[Our experience with left-sided retroperitoneal approach to resection of abdominal aortic aneurysm]. / Nase zkusenosti s levostranným retroperitoneálním prístupem pri resení výdutí brisní aorty.

INTRODUCTION: At most vascular surgery departments, transperitoneal approach predominates in resections of the aortic aneurysms. For difficult reconstructions of the aorta in the visceral segment, a left flank retroperitoneal approach is used most frequently. METHOD: The authors retrospectively evaluate the left retroperitoneal approach in the management of abdominal aortic aneurysms during a 10-year period. From the total number of 445 operated patients, the left-sided retroperitoneal approach was used in 23 cases. RESULT: All operated patients survived. Average hospital stay was 10 days in the case of elective operations. CONCLUSION: Based on favorable results, the authors confirm that left-sided retroperitoneal approach is rightly considered as a choice in the technically demanding reconstruction of the aorta in the visceral segment.Key words: aortic aneurysm visceral segment of the aorta retroperitoneal approach.

[Dual kidney transplantation - a single-center experience]. / Duální transplantace ledvin - zkusenosti jednoho centra.

INTRODUCTION: Dual kidney transplantation is one of the options to utilize the so-called marginal grafts, kidneys that would be insufficient for normal single transplantation. This time-consuming surgical procedure is also burdensome for the patient. METHODS: The authors present their experience from the Pilsen Transplant Center. Between 2008 and 2016, 13 dual kidney transplantations were performed. Median donor age was 66 years (34-77) and median recipient age 46 years (40-78). Mean operating time was 4 hours and 40 minutes (3-6 h). Mean surgery ward stay was 5 days (4-6). Bilateral surgical technique was used in all cases. Mean follow-up time was 63 months (18-101). RESULTS: From our group of DKTs (N=13), 4 patients (31%) experienced delayed graft function and we observed no primary graft non-function. Surgical complications occurred in 4 patients (31%). Currently, all 13 patients are living with good graft function, none of them being dependent on dialysis. CONCLUSION: Dual kidney transplantation is currently a viable option. The success and benefits of this surgical procedure are directly related to careful donor and recipient selection.Key words: dual kidney transplantation - marginal donor - chronic renal failure - expanded criteria donor.

[Kidney donors after circulatory death (DCD) - single centre experience]. / Dárci ledvin po nezvratné zástave obehu (DCD) - zkusenosti jednoho centra.

INTRODUCTION: Kidney procurement from donors after circulatory death (DCD) is an important part of worldwide transplantation programmes. The first kidney transplantation from DCD was successfully performed in the Czech Republic in 2002. METHOD: Forty four kidneys from DCD were procured in the Transplant Centre of Pilsen between 2002 and 2015. We used the technique of "in situ" procurement with the double balloon triple lumen catheter and 510 minutes of the no-touch interval. The method of pulsatile hypothermic perfusion was used to test the viability of the kidneys. Twenty eight recipients with mean age 51.1 (2673) years were transplanted. Sixteen (57.1%) kidneys were from the 2nd, 8 (28.6%) from the 3rd and 4 (14.3%) from the 4th category according to the Maastricht criteria. RESULTS: 30-day mortality and morbidity rates were 0 and 10.7% i. e.14.3% respectively (N=4). Primary non-function was presented in 2 (7.1%), and delayed graft function in 5 (17.9%) cases. One, five and ten years of recipient and graft survival rates were 100%, 86.4% and 76.7%; and 92.9%, 69.6% and 61.9%, respectively. The long-term results are fully comparable with kidneys transplanted from donors after brain death. CONCLUSION: DCD are an important source for kidney transplantation. Kidney transplantation from DCD is a logistically, economically and personally demanding method with very good long-term results. KEY WORDS: donors after circulatory death - kidney transplantation - results.

[Late failure of the endovascular infrarenal aortic aneurysm solutions - diagnosis and treatment]. / Pozdní selhání endovaskulárního resení aneuryzmatu subrenální aorty - diagnostika a lécba.

