Editor's Choice - Single Centre Midterm Experience with Primary Fenestrated Endovascular Aortic Aneurysm Repair for Short Neck, Juxtarenal, and Suprarenal Aneurysms.

OBJECTIVE: The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre. METHODS: Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed. RESULTS: A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088). CONCLUSION: Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival.

The Involvement of Cx43 in JNK1/2-Mediated Endothelial Mechanotransduction and Human Plaque Progression.

Atherosclerotic lesions preferentially develop at bifurcations, characterized by non-uniform shear stress (SS). The aim of this study was to investigate SS-induced endothelial activation, focusing on stress-regulated mitogen-activated protein kinases (MAPK) and downstream signaling, and its relation to gap junction proteins, Connexins (Cxs). Human umbilical vein endothelial cells were exposed to flow ("mechanical stimulation") and stimulated with TNF-α ("inflammatory stimulation"). Phosphorylated levels of MAPKs (c-Jun N-terminal kinase (JNK1/2), extracellular signal-regulated kinase (ERK), and p38 kinase (p38K)) were quantified by flow cytometry, showing the activation of JNK1/2 and ERK. THP-1 cell adhesion under non-uniform SS was suppressed by the inhibition of JNK1/2, not of ERK. Immunofluorescence staining and quantitative real-time PCR demonstrated an induction of c-Jun and c-Fos and of Cx43 in endothelial cells by non-uniform SS, and the latter was abolished by JNK1/2 inhibition. Furthermore, plaque inflammation was analyzed in human carotid plaques (n = 40) using immunohistochemistry and quanti-gene RNA-assays, revealing elevated Cx43+ cell counts in vulnerable compared to stable plaques. Cx43+ cell burden in the plaque shoulder correlated with intraplaque neovascularization and lipid core size, while an inverse correlation was observed with fibrous cap thickness. Our results constitute the first report that JNK1/2 mediates Cx43 mechanoinduction in endothelial cells by atheroprone shear stress and that Cx43 is expressed in human carotid plaques. The correlation of Cx43+ cell counts with markers of plaque vulnerability implies its contribution to plaque progression.

Outcomes of Upper Extremity Access with Surgical Exposure of the Axillary Artery in Fenestrated and Branched Endovascular Aneurysm Repair.

OBJECTIVE: This study aims to assess the safety of upper extremity access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurological and local complications as well as re-interventions associated with the technique. METHODS: All patients undergoing an F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single centre study. Endpoints were neurological and access related complications and re-interventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury, and arterial complications. RESULTS: 264 patients (192 male, mean age 70 ± 7 years) were included. Upper extremity access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2.2%) patients had early complications related to the arterial access: four with post-operative bleeding and two with acute arm ischaemia. Two patients with post-operative bleeding and both patients with ischaemic complications required re-intervention. One of these patients with arm ischaemia died five weeks after the re-intervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented with transient arm paraesthesia or sensory neurological deficit post-operatively. The symptoms completely recovered in all cases with no residual deficits. Peri-operative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion. CONCLUSION: Upper extremity access with surgical exposure of the axillary artery is a safe method for antegrade catheterisation of fenestrations and branches in complex endovascular aneurysm repair.

Single Center Experience with Endovascular Repair of Acute Thoracoabdominal Aortic Aneurysms.

