the authors confirm that left-sided retroperitoneal approach is rightly considered as a choice in the technically demanding reconstruction of the aorta in the visceral segment.Key words: aortic aneurysm visceral segment of the aorta retroperitoneal approach.

Indications to open surgical revascularization of visceral arteries in the endovascular era.

INTRODUCTION: Due to the high success rate of endovascular procedures, open surgical treatment of visceral arteries has become rarer worldwide. Yet, open surgical techniques remain essential for cases of chronic mesenteric ischemia as well as in other clinical instances. METHODS: Drawing on their own experience and literary data, the authors summarize the indications to open surgical repair of the visceral arteries. They point out the situations in which surgical management is the method of choice even in the endovascular era. Discussing the advantages and disadvantages of various vascular reconstructions, they point out their technical challenges. CONCLUSION: Although used less frequently, open surgical repair of the visceral arteries needs to remain among the vascular surgeons tools. Not only for situations when an endovascular technique fails, but also for elective procedures in patients in whom an endovascular approach is contraindicated or not possible. Key words: mesenteric ischemia aorto-mesenteric bypass endovascular approach.

[Dual kidney transplantation - a single-center experience]. / Duální transplantace ledvin - zkusenosti jednoho centra.

INTRODUCTION: Dual kidney transplantation is one of the options to utilize the so-called marginal grafts, kidneys that would be insufficient for normal single transplantation. This time-consuming surgical procedure is also burdensome for the patient. METHODS: The authors present their experience from the Pilsen Transplant Center. Between 2008 and 2016, 13 dual kidney transplantations were performed. Median donor age was 66 years (34-77) and median recipient age 46 years (40-78). Mean operating time was 4 hours and 40 minutes (3-6 h). Mean surgery ward stay was 5 days (4-6). Bilateral surgical technique was used in all cases. Mean follow-up time was 63 months (18-101). RESULTS: From our group of DKTs (N=13), 4 patients (31%) experienced delayed graft function and we observed no primary graft non-function. Surgical complications occurred in 4 patients (31%). Currently, all 13 patients are living with good graft function, none of them being dependent on dialysis. CONCLUSION: Dual kidney transplantation is currently a viable option. The success and benefits of this surgical procedure are directly related to careful donor and recipient selection.Key words: dual kidney transplantation - marginal donor - chronic renal failure - expanded criteria donor.

[Popliteal vein aneurysm]. / Aneuryzma vena poplitea.

Popliteal vein aneurysm is a rare disease of the lower limb venous system. Massive pulmonary embolism may be a clinically serious presentation of the disease. The authors present surgical management of the popliteal vein aneurysm in two case reports.Key words: popliteal vein aneurysm surgical management.

[Traumatic Thrombosis of the Renal Artery following Seat-Belt Injury]. / Traumatická trombóza renální tepny pri seat-belt injury.

Renal artery thrombosis is a rare complication of blunt abdominal injury. It occurs most frequently in car accidents in which sudden deceleration results in multiple internal injuries. Renal artery occlusion occurs rarely as an isolated blunt trauma. This report presents a case of traumatic occlusion of the left renal artery with complete ischaemia of the left kidney in a haemodynamically stable girl who suffered multiple seat-belt injuries in a car crash. Ambiguous findings on a CT scan of the abdominal cavity indicated surgical inspection of the abdomen and, since the injury-to-surgery interval was short, an attempt at revascularisation of the left kidney was made. This was performed using laparotomy through a lateral left-side incision, as an uncommon approach to the injured organs. A seat-belt fracture of the L2/3 spine was stabilised at secondstage surgery. Key words: renal artery thrombosis, seat-belt fracture of the lumbar spine.

[Kidney donors after circulatory death (DCD) - single centre experience]. / Dárci ledvin po nezvratné zástave obehu (DCD) - zkusenosti jednoho centra.

