[Thoracic Outlet Syndrome Caused by Fibrous Dysplasia of the First Rib]. / Syndrom horní hrudní apertury zpusobený fibrózní dysplazií prvního zebra.

The purpose of the case report is to present the case of a 42-year-old woman with thoracic outlet syndrome caused by fibrous dysplasia of the first rib treated by surgical therapy through cervicothoracic approach by Grunenwald with complete vascular and partial brachial plexus preparation. Key words:thoracic outlet syndrome, fibrous dysplasia, cervicothoracic approach.

[Pedal bypass using venous allograft]. / Pedální bypass s pouzitím allogenní zilní náhrady.

INTRODUCTION: Pedal or distal crural bypass surgery for limb salvage is a method with very good long-term results. For patients in whom a suitable autologous venous graft is not available, the use of a venous allograft is an alternative procedure. CASE REPORT: A 68 years old man with ischaemic disease of lower extremities and gangrene of the left foot was admitted to our Centre in August 2014. He underwent percutaneous transluminal angioplasty of crural arteries of his left lower extremity. This, however, failed to improve peripheral circulation. The patient was then indicated for pedal or distal crural vascular reconstruction. Since no suitable autologous vein was available, distal bypass surgery using a donor graft remained the only option for limb salvage. Amputation of the toes on the left foot due to gangrene was necessary. Subsequently, femoro-pedal bypass to the left common plantar artery was performed using a great saphenous vein allograft. The post-operative course was without complications, the pedal bypass was patent and toe amputation was with good healing. The patient remained in follow-up care. CONCLUSION: A good outcome of vascular reconstruction with an allograft depends on the availability of a suitable allograft and good patient compliance with post-operative care. In the case presented here, the pedal bypass grafting by means of an allograft helped to save the patients limb. KEY WORDS: pedal bypass venous allograft limb salvage.

Perigraft seroma as a rare angiosurgical complication.

Perigraft seroma is quite a rare complication that may occur after implantation of Dacron or expanded polytetrafluoroethylene (ePTFE) vascular grafts. We report a case of a 54-year-old patient with perigraft seroma around an axillofemoral bypass (ePTFE graft). Definitive treatment involved the explantation of this extraanatomic bypass with perigraft seroma and the implantation of an aortobiiliac bypass using vascular prosthesis made of a different material. Based on published studies, therapeutic options for this complication are discussed. No guidelines or recommendations are available. In conclusion, the approach to perigraft seroma treatment remains strictly individual. Vascular graft replacement using grafts made of different material seems to be the best option in the case of recurring perigraft seroma, where less invasive procedures were not successful.

[Vascular dialysis access with transposed superficial femoral vein]. / Dialyzacní cévní prístup transponovanou vena femoralis superficialis.

The authors describe the case report of a 63 years old female patient with chronic renal failure in systemic lupus erythematosus. Vascular dialysis access in upper limbs could no more be used. The condition was approached by constructing an arteriovenous (AV) fistula in the thigh with transposed superficial femoral vein as the first procedure in the Czech Republic.

Mycotic Aneurysm in the Aortoiliac Area - Current Options for Treatment.

BACKGROUND: Infection represents a less frequent cause for the development of an abdominal aortic aneurysm. The diagnosis is associated with a high risk of rapir progression and rupture. CASE REPORTS: Case 1 is a female operated on urgently for a ruptured mycotic aneurysm of the abdominal aorta. After resection of the aneurysm, we performed in situ replacement using a rifampicin-soaked vascular prosthesis. In case 2, an asymptomatic aneurysm of the right iliac artery was treated by endovascular implantation of a stent-graft. Both patients were treated with antibiotics concurrently and are still alive. DISCUSSION: The discussion deals with the up-to-date treatment modalities for mycotic aneurysms in the aorto-iliac region. The indication criteria must be adjusted individually. CONCLUSION: The prognosis of patients with a mycotic aneurysm depends particularly on an early diagnosis.

[Urgent pedal bypass as part of the treatment of an extensive lower-leg injury]. / Urgentní pedální bypass jako soucást resení rozsáhlého traumatu bérce.

The authors present the case of a subadventitial rupture of the popliteal artery and devastating injury to the crural arteries due to a crush injury to the proximal shank. The arterial injury was treated by urgent popliteo-pedal bypass grafting. Besides the surgical procedure, the authors also discuss revascularisation syndrome. The subadventitial rupture of the popliteal artery is a serious condition associated with a risk of high amputation.

