Early experiences with stentgrafts in the treatment of atherothrombotic diseases of the infrarenal aorta / Kezdeti tapasztalataink az infrarenalis aorta atherothromboticus obliteratív megbetegedéseinek sztentgraftokkal történo kezelésében

Introduction: Endovascular interventions have become the first-line treatment for peripheral arterial diseases. Athero-thrombotic disorders in the infrarenal aorta are also treated with open surgery, especially if it causes critical stenosis or embolization. The use of traditional stents leads to much more complications in such lesions; however, stentgrafts can provide excellent results.Objectives: We retrospectively analyzed our patients undergoing stengraft implantation due to atherothrombotic diseases in the infrarenal aorta and our early experiences.Methods: We included patients undergoing stentgraft implantation at our department due to symptomatic infrarenal aortic atherothrombotic diseases. We established the suitability for endovascular reconstruction with CT-angiogra-phy. Control CT-angiography was performed 6 weeks after the intervention.Results: 6 patients underwent successful stentgraft implantation between 25 February 2021 and 15 September 2021 at our department due to infrarenal aorta atherothrombotic diseases. 2 patients had critical limb ischaemia and 4 had claudication. Early postoperative complications did not occur. During the follow-up, the patients reported significant walking improvement. Control CT-angiography showed good stentgraft position without stenosis in all patients. Only 1 late postoperative complication (right iliac stent occlusion) occurred. Peripheral thrombolysis was performed for 24 hours; the stent opened and there was no need to perform further interventions.Conclusions: Both our early experiences and international studies have showed that this method is suitable for the treatment of atherothrombotic diseases in the infrarenal aorta. The use of stentgrafts in the treatment of peripheral atherosclerotic diseases is hindered by the high costs of the device, so at present it is subject to individual funding in Hungary.

Changes in the care of peripheral vascular disease at the University of Szeged / A perifériás érbetegség ellátásának változásai a Szegedi Tudományegyetemen

Introduction and aims. In recent decades health care changes have accelerated enormously. Previously, by learning an effective procedure, the doctor could guarantee his patients the highest level of care for many years. Nowadays, due to the dynamics of development, the renewal cycles of the methods have been shortened, without continuous learning and training, it is already inconceivable to provide the up-to-date care required by patients. Patients and methods. Instead of vascular replacements with prosthetic grafts, which played an important role in vascular reconstructions, the primacy of endovascular techniques has become decisive. It can be significant for aortic aneurysms that can be operated with high invasiveness. The learning of catheter techniques by vascular surgeons made it possible to treat more successfully those limb-threatening cases, which are often associated with extensive vascular involvement, through the so-called hybrid operations. In addition to the increasing prevalence of diabetes worldwide, the higher proportion of critical limb ischemia and the highlighted pathogenic role of multi-resistant bacteria in the disease caused the marginaliation of the use of previously preferred prosthetic grafts. The effectiveness of the treatment of graft infections, which thus become less frequent, is improved by the use of homografts and negative pressure therapy. An effective method of preventing stroke is carotid endarterectomy, the morbidity of which is reduced by the introduction of locoregional anaesthesia allowing direct neuromonitoring. Results/conclusions. Although the acquisition and implementation of new methods has posed a continuous challenge for our specialists and doctors over the past 10 years, our achievements have made our department one of the leading vascular surgery centres in the country.

Paradigm shift in the vascular surgery of the lower extremity at the Department of Vascular Surgery, University of Szeged, Hungary / Szemléletváltozás az alsó végtagi érrekonstrukciók gyakorlatában a Szegedi Tudományegyetem Érsebészeti Osztályán.

