Perioperative standards for the treatment of coagulation disorders and usage of blood products in patients undergoing liver transplantation used in the Clinic for Transplant Surgery in Wroclaw.

BACKGROUND: Coagulation system disorders in liver transplantation (ltx) patients are considered a serious issue. Liver cirrhosis leads to decreased synthesis of clotting factors and decreased elimination of waste products, including coagulation proteins. Platelet sequestration and dysfunction in an enlarged spleen additionally worsen these conditions. The resulting state, the most common pathology of the coagulation system, involves the reduction of clotting potential and hyperfibrinolysis. OBJECTIVES: Tackling the problem of impaired hemostasis is a dynamic process. Throughout the whole procedure, consisting of the preanhepatic, the anhepatic and the neohepatic phases, consecutive pathomechanisms disrupt the very balance that anesthesia aims to preserve. MATERIAL AND METHODS: Rotational thromboelastometry (ROTEM), having been introduced in the Clinic of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Poland, enables the efficient and early diagnosis of clotting disorders. An additional major problem which occurs during ltx, namely blood loss, could be solved using a cell separator. RESULTS: In this study, we present the standards introduced to the Transplantology Department of the Vascular Surgery Clinic, Wroclaw Medical University, Poland, that describe blood treatment during ltx procedures. CONCLUSIONS: We conclude that thromboelastometric examination and the use of a cell separator have significantly increased the safety of ltx procedures at our clinic. The introduction of thromboelastometry (TEM) and the implementation of the cell separator recovery method have enabled us to perform the dangerous and complicated surgical procedure of ltx in a much more stable and much safer manner than in the past.

Diagnosis and treatment of pelvic congestion syndrome: Single-centre experiences.

BACKGROUND: One of the underestimated causes of chronic pelvic pain (CPP) in women may be pelvic congestion syndrome (PCS) that is defined as the presence of varicose of ovarian and pelvic veins associated with chronic pain in the region of the pelvis. This pain is present longer than 6 months and intensifies with prolonged standing, coitus and menstruation. The disease constitutes a diagnostic as well as therapeutic problem, thus posing a challenge for the clinician. Transcatheter ovarian vein embolization might be a safe and effective option for PCS treatment. OBJECTIVES: The objective of this study was to evaluate the efficacy of ovarian vein embolization ovarian as a method of the PCS treatment. MATERIAL AND METHODS: Between 2002-2012, 11 embolization procedures were performed in 10 women (age range: 34-43; median age 39) with the diagnosis of PCS. One patient underwent embolization procedure twice. In 1 case the combined therapy of endovascular embolization and surgical phlebectomy of vulvar varices was performed. RESULTS: There were no major intrainterventional complications. In all the patients (100%) a significant improvement in the clinical status was noted. The procedure improved the quality of life in the patients. Three women (30%) had a mild recurrence of the symptoms at mid-term follow-up. Among 8 women who had complained of dyspareunia prior to embolization 6 patients reported complete pain relief, in other 2 cases the pain subsided partially. There was a significant decrease in the severity of symptoms associated with hemorrhoids. CONCLUSIONS: We consider embolization of insufficient ovarian veins an effective and safe way of treatment in a well-selected group of patients with PCS.

[Stem and progenitor cells in biostructure of blood vessel walls]. / Komórki macierzyste i progenitorowe w biostrukturze scian naczyn krwionosnych.

Development of vascular and hematopoietic systems during organogenesis occurs at the same time. During vasculogenesis, a small part of cells does not undergo complete differentiation but stays on this level, "anchored" in tissue structures described as stem cell niches. The presence of blood vessels within tissue stem cell niches is typical and led to identification of niches and ensures that they are functioning. The three-layer biostructure of vessel walls for artery and vein, tunica: intima, media and adventitia, for a long time was defined as a mechanical barrier between vessel light and the local tissue environment. Recent findings from vascular biology studies indicate that vessel walls are dynamic biostructures, which are equipped with stem and progenitor cells, described as vascular wall-resident stem cells/progenitor cells (VW-SC/PC). Distinct zones for vessel wall harbor heterogeneous subpopulations of VW-SC/PC, which are described as "subendothelial or vasculogenic zones". Recent evidence from in vitro and in vivo studies show that prenatal activity of stem and progenitor cells is not only limited to organogenesis but also exists in postnatal life, where it is responsible for vessel wall homeostasis, remodeling and regeneration. It is believed that VW-SC/PC could be engaged in progression of vascular disorders and development of neointima. We would like to summarize current knowledge about mesenchymal and progenitor stem cell phenotype with special attention to distribution and biological properties of VW-SC/PC in biostructures of intima, media and adventitia niches. It is postulated that in the near future, niches for VW-SC/PC could be a good source of stem and progenitor cells, especially in the context of vessel tissue bioengineering as a new alternative to traditional revascularization therapies.

