[Pedal bypass in the treatment of arterial occlusive disease of the lower extremities in diabetics]. / Pedálny bypass v liecbe uzáverovej choroby artérií dolných koncatín u diabetikov.

BACKGROUND: The increase of the number of diabetics in the population and prolongation of their survival increases also the number of patients suffering from diabetic foot syndrome. Terminal complication of diabetic foot syndrome is diabetic gangrene, which is the cause of 50% of major amputations performed in Slovak republic. The problem of major amputations is not only medical, but also economic one. Adequate treatment can reduce the number of amputations by 50%. One of the possibilities to improve the prognosis of a diabetic suffering from obliterative macroangiopathy is the treatment by distal bypass, because with the regard to the characteristic distribution of the lesions to leg arteries is the classic vessel surgery (aortofemoral and femoropopliteal/femorocrural bypasses) inefficient. After the introduction of this treatment at our department preliminary results and some prognostic factors of the surgery success were evaluated. AIM OF THE STUDY: To evaluate the efficiency of pedal bypass as a method of treatment for peripheral obliterative atherosclerosis in diabetics and to determine the predictive value of paraclinical investigations and angiography. METHODS: Retrospective analysis of clinical, paraclinical and functional parameters of patients in whom pedal bypass was indicated, focused on the analysis of angiography. RESULTS: Of the 142 patients hospitalised with diabetic foot complications 32 were indicated for pedal bypass. All the patients were in the IV stage according to Fontain, the range of gangrene reached in average 2.7 grades of Wagners scale. Early success--i.e. functional artery reconstruction after hospital discharge was achieved in 18 patients (56%). Positive criteria for early success of the surgery involve short interval from gangrene development and serum albumin level above 26 g/l as an indicator of the nutritional state. Favourable angiographic criteria were: passage free arteries of dorsum pedis (ADP, ATP, a. plantaris, ATA) in the length of 10 cm free from focal stenoses, presence of numerous collaterals of legs and dorsum pedis, opacification of metatarsal and digital arteries. CONCLUSION: Pedal bypass is an efficient method of treatment for obliterative processes of lower extremities in diabetics with involvement of leg arteries. On the basis of our results this procedure can be recommended after careful preoperative staging and analysis of angiography as the method of treatment. It is necessary to perform the operation as soon as possible regarding the worsened nutritional and healing potential of the organism in the case of gangrene. Providing the surgery is properly indicated and performed it significantly improves the life quality of the patient. (Tab. 5, Fig. 1, Ref. 22.)

[Parameters of energy metabolism in patients after vascular reconstructive surgical procedures]. / Niektoré parametre energetického metabolizmu u pacientov pocas cievneho rekonstrukcného chirurgického výkonu.

Revascularization surgery in patients with peripheral arterial occlusive disease presents an acceptable clinical model for studying the rate of ischaemia-reperfusion injury of cells and other structures of skeletal muscle of the affected extremity. Validity of carefully chosen set of biochemical parameters for determination of this injury during and after surgery as well as in the early and late reperfusion periods and during the readaptation to situation after restoration of blood circulation was verified. Blood samples were taken from the regional common femoral vein which allowed to obtain information directly from the ischaemized extremity. Analyzed biochemical parameters have given useful information about the situation in acid-base regulation, in energy metabolism as well as antioxidant capacity. These parameters were estimated in four time intervals: before aorta cross-clamping (preischaemic phase), then 30 min (early reperfusion) and 18 hours (readaptation period) after aorta-declamping. In the early reperfusion period a marked acidosis and raised carbon dioxide tension, significant increase of lactate and pyruvate levels as well as increased hypoxanthine plasma level were observed. On the contrary, in this period the lowest lipoperoxide level was found, evident in the wake of relative stability of concentration of endogenous antioxidants documented by a constant glutathione redox status that at the first postoperative day even significantly decreased as a consequence of a drop of oxidized and increased of reduced form of glutathione. Therefore, the applied biochemical parameters allow to monitor the ischaemia-reperfusion damage of afflicted region and could be used even in the study of compounds with a protective effect against possible injury of ischaemized and reoxygenized tissues. (Tab. 3, Fig. 4, Ref. 32.)

Transatrial access for left atrial pressure monitoring in cardiac surgery patients.

We describe a simple method for left atrial pressure (LAP) monitoring from the right to the left atrium (LA) by a central line catheter. The anesthesiologist cannulates vena jugularis interna and inserts two central line catheters. One catheter is placed in the vena cava superior and the second single-lumen catheter is placed in the right atrium. The surgeon positions a one-line catheter from the right in the LA during the transatrial surgical procedure. This new access diminishes bleeding complications.

[Care of the diabetic foot]. / Koncepcia staroslivosti o diabetickú nohu.

