[Surgery of subrenal aneurysms in the abdominal aorta and retroaortic localization or the left renal vein]. / Operace subrenální výdute brisní aorty pri retroaortálním ulození levé renální zíly.

The presented work is only a minor contribution to the extensively elaborated method of surgical treatment of subrenal aneurysms of the abdominal aorta, informing on the unusual pattern of important anatomical structures in the surgical field involving the retroaortal localization of the left renal artery which runs closely dorsally behind the proximal neck of the aneurysm. The incidence of major venous anomalies which are associated with the aortal section and which include in particular the circumaortal left renal vein (circumaortal annulus) left-sided transposition of the lower vena cava or its duplicity and preaortal connection of iliac veins amounts according to data in the literature to 5.6% [1], a left renal vein 2% [18] and the incidence of these anomalies in surgery of the abdominal aorta is 0.8% [3]. The presence of the anomaly we encountered was detected already before surgery due to the careful evaluation of the spiral CT and called for a change of the usual surgical technique because of the risk of injury of the renal vein during construction of the proximal anastomosis by the usual inclusion technique from the inside of the aneurysm. A more extensive release of the proximal cervix of the aneurysm was necessary with isolation of the adjacent ventral portion of the left renal vein, complete transverse severing of the aorta at the level of the proximal cervix and direct end to end suture of the proximal anastomosis. This case-history draws attention to the possibility of venous malformations which may make the course of surgery on the abdominal aorta difficult and draws attention to the importance of CT examination during elective operations of aneurysms of the abdominal aorta.

[Indications for angiography in penetrating injuries of the extremities]. / Indikace angiografie u penetrujících poranení koncetin.

The author presents a review of the approach of vascular surgeons to penetrating injuries of the extremities from the initial period of development of the discipline when surgical exploration was preferred and performed as a matter of routine, across the sixties, seventies and eighties characterized by universal use of angiography, up to the last decade and the present time when specialists accept the necessity of selective indication of angiography derived from the clinical picture. Certain persisting differences in views pertain only to some aspects of the clinical finding. Some authors were for instance concerned with investigation of the probable risk of arterial injuries with regard to the site of penetration, from their conclusion ensues in the great majority the recommendation to perform angiography in injuries of the medial side of the thigh and arm, popliteal area, leg and forearm, incl. asymptomatic ones. Other investigations sought a relationship between the incidence of injuries and the presence of some clinical symptoms and recommend to indicate angiography in injuries associated with at least one "hard" symptom (pulse or neurological ischaemic deficiency) or at least two "soft" symptoms (haematoma, haemorrhage, hypotension, malleobrachial index smaller than 1). The author presents also his own attitude to the problem and emphasizes expert comprehensive clinical examination, taking into account the site of penetration, character and mechanism of injury, character of clinical symptoms, their intensity in relation to the general state of the circulation and its possible changes, in selected cases supplementation of the clinical finding by sonographic examination.

[Autologous transplantation of peripheral hematopoietic cells and subsequent maintenance therapy with interferon alpha or interferon alpha and dexamethasone in patients with multiple myeloma--results from the 4W randomized clinical trial of the Czech Myeloma Group]. / Autologní transplantace periferních hemopoetických bunek a následná udrzovací terapie interferonem alfa nebo interferonem alfa a dexamethasonem u nemocných s mnohocetným myelomem--prubezné výsledky randomizované klinické studie 4W Ceské myelomové skupiny.

In the clinical 4W study patients with newly diagnosed multiple myeloma are included where the state of the disease calls for treatment, while high dose chemotherapy is not contraindicated. Treatment according to protocol 4W comprises induction chemotherapy VAD, mobilization of haematopoietic cells (cyclophosphamide 5 g/m2). This is followed by autologous transplantation (as a conditioning regime melfalan 200 mg/m2 is administered). The patients are randomized into two groups, the first one is given interferon alpha as maintenance treatment, in the second group alternates cyclically interferon alpha and dexamethasone treatment. So far between 1996 and Aug. 31 2000 in the 4W clinical study 167 patients were included. 113 patients after transplantation were evaluated incl. 13 (12%) who achieved complete remission of the disease (absence of paraprotein, negative immunofixation), 63 patients (56%) with remission of the disease (decline of paraprotein, by more than 75%). Another 24 patients (21%) achieved partial remission (decline of paraprotein by more than 50% but less than 75%). The peritransplantation mortality is 2.67%. So far there is no significant difference between the two groups on maintenance treatment as regards the mean period before a relapse of the disease (p = 0.567). The median of the mean survival was not reached so far. The authors describe the results of the internal analysis of data incl. statistical processing.

[Arterial autograft reconstruction of the internal carotid artery after endarterectomy using the superior thyroid artery]. / Autoarteriální plastika arteria carotis interna po endarterektomii pomocí arteria thyreoidea superior.

The author presents his experience with the technique of alternative plastic closure of longitudinal arteriotomy of the internal carotid artery (ACI) using an autoarterial graft from the ipsilateral arteria thyroidea superior (ATS) [1]. Autoarterial plastic operations were sued so far in eight patients, in six instances endarterectomy of a primary ACI stenosis with a narrow lumen was involved, and in this group in two instances a peripheral intimal step was involved. In two instances an autoarterial patch was used after resection of kinking of the thin ACI. The graft is collected from an incision commonly used in plastic operations of carotid endarterectomy and takes roughly 10 minutes. In all instances ATS provided enough material, although in two instances it had a rather thin lumen. The described plastic operation is rapid, effective, limited to one surgical field and easily performed. The favourable results of subsequent sonographic controls of the patency of the reconstructed ACI, implemented so far 1-2 years after surgery confirm that this technical solution is suitable.

