Hemoroidinių arterijų embolizacija – naujas hemorojaus gydymo metodas: atvejo pristatymas

Background / Objective Hemorrhoids are a very common anorectal condition, affecting millions of people around the world and represent major medical and socioeconomic problem. New technique for treating symptomatic hemorrhoids has been introduced in to clini­cal practice. Only limited number of cases using this technique were reported. This was a first clinical case in Lithuania using this technique for treating hemorrhoids. 44 year-old-man underwent liver transplantation for B viral cirrhosis in 2011. He de­veloped liver transplant cirrhosis, hepatorenal syndrome, portal hypertension, hiperuricaemia. He presented to us with recur­rent episodes of massive rectal bleeding, requiring multiple transfusions, with hemoglobin as low as 45 g/l. Several episodes of conservative treatment for hemorrhoids was not effective. Because of thrombocytopenia, risk of intra- and postoperative bleeding usual choice of surgical or minimally invasive treatment for hemorrhoids was not possible. The choice of selective angiography and embolization was made. On the 30th of July 2015 the patient underwent visceral and selective mesenteric angiograms. Inferior mesenteric artery was canulated. Terminal branches of the inferior rectal artery were embolized using Interblock 18 microspirals. Three spirals were used. Rectal bleeding stopped. Proctoscopy was performed after three weeks. Hemorrhoidal cushions were reduced by approximately 70%. No recurrent bleeding was observed 23 months after the pro­cedure. The patient safely underwent repeated liver transplantation within 1 month.Conclusions Embolization of inferior rectal arteries requires multidisciplinary approach. Emborrhoid is a safe, effective microinvasive treat­ment for hemorrhoids in patients, who are otherwise at high risk for surgical complications.Įvadas / tikslas Keturiasdešimt ketverių metų vyrui dėl lėtinio hepatito B išsivysčiusios kepenų cirozės 2011 m. rugsėjo 30 d. atlikta kepenų transplantacija. Progresuojant hepatitui po 4 metų išsivystė kepenų transplantato cirozė, hepatorenalinis sindromas, porti­nės hipertenzijos sindromas (splenomegalija ir hipersplenizmas, stemplės venų varikozė, tiesiosios žarnos venų varikozė), hiperurikemija. III° hemorojus komplikavosi gausiais kraujavimais. Dėl posthemoraginės anemijos kelis kartus atliktos hemo­transfuzijos. Konservatyvus gydymas buvo neveiksmingas. Dėl trombocitopenijos (45x10⁹/l), tiesiosios žarnos venų varikozės, gausaus kraujavimo operacijos metu arba po operacijos didelio pavojaus klasikinės hemoroidektomijos arba mikroinvazinių operacijų (LHP, THD) nebuvo galima atlikti. Situacija buvo aptarta konsiliume dalyvaujant intervenciniams radiologams. Buvo nuspręsta atlikti hemoroidinių arterijų embolizaciją. 2015 m. liepos 30 d. buvo atliktos visceralinė ir selektyvi angiografija. Į apatinę mezenterinę arteriją buvo įvesta kaniulė. Hemoroidinių arterijų embolizacija atlikta „Interblock 18“ mikrospiralėmis. Panaudotos trys 3 mm 6 cm ilgio spiralės. Introdiuseris pašalintas. Punkcijos vieta užsiūta „Angioseal“ prietaisu. Po embolizacijos praėjus 3 savaitėms atlikta RRS. Kraujavimo iš tiesiosios žarnos požymių neaptikta, hemorojiniai mazgai sumažėjo, apie 70 % sumažėjo tiesiosios žarnos venų varikozė. Per 23 mėn. po procedūros kraujavimų iš tiesiosios žarnos nepastebėta.Išvados Hemoroidinių arterijų embolizacija reikalauja įvairių sričių gydytojų specialistų komandos darbo – intervencinio radiologo, proktologo, pilvo chirurgo, transplantologo. Viršutinės tiesiosios žarnos arterijos (retais atvejais ir papildoma apatinės tiesio­sios žarnos arterijos) embolizacija yra patikimas, efektyvus, saugus mikroinvazinis kraujuojančio hemorojaus gydymo meto­das, taikytinas pacientams, sergantiems kepenų ciroze arba turintiems kraujo krešėjimo sutrikimų