Transplantation of autologous bone marrow mononuclear cells with VEGF gene improves diabetic critical limb ischaemia.

INTRODUCTION: The aim of this study was to assess the safety and efficacy of combined autologous bone marrow mononuclear cell and VEGF165 gene therapy in patients with diabetes mellitus suffering from critical limb ischaemia (CLI). MATERIAL AND METHODS: The administration of mononuclear cells (MNCs) and naked VEGF165 plasmid was performed in 16 limbs of 16 patients with rest pain and ischaemic ulcers due to diabetes. MNCs and plasmid were injected into the muscles of the ischaemic limbs. The levels of VEGF in serum and the ankle-brachial index (ABI) were measured before and after treatment. The Visual Analogue Scale (VAS) was used to evaluate pain sensation. CT angiography was performed before and after three months of therapy. RESULTS: Mean (± SD) plasma levels of VEGF increased non-significantly from 257 ± 80 pg/L to 391 ± 82 pg/L (p 〉 0.05) two weeks after therapy. The ABI improved significantly from 0.26 ± 0.22 to 0.49 ± 0.30 (p 〈 0.001) three months after therapy. A decrease in rest pain was observed in all patients; mean VAS decreased from 6.3 ± 1.4 to 1.2 ± 1.1 after three months (p 〈 0.002). Angiograms showed the development of collateral vessels in 12 limbs. Ischaemic ulcers healed in 12 limbs. Amputation was performed in four patients only, because of advanced wound infection. However, the level of amputations was lowered below knee level in these cases. Complications were limited to transient leg oedema in two patients and fever in two patients. CONCLUSIONS: Intramuscular bone marrow MNCs autotransplantation combined with the administration of phVEGF165 gene is safe, feasible and effective for patients with diabetes and CLI.

[The use of the dacron net in the externa tightening of the endoleak type I, after the stengraft implantation in the abdominal aorta aneurysm]. / Zastosowanie siatki dakronowej w zewnetrznym uszczelnieniu przecieku typu I, po wszczepieniu protezy wewnatrznaczyniowej w tetniaka aorty brzusznej.

Implantation of the vascular prosthesis below renal artery when the neck of the aneurysm is short, carries the risk of the appearance of the endoleak type I. At such patients one ought to make allowance for with the necessity of the single-stage or two-stage-supply of the endoleak with banding method that is to say with the tightening of the neck of the aneurysm on the stentgraft with the open method. This method consisting in to the compression of the neck of the aneurysm on stentgraft at the use of ribbons or the wide belt from the dacron net. In this paper one represented 3 patients operated with banding method. In the face the massive endoleak type I and the threat of the ruptum of the aneurysm one decided on the realization of the surgical correction with the open method with banding.

[The use of politetrafluoroethylene stent-graft and vena cava filter in the endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula]. / Zastosowanie politetrafluoroetylenowej protezy wewnatrznaczyniowej i filtra zyly glównej dolnej w leczeniu peknietego tetniaka aorty brzusznej do tyly czczej dolnej.

We report on a the endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula. The stent-graft was placed with the patient under general anaesthesia, and the abdominal aorta aneurysm was successfully treated. To prevent pulmonary embolism vena cava filter was deployed before the implantation of the sten-graft. The aneurysm was excluded and no endoleak or communication between the aorta and inferior vena cava was seen on computed tomographic imaging at the 3-month evaluation. Endovascular treatment offers an attractive therapeutic alternative to open repair in case of aortocaval fistula.