PURPOSE: To investigate feasibility and outcomes of endovascular repair for acute thoracoabdominal aortic aneurysms (TAAA). MATERIALS AND METHODS: Data from a single center were retrospectively analyzed. Patients who underwent endovascular repair for acute TAAA between January 2010 and April 2020 were included. Perioperative and mid-term follow-up outcomes were analyzed. Survival, freedom from reintervention, and target vessel patency were calculated by Kaplan-Meier analysis. RESULTS: A total of 30 patients (18 men, 67.5 ± 6.9 years) underwent endovascular repair for acute symptomatic (n = 15) or contained ruptured (n = 15) TAAA. An off-the-shelf four-branched stent-graft (T-Branch) was used in 19 (63.3%) patients, a custom-made device (CMD) with expedite order in 5 (16.7%) patients, a CMD with short anticipated delivery time in 3 (10.0%) patients, and a CMD available in the hospital in 3 (10.0%) patients. Technical success was 90.0% (n = 27). Thirty-day mortality was 10% (n = 3). There was no complete persistent paraplegia, but one (3.3%) patient suffered permanent limb weakness. Estimated survival at 1 and 2 years was 86.3% ± 6.4%, and 82.3% ± 7.2%, respectively. Estimated freedom from reintervention at 1 and 2 years was 81.4% ± 7.6% and 73% ± 8.8%. Estimated target vessel patency at 1 and 2 years was 96.6% ± 2% and 92.6% ± 2.9%. CONCLUSION: Endovascular treatment of acute TAAA in this selected group of patients was associated with low early mortality and excellent mid-term survival. The off-the-shelf stent-graft option (T-Branch) was used in the majority of patients. Endovascular repair should be considered the first option for suitable acute TAAA.

Reasons for and Outcomes of Open Abdominal Aortic Repair in the Endovascular Era.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has become the treatment of choice for most patients with abdominal aortic aneurysm (AAA). Open aneurysm repair (OAR) is still being used in a number of patients for specific reasons. The aim of the present study was to investigate the reasons and perioperative outcomes of OAR in a high-volume endovascular center. METHODS: All patients who underwent OAR in a single center institution during the period April 2010 to July 2019 were retrospectively analyzed. RESULTS: During the study period, 222 patients underwent OAR. One hundred and forty-one (63.5%) patients underwent elective surgery, and eighty-one (36.5%) patients were treated acutely. The reasons for the decision to perform OAR instead of EVAR were as follows: anatomical in 89 (40.1%) cases, rupture in unstable patient in 57 (25.7%) cases, AAA with concomitant iliac arterial occlusive disease in 44 (19.8%) cases, previous EVAR with complications in 14 (6.3%) cases, large pararenal aneurysm considered risky to wait for a customized fenestrated stent graft in 7 (3.2%) cases, young patient age in 4 (1.8%) cases, the patient's preference in 3 (1.4%) cases, infected/mycotic AAA in 2 (0.9%) cases, and simultaneous OAR with colon cancer resection (n = 1, 0.5%) and renal transplantation (n = 1, n = 0.5). Thirty-day mortality in elective cases was 5% (7/141) and in acute cases 34.6% (28/81). CONCLUSIONS: This study shows that OAR is still used for selected patients despite improvements in EVAR technology. The most common reason for OAR was an unsuitable anatomy for EVAR. Perioperative mortality of OAR both for acute and elective cases as observed in this study is in line with published outcomes of other centers.

Aneurysm Rupture and Mortality During the Waiting Time for a Customised Fenestrated/Branched Stent Graft in Complex Endovascular Aortic Repair.

OBJECTIVE: Treatment of complex aortic pathologies with customised fenestrated/branched stent grafts (F/BEVAR) is associated with a longer waiting time to the procedure. This study aimed to investigate the prevalence of aneurysm rupture and mortality during the waiting time for a fenestrated/branched stent graft in a single centre. METHODS: All patients with a pararenal (PAA), thoraco-abdominal (TAAA), or aortic arch aneurysm planned to be treated with a customised F/BEVAR between January 2010 and December 2018 were included. Patients planned for F/BEVAR who in the end did not undergo the procedure were analysed. RESULTS: 906 patients were planned to undergo F/BEVAR during the study period. Of those, 862 (95.1%) underwent the procedure as planned (FEVAR for PAA; n = 494, F/BEVAR for TAAA; n = 348, F/BEVAR for arch aneurysm; n = 20). In 44 (4.9%) patients, the procedure was cancelled. Thirty-seven (4.1%) patients died before the procedure, four (0.4%) patients turned down the procedure, two (0.2%) were cancelled because of worsened general condition, and one (0.1%) ruptured but underwent emergency open repair in another institution. Causes of death during the waiting time were: aneurysm rupture, n = 15 (1.7%); cardiac, n = 7 (0.8%); stroke, n = 3 (0.3%); gastrointestinal, n = 3 (0.3%); death after complete arch debranching, n = 2 (0.2%); infection, n = 2 (0.2%); death after transcatheter aortic valve implantation, n = 1 (0.1%); death after urological surgery, n = 1 (0.1%); unknown, n = 3 (0.3%). Aneurysm diameter was larger in patients who died of aneurysm rupture compared with patients who died as a result of other causes (79.2 ± 13 mm vs. 66.7 ± 12 mm, respectively, p = .005). CONCLUSION: Aneurysm rupture during the waiting time for F/BEVAR can occur but is rare. Patients with a larger aneurysm diameter may be at higher risk of rupture. Measures to reduce the risk of rupture during the waiting time might include the use of off the shelf devices for larger aneurysms, quicker measurement and graft plan order processes, and quicker graft construction and delivery.