INTRODUCTION: Kidney procurement from donors after circulatory death (DCD) is an important part of worldwide transplantation programmes. The first kidney transplantation from DCD was successfully performed in the Czech Republic in 2002. METHOD: Forty four kidneys from DCD were procured in the Transplant Centre of Pilsen between 2002 and 2015. We used the technique of "in situ" procurement with the double balloon triple lumen catheter and 510 minutes of the no-touch interval. The method of pulsatile hypothermic perfusion was used to test the viability of the kidneys. Twenty eight recipients with mean age 51.1 (2673) years were transplanted. Sixteen (57.1%) kidneys were from the 2nd, 8 (28.6%) from the 3rd and 4 (14.3%) from the 4th category according to the Maastricht criteria. RESULTS: 30-day mortality and morbidity rates were 0 and 10.7% i. e.14.3% respectively (N=4). Primary non-function was presented in 2 (7.1%), and delayed graft function in 5 (17.9%) cases. One, five and ten years of recipient and graft survival rates were 100%, 86.4% and 76.7%; and 92.9%, 69.6% and 61.9%, respectively. The long-term results are fully comparable with kidneys transplanted from donors after brain death. CONCLUSION: DCD are an important source for kidney transplantation. Kidney transplantation from DCD is a logistically, economically and personally demanding method with very good long-term results. KEY WORDS: donors after circulatory death - kidney transplantation - results.

Management of aortic graft infections - the present strategy and future perspectives.

Aortic graft infections (AGI) are serious complications of open and endovascular types of surgery with an incidence rate of 0.6-3 %. AGI are associated with 30-60 % perioperative mortality and 40-60 % morbidity rate with limb amputation rates between 10 % and 40 %. The economic cost of AGI is substantial. At the time of aortic reconstruction, almost 90 % of patients have one or more predisposing factors for AGI. The diagnosis is based on clinical symptomatology, laboratory markers, microbial cultures, and imaging modalities. The general principle of surgical treatment lies in the removal of infected graft, debridement of infected periprosthetic tissues, and vascular reconstruction by in situ or extra-anatomic bypass with long-term antibiotic therapy. The conservative treatment is used only for selected patients with endograft infection. This review summarizes the current knowledge about the incidence, predisposing factors, etiology, diagnosis, treatment options, and prevention of aortic vascular graft and endograft infections. With the growing number of endovascular procedures we can expect more cases of infected aortic endografts in patients with severe comorbidities in the near future, where the recent radical surgical approach (graft excision, debridement, and new revascularization) cannot be used. Therefore the less invasive, sophisticated and individualized treatment strategies will have to be used in search of the best therapeutic approach to each specific patient (Fig. 4, Ref. 82).

[Why are carotid glomus tumours dangerous?]. / Proc je tumor karotického glomu nebezpecný?

Carotid body tumours are rare, usually benign tumours. The dangerous nature of carotid body tumours is due to their hypervascularization and the intimate relationship to cervical arteries and cranial nerves. In a case report, the authors document that misdiagnosis and efforts to remove or obtain a biopsy of the tumour outside vascular centres can be more dangerous for the patient than the nature of the tumour itself.

[Simultaneous procedure in patients with abdominal aortic aneurysm and renal carcinoma]. / Jednodobý výkon u aneuryzmatu brisní aorty a renálního karcinomu.

INTRODUCTION: Renal carcinoma (RC) is present in 0.1-3% of patients with abdominal aortic aneurysm (AAA). There are several options for surgical solution as regards the type and timing of the procedure. The authors discuss the simultaneous AAA resection and radical nephrectomy as a treatment option. MATERIAL AND METHODS: 1168 patients with AAA including 19 (1.6%) with asymptomatic AAA (diameter >50mm) and RC (average diameter 74.3 mm) indicated for radical nephrectomy were operated on in the last 20 years (between 5/1994 and 5/2014). The average age of the patients was 72.8 years (5585). Pre-operatively, sixteen patients were classified as ASA II, three as ASA III. Unilateral nephrectomy was performed in 18 and bilateral nephrectomy in one patient. One-stage AAA resection (1x endovascular aneurysm repair) with nephrectomy was performed in all patients. RESULTS: Two patients with ASA III classification died within 30 days postoperatively due to acute myocardial infarction and multiorgan failure. In the other patients, the simultaneous procedure was without any complications. Four patients died within two years after the operation due to generalized RC, the others have survived in the interval of one and twelve years after the procedure. CONCLUSION: Simultaneous procedure does not represent increased operation load for patients with good health status. Nevertheless, the type of procedure should be optimised for each individual patient with regard to his or her general health status, life expectancy, disease symptomatology, the diameter of the RC and the anatomical conditions of AAA.

