[Percutaneous transluminal angioplasty of radiotherapy induced carotid stenosis--case report]

Frequent delayed effect of radiation therapy in the region of neck is stenosis of carotid arteries. We report the case of 32 years old man with history of radiation therapy due to Hodgkin lymphoma, and severe stenosis of the right common carotid artery. Stenosis was succesfuly treated by percutaneous transluminal angioplasty with implantation of two bare-metal stents.

[The future of transcatheter antitumor therapy]

Transcatheter antitumor therapy very quickly accepted during the last decade and their importance in the treatment of oncology patients will be increasing. By improvement of new targeted agents, which can be given intraarterial or systemic, efficiency of transcatheteric therapeutic approaches can be drastically increased. Numerous clinical trials (study phase I / II / III) relating to the synergy of two antitumor therapeutic approaches are already in progress. Preliminary results of these trials are already very encouraging. Further improvement in the development of specific therapeutics antitumor drugs and systemic applications will be a big step in the quest for medication against malignant tumors.

[ Air embolism during carotid dilatation with a stent]

We presented the case of endovascular treatment of the restenosis of the carotid artery occuring after carotid endarterectomy. We have shown the need of applying the protection systems during the endovascular procedure, in order to prevent the distal embolisation cused by ahterosclerotic debris and/or air.

[Partial resection of the spleen in the treatment of benign and traumatic lesions]

It has been thought that the spleen is an organ without important functions, until recently. That is, why splenectomy has been the procedure of choice in a treatment of splenic diseases. Even now, when we know the functional [figure: see text] importance of the spleen, splenectomy is performed frequently, regardless of its complications. The need of spleen functions salvage, favours partial resection of the spleen as competitive in a treatment of its traumatic and benign lesions. Improvement in diagnostic procedures, surgical techniques, transfusiology and postoperative treatment, will promote it as a treatment of choice. The authors of this study have experience with 17 partial resections of the spleen for traumatic, 11 for benign lesions of the spleen, and one ectopic spleen with hypersplenism, without mortality and with insignificant complications.

[Combined use of internal mammary and right gastroepiploic arteries in myocardial revascularization with and without extracorporeal circulation]

Use of arterial grafts represent the new approach in coronary artery bypass grafting (CABG) surgery these days. This article represents our experience in use of two or more arterial grafts in combination (internal mammary artery--IMA and right gastroepiploic artery--RGEA). Between March 2000 February 2002, 10 patients underwent CABG with exclusive use of left or both IMAs and RGEA, with or without extracorporal circulation (ECC). In the group without ECC fast truck anesthesia was used. Post CABG catheterization was performed in three patients. There were no 30 day mortality or morbidity. Post CABG catheterization in two patients showed excellent graft patency. One patient continued to have chest pain and after the catheterization we found ostial narrowing of the celiac trunck which was successfully dilated. One of participants had abdominal hernia repair. Our opinion is that use of arterial grafts in CABG surgery has much lower risk, excellent patency and good long term prognosis.

[Partial resection of the spleen and spleno-renal shunt in the treatment of portal hypertension with splenomegaly and hypersplenism]

Some of serious hepatic diseases with cirrhosis may be complicated by portal hypertension, splenomegaly and hypersplenism. Splenomegaly inhibits regenerative processes of the liver, and also intensifies sequestration of the cellular components of blood up to hypersplenism. Cytopenia caused by hypersplenism is aggravated by negative hepatic influence on bone marrow activity-hemathopoesis, and also by recurrent bleeding from oesophageal varices, and from the other site of gastrointestinal tract. This circle of pathologic conditions may be interrupted only by liver transplantation, until which patients are jeopardized by acute bleeding and chronic anemia. Partial resection of the spleen and splenorenal shunt may correct portal hypertension and hypersplenism, prevent gastrointestinal bleeding, and alleviate hepatic regenerative processes inhibition. In this study, 51 patients with partial resection of the spleen and splenorenal shunt, were analyzed.