Use of Bilateral Cook Zenith Iliac Branch Devices to Preserve Internal Iliac Artery Flow During Endovascular Aneurysm Repair.

OBJECTIVES: Iliac branch devices (IBD) have become a widespread option to preserve antegrade internal iliac artery (IIA) flow during endovascular aneurysm repair (EVAR). Reported experience with bilateral implantation of IBDs is limited. This study aimed to describe the indications, technical options, and outcomes with the use of bilateral IBDs. METHODS: All patients undergoing elective implantation of bilateral Cook Zenith IBD between January 2010 and September 2017 in a single centre were included. Bilateral IBD was indicated in physically active, anatomically suitable patients and those with previous or concomitant surgery for a thoraco-abdominal aortic aneurysm or impaired collateral circulation to the IIA. Data were collected prospectively. RESULTS: Twenty-nine patients (29 male, mean age 64.1 ± 10 years) were included. Of the 58 IBDs, 48 (83%) were implanted in one procedure and 10 (17%) in two procedures (mean time between procedures 30.4 ± 9 months). Nineteen patients (65%) had a previous or simultaneous EVAR and the remaining 10 (35%) a previous or simultaneous complex aortic repair. Mean CIA diameter was 35.2 ± 8 mm. Technical success was achieved in 55 of the 58 IBDs (95%) with no mortality. Axillary artery access was used in 13 (38%) procedures. During follow up, four (7%) IIA branches occluded (1 bilateral occlusion and 2 unilateral). Estimated IIA branch patency at one and three years was 97.8% ± 2% and 88.5% ± 7%, respectively. All patients with late IIA occlusion remained asymptomatic. Re-intervention was needed in four patients (14%): two bridging stent graft extensions for type Ib endoleak, one relining of the external iliac artery because of mural in-stent thrombus and one femoro-femoral crossover bypass to treat an external iliac limb occlusion. CONCLUSIONS: Bilateral implantation of IBDs is a safe and effective technique to preserve IIA flow in selected patients with suitable anatomy, showing similar technical success and mid-term outcomes to the unilateral use of the device.

[Clinical features and therapeutic response of our anti-SRP positive patients with myositis]. / Anti-SRP-pozitív myositises betegeink klinikai sajátosságai és terápiára adott válaszuk.

INTRODUCTION: Idiopathic inflammatory myopathies are a group of clinically heterogeneous diseases, which have been classified by myositis specific antibodies recently. The anti-SRP positive subset of this group is characterized by more severe clinical prognosis than other myositis specific antibody positive types. AIM: Our goal was to compare 16 anti-SRP positive patients in the Division of Clinical Immunology, Department of Internal Medicine, University of Debrecen with 16 antibody negative ones. METHOD: Muscle strength validated in both groups by the manual muscle test proved to be significantly decreased both before and after therapy (χ2 = 0.006 and 0.019) in the anti-SRP positive group. RESULTS: Muscle-specific inflammatory laboratory parameters showed significant difference only in case of LDH-levels after therapy. Both groups showed good clinical response to first line steroid treatment, yet the significantly higher rate of second line administration suggests worse therapeutic response of the antibody positive group. CONCLUSION: Based on these facts we determined poor clinical prognosis and therapeutic response of the anti-SRP positive group. Orv Hetil. 2017; 158(35): 1382-1389.

