Krzysztof Ziaja

Inflammatory markers in patients with internal carotid artery stenosis.

Introduction Available reports underline the significance of the inflammatory process in the development, progression and destabilisation of atherosclerotic plaques in the internal carotid artery (ICA). The aim of this study was to evaluate the relationship between the degree of ICA stenosis, ultrasound plaque morphology and serum concentration of selected inflammatory markers. Material and methods Sixty-five patients with ICA stenosis > 50% (39 symptomatic) and 30 healthy volunteers were enrolled in the study. Clinical, neurological examination and laboratory evaluation (leucocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, tumour necrosis factor-α (TNF-α), interleukins (1β, 6 and 10), anti-cytomegalovirus IgG antibody titre) were performed. Stenosis grade ≥ 70%, ulcerations on the plaque surface and a hypoechoic (or predominantly hypoechoic) structure of the plaque, obtained by colour-coded duplex examination, were accepted as the characteristics of unstable stenoses. Results Unstable ultrasound features of ICA stenosis were found significantly more often in symptomatic than in asymptomatic patients (71.79% vs. 30.71% for stenosis degree ≥ 70%, p = 0.001 and 61.23% vs. 38.46% for unstable plaque morphology, p = 0.01). Patients with ICA stenosis had significantly higher serum concentrations of interleukin-6, fibrinogen, ESR and higher CRP values than the individuals from the control group (p = 0.001, p = 0.009, p = 0.036, p = 0.009 respectively). Patients with unstable plaques structure had significantly higher concentrations of TNF-α, interleukin-6, fibrinogen, higher number of leukocytes, monocytes and higher CRP values than patients with stable plaques (p = 0.008, p = 0.049, p = 0.012, p = 0.0002, p = 0.006, p = 0.0003 respectively). No significant differences in above-mentioned parameters between the groups with stenosis < 70% and ≥ 70% were found. Conclusions There is a relationship between the activity of the selected inflammatory markers in serum and atherosclerotic unstable internal carotid artery stenosis. There is no relationship between serum concentration of inflammatory markers and degree of carotid artery stenosis.

Self-expandable metallic stents in the treatment of post-esophagogastrostomy/post-esophagoenterostomy fistula

SUMMARY.  Esophageus or gaster resection in patients with malignant disease is still a treatment of choice. It is obvious that each surgical procedure in these patients carries some possibility of complications. Esophageo-gastric or esophageo-jejuno anastomosis has a 4–27% frequency of fistula occurrence. All these result in 65% mortality in cases of poorer prognosis. The aim of this paper is not to present all types of complications but to objectively analyse the usefulness of the covered stent placement in the treatment of anastomotic fistulas. We present six patients who were treated for postoperative fistula of esophageo-gastric anastomosis (1 case) or esophageo-jejuno anastomosis (5 cases). All patients were treated with stapler suture for digestive tract reconstruction after malignancy removal during the primary surgical procedure. Signs and symptoms of suture leak between 5–8 days post-surgery were observed. Conservative therapy was not effective. Thus a new method of treatment was employed – covered stent placement. The procedure was performed under X-ray control. In all treated patients there was change for the better and quick reduction of secretion from the fistulas was observed. All patients were discharged from the department after several days and all had survived at 30 days follow-up. Covered esophageal stent placement seems to be a safe and promising method of treatment for patients with anastomotic fistula which significantly reduces mortality and improves quality of live. Our experiences confirms that of other investigators.

Endothelium injury and inflammatory state during abdominal aortic aneurysm surgery: scrutinizing the very early and minute injurious effects using endothelial markers – a pilot study

Introduction One of the most severe complications of repair surgery for abdominal aortic aneurysms (AAA) is acute kidney injury (AKI). Acute kidney injury is an inflammatory process whose pathogenesis involves endothelial cells (EC). The aim of this study was to assess the dynamics of endothelium injury markers measured during elective AAA surgery which might confirm the inflammatory character of AKI. Material and methods The study group consisted of 14 patients with AAA. We measured plasma soluble forms of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), E-selectin, P-selectin as well as the levels of von Willebrand factor (vWF) before, during (including intra-abdominal vein levels before and after aortic clamp removal) and within 2 days after surgery. Results We have found a biphasic response of ICAM-1, VCAM-1 and P-selectin with an initial fall and subsequent rise. However, only VCAM-1 changes were significant compared to its baseline value. The maximum decrease of VCAM-1 was observed in the renal vein 5 min after aortic clamp removal (335.42 ±129.63 ng/ml vs. 488.90 ±169.80 ng/ml baseline value, p < 0.05), and the highest rise 48 h after aortic clamp removal (721.46 ±333.99 vs. baseline, p < 0.05). Conclusions Vascular cell adhesion molecule-1 turned out to be the most sensitive indicator of EC injury and inflammatory status after AAA surgery. During AAA surgery, soluble forms of P-selectin, ICAM-1 and VCAM-1 demonstrate a biphasic response with an initial fall and subsequent rise. These soluble forms could have a modulatory effect on the development of inflammation.

