Influence of blood supply on fracture healing of vertebral bodies.

INTRODUCTION: The relevance of blood supply for bone fracture healing has been discussed throughout the literature, using scaphoids as the most referred to. But, there is virtually nothing known about the relevance of blood supply for the vertebral fracture healing and even the guidelines of AO do not deal with this issue. MATERIALS AND METHODS: A prospective cohort study of 107 patients was run from January 2016 to December 2016, with 54 male and 53 female patients, who were treated for traumatic vertebral fractures of thoracolumbar spine using posterior stabilization only. The average age was 67 years and the follow-up 12.3 weeks. The total number of vertebrae was 129. We analyzed the fracture morphology and measured the vertebral bodies in all three dimensions, with five reference planes. The progress of vertebral deformity in time measured before and after the surgery was correlated with the potential damage of the main vascular canal in the rear of each vertebral body. The bone pattern and morphology were analyzed in detail as well. Pathological fractures were not taken into our consideration. RESULTS: The overall deformity progression of vertebral bodies in the fractures with morphologically damaged blood supply was in all measured dimensions significantly higher than in the fractures with supposedly maintained perfusion. The osteoporosis played its role as well, but only with medium effect size compared with strong effect size of the vessel canal damage (Cohen). The combination of the both factors (damage to the vessel canal together with osteoporosis) showed also a strong correlation with a relevant deformity progression (Evans), but not much different from the vessel canal damage alone. With regard to the relevant changes of the vertebral body dimensions/volume, we found relevant changes in 52% of all fractures (SD 0.5017) generally, for the subgroup with the canal damage in 84% (SD 0.3691), with strong correlation (Evans, 0.7721). In the group of fractures with maintained perfusion, we found such changes in only in 5% of fractures (SD 0.2333). CONCLUSION: For decision making, we should take mechanical fracture analysis and dynamic processes within traumatized tissue a part of whose is the blood supply and oxygenation into surgical consideration. We recommend anterior rather than posterior stabilization for the cases with damaged vessel canal, and the vertebroplasty could pose an alternative in the elderly.

Trauma of the extracranial cerebral arteries due to injuries of the cervical spine.

INTRODUCTION: Cervical spine injuries are immanently accompanied by trauma to cerebral neck arteries. METHOD: A prospective two-cohort study, from oct. 2013 to oct. 2015. Overall 76 Patients (39W/37M) of median age 77 years, with either fractures or discoligamentary injuries have been examined with duplex-sonography and or CT-angiography. From October 2013 to October 2017 we examined 155 Patients (49% female and 51% male), with the average age of 39 years, SD 19 and age median of 34 years, with cervical-spine-distortion, using the same diagnostic modalities. We used the statistics-program Bias 11.01. RESULTS: The overall incidence of traumatic dissection of the internal carotid artery was 2.5%, in 50% of cases (1.2%) with neurological symptomato-logy. For the vertebral artery seems the incidence of 10.5%, with 25% of symptomatic patients (2.6%) comparably high. We have identified the osteophytes and dislocation as the significant risk factors. The canalis vertebralis and the skull-base are regions mostly prone to vascular injury. In the group of cervical spine distorsions we found no vascular trauma at all. The osteophytes were here identified as the main risk factor for collateral damage. CONCLUSION: One should look for vascular injuries in case of cervical relevant spine trauma. Moreover,  a rather relevant osteoligamentous injury should be assumed, when cervical vascular trauma was diagnosed. Key words: cervical spine trauma vessel-dissection duplex-sonography CT-angiography.

[Ischemic colitis following AAA procedures]. / Ischemická kolitída po operáciách pre AAA.

