Chylothorax treatment with thoracic duct embolization

The authors present a case of a patient with non-traumatic right-sided chylothorax which was successfully treated by thoracic duct embolization. The procedure was performed through the cisterna chyli which was visualised by intranodal lymphography. The coils and acrylic tissue glues were used for embolization. The patient has been followed for 5 months and is free of recurrence of chylothorax.

Aneurysm of pancreaticoduodenal arcade caused by medial arcuate ligament syndrome - case report and review of literature

INTRODUCTION

Visceral artery aneurysms are rare vascular pathologies. They are usually incidental findings during the examination for other reasons. The most common clinical symptoms are nonspecific abdominal pain and bleeding caused by their rupture, with a severe clinical presentation. Aneurysms of pancreaticoduodenal arcade are more common in patients with well-developed collateral circulation due to the coeliac trunk stenosis or occlusion.

CASE REPORT

In this case report the authors present a rare case of a patient with incidental finding of pancreaticoduodenal arcade aneurysm in the setting of severe stenosis of coeliac trunk origin caused by medial arcuate ligament compression. The diameter of the aneurysm was 40 mm and endovascular treatment was not possible because of unfavorable anatomical setting. The patient was successfully treated with resection of the aneurysm and the division of medial arcuate ligament during one surgery.

CONCLUSION

There is no correlation between the diameter and the risk of rupture of the pancreaticoduodenal arcade aneurysm. Because of high morbidity and mortality of their rupture, most authors recommend active treatment of these aneurysms. The necessity to treat truncus coeliacus stenosis or occlusion remains a controversial issue.

Combined endovascular and surgical treatment of symptomatic tandem occlusion of common carotid artery and middle cerebral artery - case repor

INTRODUCTION

Cerebrovascular events are among the most common causes of invalidity or death. The aim of treatment in acute cerebral ischemia is to restore the blood flow before irreversible necrosis of brain tissue and persistent neurologic deficit occur. Pharmacological, endovascular and surgical methods are employed in the treatment of these patients.

CASE REPORT

The authors present a case report of a 56-year-old woman with acute cerebral ischemia caused by tandem occlusion of the left common carotid artery and the M1 segment of middle cerebral artery. In the initial phase the patient was treated by intravenous thrombolysis with minimal success. Common carotid artery was occluded and mechanical extraction of embolus was successfully performed through direct carotid bifurcation puncture. Almost complete regression of neurologic deficit occurred after the endovascular recanalization. Occluded common carotid stump and bifurcation was considered as a source of embolization and therefore, to prevent further cerebrovascular event, a subclavian-carotid bypass was performed on the 15th day after the stroke.

CONCLUSION

In the reported patient with symptomatic tandem occlusion of common carotid artery and the M1 part of middle cerebral artery, recanalization of cerebral artery was attained by the combination of pharmacological and endovascular method. Consequent subclavian-to-carotid bypass was performed in tertiary prevention of further cerebrovascular event.

[Free-floating thrombus in the internal carotid artery treated by anticoagulation and delayed carotid endarterectomy]

Free-floating thrombus in the internal carotid artery is a rare clinical finding. Only case reports and small cohorts of patients are described in the literature. The authors present a case report of a patient with ischemic stroke due to arterio-arterial embolisation from ulcerated internal carotid artery stenosis with a free-floating thrombus. Initially, the patient was treated with anticoagulants, resulting in total dissolution of the free-floating thrombus based on ultrasound documentation, without any further symptomatic embolisation. Endarterectomy was performed in the second step for the critical stenosis of the internal carotid artery. After this combined treatment, the patient showed no neurological deficit. Currently, the opinion on optimal therapy of the free-floating thrombus in the internal carotid artery still remains unclear.

KEY WORDS

free-floating thrombus - anticoagulation internal carotid artery.

[Endovascular treatment of obstetric hemorrhage]

PURPOSE

To evaluate effectiveness and safety of hypogastric artery branches embolization in the treatment of postpartum hemorrhage, hemorrhage associated with cesarean section and termination of pregnancy.

MATERIALS AND METHODS

All women with intractable bleeding and who were treated by embolization, were included from the period between 1996 to 2010. The retrospective study included 16 women of mean age 30.5 years.

