Reduction of arteriovenous access blood flow in kidney transplant patients.

INTRODUCTION: Cardiovascular disease is the most frequent cause of death in kidney transplant patients. High-flow arteriovenous fistula (AVF) increases cardiac output and may contribute to hyperkinetic heart failure. AVF follow-up is not implemented in kidney transplant patients. The aim of this study was to reduce AVF blood flow in a group of patients with a high-flow AVF following kidney transplantation to reduce cardiac strain. METHODS: This prospective study was performed in kidney transplant patients who had a vascular access created before transplantation. The AVF of these patients was examined by ultrasound with a focus on AVF flow and brachial artery size. If high-flow AVF was detected, flow reduction was performed in the indicated group of patients. RESULTS: The study examined 164 patients, of whom 24 had a hyperfunctional AVF (14.8%). A total of 16 AVF flow reductions were performed, which led to an average decrease in cardiac index by 0.77 L/min/m2. Primary patency of the reconstructions was 93.33% after 12 months. All patients experienced a subjective improvement in dyspnea. CONCLUSION: Reduction in AVF flow leads to an improvement in the quality of life of kidney transplant patients. Maintaining a functional AVF is beneficial, especially for patients after repeated surgeries, where the option of creating an autologous AVF is limited.

How to proceed with a patent popliteal artery aneurysm below the chronic superficial femoral artery occlusion?

INTRODUCTION: The indications for popliteal artery aneurysm treatment are clear. In aneurysms with patent inflow and outflow arteries, the risk of peripheral embolisation from a mural thrombus is high and the treatment, mostly a vascular intervention, is focused on preventing this extremity-threatening complication. It is unclear, however, how high the risk of peripheral embolisation is and how to proceed with a patent popliteal artery aneurysm fed by the deep femoral artery when the superficial femoral artery is chronically occluded. METHODS: All patients diagnosed with popliteal artery aneurysm between 2015 and 2019 were searched in the database of the Department of Surgery II of University Hospital Olomouc. Patients with a patent popliteal artery aneurysm and chronic superficial femoral artery occlusion in the ipsilateral extremity were selected. RESULTS: We diagnosed 66 patients with 85 popliteal artery aneurysms. Four patients had a patent popliteal artery aneurysm and chronic superficial femoral artery occlusion in the ipsilateral extremity. In these patients, conservative treatment was indicated after the diagnosis was determined. In three patients, no clinically obvious complication of the popliteal artery aneurysm occurred. In one patient, popliteal artery aneurysm thrombosis occurred after a follow-up of 21 months, leading to a shortening of his calf claudication distance and limiting the patient. CONCLUSION: Our experience with this small group of patients shows the possibility of primary conservative treatment in patients with a patent popliteal artery aneurysm below the chronic superficial femoral artery occlusion site. Aneurysm thrombosis can be expected during follow-up. Patients in whom the thrombosis leads to limitations are indicated for surgical intervention. The risk of peripheral embolisation from the mural thrombus cannot be excluded with certainty. Further studies involving large groups of patients are needed to provide a more precise recommendation.

Iatrogenic thoracic aortic injury in esophagectomy - a case report and literature review.

INTRODUCTION: This case report describes bleeding from an iatrogenic thoracic aortic injury in minimally invasive thoracoscopic esophagectomy. CASE REPORT: A 53-year-old man underwent neoadjuvant radiochemotherapy for adenocarcinoma of the esophagus with positive lymph nodes. PET/CT showed only a partial response after neoadjuvant therapy. Minimally invasive thoracoscopic esophagectomy in the semi-prone position with selective intubation of the left lung was performed. However, massive bleeding from the thoracic aorta during separation of the tumor resulted in conversion from minimally invasive to conventional right thoracotomy. The bleeding was caused by a five millimeter rupture of the thoracic aorta. The thoracic aortic rupture was treated by suture with a gore prosthesis in collaboration with a vascular surgeon. Esophagestomy was not completed due to hypovolemic shock. Hybrid transhiatal esophagectomy was performed on the seventh day after the primary operation. Definitive histological examination showed T3N3M0 adenocarcinoma. CONCLUSION: Esophagectomy for cancer of the esophagus is one of the most difficult operations in general surgery in which surgical bleeding from the surrounding structures cannot be excluded. Aortic hemorrhage is hemodynamically significant in all cases and requires urgent surgical treatment.

