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.

Electrophysiological changes of the spinal cord during thoracoabdominal aortic clamping -- Experimental study / Thoracoabdominalis aortakirekesztés során fellépo elektrofiziológiai változások a gerincveloben

Severe neurological complications of the thoracoabdominal aortic clamping were published in numerous clinical and experimental studies. These hardly predictable, devastating consequences demanded to develop a monitoring system which might detect impending level of spinal cord ischemia in time ­ in order to introduce or enhance protective procedures and prevent permanent neurological deficit. The most widely used monitoring in clinical practice is the continuous surveillance of the motor evoked potentials (MEP) during and after thoracoabdominal aortic clamping. Much less used, but promising opportunity is to control the metabolic changes and cellular integrity utilizing specific markers like liquor lactate and neuron specific enolase (NSE) etc. In our earlier study we published data of our canine experiment related to coherencies between neurological outcome and specific perfusion of the spinal cord during and after one hour thoracoabdominal aortic clamping. In the present paper we investigate the behavior of motor evoked (MEP) and sensory evoked (SEP) potentials related to neurological changes. We conclude the behavior of SEP values hardly correlate with the neurologic outcome, meanwhile decrease of MEP amplitude provides reliable signal for developing spinal cord ischemia. We could not confirm a numeric correlation of these data and the level of the final neurologic outcome.

Surgical ischemia and reperfusion of the spinal cord ­ effect on specific perfusion and neurological outcome. Experimental study / A sebészi gerincvelo ischemia és reperfusio hatása a specifikus átáramlásra és a neurológiai következményekre

Clamping of the thoracoabdominal aorta reduces perfusion of the spinal cord significantly, which clinically may present as paraparesis or paraplegia ­ devastating and unpredictable complications of open thoracoabdominal aortic surgery. Introduction of monitoring of evoked potentials and/or biochemical markers, methods increasing distal arterial pressure, indirect procedures enhancing residual flow (like liquor drainage), drugs, and use of hypothermia contributed to achieve better outcome. Preconditioning of spinal cord circulation is also a promising method. New endovascular techniques for thoracoabdominal aortic aneurysms and dissections reduced surgical trauma significantly. Despite all these progressions spinal cord ischemic damage is still a significant risk. To address this problem we carried out an experimental work using a canine model focusing on the protective effect of distal arterial perfusion, spinal fluid drainage, and their combination in a one hour setting of thoracoabdominal aortic clamping. In this paper we publish our data of circulatory and specific perfusion parameters of the spinal cord during and after declamping in correlation of final neurologic outcome.

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.

Interdisciplinary Management of Visceral Artery Aneurysms and Visceral Artery Pseudoaneurysms.

The paper presents the results of treating 14 patients, namely eight patients with visceral artery aneurysms and six patients with visceral artery pseudoaneurysms. In 64.3% of the patients, the initial diagnosis was made based on the ultrasound examination. All the patients (100%) underwent CT angiography, while angiography was performed in 71.4% of the cases. Five (35.7%) patients with visceral artery pseudoaneurysms were emergently hospitalized; among them, the signs of bleeding were observed in 2 patients. In 9 patients, pathology was detected during tests for other conditions. Five (35.7%) patients underwent endovascular treatment, while 9 (64.3%) patients received surgical treatment. Endovascular interventions and open surgery demonstrated a nil mortality rate. After endovascular treatment, stent thrombosis was found in 1 patient. In the case of surgical treatment, visceral artery aneurysm was observed in 1 patient who underwent the resection of superior mesenteric artery pseudoaneurysm. Conclusions. The choice of the method of treating visceral artery aneurysms and visceral artery pseudoaneurysms depends on the location, size, anatomic features of the visceral arteries and the clinical course of the disease. Both endovascular and surgical treatment demonstrate good postoperative outcomes. Visceral ischemia is one of the most serious complications in the postoperative period, which can complicate both the diagnosis and the choice of treatment tactics.

[Visceral complications of the aortic dissections - indications and technique of the thoracoabdominal refenestration]. / Aortadissectiók zsigeri szövodményei ­ a thoracoabdominalis refenestratio javallata és technikája.

Aortic dissection is a life threatening cardiovascular catastrophy. Its incidence estimated to 5-6 cases per 100,000 patients/year. The intimal tear happens at the ascending aorta in Type A, meanwhile at the aortic isthmus in Type B, but entry point may develop anywhere alongside the entire aorta. All types may affect a short aortic segment resulting in a localized false aneurysm, others separate the intimal layer at longer extension down to the visceral segment and far beyond to the femoral arteries. Dissection of orifices of side branches may lead to cerebral, upper extremity, spinal, visceral, renal and lower extremity malperfusion. These complications beyond the aortic rupture contribute significantly to high mortality of dissection. Today, first line treatment option in Type A dissection is surgery, but it can be endovascular or medical in Type B dissection. However, awareness of surgical procedures in this field remains inevitable. In this paper we summarize the surgical options for distal malperfusion affecting spinal, visceral, renal and lower extremity circulation.

[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.

A mellkasi aorta tompa sérülése - kezelési taktika, eredmények.

