Venous reconstruction of the inferior vena cava bifurcation for retroperitoneal rhabdomyosarcoma in a child. Case report.

Retroperitoneal tumors, as well as traumatic lesions and occlusions of the bifurcation of the inferior vena cava (IVC) and the common iliac veins may require venous vascular reconstruction. We present a method for inferior vena caval bifurcation reconstruction which employs the advantages of a large size straight expanded polytetrafluorethylene (ePTFE) graft in this position after a new IVC bifurcation has been created by uniting the stumps of both common iliac veins, and construction of an arteriovenous (A-V) fistula with controlled flow to decrease the rethrombosis rate of the graft, and still not cause heart failure. This method was used in a case of recurrent rhabdomyosarcoma in an 8 year old child encroaching upon the bifurcation of the IVC as well as on both common iliac veins. The situation was managed by radical resection of the tumor and by creating a new caval bifurcation of the common iliac veins, followed by interposition of a straight ePTFE graft. An A-V fistula was created between the left femoral vein and left femoral artery using the left greater saphenous vein in controlled fashion. The arterial defect of the right common iliac artery was reconstructed by interposition of a PTFE graft end-to-end.

[Surgical treatment in patients with diabetic macroangiopathy]. / Khirurgichno lechenie na bolni s diabetna makroangiopatiia.

Diabetes mellitus is a disease distributed on a worldwide scale. Although the therapeutic approach to diabetes mellitus and its complications in current use brings about considerable prolongation of the life expectancy in diabetics, the frequency of cardiovascular complications is constantly augmenting; the latter are taken to be the underlying cause of death in this contingent of patients. The lower extremities are usually affected by chronic arterial insufficiency. The aim of this study is to analyze the results of surgical treatment of the occlusive arterial lesions in the lower extremities of diabetics, and specify the indications and type of intervention. Over a 6-year period (1987-1992), 760 arterial operations of the lower extremities are performed. Ninety-six reconstructions are done in diabetics-12.15 per cent. The youngest patient is 39 years of age, and the eldest--80 years. 75 per cent of the patients are given treatment with oral antidiabetic drugs. Most of them have concomitant diseases--72 cases (75 per cent). Seventy-one (73.96 per cent) present clinical manifestation of rest pain and/or ulcerations, and only 25 cases (26.4 per cent)--intermittent claudication according to R. Fontain. Those with arterial lesions in both segments prevailed--aorto- or iliofemoral lesion. Doppler sonography is performed in all patients with the exception of two studied by angiography. The operative procedures performed include: femoropopliteal--35, aorto-bifemoral--33, aorto- or ilio-femoral bypass-9, arterial reconstructions in both segments--14. The postoperative results are good and fair in 85 cases (88.5 per cent).(ABSTRACT TRUNCATED AT 250 WORDS)

[Carotid body tumors - diagnosis and treatment]. / Tumori na glomus karotikum - diagnostika i lechenie.

Carotid body tumors are rare, with a tendency of slow but progressive growth, giving rise to external compression and/or involvement of the carotid arteries, craniofacial nerves and other neighbouring structures. They are adequately vascularized, with surgery being the treatment of choice. Localization and vascularity require comprehensive understanding of the anatomy, and most likely, vascular surgeons with carotid experience and neurosurgeons would make the best teams. In certain cases the participation of craniofacial surgeon is likewise needed. Over the period 1989 through 1999, in the Department of Vascular Surgery, six patients presenting carotid body tumor are treated. There is not a single case with bilateral involvement, and all have negative family history for carotid body tumor. Two of them are subjected to explorative surgery elsewhere. Two patients only are asymptomatic. In 3 patients CT of the neck, and in one--MRI are used as diagnostic modalities. Five patients undergo carotid artery ultrasonography, and three--angiography. Internal carotid clamping is necessitated in one case only, undergoing explorative surgery at another hospital and presenting a big tumor, stage III (Shamblin). Postoperatively, the patients complain of slight deviation of the tongue and slurred speech. The check-up carotid ultrasound shows hemodynamically relevant stenosis of the internal carotid artery, 1 cm distally to the carotid bifurcation, without flow into the external carotid being detected. On follow-up, all patients are alive and free of local recurrences or metastases.

