[Changes in the true and false visceral segment lumen sizes following endovascular treatment of type B aortic dissections]. / Zmeny velikosti pravého a falesného lumen ve viscerálním segmentu po endovaskulární lécbe disekcí aorty typu B.

INTRODUCTION: The aim of the study was to assess technical success rates of endovascular procedures in acute and chronic type B aortic dissections and changes in the right (PL) and false (FL) lumen diameters in the visceral segment region during short-term and long-term follow up study periods. METHODS: From 2004 to 2009, the authors performed a prospective study, which included a total of 33 patients with acute and subacute (n = 16; 48.5%) or chronic (n = 17; 51.5%) type B dissections of the descending aorta, with dissections spreading as far as the visceral or infrarenal regions. The patients underwent successful implantations of stent grafts (SG) into the descending aorta. The study group included 7 female and 26 male subjects, at the time of the procedure, their mean age was 59 years, (34-70, the median of 56 y.o.a.). The mean follow up time was 39.3 months (8-68, the median of 41 months). During the study period, one of the patients exited due to another internal disorder, three subjects were converted to open replacements for progressing dilatation of the total diameter in the visceral or subrenal region. The true (PL) and false (FL) lumen diameters were measured at four levels: above the origin of truncus coeliacus (L 1), between the origin of truncus coeliacus and the origin of a. mesenterica superior (L 2), between the origin of a. mesenterica superior and the origin of aa. renales (L 3) and just distal to the origin of aa. renales (L 4). The measurements were performed 1 and 6 months after SG implantations and at the end of the study period. RESULTS: The primary entry was successfully sealed in all the study subjects. Significant widening of the true lumen in the region sealed by the stentgraft was recorded in all the subjects, however, the false lumen did not completely disappear in 3 (9%) patients. The false lumen was completely filled with thrombus down to the celiac trunk level (L 1) within one month in 7 (21.2%) patients, within 6 months in 14 (42.4%) subjects and by the end of the study period in 19 (58.6%) patients. The true lumen continued to enlarge at all the measured levels. The most significant enlargement was recorded at L 1 during the first postoperative month (the mean change of 5.9 mm). Furthermore, narrowing of the originally patent false lumen was observed as well, with the most significant change at L1 level during the first postoperative month (the mean change of 6.5 mm). At six months and during the whole follow up study period, further increases in the right lumen diameter and in the total aortic diameter were recorded at all the measured levels. At the same time, the false lumen diameters at all the measured levels continued to narrow, if patent at all. CONCLUSION: False lumen thrombosis along the extent of SG was recorded in 30 (91%) patients, SG filled the lumen completely and the false lumen disappeared. The true lumen expanded at all the measured visceral segment levels. The change was most significant during the first postimplantation month, and the true lumen expansions and the false lumen narrowing proceeded over the whole follow up study period, however, the progression was slower. The visceral segment true and false lumen changes will be monitored further.

[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.

[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.

[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.