Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection.

OBJECTIVES: The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). METHODS: Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55 ± 11 years) had OSSAF. Follow up visits were scheduled at 1, 3-6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. RESULTS: The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84 ± 40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). CONCLUSIONS: OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Early restenosis after eversion carotid endarterectomy versus carotid stenting: a single-centre retrospective study.

AIM: The aim of our study was to compare the early restenosis rate between patients undergoing carotid artery stenting (CAS) and carotid endarterectomy (CEA) at a single cardiovascular institution. METHODS: In 2004, 368 carotid endarterectomies were carried out on 347 patients and 144 internal carotid artery stentings were performed on 140 patients. The mean follow-up time was 18.4 months (range 6-38 months). Restenosis rates were calculated with the Kaplan-Meyer method and the two groups were compared by using log-rank test. Perioperative outcome was also evaluated and the groups were compared with chi-square test. RESULTS: Significantly more perioperative complications occurred in the CAS group, mainly transient neurological (7.60% vs 2.20% in the CEA group, P<0.05) and cardiovascular symptoms (4.10% vs 1.10% in the CEA group, P<0.05). Moderate restenosis (50-69%) occurred in 11.41% (42/368) of CEA cases and in 4.86% (7/144) of CAS cases (P<0.05). Severe (70%) restenosis rates were 10.05 % in the CEA group and 3.47% in the CAS group (P<0.05). CONCLUSIONS: Incidence of restenosis after carotid artery stening was less common than after carotid endarterectomy. On the other hand, perioperative complications were recorded more often after CAS than following CEA.

Changes in the plasma concentration of soluble thrombomodulin in patients with severe carotid artery stenosis after eversion endarterectomy.

OBJECTIVE AND DESIGN: The purpose of the study was to investigate the putative role of soluble thrombomodulin (sTM) in severe carotid artery stenosis. MATERIALS AND METHODS: We prospectively studied 64 patients who were undergoing carotid endarterectomy (2001-2003). Plasma sTM concentration was determined in each patient before surgery and at 14 months postsurgery. -308 TNF-alpha promoter polymorphism was also determined. RESULTS: Strong negative correlation was found between the preoperative duplex scan values and the plasma sTM concentrations (R = -0.418, p = 0.0006). Patients with 308 A TNF-alpha genotype had significantly lower (p = 0.0415) preoperative sTM values than their counterparts with no such polymorphism. Soluble TM concentrations measured in plasma samples taken at the end of the postsurgical follow-up period of 14 months duration were significantly higher compared to the preoperative values (p < 0.0001). CONCLUSIONS: Our present findings indicate that sTM may be adsorbed to the atherosclerotic plaques or inflamed endothelium in carotid arteries. The pathological significance of this adsorption remains to be determined.

Long-term restenosis rate of eversion endarterectomy on the internal carotid artery.

OBJECTIVES: The eversion endarterectomy of the internal carotid artery was introduced in Hungary in 1991. The aim of this study was to define the long-term restenosis rate of this procedure. PATIENTS AND METHODS: Between 1991 and 1993, 171 operations, on 151 patients, were performed by single surgeon: with long-term follow up of 109 patients, which included annual physical and ultrasound examinations. Restenosis rate and plaque morphology were defined. Survival and patency rate were analysed by life-tables. RESULTS: The combined perioperative stroke morbidity and mortality rate was 0.8%. The 5-year patient survival rate was 85%, the recurrent stenosis free rate was 88% at 5 years. Only 9% of the patients had carotid restenosis of more than 70% during this period. Ultrasound plaque morphology showed calcification in one case. Two patients had re-operations, with plaque histology showed myointimal hyperplasia in each case. CONCLUSIONS: Our results for restenosis are compare favourably with the 2-34% restenosis rate reported in the literature. Ultrasound and histological findings suggest that atherosclerosis does not play a significant role in the development of restenosis after the eversion carotid endarterectomy.

Marked decrease in the levels of two inflammatory markers, hs-C-reactive protein and fibrinogen in patients with severe carotid atherosclerosis after eversion carotid endarterectomy.

OBJECTIVE AND DESIGN: To study changes in the levels of two acute phase proteins, plasma fibrinogen and serum C-reactive protein (hs-CRP) in patients with severe carotid stenosis after eversion endarterectomy. MATERIAL AND SUBJECTS: A total of 117 consecutive patients who underwent eversion endarterectomy were included in the study. Blood samples for acute phase protein measurement were taken before operation as well as 5.7 weeks and 13.8 months (median) post-surgery. Plasma fibrinogen and serum hs-CRP concentrations were promptly determined. RESULTS: During the follow-up period sharp, highly significant (p < 0.0001) drop occurred in the serum concentrations of both acute phase proteins. The drop in the hs-CRP levels during the follow up period was mainly due to decrease in patients with highest baseline CRP levels. CONCLUSIONS: Our present findings indicate that removal of atherosclerotic plaques from the carotid arteries markedly decreases the production of two acute phase proteins due to the decrease of the inflammatory burden or the removal of the advanced plaques able to produce these proteins.

[Angiomorphologic indications for emergency carotid reconstruction]. / Akut carotis mútétek angiomorphológiai indikációja.

