Csaba Dzsinich

[Nutcracker syndrome - treated by surgery].

The nutcracker syndrome is caused by tight compression of the left renal vein between the superior mesenteric artery and the abdominal aorta. The consequences may vary between symptomfree conditions through moderate proteinuria and hypertension to severe hematuria. All imaging modalities have been used during diagnostic workup. Wide varieties of surgical and endovascular solutions are reported aiming to achieve decompression of the renal vein like venous or arterial transposition, bypass, renal autotransplantation, stenting, nephrectomy, etc. In our case a 21-year-old man the nutcracker syndrome was successfully solved by transposition of the superior mesenteric artery into the infrarenal aorta.

Late complications and treatment options of aortic coarctation operated in childhood

INTRODUCTION The prevalence of congenital aortic coarctation is 4 in 10 000 live birth. Aortic coarctation is typically located in the aortic isthmus, but it may occur at atypical sites. Treatment options include both surgical and endovascular interventions. In patients undergoing surgical or endovascular intervention late complications such as recoarctation or aortic aneurysm may develop. AIM The aim of the authors was to analyse their own experience in late complication and treatment options of aortic coarctation operated in childhood. METHOD Retrospective analysis of data of 32 patients treated between 1980 and 2014 for late complications 8-42 years after surgical treatment of aortic coarctation. RESULTS In 28 patients aneurysm formation after isthmic patch plasty was found. Two patients had aortobronchial fistula, 2 patients showed anastomosis disruption and 2 patients had graft stenosis. During operation hybrid solution was performed in 23 patients, isthmic aorto-aortic inlay graft interposition in 5 patients, aorto-aortic bypass in 2 patients, subclavio-aortic bypass in 2 patients, graft patch plasty in one patient and ilio-renal bypass in one patient. Complications included severe intraoperative bleeding in one patient and pneumothorax in one patient. No early or late mortality occurred. CONCLUSIONS The authors conclude that life long control is mandatory in order to detect late complications in patients who underwent operation of aortic coarctation in childhood.

Aortadissectiók zsigeri szövődményei – a thoracoabdominalis refenestratio javallata és technikája

: Aortic dissection is a life threatening cardiovascular catastrophy. Its incidence estimated to 5-6 cases per 100,000 patients/year. The intimal tear happens at the ascending aorta in Type A, meanwhile at the aortic isthmus in Type B, but entry point may develop anywhere alongside the entire aorta. All types may affect a short aortic segment resulting in a localized false aneurysm, others separate the intimal layer at longer extension down to the visceral segment and far beyond to the femoral arteries. Dissection of orifices of side branches may lead to cerebral, upper extremity, spinal, visceral, renal and lower extremity malperfusion. These complications beyond the aortic rupture contribute significantly to high mortality of dissection. Today, first line treatment option in Type A dissection is surgery, but it can be endovascular or medical in Type B dissection. However, awareness of surgical procedures in this field remains inevitable. In this paper we summarize the surgical options for distal malperfusion affecting spinal, visceral, renal and lower extremity circulation.

Atípusos aortacoarctatiók sebészi kezelésének hosszú távú eredményei

INTRODUCTION Aortic coarctation is a frequent congenital cardiovascular disorder representing 5-8% of all cases. It is typically localized in the isthmic region. However, in about 1% of cases coarctation may develop in atypical sites of the aorta and it is frequently complicated with severe hypertension. AIM The aim of the authors was to present diagnostic and surgical methods used in 27 patients with atypical aortic coarctation during the last 35 years with special interest on long-term results. METHOD There was a great advance in diagnostic and surgical treatment methods during the time period analyzed in this study. Nowadays morphologic diagnosis is most commonly obtained using computed tomography angiography and magnetic resonance angiography. Some cases were treated with endovascular techniques, but the authors used also a wide variety of surgical approaches in these patients with atypical aortic coarctation. RESULTS No patient died after surgery and hypertension was reduced in all patients, too. Reintervention was necessary in patients operated in childhood due to change of body measures. CONCLUSIONS Atypical aortic coarctation can be treated surgically with good early and late outcomes. Somatic growth of children may indicate surgical revision.Absztrakt Bevezetes: Az aortacoarctatio a leggyakoribb congenitalis cardiovascularis elvaltozasok egyike, azok 5–8%-aban fordul elő. Tipusos előfordulasi helye az isthmicus szakasz. Atipusos helyen kialakulo coarctatio az esetek mintegy 1%-aban fordul elő es tobbnyire sulyos hypertoniaval szovődik. Celkitűzes: A szerzők celul tűztek ki a korkep sebeszi kezelesi lehetősegeinek es azok hosszu tavu eredmenyeinek ismerteteset 27 beteg műteti kezelesevel szerzett tapasztalataik alapjan. Modszer: A 35 evet felolelő utankovetes soran a diagnosztika es a kezelesi modszerek valtoztak. Napjainkban a morfologiai diagnozis legaltalanosabb modszerei a komputertomografias angiografia es a magneses rezonancias angiografia. Az aortarekonstrukcio lehetősegei az endovascularis technikak bevezetesevel gazdagodtak, de atipusos aortacoartatio eseteben a szerzők ma is tulnyomoan valtozatos sebeszi megoldasokat alkalmaznak. Eredmenyek: A műtetek utan nem veszitettek el beteget. A hypertonia minden esetben jelentősen csokkent. G...

