Tibiopedal access in patients with lower limb peripheral artery disease

Introduction: Peripheral artery disease (also known as PAD) is a common circulatory problem in which narrowed arteries reduce blood flow to the limbs. Atherosclerotic vascular disease affecting the lower extremities is the most common form of peripheral vascular disease. Patients with critical limb ischemia have significant rates of amputation. However, percutaneous options for minimally in­vasive revascularization exist for most of these patients. In recent years, the retrograde tibiopedal ap­proach is increasingly being used for revascularization of complex chronic total occlusions.Methods and materials: In cases where traditional ipsilateral antegrade or contralateral cross over approaches fail, pedal access approaches utilizing the dorsalis pedis, posterior tibial, or even pero­neal arteries (most difficult of the three) have been used. The technique is performed by ultrasound guidance using arterial introducers, hydrophilic wires and vasodilators which allow for better access and easier manipulation.Results: In this particular study from a total of 39 cases, a total of 34 cases (87,2%) were successful. Access through ATA was used in 26 of the patients and through PTA in 6 patients. Recanalization of total occlusions was achieved in 14 cases.Conclusion: Preventing amputations can potentially save patient lives and improve quality of life. Tibiopedal access has emerged as an important tool to facilitate successful revascularizations. One of the major advantages of retrograde tibiopedal access is that it allows quick therapy and short pro­cedure time with less observation time in the hospital. The procedure can be used as a viable alterna­tive to antegrade access interventions. Further well-conducted studies are crucial in generating more high-quality evidence in the field of critical limb ischemia management

Drainage of abdominal abscesses in patients with Crohn`s disease

Introduction: Crohn`s disease is an inflammatory bowel disease which can affect any part of the gastrointestinal tract. It is characterized with intramural inflammation of the bowel wall. This leads to the formation of ulcers and fistulas. A further complication can be the formation of intra-abdominal abscesses. Such patients are most frequently treated via open surgery. However, with the development of percutaneous drainage for intra-abdominal abscesses a less invasive method is now available. As a result, open surgery can be delayed or avoided by using this minimally invasive method combined with antibiotic therapy.Materials and Methods: There are two patients in this case series - a 35-year-old male diagnosed with Crohn`s disease in 2010 and an 18-year-old male diagnosed in 2013. During the course of their condition they developed intra-abdominal abscesses. They were drained by inserting a 10 Fr catheter using the Seldinger technique under computed tomography control. This is a minimally invasive method which is quick, with a low risk for the patient, less expensive than open surgery and does not require prolonged hospitalization.Results: Drainage of the abscesses and antibiotic treatment allowed the bowel wall to heal and recover from the inflammation. After the successful drainage the catheters were removed without complications. There was no need for an open surgery intervention.Conclusions: Intra-abdominal abscesses due to active Crohn`s disease are challenging to treat successfully for both gastroenterologists and surgeons. Percutaneous drainage in combination with antibiotics should be the treatment of choice if the size and location of the cavity allows for it. If surgery is inevitable, then it must be delayed to lower the chance for any postoperative septic complications and to lower stoma rates

Respiratory Infections in Immunocompromised Patients

Introduction: Immunosuppressive treatment of patients undergoing organ transplantation, which is administered as a supportive therapy, often leads to severe, potentially life-threatening infections, which can be difficult to treat. Pneumocystis jirovecii and Cytomegalovirus (CMV) are some of the most common pathogens which cause pulmonary opportunistic infections in such patients.Materials and Methods:A 40-year-old man, who had undergone a kidney transplantation in May 2013 was subsequently treated with immunosuppressive drugs like tacrolimus, cellcept and corticosteroids for almost a year. The patient was then admitted to the Clinic of Pulmonology at the St. Marina University Hospital, Varna with complaints of fatigue, shortness of breath, high temperature and a hacking cough. Results: Diagnostic imaging showed infiltrative shades in both lungs. Sputum and blood culture tests yielded no isolated microbiological agents. Antibacterial therapy with Tienam, Targocid and Sumamed was initiated, however, there were persistent fatigue, febrility and a deteriorating respiratory insufficiency, which required the use of non-invasive ventilation. CT of the thorax showed changes, specific for a pneumocystic pneumonia. Consequently, Biseptol was added to the therapy. Serological tests confirmed the presence of CMV and a course of treatment with Cymevene was conducted. The patient improved substantially and was discharged and prescribed a home oxygen treatment for 3 months. His condition was influenced favourably by broad-spectrum antibiotics, antiviral therapy and non-invasive ventilation.  A CT scan was performed in February 2017 and it showed a residual emphysematous bulla in the third segment of the lung.Conclusion: Treatment with immunosuppressive drugs can be a risk factor for the development of serious opportunistic infections in patients who have undergone an organ transplantation. Such infections are not uncommon and they can be a determining factor for the following therapeutic behaviour