RESULTS

Intractable hemorrhage related to regular delivery occurred 7 times, five times after cesarean section and four times after termination of pregnancy. Seven women (44%) were in hemorrhagic shock during therapeutic embolization. Extravazation was angiographically proved in 50% cases. Embolization was successful in hemorrhage control in 87,5% of women, in two women embolization was repeated for persistent bleeding. There were 21 additional surgical procedures performed in 13 women before embolization including 2 hysterectomies. Two hysterectomies were done after embolization because of infection. In remaining 3 women embolization was done as a primary method of bleeding control. No patient died. In the group of 10 women with maximally 1 surgery before embolization length of hospital stay was 10.1 days in average, while in a group of six women having 2 to 3 surgeries before embolization the hospital stay was 21.2 days in average (p = 0.03).

CONCLUSION

Embolization of hypogastric arteries decreases length of hospital stay in patients with obstetric hemorrhage and should be done soon if routine methods of bleeding control fail.

[Survival of patients after TIPS in the University Hospital Hradec Kralove]

AIM

To analyze survival of patients after TIPS (transjugular intrahepatic portosystemic shunt).

PATIENT SAMPLE AND METHODOLOGY

Between September 1992 and August 2010, TIPS was created in 848 patients of the University Hospital Hradec Kralove. These patients were divided into groups. Survival was analyzed using Kaplan-Meier survival curves. Differences between groups were evaluated using log-rank test.

RESULTS

Ten percent of patients do not survive one month after TIPS, 40% of patients survive 5 years and 20% of patients survive 10 years. There were statistically significant differences between groups divided according to Child-Pugh classification (A vs B p = 0.0053; B vs. C p < 0.0001), indication for surgery [prevention of bleeding recurrence differed from refractory ascites (p = 0.0001) and the indication to stop acute bleeding (p = 0.026)]; aetiology of the liver disease [patients with alcoholic cirrhosis differed from patients with Budd-Chiari syndrome (p < 0.0001) and from patients with chronic viral hepatitis (p = 0.024)].

CONCLUSION

Survival of patients after TIPS is influenced by Child-Pugh score, indication and aetiology of the liver disease.

[Late surgical conversion after endovascular treatment of the abdominal aortic aneurysm]

The authors present a case report of long- term follow up of 66-year old male with the abdominal aortic aneurysm treated with aortouniiliac stent-graft implantation in combination with the cross-over femoro-femoral bypass 14 years ago. Various leaks type Ia, IIb and III developed during follow-up. In spite of endovascular treatment of these complications the size of the aneurysmal sac enlarged and the patient was successfully treated by the aortobifemoral bypass.

Non-invasive diagnosis of coronary-subclavian steal: role of the Doppler ultrasound

Coronary subclavian steal syndrome (CSSS) is a well documented cause of graft function failure in patients after left internal mammary artery (LIMA)--left anterior descending (LAD) coronary artery grafting. We present a case of the CSSS in a patient with cardiac arrest due to ventricular fibrillation. To our knowledge such a case has not yet been described. Patient with a history of LIMA-LAD grafting, complaining only of a mild chronic exertional dyspnoea developed ventricular fibrillation while walking outdoor. After successful resuscitation, blood pressure difference between both arms and abnormal LIMA flow with systolic reversal flow on the Doppler ultrasonography were suggestive of CSSS. Angiography proved the left subclavian artery (LSA) occlusion and coronary angiography confirmed reversal flow in the LIMA graft. Successful percutaneous transluminal angioplasty of the LSA re-established normal LIMA flow and improved the left ventricular hypokinesis and systolic function.

[Endovascular treatment of spontaneous hemothorax in patient with neurofibromatosis type I]

Authors present possibility of endovascular treatment of spontaneous hemothorax in the patient with neurofibromatosis type I. CT angiography was crucial in diagnostic algorithm because revealed false aneurysm of the thyreocervical artery. This artery was embolised with acrylic glue. The patient has been without signs of recurrent bleeding.

[Truncus coeliacus stenosis in duodenopancreatectomy]

INTRODUCTION

Patients with celiac axis stenosis are asymptomatic due to the rich collateral blood supply through superior mesenteric artery. Ligating and dividing gastroduodenal artery during pancreatoduodenectomy can cause ischemic threat especially to liver, less frequently stomach and spleen, or failure of anastomoses.

CASE REPORT

The authors present a case of 27-year-old female who underwent duodenopancreatectomy for pseudopapillary tumour of the head of pancreas. Celiac axis stenosis was found peroperatively and proven during angiography. Although an attempt of endovascular dilatation of celiac axis was unsuccessful, blood supply to the liver was sufficient and therefore we did not perform any other intervention to improve blood flow to the liver. Postoperative course was uneventful.

