New method for treatment of inferior vena cava tumor thrombus ­ case study.

Conventional surgical therapy for advanced renal venous tumor thrombi results in high morbidity, so there is a need for less invasive techniques. This report presents the first case of a successful inferior vena cava (IVC) tumor thrombus removal without complications with balloon catheter (BC) via internal jugular vein (IJV), called the venous tumor thrombus pushing with balloon catheter (VTTP BC). Under the control of transesophageal echocardiogram and fluoroscope, a balloon catheter was sleeved on the guide wire, which was already inserted into the right internal jugular vein (IJV) and was driven distally above the IVC tumor thrombus. The balloon was inflated to occlude the IVC for prevention of pulmonary embolization. After the occlusion, the guide wire was driven to the cavotomy and was opened at the ostium of the right renal vein. It was pulled at both ends and stretched to serve as a rail. The balloon was gently pushed toward the cavotomy and the thrombectomy was completed. This is a less invasive method for treatment of venous tumor thrombus level 3 that can reduce surgical time, blood loss, and complication rates compared to the existing surgical methods. Also, it can be performed without thoracotomy, cardiopulmonary bypass, hypothermic circulatory arrest, and liver mobilization.

Rapidly progressing fatal reperfusion syndrome caused by acute critical ischemia of the lower limb.

The most severe complication of ischemia-reperfusion injury following lower limb arterial surgery is reperfusion syndrome. Therefore, our aim was to describe the extent of muscle damage and the reperfusion syndrome-related remote organ lesions in detail, through a well-documented case of long-lasting infrarenal aorta thrombosis. After urgent revascularization, several clinical signs of multiple organ dysfunction were detectable, including the circulatory, urinary, respiratory, gastrointestinal, and hemostatic systems. Upon histological examination, intraoperative muscle biopsy showed severe muscle damage. Muscle fiber viability was assessed with a special nitroblue tetrazolium staining-based viability test developed by our team; the obtained results indicated significant degree of muscle damage before this was confirmed by conventional histological methods. Thorough postmortem examination confirmed the presence of remote organ damage. The pathological findings included acute tubular necrosis, myocardial and jejunal infarctions, ischemic pancreatitis, and diffuse alveolar damage with hyaline membrane formation in the lungs and focal centrilobular liver necrosis. By using special staining techniques, the presence of myoglobin and lipofuscin deposits was confirmed in the kidney samples. In this paper, we present a patient who developed all major complications following long-lasting arterial occlusion. We also introduce a novel method to assess the degree of ischemic injury, which may be suitable in the near future for the rapid detection of irreversible muscle injury. Therefore, the mortality of the disease might be reduced.

Postconditioning of the lower limb--protection against the reperfusion syndrome.

BACKGROUND: Postconditioning-alternating brief cycles of reperfusion/reocclusion applied at the beginning of revascularization-is a potent therapeutic technique, attenuating ischemia-reperfusion injury. Vascular surgery on the lower limb with ischemia-reperfusion injury may give rise to serious systemic complications [organ dysfunction syndrome (MODS), systemic inflammatory response syndrome (SIRS)], a phenomenon called reperfusion-syndrome. MATERIAL AND METHODS: We studied the effects of postconditioning on reperfusion-syndrome in a rodent experimental model. Wistar rats underwent 180 min of bilateral lower limb ischemia using an infrarenal crossclamping of the abdominal aorta. Postconditioning consisted of six cycles of 10-s aortic occlusion/10-s declamping at the beginning of reperfusion. Microcirculation of the lower limb was detected with laser Doppler flowmeter. After 4 h of reperfusion, plasma, urine, and histologic samples were collected. RESULTS: One hundred eighty-minute ischemia resulted in significant hemodynamic changes after reperfusion. Postconditioning affected the character of the microcirculatory flow, the limb circulation stabilized with hyperemia during reperfusion. Postconditioning caused a significant reduction in systemic inflammatory response (TNF-α, oxygen-derived free radicals). The laboratory and histologic samples implied a significant decrease in distant organ (lung and renal) dysfunctions after postconditioning. CONCLUSION: Postconditioning proves to be capable of conferring protection against different organ injuries caused by longer circulatory occlusions during elective major vascular operations.

[Acute and critical ischemia of the lower limb]. / Akut kritikus ischaemia az alsó végtagon.

