The consequences of covering the origin of the left subclavian artery by the coated part of the thoracic stent graft in patients with aneurysm or dissection of the descending aorta

Wstęp. Zastosowanie stentgraftów w leczeniu patologii aorty zstępującej jest metodą powszechnie uznaną. Implantacja stentgraftu, podczas której pokrywa się odejście lewej tętnicy podobojczykowej (LSA) może być przyczyną wystąpienia wielu powikłań, takich jak udar, niedokrwienie rdzenia kręgowego, niedokrwienie lewej kończyny górnej oraz struktur tylnego dołu czaszki. W poniższej pracy przedstawiono częstość występowania powikłań związanych z pokryciem LSA u 60 chorych, u których podczas implantacji stentgraftu do aorty piersiowej pokryto powlekaną częścią stentgraftu odejście lewej tętnicy podobojczykowej. Dodatkowo przedstawiono analizę związku pomiędzy częstością występowania powikłań a wiekiem chorych i typem patologii aorty zstępującej. Materiał i metody. Do badania zakwalifikowano 60 chorych, 12 kobiet i 48 mężczyzn, w wieku 23–83 lat. Średnia wieku wynosiła 56 lat. Spośród badanych 21 chorych operowano z powodu tętniaka prawdziwego, 9 z powodu tętniaka pourazowego, 22 z powodu rozwarstwienia aorty typu Stanford B i 8 z powodu rozwarstwienia typu Stanford A. Chorych oceniano pod kątem występowania udaru, niedokrwienia rdzenia kręgowego oraz objawów niedokrwienia struktur tylnego dołu czaszki oraz niedokrwienia lewej kończyny górnej. Częstość występujących objawów analizowano w podgrupach wyodrębnionych na podstawie patologii aorty będącej przyczyną operacji (tętniak prawdziwy, tętniak pourazowy, rozwarstwienie typu Stanford A i rozwarstwienie typu Stanford B) oraz w podgrupach wiekowych. Wyniki. Spośród 60 badanych chorych u żadnego pacjenta nie obserwowano niedokrwienia rdzenia. U 2 chorych (3,3%) odnotowano udar odwracalny (RIND) u 1 pacjenta (1,6%) — udar trwały. Objawy typowe dla zespołu podkradania, takie jak zawroty głowy, występowały u 10 (16,7%) chorych, zaburzenia równowagi u 2 (3,3%) chorych oraz osłabienie siły mięśniowej u 32 (53,2%) chorych, a gorsze ucieplenie dłoni u 26 (43,3%) chorych. W żadnym przypadku nie obserwowano bólu lewej kończyny górnej, ani spoczynkowego, ani wysiłkowego. Analiza statystyczna wykazała, iż nie istnieje związek pomiędzy wiekiem, ani typem patologii a częstością występowania powikłań. Wnioski. Pokrycie odejścia lewej tętnicy podobojczykowej jest procedurą bezpieczną. W większości przypadków chorzy nie wymagają operacji poprawiającej napływ do lewej tętnicy podobojczykowej. Acta Angiol 2011; 17, 4: 251–263Background. The usage of thoracic endografts in the treatment of thoracic aortic lesions is a universally recognized method. Intentional coverage of the left subclavian artery during deployment of the endograft could be associated with several complications such as stroke, spinal cord ischaemia, left arm ischaemia, and vertebrobasilar ischaemia. This study presents the incidence of complications associated with LSA coverage in 60 patients with LSA covered during placement of thoracic endograft. Additionally, the relationship between incidence of complications and factors such as age and type of pathology is analysed. Material and methods. Sixty patients were qualified to the study, 12 women and 48 men between the ages of 23 and 83 years. The mean age was 56 years. A total of 21 patients were operated on for true aneurysm, 9 for post-traumatic aneurysm, 22 for Stanford B dissection, and 8 for Stanford A dissection. Patients were assessed in terms of presence of stroke, spinal cord ischaemia as well as symptoms associated with left arm ischaemia and vertebrobasilar ischaemia. The incidence of present symptoms was analysed in separate subgroups based on the type of pathology of the aorta due to which patients were operated (true aneurysm, traumatic aneurysm, Stanford type A dissection, and Stanford type B dissection) and age subgroups. Results. In none of the 60 patients enrolled for the study spinal cord ischaemia was observed. Two cases (3.3%) of reversible stroke (RIND reversible ischaemic neurological deficit) and one case (1.6%) of stroke (complete ischaemic stroke CIS) were observed. Regarding symptoms typical for subclavian steal syndrome, dizziness occurred in 10 patients (16.7%), vertigo in 2 patients (3.3%), left arm weakness in 32 patients (53.2%), and coldness — in 26 patients (43.3%). Neither rest pain nor pain after exercise was observed in any case. Statistical analysis did not show any connection between the incidence of complications and age or type of pathology for which the patient had been operated. Conclusions. Planned coverage of the LSA is a safe procedure. In most of cases patients with covered LSA did not require any further reconstructions. Acta Angiol 2011; 17, 4: 251–26