DISCUSSION

Celiac axis stenosis can be caused by tumour infiltration or lymphadenopathy in malignant disease, atherosclerosis or compression of the median arcuate ligament. The stenosis can be managed by endovascular treatment or arterial reconstruction. In conclusion the authors propose a management algorithm to prevent the consequences of celiac axis stenosis.

[Endovascular treatment of carotid artery stenosis with cerebral protection: 5-year experience]

BACKGROUND

Percutaneous transluminal angioplasty and stenting with cerebral protection is a minimally invasive method for carotid artery stenosis treatment, which may be an alternative to surgical endarterectomy. The aim of our study is to evaluate results of endovascular treatment in patients at high risk of endarterectomy.

PATIENTS AND METHODS

Between years 2001-2006, 210 carotid artery stenoses in 204 patients were treated in our department. Fourty seven percent of patients suffered from symptomatic stenosis, asymptomatic stenosis was proved in 53% of patients. All asymptomatic patients had stenosis more than 70% measured according to NASCET, mostly with contralateral carotid artery occlusion.

RESULTS

The procedure was technically successful in 99% of patients, mortality was 0.49%. Periprocedural embolic complications based on transient ischemic attack were observed in 2.39% of patients, symptoms of minor stroke in 0.47% and symptoms of major stroke in 0.47% of patients. The mortality and disabled morbidity rate in the whole group was 0.96%. One hundred and fifty three patients (73%) were followed up, during this time, 7 patients (3.9%) developed hemodynamically significant restenosis.

CONCLUSION

Endovascular carotid artery stenosis treatment with cerebral protection seems to be a safe method of treatment with acceptable short-term results. However, long-term follow-up is needed to get enough data about safety and effectiveness of this method compared to endarterectomy and best medical therapy.

[The impact of secondary insertion of ePTFE-coated stent on sustainable TIPS patency]

OBJECTIVE

Retrospective evaluation of the effect of secondary insertion of ePTFE-coated stent in the treatment of TIPS dysfunction versus other current options (simple angioplasty, insertion of additional non-coated stent). PATIENT SET AND METHODOLOGY: From the beginning of 2000 to the end of 2004, there were 121 interventions for TIPS dysfunction performed in our centre in which a non-coated stent was used to make up the shunt at the time of intervention. Depending on the type of intervention, the patient set was divided in 4 groups: simple angioplasty (52 cases, 43%), insertion of non-coated stent (35 cases, 28.9%), insertion of non-dedicated ePTFE-coated stent (15 cases, 12.4%), and insertion of dedicated ePTFE-coated stent (19 cases, 15.7%). All patients were monitored on a regular basis after the intervention for shunt patency with the use of clinical examination and Doppler ultrasonography, or also portal venography. Primary shunt patency after the intervention was evaluated in all four groups by Kaplan-Meier analysis. The primary shunt patency results after the intervention were compared with the use Cox F text and logrank test.

RESULTS

The intervention was successful in 120 cases (the overall technical success rate of all interventions was 99.2%). The primary shunt patency was 49.7 % after 12 months and 25.3 % after 24 months following sole angioplasty intervention; 74.9% after 12 and 64.9% after 24 months following intervention involving the insertion of non-coated stent; 75.2 % after 12 months and 64.5% after 24 months following intervention involving the insertion of non-dedicated ePTFE-coated stent, and 88.1% after 12 months and 80.8% after 24 months following intervention involving the insertion of a dedicated ePTFE-coated stent. A statistically significant improvement in shunt patency was obtained in the group of interventions involving the insertion of dedicated ePTFE-coated stent and in the group of interventions involving the insertion of non-coated stent as compared with the group of interventions involving sole angioplasty (p < 0.01).

CONCLUSION

From among all the currently used methods of therapeutic intervention for TIPS dysfunction, the best, the best subsequent TIPS patency was obtained after intervention involving insertion of dedicated ePTFE-coated stent.

[Penetrating aortic ulcers--case report on endovascular therapy]

We report our experience with two cases of endovascular treatment of penetrating aortic ulcers (PAU). The first patient was a 71-year-old woman with 30 mm width aortic ulcer accompanied by intramural hematoma of the descending thoracic aorta. The second patient was an 80-year-old obese woman with 50 mm pseudoaneurysma of the abdominal aorta, which was result of PAU. Both patients were successfully treated by means of tubular stentgraft, implanted from surgical cut down of the right femoral artery. Penetrating aortic ulcer represents localized, potentially lethal pathology of the aorta. Together with dissection and intramural hematoma belongs among the acute aortic syndromes. During nature course PAU can progress to the acute classic dissection, pseudoaneurysma or rupture of the aorta. It is principally disease of elderly hypertensive patients. Early diagnosis and appropriate therapy improves prognosis of patients with PAU. Open surgical repair with synthetic graft has been the gold standard of treatment but endovascular therapy is an attractive option in risk elderly patients. It seems to be a safe, effective treatment but stability of results of this method should be proved.