Acute limb arterial occlusion has great clinical significance due to its high mortality and complication rates. Its diagnosis is easy; however staging after long-term occlusions can be very difficult with lack of exact criteria. It is crucial, since reversible stage should undergo revascularization, while with irreversible stage only amputation is curative. Due to occlusion, long-term ischemia occurs, resulting in injury of the muscle fibers and endothelial cells. In case of revascularization the reperfusion causes more damage, than ischemia alone locally and initiates a remote organ injury. The aim of the review is to summarize the knowledge and fact and focus on some exact methods or parameters which can determine the degree of injury. One of these methods is a new approach which is the use of enzyme-histochemical reactions, and could give rapid, precise results even preoperatively regarding tissue viability. Routine clinical application of it is predictable after proper standardization.

[Effect of postconditioning in major vascular operations on rats]. / Posztkondicionálás kísérletes alkalmazása aortakirekesztés kapcsán.

BACKGROUND: Postconditioning - using alternating brief cycles of reperfusion/reocclusion applied just at the very beginning of reperfusion - has recently been described as a potent therapeutic technique, attenuating ischaemia-reperfusion injury. In vascular surgery, certain elective interventions involve cross-clamping of major arteries, resulting in temporary ischaemia in large peripheral organs, which thus suffer ischaemia-reperfusion injury. Patients undergoing these operations may develop also serious systemic complications such as multiple distant organ dysfunctions, SIRS, detrimental redistribution of the circulation or even shock, a phenomenon called reperfusion-syndrome. We studied the effects of postconditioning on reperfusion-syndrome in a rodent experimental model. MATERIAL AND METHODS: Anaesthetized male Wistar rats underwent 180 minutes of bilateral lower limb ischaemia and 4 hours of reperfusion using an infrarenal cross-clamping of the abdominal aorta. Control animals underwent no additional intervention. Postconditioning consisted of 6 cycles of 10-second aortic occlusion/10-second declamping starting at the beginning of reperfusion. Haemodynamic parameters were observed with invasive arterial manometer, microcirculation of the lower limb was detected with laser-Doppler-flowmeter. After 4 hours of reperfusion serum, urine, and histological samples were collected. RESULTS: 180-minute ischaemia resulted in significant haemodynamic changes after reperfusion. Postconditioning affected the character of the microcirculatory flow curves, the limb circulation stabilized with hyperaemia after reperfusion. Postconditioning caused a significant reduction in systemic inflammatory response (TNF-alpha, oxygen-derived free radicals). The laboratory and histological samples implied a significant decrease in remote organ (lung and renal) dysfunctions after postconditioning. CONCLUSION: Postconditioning proves to be capable in conferring protection against different organ injuries caused by longer circulatory occlusions during elective major vascular surgeries.

Fatal outcome from extreme acute gastric dilation after an eating binge.

OBJECTIVE: A 22-year-old woman is presented with acute gastric dilation after an eating binge, who died of complications of acute reperfusion syndrome. METHOD: A young patient was admitted in our clinic with critical condition without any significant previous medical history. Her initial complaints--diarrhea, vomiting and abdominal pain--began after an enormous food intake. There was no history of medications or toxic substances. Physical examination showed a normally-developed, well-nourished female in severe distress with an extremely distended abdomen. Femoral pulses were absent. The US and CT scan showed a dilated stomach, extended into the pelvis, dislocating the intestinal organs and compressed the aorta and mesenteric veins. RESULTS: Urgent laparotomy was performed. An enormously distended stomach was encountered without volvulus, obstruction or adhesions. About 11 liters of gastric content was removed gastrotomy and nasogastric tube. Following the gastric decompression, the mesenteric and femoral pulses reappeared. During the operation, the cardio-respiratory status was stabilized, but in the following 24 hours irreversible shock developed, possibly due to the reperfusion of the retroperitoneal organs and the lower extremities. In the postoperative period disseminated intravascular coagulopathy developed. In an uncontrollable state of diffuse bleeding, 36 hours post-operation, the patient died. In retrospective investigation, the family confessed that previous psychological treatments which aimed at her bulimic attacks. CONCLUSION: Acute gastric dilatation is very uncommon and is of various etiologies, two of these being anorexia nervosa and bulimia. Several cases documenting complications of gastric dilatation were published; however, such severe complications, involving gastric infarction and compression of the aorta with ischemic injury of the bowels and lower extremities, are rare.

[Reoperations for early recurrent occlusions following femoropopliteal and femorocrural bypasses]. / Femoropoplitealis és femorocruralis bypass mútéteket követóen korai elzáródás miatt végzett reoperációink.

