Results of surgical treatment of inferior vena cava tumor thrombi in renal cell carcinoma.

INTRODUCTION: Thrombosis of inferior vena cava (IVC) is an important complication amongst oncological patients. Tumor thrombus of IVC is characteristic for patients with renal cell carcinoma, occurring in 1018%. The aim of the work is to analyze of surgical treatment in patients with cancer thrombosis of inferior vena cava in kidney cancer. METHODS: Between 2010 and 2019 we treated 32 patients with kidney cancer complicated by thrombotic infiltration of the inferior vena cava. According to Nesbitt classification the levels of thrombotic infiltration of the inferior vena cava were: I-8 (25%), II-14 (43.8%), III-6 (18.8%), and IV-4 (12.5%). Nephrectomy with thrombectomy of the cancer thrombus in the inferior vena cava was performed in all patients. In addition to laparotomy, sternotomy was approached in 4 patients with Nesbitt IV and in 2 patients with Nesbitt III. RESULTS: Primary suture of IVC was performed in 26 patients; angioplasty of IVC was performed in 4 patients; and resection of IVC with replacement using a polytetrafluoroethylene interposition graft was done in 2 patients. Radical surgical treatment was performed in 27 (84.3%) patients, and palliative in 5 (15.6%) patients. In the postoperative period, 1 (3.1%) patient (Nesbitt IV) died of cardiac failure during hospitalisation. Two-year survival was observed in 75% of the cases. CONCLUSION: Tumorous infiltration of IVC is associated with a high potential for tumour embolisation to the lungs, leading to the formation of multiple metastases and spreading of the underlying disease. Postoperative comfort is improved considerably after nephrectomy of the affected kidney and removal of the tumour thrombus, including IVC resection as appropriate, and when combined with oncological treatment, the survival rate is increased significantly, as well.

Thoracoabdominal endaortectomy in case of type B aortic dissection.

Despite remarkable progress in both, diagnostic and therapeutic development in treating aortic dissections, this continues to be one of the most severe vascular disorders and is subject to high mortality rates. While aortic dissections of Type A can be treated surgically today, in the majority of patients with Type B dissections hypotensive treatment is the method of choice, providing a better chance of survival and the effective prevention of aneurysm formation and rupture at the site of the intimal tear. However in certain cases, Type B dissection generates either isthmic aneurysm formation, or, with distal progression, may result in long segmental thoracic, thoraco-abdominal or abdominal deterioration of the aorta and its side branches. The spinal, visceral, renal and lower limb ischemia threatens the viability of these organs and hypotensive medication may enhance this risk. Emergency diagnostic work-up and selective surgical reconstruction could lead to reduced mortality. In our department we have undertaken 33 thoracoabdominal endoaortectomies with meticulous reconstruction of renal and visceral orifices. The mortality rate in this subgroup of patients was 6%. Based on our experience with Type B aortic dissections we recommend open "endoaortectomy" in selected cases in order to improve the long-term outcome.

[Management of carotid injuries]. / Az arteria carotis sérülései és azok ellátása.

The occurrence of carotid arterial injuries is relatively infrequent but have serious outcome. At the Department of Cardiovascular Surgery we have performed surgical interventions in 16 instances (7 penetrating and 9 blunt trauma patients) due to carotid injuries. Preoperatively all these patients developed neurological deficits and in the postoperative period 7 patients became asymptomatic. We lost two patients owing to stroke. Vascular injuries are generally characterized by hemorrhage and ischemia in the area supplied. In addition to the symptoms of hemorrhagic shock, penetrating vascular injuries may lead to embolism from the injured intimal surface, thrombus formation and subsequent occlusion may occur. In other instances pulsating hematomas can be formed and with combined arterial and venous trauma A-V fistula can develop. In blunt trauma patients stretching or compression of the vessel may cause intimal rupture with subsequent formation of subintimal hematoma, dissection and later pseudoaneurysm. The disruption of the atherosclerotic plaque or the accumulation on the injured intimal surface may serve as source of embolism and thrombosis. In symptomatic patients the urgent performance of the surgical correction of the carotid arterial injuries is mandatory, nevertheless in asymptomatic patients and in chronic cases the prevention of the late complications is also justified as soon as possible.

[Surgical considerations in type-B aortic dissection]. / Sebészi megfontolások B típusú aorta disszekció esetében.