Sapheno-femoral junction pathology: molecular mechanism of saphenous vein incompetence.

A molecular mechanism responsible for varicose vein occurrence was investigated. The role of potential cell cycle regulator p21 and programmed cell death in the pathology leading to the proximal long saphenous vein (LSV) incompetence was investigated. Proximal LSV specimens were obtained from 40 patients with primary varicose veins who had undergone crossectomy. The expression of the p21, p53, and fas encoding genes was investigated by the means of real-time RT-QPCR. Immunostaining for gene product presence, proliferating cell nuclear antigen (PCNA), and apoptotic cells (TUNEL assay) was carried out. The results were compared to the control healthy vein specimens and correlated with pathologic examination findings (of the valve and vein structure). A significant increase in p21, p53, and fas mRNA expression were reported in the proximal incompetent veins. The expression of p21 correlated with expression of p53 (r = 0.658; p<0.05) and negative correlation between media apoptotic index and p21 mRNA expression was found (r = -0.493; p<0.05). Decrease in the muscular component within the media and disturbances of the local structure in the incompetent LSVs were reported. Fas overexpression did not correlate with p53 expression level and did not correlate with apoptotic cell number in the respective vein layers. PCNA-positive cells were present more frequently in the media of the control veins, especially in young subjects. Apoptosis downregulation, cell cycle inhibition and smooth muscle cell hypertrophy are important factors influencing vein wall disturbances related to sapheno-femoral junction incompetence.

Assessment of subclinical acute kidney injury after abdominal aortic aneurysm surgery using novel markers: L-FABP and H-FABP

BACKGROUND One of the most severe complications of repair surgery for abdominal aortic aneurysms (AAA) is acute kidney injury (AKI). Even small rises in serum creatinine are associated with increased mortality. The aim of this study was to assess the dynamics of AKI after elective AAA surgery using novel markers. METHODS The study group consisted of 22 patients with AAA. We measured urinary liver- (u-L-FABP) and heart-type fatty acid-binding proteins (u-H-FABP) before, during and within 3 days after surgery. RESULTS We found an abrupt and significant elevation of both urine FABPs normalized to urinary creatinine; u-L-FABP reached its peak value 2 hours after aortic clamp release {137.79 (38.57-451.79) vs. 9.94 (6.82-12.42) ng/mg baseline value, p<0.05; values are medians (lower-upper quartile)}. The peak value of u-H-FABP was reported 72 hours after aortic clamp release {16.462 (4.182-37.595) vs. 0.141 (0.014-0.927) ng/mg baseline value, p<0.05}. The serum creatinine level did not changed significantly during the investigation period. CONCLUSIONS The significant rise of both u-L-FABP and u-H-FABP after AAA surgery indicates renal proximal and distal tubule injury in this population. Our results suggest that, after AAA surgery, the distal tubules could be more affected than the proximal ones. u-FABPs could serve as sensitive biomarkers of kidney tubular injury and may allow to detect the very early phases of AKI.

Platelet reactivity in thromboelastometry. Revision of the FIBTEM test: a basic study

Abstract This study aimed to investigate modifications to the FIBTEM test to better assess fibrinogen levels and the quality of fibrin polymerization in citrated blood using Multiplate impedance aggregometry to verify platelet inhibition. Blood samples from 26 healthy volunteers were subjected to thromboelastometry studies (EXTEM/FIBTEM tests) in accordance with the standard study protocol (cytochalasin D) and according to a modified protocol (synthetic IIbIIIa receptor antagonist vs. acetylsalicylic acid [ASA] + synthetic IIbIIIa receptor antagonist instead of cytochalasin D). Independent of thromboelastometry, Multiplate impedance aggregometry was used to assess the degree of restriction by the platelet blocked with the following treatments: (1) cytochalasin D, (2) synthetic IIbIIIa antagonist or (3) ASA + synthetic IIbIIIa antagonist to assess the aggregation response to activation with an agonist (ADP, collagen, thrombin receptor activating peptide-6 [TRAP-6], and arachidonic acid). Via aggregometry, cytochalasin D more weakly inhibited platelet aggregation than simultaneous administration of the -IIbIIIa receptor antagonist with ASA. However, total platelet aggregation inhibition was observed after simultaneous administration of cytochalasin D combined with a synthetic IIbIIIa receptor antagonist. In the thromboelastometry, a significant decrease of the A10, A20 and MCF parameters were observed in the EXTEM/FIBTEM tests after they were modified by the addition of a synthetic IIbIIIa receptor antagonist alone or in combination with ASA. In conclusion, in this Multiplate- and ROTEM-based laboratory approach, a two-way blockade (IIbIIIa-antagonist + cytochalasine D) was sufficient to completely inhibit procoagulant platelet function as observed by aggregometry and thromboelastometry.