UNLABELLED: The authors examine, whether urgent carotid reconstruction is indicated, when a patient is neurologically in stable condition, but unstable angiomorphologically. PROCEDURE: The authors examined data about 101 patients (out of 720 carotid reconstructions). These patients had surgery for bigger than 90% stenosis on one of their internal carotid arteries, in 1998 at the Cardiovascular Department of the Semmelweis University Budapest. Nowadays reconstruction on the internal carotid artery is a routine procedure, but the indication for emergency operation is still controversial. We re-examined our emergency carotid operations in a retrospective study, in which surgery was based on angiomorphological indications. 74 patients were operated electively and 27 patients urgently. The first group waited for the operation 1-5 days, and they received preventative medical treatment. There were no preoperative TIAs. In both groups 1 perioperative TIA occurred. The authors conclude, that emergency carotid endarterectomy is not necessary based only on angiomorphological indication. Careful preoperative preparation is suggested, and until surgery anticoagulation or antiaggregation treatment is necessary. The preoperative stroke incidence at emergency carotid reconstruction is higher than is at electively operated patients.

[Percutaneous angioplasty of the innominate artery in 89 patients: experience of 19 years]. / Az arteria anonyma percutan angioplasztikás kezelése: 19 év tapasztalata 89 betegen.

PURPOSE: To assess retrospectively the success of percutaneous transluminal angioplasty (PTA) in treating innominate artery stenoses and occlusion in a large series of patients with long-term follow-up results. METHODS: In symptomatic patients with high degree (> 60%) stenosis, innominate artery PTA was performed. Long-term follow-up was undertaken by blood pressure measurements on both arms as well as subclavian, right common carotid and right vertebral duplex scan. RESULTS: Between 1981 and 1999, primary success rate of 89 innominate artery PTA (84 stenoses, 5 occlusions) was 96.4%. Complications included 1 left occipital lobe infarction (1.5%), 2 puncture-site thrombosis (2.9%), and 4 TIA (5.8%). Two patients with restenosis were successfully treated with rePTA. Cumulative primary patency was 98 +/- 2% at 6 months, 93 +/- 4% at 16 to 117 months, secondary patency was 100% at 6 months, 98 +/- 2% at 12 to 117 months; 61% of the patients became symptomless, 32% improved, 7% showed no improvement. CONCLUSION: Angioplasty of the innominate artery has been proven to be safe and effective on a large series of patients. For innominate artery stenosis and short occlusion, PTA should be the first treatment of choice.

[Simultaneous carotid and coronary operations: experience and results of 11 years (1990-2000)]. / Szimultán végzett carotis-coronaria mútétek: 11 év tapasztalatai és eredményei (1990-2000).

Between 1990-2000 163 coronary + carotid procedures were performed. The mean age was 4 years higher than it was at patients underwent isolated CABG (63.4 y vs 59.8 y). Clinically proven obliterative artery diseases in other anatomical regions were also present in more than 60% of patients. The half of the procedures were performed under emergency and urgent circumstances. The cardiac status and the coronary morphology were found to be unstable in half of the patients. The "Euroscore" risk evaluation model was used for risk scoring. The mean score value was as high as 6.26. According to this the estimated surgical lethality could have been as high as 11.2%. The real surgical lethality value was far under this estimated level (7.36%). The 1, 5, 10 year survival rate were as high as 89%, 82%, 68% (Kaplan-Meier). The majority of the patients was in NYHA I-II at the end of the follow-up period. The majority of the early and late deaths were found to be myocardial in origin. The estimated surgical risk of the simultaneous procedures could be reduce by accepting of the severe surgical indications existing at this surgical field and with the availability of an experienced operating team.

[Late results after eversion endarterectomy of the internal carotid artery]. / Késói eredmények az arteria carotis interna everziós endarteriektómiája után.

OBJECTIVES: The eversion endarterectomy of the internal carotid artery was introduced in Hungary in 1991. The aim of this study was to define the long-term restenosis rate of this new method. MATERIALS AND METHODS: Between 1991 and 1993, 171 operations were performed by one surgeon on 151 patients: 109 patients had enough compliance to take part in long-term follow-up, which included annual physical and ultrasound (Ultramark 9) investigations. Restenosis rate and plaque morphology was defined. Survival and patency rates were calculated by life-table method. RESULTS: The perioperative combined stroke morbidity and mortality rate was 0.8%. The 5-year patient survival rate was 85%, the recurrent stenosis free rate was 88%/5 years, and 9% of the patients had restenosis greater than 70% in this period. The plaque morphology showed calcification in 1 case. Two patients needed 3 reoperations (2.4%). Plaque histology showed myointimal hyperplasia in every 3 cases. CONCLUSIONS: Comparing our results to the literature (2-34% restenosis rate) it seems to be acceptable and encouraging for the future. The ultrasound and histological findings suggest that arteriosclerosis does not play significant role in development of restenosis after the eversion method.

Comparison of perioperative results obtained with carotid eversion endarterectomy and with conventional patch plasty.