Inspite of remarkable progress in both diagnostic and therapeutic development in treating aortic dissections this continues to be one of the most severe vascular catastrophies complicated by high mortality. While aortic dissections Type A are to treat surgically in our days, in majority of patients with Type B dissections hypotensive treatment is the method of choice providing better chance for survival preventing effectively aneurysm formation and rupture at the site of intimal tear. However in certain cases Type B dissection produces either isthmic aneurysm formation, or with distal progression may afflict long segmental thoracic, thoracoabdominal or abdominal deterioration of the aorta and its side branches. The spinal, visceral, renal and lower limb ischemia threatens viability of these organs and hypotensive medication may enhance risk. Prompt evaluation and selection of these cases with proper surgical reconstruction help us to reduce mortality. At our department we have performed 33 thoracoabdominal endoaortectomies with meticulous reconstruction of renal and visceral orifices. The mortality rate in this subgroup of patients was 6%, meanwhile almost 70% in those, treated medically but had the severe distal branch involvement. Based on our experiences in selected patients with Type B aortic dissections we recommend this procedure in order to achieve improvement of results.

[New method for the intraoperative biochemical monitoring of cerebrospinal fluid in surgery of thoracoabdominal aortic aneurysms]. / Uj módszer a cerebrospinalis fluidum (CSF) intraoperatív biokémiai monitorozásában thoracoabdominalis aortaaneurysma-mútétek során.

Paraplegia remains to be one of the most dangerous complications following thoracoabdominal aortic surgery with an incidence of 0.5 to 40%. Therefore, intraoperative monitoring of spinal cord function is very important when choosing the appropriate surgical technique. Early detection of spinal cord injury continues to be a crucial problem, moreover, the currently applied electrophysiological methods appear to be inaccurate. The aim of the study was to detect prospective spinal cord injury intraoperatively by monitoring the biochemical parameters of the cerebrospinal fluid (CSF). The authors studied the reversible aerobic/anaerobic metabolic changes by monitoring CSF lactate levels, moreover S-100 protein and neuron-specific enolase (NSE) concentrations--specific for neuroglia and neuronal injury, respectively. One of the important methods to prevent paraplegia is the intraoperative CSF drainage, which may improve spinal cord perfusion. Between 1996-1998 51 patients underwent reconstructive thoracic or thoracoabdominal aortic aneurysm operation. The continuously drained CSF was collected in 10 ml fractions during the preparation, whereas during aortic cross-clamping and de-clamping 10 minute fractions were used. All CSF samples were immediately analysed intraoperatively for pH, pCO2, HCO3, potassium and lactate levels, S-100 protein and NSE were analysed by immunoluminescence. CSF lactate levels increased slightly during aortic clamping and a moderate, but non-significant increase was found in the hyperemic phase (reperfusion) in patients without spinal cord ischemia. Spinal cord injury was detected in 7 cases. These patients exhibited a significant CSF-lactate increase (control vs aortic cross-clamping: 1.9 vs 5.3 mmol/l), moreover CSF-lactate remained elevated throughout the whole operation. Paraplegia did not occur, Tarlov 2 paraparesis developed in four cases and three patients displayed cerebral damage. Intraoperative CSF--especially CSF-lactate--monitoring may help the operating team to detect early anaerobic changes of the metabolism the spinal cord.

[Popliteal artery entrapment syndrome]. / Térdhajlati veróér leszorítása.

Popliteal Artery Entrapment Syndrome (PAES) is an uncommon congenital anomaly. It arises due to compression of the popliteal artery by tendomuscular structures often combined with an anomalous position of the artery. Mostly young men are suffering of this disease. There are four common variations of this anomaly. We report on a 14 year old patient who had an acute 24 hours duration right leg ischemia caused by PAES. Using a posterior approach to the popliteal artery, following division of the accessory slip of gastrocnemius muscle we performed an arteriotomy and a floating thrombus was removed. The artery was reconstructed by direct continuous suture. One year postoperatively the boy has no complaints, peripheral pulse is palpable.

[Effect of regional hypothermia on cerebrospinal fluid parameters during thoracoabdominal aorta clamping in dogs]. / Regionális gerincveló hypothermia hatása a liquor összetételére thoracoabdominalis aortakirekesztés során állatkísérletben.