[Comparison between femoropopliteal bypass and subintimal recanalization in the treatment of critical limb ischaemia]. / Srovnání chirurgického bypassu a subintimální rekanalizace v lécbe kritické koncetinové ischemie.

INTRODUCTION: Revascularization of occlusion of the femoropopliteal region in patients with critical limb ischaemia (CLI) may be performed following the standard surgical approach using bypass with the saphenous vein graft (FP bypass). Unfortunately, up to 40% of these patients do not have a suitable saphenous vein. In these patients, revascularization may be performed surgically using bypass with prosthesis, allograft vein or by interventional radiological methods. An endovascular alternative is represented by subintimal recanalization (SIR). MATERIAL AND METHODS: Our prospective analysis evaluated mid-term results of revascularization using FP bypass or SIR in patients with occlusion of the femoropopliteal region and CLI. Our aim was to answer the question whether SIR can fully replace FP bypass in certain indications. From January 2010 to December 2012, 59 revascularizations of the CLI (Rutherford 5-6) with comparable SFA occlusion were performed. We monitored the immediate postoperative course, technical and clinical success and the process of healing of the defect. RESULTS: Healing of the defect was achieved in 78.6% of patients with FP bypass using the saphenous vein, in 62.5% of patients with FP bypass using prosthesis and in 64.9% of patients with SIR (P=0.578). When comparing the bypass group, which was subdivided into a group with revascularization using autologous vein and a group with revascularization using ePTFE prosthesis, with the SIR group, primary patency was evaluated. The results for vein 78.0% after 6, 12, 24 and 36 months, for prosthesis 74.5%, 55%, 55% after 6, 12 and 24 months, and for the SIR group 78%, 60%, 51.3% and 50.7% after 6,12,24 and 36 months. When comparing the results of the groups, no statistically significant difference was found (P =0.625). CONCLUSION: As expected, the most successful method of choice is revascularization by FPB using the saphenous vein. SIR and FP bypass using prosthesis had similar results with respect to healing of the defects.

[Hybrid procedures in the treatment of type IV and V thoracoabdominal aneurysms]. / Hybridní výkony v lébe torakoabdominálních výdutí typu IV, V.

OBJECTIVE: To evaluate our experience with hybrid endovascular and open surgical treatment of thoracoabdominal aneurysms. MATERIAL AND METHODS: Between 1996 and 2008 8 patients with thoracoabdominal aneurysm (6 Crawford type IV and 2 type V) from the total of 257 aortic aneurysms with elective endovascular repair were treated using hybrid procedure. A retrograde revascularisation of visceral and renal arteries through the open access and endovascular exclusion of aneurysms using a stent-graft were done. RESULTS: A primar technical success of the hybrid procedure was in all cases. There was no severe ischaemia of visceral organs, kidneys (no need of haemodialysis) or spinal cord (paraplegia). One patient died on an acute pancreatitis 14 postperative day. Further follow up (in range 16-52 months) showed henceforth a successful exclusion of all the aneurysms without evidence of endoleak and patency of all bypasses with a good function of revascularised organs. CONCLUSION: Owing to minimal haemodynamic load and technical simplicity with a short time of organ ischaemia hybrid procedure represents an acceptable possibility of type IV and V thoracoabdominal aneurysms repair.

[The infection of the arteriovenous hemodialysis access created with ePTFE prosthesis. Treatment based on experience or on modern examinations findings?]. / Infekce av spojky k hemodialze zalozené ePTFE interponátem. Lécba na základe zkuseností nebo podle nálezu moderních vyetrovacích metod?