INTRODUCTION: Bowel ischemia following the AAA operation is a rare complication. However, it is the most common reason of death after elective AAA operation with the incidence of 5-9% and 30-60% following RAAA operation with mortality rate around 60%. METHODS: Retrospective analysis of 207 patients undergoing elective and emergent AAA operation between 1st January 2007 and 31st July 2010 was made. We evaluated clinical and para clinical symptoms leading to the observed diagnosis. RESULTS: During the observed period we have treated 207 patients with the AAA. 174 (84%) patients were elective, 33 (16%) were urgent (RAAA). Postoperative mortality of the entire group was 19 patients (9.2%). The most common reason of death was found to be ischemic colitis--8 patients (42%). Ischemic colitis was diagnosed in 17 patients (8.2%) with the mortality 41.2%. Diagnosis was made by colonoscopy in 58.8% of patients, the rest was operated on following the clinical finding of an acute abdomen. In a group of patients with an early diagnosis and treatment of ischemic colitis (until the 4th post operative day) the mortality rate was 20%, increasing till 71.4% when the diagnosis was done later than on 4th postoperative day. DISCUSSION: Nevertheless the ischemic colitis is a rare complication following AAA operation the surgeon must be proactive regarding this severe complication especially in high risk patients. Clinical symptoms are not specific, most often too early peristaltic and diarrhoea with addition of blood is apparent. Procalcitonine and D-lactate seem to be promising among the blood markers. Colonoscopy is a method of choice if there is any doubt in postoperative process. The need of relaparotomy is given by colonoscopy finding together with clinical, biochemical symptoms, signs and the clinical status of the patient. The resection of diseased part of bowel with the colostomy is mandatory. CONCLUSION: The final diagnosis of ischemic colitis is difficult and the decision for reoperation is a matter of surgeons' experience despite of clinical and paraclinical findings. Only fast and adequate treatment can be successful. Any delay in diagnosis is fatal for the patients.

[Successfully combined management of the abberant retroesophageal arteria subcalvia dextra aneurysm (arteria lusoria)]. / Uspesné kombinované riesenie aneuryzmy aberantnej retroezofageálne prebiehajúcej arteria subclavia dextra (arteria lusoria). Kazuistika.

INTRODUCTION: Aberrant right subclavian artery arising from the distal part of the aortic arch and passing behind the oesophagus (arteria lusoria) is a rare congenital vascular anomaly, it is the 4th most common aortic arch anomaly. At the site of the orifice there is the Kommerell's diverticulum, which is the locus minoris resistentiae with the possible arise of the aortic aneurysm. Aneurysmatic dilatation of the anomalous artery and of the aorta may be the cause of distal embolism or rupture. Less frequently there is also the possibility of aortic dissection or traumatic rupture. CASE REPORT: 54-old man with a symptomatic aberrant aneurysmatic dilated right subclavian artery (arteria lusoria) and an anerurysmatic dilatation of the Kommerell's diverticulum was indicated to staged combined management. Firstly we performed open surgical debranching of two supraaortic trunks (both subclavian arteries). Thereafter we excluded the orifice of the aberrant artery with the Kommerell's diverticulum by use of the endovascular techniques. There have been no complications during the perioperative period and the effect of surgery was optimal. DISCUSSION: It is generally accepted that the presence of aneurysm of the aberrant right subclavian artery is an indication for surgery, whether symptomatic or not. The conventional surgery is usually staged. Firstly there is a carotid-subclavian bypass or transposition on the right side and thereafter a transthoracic resection of the Kommerell's diverticulum and aortic angioplasty. The combined management with supraaortic revascularization followed with the stentgraft exclusion of the aneurysm is a sophisticated alternative. CONCLUSION: Experiences with the combined treatment published in the literature and ours are excellent, this technique is miniinvasive with a low complication rate. In our opinion it is the management of choice.

Devastating injury of the groin with vascular lesion.