The blunt injury of the thoracic aorta constitutes one of the most severe chapter of traumatology. Open and transmural aortic injury leads to death on site, but its blunt trauma provides chance for survival if expeditious transport, diagnostic workup and proper selection of treatment are given. The blunt trauma of the aorta usually is a part of multiple injuries which determines the final outcome significantly. To select among acute, subacute interventions and conservative treatment options needs great experience following personalized algorithm. The wide variety of the clinical picture makes difficult to formulate an individualized clear guideline - so we think it is important to summarise own experiences and overview related literature.

[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.

[Thoracoabdominal aortic aneurysm hybrid repair]. / Thoracoabdominalis aneurysma hybrid megoldása.

Introduction of endografting has significantly changed the treatment options of aortic aneurysms; they can be successfully applied for aortic arch or thoracoabdominal aorta aneurysm repairs, as well. In order to create safe landing zones for the endografts on these segments, a modification of the original anatomy is needed using transpositions and/or bypasses, which is called "debranching". These hybrid procedures that combine traditional and endovascular techniques may reduce surgical trauma and offer solution for patients being unfit for major surgery. We carried out a hybrid intervention in a lady who had a 60 mm Crawford Type IV aortic aneurysm including the orifice of the celiac trunk. First, an aorto-splenic artery PTFE bypass was performed and the celiac trunk was oversewn proximally to its trifurcation. The spleen remained viable through the gastroepiploic artery. Four days thereafter we covered the aneurysm using a 34 mm Thoracic Excluder. The patient tolerated both procedures well, and was discharged in stable condition. One year after this intervention, a follow-up CT scan confirmed the good position of the endograft, no endoleak and involution of the aneurysm was detected. Good patency of the aorto-splenic artery bypass was seen. This was the first thoracoabdominal hybrid surgery case performed in Hungary.

[Bilateral internal carotid aneurysms]. / Bilateralis carotis interna aneurysma.

The authors discuss the treatment of five patients with bilateral carotid aneurysms and review the relevant literature. During the preoperative workup duplex scan, angiography and CT scan were obtained. The diameter of the aneurysms was in the range from 9 to 40 mm. Treatment plans were largely individualized. Two patients had bilateral and two had unilateral reconstructions carried out with end-to-end anastomosis. One patient was treated conservatively. In one case, a staged approach was chosen due to multiple aneurysms. As a postoperative complication, a reversible stroke was detected in one patient. All patients were followed up (between 3 to 14 years) by six monthly duplex scans. The authors suggest surgical treatment for carotid aneurysms with a diameter above 15 mm, increasing size, thrombotic plaques or neurological sings in order to avoid high risk complications (compression, rupture, embolisation).

[Hybrid solution in aortic arch surgery]. / Hybrid megoldások az aortaív sebészetben.

Since the introduction of endografts, treatment of vascular diseases has remarkably changed. Due to less surgical trauma patients--those were not amenable to open surgery--now have the chance to be treated with remarkably lower risk. At certain segments of the aorta with life important side branches combination of open surgery is needed to get free segment for deployment of endografts. These "hybrid" interventions have opened new horizon at aortic arch surgery without use of cardiopulmonary bypass and deep hypothermia. In selected types of diseases by debranching of the aortic arch and transposition of the supra-aortic trunks we can achieve suitable landing zones to fix the endografts properly. In this paper we provide an overview of the possible solutions.

[New chapter of vascular surgery; stent-graft placement in the treatment of aortic aneurysm]. / Az ersebészet uj fejezete: az aorta aneurysmák endoluminalis "stentgraft" kezelése.

INTRODUCTION AND AIM: This paper deals with a novel chapter of aneurysm surgery, the stent-graft implantation. The interdisciplinary cooperation between angio-radiology and surgery made available a much less invasive therapeutic option. The new technique was first applied in 1991.The authors present the technique, conditions and results of the procedure and also give a survey on the domestic situation. METHOD: In general anaesthesia using inguinal approach a self-expanding stent-graft (diameter: 8 mm) equipped with barbs was inserted in the aorta and deployed into the aneurysm under X-ray guidance. Vanguard (Boston-Scientific Co.), Talent (Medtronic Co.) and Exluder (Gore-Tex Co.) instruments were used. RESULTS: In 40 patients (29 men and 11 women, mean age: 59.7 years) 55 stent-grafts were implanted. Thirty-one thoracic and 9 infrarenal aneurysms were treated. In 3 patients ruptured aneurysm, in 3 other instances covered ruptured aneurysm, and in 3 persons symptomatic aortic aneurysm were treated. Thirty-one patients underwent elective procedures. Two deaths occurred in the early, and 4 in the late postoperative period (at months 3, 6, 7 and 36 postoperatively). In 9 patients adjunctive vascular surgery interventions were performed in 13 instances. Primary endoleak occurred in 3, whereas secondary endoleak was observed in 4 instances. All of these healed spontaneously. The authors compared the domestic results with internationally published data. This included 1120 traditional aneurysm resections and 110 stent-graft implantations performed in Hungary and 2283 surgical and 3843 endovascular procedures published in international scientific journals. CONCLUSIONS: The indications for this new procedure are still being formed. Despite the higher incidence of complications, this less traumatic intervention can be applied with benefit for patients. Nevertheless, at the time being, financial considerations may prevent the more widespread use in the practice. In Hungary the conditions are already available for this endovascular treatment and the authors support its employment.