[The endovascular treatment of the aortic trauma]

BACKGROUND

Traumatic injuries of the thoracic aorta are very frequent during motor vehicle accidents with sudden deceleration. Spiral CT has become the modality of choice for evaluating significant blunt trauma and grading system for aortic injury has been developed. Immediate diagnosis, introduction of antihypertensive therapy and endovascular treatment by means of stentgraft give a better chance for patients with blunt aortic injury.

AIM

Prospective evaluation of results of endovascularly treated patients with blunt aortic injury.

MATERIALS AND METHODS

We prospectively followed patients after endovascular treatment of acute aortic injury. Diagnosis was based on chest x-ray and CT examination. Stentgrafts were placed under fluoroscopic guidance and patients were routinely followed by CT and clinical visit.

RESULTS

Between December 1999 and September 2004 we endovascularly treated seven patients (6 men, 1 woman, mean age 41.7 years) for blunt aortic injury of the thoracic aorta. Stentgraft was implanted between 5 hours and 6 days (mean 3.2 days) after injury. Seven stentgrafts were implanted in 7 patients in total. One patient died due to failure of endovascular technique for collapsed stentgraft. A new onset of lower legs paraparesis was detected in one patient. Other five patients are regularly followed (3-55 months, mean 30.7 months) without any complications.

CONCLUSION

Endoluminal technique can be used successfully in the immediate repair of aortic trauma. At present time in our center, treatment by means of the stentgraft placement is the first line therapy in injured patients. It allows rapid stabilization of aortic trauma and further treatment of other injuries.

[Cooperation between a surgeon and an interventional radiologist in cases of internal bleeding]

INTRODUCTION

Internal bleeding still remains a serious condition, which must be urgently diagnosed and treated. In the Faculty Hospital in Hradec Králové the diagnosis of the internal bleeding source and its consequent treatment is managed under cooperation between a surgeon and an interventional radiologist. A CASE-REVIEW: In the case-review section of this report, a total number of five patients with serious cases of internal bleeding, the source of which was diagnosed and treated under cooperation between the above mentioned specialists is presented. The patients concerned suffered from the following: a trauma to the liver parenchyma, posttraumatic arterioportal shunts, an intraheparic aneurysm, a relaps of the uterine carcinoma with hemorrhaging into the colon and the vagina, bleeding into retroperitoneum. In all the cases the lesion was successfully treated and the hemorrhage was managed.

DISCUSSION

Exact location of the bleeding artery during an arteriogragraphic examination is a prerequisite of a successful treatment of the condition. Both, the absorbable materials which allow gradual recanalization of the embolized vessel, and the non-absorbable materials may be used to conduct embolization of the affected vessel. It is necessary to haemodynamically stabilize the patient prior to the procedure.

CONCLUSION

In many cases, the cooperation between a surgeon and an interventional radiologist allows for the source of the internal bleeding to be located and managed. It is indicated in certain cases of benign and malignant disorders and in some cases of the parenchymatose organs trauma.

[Endovascular treatment of atherosclerotic stenoses of the subrenal aorta]

The authors present results of endovascular treatment of subrenal aortic atherosclerotic stenoses. Between 1996 and 2001 they treated 9 patients (5 men, 4 women, mean age 57.4 years). Aortic stenoses were caused by an atherosclerotic process in all cases. In addition, in three patients iliac arteries were affected by sclerotic lesions. The endovascular procedure consists of predilatation performed by a small calibre angioplasty balloon catheter and implantation of a stent. Three times a balloon expandable stainless steel stent was implanted and self-expandible nitinol stents were used in the six cases. The primary technical success rate was 100%, no major complications were observed. One distal embolization was successfully resolved by intraarterial thrombolysis. Only one stent restenosis occurred after 36 months. It was successfully treated by implantation of a longer stent. That means that the primary patency of stented subrenal aorta during a mean follow-up period of 19 months was 87.5%. The claudication interval improved in six patients and three patients were symptom free. Endovascular therapy can be recommended for short sclerotic stenoses of the infrarenal aorta. This miniinvasive technique has a high technical and clinical success rate, favourable long-term patency and low complication rate.