[The comparison of the healing of the classic vascular prostheses and stentgrafts in the abdominal aneursyms]. / Porównanie wgajania syntetycznych protez naczyniowych klasycznych i wewnatrznaczyniowych w tetniakach aorty brzusznej.

THE PURPOSE: Every foreign body injected into an organism causes an inflammatory condition. Among other things leukocytes take part in it. The healing of a vascular prosthesis means gradual subsiding of an inflammatory condition. The process can be monitored with the series of scintigraphy following decrease of an area of concentrating of Technetium-labeled leukocytes. The purpose of work was an appraisal of the healing of both types of prostheses in cases of patients operated because of aneurism of abdominal aorta. MATERIAL AND METHODS: In three years 64 patients have been examined. They were divided into two equal groups: I-patients after (stent-graft) being implanted because of abdominal aneurysm, II-patients after aortobifemoral prosthesis being implanted of the same reason. The scintigraphy was done in 3-4 day, in 3-, 6- and 12 after a surgery. A surface of concentrating of leucocytes was counted in a computer programme which allows manual marking of a contour. The results were put through a statistical processing. RESULTS: During a period after surgery an intensified inflammatory condition has been stated in a group of patients operated in classic way. In both groups a decreasing of an inflammatory condition has been observed. After 12 months an area of concentrating of leucocytes took up to 10 percent of initial values. CONCLUSIONS: The decreasing of an area of concentrating of leucocytes was observed independently of a type of vascular prosthesis. The higher reaction was where the classic prostheses were used. The scintigraphy shows only a cellular part of an inflammatory answer and it cannot be an independent way of a monitoring of the healing of the prostheses.

Cytokine gene expression in kidney allograft biopsies after donor brain death and ischemia-reperfusion injury using in situ reverse-transcription polymerase chain reaction analysis.

BACKGROUND: This study focuses on the cytokine genes expression after brain-death, ischemia-reperfusion injury, and during allograft rejection. METHODS: A total of 49 needle core biopsies from kidney transplant recipients, performed before and during transplantation procedures were studied. The first biopsy was taken during procurement of the organ, the second after cold ischemia, and the third after approximately 30 min of reperfusion. We also assessed 34 allograft biopsies obtained during acute rejection. Tubular and glomerular expression of interferon (IFN)-gamma, transforming growth factor (TGF)-beta1, platelet-desired growth factor-B (PDGF-B), interleukin (IL)-2, IL-6, IL-10 mRNA was analyzed with reverse-transcription polymerase chain reaction (RT-PCR) in situ technique, which allows to detect a few copies of the target gene without destruction of the tissue architecture. RESULTS: Compared with normal kidney tissue from living donor, high gene expression of IFN-gamma, TGF-beta1, PDGF-B, IL-2, IL-6, and IL-10 was detected in all procurement specimens. After reperfusion gene expressions of IL-2, IL-6, and IL-10 were significantly upregulated in renal tubules compared to biopsies taken after cold ischemia. The gene expression of IFN-gamma, TGF-beta1, and PDGF-B remained stable after organ procurement, during cold ischemia, and after reperfusion. Gene expression of IFN-gamma, IL-2, IL-6, IL-10, and PDGF-B in procurement biopsies, as well as in those taken after cold ischemia and reperfusion, were significantly higher than during the period of acute rejection. CONCLUSION: The data presented herein strongly point out the importance of the immunological and morphological injury that occurs before and during transplantation. The increase of inflammatory response after brain death is important for further stimulation of the immune response and long-term kidney survival.

[The use of intravascular nitinol stents in the treatment of subclavian vein compression for thoracic outlet syndrome]. / Zastosowanie samorozprezalnych nitynolowych stentów naczyniowych w powiklaniach ucisku tylnego w przebiegu zespolu uciskowego górnego otworu klatki piersiowej.

