Surgical solutions in multivisceral arterial occlusions / Sebészi megoldások krónikus multivisceralis arteriás elzáródások esetében

Introduction: Acute occlusions of the visceral arteries result in fulminant clinical consequences and without fast and appropriate treatment may lead to fatal outcome. If the obliterative disease has slow progression the huge capacity of the collateral circulation of the visceral arteries may remain free of symptoms at long run. By progression of the obliterative disease and extension to both, the renal arteries and the aortoiliac segment the clinical picture becomes more colourful. Symptoms mimicking other abdominal disorders may easily lead to misdiagnosis and/or unnecessary delay of adequate treatment ­ finally to organ or life threatening condition. In the present paper we deal with this infrequent, but severe disease in order to recognize it in time, to recommend proper diagnostic workup and propose adequate treatment.

Treatment options for complex aortic aneurysms ­ own experiences / Complex aortaaneurysmák kezelési lehetoségei - saját tapasztalatok

Complex aortic aneurysms extend to more aortic segments, and/or include one or more orifices of highly important side branches. Meanwhile complex aneurysms need reconstructive solutions in one sitting or hybrid procedures timely close to each other, multiple aneurysms can be treated technically and timely separated. Previously, open surgery was the only opportunity to intervene, which was associated with significant surgical trauma and was not suitable for high risk patients when devastating complications were likely. Recently combination of lower risk surgery with endovascular treatment options ­ the so called hybrid techniques ­ resulted in that indications for treatment remarkably widened. In addition, permanent technical progress made available pure endovascuar solutions, so a wide range of surgical procedures provide number of options for treatment. In this paper we report on the treatment options of complex aortic aneurysms, and present our own relevant experience.

Kommerell diverticulum ­ rare complications of a rare disease / Kommerell diverticulum - egy ritka betegség ritka szövodményei

Incidence of anomalies of the aortic arch is estimated 1-2 per cent in newborn babies. Lusory artery may arise either from left sided aortic arch in 0.7­2 per cent, or from right sided aortic arch in 0.4 per cent. Leading symptoms develop from compression of the oesophagus or trachea, or both. If lusory artery dilates conically over the time reaching 3 cm or more we call it Kommerell diverticulum. Very rare complications of this are the Type B aortic dissection, which may turn into chronic thoracoabdominal aneurysm, or its shaggy inner surface can be the source of upper extremity embolism. Rupture is extremely rare complication. In our report we focus on five cases of the mentioned complications with their clinical workups and technical solutions. In a female patient with right sided arch transection of the lusory artery was followed by transposition into the right common carotid artery. The central stump 10 years later gradually expanded and the saccular aneurysm indicated intervention. After complete arch debranching thoracic endograft was implanted. In this group of patients with variable surgical and hybrid procedures neither complication nor mortality occurred.

[Surgical treatment of atypical aortic coarctation -- long-term results]. / Atípusos aortacoarctatiók sebészi kezelésének hosszú távú eredményei.

INTRODUCTION: Aortic coarctation is a frequent congenital cardiovascular disorder representing 5-8% of all cases. It is typically localized in the isthmic region. However, in about 1% of cases coarctation may develop in atypical sites of the aorta and it is frequently complicated with severe hypertension. AIM: The aim of the authors was to present diagnostic and surgical methods used in 27 patients with atypical aortic coarctation during the last 35 years with special interest on long-term results. METHOD: There was a great advance in diagnostic and surgical treatment methods during the time period analyzed in this study. Nowadays morphologic diagnosis is most commonly obtained using computed tomography angiography and magnetic resonance angiography. Some cases were treated with endovascular techniques, but the authors used also a wide variety of surgical approaches in these patients with atypical aortic coarctation. RESULTS: No patient died after surgery and hypertension was reduced in all patients, too. Reintervention was necessary in patients operated in childhood due to change of body measures. CONCLUSIONS: Atypical aortic coarctation can be treated surgically with good early and late outcomes. Somatic growth of children may indicate surgical revision.

[Nutcracker syndrome - treated by surgery]. / Nutcracker-syndroma sikerrel operált esete.

The nutcracker syndrome is caused by tight compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. The consequences may vary between symptomfree conditions through moderate proteinuria and hypertension to severe hematuria. All imaging modalities have been used during diagnostic workup. Wide varieties of surgical and endovascular solutions are reported aiming to achieve decompression of the renal vein like venous or arterial transposition, bypass, renal autotransplantation, stenting, nephrectomy, etc. In our case a 21-year-old man the nutcracker syndrome was successfully solved by transposition of the superior mesenteric artery into the infrarenal aorta.