[Infectious aneurysm of the abdominal aorta caused by Salmonella: diagnosis, endovascular therapy]

The authors present a case of an infected abdominal aortic aneurysms by means of a minimally invasive endovascular method using a stent graft. This patient had already been treated by TIPS (transjugular intrahepatic portosystemic shunt) for repeated varicose bleeding due to liver cirrhosis. Standard surgical therapy of infected abdominal aneurysms and about advantages and possibilities of endovascular treatment with stent grafts are discussed. Regular follow-up of the patient and long-term antibiotics therapy are important for accurate assessment of an implanted stent graft into the infected abdominal aorta. Endovascular stent graft combined with antibiotic therapy may be an alternative to conventional open surgery in managing infected infrarenal abdominal aneurysms.

Endovascular brachytherapy potentiated by hyperthermia in the prevention of vascular restenosis. A case report

BACKGROUND

The combination of hyperthermia and radiotherapy has additive or synergistic effects. This combination has been studied extensively in radiation oncology, but not in the prevention of vascular restenosis.

CASE REPORT

A patient with restenosis of cephalic vein underwent percutaneous transluminal angioplasty (PTA) followed by endovascular irradiation with 192Iridium (12 Gy) using a high dose rate afterloading technique. After endovascular irradiation, one fraction of external ultrasound hyperthermia was administered to the irradiated segment. There was no restenosis in the treated vessel segment according to duplex sonography performed 192 days after treatment. No radiation or hyperthermia associated side effects were observed.

CONCLUSIONS

Present observations suggest that endovascular brachytherapy of restenosis potentiated by hyperthermia is a technically feasible and well-tolerated treatment. The additive and synergistic effects of hyperthermia, in conjunction with radiation, could be of benefit in the prevention of vascular restenosis.

Endovascular brachytherapy in the prevention of vascular restenosis

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

Ten patients with recurrence of stenosis in the femoropopliteal region underwent PTA followed by endovascular irradiation with Iridium-192 a high-dose rate after-loading technique. We used a single fraction of dose 12 Gy given in 3 mm from the source axis in the stenotic vessel segment.

RESULTS

During follow-up of 59-580 days restenosis occurred in four patients 111, 460, 472 and 580 days after irradiation. All other patients are without restenosis. No radiation-associated side effects were observed.

CONCLUSIONS

Endovascular brachytherapy of restenosis in the femoropopliteal region is technically feasible, and may be done as a part of the PTA. These encouraging results open the possibility of reduction of restenosis by the present method.

Value of Doppler sonography in revealing transjugular intrahepatic portosystemic shunt malfunction: a 5-year experience in 216 patients

OBJECTIVE

The purpose of the study was to evaluate the long-term clinical efficacy of Doppler sonography in revealing failure of transjugular intrahepatic portosystemic shunts (TIPS).

SUBJECTS AND METHODS

During a 5-year period, 1192 Doppler examinations were performed in 216 patients with TIPS. No regular follow-up shunt venography was performed. Doppler examinations were retrospectively compared with the results of shunt revisions. Sonograms with negative findings were compared with the patients' clinical status so that the number of false-negative sonographic findings leading to an episode of shunt failure (recurrence of gastrointestinal bleeding or ascites) could be ascertained. Sonographic parameters assessed included diameter, velocity, flow volume, and congestion index of the portal vein; and shunt velocities.

RESULTS

Doppler sonography revealed shunt occlusion in 25 of 26 angiographically proven cases (sensitivity, 96%). The combination of velocity criteria (peak intrashunt velocity > or =250 cm/sec, maximum velocity in the portal third of the shunt < or =50 cm/sec, or maximum portal vein velocity less than or equal to two thirds of the baseline value) revealed shunt stenosis in 103 of 110 cases (sensitivity, 94%). Doppler sonography missed a significant shunt stenosis that led to an episode of gastrointestinal bleeding or ascites recurrence in only seven cases. The congestion index of the portal vein showed significant differences between patent and malfunctioning shunts (p < 0.001).

CONCLUSION

Doppler sonography is an effective primary imaging method for long-term follow-up of patients with TIPS.

[Percutaneous aspiration thrombectomy in the popliteal and calf area--a 4-year experience]

PURPOSE

Retrospective analysis of results of percutaneous aspiration thrombectomy (PAT) in the popliteal and tibioperoneal arteries in patients with primary and iatrogenic peripheral embolization and during intraarterial thrombolysis.