The most feared complication of thoracoabdominal clamping is the paraplegia or paraparesis following ischemic injury of the spinal cord. Early intraoperative recognition of this complication has not been solved yet. In our earlier experiment we found significant alterations of CSF glucose, lactate, pCO2 and Neuron Specific Enolase (NSE) levels during 60 minutes thoracoabdominal aortic clamping in dogs. The analysis of these parameters proved to be proper to follow metabolism of the spinal cord during this type of surgery. In our present paper we studied protective effect of regional hypothermia using peridural cooling by registration of above parameters. Statistical analysis of our data showed prevention of production of anaerobe metabolites in animals with icy peridural irrigation. The biochemical approach is appropriate for monitoring effectiveness of regional hypothermia of the spinal cord during aortic surgery.

[Bilateral renal artery stenosis diagnosed during pregnancy]. / Terhesség folyamán felismert kétoldali arteria renalis stenosis.

Bilateral renal artery stenosis was diagnosed noninvasively in the 17th gestational week, in a chronically hypertensive pregnant woman, by renal artery duplex ultrasound examination, MRI and MR angiography. Continuous monitoring of the mother and the fetus was performed. Blood pressure was stabilized by complex antihypertensive therapy, but from the beginning of the third trimester superimposed preeclampsia developed gradually. In the 34th gestational week a 1600-g newborn was delivered by elective cesarean section. The case report draws attention to the significance of the thorough examination of hypertensive women before pregnancy.

[Traumatic rupture of the descending aorta]. / Az aorta descendens traumás eredetü rupturája.

During a ten-year period 16 patients were seen with aortic rupture and false aneurysm secondary to blunt trauma. One patient underwent an acute operation, 4 patients had operative therapy elective delayed and 11 patients were operated on for chronic traumatic false aneurysm. Operative delay was done in case of simultaneous multisystem injury (e.g. shock caused by abdominal injuries, cerebral contusion or pulmonary contusion on the right side). The shunt bypass method of repair was used in the case of 3 patients, cardiopulmonary bypass in 6 cases and simple aortic cross-clamping in 6 patients. One operation was performed without aortic cross-clamping. Primary repair was achieved in three patient, in 3 more cases a patch was inserted and in 9 cases interposition Dacron grafting was accomplished. One "wrapping" operation was performed. In 2 cases, reoperation was necessary because of postoperative bleeding. One patient died in the perioperative period. Right sided hemiparesis occurred in one patient postoperatively. Rupture does not affect the whole aortic wall, especially in young people because of the natural elasticity of vessel. The appearing shock and hypotension might protect the mediastinal pleura against bursting. This could provide a chance to survive. Our experience indicate: Elective delay of operation in patients with multiple system injuries can be achieved with antihypertensive therapy.

Surgical management of renal artery aneurysm.

Between 1978 and 1990, 32 patients (15 men and 17 women; mean age 48 (range 15-83) years) underwent 35 operations for renal artery aneurysm (4.2% of 829 renal artery repairs). Eleven patients presented with acute symptoms (nine with hematuria, eight with abdominal pain, two with acute hypertension). Twenty-eight of the 32 patients had chronic hypertension. The diagnosis was confirmed by angiography in all but two. The mean diameter of the renal artery aneurysm was 1.7 (range 0.7-9.0) cm. Seventeen patients had concomitant renal artery stenosis; none of the aneurysms ruptured. Nephrectomy was performed in seven patients and excision of the aneurysm without reconstruction in five. Twenty patients underwent 23 reconstructions using lateral suture (three procedures), vein patch (three), saphenous vein (13), Dacron (three) or composite (vein and hypogastric artery) graft (one). Seven patients underwent ex vivo renal artery repair. There was no perioperative death or secondary nephrectomy. One postoperative graft occlusion was successfully revised. Hypertension improved in 50% of patients. The presence of hypertension, enlargement of a renal artery aneurysm, solitary kidney, bilateral involvement, acute hematuria or potential loss of kidney or renal function may be indications for surgical treatment of an aneurysm > 1.5 cm in diameter. A renal artery aneurysm of any size should be repaired in women who may become pregnant. Where there is branch involvement, ex vivo repair is the procedure of choice for renal salvage.

Failure of selective shunting to intercostal arteries to prevent spinal cord ischemia during experimental thoracoabdominal aortic occlusion.