AIM: The purpose of this study is to evaluate the multimodal treatment (thrombolysis, anticoagulation and surgical decompression) of subclavian-axillary vein thrombosis (Paget-Schroetter syndrome) and possibility of shortening of time of therapy. MATERIAL AND METHODS: In this paper 23 patients with Paget-Schroetter syndrome in Department of Vascular, General and Transplantological Surgery is presented. Thrombolysis with rt-PA, anticoagulation with heparin and intra venous angioplasty with the use intravascular stent, and operation with resection of the first rib in the treatment of subclavian vein thrombosis was used. During the follow up period the patients were divided into two groups: group I (13 patients) with traditional surgical decompression after 3-4 months (potential risk of hemorage) and group II (10 patients) with early surgical treatment (median 8 days). Long-term follow-up was obtained by chart review and asking patients to complete the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire that was developed by the American Academy of Orthopedic Surgeons. RESULTS: Complete revascularization with venous thrombolysis was achived in all patients. Decompresion with transaxillary resection of first rib and venous revascularization were performed in the same procedure in all patients. Statistical difference were not found in both groups. Most patients report no disability of upper limb at work and sport activity. CONCLUSIONS: Multimodal treatment of Paget-Schroetter syndrome (thrombolysis, the use of intravascular stents and early thoracic outlet decompression) can be used as a optimal of therapeutic method to subclavian vein thrombosis. The advantages of immediate surgical treatment are a promotion of rapid resumption of athletic activities.

[Complex gene-cell therapy in treatment of critical lower limbs ischemia]. / Kompleksowa terapia komórkowo-genowa w leczeniu krytycznego niedokrwienia konczyn dolnych.

THE AIM: The paper presents the results of our hybrid gene-cell therapy in case of critical lower limb ischemia. Eighteen patients with critical limb ischemia were enrolled to the study. The bone marrow from each patient was harvested. It had been incubated with VEGF165 gene plasmid for two hours before it was administrated intramuscularly into patient's lower limb. METHODS: In the study we evaluated: safety, clinical outcomes of the therapy, venous blood VEGF protein concentration before and after (at: 7th, 14th, 28th and 90th day) administration of the stem cells. We obtained samples of muscles from the patients who underwent the limb amputation, which were examined histological and by PCR (Polymerase Chain Reaction) for detection of plasmid genes. RESULTS: We observed very good clinical outcomes of the therapy. In ten of eighteen patients (-55%) critical lower limb ischemia symptoms subsided--they saved their limbs. The serum VEGF concentration was higher than in healthy controls (p < 0.05). We observed the increase of the concentration of the cytokine at the 14th day an decrease at the 90th day after administration of cells with plasmid. We found expression of plasmid VEGF in transfected stem cells and in tissues taken from amputated limbs. However histological examination did not reveal any sings of new blood vessels formation in the samples taken from ischemic limbs. CONCLUSIONS: The therapy is safe and effective. We observed significant improvement in patient's clinical state. The therapy needs further investigations.

[Application of biliary stents in endoscopic stenting of biliary ducts]. / Zastosowanie protez zólciowych w endoskopowym protezowaniu dróg zólciowych.

Extra hepatic bile ducts with the gallbladder are the center place for many disease processes. In extreme cases of significant strictures of bile ducts and impairment of bile flow, obstructive jaundice occurs. There are benign and malignant biliary strictures. The treatment of obstructive jaundice depends on the removal of blockage using endoscopic and surgical methods which return the efficient bile flow to the digestive tract. The endoscopic treatment from Vater's papilla access using plastic and metal stents is the method of choice. The choice of proper prosthesis depends on the reason for biliary strictures. The plastic stents (straight, pigtail) are applied the most. Due to their low cost, easy insertion to biliary ducts and exchangeability, they are applied in benign and malignant strictures. However, metal stents (Wallstent, Diamond, Z-stent, InStent), due to the wide diameter after expansion and no possibility of removal, are applied only in malignant strictures. Endoscopic insertion of biliary endoprostheses can be burdened with complications. There have been reports of occlusion, migration with duodenal wall injury and hemorrhaging.

[The treatment of abdominal aortic aneurysms by use of endovascular prosthesis and classic vascular prosthesis]. / Leczenie tetniaków aorty brzusznej z wykorzystaniem protez wewnatrznaczyniowych i klasycznych.

