Open revascularization in a patient with chronic mesenteric ischemia and a history of aorto-bifemoral bypass - a case report.

INTRODUCTION: This case report describes surgical treatment of chronic mesenteric ischemia in a polymorbid patient with the history of an aorto-bifemoral bypass implant. CASE REPORT: The patient suffered from chronic occlusions of the mesenteric arteries. He experienced postprandial pain and significant weight loss. Endovascular repair of the occlusions failed. Open single retrograde bypass from the left branch of the aorto-bifemoral graft to the superior mesenteric artery was implanted successfully. CONCLUSION: The discussion briefly mentions current trends in the treatment of chronic mesenteric ischemia. Despite the development of interventional radiology, surgical treatment remains a relevant alternative for the management of chronic mesenteric ischemia.

Fresh arterial allograft as a replacement for an infected common femoral prosthetic graft and recurrent false aneurysm.

Replacing an infected vascular prosthetic conduit with an allograft is a possible solution of this complication given the low recurrence of infection. It is most commonly utilized for cases where the use of autologous tissue is not an option. We present the case of a 70-year-old patient who had undergone repeated vascular reconstructions in the right lower limb. He was admitted to our department due to a progressively growing mass in the right groin and subsequently placed on the waiting list for a fresh allograft. The patient had the infected false aneurysm and prosthetic material of the femoral bifurcation replaced with an arterial allograft. The previous femoral popliteal autovenous bypass graft was reimplanted into the allograft. There were signs of sepsis during the operation; however, the blood culture was negative. Cultures from neither the wound nor the drain revealed the presence of any bacteria. The patient was discharged on the seventh post-operative day with prophylactic antibiotics. An early followup confirmed that there were no signs of recurrent infection and that the reconstruction remained patent. Seven and half months after the surgery, the femoral popliteal bypass graft became occluded and a conservative approach was chosen. A small thrombosed false aneurysm of the graft was revealed two years after the surgery due to transient non-compliance of the patient to immunosuppression therapy. It was treated conservatively. Two and a half years after the surgery, the allograft still remains open and the limb is preserved.

Early Uterine Transplant Graft Loss Due to Thrombosis: Single-Center Experience With Causes, Prevention, Diagnosis, and Treatment.

Uterus transplantation (UTx) is a promising treatment option for women who wish to give birth but suffer from absolute uterine factor infertility. This paper presents an interim analysis of a trial focusing on the causes, prevention, diagnosis, and management of graft thrombosis. Our team analyzed 10 cases of UTx (recipients numbered 1 to 10). Early thrombosis developed in 2 of 10 (20 %) recipients, and thrombectomy and temporary viability preservation were achieved in both cases. However, re-thrombosis developed in both cases, and a graft hysterectomy was carried out. In recipient number 2, vascular changes might have contributed to graft thrombosis. The histopathological finding of the explant revealed subintimal excentric fibrosis with focal sclerotic changes. In recipient number 8, thrombosis was facilitated by external compression of the vascular pedicles by the hematoma as well as production of de novo donor-specific antibodies. Thrombosis led to graft loss in both cases despite an attempt at a thrombectomy. Therefore, the focus must be on prevention including a thorough evaluation of the donor candidate. In the postoperative course, perfusion is closely followed-up with an ultrasound, Doppler flow monitoring, and macroscopic evaluation of the cervix. In the event that findings are unclear, a relaparotomy should be promptly indicated. If thrombosis is revealed, a thrombectomy and an attempt to salvage the graft are indicated; however, the role of this strategy is questionable due to the low chance of long-term success. The indication of upfront graft removal and early re-transplantation in the treatment of uterine graft remains debatable.

Thrombolysis as a treatment for transplant renal artery thrombosis - a report of three unsuccessful cases and an overview of reported cases.

