Dunbar syndrome - single-center experience with surgical treatment.

INTRODUCTION: Dunbar syndrome is caused by compression of the truncus coeliacus (TC), most commonly by the median arcuate ligament. Chronic irritation of the TC during breathing leads to fibrous changes of the arterial wall and formation of fixed stenosis. This compression syndrome is often associated with specific complaints including weight loss and early postprandial epigastric pain. In this study, we summarize our experience with a group of 14 patients from a single institution. METHODS: In 14 patients who were diagnosed with Dunbar syndrome and who were referred for surgery, we performed an invasive measurement of systemic pressure in a. radialis during the operation and compared it with invasively measured pressure in a. gastrica sinistra before and after the release of TC. In patients with significant stenosis (pressure gradient above 15 mmHg), a bypass was performed. RESULTS: The initial pressure gradient of 56±19 mmHg decreased after the release of TC to 39±16 mmHg (p.

[Postoperative re-stenosis of the carotid--A case for reoperation or endovascular management?]. / Pooperacní restenóza karotidy--reoperace nebo endovaskulární resení?

The aim of this work was to assess frequency rates of re-stenoses following surgical or endovasular treatment of re-stenoses after primary endarterectomies of the carotid artery, taking into consideration concomitant disorders and the contralateral findings. Another objective was to assess differences in peroperative and postoperative complications frequency rates. The retrospective study included patients undergoing vascular surgery during a seven-year period. The study revealed that repetitive restenoses were statistically significantly (3x) more frequent in cases of the endovascular management compared to that in re-operations (p = 0.015). In the repetitive re-stenoses patients, the rate of the contralateral carotid affection was significantly higher (93.8%, p = 0.05) and also the rate of the contralateral artery obliteration was higher (43.8%, p = 0.05). The highest frequency rates of the repetitive carotid re-stenosis was in patients with a concomitant affection of the contralateral artery. Surgical management of the repetitive re-stenosis of the carotid artery following its primary surgical management showed better results than the endovascular management.

[Allografts in the vascular surgery]. / Alografty v cévní chirurgii.

The use of allografts represents one of the therapeutic options in the treatment of vascular prosthetic infection. Close cooperation with a transplant center is unconditional for successful graft harvest and storage. Although the transplantation programme in the Czech Republic is handled in several centers across the country the use of vascular allografts is still exceptional. During multiorgan harvest procedures arterial or venous grafts have been removed and stored in antibiotic solution at 4 degrees C till implantation. Cardioplegic and short-term organ preserving solution Custodiol was used in our cohort. At the Department of Vascular Surgery of the Na Homolce Hospital in Prague fresh arterial allografts were used in 14 patients in the years 2001-2004. In all, absence of usable autologous graft was the common denominator. In ten cases previous synthetic vascular grafts were infected. Of these, critical limb ischaemia and imminent amputation due to the poor outflow tract occurred in three patients. Once, false femoral artery aneurysm infected with methicilin-resistant Staphylococcus aureus (MRSA) led to several hemorrhagic episodes. There was no early mortality but one early occlusion with subsequent major amputation. In 11 patients (79%) the procedure was uneventful at the short-term follow-up. All patients were treated with cyclosporine.

[Bacterial aortitis]. / Aortitis bacterialis.

A cohort of 14 patients with bacterial destruction of various segments of the aortic wall is presented. The Salmonella enteritidis strain was predominantly responsible. Most patients had typical history of symptomatic trias of sepsis, abdominal and/or back pain and positive blood cultures. CT scan showed pseudoaneurysm within the thoracic, subphrenic or subrenal aorta as well as acute hemorrhage in three patients. One of these was excluded from invasive treatment due to hopeless prognosis. In one patient primary aortoduodenal phistula was responsible for GI bleeding. Five patients were operated and prosthetic replacement of subrenal or iuxtarenal aortic portion together with aortorenal bypass in a couple of cases was performed. In eight patients stentgrafts (SG) of various types were deployed completed with femorofemoral crossover bypass when necessary. All patients were subject to long-standing antibiotic therapy. Two patients expired following SG insertion, all operated patients survived. Average follow-up has been 1 year (1-22 months) so far. A groin abscess was later drained in one patient. Neither CT nor isotope scanning showed persistent or recurrent infectious or hemorrhagic foci in any survivors whatsoever. The authors review and consider the doubtful indication of aortic SG deployment into the septic terrain in selected cases. Midterm results might justify its use in overly debilitated patients otherwise not eligible for radical operation due to its prohibitive risk.