Classic Dissection of Thoracic Aorta Complicated by Ascending Aortic Intramural Hematoma: Promt Diagnosis and Successful Endovascular Repair

We reported a case of 68-year-old man, with a previous history of hypertension. Patient was admitted to our institution for evaluation of a severe, constant, tearing anterior chest pain radiated to the neck with suspicion of acute aortic dissection. A multidetector computed tomography scan of thorax and abdomen demonstrated a dissection starting from the middle part of aortic arch and extending downward to the descending aorta till the middle part of the thoracic aorta. The dissection was classified as Stanford A, De Bakey I. Surgical treatment of patient was started with bypass graft from the right common carotid artery to the left common carotid with subsequent revascularization of left subclavian artery. Lower parts of above-mentioned arteries were ligated. At the second stage an emergent prosthetic stent-graft was placed distally from the truncus brachiocephalicus up to the proximal part of the descending aorta. We reported a case report to present diagnostic and possible interventional treatment for patient with acute aortic type A dissection

Perkutaninio šlaunies arterijos kateterizavimo vietinių komplikacijų gydymo taktika

Darbo tikslas Nustatyti po intervencinių kardiologinių procedūrų per šlaunies arteriją susidariusių vietinių komplikacijų dažnį, pažeidimo vietos tipą ir optimalų gydymo metodą. Tyrimo medžiaga ir metodai Atlikta 166 pacientų, 2007–2011 metais patyrusių vietinių komplikacijų po kateterizavimo dėl įtariamos vainikinių arterijų patologijos, ligos istorijų duomenų retrospektyvi analizė. Vietinės kraujagyslių komplikacijos diagnozuotos ir gydytos krau­jagyslių chirurgų. Rezultatai Tiriamąją grupę sudarė 96 (57,8 %) moterys ir 70 (42,2 %) vyrų. Vidutinis pacientų amžius buvo 69,1 metų (±11,4 metai). 63 pacientams (38 %) nustatyta sutrikusi kojų arterinė kraujotaka. Po kateterizavimo, atlikto dėl širdies kraujagyslių sistemos pa­tologijos, šlaunies arterijos pseudoaneurizma išsivystė 162 (97,6%), arterioveninė fistulė – 3 (1,8 %), didelė hematoma – 1 pa­cientui. 111 (66,9 %) pacientų gydyta konservatyviai. Chirurginio gydymo prireikė 55 (33,1 %) pacientams. Operuotos 37 mo­terys (67,3 %) ir 18 vyrų (32,7 %). Vidutinis operuotų pacientų amžius buvo 69,9 (±10) metai. Pseudoaneurizmos pašalinimas ir arterijos plastika venos lopu atlikta 33 (60 %) pacientams, pašalinti krešuliai ir užsiūti arterijos defektai 22 (40 %) pacientams. Išvados Vietinių kraujagyslių komplikacijų po intervencinių kardiologinių procedūrų per šlaunies arteriją įvyko 166 pacientams (0,706 %). Dažniausia komplikacija po šlaunies arterijos kateterizavimo – pseudoaneurizma. Pseudoaneurizmos sėkmingai gydytos konservatyviai 111 pacientų (66,9 %). Punkcijos vietos kraujagyslių komplikacijos buvo dažnesnės ligoniams, ku­riems buvo periferinių arterijų aterosklerozinis pažeidimas (p<0,01). Reikšminiai žodžiai: jatrogeninis šlaunies arterijos pažeidimas, pseudoaneurizma Treatment of local complications that develop after catheterisation through the femoral artery punctureIngrida Ašakienė, Andrius Černauskas, Nerijus Misonis, Vaidotas Zabulis, Robertas Breivis, Sigitas Tvarionavičius, Ramūnas Kvietkauskas ObjectiveTo determine what is the rate, type, and the best treatment of local femoral access complications after interventional cardiol­ogy catheterisation procedures through percutaneous femoral artery puncture.Materials and methodsRetrospective analysis of 166 patient medical records was carried out. All the patients underwent coronarography for the suspected coronary artery disease. All of them from 2007 to 2011 developed local femoral access complications. All complica­tions were diagnosed and treated by vascular surgeons.ResultsThe study group consisted of 96 (57.8%) women and 70 (42.2%) men. The average age of the patients was 69.1 years (±11.4 years). Limb ischemia was determined in 63 patients (38%). After catheterisation due to cardiovascular pathology, femoral artery pseudoaneurysm developed in 162 patients (97.6%), arteriovenous fistula in 3 patients (1.8%), and massive hematoma in 1 patient; 111 patients (66.9%) were treated conservatively and 55 (33.1%) surgically. The surgically treated group consisted of 37 women (67.3%) and 18 men (32.7%). The average age of surgically treated patients was 69.9 (±10) years. Pseudoaneurysm removal and venous patch plasty were performed in 33 patients (60%). The removal of blood clots and direct suture of arterial defects were performed in 22 patients (40%).Conclusions166 patients (0.706%) developed local vascular complications after cardiovascular interventions through the femoral artery. Pseudoaneurysm was the most common complication after femoral artery catheterisation. Conservative treatment was suc­cessful in 111 patients (66.9%). Local vascular complications of the puncture site were more common in patients with a pe­ripheral arterial disease (p < 0.01).Key words: iatrogenic femoral artery damage, pseudoaneurys