INTRODUCTION: Thrombolysis has been suggested as a feasible method to treat arterial renal transplant thrombosis under conditions of short duration of ischemia. Data on maximal duration of ischemia that are still feasible to treat are scarce. METHODS: We retrospectively analysed our experience involving three attempts to utilize thrombolysis to treat transplant renal artery thrombosis. We searched through literature on PubMed and compared the data we found with our own experience. RESULTS: In case number 1 of our cohort, thrombolysis was initiated 12 hours after the onset of thrombosis and had to be ceased after five hours due to the formation of a haematoma. Perfusion of the graft was restored but it did not regain function, most likely due to long ischemia time. In case number 2, an attempt to use thrombolysis was unsuccessful due to failure to cross the graft artery occlusion with a guidewire. Thrombosis was most likely caused by chronic rejection of the graft. In case number 3, thrombolysis restored arterial patency but, due to an onset of ischemia, which lasted 2 to 3 days, did not lead to restoration of graft function. The prolonged ischemia period in case three occurred, at least in part, due to failure to perform an ultrasound scan when the patient was first admitted. CONCLUSION: We can confirm that thrombolysis for transplant renal artery thrombosis seems to be feasible only when the condition has a short duration. In the event of sudden deterioration of graft function, the absence of perfusion must always be ruled out by ultrasound scan.

Extensive bile duct injury resulting from a laparoscopic cholecystectomy resolved by a Roux-en-Y tri-hepaticojejunostomy: a case report.

INTRODUCTION: Bile duct injuries (BDIs) that occur after a laparoscopic cholecystectomy (LC) are among the most serious iatrogenic injuries and have high morbidity and mortality. They significantly impact the quality of life of the patient. They are one of the most common causes of benign biliary strictures, which can result in serious complications such as recurrent cholangitis or secondary biliary cirrhosis. Although LC is a common operation today, the incidence of BDIs associated with LC is twice that of BDIs resulting from open cholecystectomies. CASE REPORT: In this paper, we present a case report of a patient after LC with the Class III-D injury according to the Stewart-Way classification. The injury was a result of a misleading description from a preoperative ultrasonography and a subsequent misunderstanding of the anatomical conditions of a patient with congenital gallbladder agenesis. The BDI was recognised first day after surgery. Thanks to a prompt transfer to our centre the patient was in a good condition. Biliary reconstruction could be done because there was no serious inflammation or biliary peritonitis at the time of reoperation. Due to the extent of the injury a Roux-en-Y tri-hepaticojejunostomy combined with external transhepatic biliary drains was performed. CONCLUSION: Iatrogenic BDI after a LC is a rare, but potentially life-threatening complication. The main risk factor is the presence of anatomical variants of the biliary tract. Early recognition and treatment in a department with adequately experienced hepatobiliary specialists are crucial for a positive outcome. The most frequent surgical treatment is a Roux-en-Y hepaticojejunostomy.

The most recent recommendations for the surgical treatment of inguinal hernia.

INTRODUCTION: The publication of new guidelines in recent years shows that surgical treatment of inguinal hernia remains topical. The main goal is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain. The main purpose of this article is to summarize the latest recommendations in surgical treatment of the groin hernias, especially in the case of strangulation. METHODS: The authors made literature review of all the guidelines published by the hernia societies, including related articles, in the last ten years. RESULTS: The use of the EHS classification system is suggested. In elective operations, mesh repair is recommended. The Lichtenstein technique is the standard in open inguinal hernia repair. Transabdominal preperitoneal and totally extraperitoneal approach have comparable outcomes. Their clear advantages include minimal invasiveness. Mesh repair is recommended also in the case of strangulation, but only in clean and clean-contami-nated operations. A laparoscopic approach should be considered as well. Inter alia, it allows an assessment of bowel viability during the whole procedure. The need of bowel resection is hence lower compared to open surgery. If it is not possible to use the mesh, the Shouldice method is regarded as the best non-mesh repair technique. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is recommended. Hernioscopy is a simple and safe procedure that uses the hernia sac for insertion of a port following insufflation and diagnostic examination. It requires less advanced laparoscopic skills than does emergency laparoscopic hernia repair. It can be performed even by surgeons who lack sufficient experience with laparoscopy. CONCLUSION: In elective procedures, the mesh repair is recommended. It is recommended also in the case of strangulation, but not in a contaminated-dirty surgical field. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is needed.