MATERIAL AND METHOD

Percutaneous aspiration thrombectomy was used in 41 patients (42 arteries). In 12 cases this method was used as the first choice in treatment of the peripheral artery disease, in 14 cases during intraarterial thrombolysis and 16 times after iatrogenic embolization secondary to balloon angioplasty. An antegrade approach to the common femoral artery was performed in all cases. In 40 patients the aspiration thrombectomy was performed from the popliteal region and proximal parts of tibioperoneal arteries.

RESULTS

Overall success (n = 42) was achieved in 67%, partial success in 23%. Aspiration thrombectomy was unsuccessful in. 10%. PAT was successful in 88% after iatrogenic peripheral embolization (n = 16), in patients during thrombolysis (n = 14) a good result was achieved in 40%, partial success in 50% and this method failed in 10%. Primarily performed aspiration thrombectomy (n = 12) in occlusion of peripheral arteries was successful in 50%. No major complications were recorded.

CONCLUSION

PAT is a highly effective method in treatment of iatrogenic peripheral embolizations after endovascular procedures and effective accessory method in combination with intraarterial thrombolysis. This method can be used primarily in acute occlusion of distal popliteal artery.

Endovascular brachytherapy of transjugular intrahepatic portosystemic shunt

PURPOSE

To evaluate the technical feasibility and efficacy of endovascular brachytherapy with Iridium-192 in the prevention of restenosis caused by neointimal hyperplasia of transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

The endovascular brachytherapy with high dose rate automatic afterloading system was performed in six patients with recurrent of stenosis of TIPS. We used a single dose fraction of 12 Gy delivered at 3 millimeter (mm) from the source axis to the stenotic vessel segment in five patients with spiral Z-stent, and 15 Gy at 5 mm in one patient with Wallstent.

RESULTS

Follow-up time ranged from 148 to 639 days. In one patient, restenosis occurred in the treated vessel segment, diagnosed 71 days after endovascular brachytherapy by doppler ultrasound. All other patients were, during the follow-up time, without restenosis in the irradiated vessel segment. Radiation-associated side effects were not observed.

CONCLUSIONS

Endovascular brachytherapy of TIPS is technically feasible and may be done as a part of the percutaneous revision of the shunt. This pilot study may be the largest experience of treating TIPS restenosis in humans to date. For definitive conclusions, a lot of studies are needed.

[Surgical interventions in dialysis fistulae]

PURPOSE

To evaluate the efficacy, feasibility and safety of interventional procedures in patients with hemodialysis shunts in retrospective analysis. We report the technical success rate and the midterm primary and secondary patency rate in our patients.

MATERIAL AND METHODS

Between April 1996 and May 1999 (35 months) we performed 129 interventional procedures on hemodialysis shunts in 87 patients (40 women and 47 men in age 22-88 years, mean age 67 years). We treated 46 occlusions and 83 stenoses. There were native fistulas--63 radiocephalic fistulas, 7 brachiocephalis fistulas, 1 brachiobasilic fistula, and hemodialysis grafts--14 vein allografts and 2 synthetic PTFE grafts. Indication for fistulography and intervention was decreasing efficacy of hemodialysis (in case of stenosis) or shunt occlusion. Patients were treated by means of percutaneous transluminal angioplasty, thrombolysis and percutaneous mechanical thrombectomy with hydrolyser or with thrombectomy basket. Stents were placed twice. Once in suboptimal result of local thrombolysis, second time in case of central venous stenosis. Follow up ranged from 0.3 to 35 months (mean 11 months). Nine patients were lost for follow up, 15 patients died during follow up.

RESULTS

Overall technical success rate was 84% (108 procedures, n = 129), technical success in cases of occlusion was 57% (27 procedures, n = 46), in stenoses treatment was 98% (81 procedures, n = 83). Overall primary patency rate in 6 months is 40% (n = 59), in 12 months 24% (n = 59) and in 2 years 5% (n = 59). The primary assisted patency rate and secondary patency rate is 95% (n = 59) in 6 months, 88% (n = 59) in one year and 73% (n = 59) in two years.

CONCLUSION

Repeated percutaneous interventional procedures in patient with hemodialysis shunts can extent shunt patency. Despite relatively low primary patency rate we can achieved good primary assisted or secondary patency rate in patients with stenoses of shunt.

[Percutaneous therapy of obliterative disease of the femoropopliteal arteries using stents--2 years' experience]

PURPOSE

To evaluate the clinical results and short and mid-term stent patency in patients with femoropopliteal stent placement.

MATERIAL AND METHODS

Forty-one patients (42 limbs) underwent stent placement--27x into superficial femoral artery, 15x into popliteal artery. There were inserted 44 self-expandable stents. In 3 cases PTA of stents and in 2 cases local endovascular brachytherapy were performed because of restenosis. The mean follow-up is 12.9 months (1-24 months).