Összefoglaló. Bevezetés: Az endovascularis intervenciókat kezdetben radiológusok alkalmazták, manapság, megfelelo képzést követoen, jó eredménnyel végeznek ilyen beavatkozásokat érsebészek is. Ezt a világszerte uralkodóvá váló szemléletet kívántuk meghonosítani a Szegedi Tudományegyetemen, melynek bevezetése nélkül elorevetítheto az érsebészet muködésének átalakulása az érrekonstrukciós beavatkozások csökkenésével. Célkituzés: Egyetemünkön radiológus- és érsebész-munkacsoport végez perifériás érintervenciókat. Célunk a két intézet alsó végtagi endovascularis tevékenységének összehasonlítása volt. Módszer: Vizsgálatunkba a Szegedi Tudományegyetemen 2012. 01. 01. és 2019. 12. 31. között alsó végtagi endovascularis beavatkozásokon átesett betegeket válogattuk be. A betegeket a rizikófaktoraik, a kezelt anatómiai régiók, a hospitalizációs ido és a szövodmények tekintetében hasonlítottuk össze. Egyéves utánkövetés során vizsgáltuk a 'redo' mutétek , az amputációk és a halálozások gyakoriságát. Eredmények: A beavatkozásokat 653 esetben radiológus, 573 esetben érsebész végezte. Az érmutoben infrainguinalis (63,2%), a radiológián suprainguinalis érintervenciók (68,6%) történtek nagyobb arányban. A percutan végzett beavatkozásokat vizsgálva a hospitalizációs idoben (2,5 ± 4,4 nap vs. 2,4 ± 2,5 nap, p = 0,78), valamint a minimálisan invazív módon végzett beavatkozások utáni szövodmények gyakoriságában (30/653 - 4,6% és 11/257 - 4,3%, p = 0,837) nem volt különbség a két betegcsoport között. 'Redo' mutétek (73/485 - 15,1% és 33/562 - 5,9%, p<0,001) és amputációk (31/485 - 6,4% és 12/562 - 2,1%, p<0,001) gyakrabban fordultak elo az érmutoben kezelt betegek körében, ebben a csoportban azonban a kritikus végtagischaemia elofordulása is gyakoribb volt (45,4% és 38,6%, p = 0,016). A mortalitásban nem volt szignifikáns különbség (5,8% és 3,9%, p = 0,16). Következtetés: A szoliter érelváltozások kezelését mindkét intézet hasonló hatásfokkal végezte. A több anatómiai régiót érinto betegség miatt érmutoben végzett beavatkozások utáni szövodmények elofordulása kissé magasabbnak bizonyult. Orv Hetil. 2021; 162(24): 943-951. INTRODUCTION: Endovascular interventions were initially performed by radiologists. Nowadays properly trained vascular surgeons also effectively perform these interventions. We wished to apply this widespread practice at our university because without this advancement the number of reconstructive surgeries was expected to decrease significantly. OBJECTIVE: Both radiologists and vascular surgeons perform endovascular interventions at our university. We compared the outcomes of lower extremity endovascular interventions between the two institutes. METHOD: We included patients who underwent lower extremity endovascular interventions between 01. 01. 2012 and 31. 12. 2019. We compared the risk factors, treated anatomical regions, hospitalization time and complication rate. During the one-year follow-up, we examined the occurrence of redo surgeries, amputations and mortality. RESULTS: 653 interventions were performed by radiologists and 573 by vascular surgeons. Vascular surgeons carried out more interventions in the infrainguinal region (63.2%), while radiologists in the suprainguinal region (68.6%). The hospitalization time after percutaneous interventions (2.5 ± 4.4 days vs. 2.4 ± 2.5 days, p = 0.78), and the rate of complications after minimally invasive interventions did not show significant difference (30/653 - 4.6% vs. 11/257 - 4.3%, p = 0.837). Redo surgeries (73/485 - 15.1% vs. 33/562 - 5.9%, p<0.001) and amputations (31/485 - 6.4% vs. 12/562 - 2.1%, p<0.001) occurred more frequently in the surgical group. However, the incidence of chronic limb ischaemia was also higher (45.4% vs. 38.6%, p = 0.016). There was no significant difference in the mortality (5.8% vs. 3.9%, p = 0.16). CONCLUSION: Both institutes had similar efficacy in performing peripheral interventions on solitary vascular lesions. Complications occurred more frequently in the surgical group, but the majority of these patients had extended atherosclerotic diseases. Orv Hetil. 2021; 162(24): 943-951.