Paraplegia from spinal cord ischemia during thoracoabdominal aneurysm repair remains an unpredictable and unpreventable complication. In an effort to prevent spinal cord ischemia during aortic cross-clamping, preoperative angiographic localization of the blood supply to the spinal cord was performed in dogs. Sixteen animals underwent 60 minutes of thoracoabdominal aortic cross-clamping either without (control, n = 8) or with (shunted, n = 8) a selective shunt. Shunting was performed from the aortic arch to that isolated aortic segment angiographically shown to supply the thoracolumbar anterior spinal artery. Spinal cord blood flow was measured with microspheres just prior to cross-clamping, at 5 and 60 minutes after cross-clamping and at 5 minutes after restoration of aortic blood flow. Functional neurologic outcome was evaluated in animals at 24 hours postoperatively. Shunting did not decrease spinal cord injury. Seven of the 8 animals in the control group and 7 of the 8 in the shunted group developed paraplegia or paraparesis. Thoracic, but not lumbar spinal cord blood flow, was significantly increased in shunted animals. Spinal cord blood supply in dogs may be more segmental than previously believed. Technical problems in angiographic localization, spinal artery spasm, loss of spinal cord autoregulation or poor collateral circulation from the distal thoracic to the lumbar cord may also account for these results. Although shunting to aortic segments supplying the anterior spinal artery during thoracoabdominal aortic clamping may be attractive in humans, no benefit could be shown in this experimental model.

Primary venous leiomyosarcoma: a rare but lethal disease.

Primary venous leiomyosarcoma is rare, only 197 patients have been reported. To examine progress in diagnosis, treatment, and clinical outcome, we retrospectively reviewed data of 13 patients, 12 women and one man (mean age, 55 years; range, 19 to 75 years), who in the last 35 years underwent surgical treatment for primary venous leiomyosarcoma at our institution. The tumor arose from the inferior vena cava in eight, iliac vein in two, ovarian vein in one, and greater saphenous vein in two patients. Primary venous leiomyosarcoma was detected by physical examination in nine patients, symptoms were present in six. The 13 patients underwent 16 surgical procedures to resect primary (12), recurrent (2), or metastatic (2) tumors. Local excision alone was performed in seven, and local excision with reconstruction of the inferior vena cava or iliac vein was performed in six patients. The tumor was greater than 10 cm in eight patients. The perioperative mortality rate was 15% (2 of 13). Median survival of the 11 early survivors was 3.5 years (range, 6 months to 17 years). Currently five patients are alive (four of them free of known tumor), with a median survival of 3 years (6 months to 17 years) after surgery. Of the eight deceased patients, primary venous leiomyosarcoma recurred after resection in six. Tumor recurrence was not affected by tumor grade, size, or adjuvant treatment. Although early detection with modern imaging techniques could potentially be of benefit, wide local excision with selective venous reconstruction affords the only hope for prolonged survival.

The importance of endothelial cells in the course of vascular surgical interventions.

Aorto-coronary bypass made by implanting the patient's own saphenous vein may exhibit a tendency to early and late occlusion. This phenomenon is influenced by a number of factors including intraoperative damages of the graft. To determine preferable techniques for preserving vein integrity, various human graft preparation techniques were compared. Endothelial damage may occur during the preparation of the saphenous vein; the extent of damage depends on the preparation technique. In our studies the endothelium was best preserved by Rheomacrodex filling at 100 water cm pressure. Early occlusion seems to be best avoided in certain conditions using Gore-tex (polytetrafluoro-ethylene) prostheses due to the fact that the structure of Gore-tex simulates the normal endothelium covering of the luminal surface of the vessels and renders quick "re" endothelialization. This may reduce the hazard of early graft occlusion. In the present study experimental models and grafts implanted in humans were compared and results were tested by scanning electron microscopy.

Surgical treatment of renovascular hypertension in children and adolescents.

Renovascular disorders are rather rare in children and adolescents but have severe consequences due to complicating hypertension. Six cases successfully treated by surgery are described. The importance of early diagnosis and vascular correction is stressed; normalization of blood pressure has been achieved in every case.

Arteriovenous fistula after partial nephrectomy--successful surgical repair. Report of a case.

The postnephrectomy arteriovenous fistula is a very rare condition. There have been 49 cases reported in the world literature to date. Our case is the 50th of this series, and, to our knowledge, the first one following partial nephrectomy. Recurrence of the hypertension after nephrectomy, increasing heart failure, lumbar or upper abdominal bruit are the most characteristic clinical signs suggesting the presence of an arteriovenous communication. The basic diagnostic procedure is angiography. The proper surgical treatment is the separate ligature of the 2 vessels involved.