[Angiographic characteristics of the internal thoracic artery--anatomic variations and their surgical importance]

INTRODUCTION

The internal thoracic artery is considered the graft of choice for surgical revascularization of the ischemic myocardium. The real incidence of anatomic variations of the internal thoracic artery is not known, although it is an extremely important issue, considering surgical strategy, as well as immediate and long-term outcome.

MATERIAL AND METHODS

During a period of three months (Jun. 1st-Aug. 31st 1998) we have evaluated the left internal thoracic artery (ITA) in 80 randomly selected patients (62 men, average age being 57.4 +/- 5.2).

RESULTS

Typical take-off, side branches, terminal division and absence of any atherosclerotic lesions were noted in 69 patients (86.25%). Angiographically apparent atherosclerotic lesions were not noted; anomalous take-off from the left subclavian artery was noted in 9 cases (11.25%--including one case of aneurysmatic proximal portion of the ITA); there were two cases where the lateral thoracic artery was present (2.5%) and three cases where the distal division was of a trifurcation type, which is not of surgical importance (3.75%). Average diameter of the left ITA was 2.19 +/- 0.24 mm for the entire group (2.20 +/- 0.19 mm for men, and 2.10 +/- 0.21 mm for women, p = NS).

DISCUSSION

Results that we have obtained are in accordance with previously published data. We did not find significant (angiographically visible) atherosclerotic lesions of the ITA, however variations in the take-off and branching were found to be frequent (11.25%). Aneurysmatic left ITA is an extremely rare finding in the literature. Angiographically found variations (capable of causing coronary steal) are impossible to be detected during operation. This raises a question of a need for routine angiographic evaluation of the ITA before operation. For some patients, routine angiographic evaluation of the ITA before myocardial revascularization is mandatory: in pts with previous myocardial revascularization, in whom ITA was not used, but could have been damaged; in pts with atherosclerotic lesions of the supraaortic vessels; in pts with previous irradiation of the anterior mediastinum (ITA could be fibrotic); in pts with actual or corrected coarctation of aorta (ITA could be aneurysmatic).

CONCLUSION

The incidence of anatomic variations of the ITA (that may be of surgical importance) is not negligible (13.25%). These data indicate that routine angiographic evaluation of the ITA should be considered in all patients in need for myocardial revascularization.

[Doppler-duplex ultrasonography in the diagnosis of cavernous portal vein]

Prehepatic portal hypertension caused by cavernous transformation of the portal vein has been more and more considered as a multiorgan disease with circulatory changes in numerous organs related to systemic and splanchnic vascular network [1]. Honeycomb-like, spongy, cavernous portal vein is a rare clinical and pathoanatomical entity which usually results from portal vein thrombosis. Recanalization and neovascularization processes lead to cavernomatous transformation of the portal vein lumen and formation of periportal collateral hepatopetal venous varices (Petren's veins) [5, 6]. Recently, with Doppler ultrasonography and angiography cavernous portal vein has been identified as the cause of prehepatic portal hypertension. Usage of color Doppler and duplex Doppler ultrasonography has greatly contributed to diagnostic efficiency, while therapeutically, the disease remains a serious and controversial problem.

METHODS

At the Institute of Digestive Diseases, Clinical Centre of Serbia, 8 patients with cavernous portal vein were studied in the period 1995-1997. Real-time duplex and color Doppler ultrasonography (Toshiba-SSA 100A with sector duplex probe 3.75 MHz, and 9 ATL with color Doppler convex duplex probe 3.5 MHz) were used. Indirect (arterial) portography was used for imaging of lienoportal system in the venous phase of angiography as follows: catheterization (Seldinger's technique) of the coeliac trunk or lienal artery, and catheterization of the superior mesenteric artery. Indirect portography was performed by injection of 60-80 ml of the contrast medium by an automatic pump, at 10-14 ml/sec, i.e. 8-10 ml/sec by the digital technique [7]. Peroral fiberendoscopy was performed in all patients by Olympus GIF-XQ 10 endoscope.