[Replantation of IMA and accessory right RA during infrarenal AAA repair and a current view on indications for IMA replanting]. / Reimplantace AMI a akcesorní pravé AR u infrarenálního AAA a soucasný pohled na indikacní kritéria k reimplantaci AMI.

INTRODUCTION: Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair is a measure which might prevent development of colon ischemia under certain circumstances. These circumstances and patients who would benefit from this procedure are not well defined. CASE REPORT: 64-year old man underwent an elective operation on infrarenal AAA at our institution in December 2009. From preoperative CT angiography we knew about the accessory right renal artery branching directly from AAA and bilateral occlusion of hypogastric arteries. We performed open resection of AAA with implantation of a bifurcated graft. Proximal anastomosis was situated below renal arteries, distal anastomoses were bilaterally constructed on external illiac arteries. The accessory right renal artery was anastomosed into the right limb of the graft and IMA was replanted into the body of the graft. Postoperative recovery of the patient was uneventful. His follow-ups 3 and 6 months after the operation have been showing good clinical state of the patient, absence of abdominal complaints and normal levels of urea and creatinine. CT angiography which was performed 3 months after the operation discovered an occlusion of the reimplanted IMA, but patent replanted accessory right renal artery. DISCUSSION: Assessment of collateral circulation of large intestine during infrarenal AAA repair is influenced by many preoperative and intraoperative factors. Most surgeons judge the adequacy of the collateral circulation by IMA backbleeding combined with inspection of sigmoid colon after restoring aortic flow. There have been numerous attempts to replace this subjective approach with more objective methods like intraoperative colon mucosal saturation measurement, laser Doppler flowmetry, IMA stump pressures, photophletyzmographic technique. Even though these methods describe conditions when a collateral circulation of rectosigmoid is inadequate after IMA ligature, they are unable to fully eliminate the occurrence of colon ischemia because of its multifactorial nature. Solving the problem of collateral circulation of the large intestine represents only a part of the obstacle presented by colon ischemia after infrarenal AAA repair. CONCLUSION: IMA replantation during infrarenal AAA repair does not fully prevent an occurance of colon ischemia. On the other side, this moneuver does not increase perioperative morbidity, nor prolongs an operation significantly. Our policy is to replant IMA whenever we thing the circulation of large intestine is under threat or in borderline situations.

[Autogenous superficial femoral vein for replacement of an infected aorto-ilio-femoral prosthetic graft]. / Autogenní vena femoralis superficialis jako náhrada infikované aorto-iliako-femorální cévní protézy.

A group of 12 patients (10 men, 2 women; average age, 52.7 years; range, 50-79 years) with vascular prosthetic graft infection (n=9) or with an increased risk of such infection (n=3) underwent arterial aorto-ilio-femoral reconstruction using autogenous superficial femoral vein. None of the patients died or had to have revision surgery during the follow-up (mean +/- SD, 14.1 +/- 7.3 months; range, 3-27 months). No pulmonary embolism occurred, nor were any early or late complications such as recurrent infection, graft occlusion, limb amputation or aneurysmal dilatation of vein graft recorded. In one patient, benign oedema of the limb following deep vein harvest persists, but this is well managed with a compression stocking. The findings reported in the international literature as well as the authors' experience show that the use of autogenous femoral vein gives very good results in the treatment of an infected vascular prosthetic graft, one of the most feared and most serious complications of vascular surgery.

[Pedal bypass--ten years experience]. / Pedální bypass--desetileté zkusenosti.

The authors evaluate a group of 110 patients to whom a pedal bypass was implanted in the period from October 2000 to July 2009. In all cases the limb was at risk of high amputation and the possibilities of endovascular and conservative therapy were exhausted. No patient died during the procedure, early postoperative mortality was 1.8%. During the follow-up (average, 30 +/- 26.4 months; range, 1.2-91.2 months) 21 bypass occlusions occurred, of which in 8 cases bypass patency was restored by an early intervention. In the reference period the cumulative probability of primary and secondary patency of pedal bypasses is 67.2% and 69.5%, the cumulative probability of limb salvage by pedal bypass surgery is 78.0%. A part of the study is a statistical evaluation of the data and findings of how the primary and secondary patency of pedal bypasses and the probability of limb salvage are influenced by diabetes mellitus.