The abdominal aortic aneurysm is a dilatation of infrarenal part of aorta. Its ethiology is still unknown. An infection and congenital disorders of conjunctive tissue are regarded as the main risc factors. Other factors could be a perimural thrombus and elastin and colagen degradation. It's not proved that atheromatosis is a risc factor. The disease concerns mainly the old males. Not treated aneurysm grows until rupture. The aneurysms are usually asympthomatic. Majority of them are found incidentally. Ultrasonography and computed tomography are used to extended diagnosis. The open surgery or endovascular surgery are only possible ways of treatment. The aneurysm with diameter over 55 milimeters, sympthomatic or rupted is an indication for surgery. The aim of the open surgery is implantation of the vascular prosthesis into retroperitoneal space. Endovascular method consist in placement of stent-graft in the lumen of aneurysm through small incision in a peripherial vessel. Stent-graft consists of metal chassis covered by classic vascular prosthesis. This method still requires the long-term assessment.

[Gene expression of INF-gamma, IL-10, IL-2, IL-6, PDGF-B i TGF-beta in kidney tissue after renal transplantation]. / Ekspresja genów dia: IFN-gamma, IL-10, IL-2, IL-6, PDGF-B i TGF-beta w wycinkach nerek od biorców przeszczepu nerki.

UNLABELLED: The aim of the study was to evaluate the effect of brain death, ischemia-reperfusion injury and alloreactivity of some cytokines on intragraft mRNA expression. MATERIAL AND METHODS: We have examined 49 needle core biopsies of kidney allografts from cadaveric donors. Samples were taken before harvesting, after cold ischemia and approximately after 20-30 minutes of reperfusion. We have also assessed 56 allograft biopsies taken after transplantation. Tubular and glomerular expression of IL-2, IL-6, IL-10, IFN-gamma, TGF-beta 1 and PDGF-B mRNA was assessed using semiquantitative evaluation of the RT-PCR in situ on paraffin tissue sections. RESULTS: In all pre-procurement specimens high glomerular and tubular IL-2, IL-6, IL-10, TGF-beta 1, PDGF-B and IFN-gamma mRNA expression was detected. After reperfusion an increase of IL-2, IL-6, and IL-10 mRNA expression was observed in all specimens and was limited only to tubules. Biopsies samples with borderline changes exhibited the lowest levels of cytokine gene expression close to the intensity in control specimens. An intense, comparing to normal kidney, tubular and glomerular all examined cytokines gene expression was also noticed during acute rejection. No significant differences between acute cellular and vascular rejection were noticed. The mRNA expression of IFN-gamma and IL-2, IL-6, IL-10 in chronic rejection did not differ from acute rejection. The tubular expressions of mRNA for IL-6 and TGF-gamma 1 in biopsies with acute rejection obtained from patients treated with MMF were significantly lower than in biopsies obtained from patients treated with azathioprine.

[Biopsy eosinophilia as a predictor of renal graft dysfunction]. / Naciek eozynofilowy w biopsji jako czynnik prognostycny dysfunkcji przeszczepionej nerki.

Effector cells such as eosinophils and mononuclear cells play crucial role in the mechanism of injury during acute renal allograft rejection (ARAR). The aim of the study was to evaluate an influence of tissue eosinophilia observed in the renal allograft biopsy (RAB) during ARAR on rejection severity (reversibility) as well as long-term graft function. The histopathological examination and the quantitative assessment was performed in 165 RAB with symptoms of ARAR. The numbers of eosinophils were counted at high power (40xobj), over the entire renal cortex, minimum 10 high power fields(hpf). Results. Significant tissue eosinophilia was found in 49 RAB (29%). In the Eosinophilic Group (EG) we observed: more frequent biopsy-confirmed ARAR episodes (1.79 vs. 1.33/pts; p=0.03), higher grade of acute rejection according to the Banff classification (p=0.007), more severe clinical course of rejection expressed as worse graft function at 6 month after treatment (serum creatinine 2.2 vs. 1.5 mg/dl). Chronic rejection was seen in 25% pts of EG and in 11% pts of Control Group (CG) in the first year after Tx. Graft survival at 6 month in the EG was shorter then in the CG (91% vs 96.3%). Conclusions. Eosinophilic infiltration of RAB is a negative predictor, which can indicate more severe course of ARAR and increased resistance to an anti-rejection therapy. It can determine an appearance of chronic allograft dysfunction hazard.