[Late failure of the endovascular infrarenal aortic aneurysm solutions - diagnosis and treatment]. / Pozdní selhání endovaskulárního resení aneuryzmatu subrenální aorty - diagnostika a lécba.

INTRODUCTION: Nowadays, there are two possible solutions to aneurysms of the abdominal aorta. One is an open resection, which is undoubtedly one of the major surgeries and endovascular solutions, and which represents a smaller operating load for the patient. Long-term monitoring of patients after the endovascular solutions showed late failure in 7-17% of cases. The late incidence of endoleaks and the migration of stents are explained by changing the anatomy of the aneurysm and the resulting change in the mechanical pressure on the stent graft. If these conditions cannot be solved by an endovascular procedure the situation may present a technical challenge for the vascular surgeon. MATERIAL AND METHODS: Our report on the five case studies points to possible late complications of EVAR and solutions to their individual states. CONCLUSIONS: In the future, it should be recognized that if the endoleak is not proven it does not mean that it cannot occur over the years and massively fill the excluded aneurysm with the risk of rupture. Undoubtedly, re-operating the open patch is a challenging exercise. Nevertheless, it is possible even with the patients who were, primarily in terms of polymorbidity, indicated EVAR.

[Internal carotid artery surgery under locoregional anaesthesia at the Department of Surgery in Pilsen during the past 10 years (2002-2011)]. / Operace na vnitrních karotidách v lokoregionální anestezii na chirurgické klinice v Plzni za uplynulý h 10 let (2002-2011).

During the ten-year period (2002-2011), carotid artery surgery was performed in 1164 patients, with a mean age of 68 years (44 to 86 years), at the Department of Surgery, University Hospital in Pilsen. In total, 1304 procedures on internal carotid arteries were performed, and the ratio of procedures in men and women was 912/392. The ratio of procedures in asymptomatic vs. symptomatic findings was 938/366. The ratio of patients with unilateral vs. bilateral damage to the internal carotid artery was 930/234. All surgical procedures on internal carotid arteries were performed under locoregional anaesthesia. From the total number of internal carotid artery operations (1304), the 30-day mortality and morbidity rate was 1.46%.

[Leriche's syndrome]. / Lerichuv syndrom.

INTRODUCTION: Leriche's syndrome is defined as atherosclerotic occlusion of the infrarenal aorta and/or the iliac axis. It is associated with claudications or critical limb ischaemia and erectile dysfunction in men. MATERIAL AND METHODS: Twenty patients with Leriche's syndrome were operated on at the Department of Surgery, University Hospital in Pilsen between 2008 and 2012. There were 6 women and 14 men of average age 60.3 years (41-76 years). Three patients were in group C and 17 in group D according to the Trans-Atlantic Inter-Society Classification IIb (TASC IIb). Fifteen patients suffered from chronic claudication or rest pain, five patients had acute limb ischaemic symptomatology. Aortobifemoral bypass with subsequent anti-aggregation therapy was the only treatment option. RESULTS: Primary 30-day patency was 100%. 30-day postoperative mortality was 5% (one patient died of acute myocardial infarction). Two patients died in two and four years after the reconstruction (10%) due to cerebral ischaemia and bronchopneumonia. Only one extremity amputation was performed within the five-year interval after vascular reconstruction. All aortobifemoral reconstructions were patent in two months to five years after the operation. We had to manage only one false aneurysm in the groin three years after the aortobifemoral reconstruction. CONCLUSION: Aortobifemoral bypass is a method of choice for the treatment of Leriche's syndrome. Endovascular treatment is suitable for patients with severe comorbidities.