[Minilaparotomy as an access route to vascular reconstruction procedures in the aortoiliac region]. / Minilaparotomie jako prístup k cévním rekonstrukcím v aortoilické oblasti.

Following the example of general surgical procedures, also vascular surgery gradually minimizes the size of its surgical entrances. Miniinvasive surgical procedures significantly reduce postoperative complaints and shorten the patients recovery rates. Minilaparotomy, either a hand-assisted or a laparoscopy-assisted procedure, a procedure conducted fully via laparoscopy or thoracoscopy and a robot-assisted procedure, all of the above are contemporary options for miniinvasive procedures in the vascular surgery. The authors introduce their initial experience with the use of minilaparotomy in the aortoiliac region. From November 2002 to April 2004, 29 procedures were performed for the abdominal aortic aneurysm repair or for aortoiliac occlusive disease. In 15 cases the abdominal aortic aneurysm was managed and in 14 cases the aortoiliac occlusive disease was managed.

[Upper thoracic thoracoscopic sympathectomy as the method of choice for reoperation of the thoracic sympathetic nerve]. / Torakoskopická horní hrudní sympatektomie jako metoda volby reoperace na hrudním sympatiku.

The authors present in their paper the possibility of thoracoscopic thoracic sympathectomy as the method of choice for reoperation of the thoracic sympathetic nerve 14 years after classical surgical upper chest sympathectomy, as the original effect had receded. They mention the possibility of reoperation of the sympathetic nerve with a subsequent favourable effect by the endoscopic method which reduces the risk of complications to a minimum.

[A comprehensive approach to the treatment of popliteal artery aneurysms--personal experience]. / Komplexné prístup k lécbe výdutí zákolenní tepny--nase zkusenosti.

UNLABELLED: During a five-year retrospective follow-up period the authors treated a group of 46 patients with the diagnosis of aneurysm of the popliteal artery (AAP). The group comprised 42 men (91%) and 4 women (9%). The mean age was 62 years. In 32 patients (69%) AAP was on both lower extremities, in the remaining 14 (31%) it was unilateral. Forty-one patients (90%) had surgery and a total of 48 AAP were operated. The remainder was treated by conservative methods (10%). The first symptoms of AAP in the investigated group were: claudication in 17%, thromboembolic complications in 46%, rupture of the AAP in 4%. An asymptomatic aneurysm was detected in 33%. RESULTS: The authors did not record any death or occlusion of the reconstruction during hospitalization. When using a vein the primary patency is 100%. When a prosthesis (PTFE) is used the results are worse but still satisfactory and the five-year secondary patency is 85%. Five patients with thromboembolic complications of AAP were successfully treated by i.a. fibrinolysis. In all exclusion of the aneurysm and revascularization of the extremity followed. In the conclusion the authors emphasize the necessity of early surgical treatment as soon as the condition is detected, before the development of thromboembolic complications of AAP. If they develop it is essential to attempt local fibrinolysis and in the second stage revascularization of the extremity, if possible by a vein.

Ruptured abdominal aortic aneurysm: role of initial delay on survival.