Early experience with self-expanding flexible stent for the treatment of atherosclerotic diseases in the popliteal artery / [Kezdeti tapasztalataink öntáguló flexibilis sztenttel az arteria poplitea atheroscleroticus betegségeinek kezelésében]

Introduction: The incidence of peripheral arterial diseases and the rate of chronic limb-threatening ischaemia are increasing year by year. Minimally invasive peripheral interventions have gradually replaced traditional operations. Earlier steno-occlusion of the popliteal artery was an indication for femoropopliteal bypass below the knee. Nowadays, endovascular procedures are also used, but the indication of the stent placement into the popliteal artery is controversial. Aim: We have been using Jaguar stent for the treatment of popliteal artery steno-occlusion since January 2016. The aim of our study was to evaluate the efficacy of this treatment. Method: We included patients who underwent popliteal artery angioplasty with Jaguar stent placement between 1 January 2016 and 31 December 2017 in our department. During the one-year follow-up, we examined the popliteal stent patency, amputation-free survival and risk factors that influence stent patency. Statistical analysis: For the comparison of mean values, two-sided t-tests were used. Categorical data were analyzed by using chi-square test. Results: 33 patients underwent popliteal or femoropopliteal endovascular intervention with Jaguar stent placement into the popliteal artery. Postoperative complications that required surgical treatment occurred in 2 patients. At the end of the follow-up, the primary patency of the popliteal stents was 58.1%, the secondary patency was 74.2% and amputation-free survival was 96.8%. Conclusion: Compared with international data, the primary patency of the Jaguar stents in our study is relatively lower, but amputation-free survival is much better, and in most cases there is less operative strain compared with traditional operations. Orv Hetil. 2020; 161(15): 588­593.

Neuronal Nitric Oxide Mediates the Anti-inflammatory Effects of Intestinal Ischemic Preconditioning.

BACKGROUND: Ischemic preconditioning (IPC) can provide a defense against ischemia-reperfusion (IR)-induced acute inflammation and barrier dysfunction in many organs. Because nitric oxide (NO) has been implicated as a trigger or mediator in the IPC mechanism and because neuronal NO synthase (nNOS) is a dominant isoform of NOS in the gastrointestinal tract, our aim was to investigate the role of nNOS in IPC-induced protection after mesenteric IR. MATERIALS AND METHODS: Intestinal IR was induced in sodium pentobarbital-anesthetized dogs by clamping the superior mesenteric artery for 60 min followed by 2 h of reperfusion (IR group; n = 7). In further groups, IPC was used (three cycles of 5-min ischemia/5-min reperfusion periods) before IR in the presence or absence of selective inhibition of nNOS with 7-nitroindazole (5 mg/kg, intravenously, in a bolus 15 min before IPC, n = 6 each). Changes in mesenteric vascular resistance, intramucosal pH (pHi), and small bowel motility were monitored. Plasma nitrite/nitrate levels, intestinal NO synthase activity, leukocyte accumulation, mast cell degranulation, and histologic injury were also determined. RESULTS: Ischemia significantly decreased mesenteric vascular resistance and pHi, whereas IR induced a temporary bowel hypermotility and acute inflammatory reaction. IPC facilitated pHi recovery, attenuated motility dysfunction, elevated NOS-dependent NO production, and reduced leukocyte accumulation, mast cell degranulation, and mucosal injury. Pretreatment with 7-nitroindazole halted the IPC-induced increase in NO availability, pHi recovery, and the anti-inflammatory and morphologic effects. CONCLUSIONS: Our data demonstrate that NO generated by intestinal nNOS plays a pivotal role in IPC-linked tissue protection by inhibiting an IR-related acute inflammatory response.

[Management of extracranial carotid artery aneurysm]. / Extracranialis carotis aneurysmák korszeru kezelése.

Introduction: Aneurysm of the extracranial carotid artery is a rare condition and there is a diversity in the etiology. The proper treatment could be a real challenge for the surgeons. Aim: Analysis of perioperative and long term results of invasive treatment for carotid artery aneurysm. Method: A retrospective review was conducted of patients who had open or endovascular surgery due to carotid artery aneurysm through the last 13 years at the Department of Vascular Surgery of the Semmelweis University and at the Department of Surgery of the University of Szeged. Medical history, characteristics of the aneurysms, therapy and the follow-up results were reviewed. Results: Over the study period, 25 interventions were performed due to carotid artery aneurysm. There were 10 men and 15 women with a mean age of 57.8 ± 15.15 years. Seventeen patients (68%) were symptomatic. The mean aneurysm diameter was 26.8 ± 11.25 mm. The underlying etiology was atherosclerosis in eleven (44%), prior carotid endarterectomy in four (16%), infection in four (16%) and other cause (connective tissue disease, dissection, trauma) in six (24%) cases. Nineteen patients underwent open surgery, six underwent endovascular treatment. Death within 30 days was documented in one (4%) case. The mean postoperative hospital stay was 4.52 ± 2.38 days. Three (12%) patients required reintervention postoperatively. Peripheral nerve injuries were detected in four (16%) patients, all after open surgery. No stroke was documented within 30 days. The mean follow-up was 41.2 ± 38.54 months. Five (24%) deaths were not related to the carotid artery disease. One patient had stroke, one had transient ischaemic attack (TIA), and in two cases asymptomatic internal carotid artery occlusion was described. Conclusion: Both open surgery and endovascular intervention can be safely applied in the treatment of carotid artery aneurysm. Considering the variable etiology and rarity, we recommend to perform the interventions in vascular surgery centres. Orv Hetil. 2019; 160(21): 815-821.