INTRODUCTION: Nowadays, there are two possible solutions to aneurysms of the abdominal aorta. One is an open resection, which is undoubtedly one of the major surgeries and endovascular solutions, and which represents a smaller operating load for the patient. Long-term monitoring of patients after the endovascular solutions showed late failure in 7-17% of cases. The late incidence of endoleaks and the migration of stents are explained by changing the anatomy of the aneurysm and the resulting change in the mechanical pressure on the stent graft. If these conditions cannot be solved by an endovascular procedure the situation may present a technical challenge for the vascular surgeon. MATERIAL AND METHODS: Our report on the five case studies points to possible late complications of EVAR and solutions to their individual states. CONCLUSIONS: In the future, it should be recognized that if the endoleak is not proven it does not mean that it cannot occur over the years and massively fill the excluded aneurysm with the risk of rupture. Undoubtedly, re-operating the open patch is a challenging exercise. Nevertheless, it is possible even with the patients who were, primarily in terms of polymorbidity, indicated EVAR.

[Internal carotid artery surgery under locoregional anaesthesia at the Department of Surgery in Pilsen during the past 10 years (2002-2011)]. / Operace na vnitrních karotidách v lokoregionální anestezii na chirurgické klinice v Plzni za uplynulý h 10 let (2002-2011).

During the ten-year period (2002-2011), carotid artery surgery was performed in 1164 patients, with a mean age of 68 years (44 to 86 years), at the Department of Surgery, University Hospital in Pilsen. In total, 1304 procedures on internal carotid arteries were performed, and the ratio of procedures in men and women was 912/392. The ratio of procedures in asymptomatic vs. symptomatic findings was 938/366. The ratio of patients with unilateral vs. bilateral damage to the internal carotid artery was 930/234. All surgical procedures on internal carotid arteries were performed under locoregional anaesthesia. From the total number of internal carotid artery operations (1304), the 30-day mortality and morbidity rate was 1.46%.

[Leriche's syndrome]. / Lerichuv syndrom.

INTRODUCTION: Leriche's syndrome is defined as atherosclerotic occlusion of the infrarenal aorta and/or the iliac axis. It is associated with claudications or critical limb ischaemia and erectile dysfunction in men. MATERIAL AND METHODS: Twenty patients with Leriche's syndrome were operated on at the Department of Surgery, University Hospital in Pilsen between 2008 and 2012. There were 6 women and 14 men of average age 60.3 years (41-76 years). Three patients were in group C and 17 in group D according to the Trans-Atlantic Inter-Society Classification IIb (TASC IIb). Fifteen patients suffered from chronic claudication or rest pain, five patients had acute limb ischaemic symptomatology. Aortobifemoral bypass with subsequent anti-aggregation therapy was the only treatment option. RESULTS: Primary 30-day patency was 100%. 30-day postoperative mortality was 5% (one patient died of acute myocardial infarction). Two patients died in two and four years after the reconstruction (10%) due to cerebral ischaemia and bronchopneumonia. Only one extremity amputation was performed within the five-year interval after vascular reconstruction. All aortobifemoral reconstructions were patent in two months to five years after the operation. We had to manage only one false aneurysm in the groin three years after the aortobifemoral reconstruction. CONCLUSION: Aortobifemoral bypass is a method of choice for the treatment of Leriche's syndrome. Endovascular treatment is suitable for patients with severe comorbidities.

[Traumatic rupture of thoracic aorta]. / Traumatická ruptura hrudní aorty.

INTRODUCTION: Thoracic aortic injury (TAI) is burdened with high mortality (80-90%). The diagnostic and therapeutic algorithm has changed radically over the last couple of years. The authors present their experience with diagnosis and treatment of TAI at the University Hospital Trauma Centre. MATERIAL AND METHODS: 24 TAIs were evaluated in a retrospective study, in 20 (83.3%) cases they were part of a polytrauma. The average age of the patients was 39.4 years (20-67). Traffic accidents formed the majority of TAIs (87.5%). Multi-detector computed tomography was used as a basic examination to detect TAI. Thoracic endovascular aortic repair (TEVAR) was the treatment of choice in 21 and open surgery in 3 injured patients. RESULTS: The 30-day postoperative mortality was 12.5%, in one case it was associated with TEVAR. 30-day morbidity was 37.5% (circulatory instability, respiratory insufficiency, bronchopneumonia, type I endoleak). CONCLUSION: MDCT and TEVAR are currently the methods of first choice in the diagnosis and treatment of TAI. TAI requires a highly specialized multidisciplinary approach within Trauma Centres providing complex cardiovascular services.

[Vascular reconstructions infections in the aortofemoral region]. / Infekce cévních rekonstrukcí v aortofemorální oblasti.