["Debranching" -- a new surgical option for the aortic arch and thoracoabdominal aorta hybrid interventions]. / "Debranching" -- új érsebészeti feladat az aortaív és a thoracoabdominalis aorta hibrid mutétei számára.

INTRODUCTION: Endovascular techniques in vascular surgery are frequently applied to treat aortic diseases. These minimally invasive procedures changed aortic interventions remarkably. We have to be familiar with new terminology and methods. METHOD: New and old surgical procedures gained new role in preparation of endograft implantations. Transforming anatomy of aortic branches - "debranching" - is aimed to create a sufficient fixation of the endografts at safe "landing zones". CONCLUSIONS: Knowing the option of hybrid procedures is a fundamental requirement for the vascular surgeon. Equally important is to know the biomechanical characteristics of the available endografts, the possible complications during and after implantation and the treatment options. We have to be aware of the limitations of these new methods and the role of traditional open surgery in the new era. Our intention in this paper is to summarize methods of debranching.

[Late complications and treatment options of aortic coarctation operated in childhood]. / Gyermekkorban operált aortacoarctatiók késoi szövodményei és ellátásuk.

INTRODUCTION: The prevalence of congenital aortic coarctation is 4 in 10 000 live birth. Aortic coarctation is typically located in the aortic isthmus, but it may occur at atypical sites. Treatment options include both surgical and endovascular interventions. In patients undergoing surgical or endovascular intervention late complications such as recoarctation or aortic aneurysm may develop. AIM: The aim of the authors was to analyse their own experience in late complication and treatment options of aortic coarctation operated in childhood. METHOD: Retrospective analysis of data of 32 patients treated between 1980 and 2014 for late complications 8-42 years after surgical treatment of aortic coarctation. RESULTS: In 28 patients aneurysm formation after isthmic patch plasty was found. Two patients had aortobronchial fistula, 2 patients showed anastomosis disruption and 2 patients had graft stenosis. During operation hybrid solution was performed in 23 patients, isthmic aorto-aortic inlay graft interposition in 5 patients, aorto-aortic bypass in 2 patients, subclavio-aortic bypass in 2 patients, graft patch plasty in one patient and ilio-renal bypass in one patient. Complications included severe intraoperative bleeding in one patient and pneumothorax in one patient. No early or late mortality occurred. CONCLUSIONS: The authors conclude that life long control is mandatory in order to detect late complications in patients who underwent operation of aortic coarctation in childhood.

[Penetrating atheromatous ulcer of the thoracic aorta. Treatment options]. / A mellkasi aorta penetráló atheromás ulcusa. Kezelési lehetoségek.

INTRODUCTIONS: Atherosclerosis is a generalized degenerative disease of arteries. A rare manifestation of that is the penetrating atheromatous aortic ulceration of the aortic wall which may be complicated by subintimal hematoma, dissection, false aneurysm and rupture (acute aortic syndrome). AIM: The aim of the authors was to analyse their experience with this rare disease. METHOD: In the department of the authors 10,212 patients underwent surgery for cardiovascular diseases. Among these, 18 patients were diagnosed with penetrating atheromatous aortic ulceration located in the thoracic aorta (ascending aorta 2, aortic arch 8, descending aorta 6 and thoracoabdominal aorta 2 patients). Severe comorbidities were present in the majority of patients. RESULTS: Depending on the localisation the authors used various treatment options such as open surgery (4 patients), hybrid techniques (7 patients) and pure endografting (7 patients). One patient died on postoperative day 3. Two patients had late complications due to endoleaks treated successfully by open surgery. CONCLUSIONS: The authors conclude that when this dangerous condition detected in time, a wide variety of open, hybrid and endovascular methods can be applied with good results.

[Splenic vein aneurysm -- a case report]. / Lépvéna-aneurysma operált esete.

Authors report a very rare case of splenic vein aneurysm in a 34-year-old female patient. She underwent investigation for upper abdominal pain which was not related to eating. Diagnostic workup revealed a thin wall saccular splenic vein aneurysm of 40 mm in diameter which caused an indentation of the posterior wall of the pancreas. She underwent surgery, a tangential resection was carried out preserving the continuity of the splenic vein and spleen. The patient had an uneventful postoperative course and she was discharged on the 5th postoperative day.