Impact of severe diabetic kidney disease on the clinical outcome of autologous cell therapy in people with diabetes and critical limb ischaemia.

AIM: To assess the impact of autologous cell therapy on critical limb ischaemia in people with diabetes and diabetic kidney disease. METHODS: A total of 59 people with diabetes (type 1 or type 2) and critical limb ischaemia, persisting after standard revascularization, were treated with cell therapy in our foot clinic over 7 years; this group comprised 17 people with and 42 without severe diabetic kidney disease. The control group had the same inclusion criteria, but was treated conservatively and comprised 21 people with and 23 without severe diabetic kidney disease. Severe diabetic kidney disease was defined as chronic kidney disease stages 4-5 (GFR <30 ml/min/1.73 m²). Death and amputation-free survival were assessed during the 18-month follow-up; changes in transcutaneous oxygen pressure were evaluated at 6 and 12 months after cell therapy. RESULTS: Transcutaneous oxygen pressure increased significantly in both groups receiving cell therapy compared to baseline (both P<0.01); no significant change in either of the control groups was observed. The cell therapy severe diabetic kidney disease group had a significantly longer amputation-free survival time compared to the severe diabetic kidney disease control group (hazard ratio 0.36, 95% CI 0.14-0.91; P=0.042); there was no difference in the non-severe diabetic kidney disease groups. The severe diabetic kidney disease control group had a tendency to have higher mortality (hazard ratio 2.82, 95% CI 0.81-9.80; P=0.062) than the non-severe diabetic kidney disease control group, but there was no difference between the severe diabetic kidney disease and non-severe diabetic kidney disease cell therapy groups. CONCLUSIONS: The present study shows that autologous cell therapy in people with severe diabetic kidney disease significantly improved critical limb ischaemia and lengthened amputation-free survival in comparison with conservative treatment; however, the treatment did not influence overall survival.

Deceased Donor Renal Transplantation Combined with Bilateral Nephrectomy in a Patient with Tuberous Sclerosis and Renal Failure.

INTRODUCTION: A 27-year-old female patient with known tuberous sclerosis complex (TSC), polycystic kidneys with multiple large bilateral angiomyolipomas, and failing renal functions with prehemodialysis values (urea: 19 mmol/L; creatinine: 317 µmol/L; CKD-EPI 0,27) was admitted to our department for pre-renal transplant evaluation. The patient was placed on the transplant waiting list as the living donor did not pass pretransplant workup and was subsequently contraindicated. Patient was placed on the "cadaverous kidney transplant waiting list". METHOD: Computed tomography angiography revealed symptomatic PSA in the right kidney angiomyolipoma (AML). The patient underwent urgent transarterial embolisation of the PSA's feeding vessel in the right kidney AML. Based on the "kidney transplant waiting list" order patient underwent a bilateral nephrectomy combined with transperitoneal renal allotransplantation of a cadaverous kidney graft through midline laparotomy, appendectomy, and cholecystectomy. RESULTS: Postoperative period was complicated by delayed graft function caused by acute tubular necrosis requiring postoperative hemodialysis. The patient was discharged on the 17th postoperative day with a good renal graft function. Patient's follow-up is currently 23 months with good graft function (urea: 9 mmol/L; creatinine: 100 µmol/L). CONCLUSION: Renal transplantation combined with radical nephrectomy provides a definitive treatment for TSC renal manifestations.

Transabdominal two-cavity approach for radical nephrectomy combined with inferior vena cava thrombectomy for malignant thrombus caused by renal cell carcinoma: a case series.