Fulminant course of visceral malperfusion due to type B aortic dissection

Rozwarstwienie aorty typu B może być skutecznie leczone zachowawczo w wielu niepowikłanych przypadkach i odsetek ten może wynosić nawet 90% chorych. Wystąpienie dodatkowych objawów bólowych z zakresu klatki piersiowej lub jamy brzusznej powinno nasuwać podejrzenie powikłań naczyniowych. Niedokrwienie trzewi jamy brzusznej jest obserwowane w około 30% przypadków rozwarstwień. Jednoczesne wystąpienie objawów w klatce piersiowej i jamie brzusznej obserwowane jest wyjątkowo rzadko. Mężczyzna 54-letni został przyjęty do kliniki w trybie nagłym z podejrzeniem rozwarstwienia aorty. W wykonanej angiotomografii stwierdzono rozwarstwienie aorty piersiowej rozpoczynające się tuż poniżej lewej tętnicy podobojczykowej i sięgające tętnic biodrowych zewnętrznych. Chory miał wysokie nadciśnienie tętnicze. Jednocześnie stwierdzono objawy zapalenia otrzewnej i radiologiczne cechy perforacji przewodu pokarmowego. Wykonano pilnie laparotomię stwierdzając ogromny ubytek ścian części przedodźwiernikowej żołądka i niedokrwienie śluzówki z plackami martwicy sięgające połowy jego trzonu. Wykonano resekcję żołądka sposobem B II na pętli Laheya. W badaniu histopatologicznym nie znaleziono wrzodu trawiennego. W przebiegu pooperacyjnym obserwowano ponownie objawy niedokrwienia jelit pod postacią obkurczenia pętli doprowadzającej zespolenia . Chory otrzymywał antybiotyki i całkowite żywienie pozajelitowe, jednak jego stan nie ulegał poprawie. Dlatego pomimo objawów zakażenia zdecydowano się na implantację stentgraftu aortalnego zamykającego wrota rozwarstwienia. Procedura ta zmieniła przepływ w aorcie piersiowej i poprawiła napływ do tętnic jamy brzusznej. Jednak chory był operowany jeszcze dwukrotnie z powodu postępującej martwicy jelit, szczególnie w okolicy wykonywanych zespoleń jelitowych i tworzących się przetok jelitowych. Ostatecznie pacjent wyzdrowiał po trzech miesiącach od momentu przyjęcia do kliniki. W trakcie pobytu przebył także udar mózgu.Rozwarstwienie aorty typu B powikłane niedokrwieniem trzewi jamy brzusznej wymaga pilnego leczenia chirurgicznego. Założenie stentgraftu aortalnego wydaje się złotym środkiem w takiej sytuacji. Leczenie to powinno wyprzedzić powstanie martwicy ściany jelit i zależne od tego powikłania septyczne. Wydaje się, że odzyskanie kanału prawdziwego poniżej założonego stent-graftu aortalnego może wymagać czasu, gdyż obkurczenie się kanału fałszywego wypełnionego już skrzeplinami nie występuje bezpośrednio po leczeniu endowaskularnym. Aortic type B dissection can be treated conservatively in up to 90% of uncomplicated cases. Additional symptoms comprising of the pain in the thorax and abdominal cavity may suggest vascular complications. Visceral ischemia is observed in about 30% of aortic dissections. Synchronous symptoms in the thorax and abdomen are very rare situation. A 54-year old male patient was admitted to the clinic on duty with diagnosis of aortic dissection. Angiotomography proved a dissection starting just below the origin of the left subclavian artery and running along the aorta to the external iliac arteries. The patient presented also with very high systemic pressure and abdominal symptoms of diffuse peritonitis. Plain abdominal x-ray proved perforation of his gastroalimentary tract. Emergency laparotomy was performed disclosing a vast defect of gastric walls in the prepyloric region and visible ischemia of mucosa with patches of necrosis reaching up to the half of the stomach. B II resection was performed with anastomosis of the stomach stump to the small intestine on so-called Lahey loop. Histological evaluation did not prove the existence of peptic ulcer. In the postoperative period ischemia of the intestines was observed again. The afferent loop of gastrointestinal anastomosis was shrunken due to this fact. Patient received wide spectrum antibiotics and was maintained on total parenteral nutrition. Apart from this treatment the state of the patient did not change. It was decided that closure of the entry tear in the thoracic aorta was the only way to restore a proper blood flow in it. Aortic stent-graft was implanted to the thoracic aorta descending to the level of the celiac trunk despite the symptoms of septicemia. This endovascular procedure changed the blood flow in the thoracic aorta and improved the inflow to visceral arteries but the patient was operated two more times because of progressing necrosis in the vicinity of intestinal anastomoses with fistulae formation. Finally the patient recovered within three months since admission. He also experienced stroke during his hospital stay. Type B aortic dissection complicated with visceral ischemia requires an urgent surgical treatment. Aortic stent-graft placement seems to be the gold standard in such cases. This treatment should precede formation of intestine necrosis with fistulae and subsequent septic complications. It seems that regaining of the true channel below the stent-graft may require certain time for the shrinking of the false one filled with thrombi does not appear just after the endovascular procedure.