[Vascular system injuries]. / Poranení cévního systému.

PURPOSE OF THE STUDY: The aim of this retrospective study is to present our experience with the management of injuries to the vascular system at the Trauma Centre, University Hospital in Plzen. We show the most frequent mechanisms of injury, diagnostic pitfalls, therapeutic options and evaluate both the short-term and long-term results of surgical treatment and interventional radiology procedures. MATERIAL AND METHODS: We evaluated a group of patients with a serious vascular injury who were treated at the Traima Centre during the five-year period from January 2006 to December 2010. The group included 82 patients, 59 men and 23 women, with the average age of 34.5 years. We assessed the success rate of vascular reconstruction, primary and secondary graft patency and mortality and morbidity rates. Recovery of function in the injured extremities and return of the patient to normal daily activities were considered the most important parameters. In 28 patients (34%) vascular injury was due to polytrauma, in nine (11%) it was part of a combined injury, and 45 patients (55 %) sustained monotrauma. Most of the patients (68; 83%) were managed surgically. The most frequent procedures included direct suture of a lesion, resection and replacement of an injured artery or bypass grafting. In 13 patients we used interventional radiology procedures (in most cases it was for thoracic endovascular aortic repair). In one patient we were able to use a conservative treatment. RESULTS: The 30-day mortality rate was 8.5%, i.e., seven patients died of polytrauma. The morbidity rate was 35% (29 patients). The most frequent complications included respiratory failure in polytrauma (13%), transient leg/arm swelling (6%) and wound infection (4%). Primary and secondary graft patencies were 100% and 95.5%, respectively. Vascular reconstruction failed in three patients and, in two of them, we had to carry out limb amputation. CONCLUSIONS: From the viewpoint of vascular surgery, even very serious injuries of upper and lower extremities can be managed, if possible associated injuries of the skeletal and nerve structures allow for it. The key to success is good co-operation of the orthopaedic trauma surgeon, vascular surgeon and neurosurgeon.

[Traumatic rupture of thoracic aorta]. / Traumatická ruptura hrudní aorty.

INTRODUCTION: Thoracic aortic injury (TAI) is burdened with high mortality (80-90%). The diagnostic and therapeutic algorithm has changed radically over the last couple of years. The authors present their experience with diagnosis and treatment of TAI at the University Hospital Trauma Centre. MATERIAL AND METHODS: 24 TAIs were evaluated in a retrospective study, in 20 (83.3%) cases they were part of a polytrauma. The average age of the patients was 39.4 years (20-67). Traffic accidents formed the majority of TAIs (87.5%). Multi-detector computed tomography was used as a basic examination to detect TAI. Thoracic endovascular aortic repair (TEVAR) was the treatment of choice in 21 and open surgery in 3 injured patients. RESULTS: The 30-day postoperative mortality was 12.5%, in one case it was associated with TEVAR. 30-day morbidity was 37.5% (circulatory instability, respiratory insufficiency, bronchopneumonia, type I endoleak). CONCLUSION: MDCT and TEVAR are currently the methods of first choice in the diagnosis and treatment of TAI. TAI requires a highly specialized multidisciplinary approach within Trauma Centres providing complex cardiovascular services.

[Vascular reconstructions infections in the aortofemoral region]. / Infekce cévních rekonstrukcí v aortofemorální oblasti.