The influence of atmospheric pressure on aortic aneurysm rupture — is the diameter of the aneurysm important?

BACKGROUND The rate of aortic aneurysm rupture correlates with the aneurysms diameter, and a higher rate of rupture is observed in patients with larger aneurysms. According to the literature, contradictory results concerning the relationship between atmospheric pressure and aneurysm size have been reported. AIM In this paper, we assessed the influence of changes in atmospheric pressure on abdominal aneurysm ruptures in relationship to the aneurysms size. METHODS The records of 223 patients with ruptured abdominal aneurysms were evaluated. All of the patients had been admitted to the department in the period 1997-2007 from the Silesia region. The atmospheric pressures on the day of the rupture and on the days both before the rupture and between the rupture events were compared. The size of the aneurysm was also considered in the analysis. RESULTS There were no statistically significant differences in pressure between the days of rupture and the remainder of the days within an analysed period. The highest frequency of the admission of patients with a ruptured aortic aneurysm was observed during periods of winter and spring, when the highest mean values of atmospheric pressure were observed; however, this observation was not statistically confirmed. A statistically non-significant trend towards the higher rupture of large aneurysms (> 7 cm) was observed in the cases where the pressure increased between the day before the rupture and the day of the rupture. This trend was particularly pronounced in patients suffering from hypertension (p = 0.1). CONCLUSIONS The results of this study do not support the hypothesis that there is a direct link between atmospheric pressure values and abdominal aortic aneurysm ruptures.

Intraluminal thrombus thickness is not related to lower concentrations of trace elements in the wall of infrarenal abdominal aortic aneurysms

BACKGROUND Intraluminal thrombus (ILT) formation plays a significant role in the progression of infrarenal abdominal aortic aneurysms (AAA). Potentially, as ILT thickness increases the availability of trace elements in the aneurysm wall could decrease thereby leading to oxidative stress and intensifying pro-inflammatory cytokine generation. AIM To determine if thrombus thickness is related to the concentration of trace elements in the wall of infrarenal AAA. PATIENTS AND METHODS The concentrations of trace elements in the wall of the aneurysm sack and ILT obtained from 19 consecutive patients during surgery for infrarenal AAA were determined using emission spectrometry. RESULTS The concentrations of magnesium, zinc, manganese, and lead in the wall of AAA were significantly greater than in the ILT. Only the concentration of copper was lower in the AAA wall compared with the thrombus. The concentration of calcium, phosphorus, zinc, lead, copper, and magnesium increased with ILT thickness. The concentrations of no other trace elements in the wall of AAA were found to be related to the ILT thickness. CONCLUSIONS Intraluminal thrombus thickness is not associated with a lower concentration of trace elements in the wall of the infrarenal AAA. Thus, the intraluminal thrombus participates in the progression of AAA by mechanisms independent of trace element supply to the wall of the aneurysm sack.

Purulent Cutaneous Fistula: As the First Symptom of the Late Aortic Stent-Graft Infection—A Case Report and Review of the Literature

Purpose. Aortic stent-graft infection with fistula formation is a rare complication with high mortality rate when treated surgically by stent-graft removal. We report a case of a patient with aortic stent-graft infection, prosthetic-duodenal, and prosthetic-cutaneous fistulas operated without the removal of an infected prosthesis and ineffectively tailored antibiotic therapy. Case Report. A 66-year-old patient with high cardiovascular risk and endovascular stent-graft implantation developed a symptomatic infection of the aortic stent graft 42 months after procedure. It was manifested by iliolumbar muscle abscess and two fistulas: prosthetic cutaneous and prosthetic duodenal. The prosthetic-duodenal fistula was excised and separated from the prosthesis. The perforation within the duodenum was closed in layers. Iliolumbar abscess was removed and drainage was effected .The stent graft was left. The patient received tailored antibiotic therapy. He was readmitted to hospital after 4 weeks with symptoms of infection and leakage of pus discharge in the lumbar area. Despite the antibiotic therapy, the total parenteral nutrition of the patients clinical status and malnutrition deteriorated and he died of cardiac arrest. Conclusion. The presented case confirms that leaving off of the infected stent graft in the patient with severe comorbidity and treated with a tailored antibiotic therapy may not be effective.

Acute Leg Ischaemia from Aortic Occlusion due to Tension Pneumoperitoneum

In this paper, an unusual case of acute leg ischaemia originating from compression by a high pressure pneumoperitoneum is described.