[Lower extremity deep vein as arterial replacement in the treatment of prosthetic graft infection]. / Hluboká zíla dolní koncetiny jako tepenná náhrada pri resení infekce cévní protézy.

In June 2007, an autologous lower extremity deep vein was used for arterial reconstruction for the first time in the Czech Republic. For this procedure, the superficial femoral vein was harvested in its full length, including part of the popliteal vein. Due to previous explantation of an infected prosthesis, the patient had critical ischemia and progressive gangrene of the lower extremity. His condition required an iliac-femoral artery reconstruction. Because of the high risk of recurrent infection, none of the conventional approaches involving a vascular prosthesis could be used. The implantation of a lower extremity deep vein appears to be very efficient in the treatment of prosthetic graft infection, which is one of the most serious and feared complications in vascular surgery.

[Blood vessel reconstruction infections: a practical view]. / Infekce tepenných rekonstrukcí: praktický pohled.

Infection represents a serious complication in vascular surgery. The average of 2-3% of reconstructions are involved. The article offers a review of current diagnosis and treatment of infection after vascular reconstruction. Emphasis is put on early diagnosis and its impact on prognosis of patients. We summarize the practical potential of surgical treatment. The situation is illustrated by our results from the years 2004-2006. During the last 3 years 19 patients were operated on for infection of the arterial reconstruction (15 ways aorto-femoral and 4 ways femoro-popliteal bypass). The main agent was Staphylococcus aureus (9 patients, i.e. 47.4%). In most cases explantation of the whole infected reconstruction was performed (13 patients). The early mortality rate is 26.3%. Amputation was necessary in 6 patients (i.e. 31.5%). Our results are fully comparable to those from other centres of vascular surgery.

[Treatment of vascular prosthesis infection and aorto-enteric fistula as a late complication after reconstructive surgery of the abdominal aorta--a case report]. / Lécba infekce cévní protézy a aorto-enterické pístele jako pozdní komplikace rekonstrukcního výkonu na abdominální aorte--kazuistika.

Vascular prosthesis infection is a serious diagnostic and therapeutic problem. Timely diagnosis and adequate treatment are essential for the patient's future condition. We present a case report of a 60-year-old man with aortobifemoral prosthesis infection and with an aortoduodenal fistula. The prosthesis infection was confirmed by fluorodeoxyglucose positron emission tomography. Urgent surgery was indicated due to massive gastrointestinal bleeding. Because of lower limb Ischaemia after removal of the infected bifurcation prosthesis, an implantation of an axillobifemoral bypass was performed in a one stage procedure. 8 months after the surgery, the patient is in good condition without walking limitation.

[Interdisciplinary approach to treatment of multiple arterial aneurysms in patient with eighth recurrence of incisional hernia--a case report]. / Interdisciplinární prístup k riesení mnohocetných tepenných aneuryzmat u pacienta s osmou recidivou incizionální kýly--kazuistika.

Vascular surgery is not the only option for arterial aneurysm treatment. Minimally invasive techniques are being increasingly used, especially methods of interventional radiology. We present a case of a 51-year-old man who came to our department in July 2005 because of sonographically diagnosed popliteal artery aneurysm. Simultaneous presence of subrenal abdominal aortic aneurysm, bilateral iliac and femoral artery aneurysms and left popliteal artery aneurysm was found. This patient was operated on for pancreatic pseudocyst in 2000 and then during next three years eight times for incisional hernia and its recurrences. The operations were carried out in other surgical departments. Eighth recurrence of incisional hernia was already present. Because of these facts, the risk of resection was deemed too high. Therefore, we chose stent graft implantation for abdominal aortic aneurysm treatment. The endovascular approach was also used to treat some complications that occurred. In this case report, we would like to present a combination of surgical and interventional radiological approaches to treatment of arterial aneurysms as a typical example of interdisciplinary cooperation.

Infection of vascular prosthesis in aortofemoral area.