RESULTS

Stents were successfully inserted in all cases. Clinical improvement at the time of latest follow-up occurred in 77% of patients, no improvement in 13% and clinical worsement in 10% of patients. Primary patency rates at 6 months, 12 an 24 months were 83.8%, 67.7% and 67.7%, respectively. Primary assisted patency were 90.3% at 6 months, 77.4% at 12 months and 77.4% at 24 months.

CONCLUSION

Stents implantation in femoropopliteal arteries is a method of choice after suboptimal angioplasty results in patients with critical limb ischemia for whom no reasonable surgical alternative exists.

[Complications of endovascular therapy of abdominal aortic aneurysms. Analysis and possible treatment]

The required result of correctly implemented endovascular treatment is bridging and elimination of the aneurysmatic sac from the blood flow in the aorta. Perfusion of the sac after release of the endovascular prosthesis is one of the most frequent complications of endovascular treatment. The majority of these perfusions is caused by a leak of the endovascular prosthesis at the site of the stented anastomosis, or more rarely by a collateral flow into the aneurysmatic sac or rupture of the endoprosthesis. Perfusion of the sac "endoleak" complicates endovascular treatment in cca 30%. During the postoperative period about half the perfusions recede spontaneously and about half require further treatment. Based on their own experience the author submits suggestions for the classification of leakage of endovascular prostheses with regard to the method of their treatment.

[Interventional procedures in patients after vascular reconstructive surgery of the lower extremities]

This study reports the results and complications of local thrombolysis therapy of recently occluded grafts manifested by acute ischemia in comparison with transluminal angioplasty of graft stenoses. Stenoses were diagnosed by means of ultrasound (asymptomatic patients) or manifested by claudications. The aim of our study is to emphasize the difference between efficacy of these two kinds of treatment and their difficulties. Fourty three patients were treated in the period of 39 months (March 1994-June 1997). Sixty seven interventional procedures were done, including 32 local thrombolysis in 20 patients and 35 angioplasties in 23 patients. Types of grafts were: aortofemoral (n = 8), ilicofemoral (n = 4) and one aortotibioposterior, femoropopliteal vein (n = 18) and synthetic (n = 9) and two distal tibioposterior bypasses. Fourty one bypasses were created due to arteriosclerotic occlusion, one for traumatic amputation and one due to stenosis after perinatal catheterization. The period between surgery and intervention varied from 1 month to 11 years (mean 33 months), the mean follow up period was 13 months. Technical success rate in patients treated by local thrombolysis was 69% (n = 22). Midterm graft patency in the this group is 40% (n = 8) with 95% (n = 19) limb salvage. In patients treated by transluminal angioplasty was technical success rate 97% (n = 34). In this group is patent 96% (n = 20) bypasses with 31% (n = 4) restenoses. All patients with patent grafts have a good run-off with at least 2 patent calf arteries. Six complications occurred during local thrombolytic therapy. Our results indicate that despite of the high initial success rate are the late results poor in the group treated by thrombolysis because of the high rate of rethromboses. The result depends on number of patent calf arteries. Results in patients treated by angioplasty only are much better with lower risk of complications during procedure. Our results prove that it is better to follow patients after lower limb bypass surgery by ultrasonography and perform angioplasty when stenoses occur.

[Revascularization of the aortoiliac arteries using stents]

The authors summarised their three year experience with endovascular treatment of the aortoiliac artery obstructive lesions using stents and transluminal angioplasty. Fifty-seven patients (61 limbs) underwent stent implantation to treat claudications (n = 50 limbs), rest pain (n = 6), non-healing defects (n = 4) and one patient was asymptomatic (n = 1). After stent placement patients were followed-up using clinical and duplex ultrasound examinations at 3 months and 6 months thereafter. Immediate angiographic success was achieved in all cases. Three serious complications were observed. Percutaneous reinterventions because of stenosis inside the stent were performed in 7 patients (7 limbs). The primary patency rates were 92% at 1 year, 88% at 2 years and 86% at 3 years. Cumulative primary assisted patency were 98% (mean follow-up 15.8 months, range 3-47 months). Regular clinical and ultrasound follow-up examinations can reveal the asymptomatic instent stenosis and percutaneous reinterventions can improve long-term stent patency.