The infected ePTFE prosthesis for hemodialysis threatens the patient with local complications such as occlusion, the tunnel infection and massive hemorrhage. These complications are associated with the loss of function of the fistula. Infected prosthesis can work as a source for metastatic infections (endocarditis, arthritis, pneumonia), and sepsis. In European countries, interposition of ePTFE graft usually represents the last option of angioaccess beside the catheterization of central venous system; hence attempts occur to maintain the fistula function despite the manifestation of infection. Authors evaluate the total graftectomy (TGE) and the partial graftectomy (PGE) on the basis of their knowledge and literature findings. They take a stand whether it is preferable to remove an infected graft according to experience or to proceed conservatively following the modern examinations (USG, microbiology, PET CT). According to the documented case-report they tend more to the solution based on experience. If the infection of graft is of gram-negative etiology the total graftectomy (TGE) is recommended.

[Infrarenal aortic graft infection]. / Infekce náhrad abdominální aorty.

INTRODUCTION: The incidence of vascular replacement infection is reported between 0.5-6.0%. The infection of aortal valve replacement is usually managed by its removal and axilofemoral reconstruction. Replacement removal and reconstruction in situ is another alternative. The aim of our work is to give the comparison of the results obtained with the extra-anatomic reconstruction and alternative techniques. MATERIALS AND METHODS: Between January 1987 and August 2008 1324 abdominal aortal replacements were performed in our department. In 14 patients (1.05%) the infection of the replacement occurred; one of the patients was operated on in another hospital. In eight patients axilobifemoral/axilopoplietal by-pass was applied (Group A). In two patients the whole replacement was removed together with in situ reconstruction (ISR) using a new bifurcation replacement. In two patients a partial resection of the replacement and the resected part substitution or femoro-femoral cross-over by-pass was performed. Three patients were treated with a total or partial replacement removal without the following reconstruction. RESULTS: In Group A no haemorrhage from the aortal stub occurred. The mean value of surgical management due to the replacement infection was 3.5 (1-6). For Group B the number was 5 (1-16). In Group B there were three reinfections, in Group A none. In both Group A and B one patient died; one thigh amputation was necessary in Group A, two in Group B. CONCLUSIONS: The partial or total removal of the replacement followed with in situ reconstruction is considered a safe and good method solving the infection of the aortal replacement in some patients. The results are comparable to those obtained with extra-anatomic reconstruction that remains the method of choice in patients with virulent infections.

Peroneal nerve injury during varicose veins surgery.

AIM: The aim of the presented work was to assess the causes of injury to great nerves during varicose vein surgery and comment on the consequences. METHODS: This was a retrospective study of 2344 patients operated on for primary varicose veins between the years 1980 and 2005. RESULTS: In three patients out of 2344 the peroneal nerve was injured. The three patients underwent neurosurgery. In the first patient transplantation of the sacral nerve was performed. In the second patient the nerve was released from ligatures, and in the third patient the nerve was first released from the cicatrice and the transposition of the tendon of the posterior tibial muscle followed. All three patients went through intensive rehabilitation. The first patient still wears peroneal splint, the limb is atrophic. In the second patient the function has been well restored and he is not disabled anymore. However, the restitution of the lower limb function is not sufficient for him to work as a teacher of physical education. The third patient still suffers from serious paresis of the peroneal nerve. CONCLUSIONS: Even a frequent and relatively simple intervention such as varicose vein surgery may be accompanied by serious complications affecting patients for the rest of their lives. Serious motor nerve injuries are encountered only in operations in the popliteal fossa and the fibula head. Complications are more frequent when operations are performed by young general surgeons than when they are performed by an experienced surgeon or an expert in vascular surgery. The affected patients should be referred for neurosurgery; however, results are unpredictable. In spite of an intensive rehabilitation and possible plastic surgery the patients are permanently affected.

[Surgery of the low extremity varices as a part of a same-day surgery programme]. / Operace varixu dolních koncetin v rámci jednodenní chirurgie na klinickém pracovisti.