INTRODUCTION: The incidence of prosthetic vascular graft infections in the aortofemoral region is reported at 0.6-3%. These complications are burdened with a high mortality of up to 50% and an amputation rate of up to 20%. The aim of our study was to give a complex view on the diagnostic and treatment possibilities of these serious complications of reconstructive vascular surgery. MATERIAL AND METHODS: Prosthetic bypass grafts were performed in 1088 patients in the aortofemoral region between 2001-2011 at the Department of Surgery, Teaching Hospital and the Faculty of Medicine, Charles University, in Pilsen. 24 (2.2%) patients suffered from graft infection at various time intervals after primary vascular reconstruction. Clinical examination, computed tomography and positron emission tomography were the main diagnostic methods of vascular graft infection. "In situ" reconstructions dominated over extra-anatomic reconstructions. When the infection involved only the peripheral part of the prosthetic graft, a more conservative approach - local debridement and drainage - was used. RESULTS: The mortality of the patients was 20.8%, high amputation rate 12.5%, and morbidity rate 58.3%, respectively. The average time of hospitalization in surviving patients was 46.5 days. Primary 30-day patency rate in "in situ" and extra-anatomic reconstructions was 100 and 60%, respectively. CONCLUSION: Prosthetic vascular graft infections in the aortofemoral region require tailored multidisciplinary treatment approach in vascular centres. "In situ" reconstructions are the method of first choice. A more conservative approach in infections involving only the peripheral part of the vascular reconstruction has a positive treatment effect.

[High chronic ileus and subrenal aortic aneurysm -- an interesting case review]. / Vysoký chronický ileus a výdut' subrenální aorty -- zajímavá kazuistika.

Ileus caused by small intestinal obturation due to an enterolith, as a complication of jejunal diverticulosis, is rare, however, a number of case reviews describing the conditions can be found in literature. The presented case review documents difficulties with entherolith ileus diagnostics and its management together with a growing abdominal aneurysm, as a single step procedure.

[Abdominal aortic aneurysms--long-term treatment results]. / Aneuryzma abdominální aorty--dlouhodobé výsledky lécby.

OBJECTIVE: To evaluate the single center experience in the treatment of patients with AAA. METHODS: 586 patients undergoing open resection (OR) and EVAR (2000-2009). The average age was 72.2 +/- 7.7 years. AAA diameter was 8.3 cm (range 5.0-13.1 cm). 451 (76.9%) patients had asymptomatic AAA, 135 (23.1%) RAAA. 448 patients (76.5%) suffered from various co-morbidities. 430 (73.4 %) OR, 156 (26.6%) EVAR and 52 (8.9%) one staged procedure (for concomitant diseases) was performed. RESULTS: 30 days mortality rate of elective OR and EVAR was 6.2, resp. 2.9% (n.s.) versus 36.6% of RAAA (p < 0.0001). 30 days mortality rate of one staged and single procedure was 19.5, resp. 3.6% (p < 0.0001). 30 days morbidity rate was in the whole group 52.1% (80.7% in RAAA x 43.4% in asymptomatic AAA - p < 0.0001), in one-stage procedures 60.8% x 51.1% in single procedures - n.s., 45.1% in OR x 39.0% in EVAR - n.s. Redo procedures were significantly higher in EVAR x OR in the long-term period after primary procedure. 1-, 3-, 5-, and 8 years survival of patients with asymptomatic AAA and RAAA was 91.6, 85.9, 81.1 and 73.6%, resp. 54.9, 48.9, 45.9 and 43.5 years (p < 0.0001). 1-, 3-, and 5 years patients survival with single versus one staged procedures was 85.5, 80.5 and 71.0% versus 71.1, 68.0 and 74.6% (n.s.). 1-, 3-, and 5- years patients survival after OR or EVAR was 91.2, 87.1 and 80.6%, resp. 90.7, 79.9 and 74.6 % (n.s.). The significant influence on patients long-term survival had RAAA, age of patients, postoperative complications and one stage procedures. CONCLUSION: High percentage of polymorbidity was the cause of the significant 30 days postoperative mortality of patients after OR. EVAR and OR have similar long-term results. One staged procedures should be used very carefully in selected patients due to the higher mortality rate and worse long-term patients survival.