[Endovascular treatment of abdominal aortic aneurysms. Morphology of aneurysms as one of the deciding indicating factors]

Endovascular treatment of aneurysms of the abdominal aorta is based on intravascular bridging of the aneurysm using of an endovascular prosthesis. The prosthesis must be safely anchored above and below the sac of the aneurysm in the non-dilated artery. Therefore the indication of endovascular treatment depends on the morphology of the aneurysm. The objective of the work was to analyse the morphology of the aneurysm with regard to the possibility of endovascular treatment. The morphology of the aneurysm was evaluated with regard to the angiographic examination and examination by computed tomography. The following parameters were investigated: diameter and length of the proximal and distal neck, diameter of the sac in two planes, diameter and tortousity of the iliac arteries, tortousity of the infrarenal aorta. A total of 70 patients with aneurysms of the abdominal aorta were examined. The patients were divided into three groups according to the morphology of the aneurysm. I. infrarenal aneurysms not affecting common iliac artery (n = 20) 28.5%, II. infrarenal aneurysms affecting common iliac artery (n = 38) 54.2%, III. juxtarenal aneurysms regardless of the affection of common iliac arteries (n = 12) 17.1%. Of the total of 70 examined patients 24 (34.2%) with infrarenal aneurysm and 6 (8.57%) with juxtarenal aneurysm were suitable for endovascular treatment.

[Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of symptomatic portal hypertension]

BACKGROUND

A transjugular intrahepatic portosystemic shunt (TIPS) is the creation of a percutaneous portosystemic anastomosis which is used as an alternative method of surgical portosystemic shunts and endoscopic treatment in the therapy of complications of portal hypertension. The objective of the present work was to summarize experience with TIPS in 100 patients.

METHODS AND RESULTS

In 1992-1995 the authors treated 100 patients with symptomatic portal hypertension by TIPS. To create the shunt in 84% patients a spiral Z stent was used, in the remainder a Wallstent. In 86% patients the indication for TIPS was haemorrhage associated with portal hypertension and in 14% refractory ascites. TIPS was implemented in 98% patients. The pressure in the portal vela was not reduced on average to 58% of the original value. Haemorrhage was not stopped in one of 7 patients. Haemorrhage from varices reappeared in 7% patients indicated on account of repeated haemorrhage and was always associated with the finding of chronic stenosis of the shunt. The mortality in conjunction with the procedure was 4%, the mortality within 30 days after operation was 8%. Uncontrollable encephalopathy developed in 3% of the patients. Primary patency of the shunt created by the spiral Z stent was 85% after 6 months, after 12 months 72% and thus does not differ from primary patency when Wallstents are used, as reported in the literature.

CONCLUSIONS

TIPS is an effective method to reduce the pressure in the portal vein in portal hypertension. The main limiting factor of the method is stenosis of the shunt due to hyperplasia of the neointima. Stenoses of the shunt can be effectively dilated by percutaneous balloon angioplasty.

[Subacute thrombosis of the abdominal aorta with suprarenal involvement and successful treatment with pharmacomechanical fibrinolysis]

In a 43-year-old patient with Ebstein's anomaly and a history of acute myocardial infarction by means of duplex ultrasonography and aortography the diagnosis of thrombotic occlusion of the a aorta was established, starting above the insertion of the renal arteries and reaching as far as the bifurcation of the aorta and the common iliac arteries. In the clinical picture dominated complete anuria with uraemia and marked hyperkaliaemia as a result of ischaemic affection of the extremities due to thrombosis of the aorta; at the onset of hospitalization also left ventricular failure with hyperhydration and later also signs of the hyperviscous syndrome. The latter developed after repeated haemofiltrations which led to a rise of the originally high haemoglobin and haemotocrit values a result of a righ-left shunt in Ebstein's anomaly. After improvement of the clinical condition local fibrinolytic treatment of the aortal thrombosis with urokinase (total dose 2,160,000 u. administered within 24 hours) was provided. The thrombus with a total length of 13.5 cm was dissolved except for a residual portion of 10 mm located in the area of insertion of the right renal artery. After dissolution of the thrombus it proved possible to restore the blood flow into the left kidney a and lower extremities, but not into the right kidney because of the residual thrombus. Seventy-two hours after terminated fibrinolysis - and after 31 days of anuria - the diuresis was restored and after a polyuric stage normalization of mineral, urea levels was restored and the creatinine value was slightly above the upper normal range. Concurrently with fibrinolytic therapy angioplasty of the aorta was carried out and a stent was placed on the left iliac artery. The clinical condition of the patient was improving, the patient started to mount stairs. Death occurred suddenly and the cause was cardiac failure due to very serious congenital heart disease.