[Surgical treatment of vasorenal hypertension in children]. / Khirurgichno lechenie na vazorenalna khipertoniia u detsa.

Renal artery hypoplasia is a relatively rare condition in childhood causing renovascular hypertension. We present a case of hypoplasia of the proximal two thirds of the right renal artery, and almost normal distal third of the renal artery as well as normal parenchymal branches managed with hypogastric autoarterial conduit. We discuss conduit options and technical considerations when dealing with this delicate condition in paediatric population.

[Aorto-enteral fistulae: clinical course, diagnosis and management]. / Aorto-enteralni fistuli: klinika, diagnostika, lechenie.

Aorto-enteric fistula (AEF) is a very rare entity. Any direct or indirect communication between the arterial tree and the intestine represents a life threatening situation. Major symptom is gastro-intestinal bleeding with varying longevity and gravity. Preoperative diagnosis is difficult and this is why higher level of suspicion is necessary. Presence of Abdominal Aortic Aneurysm (AAA) or aorto-iliac grafts makes the diagnosis more likely. AEF are: primary, predominantly a complication of ruptured AAA, and secondary, after aorto-iliac reconstruction. The most frequent location of AEF is the end part of tue duodenum. In the group of secundary AEF the paraprosthetic type represents the most frequent morphological findings. Preoperative confirmation of an AEF however proved difficult despite the improvement in endoscopic and imaging technology. Diagnostic modality of choice is enhanced computed tomography. Management is surgical only. The choice of surgical repair is still controversial. Every effort must be made to prevent its occurrence by separating bowel and artery at the first aortic operation. Our experience in diagnosis and treatment of AEF is based on 3 cases with aorto-duodenal fistulas. Pathogenesis, clinical features and therapeutic aspects are presented and discussed.

[A case of surgically removed retroperitoneal rhabdomyosarcoma in a child requiring vascular reconstruction]. / Sudovi rekonstruktsii pri radikalno otstraniavane na retroperitonealen rabdomiosarkom u dete.

Retroperitoneal tumors engaging large vessels require vascular reconstruction when surgically removed. We present a case of retroperitoneal rhabdomiosarcoma in a child, which required inferior vena cava (IVC) grafting, creating a new bifurcation of IVC, and an A-V fistula between greater saphenous vein and femoral artery as well as grafting of right common iliac artery.

[Rupture of abdominal aortic aneurysm into the inferior vena cava]. / Ruptura na koremna anevrizma vuv vena kava inferior.

Aorto-caval fistula is a rare complication of infrarenal abdominal aortic aneurysm /AAA/, and it occurs when the aneurysm ruptures into inferior vena cava. Literature indicates that such a communication is present in less than 2% of the elective AAA resections and in 3%-6.97% of the cases of AAA ruptures. From 1986 and 2000 in the University Hospital "St. Ekaterina" 207 elective AAA cases and 43 ruptured AAA cases underwent surgery. In 2 cases (4.65% of the ruptured AAA) we encountered aorto-caval communication. We report a patient with infrarenal AAA having significant oedema of lower extremities bilaterally, treated in another hospital for iron deficiency anemia and vegetative disorders. Patient presented for consultation and abdominal Echo showed AAA. The angiogram performed demonstrated aorto-caval fistula. At surgery bifurcated graft was implanted successfully. This is the first case of diagnosed prior to surgery aorto-caval fistula followed by successful surgery reported in Bulgaria.

[Arterial reoperation of the aorto-femoral segment]. / Reoperativna arterialna khirurgiia v aorto-femoralniia segment.

Late rethromboses of aortofemoral prostheses following arterial reconstructions for aortoiliac occlusive disease (AIOD) are among the serious challenges faced by vascular surgeons. Hyperplasia of the intima, progressive atherosclerotic process, as well as regional hemodynamics impairment are taken to be the major factors promoting late rethrombosis development after arterial bypass for AIOD. It is the purpose of the study to assay the underlying causes and terms of rethrombosis in aortofemoral bypasses for AIOD, and analyze the results of the arterial reoperation procedures used. Over the period 1990-1997, 408 aortofemoral bypass procedures are performed in the University Hospital "St Catherine", with rethrombosis of the prostheses occurring in 19.45 per cent of the branches within 5 years of the initial intervention. Five methods of reoperation are used, with optimal results--100 per cent patency of prostheses--attained in aortobifemoral re-bypasses. Nevertheless, this particular operative procedure is considered as practicable in isolated, properly selected, relatively young patients free of associated diseases. In adults or patients with health problems preference is given to rather simple procedures, if possible performed under regional anesthesia, such as thrombectomy of the prosthesis (TE) using a deep femoral artery patch and/or sequence distal bypass towards arteria poplitea. The latter method accounts for limb salvage in 97.14 per cent of cases. A satisfactory outcome (88.58% preserved limbs) is likewise secured by resection of the failing distal anastomosis, and its substitution for neobifurcation towards the unobstructed AFS and APF. In elder and/or poor health patients the application of cross-over and axillofemoral bypasses are also advisable.