A 13-year-old girl suffered an injury of the left inguinal region in October 2002. The mechanism of the injury was a fall off a merry-go-round with subsequent trailing by the iron frame, which resulted in devastation of the soft tissues and vessels of her left groin. The patient was transported to the Department of Paediatric Surgery in a state of haemorrhagic shock. A part of the iron frame was still sticking out of her groin. Emergent surgery and haemostasis was followed by reconstructive vascular surgery. Vascular ischaemic-reperfusion syndrome appeared 8.5 hours after the injury. A second episode of haemorrhagic shock developed on the 6th post-operative day, after a dislodgement of an arterial thrombus from a small artery, which was not obvious during the surgery. The situation required emergent wound exploration and surgical control of the bleeding. A third episode of haemorrhagic shock developed on the 9th post-operative day, after an excessive administration of heparin. This time no surgical bleeding was detected during wound exploration. The last episode of haemorrhagic shock appeared 6 months later, during the patient's menarche. She was ashamed to tell her parents about her heavy bleeding for several days. Authors of this article conclude that it is not necessary to increase the dose of Heparin above 20 mcg/kg/hour, even though the value of aPTT is not as high as we would expect. We should expect also the possibility of severe bleeding due to menarche on the anticoagulant therapy in adolescent female patients. Authors also consider both arterial and deep venous reconstructions to be adequate methods of treatment in case of extensive devastating injury of the groin region in the adolescent period (Fig. 5, Ref. 5). Full Text (Free, PDF) www.bmj.sk.

[Superficial thrombophlebitis--diagnostics and treatment]. / Povrchová tromboflebitída--diagnostika a liecba.

Superficial thrombophlebitis (ST) is a common disease, usually considered benign. However, the practice of systemic duplex ultrasonography has revealed a large number of deep-vein thromboses concomitant with ST. In contrast with extensive information on the management of deep vein thrombosis, little is known about the most appropriate treatment of the ST. Systematic duplex ultrasonography investigation has been proposed in the initial management of ST, to detect the presence of any underlying deep vein thrombosis. Because ST may extend into the deep venous system and potentially engender pulmonary embolism, treatment with low-molecular-weight-heparins might be the best choice. In our work diagnostic and therapeutic procedures for ST, proposed by Slovak angiological society, Slovak society for vascular surgeons, Slovak dermatological society, Slovak society for haemostasis and thrombosis, Slovak surgical society and Slovak internistic society are discussed.

[Peripheral arterial disease of extremities--guidelines for diagnostic and treatment]. / Odporúcania pre diagnostiku a liecbu periférneho artériového ochorenia koncatín (PAO).

Diagnostic and therapeutic guidelines of peripheral arterial disease of extremities recommanded by five scientific societies of Slovak Medical Association (Slovak Angiological Society, Slovak Society for Vascular Surgery, Slovak Cardiologic Society, Slovak Internal Society and Slovak Radiologic Society) are discussed in this article. Peripheral arterial disease (PAO) of extremities is an important manifestation of systemic atherosclerosis The lower the ankle-brachial pressure index, the greater the risk of serious cardiovascular events (e.g. myocardial infarction, stroke). Nevertheless, patients with PAO are undertreated with regard to use of antiplatelet drugs or lipid-lowering drugs, as compared with patients with coronary artery disease.

[Clinical significance of venoplasties in infragenicular prosthetic bypass grafts]. / Klinický význam zilovej plastiky distálnej anastomózy pri infragenikulárnych protetických bypassoch.

AIMS: Analysis of medium-term patency of prosthetic infragenicular bypass grafts with venoplasty of distal anastomosis and evaluation of venoplasties in patients with critical limb ischemia. STUDY DESIGN: A single centre, retrospective, non-randomised study. METHODS AND RESULTS: In 1998-2005, 42 patients with critical limb ischemias were surgically managed at our clinic using infragenicular prosthetic bypass graft implantation with distal anastomosis venoplasty. 3 types of plasty were employed: Linton's, St. Mary's boot and Taylor's plasty. Mean follow-up period was 25 months and primary functionality was 69%. Long-term functionality (over 5 years) was 35% and limb salvage rate was 38%. Functionality was assessed using life table analysis. 19% of patients exited during the follow-up period. In up to 30% patients, thrombolytic therapy was indicated for late bypass occlusion with a success rate of 63%. CONCLUSION: Prosthetic crural bypass is a relevant alternative to proximal level limb amputation. Venoplasty of distal anastomosis increases volume of the anastomosis and compensates for incongruencies of the graft and recipient vein lumen. Based on our experience, not a type of venoplasty, but a fact of increasing the anastomosis volume is most important. Whenever crural reconstructions are indicated, patient's quality of life, expected survival period, degree of patient's independence prior to surgery and patient's compliance must be considered.