Intestinal nitric oxide synthase activity changes during experimental colon obstruction.

OBJECTIVE: The experiments in this study were designed to follow the time course of nitric oxide (NO) synthesis in the large bowel during acute mechanical ileus. MATERIAL AND METHODS: Occlusion of the mid-transverse colon was maintained for 420 min in anesthetized dogs. Strain-gauge transducers were used to analyze motility changes on the hepatic and lienal flexures, respectively. Constitutive NO synthase (cNOS) and inducible NOS (iNOS) activities were determined in tissue biopsies, and plasma nitrite/nitrate (NOx) level was measured in the portal blood. Following completion of the baseline studies, the animals were treated with either 7-nitroindazole (7-NI, selective neuronal NOS inhibitor), or N-nitro-L-arginine (NNA, non-selective NOS inhibitor). RESULTS: In the sham-operated group the cNOS activities differed significantly in the oral and aboral tissue samples (oral: 102.9; versus aboral: 62.1 fmol/mg protein/min). The obstruction elicited a significant increase in portal NOx and elevated tissue inducible NO synthase (iNOS) activity. NNA treatment decreased the motility index in both intestinal segments for 60 min, but 120 min later the motility index was significantly elevated (2.5-fold increase in the oral part, and 1.8-fold enhancement in the aboral segment, respectively). Treatment with 7-NI decreased the cNOS activity in the oral and aboral parts by approximately 40% and 70%, respectively, and suppressed the motility increase in the aboral colon segment. CONCLUSIONS: The motility of the colon was either significantly increased or decreased, depending on the type and selectivity of the NOS inhibitor compounds applied. NO of neuronal origin is a transmitter that stimulates peristaltic activity; but an increased iNOS/nNOS ratio significantly moderates the obstruction-induced motility increase.

[Dual effects of nitric oxide in acute colon obstruction]. / A nitrogen-monoxid kettos hatása a vastagbél elzáródás kórfolyamatában.

UNLABELLED: Nitric oxide (NO) plays central role in the pathophysiology of large bowel diseases. In the gastrointestinal tract the predominant form of nitric oxide synthase (NOS) isoenzymes is neuronal NOS (nNOS). The aims were to investigate the role of NO and the activation of NOS isoforms during acute colonic obstruction. Haemodynamic changes, large bowel motility and plasma levels of nitrate-nitrite (NOx) were observed for 7 hrs in anaesthetized dogs. Group 1 (n=6) served as sham-operated control. In groups 2 (n=8), 3 (n=6), and 4 (n=6) colon obstruction was initiated. Groups 3 and 4 were treated with non-selective NOS inhibitor N-nitro-L-arginine (NNA, 4 mg/kg) or with the selective nNOS inhibitor 7-nitroindazol (7-NI, 5 mg/kg) 3 hr after the obstruction. At the end of the experiments, tissue biopsies were taken from the oral and aboral parts of the colon to determine the constitutive and inducible NOS (cNOS and iNOS, respectively) activities. RESULTS: The cNOS activity of the colon was significantly higher orally then aborally in each group. After obstruction the characteristic features of hyperdynamic sepsis were observed. The obstruction caused significant increase in iNOS activity, which was significantly reduced by the NOS inhibitors. The obstruction increased the motility on both parts of the colon. The administration of NNA transiently inhibited, but later significantly increased the motility of the colon segments. Inhibition of nNOS by 7-NI treatment did not influence the hemodynamic parameters but decreased the motility. CONCLUSION: Neuronal NO increases colon motility at the early stage of large bowel obstruction, however, during a concomitant sepsis the excess of inducible NO will moderate this effect.