[Live-donor kidney transplantations. The problems of vascular reconstructions]. / Bubrechni transplantatsii ot zhiv donor. Problemi na sudovite rekonstruktsii.

The aim of the study was to evaluate the vascular surgery problems in 59 kidney transplantations from live donor, performed by the team for kidney transplantations (vascular surgeons and urologists) of Medical University--Sofia, for the period from April 1996 to May 1999. Nephrectomy was performed on 59 relatives (44 female and 15 males)--54.33 years average age. Donor kidneys were transplanted to 37 males (55.71 years average age) and 22 females (36.85 years average age). The average duration of hemodialysis prior to transplantation was 60.18 months (5.015 years). Most of donor kidneys were right--38, while only 21 were left. In six kidneys duplex renal veins were presented (10.16%), while in other 7 cases (11.76%) there were duplex renal arteries. We preferred termino-terminal anastomoses of donor renal artery to the hypogastric artery of the recipient, which provides not only better regional hemodynamics guaranteeing long term patency of the anastomoses, but presents optimal positioning of new kidney to the retroperitoneal space of recipient avoiding external compression of renal vessels. The standard performance of venous anastomoses was termino-lateral to the iliac vein of the recipient. In 7 cases, saphenous vein graft was used to replace or prolong the donor arteries or veins. Postoperative results of live donor kidney transplantation were successful in all cases, except one case (1.74% of 71 venous anastomoses) with late deep venous thrombosis of recipient's iliac vein resulting in kidney rupture and unavoidable nephrectomy. There were also 5 cases of haemorrhage (8.47%): in 3 of them from the renal hilus and in 2--profuse bleeding from the operative approach, all successfully treated after reoperation. Our satisfactory results in live donor kidney transplantation prove this method as a method of choice in certain cases of chronic renal insufficiency, especially in lack of cadaver kidneys. Contemporary vascular surgery disposes of various techniques that makes possible transplantation even in cases with serious anomalies of renal vessels. The atraumatic nephrectomy of donor kidney remains one of the main factors contributing to the successful outcome of kidney transplantation.

[Problems relating to vascular reconstruction in renal transplantation from a living donor]. / Problemi na s'dovite rekonstruktsii pri b'brechni transplantatsii ot zhiv donor.

We discuss vascular surgical problems in 59 kidney transplantations using alive donors. From April 96 till May 99 we harvested 59 kidneys from relatives (44 women and 15 men), mean age 54.33 years. Those kidneys were transplanted to 37 men (mean age 55.71 years), and 22 women (mean age 36.85 years). Preoperative dialysis was performed for a period of 5.015 years (mean). Thirty eight of the kidneys are right, and 21 of them are left. Six kidneys have two renal veins (10.16%), and 5 of them have two renal arteries (8.47%). We prefer end-to-end anastomosis between the donor renal artery and the recipient hypogastric artery. It ensures best regional hemodynamics, long-term patency and best positioning of the kidney avoiding vascular compression. The venous anastomosis is performed end-to-side to the iliac vein of the recipient. In 7 cases of short renal artery of the donor kidney greater saphenous vein is used as arterial conduit to ensure tension-free anastomoses. Only 1 patient (1.74%) of 59 cases (71 venous anastomoses) suffered thrombosis of the iliac vein, which caused kidney rupture. We had 5 cases of postoperative bleeding (8.47%), three of them were from the kidney hilus, and two from exposure sites. After reexploration all of them have normal function. Vascular anomalies and/or vascular disease do not preclude the procedure. Atraumatic harvesting of the kidney is critical.