Ultrasound-guided foam sclerotherapy of great saphenous vein with 2% polidocanol – one-year follow-up results

Introduction : Ultrasound-guided foam sclerotherapy (UGFS) of varicose veins is a useful treatment option. It is a relatively safe method in the case of limited, small varicose veins. In theory, a justified concern could be raised that the injection of an active drug into the large superficial venous vessels may potentially cause life-threatening consequences. Aim : To assess the safety and efficacy of UGFS using a 2% solution of polidocanol (Aethoxysklerol 2%) in the case of great saphenous vein incompetence. Material and methods : Fifty-two patients with great saphenous vein incompetence underwent ultrasound-guided foam sclerotherapy. The efficacy criterion was the elimination of reflux measured ultrasonographically and withdrawal or decrease of complaints: 1 week, and 1, 3, 6 and 12 months after the treatment. Complications of sclerotherapy were reported during follow-up. Results : Decrease or withdrawal of complaints of chronic venous insufficiency was reported in 96% of cases (50 patients). Disappearance or decrease of varicose veins was noted in all patients (100%). During examination after 12 months, full success of ultrasound was achieved in 38 (73%) cases, and 11 (21%) patients presented a partial desired effect according to the consensus from Tegernsee. Persistence of reflux longer than 1 s in the treated great saphenous vein was reported in 3 (6%) cases. Serious complications, such as deep vein thrombosis, pulmonary embolism, dyspnea, anaphylaxis, or neurological abnormalities, were not recorded. Conclusions : Ultrasound-guided foam sclerotherapy of incompetent great saphenous vein and varicosities with 2% polidocanol was found to be an effective and safe method of treatment during 1 year of observation. However, longer observation is necessary

Time-resolved contrast-enhanced MR angiography : value of hemodynamic information in the assessment of vascular diseases

Background: To assess the quality of images obtained from time-resolved MRA together with the accuracy of this technique in diagnosing vascular diseases and the usefulness of haemodynamic information provided by this method. Material/Methods: The study group included 120 patients with different vascular pathologies excluding of intracranial vessels. All patients underwent time-resolved MRA on 1.5T unit. Results were correlated with other imaging techniques: DSA (n=36), CTA (n=28), Doppler ultrasound (n=71) and intraoperative findings (n=10). Independently, two radiologists evaluated the MRA studies assessing the quality of the images in a 3 point scale (3 - good, 1 - poor), as well as the presence or absence of haemodynamic information (3 - relevant dynamic information, 2 - irrelevant dynamic information, 1 - lack of dynamic information) for different vascular pathologies. Results: Mean quality of MRA examinations was 2.94 (reader A and B) and was similar for different pathologies (kappa value =0.757). The mean grading (reader A and B) for the presence of dynamic information was above 2 for the following pathologies: celiac artery branch pseudoaneurysm (3), vascular malformation (3), subclavian steal syndrome (2.5), Leriche's syndrome (2.25), aortic dissection (2.06), renal artery stenosis (2.03); and below 2 for: pelvic arterial occlusive disease (1.75), abdominal aortic aneurysm (1.31), carotid artery stenosis (1.1), thoracic aortic aneurysm (1.0). Kappa value was 0.802. The sensitivity was 95%, specificity 96% and positive predictive value 98%. Conclusions: Time-resolved MRA provides good quality images and enables reliable diagnosis of vascular pathologies