OBJECTIVES: To determine the frequency of vascular prosthesis infection in aortofemoral area and to demonstrate their course, treatment and risk factors. METHODS: The file was formed by patients who had been operated on because of infection of vascular reconstruction in aortofemoral area at IInd department of surgery of the St. Anne's Faculty Hospital in Brno in the 2000-2004 period. The data from personal case histories and risk factors were evaluated by means of basic statistical methods. We present the diagnostic methods used and operation procedures. The results were compared to the ones from the vascular register and to the conclusions from other vasculosurgical workplaces. RESULTS: In the period discussed, 7 patients were operated on for infection of vascular reconstruction in aortofemoral area. The period between the implantation proper and the manifestation of the infection ranged from 13 months to 15 years. The infection manifested most often by purulent secretion in groin. The most frequent infection agent is the staphylococcus. In 4 cases immediate explantation of the whole vascular prosthesis was carried out. In 3 cases partial resection was carried out, followed by explantation of the remainder of the prosthesis after stabilisation in 2 cases. In 4 patients revascularization by extra-anatomic bypass was carried out. Three patients died during their hospitalization as a result of sepsis. On the whole 6 high amputations of lower limbs were carried out with 4 patients. CONCLUSION: Vascular prosthesis infection in aortofemoral area is among less frequent, but substantially serious and difficult-to-solve complications of vascular surgery (Tab. 3, Ref 18). Full Text (Free, PDF).

Pedal bypass grafting on arteriographically invisible foot arteries detected by duplex ultrasound for limb salvage.

AIM: In this study the long-term outcomes in patients undergoing pedal bypass grafting were evaluated and the risk of graft occlusion was related to whether, preoperatively, the pedal arteries were visualized by angiography or not and were only detected by duplex ultrasonography. METHODS: In 2000-2005, 81 pedal bypass grafts were performed in patients with chronic critical lower-limb ischemia, of which 54 (66.7%) had diabetes. Tissue loss (SVS/ISCVS-category 5) was recorded in 68 (84%) limbs and rest pain (SVS/ISCVS-category 4) in 13 (16%) limbs. In 24 limbs (29.6%) bypass grafts were implanted on the pedal arteries that had not been visualized by preoperative angiography, but had been detected only by duplex ultrasound. RESULTS: During the follow-up (median, 17 months; range, 3-69 months), 18 grafts (22.2%) failed. Seven limbs had to be treated by early thrombectomy, which resulted in long-term graft patency and limb salvage. The early postoperative mortality rate was 2.5%. Cumulative primary and secondary graft patency rates, and limb-salvage rates were 70.2%, 80.2% and 82.4%, respectively. No significant difference in graft occlusion was found between the patients with visible and those with not visible pedal arteries on preoperative arteriograms (Fisher's exact test). CONCLUSIONS: Duplex ultrasonography is a reliable modality for detection of target pedal arteries not visualized by preoperative arteriography and it helps reduce the number of patients with non-operable arterial occlusion disease by about 25%.

[Infection in vascular reconstructive surgery]. / Infekce v rekonstrukcní cévní chirurgii.

PURPOSE: Infection is one of the most serious complications in vascular surgery. METHODS: We summarize the patients operated on in our clinic during a 3-year period for infection of the arterial reconstruction. RESULTS: 577 primary arterial reconstructions were performed in the region of abdominal aorta and lower limb arteries during the years 2003-2005. In the same period 17 patients were operated on for infection of the arterial reconstruction grade III of Szilagyi (13x aortofemoral, 4x femoropopliteal region). The main agent of infection was Staphylococcus aureus (47.1%). In most cases the therapy involved revision of the infected groin (10x) with subsequent explantation of the reconstruction (7 patients). Eight extraanatomic reconstructions were performed. Three patients died during the follow-up (2 within 30 days of an operation). The one year mortality rate is 17.6%. Amputation was necessary in 6 patients (i.e. 35.3%) CONCLUSIONS: Handling vascular infection still remains a challenging diagnostic and therapeutic problem.

Pedal bypass as urgent surgical revascularisation.

Pedal bypass (arterial reconstruction with distal anastomosis on the dorsal pedal artery (DPA) or in the submalleolar portion of the posterior tibial artery) is now considered as a standard method of revascularisation in critically ischaemic limb with obliteration of the crural arterial system. While a number of studies in large cohorts have proved the success of this method in saving limbs with chronic critical ischaemia, only few papers report the pedal bypass as an urgent intervention. In this study, the authors describe 3 cases where urgent pedal bypass saved the limb threatened by an acute ischaemia (Fig. 3, Ref. 12).

Pedal bypass for limb salvage.