[Post-catheterization pseudoaneurysm of the femoral artery--an unusual cause of femoral vein thrombosis--case report and review of the literature]. / Postkatetrizacná pseudoaneuryzma femorálnej tepny--nezvyklá prícina femorálnej zilnej trombózy--kazuistika a prehlad literatúry.

Invasive diagnostic procedures cause considerable increase of local arterial complications. Common femoral artery represents the most frequently used access artery. Our short report describes indications for treatment and treatment modalities of postcathterization false aneurysms with review of the literature. We present a case report of the patient with iliofemoral venous thrombosis related to external compression due to postcathterization false arterial aneurysm.

[Recent patho-biochemical view of ischemia-reperfusion injury]. / Súcasný patobiochemický pohl'ad na ischemicko-reperfúzne poskodenie tkaniva.

Ischemia-reperfusion injury (IRI) in patients with limb ischaemia remains still a topical problem and it is a subject of research. Some degree of tissue injury is expressed in each patient, regardless of type of ischaemia (acute or chronic). The difference is stated in extent of injury and in clinical relevance. In our article we provide current theoretical view of IRI and possibilities to influence it.

[The influence of chloroquine on some biochemical and hematological parameters in patients with critical limb ischemia]. / Vplyv chlorochinu na niektoré biochemické a hematologické parametre u pacientov s kritickou koncatinovou ischémiou.

CLI represents a major medical and social problem. The incidence is increasing and currently it was estimated 500-1000 per 1 million inhabitants. We carried out a clinical study (2000-2004) concerning monitoring of some hematological and biochemical markers during reperfusion in patients with CLI. The subject of our interest included possibilities to influence PMNL elastase by medical means and neutrophil-lymphocyte ratio which is considered a reliable and simple parameter to assess severity of clinical conditions.

[Cystic degeneration of the adventitia of the popliteal artery--case report]. / Cystická degenerácia adventície a. poplitea--case report.

Cystic adventitial disease (CAD) is a rare diagnosis with a higher number of the patients in recent years. The article gives a brief of the pathology and etiolopathogenesis of adventitial cystic disease and two case reports of the patients with CAD of the popliteal artery treated in our department between 1997 and 2001. Successful results are achieved only with surgical treatment.

[Regional biochemical and hematologic changes in patients after revascularization of the lower extremities in ischemia of the extremities]. / Regionálne biochemické a hematologické zmeny u pacientov po revaskularizácii dolných koncatín pre koncatinovú ischémiu.

INTRODUCTION: Surgical treatment of PAOD is related to iatrogenic ischaemia caused by arterial clamping and ischaemia which is result of natural development of the disease. The pathway of skeletal muscle reperfusion injury is complex and one of the most important factors related to injury is endothelial damage. The expected reason of endothelial damage is increased production of oxygen free radicals by prematurely activated PMN (polymorphonuclear) leukocytes (direct injury). Non-specific tissue injury is related to releasing of PMN elastase. Endothelial dysfunction, hypercoagulable state and microcirculation stasis are responsible for indirect injury and no-reflow fenomena. STUDY DESIGN: Observational pilot study. METHODS: 10 patients underwent surgery because of PAOD (all suffering from critical limb ischaemia). During reperfusion period in defined intervals following parameters were measured (samples were taken from ipsilateral femoral vein): PMN elastase, lactate, total antioxidant status, malondialdehyd, minerals, acid-base balance, blood count, APTT, prothrombin time, fibrinogen and HTI (heparin tolerance index). RESULTS: Patients with PAOD are threatened by hypercoagulable state with its clinical and surgical consequences. Maximal grade of local acidosis is reached 2 hours from the beginning of reperfusion. Tissue damage is expressed by maximum activity of PMN elastase 18-24 hours during reperfusion and represents non-specific tissue damage. Low total antioxidant status reveals high sensibility to oxygen free radicals. MDA does not achieve the pathological range in observed series. CONCLUSION: Our results confirmed inevitable importance of prevention of hypercoagulability, oxygen free radical tissue damage and PMN elastase activation to avoid of non-specific tissue damage.