INTRODUCTION: The incidence of prosthetic vascular graft infections in the aortofemoral region is reported at 0.6-3%. These complications are burdened with a high mortality of up to 50% and an amputation rate of up to 20%. The aim of our study was to give a complex view on the diagnostic and treatment possibilities of these serious complications of reconstructive vascular surgery. MATERIAL AND METHODS: Prosthetic bypass grafts were performed in 1088 patients in the aortofemoral region between 2001-2011 at the Department of Surgery, Teaching Hospital and the Faculty of Medicine, Charles University, in Pilsen. 24 (2.2%) patients suffered from graft infection at various time intervals after primary vascular reconstruction. Clinical examination, computed tomography and positron emission tomography were the main diagnostic methods of vascular graft infection. "In situ" reconstructions dominated over extra-anatomic reconstructions. When the infection involved only the peripheral part of the prosthetic graft, a more conservative approach - local debridement and drainage - was used. RESULTS: The mortality of the patients was 20.8%, high amputation rate 12.5%, and morbidity rate 58.3%, respectively. The average time of hospitalization in surviving patients was 46.5 days. Primary 30-day patency rate in "in situ" and extra-anatomic reconstructions was 100 and 60%, respectively. CONCLUSION: Prosthetic vascular graft infections in the aortofemoral region require tailored multidisciplinary treatment approach in vascular centres. "In situ" reconstructions are the method of first choice. A more conservative approach in infections involving only the peripheral part of the vascular reconstruction has a positive treatment effect.

[Procedures on internal carotid performed under locoregional anesthesia in the Plzen Surgical Clinic, over a seven-year period. A discussion on AHA and ESVS guidelines]. / Operace na vnitrrních karotidách v lokoregionální anestezii na chirurgické klinice v Plzni za uplynulých 7 let. Diskuse nad AHA a ESVS guidelines.

During a seven-year period (2002-2008), 830 patients underwent internal carotid surgery in the Plzen Surgical Clinic. The mean age of the patients was 68 y.o.a. (range 48-86 years). A total of 916 internal carotid procedures were performed, the male/female ratio was 667/249. 639 procedures were performed for asymptomatic and 277 for symptomatic conditions. 677 patients suffered from unilateral carotid disorders and 153 subjects from bilateral carotid disorders. All the procedures were performed under locoregional anesthesia. The 30-day mortality rate was 1% (9 subjects) of all the procedures.

Internal carotid artery surgery in regional anesthesia at the Clinic of Surgery in Pilsen during the past 5 years.

A low percentage of perioperative complications and excellent long-term outcome following carotid artery surgery in Vascular Centers demonstrate the priority of surgical solutions in patients with significant findings on carotid arteries, in the prevention and treatment of ischemic cerebrovascular accidents. The group of patients from the Clinic of Surgery in Pilsen demonstrates the benefits of regional anesthesia during internal carotid artery surgery, both in terms of the patients' health and the financial costs incurred by the hospital.

[Surgical aspects of Buerger's disease]. / Buergerova choroba z chirurgického pohledu.

BACKGROUND: The Buerger's disease (BD) is known for more than 100 years. It inflicts especially young men, smokers, at the age of about 40 and manifests itself by ischemia in the periphery of limbs which cannot be explained by precedent injury, embolism, diabetes or hyperlipemia. The disease inflicts the medium or small peripheral arteries of extremities. The occurrence of BD is most frequent in the Mediterranean and East-Asian countries. The therapy is so far symptomatic and is unsuccessful in cases when the patient is reluctant to cease smoking. AIM: The study is aimed at ascertainment of the results of surgical therapy in 14 patients with BD hospitalized in the Surgical Clinic FN in Plzen during the period from 1986 to 1995. METHODS: The average age of patients was 39.6 +/- 1.2 y. The ratio males/females was 13:1. All patients were smokers. 4 patients had a trophic defect in the periphery of the upper and 11 of the lower limbs. 9 (64.3%) patients displayed the Raynod's phenomenon and seven (50%) had thrombophlebitis. All patients were treated conservatively (vasodilators, anticoagulants, antiaggregants, corticoids, prostacyclins, nifedipine). Sympatectomy (lumbal, upper thorax) was performed in 10 (71.4%), and profundoplasty in 2 patients (14.3%). RESULTS: Conservative therapy, sympatectomy and revascularization methods failed to have a long-term effect. Repeated hospitalization of the patients was necessary, namely 7 times in average, and limbs were amputated in high percentage of patients (50%). However in cases when patients ceased smoking, the disease withdrew or became stabilized. CONCLUSION: Despite the fact that BD has become less frequent in our population, it still disables young groups of patients. The therapy is so far symptomatic and the successfulness of therapy strongly depends on the patient's willingness to cooperate (cessation of smoking) and as such it is often unsuccessful. The surgical therapy, so far, fails to have a long-term effect and high percentage of limb amputation is necessary. (Ref. 11.).