BACKGROUND: Advanced renal cell carcinoma in some cases causes malignant intravascular thrombus with the potential for growth into the inferior vena cava or even the right atrium. Renal cell carcinoma is accompanied by malignant intravascular thrombus in up to 10% of cases. We present an overview of three patients diagnosed as having renal cell carcinoma with malignant intravascular thrombus requiring radical nephrectomy combined with inferior vena cava thrombectomy. CASE PRESENTATION: Three patients diagnosed as having renal cell carcinoma were indicated for renal cell carcinoma combined with inferior vena cava thrombectomy between 2014 and 2017 at our department: a 69-year-old white Caucasian woman, a 74-year-old white Caucasian woman, and a 58-year-old white Caucasian woman. According to the Novick classification of inferior vena cava tumor thrombus, there was one infrahepatic (level II) and two supradiaphragmatic (level IV) malignant intravascular thrombi. The average age of these patients was 67 years (range 58-74 years). All patients underwent radical nephrectomy combined with inferior vena cava thrombectomy through transabdominal approach. In patients with level IV malignant intravascular thrombus, transesophageal echocardiogram was used to guide the placement of the inferior vena cava cross-clamp above the diaphragm. In one patient the pericardium was opened to place a cross-clamp above a tumor just below the right atrium. There were no postoperative mortalities to date with an average follow-up of 23 months (range 2-48 months). To date, no patient has demonstrated recurrent inferior vena cava malignant intravascular thrombus requiring secondary inferior vena cava thrombectomy or any other treatment. A comparison of estimated blood loss and transfusion rate was not significantly different in all three cases. CONCLUSION: Despite the technical complexity of the procedure, caval thrombectomy combined with radical nephrectomy currently represents the only radical treatment for renal cell carcinoma accompanied by malignant intravascular thrombus with good mid-term oncological outcomes.

Orthotopic liver transplantation with reduced and rotated graft in adult situs inversus recipient: a case report and a review of reported cases.

INTRODUCTION: Situs inversus is a rare congenital anomaly characterized by a mirror-image orientation of abdominal and mostly also thoracic organs. Liver transplantation in these patients is a demanding procedure due to the difficulties pertaining to positioning of the graft and the presence of frequently associated vascular abnormalities. Several reports have been published regarding successful liver transplantation in adult situs inversus recipients with different proposed positions of the graft. Relevant experience remains limited. CASE REPORT: In this paper we present a case of successful transplantation of a reduced-size cadaverous left hemi-liver graft to an adult situs inversus recipient in a 90-degree clockwise rotation. A complex arterial reconstruction was established. A review of published liver transplantations in adult situs inversus recipients along with the techniques employed is provided. RESULTS: No vascular or spatial problems were encountered using this technique. The graft function is perfect at 27 months from the transplant procedure. The first liver transplantation with a reduced-size left hemi-liver graft from a situs solitus cadaveric donor to the situs inversus adult recipient is presented. CONCLUSION: The devised method of 90-degree clockwise rotation provides perfect spatial adjustment. Relatively smaller grafts are to be preferred as they allow maximum flexibility. Vascular conduits should be readily available.

Aorto-iliac endarterectomy: Old-fashioned or re-newed method?

INTRODUCTION: Aorto-iliac occlusive disease is best treated with endovascular angioplasty/stenting or surgical bypass, depending on disease severity. Aorto-iliac endarterectomy was frequently used until the 1980s. However, it can still be performed in cases of previous failure or contraindication of standard methods. The aim was a retrospective evaluation of a single-center case series of aorto-iliac endarterectomy. METHODS: Seven patients at mean age 60±8 years (5768 years) were treated by aorto-iliac endarterectomy between 2013 and 2018. Rutherford categories of leg ischemia were 2 (moderate claudication) 3x, 3 (severe claudication) 2x, 4 (rest pain) and 5 (toe gangrene). The reasons for endarterectomy approach were: late in-stent iliac occlusion in an oncology patient, failure or complication of previous endovascular treatment of short iliac stenosis 2×, high infection risk of prosthesis use in long iliac-femoral occlusion, and short iliac occlusions 3x. Two patients after previous organ transplant were on immunosuppression. RESULTS: Technical success rate was 100%. There was no peri-operative (30 days) death or amputation. Mean follow-up was 17 months (1.1 month3.3 year). One patient required additional tibial bypass 1 month after endarterectomy to heal foot gangrene. One patient developed symptomatic re-stenosis which was treated with iliac stenting 8 months after procedure. All patients clinically improved and recovered from leg ischemia. Two patients died of tumor with preserved limb 1.1 month and 3.1 years after procedure, respectively. Five remaining patients are asymptomatic with patent revascularization to date. CONCLUSION: Aorto-iliac endarterectomy is a vital alternative technique for revascularization in selected patients when other methods seem inappropriate. Key words: endarterectomy - peripheral arterial disease - iliac artery - abdominal aorta.