We analyse the early results of 333 patients who had been operated on because of femoropopliteal occlusions between 1996 and 2000. Most interventions (90.4%) were below knee reconstructions. The rate of crural bypasses was high (40.5%). We examined whether the length and type of the graft influenced the outcome of the primary operation. If below knee bypass was necessary in every operation autologous grafts were preferred either partially or entirely (saphenous vein or arm vein). The number of reocclusions and amputations was significantly higher if the distal anastomosis involved the crural arteries (p < 0.02), or the graft was not autologous (p < 0.01). There was no statistical difference between early results of saphena and arm vein bypasses (p = 0.2). Thirty-six reoperations were performed for early graft failures. Either the patient's general condition or local findings did not allow reoperations in 17 patients with occluded graft, they were treated conservatively. Nine patients died after surgery (2.7%). In the postoperative period 21 major amputations were necessary (6.3%), in six cases the graft was patient. After reoperations 7 patients needed amputations (19.4%), in the 17 patients not reoperated on the second time, 8 amputations were necessary (47%), the difference is significant (p < 0.05). We are convinced about the importance of urgent reoperation in case of early graft occlusion. If the run-off to the distal arteries was doubtful intraoperative angiography was performed. When distal extension of the operation was necessary we tried to use autologous grafts. The amputation rate was significantly lower after reoperations if the cause of graft occlusion was found and corrected compared to simple thrombectomies (p < 0.05).

[Chronic pancreatitis combined with obliterative arterial disease]. / Chronicus pancreatitis és obliteratív veróérbetegég együttes elófordulása.

We performed a prospective study at the 1st Surgical Department, Semmelweis University Budapest between 1996 and 2000, in which we examined the common occurrence of chronic pancreatitis and obstructive vascular disease in patients admitted to our department because of either of these illnesses. There were 37 patients suffering from both diseases, all are included in our trial. Control groups were set up of 50 consecutive chronic pancreatitis patients and 50 consecutive vascular patients. In all patients with two disease chronic pancreatitis developed earlier than vascular disease. Occurrence of vascular disease is twice as common among patients with chronic pancreatitis as in normal population. Risk factors like smoking, coffee-abuse and alcohol, which might trigger both diseases, didn't vary in the three groups. This combination of diseases usually starts in the young, and causes severe and progressive deterioration in the quality of life. In four patients after operations performed because of chronic pancreatitis, peripheral arterial operation was also necessary. Operative mortality rate in the chronic pancreatitis group was 2%, in vascular patients 4% and in the group with both diseases it was 16%. We found in our study that there is relation between chronic pancreatitis and peripheral obstructive vascular disease. Further examinations are necessary to examine the etiology. In patients with chronic pancreatitis we must always think of the possibility of later obstructive vascular disease.

[Role of extra-anatomical bypasses in the treatment of aorto-iliac occlusion]. / Az extraanatomicus áthidalások szerepe az aortoiliacalis veróér elzáródás kezelésében.

In the last six years we have performed 468 operations because of aortoiliac occlusion or septic complications of these arteries. 410 (87.6%) of these operations were anatomical reconstructions, in 58 (12.4%) patients we performed extra anatomical bypasses. The distribution of the operations was the following; 12 obturator, 23 femoro-femoral crossover, 13 axillofemoral and 10 axillobifemoral bypasses. The indication for extra-anatomical reconstruction in 24 (41.4%) patients was septic complication (EABS), and in 34 cases (58.6%) poor general condition or difficulties during surgery. The average age of the patients with non-septic indication (EABNS) was significantly higher than the average age of the patients treated with anatomical reconstruction (AR) (66.3 vs. 60.9 year, p < 0.01). There were more REDO operations in the group EABNS then in the AR group (35.3%/11.7% p < 0.02). Despite of the high operative risk, the rate of early complications (EABNS 13.8%, AR 10%) and postoperative mortality (EABNS 3.7%, AR 4.0%) was not statistically different between the two groups. If the indication was aorto-duodenal fistula (6 patients) or acute limb ischaemia (7 patients), the mortality was significantly higher compared to other extra-anatomical operations (46.2% vs. 4.4%, p < 0.01). The postoperative mortality after EABNS and EABS operations was similar (11.7% vs. 16.6%), but we performed more reoperations after EABS operations (10/24 vs. 2/34, p < 0.05). According to our early postoperative results elective extra-anatomical bypasses are suitable for the treatment of aortoiliac occlusion in high risk patients, with poor life expectancy. Extra-anatomical bypasses are performed because of acute ischemia or septic complications which are life or limb threatening complications, so early results must be validated concerning this fact.