INTRODUCTION: One-day surgical methods lower the procedures costs as well the need for urgent beds in surgical clinics. The varix operation seem to be the optimal diagnosis suitable for the one-day surgical procedure. AIM: The aim of this work is to assess a feasibility of the one-day surgery for the low extremities varix operations. METHODOLOGY: During the period starting in January until December 2003, 98 extremities were operated for varices. The surgical procedure was the same for the hospitalized as well as for the patients assigned to the one-day surgery programme. Each patient was examined with the duplex ultrasound prior to the surgery, after the surgery a compressive bandage was indicated. RESULTS: We operated 98 extremities in 96 patients suffering from varices during the period from January 2003 to December 2003. The trial group consisted of 67 females and 29 males aged 21-79 years of age (the average of 45.3 years). According to the CEAP classification, 57 extremities (58.2%) were assigned to the C2 category, 30 extremities (30.6%) to the C3 category, 6 extremities (6%) to the C4 category, 4 extremities (4%) to the C5 category and one extremity (1%) to the C6 category. 14 extremities in the group were operated due to the disease relapse. 62 patients (i.e. 65%) were released for the home-care on the day of the operation, 27 patients (28%) were released the following day. One patient was hospitalized for two days, three patients for three days, one patient for four days and two patients for five days. 91 out of the total 98 extremities (i.e. 93%) underwent the one-day surgery. CONCLUSION: Although some patients require hospitalization, the varix surgery is safe and suitable for the one-day surgery. A thorough preoperative examination as well each patient's cooperation are both very important.

[Solid papillary neoplasia of the pancreas--case report]. / Solidní papilární neoplazie pankreatu--kazuistika.

Solid papillary neoplasia of the pancreas is a rare tumour that occurs most commonly in young women. This tumour has low malignant potential and favourable prognosis following surgical resection. Therefore it is mandatory to distinguish this tumour from other types of pancreatic tumours. The paper reports the case of a 31-year-old woman with a large solid papillary neoplasia of the head of pancreas where successful pancreatoduodenectomy was performed.

[Blunt injuries of the iliac artery--case reports]. / Tupé poranení ilické arterie--kazuistické sdelení.

The authors describe three patients with blunt injuries of the iliac artery. They mention the causes and mechanism of their development, symptomatology, diagnosis and treatment. They draw attention to early diagnosis and an active approach; they discuss the type of vascular prosthesis and mention alternative therapeutic procedures. In all patients surgical treatment (resection and prosthesis of the affected part) led to favourable long-term results.

[Effect of portosystemic anastomosis on the degree of splenic inhibition]. / Vliv portosystemické spojky na míru splenického útlumu.

UNLABELLED: Secondary hypersplenism is a well-known complication of portal hypertension. Reduced platelet count is a more alarming sign for the physician than risk for the patient. Improvement of thrombocytopenia is urgent, when portal hypertension with splenomegaly and thrombocytopenia presents with life-threatening haemorrhage from gastroesophageal varices. In this case, treatment aimed at stopping the bleeding may be more beneficial than any intervention on the spleen. In this study, we evaluated long-term effects of an elective distal splenorenal shunt or small diameter H-shunt on splenomegaly and thrombocytopenia in 26 patients with portal hypertension operated for repeated bleeding from oesophageal varices. 25 patients had splenomegaly and 16 patients had thrombocytopenia before shunting. Surgery corrected splenomegaly in 16 patients (64%), platelet counts increased in 13 of 16 patients with thrombocytopenia (81.2%). CONCLUSION: Selective or partial portal decompression is sufficient to alleviate thrombocytopenia and splenomegaly associated with portal hypertension.

[Are problems with portosystemic shunts still a reality and is shunt selectivity the deciding factor for justifying its use?]. / Je problém portosystémové spojky stále aktuální? A je selektivita spojky rozhodujícím faktorem pro její oprávnenost?

OBJECTIVE: The objective of the work is detailed evaluation of portosystemic shunts. The criterium of suitability and justification is their selectivity and preservation in the course of time. METHODS: The authors used a clinical group of patients who had either a Warren shunt or a mesocaval H-shunt with a limited blood flow (diameter 8 mm). In these patients the blood flow was assessed by dopplerometry in the portal vein and before the shunt, i.e. in the lienal or possibly mesenterial vein. RESULTS: Of 32 shunts made during the last five years it was possible to make 12 assessments (8 Warren and 4 H-mesocaval shunts). An adequate decline in the blood flow in the portal vein was recorded and a corresponding increase in the lienal or mesenteric vein. Even after one year no marked drop in the flow through the portal vein was recorded. CONCLUSION: A distal Warren shunt and H-mesocaval shunt with a restricted blood flow preserve the signs of selectivity even after one year. An adequate blood flow through the liver is also preserved. From this aspect selective shunts are still suitable treatment of portal hypertension. Obviously correct indication is the basic prerequisite of success.