BACKGROUND: Pedal bypass grafting is often the only method of limb salvage in patients with chronic critical lower limb ischemia due to atherosclerotic obliteration of the crural arteries, including patients with diabetic foot gangrene. It involves arterial reconstruction with distal anastomosis to one of the pedal arteries. MATERIAL AND METHODS: Between January 2000 and June 2004, 54 pedal bypasses were performed in 53 patients with chronic critical lower limb ischemia. Forty-seven (87%) patients had gangrene or ischemic ulcer, 36 (68%) had diabetes. In some of the patients (16.7%), previous percutaneous transluminal angioplasty (PTA) of the crural arteries had failed. Preoperative angiographic findings were unsatisfactory in the majority of the patients; the plantar arch was not visualized in 36 (66.7%) limbs. RESULTS: In the period investigated (54 months) 11 grafts (20.4%) failed. Early thrombectomy resulting in long-term graft patency salvaged five limbs. One limb with graft occlusion occurring after foot ulcer healing was also salvaged. However, one amputation had to be performed despite a patent graft. The perioperative mortality rate was 3.8%. Cumulative primary and secondary graft patency rates and limb-salvage rates at 54 months were 76%, 78% and 81%, respectively. CONCLUSION: Pedal bypass grafting is a safe method with very good long-term outcomes. The absence of the pedal arteries or plantar arch on preoperative angiograms need not be taken as a contraindication to pedal vascular reconstruction. In discussions on the plantar arch it is recommended to discriminate between its actual absence and a mere "angiographic" absence.

Pseudo-aneurysms after iatrogenic affection of artery--experiences and recommendations for procedures to prevent their incidence and potential treatment.

In the present modern times we see that the population is gradually ageing and along with it also the incidence of civilisation diseases, including those of the cardiovascular system, is increasing. As the care of these patients develops, so does the number of surgeries of invasive cardiology. Even though the development in this area is still dynamic, the techniques are improving and new technologies are appearing. However, these invasive methods are still associated with certain risks for the patient. In terms of vascular surgery, the most frequent complications are iatrogenic pseudo-aneurysms and large haematomas. The objective of the present study was to evaluate the development in the incidence of pseudo-aneurysms (PSA) appearing after punctures of femoral artery due to coronarography or PTCA, to verify the hypothesis that the ratio of the number of PSA to the total number of invasive-cardiologic diagnostic and therapeutic surgeries is decreasing and to indicate possible solutions of complications associated with catheterisation. The study presents a retrospective account of the number of invasive surgeries conducted at the 1st Department of Medicin - Cardioangiology of the St. Anne's University Hospital Brno (UH) from 1996 to 2004. Summarised are numbers of PSA's conducted in this period by surgeons of the 2nd Department of Surgery of the St. Anne's University Hospital Brno (Tab. 1, Fig. 5, Ref. 17).

Efficiency of a second-generation HIV-1 protease inhibitor studied by molecular dynamics and absolute binding free energy calculations.

A subnanomolar inhibitor of human immunodeficiency virus type 1 (HIV-1) protease, designated QF34, potently inhibits the wild-type and drug-resistant enzyme. To explain its broad activity, the binding of QF34 to the wild-type HIV-1 protease is investigated by molecular dynamics simulations and compared to the binding of two inhibitors that are used clinically, saquinavir (SQV) and indinavir (IDV). Analysis of the flexibility of protease residues and inhibitor segments in the complex reveals that segments of QF34 were more mobile during the dynamics studies than the segments of SQV and IDV. The dynamics of hydrogen bonding show that QF34 forms a larger number of stable hydrogen bonds than the two inhibitors that are used clinically. Absolute binding free energies were calculated with molecular mechanics-generalized Born surface area (MM-GBSA) methodology using three protocols. The most consistent results were obtained using the single-trajectory approach, due to cancellation of errors and inadequate sampling in the separate-trajectory protocols. For all three inhibitors, energy components in favor of binding include van der Waals and electrostatic terms, whereas polar solvation and entropy terms oppose binding. Decomposition of binding energies reveals that more protease residues contribute significantly to the binding of QF34 than to the binding of SQV and IDV. Moreover, contributions from protease main chains and side chains are balanced in the case of QF34 (52:48 ratio, respectively), whereas side chain contributions prevail in both SQV and IDV (main-chain:side-chain ratios of 41:59 and 45:55, respectively). The presented results help explain the ability of QF34 to inhibit multiple resistant mutants and should be considered in the design of broad-specificity second-generation HIV-1 protease inhibitors.