Treatment options for complex aortic aneurysms ­ own experiences / Complex aortaaneurysmák kezelési lehetoségei - saját tapasztalatok

Complex aortic aneurysms extend to more aortic segments, and/or include one or more orifices of highly important side branches. Meanwhile complex aneurysms need reconstructive solutions in one sitting or hybrid procedures timely close to each other, multiple aneurysms can be treated technically and timely separated. Previously, open surgery was the only opportunity to intervene, which was associated with significant surgical trauma and was not suitable for high risk patients when devastating complications were likely. Recently combination of lower risk surgery with endovascular treatment options ­ the so called hybrid techniques ­ resulted in that indications for treatment remarkably widened. In addition, permanent technical progress made available pure endovascuar solutions, so a wide range of surgical procedures provide number of options for treatment. In this paper we report on the treatment options of complex aortic aneurysms, and present our own relevant experience.

Kommerell diverticulum ­ rare complications of a rare disease / Kommerell diverticulum - egy ritka betegség ritka szövodményei

Incidence of anomalies of the aortic arch is estimated 1-2 per cent in newborn babies. Lusory artery may arise either from left sided aortic arch in 0.7­2 per cent, or from right sided aortic arch in 0.4 per cent. Leading symptoms develop from compression of the oesophagus or trachea, or both. If lusory artery dilates conically over the time reaching 3 cm or more we call it Kommerell diverticulum. Very rare complications of this are the Type B aortic dissection, which may turn into chronic thoracoabdominal aneurysm, or its shaggy inner surface can be the source of upper extremity embolism. Rupture is extremely rare complication. In our report we focus on five cases of the mentioned complications with their clinical workups and technical solutions. In a female patient with right sided arch transection of the lusory artery was followed by transposition into the right common carotid artery. The central stump 10 years later gradually expanded and the saccular aneurysm indicated intervention. After complete arch debranching thoracic endograft was implanted. In this group of patients with variable surgical and hybrid procedures neither complication nor mortality occurred.

[Operative treatment of dialysis associated steal syndrome: basilic vein graft applied for revision using distal inflow (RUDI) procedure]. / Dialízis-asszociált steal syndroma mutéti kezelése: AV anastomosis distalizációjával, vena basilica interpositum felhasználásával.

Introduction: Artificial arterio-venous fistula-induced steal syndrome and subsequent distal ischemia are one of the most serious complications of arterial-venous fistula (AVF) surgery, ranging from 1 to 8% of cases. Traditionally, the complication is difficult to treat without losing the fistula. Treatment options include ligature of the fistula, fistula banding, distal revascularization with interval ligation (DRIL), proximalisation of the arterial inflow (PAI), and revision using distal inflow (RUDI). We would like to present a case of a 45-year-old woman who has developed dialysis associated steal syndrome with necrosis on the left arm 5 months after a cubital AVF was created. In order to maintain her arterio-venous fistula, RUDI procedure was performed to eliminate ischemia. We used basilic vein graft for distal revision of the astomosis. As a result of the procedure, ischemic complaints ceased, dialysis did not need to be interrupted, no further vascular access was necessary. Distalization of arterial inflow (RUDI) is an easy-to-implement, good-performing method for which the use of vena basilica graft is a very obvious solution.

[Visceral complications of the aortic dissections - indications and technique of the thoracoabdominal refenestration]. / Aortadissectiók zsigeri szövodményei ­ a thoracoabdominalis refenestratio javallata és technikája.

Aortic dissection is a life threatening cardiovascular catastrophy. Its incidence estimated to 5-6 cases per 100,000 patients/year. The intimal tear happens at the ascending aorta in Type A, meanwhile at the aortic isthmus in Type B, but entry point may develop anywhere alongside the entire aorta. All types may affect a short aortic segment resulting in a localized false aneurysm, others separate the intimal layer at longer extension down to the visceral segment and far beyond to the femoral arteries. Dissection of orifices of side branches may lead to cerebral, upper extremity, spinal, visceral, renal and lower extremity malperfusion. These complications beyond the aortic rupture contribute significantly to high mortality of dissection. Today, first line treatment option in Type A dissection is surgery, but it can be endovascular or medical in Type B dissection. However, awareness of surgical procedures in this field remains inevitable. In this paper we summarize the surgical options for distal malperfusion affecting spinal, visceral, renal and lower extremity circulation.