[Autogenous bilateral aortofemoral reconstruction using the popliteal and superficial femoral veins]. / Autogenní oboustranná aortofemorální rekonstrukce popliteálními a povrchními femorálními zilami.

The author presents a case-history of a late infection of a bilateral aortofemoral bypass by a coagulase-negative staphylococcus and the definite solution by substitution of the contaminated vascular prosthesis by an anatomical autogenous bilateral bypass made from popliteal and superficial femoral veins. From the technical aspect the operation was very satisfactory without marked peroperative difficulties, the early postoperative course was also favourable, with readily palpable peripheral pulsations, without marked manifestations of venostasis on the lower extremities. From the third postoperative day onwards however progressive manifestations of multiorgan failure developed associated with septic shock and leading to a fatal outcome. Despite this the author considers in patients with a reasonable surgical risk this method of substitution of an infected vascular prosthesis in the aortofemoral region feasible with regard to its resistance to infection and long-term patency, though the operation is technically pretentious but easy to implement.

[Continuous loop suture in a longitudinal arteriotomy]. / Osmickový pokracující steh podélné arteriotomie.

The author describes a technical 8-shaped variation of continuous suture of longitudinal arteriotomy. He describes the technical details of implementation of the suture which by crossing of the thread between the margins of the arteriotomy prevents overlapping of the margins and thus narrowing the arterial lumen. Practical aspects of the use of the suture are described, incl. evaluation of conditions and local findings where this continuous suture can, due to its functional effect, replace autovenous or prosthetic plastic surgery of the artery.

[Cystic degeneration of the popliteal artery adventitia]. / Cystická degenerace adventicie podkolenní tepny.

The author presents the case-history of a typical clinical picture of a rare vascular affection--cystic degeneration of the adventitia of the popliteal artery in a young man. The diagnostic conclusion was reached by means of duplex sonography and angiography of the extremity, the condition was treated by reconstruction surgery. With regard to its long-term effect the author prefers it to some non-surgical procedures which include in particular transluminal angioplasty or sonographically assisted needle aspiration of the cyst.

[Treatment of multiple myeloma with high-dose chemotherapy and transplantation of autologous hematopoietic stem cells and subsequent maintenance therapy with interferon alfa-2b or interferon alfa 2b and dexamethasone. Report of the ongoing study of the "4W" Czech Myeloma Group]. / Lécba mnohocetného myelomu vysokodávkovanou chemoterapií s transplantací autologních kmenových hemopoetických bunek a následující udrzovací lécbou interferonem alfa-2b nebo interferonem alfa-2b a dexametazonem. Zpráva o probíhající studii "4w" Ceské myelomové skupiny.

We report our results with high-dose chemotherapy in previously untreated multiple myeloma patients (4 courses of VAD chemotherapy, collection of PBSC after priming with cyclophosphamide, 5 g/m2, high-dose chemotherapy with melphalan, 200 mg/m2). Second transplantation was indicated only for patients who did not achieve remission after the first high-dose therapy (paraprotein lower than 25% of the pretreatment value). For the second transplantation melphalan (200 mg/m2) with methylprednisolone (1.5 g for 5 days) were used as conditioning regimen. After high-dose therapy all patients were randomized into two arms of maintenance therapy: interferon alpha-2b or sequential maintenance therapy (interferon alpha-2b for 3 months followed after 4 week pause by 40 mg of dexamethasone days 1-4, 10-13 and 20-23. The administration of interferon alpha was resumed four weeks after the last dexamethasone for next three months. The maintenance therapy continued for 48 months or until the progression. Fifty-five patients were enrolled in the study from January 1996 to August 1997. Thirty-five patients have undergone the first transplantation and 57% of them reached complete remission. There were 10% of non-responders after the first high-dose regimen. The mean time to reach white blood cell count above 1 x 10(9)/L after the application of high dose melphalan and platelets more than 50 x 10(9)/L were 12.2 (range 6-16 days) and 12.4 (range 0-25 days), respectively. Grade 4 mucositis according to SWOG classification requiring total parenteral nutrition was presented in 40% of the patients. The mean number of 1 unit of platelets and 2 units of packed red blood cells transfusions were given within the posttransplant period. Early transplant related mortality was 3%. This paper describes the response and tolerance of each particular step of therapy. The follow-up has been too short to evaluate event-free and overall survivals.

[Isolated defect injuries of the common femoral and external pelvic veins]. / Izolované ztrátové poranení spolecné stehenní a zevní pánevní zíly.

The author describes the case-history of an injury of the common femoral and external pelvic vein. He describes the method of replacement of the loss using an autovenous graft formed from the trunk of the vena saphena magna which was split longitudinally and then sutured in a spiral fashion. The applied reconstruction method can be evaluated as reliable, technically feasible. The reconstruction is patent after two years and the affected extremity bears no signs of venostasis.