[The popliteal artery entrapment syndrome--personal experience]. / Entrapment syndróm popliteálnej artérie--nase skúsenosti.

OBJECTIVE: In a retrospective study we analyze 5 patients with popliteal artery entrapment syndrome who were treated since 1999 to 2000 in our department. METHODS AND RESULTS: 5 patients were found to have popliteal vascular entrapment during a two-year period. From the total number of 5 patients, we performed surgery in 3 patients (5 operations). One patient rejected proposed surgical therapy, in another case the morphological lesion of the popliteal artery was not suitable for revascularisation. 3 patients underwent interposition of the diseased popliteal artery using a venous graft from a dorsal approach. Twice the decompression (myotomy) of the medial head of gastrocnemius muscle was sufficient. The study group is included in our follow up programme (median follow up 12.8 months, range from 3 to 24 months), primary and long term patency has been 100%. RESULTS: On the basis of our experience, we advice total replacement of the diseased popliteal artery. A dorsal approach (Hamming's "S" shaped incision) with interposition of the popliteal artery with autogenous venous graft, end to end anastomosis on both sides, seems to be the optimal solution. In case, the arterial wall is not irreversibly changed, surgical decompression (myotomy) is sufficient to prevent the development of symptomatic disease, also using the dorsal approach.

Diagnostic importance of magnetic resonance angiography in arterial reconstructive surgery.

Magnetic resonance angiography (MRA) permits the non-invasive visualisation of blood flow in arteries and veins. It has an enormous potential in imaging of various vascular pathologies and it has been establishing itself as a reliable alternative to widespread contrast X-ray methods explaining morphology of vascular system. This advanced and safe diagnostic method is very rarely used in the clinical practice of vascular surgeons in Slovak republic. The aim of this report is to outline a clinical importance of MRA for arterial reconstructive surgery, its advantages, limitation as an imagine technique and its practical application in different anatomical areas of the human body which are related to operative activity of vascular surgeons. It is intended for briefly comparing MRA with other vascular imagine techniques more common used in clinical practice of our surgical and vascular surgery departments and outpatient clinics.

[Surgical treatment of abdominal aortic aneurysms in severe ischemic coronary disease]. / Operacná liecba aneuryziem abdominálnej aorty pri závaznej ischemickej chorobe srdca.

BACKGROUND: The abdominal aortic aneurysm (AAA) is one of the most serious problems of vascular surgery and general medicine, as well. Endovascular methods of treatment have been developing very rapidly, however, the conventional treatment of the AAA still predominates. The results of operative treatment have been influenced besides the delayed diagnostics of the AAA resulting in a high rate of ruptured AAA by the high comorbidity of the AAA patients population. The accentuation of the proper preoperative and perioperative management of patients could therefore significantly influence the results of the surgery. MAIN PURPOSE AND STARTING POINTS: Striking difference between the mortality of elective and emergent surgery of AAA has been unchanged despite the intensive effort of many centers. One of the main factors of mortality is the concomitant serious coronary heart disease (CHD), predominantly the acute myocardial infarction (MI). The paper analyses the possibilities to improve the results of AAA surgery by means of the patients selection and effective preparation before the elective surgery. The risk factors and concomitant diseases of patients suffering from the AAA, the elective and emergent surgery ratio and the operative mortality are referred. The results of surgical treatment before and after accepting the modern CHD management algorithm are compared. METHODS: The present study is a retrospective analysis of the data of 343 consecutive patients with AAA operated on during the 20-years period from 1 January 1979 to 31 December 1998. The 1st group of 249 patients operated on during the 18-years period from 1. January 1979 to 31 December 1996 was not subjected to special attention concerning the CHD and was compared with the 2nd group of 93 patients operated on from 1 January 1997 to 31 December 1998. In this group of patients special attention was focused on the improvement of surgical techniques, intensive care and comprehensive diagnostics, evaluation and proper management of the concomitant CHD. RESULTS: The mortality rate of the elective surgery in the 1st group was 5.5%, in the 2nd group decreased to 3.6%, the difference was not statistically significant. Evident improvement of the results was apparent in emergency operations for ruptured AAA. The mortality rate in the 1st group of 76% dropped to 40% in the 2nd group (p < 0.05). The improved policy in the management has lead to statistically significant decrease of the MI incidence in the perioperative period (87.2% to 28.5%, p < 0.001). CONCLUSION: The improved diagnostics, selection of patients with special concern to the CHD and management of the patients before surgery, improved surgical techniques and intensive care lead to evident improvement of the results in the surgical management of the AAA. This fact is confirmed by improved results of the 2nd group of patients because of improved CHD management algorithm. (Tab. 5, Fig. 1, Ref. 35.)

