Infrarenal abdominal aortic dissection with aberrant renal arteries and lead-ing symptom right leg ischemia: case report.

INTRODUCTION: Isolated infrarenal abdominal aortic dissection is a rare clinical entity. Most cases are treated by endovascular techniques, and open surgery is seldom necessary. CASE DESCRIPTION: We present a rare case of spontaneous symptomatic infrarenal aortic dissection with leading symptom right leg ischemia. We opted for abdominal surgery as the attempt for open surgical fenestration of the dissecting flap exit through right femoral access was unsuccessful. Dacron vascular prosthesis was implanted with aortoiliofemoral bypass on the right side. One of the two accessory right renal arteries was ligated, which led to a confined zone of renal ischemia. Upon follow-up, complete restoration of the renal parenchyma was observed; kidney function remained unaffected. CONCLUSION: By infrarenal abdominal aortic dissection with accessory renal arteries, abdominal surgery with selective clamping is a reliable therapeutic approach allowing maximal preservation of renal blood flow. HIPPOKRATIA 2019, 23(4): 186-189.

ENDOVASCULAR TREATMENT OF AN ANEURYSM OF THE SPLENIC ARTERY.

Aneurysms of the splenic artery account for about 60% of all aneurysms of visceral arteries. Most of them are asymptomatic until rupture and are discovered accidentally, usually after an imaging study. The treatment is surgical or endovascular depending on the type, location and size. We present a case of a patient with an asymptomatic, accidentally found aneurysm of the splenic artery which we successfully treated with a covered stent. The control CT-angiography on 6th month showed patent stent and totally occluded aneurysm. It is very important in cases of acute abdomen and hemorrhagic shock to think of a ruptured aneurysm. In these cases the treatment of choice is endovascular as it is mini-invasive and organ-saving.

Aorto-bifemoral revascularisation after radiation, peritonitis and colostomy.

The success of all vascular interventions depends mainly on the chosen strategy and access, especially in patients with severe co-morbidities, preceding operations or infection. In these cases the combination of retroperitoneal approach and extra-anatomical bypasses makes the revascularization possible. We present a clinical case of a patient after radiotherapy, peritonitis and colostomy with persistent pain in the lower extremities and angiographic finding of bilateral occlusion in the aorto-iliac segment. We did a right retroperitoneal aorto-femoral reconstruction and a crossover femoro-femoral bypass. It is also possible to perform visceral and renal arterial reconstructions with the retroperitoneal approach. In addition, symptomatic and ruptured aneurysms, as well as infected aortic grafts can be operated on with optimal results, without a notable increase in mortality.

Embolization of anomalous vessels in tumor formation.

Embolotherapy or embolization has rapidly developed in recent years and now represents an integral part of interventional radiology practice. Embolotherapy is defined as the percutaneous endovascular application of one or more of a variety of agents or materials to accomplish vascular occlusion. Embolization has grown dramatically in scope and complexity over the past three decades, and with this growth, there is now a need to define standards for those practicing in this field, including: appropriate training with monitoring of outcomes; provision of pre-, intra-, and postprocedure patient care; and performance of the technical aspects of the procedure. We present 58 patients from clinic of Vascular Surgery and Angiology at "St. Ekaterina" University Hospital. After four abnormal nutrition artery embolization in two consecutive procedure due to recurrences formation of adrenal tumor.

[The renaissance of lumbar sympathectomy].

The question addressed was whether the use of sympathectomy was of benefit in non-revascularisable critical leg ischaemia. Altogether 387 papers were found, of which 13 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that lumbar sympathectomy is a minimally invasive procedure with a low complication rate. Randomized controlled trials have failed to identify any objective benefits for lumbar sympathectomy, but subjective improvements in symptoms for patients with highly symptomatic critical leg ischaemia have been consistently demonstrated in multiple cohort studies with sustained symptom improvements in approximately 60% of patients. Lumbar sympathectomy is in process of renaissance and should be considered for symptomatic patients with critical leg ischaemia as an alternative to amputation in patients with otherwise viable limbs.

[Adjuvant and individual application of lumbar sympathectomy at patient with arterial disease in lower limb].

The first lumbar sympathectomy for treatment of arterial occlusive disease of the lower extremity was performed in 1924 by Julio Diez of Buenos Aires. The standart anatomy textbooks indicate, as a rule that the lumbar sympathetic trunk contains four or five ganglia. The overall anatomic denervation is important for achievement of an adequate sympathectomy of a given segment of an extremity. Criteria and indications for complete sympathetic block are still not clear. Exceptionally important for the improvement of the reology of the lower limbs is the option for a direct increase of the collaterals' debit which could be achieved by extensive profundoplasty. As an addition to the arterial reconstructions, the sympathectomy increases the passability of small vessel anastomosis and the recovery of traumatized arteries. Unilateral or bilateral lumbar sympathectomy is performed by retroperitonal access. From 01.01.2008 till 01.11.2008 in our clinic were performed 117 isolated and after arterial reconstruction lumbar sympathectomies.

[A rare case with excessive congenital arterio-venous angiodysplasy of the upper extremity].

The congenital vascular anomalies of an upper extremity are rare, but may cause serious complications during them development and haemodynamic. We present a case of one patient with congenital arterio-venous malformation of the right arm and fore-arm, advanced and progressed by impossible level of an operation or invasive treatment. The changes in the venous system are with obligate predisposition for dyabrosis, rupture and profuse bleeding from the extremity. The problems by the complex treatment of the congenital arterio-venous vascular diseases are considerable, in spite of all that the lower frequency and manifest expression to them, in particular in the cases with polyorgans comorbidity.

[Diagnostic criteria when establishing indications for revascularisation of profunda femoris artery].