[The role of radical surgical approach in the treatment of benign multinodular goitre depending on anatomical variations of the recurrent laryngeal nerve]. / A radikalitás helye a benignus pajzsmirigybetegségek sebészi kezelésében a nervus rekurrens anatómiai sajátságainak tükrében.

UNLABELLED: From time to time there is a surprise at the end of surgery - even after subtotal resection - when a vocal cord is observed on indirect laryngoscopy to be non-functional. Surgeons are highly individualistic and develop their own special ways of locating and protecting the nerve. The present study has tried to clarify whether relying on palpation alone during surgery is safe enough in each case. MATERIALS AND METHODS: Between 01.01.2001 and 31.12.2008, 1228 recurrent laryngeal nerve (RLN) were exposed in 702 patients on thyroid surgery. The RLN was found and traced until the laryngeal entry point in all patients. Substernal spreading was noted in 38.6% (271/702), while tracheal compression or dislocation was present in 19.5% (137/702). Recurrent thyroid disease counted for 8.4% (59/702) of all cases. Total thyroid lobectomy was carried out in 82.2% (1009/1228), near-total thyroidectomy in 15.5% (191/1228), and subtotal resection only in 2.3% (28/1228). RESULTS: Palpation was helpful in 80.7% (991/1228), proved false positive in 8.7% (107/1228), while in 10.6% (130/1228) it did not provide any help in the localization. The palpability of the RLN showed marked discrepancy between the two sides. False positivity was noted with palpation in 3.4% (21/625) and 14.3% (86/603) on the right and left side, respectively. On the other hand, palpation helped localization in 4.8% (29/603) on the left side, while the same figure was 16.2% (101/603) on the right side. Definitive RLN palsy was experienced in 0.8% of all cases (10/1228), whilst transient paresis was encountered in 1.4% (17/1228). Occult malignancy was noticed in 5.6% (39/702). CONCLUSIONS: No indication has been left for subtotal resection. Even if benign multinodular goitre is present, since the clinical and pathophysiological evidences suggest that multinodular goitre affects the entire gland, any surgery that leaves potentially abnormal thyroid tissue in situ carries a risk of recurrent disease. RLN palpatory method is a useful part of thyroid surgery but it is suitable for rough orientation only.

[Malignant gastrointestinal stromal tumor arising in a duodenal diverticulum]. / Duodenum-diverticulumban kialakult gastrointestinalis stromalis tumor.

Malignant gastrointestinal stromal tumor arising in a duodenal diverticulum. The authors describe the case of a 74-year-old male patient who was operated on for a GIST found in a large duodenal diverticulum, co-using gastrointestinal bleeding. This diverticulum--including the tumor--was removed by resection the distal part of the stomach and proximal third of duodenum. The histology revealed malignant gastrointestinal stromal tumor (GIST). 6 months after the operation he remained tumor free according to the control examinations. On the basis of new pathologic classification we summarise the signs, the diagnostic and therapeutic possibilities and the histologic characteristics of gastrointestinal stromal tumors.

[Dilemmas arising from surgical treatment of epiphrenic diverticulum]. / Az epiphrenalis nyelocso-diverticulum sebészi kezelésének dilemmái.

INTRODUCTION: Epiphrenic diverticulum cannot be considered a primary anatomical alteration, there is a manometrically verifiable motility disturbance in the background. OBJECTIVES: To determine the place, type and time of surgical solution in the treatment. PATIENTS: Between 1999 and 2004 seven patients were treated for epiphrenic diverticulum causing complaints. Average age was 61 years, and the leading symptom was dysphagia and regurgitation. Motility abnormalities characteristic of achalasia in four cases, hypertensive LES in three cases, and incompetent and normal LES, and diffuse esophageal spasm in one patient each could be revealed. The size of diverticuli varied between 5-9 cm. RESULTS: In four cases transthoracic diverticulectomy myotomy and partial antireflux plasty, in two cases esophagus resection, and in the case of one patient myotomy and fundoplication was performed. In the removed diverticuli an ulcer and a malignant transformation in one case each was detected. No major complications could be observed. Six patients are completely satisfied with the operation, only one reported well tolerable occasional regurgitations. CONCLUSION: Even in the era of minimal invasive surgery the traditionally performed, combined - diverticulectomy, myotomy, fundoplication - operative solution should be considered the gold standard. Surgical intervention is justified even for accidentally discovered symptomless patients, due to the considerable potential complications of the disease.