RESULTS

In our study the conventional ultrasonographic examination failed to provide an appropriate image of the normal portal vein. In hepatoduodenal ligament multiple tubular and round structures were seen, revealing an atypical honeycomb or spongycavernous shape of the venous lumen (Figs. 1 and 2). Doppler ultrasonography of the lumen of these venous collateral structures revealed a continuous, hypokinetic flow, mid-rate 7.4 cm/sec, which was always hepatopetally directed (to the liver). Color Doppler ultrasonography detected extensive portosystemic collateralls in all patients, and varices in the gallbladder wall in 1 patient. The results of indirect portography correlated well with Doppler ultrasonographic findings. In all patients hepatopetal flow was found (Figs. 3 and 4). The aetiology was diverse: idiopathic, liver cirrhosis, haematological diseases, Crohn's disease and Marfan's syndrome. Two patients had IV degree varices in the distal third of the oesophagus, and 4 patients had II/III degree varices. Patients with posthepatic liver cirrhosis and Crohn's disease had no varices in the distal third of the oesophagus and gastric fornix.

DISCUSSION

Since Pick (1909) described this malformation as the hepatopetal collateral, the haemodynamic concept of this entity has not been changed. Doppler ultrasonography and angiography confirm that the blood flow in cavernomas is hepatopetal, i.e. compensated and functional. Cavernous transformation of the portal vein is clinically manifested by bleeding from oesophagogastric varices. Haemathemesis is the most alarming complication and may be the first clinical sign. The haemorrhage is usually recurrent and profuse, but in most cases it is tolerated well owing to preserved hepatic function in patients without liver cirrhosis [19]. Portosystemic collateral circulation may take place via retroperitoneal and other spontaneous venous shunts, not involving the left gastric vein or vv. gastricae breves, when oesophagogastric varices are absent (our patient with Crohn's disease and posthepatitic B cirrhosis). Splenomegaly with hypersplenism is always present with cavernous transformation of the portal vein, and usually precedes the occurrence of gastrointestinal hae

Acute hemodynamic effects of metoprolol +/- nitroglycerin in patients with biopsy-proven lymphocytic myocarditis

We evaluated acute hemodynamic effects of metoprolol +/- nitroglycerin in 11 patients with left ventricular dysfunction and biopsy-proven lymphocytic myocarditis. Acute administration of metoprolol improved ejection phase indexes, probably through the prolongation of diastole; the addition of a vasodilator further enhanced these effects by improving arterial elastance.

[Traumatic arteriovenous fistulas during a period of peace]

The aim of the study was to point out the significance of clinical vascular examination and angiography in diagnosis setting, with the presentation of the patients treated for traumatic arteriovenous (AV) fistulas, so as the significance of timely treatment of that specific traumatic entity. In the period 1985-1996 11 patients with traumatic AV fistulas were treated. The most frequent causes of injury were bullet from firearms and blunt injury. The most frequent injury localization was in upper leg (4 cases). The interval from injury till registration and/or treatment of AV fistula was from 10 days to 33 years. Murmur was noticed in nine patients, thrill in eight, and weakened or absent arterial pulsations below the place of injury were observed in five patients. The diagnosis was confirmed by classic or cine-angiography. Major blood vessels were surgically reconstructed by various techniques, and non-major were ligated or percutaneous transluminal embolization was used. It was concluded that the noticing of murmur and thrill above the place of injury pointed out the existence of traumatic AV fistula, and angiography represented reliable diagnostic method and should be used for diagnostic, as well as therapeutic purposes. In the case of major blood vessel injury, surgical reconstruction is the method of choice.

[Isolated interrupted aortic arch]

Interrupted aortic arch is rarely presented as an entirely isolated lesion (in childhood or young adult life) in a manner similar to classical coarctation and in association with obvious collateral circulation. We present a 24-year old male with arterial hypertension of the upper body part caused by interrupted aortic arch. In this patient the femoral pulses were reduced, collateral circulation was palpable intercostally. Echocardiography has provided information about the site of interruption of the aortic arch. Exact diagnosis was established by cineangiography which has displayed interruption of aortic arch just distally to the left truncus brachiocephalicus (type A) and extensive collateral circulation. At the same time other cardiac defects were excluded.