In patients with chronic limb ischemia (CLI) the atherosclerotic process involves the aorto-iliac and/or the femoro-popliteal segment. In most cases there are steno-occlusive lesions of the superficial femoral artery but the profunda femoris artery is often spared. In 30% of the diabetic patients and in 9% of the nondiabetic there are lesions of the profunda femoris artery which are mainly ostial or can be found at the most proximal part. The revascularization of the profunda femoris artery is an important operative method especially in many cases where there is no other possibility of vascular reconstructive operation. In this paper we discuss different diagnostic tests and criteria. which we used when deciding which patients are suitable for profundoplasty--segmental pressures, angiography, Doppler triplex scan.

[Surgical treatment for stenotic lesion of the subclavian artery].

We present a case of a 56-year-old male patient who was admitted at the clinic with complains of pain and blue-colored index finger of the left hand since a couple of days. He has an anamnesis of claudication of the left arm. After the contrast CT-angiogram, which showed a 80% stenosis of the left subclavian artery, the patient had an allergic reaction. This changed our initial plan for an endovascular intervention and we proceeded to an open surgical procedure. Because of the suitable anatomical characteristics we did a replantation of the subclavian artery to the common carotid artery. The postoperative period went smoothly. Six months after the intervention the patient is feeling fine. He has pulse on the radial and ulnar arteries and no sign of the necrosis of the index linger. Subclavian-carotid transposition is a safe method for the treatment of steno-occlusive lesions of the subclavian artery. Except the ortograde physiological blood flow through the vertebral artery and the construction of only one anastomosis, the main advantage over the bypass surgery is not using autogenous or heterogenous prosthetic material.

[Diagnostic criteria when establishing indications for revascularisation of profunda femoris artery].

In patients with chronic limb ischemia (CLI) the atherosclerotic process involves the aorto-iliac and/or the femoro-popliteal segment. In most cases there are steno-occlusive lesions of the superficial femoral artery but the profunda femoris artery is often spared. In 30% of the diabetic patients and in 9% of the nondiabetic there are lesions of the profunda femoris artery which are mainly ostial or can be found at the most proximal part. The revascularization of the profunda femoris artery is an important operative method especially in many cases where there is no other possibility of vascular reconstructive operation. In this paper we discuss different diagnostic tests and criteria, which we used when deciding which patients are suitable for profundoplasty--segmental pressures, angiography, Doppler triplex scan.

[Endovascular recanalisation of subclavian artery stenotic-occlusive lesions].

Recently, percutaneous transluminal angioplasty (PTA) with stent placement has gained greater acceptance for the treatment of hemodynamically significant atherosclerotic lesions involving the brachiocephalic, subclavian and vertebral vessels. PTA is performed instead of extratoracic bypass surgery, which is associated with several risks and complications. Main indications for PTA and stent include short occlusions and elderly patients with increased surgical risk. We present 4 cases with occlusion of the left subclavian artery, including 1 case ofthombosed distal anastomosis of carotid-subclavian bypass.

[Vascular complications of Baker's cyst].

The presence of Baker's cyst is clinically demonstrated as compression syndrome of the vessels and nervous stem in the popliteal area. This result frequent in deep venous thrombosis, nervous injuries and blood flow insufficiency distal to the compression site. We present two cases of compression stenosis of the popliteal vessels, clinically manifested. The patients underwent surgical decompression and cystic removal, thus leading to arterial perfusion and/or venous derivation improvement of the lower extremity.

[Iatrogenic phlebothrombosis of the internal jugular vein after application of implantable central venous catheter].

We present a case report of a 56-year-old male patient diagnosed as B-cell non-Hodgkin lymphoma with iatrogenic phlebothrombosis of the right internal jugular vein after introduction of totally implantable venous catheter. He was admitted to the Clinic of Vascular Surgery at "St. Ekaterina" Hospital two weeks after the implantation complaining of pain and edema in the right cervical region, as well as ipsilateral blepharoptosis. The thrombus was removed operatively and revascularization of the vein was achieved. The patient was dismissed without clinical symptoms and with advice to continue his anticoagulant therapy. In this case we think that the most likely cause for the thrombosis of the internal jugular vein is the malposition of the catheter tip based on the observation that the device was not properly fixed to the skin and was found partly extracted. Routine heparinization proved to be insufficient for the prevention of thrombosis.

[Analysis of the results of femoro-popliteal arterial bypasses depending on the clinical stage of disease].

The strategy of treating infra inguinal arterial lesions according to the clinical Fontaine stage is very difficult and complicated. Critical limb ischemia is considered a strong indication for revascularization without delay. It is still not clear what operative treatment should be chosen for patients in Fontaine stage II. Early femoro-popliteal bypass reconstruction is a new practical doctrine and the wise alternative before the onset of severe and irreversible changes in the peripheral arterial vessels and the microcirculation. This conception takes a very important part in the evaluation of the long-term perspective of patients.

[Endovascular procedures in case of cancers engaging the vessels of the small pelvis].

Cervix cancer is quite common nowadays. Its progress is followed by painful symptomatology, urosepsis, lymphedem, flebothrombosis and ischemia of the lower limbs. The surgical treatment and the following chemotherapy and radiotherapy causes proliferation of the fibroid tissue, which embraces and presses the vessels of the small pelvis. We are to depict two clinical cases in which the choice of the percutaneous transluminal angioplasty and the implementation of a covered stent - graft is preferable to the open surgery. During the predilatation with a balloon catheter, our first patient suffered of a vessel rupture, visualized on the intraoperative angiogram. The rupture of vessel during angioplasty usually demands open surgical correction, but endovascular procedure can provide a fast, efficient, and less aggressive method. Covered stent-grafts are applicable for both treatment and stabilization of vessel lesions.