Synchronous electrogastrographic and manometric study of the stomach as an esophageal substitute.

AIM: To investigate the electric and contractile mechanisms involved in the deranged function of the transposed stomach in relation to the course of the symptoms and the changes in contractile and electrical parameters over time. METHODS: Twenty-one patients after subtotal esophagectomy and 18 healthy volunteers were studied. Complaints were compiled by using a questionnaire, and a symptom score was formed. Synchronous electrogastrography and gastric manometry were performed in the fasting state and postprandially. RESULTS: Eight of the operated patients were symptom-free and 13 had symptoms. The durations of the postoperative periods for the symptomatic (9.1+/-6.5 mo) and the asymptomatic (28.3+/-8.8 mo) patients were significantly different. The symptom score correlated negatively with the time that had elapsed since the operation. The percentages of the dominant frequency in the normogastric, bradygastric and tachygastric ranges differed significantly between the controls and the patients. A significant difference was detected between the power ratio of the controls and that of the patients. The occurrence of tachygastria in the symptomatic and the symptom-free patients correlated negatively both with the time that had elapsed and with the symptom score. There was a significant increase in motility index after feeding in the controls, but not in the patients. The contractile activity of the stomach increased both in the controls and in the symptom-free patients. In contrast, in the group of symptomatic patients, the contractile activity decreased postprandially as compared with the fasting state. CONCLUSION: The patients' post-operative complaints and symptoms change during the post-operative period and correlate with the parameters of the myoelectric and contractile activities of the stomach. Tachygastria seems to be the major pathogenetic factor involved in the contractile dysfunction.

[Considerations in the surgical treatment of enterogenic mediastinal cyst]. / Mediastinalis enterogen cysta sebészi kezelésének dilemmái.

INTRODUCTION: Mediastinal alterations causing esophageal dysfunctions originate from malignant or inflammatory diseases and in a few cases from congenital anomalies. CASE REPORT: The authors report the medical history of a 27-year-old woman whose large (35-40 mm in diameter) cystic lesion was causing compression of the middle third esophagus and dysphagia. Because of subjective complaints resection was made from a right posterolateral "muscle-preserving" thoracotomy. Histological examination verified an intramural, esophageal cyst. After the 7th postoperative day the patient was discharged from the hospital, currently she is without symptoms and complaints. DISCUSSION: In the background of esophageal dysfunctions can be a mediastinal lesion causing external compression. This lesion, in a few cases, is a congenital anomaly, which develops during the separation of the respiratory- and the digestive apparatus. Probably the effect of increased divisional tendency can create the partial duplication of developing organs, i.e. trachea, esophagus. Later these are described as bronchogenic or enterogenic cysts. Literature mentions cases about ciliated columnal epithelium, ventricular mucosa or malignancy covering the inner surface of the cyst. Preoperative examinations are not enough to describe a mediastinal cyst. According to the surgical guidelines a case without complaints is only a relative indication to operate. If it is followed, an occasional malignant transformation will not be recognized, or will be recognized too late. CONCLUSION: As we know, a mediastinal cystic lesion never regresses. Because of the tendency of malignant transformation, in the absence of operative contraindication, surgical resection is the method of choice even in symptom-free cases.

[Antral ectopic pancreas causing gastric outlet obstruction]. / Gyomorürülési zavart okozó antrális ectopiás pancreas.

Ectopic pancreas is an uncommon clinical finding. It is rare for heterotopic pancreas tissue to cause symptoms, however every disease of the pancreas may develop in it. The most common sites for ectopic pancreas are the submucosal layer of the stomach and the small intestine. Symptomatic ectopic pancreas usually causes diagnostic difficulties. Surgical excision is recommended if the patient has complaints. We report the case of a 32-year-old man. We performed subtotal gastrectomy because of a submucosal, antral tumour, that caused gastric outlet obstruction. The histological examination verified ectopic pancreas tissue. The patient recovered without any complications.