In the years 1990 to 1997, 103 patients with RAAA were operated on at the Department of Vascular Surgery of the Hospital Na Homolce in Prague. Men outnumbered women, mean age was 70 years. The mean delay between onset of symptoms and hospital admission was 25 hours. Prior to transportation 85 patients were submitted to at least one confirmative evaluation test (CAT, ultrasound, angiography) and 33 patients to a combination of two or more herementioned examinations. Twenty-eight patients were referred via two or more hospital departments. In 71% of patients profound shock with oligoanuria and hypotension was found upon admission. Anuria/hypotension proved to occur in a significantly lower rate in later survivors compared to later non-survivors (S vs. NS = 30% vs. 92.1%, p < 0.002) and preoperative hematocrite and S-creatinine values copied the clinical trend. At surgery, persistent hypotension together with necessity of resuscitation steps as well as finding of free blood within the abdominal cavity showed up as further significant death predictors. Postoperatively, acute renal and/or multiorgan failure occurred in 36 patients and significantly prevailed in the NS vs. S group (48.3% vs. 22.5%, p < 0.03). Both early hemorrhage and myocardial infarction infavorably influenced the outcome. Seven patients (6.8%) expired during operation. The total of 63 patients died (61.2%) fifty-eight patients within the 30-day period (56.3%). Within the first five days 58.7% of all deaths occurred particularly related to hemorrhagic shock. The latter fatalities (41.3%) were caused by both organ failure and septic complications. In our cohort regardless of age, type or extent of surgery, outcome was determined by status upon admission. Delay in surgical treatment caused both by time consuming confirmative evaluation and patient's lengthy transfers is responsible for ominous protraction of the original shock. Especially in intraperitoneal rupture, the irreversible sequels of devastating hemorrhage only rarely do not lead to a fatal end albeit the patients survive the aortic reconstruction.

[Ruptured abdominal aortic aneurysm]. / Aneurysma aortae abdominalis cruens.

In the years 1990-1994, 43 patients with ruptured abdominal aortic aneurysms (RAAA) were operated on at the Department of Vascular Surgery of the Na Homolce Hospital in Prague. Men outnumbered women, average patient age was 70 years. The mean delay between onset of symptoms and hospital admission counted 27 hrs. Prior to transportation, one half to two thirds of patients went through at least two types of confirmative evaluation (CAT, ultrasound, angiography) and/or were referred via two or more hospital departments. In two thirds of patients profound shock with oligoanuria and hypotension were found. Anuria/hypotension proved to occur in a significantly lower rate in later survivors compared to later dead (11.8% vs. 23.5%: p < 0.05). Persistent hypotension during surgery together with eventual resuscitation as well as free blood found within the abdominal cavity showed up as further ominous factors. Renal failure was the leading postoperative complication (51.2%) with 27.9% of patients requiring hemodialysis after repair. Sepsis (25.6%), pneumonia (20.9%) and hemorrhage (13.9%) followed. Twenty-six patients were lost (60.5%) either within the first hours and days after surgery because of irreversible hemorrhagic shock or between the second and fourth week due to the sequels of organ failure and sepsis. In our cohort, regardless of age, sex, concomitant disease or the type of surgery, the patient's status on admission determined his/her further destiny. Urgent transfer to a specialized center going hand in hand with prompt and effective reanimation steps are the patient's only hope for survival.

[Peroperative transluminal angioplasty as a supplementary procedure to arterial reconstruction surgery]. / Peroperacní transluminální angioplastika jako výkon doplnující tepennou rekonstrukcní operaci.

Patients with affections of the vascular system of the lower extremities at several levels present a complicated problem for vascular surgery. The authors submit their experience with a combination of vascular reconstruction and peroperative transluminal angioplasty. In 25 patients, mean age 64 years, they performed 29 of these combined operations, 10 times on account of claudications, 11 times on account of pain at rest, 8 times on account of trophic defects. The pelvic vessels were dilated 6 times; the dilated vessels as well as the reconstruction remained patent. Peroperative angioplasty of the superficial femoral artery was performed 6 times, occlusion occurred once. Twelve times they dilated the distal portion of the popliteal artery or the vessels of the leg, 3 times the dilated portion became occluded. None of the patients lost the limb, one patient died from acute myocardial infarction shortly after operation. The authors describe the technique of peroperative transluminal angioplasty, evaluate the results and discuss the advantages and disadvantages of this method.

[Immunosuppressive therapy with low cyclosporin A doses in rats]. / Immunsuppressive Therapie mit niedrigen Cyclosporin-A-Dosen bei Ratten.

An optimum blood level of cyclosporine-A (Cs-A) after allotransplantation in rats is very important for the survival of the transplanted organ. An auxiliary allotransplantation of the heart into the abdominal cavity were carried out in 10 rats. A Cs-A blood level of 200 to 300 ng ml was obtained by administration in the animal food in a dosage of 7 mg kg body weight day. A rejection of the graft was prevented in this way without any symptom of toxicity during 90 days. The results of the experiments were well reproducible. The obtained Cs-A blood level is relatively stationary, frequent laboratory tests are not necessary.