Miego arterijų angioplastikos ir stentavimo ankstyvųjų bei vėlyvųjų rezultatų ir jiems poveikį darančių veiksnių tyrimas

The aim - to assess the carotid artery angioplasty and stenting early and late results and influencing factors. Methods. The study assessed CAS procedures performed in 2006-2013. A total of 227 procedures performed in 211 patients, of which 156 (75.3%) males and 55 (24.7%) females. Results. The study revealed that CAS procedure duration among patient with 3 aortic arch type was significantly longer and the microemboli protection systems were used more frequently. Protection systems were used more frequently when the CAS procedure lasted longer. Protection systems in CAS procedure was used in 70.9% patients. In men and younger patients protection system has been used more frequently. Microemboli in the protection systems have been identified by 17.6% patients and were more determined using the EZ FilterWire and Emboshield-NAV protection system. Increased right ICA stenosis was more common in patients who smoke, and left ICA with a history of myocardial infarction and smoking. Protection system was often used in patients who have had severe left ICA stenosis. The lethality rate in the early post procedural period among men and women was 1.2% and 1.8%, and in 2-year period was 18.7% and 28.6%, respectively. The lethality rate during 2-year period, which have been used for protective systems have been lower. The possibility to experience complications (stroke or TIA) increased 3 aortic arch type and the right common carotid artery stenosis, reduced protection systems using. Focal, linear, Ipsi- and bilateral ischemic cerebral injury was diagnosed less frequently in patients who have undergone Emboshield-NAV type of protection. During 1 year after the CAS cognitive and motor functions worsening, but no significant improvement was obtained. Before CAS poorer cognitive function compared with the control group, was established in symptomatic patients. Both symptomatic and asymptomatic patients before the CAS significantly lower by motor tasks as compared with the control subjects

Evaluation of early and late results and predetermining factors after carotid artery angioplasty and stenting

The aim - to assess the carotid artery angioplasty and stenting early and late results and influencing factors. Methods. The study assessed CAS procedures performed in 2006-2013. A total of 227 procedures performed in 211 patients, of which 156 (75.3%) males and 55 (24.7%) females. Results. The study revealed that CAS procedure duration among patient with 3 aortic arch type was significantly longer and the microemboli protection systems were used more frequently. Protection systems were used more frequently when the CAS procedure lasted longer. Protection systems in CAS procedure was used in 70.9% patients. In men and younger patients protection system has been used more frequently. Microemboli in the protection systems have been identified by 17.6% patients and were more determined using the EZ FilterWire and Emboshield-NAV protection system. Increased right ICA stenosis was more common in patients who smoke, and left ICA with a history of myocardial infarction and smoking. Protection system was often used in patients who have had severe left ICA stenosis. The lethality rate in the early post procedural period among men and women was 1.2% and 1.8%, and in 2-year period was 18.7% and 28.6%, respectively. The lethality rate during 2-year period, which have been used for protective systems have been lower. The possibility to experience complications (stroke or TIA) increased 3 aortic arch type and the right common carotid artery stenosis, reduced protection systems using. Focal, linear, Ipsi- and bilateral ischemic cerebral injury was diagnosed less frequently in patients who have undergone Emboshield-NAV type of protection. During 1 year after the CAS cognitive and motor functions worsening, but no significant improvement was obtained. Before CAS poorer cognitive function compared with the control group, was established in symptomatic patients. Both symptomatic and asymptomatic patients before the CAS significantly lower by motor tasks as compared with the control subjects