After limited experience with eversion endarterectomy of the internal carotid artery, comparison has been made between perioperative results obtained with the eversion technique and with the conventional method. The perioperative results of 715 consecutive cases of patch plasty of the internal carotid artery performed between January 1986 and December 1990 were reviewed and compared with perioperative data of 739 consecutive cases of eversion endarterectomy, performed between January 1991 and December 1993. The duration of surgery was also recorded. Statistical analysis was carried out, using chi2 test, Fisher's Z test and Student's t-test. The postoperative stroke rate was 2.9% in the conventional endarterectomy group, and 0.95% in cases of eversion endarterectomy (P<0.01); the stroke mortality rates were 1.8% and 0.54% respectively (P<0.05). Overall mortality rate was 2.9% in the conventional group and 0.95% in the eversion group (P<0.01): combined morbidity and mortality rate was 4% versus 1.35% (P<0.001). A statistically significant difference was found in favour of the eversion method between the duration of surgery (90.9 min versus 52.8 min; P<0.005) and between the mean clamp time (34.9 min versus 22.4 min: P<0.005). On the basis of these results, it is concluded that eversion endarterectomy of the internal carotid artery is a safe and rapid technique and its immediate results were superior to those obtained after conventional endarterectomy and patch plasty.

Eversion endarterectomy in surgery of the internal carotid artery.

A total of 361 eversion endarterectomies of the internal carotid artery have been carried out on 348 patients between January 1991 and December 1992. Of these patients, 126 were women and 222 were men; average age was 62.9 (range 42-84) years. Some 239 patients had hemispheric symptoms; 37 symptomless patients had a carotid endarterectomy before major vascular reconstruction, and 21 had the operation combined with heart surgery (19 aortocoronary bypasses, two valve replacements). In nine cases (2.5%) a 6-mm interposition graft was used because of unsuccessful eversion endarterectomy. Postoperative bleeding occurred in six patients (1.7%) and postoperative stroke in seven (1.9%); of these patients, four died and two still have mild neurological symptoms. Four reocclusions occurred during the first 6 months that the new method was used. Eversion endarterectomy of the internal carotid artery is a safe and useful technique and is comparable with standard endarterectomies. This technique may reduce the risk of restenosis.

Multicentric extraabdominal desmoid tumour: a case report.

The very rare condition of multicentric desmoid tumours involving two distant and apparently independent sites is reported in a 17-year-old man. The tumours grew simultaneously and reached approximately equal size. No evidence of familiar polyposis or any other feature of Gardner's syndrome were noted. The proximal desmoid tumour developed from the left hip region and extended into the femoral bone, whereas the distal mass was attached to the left popliteal fossa infiltrating the flexor muscles, the nerves and vessels. On the basis of the good results published recently in the literature and our own earlier experiences, the intralesional resection of the desmoid tumours was completed with postoperative fractionated radiotherapy.

[Treatment of an infected vascular prosthesis by irrigation-suction (lavage)]. / Septikus érprotézis öblítö-szívó (lavage) kezelése.

The number of the infections of vascular prosthesises is more and more increasing in the past few years, in connection with the developing of vascular surgery. In our clinic, all septical complications amount to a 2-3% of the total number of reconstructive vascular interventions (8). In a period of 01. 01. 1980-06. 30. 1988 lavage procedure was performed in 19 cases. In 14 patients a primary wound healing was available, in 2 patients after moving away of the original prosthesis, an extra-anatomical bypass was necessary, and in three patients we could not avoid amputation. The above mentioned method is known in the literature since 1959, but in spite of this, there are few publications--with few cases--about this topic. The authors emphasize the relatively good results of this simple method.

Arteriovenous shunts associated with peripheral obliterative arterial disease. Haemodynamic, arteriographic and isotope studies.

From among 210 patients with severe peripheral obliterative arterial disease, the presence of an arteriovenous shunt was demonstrated in 17 cases. Arteriovenous communications were visualized by serial angiographic records and 99mTc macroaggregate isotope testing. The regulation of the limb circulation was investigated using the venous isotope dilution method. Characteristic haemodynamic changes were revealed in arteriovenous shunts associated with peripheral arterial obliterative disease: total limb blood was comparatively high, arteriovenous difference was low and limb O2 consumption was decreased. The clinical significance of the haemodynamic changes in arteriovenous shunting associated with obliterative arterial disease is discussed.

Limb circulation in varicosity of various types.

Regulation of limb circulation was studied by the use of the venous isotope dilution technique in 35 patients with leg varicosities. The circulatory parameters of 54 patients with normal limb circulation served as control. The various types of varicosity revealed characteristic circulatory patterns. (i) In the cases of congenital, "juvenile", varicosity limb blood flow is high, the limb AV-O2 difference is very slight and limb O2 uptake is normal. (ii) In secondary varicosity consecutive to thrombophlebitis the limb (total) blood flow is slightly reduced, the limb AV-O2 difference is smaller than normal and O2 uptake by the extremital tissues is diminished. (iii) In non-congenital, primary varicosity, i.e. in the most common form, limb blood flow is normal, the limb vascular resistance is slightly increased. The possibilities of the production of an AV shunt and the clinical implications of the circulatory changes accompanying the various types of varicosity are discussed.