[Use of the internal jugular vein as the outflow tract in arteriovenous shunts for hemodialysis] . / Pouzití vena jugularis interna jako výtokového traktu u arteriovenózních spojek k hemodialýze.

In the presence of a long stenosis or an occlusion in the axillo-subclavian venous tract, the vena jugularis interna can be useful as an outflow tract in arteriovenous shunts for haemodialysis. The use of this vein was indicated for primary shunts with vascular grafts and also for treatment of venous hypertension of the upper limb. In both these indications a 6 mm ePTFE (GORE) prosthesis was used. Regular follow-up by Doppler ultrasound was useful for diagnosis of a developing of stenosis in these shunts. With early treatment of these stenoses the long-term function of these shunts could be ensured.

[Classic carcinoids of the appendix]. / Klasické karcinoidy apendixu.

Nine classic carcinoids smaller than 2 cm, situated elsewhere than at the base of the appendix have been diagnosed in the Department of Pathology of the University Hospital in Olomouc during the period from 1994 to 1999. Appendectomy including removal of the mesenteriolum was performed in all cases. The literature mentions favourable prognosis of patients with small appendiceal carcinoids--100 per cent 5-year survival rate. Tumours greater than 2 cm recur and metastasise. These tumours require oncological therapy in cases with unresectable metastases. This worsens the 5-year survival rate to 21-42%.

[Inflammatory (infectious) complications in arteriovenous fistulae for hemodialysis]. / Zánetlivé (infekcní) komplikace arteriovenózních (av) spojek k hemodialýze.

Angioaccess procedures for hemodialysis over a 12-year period were retrospectively reviewed to ascertain the frequency of infectious complications. A total of 571 angioaccess procedures were performed including 88 e-polytetrafluoroethylene (ePTFE) grafts. Early infectious complications occurred only in 5 autologne fistulae. Late infectious complications developed in 2.3% autogenous fistulae and in 7.95% ePTFE grafts. Infected arteriovenous fistulae can be the cause of further complications (thrombosis, bleeding, aneurysm, sepsis) and call for surgical repair.

[Infected arteriovenous fistulae for hemodialysis]. / Infikovaná arteriovenózní spojka k hemodialýze.

Angioaccess procedures for hemodialysis over a 12-year period were retrospectively reviewed to ascertain the frequency of infectious complications. A total of 571 angioaccess procedures were performed including 88 e-polytetrafluoroethylene (GORE) grafts. Early infectious complications occurred only in 5 autogenous fistulae. Late infectious complications occurred in 2.3% autogenous fistulae and in 7.95% ePTFE grafts. Infected arteriovenous fistula can be the cause of further complications (thrombosis, bleeding, aneurysm, sepsis) and demands surgical repair.

[Late infections of aortic prostheses]. / Pozdní infekce aortální protézy.

The authors present their experience in late infection of aortoilliacofemoral reconstruction by means of the Dacron vascular prosthesis. They found such complication in 8 of 620 (1.5%) reconstructions in that region in period 1988-1998. There is essential position of scintigraphy (Le 99mTc-HMPAO) and CT in diagnostic of location and extent of an affection. Conservative approach and local surgery were not permanently successful. The alternative approach is radical removing of the whole graft. The alternative of aortofemoral reconstruction is axillobifemoral bypass using ePTFE graft in case of an infection of the bifurcation graft.

Aneurysm of the subclavian artery.

In this case report about a female patient with a true aneurysm of the left subclavian artery (SAA), the authors would like to present the symptoms, possibilities of diagnostics and management of this rarely appearing pathology. The diagnosis of a randomly found aneurysm in a symptom free patient was confirmed by spiral AGCT. Classical surgical procedure was indicated for the patient. With a combined supra- infraclavicular approach the partial resection of the aneurysm and its revascularization by a ePTFE prosthetic interposition were performed. A histological investigation showed nonspecific changes in the aneurysm wall. Two years after the operation the patient is without any complications and with complete functional vascular reconstruction and optimal limb function.