[Arterial "crossover" reconstruction in ischemic disease of the lower extremities]. / Tepenné rekonstrukce typu "crossover" u ischemické choroby dolních koncetin.

The authors present a group of 20 patients where in the course of a 15-year period (1978-1992) a crossover bypass was made to save a lower extremity with advanced ischaemia. Based on their own experience which they compare with results of physicians abroad they submit an analysis of indications for this type of extra-anatomical reconstruction. In the authors' opinion crossover bypasses have their place in reconstruction surgery of the arteries of the lower extremities if they are perceived as extra-anatomical reconstructions and thus are subjects to strict criteria for indication.

[A kidney harvesting technic from a non-heart beating donor]. / Technika odberu ledvin z nebijícího dárce (NHBD).

The authors describe the technique of collection of kidneys from NHBD. They present their own protocol elaborated in Plzen for collection of kidneys from NHBD. For collection they use a special double-balloon catheter inserted into the aorta to ensure that the perfusion fluid will penetrate into visceral branches of the aorta. For the flow of the perfusion fluid a urinary catheter is used inserted via the femoral vein into the vena cava inferior. Immediately after the beginning of perfusion laparotomy is performed with immediate cooling of the kidney with ice. The authors give an account of their own experience and discuss further technical possibilities as regards collection of kidneys from NHBD.

[Aneurysms of the abdominal aorta]. / Aneuryzma abdominální aorty.

The authors present the experience of the Plzen department with treatment of aneurysms of the abdominal aorta (AAA) during the last five-year period (1992-1996) when they operated a total of 111 AAA in patients with an average age of 67.9 years (44-91 years). The number of symptomatic AAA was 15 (13.5%), 36 ruptures (32.4%). The most frequent risk factor was ischemic heart disease (IHD) in 74 (66.7%) and hypertension in 47 (42.3%) of the patients. Within 30 days after surgery two asymptomatic patients died (3.9%) and three (20%) with symptomatic AAA. The most frequent cause of death was acute myocardial infarction (AIM) in four (80%). Of 36 patients with rupture of AAA 17 (47.2%) died. A statistically significant factor for death of patients with rupture of the AAA was sever shock (blood pressure < 40 mm Hg) before surgery (p < 0.01), blood in the abdominal cavity (p < 0.01) and hypertension in the patient's case history (p < 0.05). Aimed screening of AAA in patients of risk groups and early elective surgery are important for reducing the incidence of ruptures of AAA. A patient with rupture of the AAA needs surgery urgently and unnecessary examination (CT, USG) frequently causes delay and reduces the patient's chance of survival.

[Abdominal aneurysm resection in aged patients at the Surgery Clinic in Plzen from 1998 to March 2003]. / Resekce aneuryzmat abdominální aorty u nemocných vysokého veku na chirurgické klinice FN v Plzni v období 1998-3/2003.

The authors evaluate resection therapy on aneurysms of abdominal aorta in patients of high age (mean 85 years) at the Clinic of Surgery in Plzen. In the period of 1998-March 2003 the authors performed 13 elective resections on aneurysms of abdominal aorta in patients of high age with zero mortality and 21 acute resections with 38% mortality. In the given period of time, 178 resections of aneurysms of abdominal aorta were made in patients younger than 78 years, 57 being acute interventions. Mortality of elective interventions was 2.9%, in acute interventions being 28%. The present groups indicate that mortality of resection therapy sharply increased in relation to circulation instability of the patients in cases of ruptured aneurysm, but nor in relation to age of the patients.

[Initial experience with transplantation of a kidney from a non-beating heart donor (NHBD)]. / Nase první zkusenosti s transplantací ledvin odebraných z nebijícího dárce (NHBD).