Impact of periprocedural factors on revascularization success and good clinical outcomes in anterior circulation stroke patients treated with mechanical thrombectomy

Background. Constantly evolving guidelines for the treatment of ischemic stroke in light of widely published clinical trials show no final consensus; many factors that may significantly alter treatment outcomes are still under investigation. Each stroke center treats patients with ischemic stroke due to major artery occlusion differently depending on available resources, expert judgment, and clinical experience. The aim of this study was to evaluate the influence of periprocedural factors (intravenous thrombolysis, balloon-occlusive catheter use, number and timing of thrombectomy sessions, and type of anesthesia) on recanalization success and good clinical outcomes. Materials and methods. We included 191 patients who were treated with mechanical thrombectomy (MTE) due to large vessel occlusion in the anterior circulation from January 2015 to November 2018 in Vilnius University Hospital Santaros Clinics. Demographic, work organization, and clinical variables were evaluated. The primary outcome was functional independence after 90 days (modified Rankin scale 0-2). Secondary outcomes were successful reperfusion (TICI 2b-3) and change in neurological status by NIHSS at 2 and 24 hours. Results. No significant difference in outcomes was found between MTE groups of direct and combined therapy, the balloon-occlusive catheter use or the type of applied anesthesia. MTE procedure time is related to the recanalization success and good clinical outcome (p<0.0001): in the case of a successful MTE procedure the duration of MTE was almost half that of a failed MTE (mean 42.6 min. and 74.2 min., respectively). The probability of good clinical outcome decreases by 1.78-fold for patients over 70 years old (95% CI 0.999-3.274). Every 10-year increase in age was associated with a 1.32-fold decrease (95% CI 1.008-1.765) and every 30 min. increase in MTE procedure time with a 2.32-fold decrease in the probability of a good outcome at 90 days (95% CI 1.607-3.475). Each recanalization over 270 min. from symptom onset decreased the odds of a good outcome by 2.28-fold (95% CI 1.219-4.289). Conclusions. MTE procedure time was inversely proportional to the success of the procedure itself and good clinical outcome. Trends towards better clinical outcomes were observed in younger patients and in those who started treatment with MTE within 4.5 hours of onset of stroke symptoms. The added value of intravenous thrombolysis and balloon-occlusive catheter use for the success of the MTE procedure and good clinical outcomes was not established

Intravenous r-tPA dose influence on outcome after middle cerebral artery ischemic stroke treatment by mechanical thrombectomy

Background and Objectives: Pretreatment with intravenous thrombolysis (IVT) is still recommended in all eligible acute ischemic stroke patients with large-vessel occlusion before mechanical thrombectomy (MTE). However, the added value and safety of bridging therapy versus direct MTE remains controversial. We aimed at evaluating the influence of r-tPA dose level in patients with middle cerebral artery (MCA) occlusion treated with MTE. Materials and Methods: We prospectively compared clinical and radiological outcomes in 38 bridging patients, with 65 receiving direct MTE for MCA stroke admitted to Vilnius University Hospital Santaros Clinics. Following our protocol, r-tPA infusion was stopped just before MTE in the operating room. Therefore, we divided all bridging patients into three groups according to the amount of r-tPA they received: bolus, partial dose or full dose. Functional independence at 90 days was assessed by a modified Rankin Scale score, i.e., from 0–2. The safety outcomes included 90-day mortality and any intracerebral hemorrhage (ICH). Results: Baseline characteristics and functional outcome at 90 days did not di er between the bridging and direct MTE groups. Shorter MTE procedure and hospitalization time (p = 0.025 and p = 0.036, respectively) were observed in the direct MTE group. An IVT treatment subgroup analysis showed higher rates of symptomatic ICH (p < 0.001) and longer intervals between imaging to MTE (p = 0.005) in the full r-tPA dose group. Conclusions: In patients with an MCA stroke, direct MTE seems to be a safe and equally e ective as bridging therapy. The optimal r-tPA dose remains unclear. Randomized trials are needed to accurately evaluate the added value of r-tPA in patients treated with MTE