BACKGROUND: The diabetic foot is the most frequent complication of diabetes requiring hospitalization. According to large sets of patients, as many as 25% of diabetic patients develop damage to their feet during their life. Regarding the growing number of diabetic patients it is necessary to elaborate a prospective conception of the treatment of patients afflicted by this complication. OBJECTIVE: The study's aim is to respond to the question of differentiation of treatment of patients with the diabetic foot. METHODS: A retrospective analysis of two sets of patients hospitalized at the surgical clinic. RESULTS: The group I (1989-1993) included 264 patients treated by "classical surgical management". The group II (October 1994-January 1996) included 142 patients subdued to "intensified therapy" with maximum possible use of revascularization procedures, 52-57% of patients were admitted with extensive gangrene, 65-68% with ischaemic disease of the lower extremities in the stage of CLI. The proportion of revascularizations was 26% vs 68%, the proportion of large amputations was 60% vs 38%. Despite maximum surgical forcefullness, a large proportion of large amputations reaching 38%, perseveres. The authors additionally surveyed the patients of group II as to the degree of their knowledge on the possible chronic complications of diabetes. The predominant majority of patients (63%) had insufficient knowledge about the prevention of the diabetic foot. CONCLUSIONS: Even a maximum use of surgical procedures is not sufficient in procuring a decrease in the proportion of large amputations of lower limbs in diabetic patients who have been hospitalized with their disease being in a progressed stage caused by neglection. Therefore it is necessary to transfer the emphasis of treatment of the diabetic foot into the period preceding the stage of manifestant infectious and necrotic complications. It would be most appropriate to delegate this "frontman" task to diabetologists. USE IN PRACTICE: Even though the only definitive solution of this dissatisfying situation resides in the establishment of specialized centres focused on the therapy of the diabetic foot, certain progress can be achieved also under current conditions by a consequent use of the existing net of diabetologic out-patients clinics, improvement of the quality of the diagnostic process and enhancement of educational activities. (Tab. 5, Ref. 18.)

[Removal of the intravenous pacing system using the inflow occlusion technique]. / Extrakcia intravenózneho stimulacného systému pomocou techniky "inflow occlusion".

Infection of the stimulative system with a septic state or endocarditis is the ultimate requirement for the extraction of intravenous parts of the implanted stimulative system. The extraction performed by the classical method or by means of catheter does not have to be necessarily successful. The use of extracorporeal circulation is optimal for the surgeon, however, it is expensive and not indifferent for the patient. The inflow occlusion technique under our conditions has shown to be fast, safe and an advantageous alternative. We have used it in 11 patients out of 14. All cases involved an extraction of a foreign body. 78.5% of extractions were performed due to infected stimulative system. 2 patients were subdued to a simultaneous implantation of DDD, others have had VVI system implanted by epimyocardial or transvenous way. We have not been encountered with any serious complications. (Tab. 1, Fig. 3, Ref. 7.)

Biochemical monitoring in patients during revascularization surgery.

Changes in the metabolism of patients with peripheral arterial occlusive disease were studied in the light of biochemical parameters during and after vascular reconstructive surgery (aorto-bifemoral bypass). Biochemical parameters were determined in arterial and regional venous blood in 10 successive intervals covering the period before ischemia, during acute ischemia and in the course of reperfusion of the lower extremity. After successful revascularization of the extremity, marked increases were recorded particularly in the levels of thiobarbituric acid reactive substances and of lactate in the early and late period of reperfusion. Monitoring of the given biochemical parameters may yield an adequate criterion for determining the degree of ischemia-reperfusion injury in vascular reconstructive surgery and may also be of value in assessing the effectivity of the applied mode of protecting the patient against functional and metabolic injury.

[Endarterectomy of the coronary arteries]. / K problematike endarterektómie koronárnych artérií.

The authors analyze 50 patients with endarterectomy of the coronary arteries during the periods of 1972-1974 and 1988-1990. The results of endarterectomy of the right and left coronary artery provide evidence of its justification in indicated cases whereby contrary to some departments the results of endarterectomy of the left coronary artery are comparable with endarterectomy of the right coronary artery.

[Tumors of the heart and arterial embolisms]. / Tumory srdca a arteriálne embólie.

Tumors of the heart are a rare cause of embolism of the peripheral arterial system. A series of 26 patients operated on for heart tumor in the Institute of Cardiovascular Diseases in Bratislava over the years 1979-1988 was analyzed. Pseudomyxoma was histologically verified in 24 patients and rhabdomyoma and rhabdomyosarcoma in the other two patients. A total of 12 embolic events was recorded in 9 patients (34.6%). There were 8 instances of embolism in the central nervous system and 4 in the extremities. In all cases pseudomyxoma of the left parts of the heart was the source of embolism. In 21 cases diagnosis was established and operation indicated on the basis of ultrasonographic evidence. The authors recommend the biatrial transseptal approach. Early surgical removal of a heart tumor is the therapy of choice which prevents the development of potential complications from the heart and peripheral arteries.