Blunt injury of the thoracic aorta - management tactics and results.

Absztrakt A mellkasi aorta serulese a traumatologia egyik legsulyosabb fejezetet alkotja. A nyilt es transmuralis aortaserules helyszini halalt okoz, a mellkasi aorta tompa serulese azonban gyors szallitassal, diagnosztikaval es megfelelő kezelesi taktikaval az esetek egy reszeben eredmenyesen kezelhető. Az aorta tompa serulese politrauma resze, a beteg sorsat az aorta serulesenek sulyossaga a tarsserulesekkel egyutt jelentősen befolyasolja. A prioritasok meghatarozasa alapjan donthetunk a kezeles mikentjeről es utemezeseről. Az azonnali, a szubakut es a konzervativ kezeles lehetősegei valtozatosak, alkalmazasuk kivalasztasa nagy tapasztalatot es megfelelő, egyenre szabott terapias terv koveteset teszi szuksegesse. A korkep valtozatossaga egyseges vezerfonal kialakitasat neheziti, ezert fontosnak tartjuk sajat tapasztalataink osszefoglalasat es a vonatkozo irodalom attekinteset.

Penetrating atheromatous ulcer of the thoracic aorta. Treatment options

INTRODUCTIONS Atherosclerosis is a generalized degenerative disease of arteries. A rare manifestation of that is the penetrating atheromatous aortic ulceration of the aortic wall which may be complicated by subintimal hematoma, dissection, false aneurysm and rupture (acute aortic syndrome). AIM The aim of the authors was to analyse their experience with this rare disease. METHOD In the department of the authors 10,212 patients underwent surgery for cardiovascular diseases. Among these, 18 patients were diagnosed with penetrating atheromatous aortic ulceration located in the thoracic aorta (ascending aorta 2, aortic arch 8, descending aorta 6 and thoracoabdominal aorta 2 patients). Severe comorbidities were present in the majority of patients. RESULTS Depending on the localisation the authors used various treatment options such as open surgery (4 patients), hybrid techniques (7 patients) and pure endografting (7 patients). One patient died on postoperative day 3. Two patients had late complications due to endoleaks treated successfully by open surgery. CONCLUSIONS The authors conclude that when this dangerous condition detected in time, a wide variety of open, hybrid and endovascular methods can be applied with good results.

Mycotic Aneurysms of the Thoracic and Thoracoabdominal Aorta

We report seven mycotic aneurysms. In five cases the thoracoabdominal aorta, including visceral and renal tributaries, was affected; in one the distal aortic arch was involved; and in one the descending thoracic aorta was affected. The sources of infection were enteritis, chest trauma, peritonitis, pyelitis, pneumonia, and gunshot and splinter injuries. In four cases the septic origin was first detected during surgery. Klebsiella, coagulase-negative Staphylococcus (m = 2), and Salmonella and Escherichia coli were found in cultures; no organism had been recognized in three emergency cases at the time of surgery and the identification remained obscure in one. Debridement, disinfection, and in situ replacement involving side branches were done in four cases; direct suture and patchplasty were performed in the others. Two patients died within 36 h, one 40 days following rupture of the sutures. One patient died after 6 months owing to septic hemorrhage; graft explantation and homograft implantation could not prevent the fatal outcome. Three patients survived, one of whom, a young boy, has been doing well for 10 years. Another patient who had had aggressive antibiotic pretreatment has survived 5 years without signs of recurrence. The third patient underwent aortic replacement 5 months ago and so far has been doing well. Septic aneurysms have a poor prognosis, although antibiotic pretreatment may reduce the risk. If the mycotic aneurysm ruptures or main tributaries are involved, surgery has little chance to prevent a fatal outcome.

Atypical Thoracoabdominal Aortic Coarctation

Atypical aortic coarctation accounts for approximately 2% of all coarctations. The pathological background is supposedly congenital, but the role of Takayasu or autoimmune aortitis has been emphasized in recent studies. During 1980–1999 we registered 23 patients (8 females, 15 males) with atypical aortic coarctation. The age ranged between 2 and 50 years (mean 22 years). Morphology varied from short stenosis to involvement of the entire thoracoabdominal aorta. Clinical manifestations were hypertension (n = 22), claudication (n = 4), and malabsorption (n = 2). Excessive hypertension led to cardiac failure in four patients. Epigastric bruit was a typical sign. Digital Subtraction angiography provided the diagnosis. Localization was thoracic in 5 cases, thoracoabdominal in 6, suprarenal in 11, and infrarenal in 1. Surgery included patchplasty in 17, aortoaortic bypass in 4 (with reimplantation of visceral and renal arteries in 2), splenorenal bypass in 2, and splenohepatorenal bypass in 1. There was no early morbidity. The follow-up period ranged between 3 and 20 years (mean 8 years). An aortoenteric fistula developed in one patient but healed but after removal of the infrarenal patch. Two patients required repeated surgery 8 and 4 years, respectively, after primary repair (following growth). All patients ultimately became normotensive. We concluded that atypical aortic coarctation may be found in the background in hypertensive children or in young adults. Surgical repair provides good results, but normal growth may necessitate repeated surgery.