[Intra-arterial administration of prostaglandin E1 in occlusive arterial diseases]

The authors present their result of a two-year follow-up of 106 patients to whom an intra-arterial perfusion of prostaglandin E1 was administered, as limb salvage procedure. The patients were in the IIIrd and IVth stage of occlusive diseases by Fountain, and surgical reconstructions were not possible. All patients were divided into five groups: A--diabetic angiopathy (5), B--distal form of atherosclerosis (40), C--diabetic angiopathy and atherosclerosis (45), D--Burger disease (10) and E--adjuvant therapy in reconstruction with poor run-off (6). The Doppler sonographic and angiographic measurements were performed. After transcutaneous (16 cases), or intraoperative (90 cases) introduction of the catheter into superficial of profunda femoral artery, a continuous intraarterial administration of prostaglandin E1 was carried out in a dose of 10 nanograms/kg body weight/minute (total dosage 3000 nanograms). The patients were controlled immediately after the treatment, as well as 1, 3, 6, 12, 24 and 36 months after the treatment. In efficiency of the treatment was estimated on the following basis: elimination of rest pain, healing of trophic ulceration and demarcation of gangrenous processes. Our late results of intra-arterial administration of prostaglandin E1 proved to be a very successful limb salvage procedure. The treatment was more successful in a connections between the upper knee arterial net and pedal arterial arches were preserved.

[Nonparasitic true cysts of the spleen]

Nonparasitic true cysts of the spleen are rare, but not so rare as it has been thought. Thanks to the new imaging techniques, first of all ultrasonography, they are discovered easily and quickly. Usually, there is only one cyst. Rarely, the patient may have the polycystic liver and the kidney, and the pancreatic disease. We present four patients with nonparasitic true cysts of the spleen. There were three women and one man, 37-years-average age (range from 31 to 45 years). Three patients had solitary splenic cysts. In one patient a large dominant cyst and many small cysts up to 0.5 cm in diameter were found. All patients suffered from left subcostal pain. The size of cysts varied from 6 to 8.5 cm in diameter (average size of 7 cm). All patients were treated surgically by splenectomy, without complications or mortality. Histological findings revealed lyphangiomatic cysts in three patients and epidermoid cyst in one subject. All patients are symptom-free so far.

[Surgical treatment of aneurysms of the femoral artery]

The authors have presented the importance and technics of operative treatment of femoral aneurysms as the only correct method of treatment aiming at prevention of complications which are the consequence of the natural course of the disease. The majority of current operative technics involve total or partial resection of an aneurysm and reconstructive operative approach (graft interposition, bypass) aiming at establishment of the arterial continuity. In the same time the authors have emphasized the importance of echosonographic diagnostical procedure which has even some advantages over angiography, especially in cases with normal central recanalization of the clot.

[Femoro-axillary bypass in the treatment of subclavian steal syndrome]

Extra-anatomic bypass is a nonanatomic procedure of vascular graft from the donor to the recipient artery. The subclavian or axillary artery is very often used for the revascularization of the lower limbs (axillary-femoral bypass). The usage of the femoral artery for the arm or cerebral revascularization is seldom. The authors describe 74-year old woman with femoral-axillary bypass. The bypass was due to subclavian steel syndrome (cerebral and arm vascular insufficiency). Desobstruction and patch angioplasty of the subclavian artery or aorto-subclavian bypass after, transthoracic approach were a contraindication because of the patients advanced age and subcompensated cardiomyopathy. The authors made no typical extraanatomyc bypasses between branches of the aortic arch (carotidosubclavian, or subclavian-subclavian bypass) because of changes on these arteries (occlusion of the left common carotid artery and stenosis of the innominate artery). This is the reason why the femoroaxillary reconstruction was the only possibility of the cerebral and arm revascularization. The Doppler sonographic and angiographic control examination gave good early, and late results. This case is the confirmation of the good use of this unusual method in surgery of subclavian steel syndrome.