Liver resection for recurrent sarcoma with allogenic aortic patch as partial inferior vena cava replacement - case report and review of literature.

In this case report, we discuss the topic of hepatic sarcomas, their occurrence and treatment options. We present a case of successful radical resection in a young man with recurrent sarcoma of the liver with inferior vena cava infiltration. We describe the surgical procedure in steps and point out the severity of the disease with frequent recurrences. We also review evidence behind the topic aimed to support our treatment approach.Key words: hepatectomy - sarcoma - inferior vena cava - blood vessel prosthesis - allograft.

Attachment of human endothelial cells to polyester vascular grafts: pre-coating with adhesive protein assemblies and resistance to short-term shear stress.

Cardiovascular prosthetic bypass grafts do not endothelialize spontaneously in humans, and so they pose a thrombotic risk. Seeding with cells improves their performance, particularly in small-caliber applications. Knitted tubular polyethylene-terephthalate (PET) vascular prostheses (6 mm) with commercial type I collagen (PET/Co) were modified in the lumen by the adsorption of laminin (LM), by coating with a fibrin network (Fb) or a combination of Fb and fibronectin (Fb/FN). Primary human saphenous vein endothelial cells were seeded (1.50 × 10(5)/cm2), cultured for 72 h and exposed to laminar shear stress 15 dyn/cm(2) for 40 and 120 min. The control static grafts were excluded from shearing. The cell adherence after 4 h on PET/Co, PET/Co +LM, PET/Co +Fb and PET/Co +Fb/FN was 22%, 30%, 19% and 27% of seeding, respectively. Compared to the static grafts, the cell density on PET/Co and PET/Co +LM dropped to 61% and 50%, respectively, after 120 min of flow. The cells on PET/Co +Fb and PET/Co +Fb/FN did not show any detachment during 2 h of shear stress. Pre-coating the clinically-used PET/Co vascular prosthesis with LM or Fb/FN adhesive protein assemblies promotes the adherence of endothelium. Cell retention under flow is improved particularly on fibrin-containing (Fb and Fb/FN) surfaces.

[Intraarterial peroperative thrombolysis in therapy of the acute limb ischemia]. / Peroperacní intraarteriální trombolýza v terapii akutní koncetinové ischemie.

Acute limb ischemia is serious situation, jeopardizing limb salvage, causing embolization or thrombosis of the native arteries or vascular graft. Immediate surgical revascularization with balloon thromboembolectomy is indicated in patient with acute ischemia stage IIB of the Rutherford classification. Unfortunately, operative thromboembolectomy is frequently incomplete, with persistent thrombus remaining in the majority of patients. Residual thrombus compromises the clinical outcome, leading to poor revascularization and an increased risk of tissue loss. On depending of amount of the residual thrombus after surgical thromboembolectomy, we can choose one of the three options of intraoperative thrombolysis. This article summarized indication and technical realisation of intraoperative thrombolysis and describe cause report of the first patient treated with this method in our country. The combined use of intraoperative thrombolytics following mechanical thromboembolectomy is safe and efficacious method in patients with acute vascular occlusion.

