Hybrid treatment of the infected carotid-subclavian graft complicated by the septic haemorrhage

The paper presents combined method of treatment to 90-year-old female, admitted with the hemorrhage from the chronic purulent fistula in her left neck in the incision post left carotid to subclavian artery bypass in 1971. In the vascular center where she was operate on (outside of Poland) it was suggested, that she should undergo graft excision because of the possibility of graft blow and subsequent exsanguinations as the most severe complication but finally she gave up. In the new circumstances, in the face of no-indirect threat to life, there was urgent need for surgical treatment. Being aware of multiple risk factors from age, general condition and changes in local, developed the concept of radical, yet more saving, to-step procedure. At first by percutaneous means covered stents were implanted into the places of vascular anastomoses, followed by angioplasty of the narrowed origin of left subclavian artery. In the second phase, after a few days, the infected prosthesis was excised and the cavities in the arterial walls of the two arteries were provided. Before, during and after surgery targeted antibiotics were used with classic antiplatelet therapy regimen. Post-operative course was uneventful. The wound healed properly. Which currently consisting of 93 years, as for her age, she in excellent condition overall. There were no signs of infection recurrence observed

Original method of treatment applied to the patent with rupturing thoracoabdominal aortic aneurysm, multi-organ insufficiency and advance limb ischemia

W pracy przedstawiono niekonwencjonalny sposób leczenia chorego z pękającym tętniakiem aorty piersiowo-brzusznej II typu Crawforda, niedomogą wielonarządową oraz głębokim niedokrwieniem kończyn dolnych, spowodowanym rozwarstwieniem i zakrzepicą tętniaka w segmencie podnerkowym. Ze względu na zbyt wysokie ryzyko powikłań, wcześniej zrezygnowano z operacji resekcyjnej. Nowe okoliczności — pękanie tętniaka i bóle spoczynkowe kończyn wymusiły podjęcie próby oryginalnego leczenia. Z kilku protez naczyniowych skonstruowano układ, który wszyto do worka zakrzepniętego tętniaka aorty brzusznej. Odnogi przeszczepów zespolono z tętnicami nerkowymi, krezkową górną i obiema udowymi. W kolejnym etapie, przez ramię techniczne wszytego układu, sforsowano miejsce niedrożności i wprowadzono do aorty piersiowej wielosegmentowy stent-graft. Umożliwiło to wyłączenie tętniaka i odtworzenie napływu krwi do nerek, trzewi oraz kończyn dolnych. Na zakończenie niezbędne okazało się wykonanie dodatkowego zespolenia krezkowo-trzewnego. Przebieg pooperacyjny, poza przejściowym pogorszeniem funkcji nerek, był niepowikłany. W rok po operacji stan pacjenta był zadowalający. W dostępnej bibliografii nie ma opisu podobnego przypadku.Presented is nonconventional method of treatment of patent with rupturing thoracoabdominal aortic aneurysm (Crawford type II), with multi-organ insufficiency and critical ischemia lower extremities due to dissection and thrombosis in the infra-renal part of an aneurysm. Due to high risk for surgery the patient was previously disqualified from the surgical treatment. On the new circumstances, that is the rupturing of an aneurysm and rest pain extremities forced us to try, to give it a chance for original method of treatment. From several vascular prostheses a special system of branches was constructed, it was then anastomosed by one and into coagulated sack of infra-renal part of an aneurysm. The branches of this system were then anastomosed with the renal arteries, mesenteric superior artery and with both common femoral arteries. In the second step through the technical branch of the system (conduit), the multi-segmented stent-graft was forced through the occluded aneurysm, thus restoring the blood flow to the kidneys, abdominal viscera and lower extremities. At end of the procedure there was a need for additional mesenteric to celiac anastomoses. In postoperative period transient functional renal impairment was observed, with no other adverse complications. After 12 months follow up the patient was found in the satisfactory condition. In bibliography there is a lack of description of the similar case

Multivariate logistic regression for planned versus non-planned dialysis start.

<p>Pseudo r2 = 0.26.</p

Type of dialysis access at first dialysis session accordingly with different studied subgroups.

<p>Abbreviations: ER+P, early referral and planned patients; ER+NP, early referral and non-planned patients; LR+P, late referral and planned patients; LR+NP, late referral and non-planned patients. PD, peritoneal dialysis; HD, hemodialysis; AVF, arterio-venous fistula. Figure represents a diagram of bars showing the different types of accesses at first dialysis session. Accesses were as follows for the total population: 34.5% AVF, 8% peritoneal catheter, 8.5% temporal hemodialysis catheter and 49% permanent HD catheter. For ER+P: 77% AVF, 21% peritoneal catheter, no temporal hemodialysis catheter and 2% permanent HD catheter. For ER+NP: 0.8% AVF, 2.6% peritoneal catheter, 9% temporal hemodialysis catheter and 88% permanent HD catheter. For LR+P: 89% AVF, 8% peritoneal catheter, no temporal hemodialysis catheter and 3% permanent HD catheter. For LR+NP: 0.4% AVF, 1% peritoneal catheter, 18% temporal hemodialysis catheter and 80% a permanent HD catheter.</p

Characteristics of patients with early referral (>3months) to Integrated Care Settings clinics follow-up according to planning of dialysis start.

<p>Characteristics of patients with early referral (>3months) to Integrated Care Settings clinics follow-up according to planning of dialysis start.</p

Clinical characteristics according to planning of dialysis start.

<p>Clinical characteristics according to planning of dialysis start.</p

Reasons for non-planned start and need of urgent dialysis start.

<p>Reasons for non-planned start and need of urgent dialysis start.</p

Peritoneal dialysis (PD) incidence (%) according with different studied subgroups.

<p>Maximum PD incidence was observed in the optimal care treated patients group being 22%. PD ranged 18% in the planned dialysis start, 16% in the early referred patients, 12% at modality information provision, 6% in the non-planned dialysis start, 5% in the late referral and no PD was observed if never previously informed. PD at the first dialysis session occurred in 8% and as first chronic RRT in 11% of the total studied population.</p

Patients Flowchart for clinical study evaluation.

<p>Abbreviations: ER, early referred patients; LR, late referred patients; P, planned dialysis start patients; NP, non-planned dialysis start patients; ER+P, early referral and planned patients; ER+NP, early referral and non-planned patients; LR+P, late referral and planned patients; LR+NP, late referral and non-planned patients. A total of 626 patients started dialysis in 2012 from 25 Integrated Care Setting Clinics in Poland, Hungary and Romania at Diaverum Renal Services but only 547 were evaluated after excluding patients returning from a previous kidney transplantation (n = 23) and from one center with incomplete data (n = 56). Evaluated patients were primarily divided into two groups according with type of referral being 281 patients ascribed to the early referral and 266 patients into the late referral. Both groups were secondarily divided into another two groups each, depending on type of dialysis start. 168 patients were considered as early referred and with a planned dialysis start, 113 patients were considered as early referred but with a non-planned dialysis start, 63 patients were considered late referred but with planned dialysis start and 203 patients were late referred and had non-planned dialysis start. Planned dialysis patients were 231 of the total population and non-planned dialysis start were 316.</p