[Variable expression of CD28 costimulatory molecule and CTLA4 inhibitory molecule on peripheral blood CD4+ cells in kidney allograft recipients with and without acute graft rejection]. / Zróznicowana ekspresja kostymulujacej czqsteczki CD 28 i hamujacej CTLA4 na limfocytach krwi obwodowej CD4+ biorców przeszczepu nerki z ostrym i bez ostrego odrzucania.

UNLABELLED: Alloimune activation is one of the most significant post transplant events, which results in increased expression of costimulatory molecules. These molecules have been suggested to play a role in determining the outcome of immune response including graft rejection. MATERIAL AND METHODS: We examined the CD28 and both surface and intracellular CTLA-4 expression on freshly drawn and anti-CD3+rlL-2 stimulated peripheral blood CD4+ T cells in kidney transplant recipients with acute graft rejection and with non-complicated post transplant course. Dual immunofluorescence and flow cytometry methods were used. The proportion of freshly isolated CD4+/ CTLA4 was higher in both groups of graft recipients in comparison to healthy controls reflecting in vivo allostimulation. RESULTS: We found the increased percentage of CD4+ cells expressing surface CTLA4 after stimulation, unstimulated intracellular CTLA4 and lower percentage of CD4+ cells expressing CD28 after stimulation in kidney recipients without rejection. CONCLUSIONS: Our results indicate the possible relationship between the expression pattern of CTLA4 inhibitory molecule on CD4+ cells and clinical course after renal transplantation.

[Mycophenolic acid concentration profiles may select recipients with high-risk of acute rejection in renal transplant recipients]. / Przydatnosc pomiarów stezenia kwasu mykofenolowego w osoczu w okresleniu zagrozenia wystapieniem ostrego odrzucania u biorców przeszczepu nerki.

UNLABELLED: The aim of the study was to assess relationship between the pharmacokinetics of mycophenolic acid (MPA) and the risk of developing acute rejection within 6 months after renal transplantation. MATERIAL AND METHODS: MPA concentrations were measured using validated HPLC. Venous blood samples for assay of MPA plasma concentrations were evaluated before (trough level; C) and 40 minutes, 1, 2 and 4 hours after mycophenolate mofetil (MMF) oral administration. The study included adult kidney cadaveric graft recipients: 26 patients treated with CsA, MMF and prednisone. MPA AUC was determined using the linear trapezoidal rule. Statistical significance was assessed using ANOVA Statistica. RESULTS: A total of 13 patients experienced biopsy proven rejection. Patients with acute rejection had lower GFR, lower serum albumin and were younger. There was statistically significant difference for MPA AUC(0-4), C40, C(max) between patients with acute rejection and patients with uneventful outcomes: mean MPA AUC(0-4): 11,4 +/- 7,23 microg x h/ml versus 34,0 26,8 microgxh/ml (p 0,01). Recipients with MPA AUC(0-4) <20 g x h/ml had a greater risk of acute rejection. CONCLUSIONS: MPA AUC(0-4) was a useful predictor of outcome in renal recipients within first 6 months after renal transplantation.

[The surgical treatment of thoracic outlet syndrome]. / Leczenie chirurgiczne zespolu uciskowego górnego otworu klatki piersiowej.

UNLABELLED: In this paper the surgical treatment of thoracic outlet syndrome (TOS) is presented. MATERIAL AND METHODS: The investigation of 74 patients treated for vascular complications of the TOS the Paget-Schroetter syndrome and postthrombotic syndrome (27 patients), as well as upper limb ischemia and/or the subclavian artery aneurysm (14 patients) and for neurological complications of the TOS (33 patients) was performed. In case of venous thrombosis the treatment consisted of thrombolytic therapy and decompressive procedures that included transaxillary first rib resection and other surgical procedures that excise different anomalies in the region of the thoracic outlet. In case of complications associated with compression of the subclavian artery the operation consisted of resection of the first rib and accessory osseous and muscular pathological elements using supraclavicular and/or infraclavicular approach with implantation of vascular bypass were performed. In the neurological syndrome of TOS the operation consisted of transaxillary first rib resection and other surgical procedures that excise different anomalies in the region of the thoracic outlet. The therapy results were estimated with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire of the American Academy of Orthopedic Surgeons. RESULTS: In case of venous complications the thrombolytic therapy was successful in all cases the restoration of complete patency was obtained. In all patients first rib was resected via transaxillary approach. The DASH questionnaire revealed the full return of upper limb function in most of patients. Improvement was obtained the in the cases with postthrombotic syndrome. In case of upper limb ischemia the improvement of blood flow was obtained after the subclavian-brachial bypass implantation (5 patients). In this group the DASH score showed return to full activity. In case of subclavian artery aneurysm surgery (9 patients) the DASH scale revealed worsening of limb function in 4 patients during the follow-up period. In the neurological syndrome of TOS the restoration of complete activity of limb was observed. The DASH scale revealed worsening of limb function in 4 patients during the follow-up period. CONCLUSIONS: The optimal therapy of vascular complications is multimodal treatment (thrombolysis or reconstructive vascular procedure with decompressive surgery). The surgical treatment of neurological TOS halts degradation of brachial splice. The decompression of neurovascular bundle in vascular TOS should include the first rib resection in each case.