[Clinical experience with cold-preservation of venous and arterial allografts. long-term outcomes]. / Klinické zkusenosti s pouzitím chladem konzervovaných zilních a tepenných allostepu: dlouhodobé výsledky.

INTRODUCTION: Venous and arterial allografts extend the possibilities of peripheral arterial disease as well as vascular prosthesis infections treatment. MATERIAL AND METHODS: Between 10/1997 and 1/2009 we used 112 allogeneic vessels (30 arteries, 82 veins) in 104 patients. Venous allografts were used for 82 reconstructions in 75 patients (M/F 41/34, aged 41-85 years, median 66 years) with critical limb ischemia and no suitable autogenous venous material. Arterial allografts were used in 9 patients (M/F 8/1, aged 56-77 years, median 63 years) with aortoiliac prosthetic infections or mycotic abdominal aortic aneurysms and in 20 transplanted patients (M/F 11/9, aged 32-67 years, median 56 years) with aortoiliac atherosclerotic disease. RESULTS: Patients survival rate after allovenous bypasses was 92% at 1 year and 78% at 3 years. Limb salvage rate was 67% at 1 year and 53% and 3 years. Secondary patency rate was 48% at 1 year and 27% at 3 years. Patient survival rate after alloarterial bypasses was 86% at 1 year and 69% at 3 years. No signs of arterial grafts aneurysmal formation and no need for secondary intervention of any arterial reconstruction was observed during the follow up period in any patient after alloarterial transplantation. CONCLUSIONS: Cold-stored venous and arterial allografts are suitable alternative conduits for limb salvage procedures, vascular prosthesis infections as well as for arterial reconstructions in transplanted patients.

[Vascular prostheses: 50 years of advancement from synthetic towards tissue engineering and cell therapy]. / Cévní protézy: 50 let vývoje od syntetických k tkánovému inzenýrství a bunecné terapii.

Since more than 50 years, the gold standard in synthetic vascular prostheses has been represented by polyethylene terephtalate (PET, Dacron) and expanded polytetrafluoroethylene (ePTFE). These polymers perform well as sustitutes of large-caliber vessels, however, their long-term patencies are disappointing in small-caliber applications (< 6 mm). Thus, patient's own artery or vein remains the material of choice in coronary, crural or microvessel bypass surgery. Synthetic materials fail due to thrombosis and insufficient healing process that consists in highly incomplete endothelial cells coverage and intimal hyperplasia caused by compliance mismatch and hemodynamic imbalance. To find better small-caliber vascular graft, surgical techniques have been modified, novel biomaterials have been investigated and cell and tissue culture technologies have been adopted. Partly or fully tissue-engineered vascular grafts have been produced and experimentally and clinically evaluated with some promising result. The aim of this review is to briefly list currently used and examined vascular graft materials with special attention to cell/biomaterial ineractions, tissue engineering and authors' own experience.

Blood vessel replacement: 50 years of development and tissue engineering paradigms in vascular surgery.

The gold standard material in bypass surgery of blood vessels remains the patient's own artery or vein. However, this material may be unavailable, or may suffer vein graft disease. Currently available vascular prostheses, namely polyethylene terephthalate (PET, Dacron) and expanded polytetrafluoroethylene (ePTFE), perform well as large-caliber replacements, but their long-term patency is discouraging in small-caliber applications (<6 mm), such as in coronary, crural or microvessel surgery. This failure is mainly a result of an unfavorable healing process with surface thrombogenicity, due to lack of endothelial cells and anastomotic intimal hyperplasia caused by hemodynamic disturbances. An ideal small-diameter vascular graft has become a major focus of research. Novel biomaterials have been manufactured, and tissue-biomaterial interactions have been optimized. Tissue engineering technology has proven that the concept of partially or totally living blood vessels is feasible. The purpose of this review is to outline the vascular graft materials that are currently being implanted, taking into account cell-biomaterial physiology, tissue engineering approaches and the collective achievements of the authors.