Location and Incidence Rate of Anastomotic Aneurysms – own Clinical Material and Literature Review

Anastomotic aneurysms occurs at various levels of arterial system. Determining their location and incidence rate required investigation of large patient clinical material. Material and methods. In the years 1989-2010 in local centre 230 anastomotic aneurysms were operated in 180 patients. Results. For 187 (81.3%) patients anastomotic aneurysms were localised in the groin, while for remaining 43 (18.7%) they occurred in other localisations. In aortic arch branch they occurred four times (1.7), in descending aorta - three times (1.3%), in abdominal aorta - 14 (6.1%) and in iliac arteries - 6 (2.6%). While for anastomosis with popliteal artery they were diagnosed in 16 (7%) patients. Own clinical material was compared with literature data. Conclusions. Anastomotic aneurysms in over 80% of cases occur in the groin, remaining percentage corresponds to other localisations

Anastomotic aneurysms- 20-years of experience from one center

Anastomotic aneurysms may develop after any type of vascular surgery, in different areas of the arterial system, and require reoperation. The frequency of occurrence of the above-mentioned is estimated at 1-5%. Material and methods. During the period between 1989 and 2010, 180 patients with 230 anastomotic aneurysms were subject to surgical intervention at the Department of General and Thoracic Surgery, Warsaw Medical University. The study group comprised 21 (11.7%) female and 159 (88.3%) male patients, aged between 30 and 87 years (mean age - 62.8 years). In relation to the number of anastomoses aneurysms were diagnosed in 2.1% of cases. Twenty-four (10.4%) patients were diagnosed with recurrent aneurysms. Results. Surgical procedures performed were as follows: artificial prosthesis implantation (119), reanastomosis (40), patch plasty (25), graftectomy (19), prosthesis replacement (9), and stent-graft (7) implantation. 195 (84.8%) aneurysms were subject to planned surgery, while 35 (15.2%) required emergency intervention. 77.8% of patients were diagnosed with aseptic aneurysms, while the remaining 22.2% with infected perioperative aneurysms. Good treatment results were obtained in 149 (82.8%) patients. Limb amputations were performed in 19 (10.5%) cases. Twelve (6.7%) patients died as a consequence of infection and general complications. Conclusions. Vascular reoperations are a difficult clinical problem and are burdened with a high rate of complications. The above-mentioned often require complex treatment, in order to improve therapeutic results

Results of General Surgical Treatment of Patients Over 80 Years of Age in Single-Site Experience

The aim of the study was to evaluate the results of general surgical treatment of patients over 80 years of age.Material and methods. Three hundred and four patients aged 80 to 105 years with general surgical disorders, treated in 2005-2009, were retrospectively included in the study. The collected information included demographic data, coexisting diseases, the mode of admission, the diagnosis, the method and result of treatment, and also potential complications and 30-day mortality. The data were subjected to statistical analysis.Results. The study group included 186 women and 118 men. Two hundred patients (65.8%) were admitted in an emergency setting. The most common causes of immediate hospitalisation were: mechanical ileus (26.5%), gastrointestinal bleeding (22%), trauma (16%), and gall-bladder disorders (8.5%). The remaining 104 (34.2%) patients were operated upon on an elective basis. An emergency operation was required by 121 (60%) of the patients admitted in an emergency setting; the remaining ones were treated conservatively. Hernia plasties (27.5%), cholecystectomies (15.3%), colorectal resections (13.2%), strumectomies (11.2%) and endoscopies (6.1%) predominated among elective surgeries.The total number of complications and mortality were 19.4% and 14.5%, respectively. The number of complications and mortality were significantly higher in the group of patients admitted in an emergency setting (25.5% and 20.5%, respectively) than in patients admitted on an elective basis (8.7% and 2.9%, respectively), p<0.01.The mean duration of hospitalisation was 9.7 days (1 to 60 days), with a small difference between the groups of patients treated on an elective and emergency basis (8.5 and 10.4 days), p=0.181.Conclusions. The results of surgical treatment of elderly patients do not significantly differ from the results of treatment of the general population. Much worse results, coupled with a significant increase in mortality, are observed in patients admitted and treated on an emergency basis