["Debranching" -- a new surgical option for the aortic arch and thoracoabdominal aorta hybrid interventions]. / "Debranching" -- új érsebészeti feladat az aortaív és a thoracoabdominalis aorta hibrid mutétei számára.

INTRODUCTION: Endovascular techniques in vascular surgery are frequently applied to treat aortic diseases. These minimally invasive procedures changed aortic interventions remarkably. We have to be familiar with new terminology and methods. METHOD: New and old surgical procedures gained new role in preparation of endograft implantations. Transforming anatomy of aortic branches - "debranching" - is aimed to create a sufficient fixation of the endografts at safe "landing zones". CONCLUSIONS: Knowing the option of hybrid procedures is a fundamental requirement for the vascular surgeon. Equally important is to know the biomechanical characteristics of the available endografts, the possible complications during and after implantation and the treatment options. We have to be aware of the limitations of these new methods and the role of traditional open surgery in the new era. Our intention in this paper is to summarize methods of debranching.

[Late complications and treatment options of aortic coarctation operated in childhood]. / Gyermekkorban operált aortacoarctatiók késoi szövodményei és ellátásuk.

INTRODUCTION: The prevalence of congenital aortic coarctation is 4 in 10 000 live birth. Aortic coarctation is typically located in the aortic isthmus, but it may occur at atypical sites. Treatment options include both surgical and endovascular interventions. In patients undergoing surgical or endovascular intervention late complications such as recoarctation or aortic aneurysm may develop. AIM: The aim of the authors was to analyse their own experience in late complication and treatment options of aortic coarctation operated in childhood. METHOD: Retrospective analysis of data of 32 patients treated between 1980 and 2014 for late complications 8-42 years after surgical treatment of aortic coarctation. RESULTS: In 28 patients aneurysm formation after isthmic patch plasty was found. Two patients had aortobronchial fistula, 2 patients showed anastomosis disruption and 2 patients had graft stenosis. During operation hybrid solution was performed in 23 patients, isthmic aorto-aortic inlay graft interposition in 5 patients, aorto-aortic bypass in 2 patients, subclavio-aortic bypass in 2 patients, graft patch plasty in one patient and ilio-renal bypass in one patient. Complications included severe intraoperative bleeding in one patient and pneumothorax in one patient. No early or late mortality occurred. CONCLUSIONS: The authors conclude that life long control is mandatory in order to detect late complications in patients who underwent operation of aortic coarctation in childhood.

[Penetrating atheromatous ulcer of the thoracic aorta. Treatment options]. / A mellkasi aorta penetráló atheromás ulcusa. Kezelési lehetoségek.

INTRODUCTIONS: Atherosclerosis is a generalized degenerative disease of arteries. A rare manifestation of that is the penetrating atheromatous aortic ulceration of the aortic wall which may be complicated by subintimal hematoma, dissection, false aneurysm and rupture (acute aortic syndrome). AIM: The aim of the authors was to analyse their experience with this rare disease. METHOD: In the department of the authors 10,212 patients underwent surgery for cardiovascular diseases. Among these, 18 patients were diagnosed with penetrating atheromatous aortic ulceration located in the thoracic aorta (ascending aorta 2, aortic arch 8, descending aorta 6 and thoracoabdominal aorta 2 patients). Severe comorbidities were present in the majority of patients. RESULTS: Depending on the localisation the authors used various treatment options such as open surgery (4 patients), hybrid techniques (7 patients) and pure endografting (7 patients). One patient died on postoperative day 3. Two patients had late complications due to endoleaks treated successfully by open surgery. CONCLUSIONS: The authors conclude that when this dangerous condition detected in time, a wide variety of open, hybrid and endovascular methods can be applied with good results.