The authors present their initial experience with transplantations of the kidneys from a donor with a non-beating heart (NHBD). This programme was developed because of the permanently declining number of cadaverous kidney donors with a beating heart. Since January 2002 the authors collected a total of three kidneys from NHBD 3 kidneys of which were used for transplantation. The first two started to function immediately, the third one restored its function three weeks after transplantation. The viability and suitability of use of kidneys from NHBD is evaluated with regard to vascular resistance and flow of the perfusion fluid through the kidneys when using a perfusion pump and by means of totalglutathione-S-transferase (tGST) assessed at intervals in the perfusion fluid. The values of the above parameters are limiting between the 6th and 8th hour after the onset of instrumental perfusion of the collected kidneys when the perfusion values should be within the range of 30-50 ml/min/100 g and the vascular resistance should be < 0.7 mmHg and tGST < 100 U/l. For immunosuppression the authors use during the fist days after transplantation basiliximab, rapamycin and corticoids, later in case of satisfactory function of the graft they add cyclosporin A. The initial results of renal transplantation from NHBD are promising and the programme will be developed further.

[Injuries of extremity blood vessels, personal experience and results]. / Poranení koncetinových cév, nase zkusenosti a výsledky.

The authors evaluated the results achieved in 47 patients with injuries of the acral vesels where they performed a total of 50 vascular operations during the five-year period from 1998-2001. 21.3% injuries were part of multiple injuries. The mean period of hospitalization was 14.7 days. The 30-day mortality was 6.4% and the morbidity 12.8%. The upper extremity was saved in all instances (100%), the lower extremity in 77.3% of the injured. The reason for high amputations of the lower extremity were most frequently injuries of the popliteal artery associated with skeletal injury and extensive contusion of the soft tissues of the extremity. The authors discuss the optimal diagnostic and therapeutic procedures in injuries of the acral vessels. They emphasize a multidisciplinary approach without delay with early, frequently during the primary operation indicated fasciotomy, to prevent the development of compartment syndrome. The order of operations in concurrent injuries of the acral skeleton depends on the stage of ischaemia, type of injury and solution of the skeletal fractures. This type of injury frequently calls for repeated redressing in the operation theatre with repeated necrectomies of soft tissues to prevent infection which may prove fatal for the extremity. Injuries of the acral vessels should be nowadays treated in specialized departments with a 24-hour diagnostic and therapeutic traumatological service which comprises a highly specialized team of vascular surgeons.

[Cystic abdominal lymphangioma in adults]. / Abdominale Form des zystischen Lymphangioms mit Manifestation im Erwachsenenalter.

Cystic abdominal lymphangioma is a rare tumor in adult age. It occurs usually in children and is localised mostly in the head and neck. Only 2-8 % of lymphangiomas are localised intraabdominally. We present a case of a 20-year-old man who complained about acute abdominal pain after physical activity. Diagnosis of intraabdominal multilocular cyst was done by ultrasound, computed tomography and coeliacography. The definitive diagnosis of lymphangioma of the hepatoduodenal ligament was established by laparotomy and histologic examination of the specimen. Cystic abdominal lymphangioma is a rare disease in adults with difficult preoperative diagnosis. The surgical extirpation often completed with resection of involved organ is the method of choice in the treatment of this rare disease.

[Extraanatomic bypass surgery for peripheral arterial vascular disease--is it still justified?]. / Haben extraanatomische Rekonstruktionen bei peripherer arterieller Verschlusskrankheit noch ihre Berechtigung?

OBJECTIVE: Our results of extraanatomic bypass surgery in the last 5 years should be analysed in a retrospective study. PATIENTS AND METHODS: 66 extraanatomic reconstructions were performed in 65 patients (52 male, 13 female). Femoro-femoral bypasses (78.8 %) were mainly included in this study, followed by axillo-femoral (bifemoral) and obturator bypasses. The procedures could be divided in 45 (68.2 %) primary and 21 (31.8 %) recurrent operations. 57.6 % of the patients revealed a critical lower limb ischemia. RESULTS: The bypass patency rates were 97 % after one year and 81.1 % after 3 years. 24.2 % of the patients showed immediate postoperative complications, 12.1 % of them major complications (surgical and nonsurgical). No patient died postoperatively or in the first year after operation. The 3-year mortality rate ranged to 10.8 %. Major amputations had to be carried out in 4 patients (6.1 %) during the first year and in one patient later on, so that the total amputation rate amounted to 7.6 %. CONCLUSIONS: Our results prove extraanatomic reconstructions to be a valuable surgical tool in lower limb ischemia with good long-term success. Extraanatomic bypasses are technically simple procedures in the majority of cases and take good care of the patient with low morbidity and mortality.