[Prevention and treatment of prosthesis-related sepsis in vascular surgery]. / Prevencia a liecba protetickej sepsy v cievnej chirurgii.

BACKGROUND: The first synthetic vascular prosthesis have been implanted 47 years ago. 5 years after have been referred the first aortoenteric fisula in connection with the synthetic vascular prosthesis implantation. MAIN PURPOSE AND STARTING POINTS (OBJECTIVES): The incidence of the infection and septic postoperative complications after vascular surgery was relatively high in the past. Several authors note a reduction in the incidence with experience. Another change has been widely noted recently concerning the incidence of various strains of bacteria isolated from the infected tissue and infected prostheses. The most common strain at present is St. epidermidis, known in the past as a saprophyte. There have been also changed the methods of diagnosis and the management policy. The authors of the present paper has been tried to summarize the knowledge in this field on the background of their own experience. They have summarized the clinical classification, bacteriology and the pathophysiologic mechanism of the infection, the most common clinical features, basic diagnostic possibilities, prophylactic and therapeutic policy in the postoperative septic complications, as well.

[Takayasu arteritis and the algodystrophic syndrome]. / Takayasuova arteritída a algodystrofický syndróm.

Algodystrophic syndrome represents a group of symptoms involving pain and oedema of the affected extremity, with movement disorders, vegetative and vasomotor disturbances and focal osteoporosis development. The key role in the pathogenesis of the syndrome plays intensive and prolonged stimulation of pain receptors. The authors present a case report of 47 years old woman with Takayasu's arteritis complicated by skin defects on right instep and sole with consequent development of algodystrophic syndrome on both lower extremities. Combined influence of both types of nociceptive stimuli is demonstrated, ischaemic-obstruction of peripheral arteries and alterative-skin defects. (Fig. 3, Ref. 13.)

A modified supraclavicular approach for resection of a subclavian aneurysm.

The incidence of right aneurysms of the innominate or subclavian arteries is not very high. The majority of these aneurysms is placed in the distal segment of subclavian arteries. These aneurysms are involved in the complex of the thoracic outlet compressive neurovascular syndrome, especially in occurrence of the cervical rib. All aneurysms in this region can rupture and embolize. This is the main purpose of surgical management of this clinical entity. The aim of this study is to refer an interesting case history of a relatively young patient with a right aneurysm of the middle portion of left subclavian artery. The patient had no known vascular risks and the aneurysm was asymptomatic, the only sign was the visible and palpable pulsating mass over the left clavicle. The aneurysms of the middle and central portion of the left subclavian artery are usually explored through the left high posterolateral thoracotomy. The authors refer their experience with the use of a modified technique of exposure--supraclavicular (or transclavicular) incision with the subperiostal resection of the medial portion of the clavicle. This approach affords excellent exposure and a safe surgical procedure. This approach has been described in 1988 by H. Machleder. The advantage of this approach is a diminished risk of surgery in comparison with the transthoracic approach. The authors suppose, however, that it can be useful in traumatic or occlusive lesions, as well.