Organ donor with complete situs inversus. Case report and review of the literature.

Complete situs inversus (SI) is a very rare anomaly characterized by the total inversion of all abdominal and thoracic organs. SI has been traditionally considered an absolute contraindication for liver and heart transplantation. We report a case of a donor with complete SI diagnosed at the time of organ recovery and we review the literature concerning this anomaly and organ transplantation.

[Application of VEGF165 plasmid in treatment of critical lower limb ischemia]. / Zastosowanie plazmidu VEGF165 w leczeniu krytycznego niedokrwienia konczyn dolnych.

UNLABELLED: In the study we assessed the clinical and histological benefits of gene therapy in no-option patients with critical lower limb ischemia. MATERIAL AND METHODS: We administrated VEGF165 (Vascular Endothelial Growth Factor) plasmid to 10 patients. The plasmid was injected intramuscularly into lower limb. In the study we evaluated: clinical outcomes, venous blood VEGF protein concentration before and after (7th, 14th, 28th and 90th day) administration of plasmid. From patients who required amputation we obtained samples of muscles, which were examined histological and by PCR (Polymerase Chain Reaction) for detection of plasmid genes. RESULTS: Only two patients from the group did not require amputation due to the therapy. In eight patients the operation was essential. Serum VEGF concentration was higher than in healthy controls (p < 0.05). We observed increase of the concentration of the cytokine on the 14th day an decrease on the 90th day after administration of plasmid (p < 0.05). Histological analysis did not reveal any sings of new blood vessels formation in the samples taken from amputated limbs. There was also no signs of expression of plasmid primers in PCR. CONCLUSIONS: The therapy is safe. We did not observe significant improvement in patient's clinical state. The therapy needs further investigations.

[Molecular basics of angiogenesis]. / Molekularne podstawy angiogenezy.

In the article we present the latest knowledge about angiogenesis. We have divided the paper into three main parts, in which the involvement of the extracellular matrix, cells, and cytokines/growth factors in the growth of new blood vessels is described. In brief, the extracellular compartment plays a crucial role in the formation of new vasculature. Degradation of matrix is a very important and precisely controlled process performed mostly by a family of proteins called matrix metallproteinases (MMPs). The extracellular compartment, through the special transmembrane proteins integrins, transmit a wide variety of signals into the cells and thus influence such cell behavior as proliferation, invasion, shape, migration, and maturation. Many products of matrix degradation are potent (mostly negative) regulators of angiogenesis; this self-limiting system prevents excessive proteolysis of the matrix components. The cells involved in the process are endothelial progenitor cells (EPCs), which are derived from bone marrow. The major surface antigens of the cells are CD34+, CD133+, and VEGFR2+. It has been demonstrated that EPCs are responsible for maintaining the functional integrity of endothelium. The number of EPCs in peripheral blood samples inversely correlates with cardiovascular risk factors. In the last section of the article the role of cytokines/growth factors is described. VEGF, as a key regulator of the initial steps of angiogenesis, controls the mobilization and incorporation of EPCs into the site of ischemia. The most important cytokine that facilitates the mobilization of EPCs from bone marrow is SDF-1, which is the strongest chemoattractant for EPCs. Ang-1, on the other hand, controls new blood vessel maturation and stabilization.