Nina Kobilica

Treatment of Primary Infected Juxtarenal Aortic Aneurysm With the Multilayer Stent

Purpose: To report the use of multilayer uncovered stent to treat primary infected juxtarenal aortic aneurysm. Case Report: A 50-year-old man was admitted to hospital for rapid onset of intractable abdominal pain and high fever. Computed tomographic scan showed 2 juxtarenal saccular aneurysms of abdominal aorta with morphologic and clinical changes compatible with infectious etiology. Patient was treated with multilayer flow-modulating stent. Follow-up imaging showed persistent aneurysm exclusion and continuous aneurysm shrinkage of the sac until complete regression to a normal aortic configuration was seen at 1 year. During follow-up (24 months), patient continued to do well, and there was no recurrence of infection. Conclusion: Multilayer stent appeared to be an acceptable treatment option for primary infected juxtarenal aortic aneurysms. Aneurysmal sac completely disappeared and visceral branches remained patent at 2-year follow-up. However, longer follow-up is necessary to evaluate the long-term patency of involved visceral arteries.

Infected femoral pseudoaneurysms from intravenous drug abuse in young adults

SummaryIntravenous or parenteral drug abuse is the most common cause of infected femoral artery pseudoaneurysms (IFAP). This complication of intravenous drug abuse is not only limb threatening but can also be life threatening. The management of IFAP is difficult and controversial. Generally speaking, ligation and excision of the pseudoaneurysm without revascularization is accepted procedure in the majority of patients, with acceptable morbidity and low rate of limb loss. However, it is not an appropriate procedure for cases of acute interruption of the femoral artery flow, where a high probability of amputation is expected. We present four cases of young patients (average 19.5 years, range 17–24) with IFAP, where primary reconstruction was performed due to the absence of a Doppler signal over the pedal arteries after ligation of the common femoral artery. In two cases complications in the form of hemorrhage and repeated infection developed in the late postoperative period; in one case excision and ligation was performed, and in the last case reconstruction with a silver-impregnated dacron prosthesis. None of the patients required an amputation. Overall prognosis is uncertain because of the high incidence of postoperative drug injection despite aggressive drug rehabilitation.

Pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head with venous resection

Abstract Background Recent reports have shown that patients with vascular tumour invasion who undergo concurrent vascular resection can achieve long-term survival rates equivalent to those without vascular involvement requiring pancreaticoduodenectomy alone. There is no consensus about which patients benefit from the portal-superior mesenteric vein resection and there is no consensus about the best surgical technique of vessel reconstruction (resection with or without graft reconstruction). As published series are small the aim of this study was to evaluate our experience in pancreatectomies with en bloc vascular resection and reconstruction of vessels. Methods Review of database at University Clinical Centre Maribor identified 133 patients (average age 65.4 ± 8.6 years, 69 female patients) who underwent pancreatoduodenectomy between January 2006 and August 2014. Clinical data, operative results, pathological findings and postoperative outcomes were collected prospectively and analyzed. Current literature and our experience in pancreatectomies with en bloc vascular resection and reconstruction of portal vein are reviewed. Results Twenty-two patients out of 133 (16.5%) had portal vein-superior mesenteric vein resection and portal vein reconstruction (PVR) during pancreaticoduodenectomy. In fourteen patients portal vein was reconstructed without the use of synthetic vascular graft. In these series two types of venous reconstruction were performed. When tumour involvement was limited to the superior mesenteric vein (SPV) or portal vein (PV) such that the splenic vein could be preserved, and vessels could be approximated without tension a primary end-to-end anastomosis was performed. When tumour involved the SMV-splenic vein confluence, splenic vein ligation was necessary. In the remaining eight procedures interposition graft was needed. Dacron grafts with 10 mm diameter were used. There was no infection after dacron grafting. One patient had portal vein thrombosis after surgery: it was thrombosis after primary reconstruction. There were no thromboses in patients with synthetic graft interposition. There were no significant differences in postoperative morbidity, mortality or grades of complication between groups of patients with or without a PVR. Median survival time in months was in a group with vein resection 16.13 months and in a group without vein resection 15.17 months. Five year survival in the group without vein resection was 19.5%. Comparison of survival curves showed equal hazard rates with log-rank p = 0.090. Conclusions Survival of patients with pancreatic cancer who undergo an R0 resection with reconstruction was comparable to those who have a standard pancreaticoduodenectomy with no added mortality or morbidity. Synthetic graft appeared to be an effective and safe option as an interposition graft for portomesenteric venous reconstruction after pancreaticoduodenectomy.

Revascularization of the superior mesenteric artery alone for treatment of chronic mesenteric ischemia

SummaryBackgroundSymptomatic patients with chronic mesenteric ischemia (CMI) should be treated without much delay because symptoms of CMI are present in 43 % patients who present with acute mesenteric ischemia. There are few reported series with large numbers of patients undergoing surgery for CMI, and many controversies persist regarding the optimal surgical treatment. These controversies include the type of surgical repair (antegrade vs. retrograde bypass), and the number of arteries that should be treated (single- vs. multiple-vessel reconstruction). It was the aim of presented study to report our experience and long-term results with single-vessel bypass grafting from infrarenal aorta to superior mesenteric artery.MethodsPatients who were admitted because of mesenteric ischemia at the surgical clinics of University Clinical Center Maribor between January 1999 and January 2009 were identified with a computerized medical data registry. Patients who underwent revascularization for CMI with retrograde synthetic aortomesenteric bypass were included in the study. Demographics, clinical characteristics, imaging, and operative data were obtained from the medical records. Significant superior mesenteric artery stenosis (> 70 % diameter stenosis) was confirmed by spiral computed angiography. All patients underwent retrograde aortomesenteric arterial bypass with synthetic bypass graft originating from the infrarenal aorta. Doppler sonography combined with color Doppler was used to evaluate disease progression in patients at 3-month interval during the first year and from then at 6-month intervals. Endpoints of the study were occlusion of graft or death by any cause.ResultsData are presented for a cohort of 19 women and 8 men with a mean age at admission 73 years (range 56–88 years). The mean duration of follow-up was 71 months (range 1–118 months). There was one early death (4 %). Four patients died during the follow-up period, and three were lost for follow-up. None of the deaths was connected with mesenteric ischemia. During follow-up period none of the patients developed restenosis, and no occlusions were observed. There were no reinterventions. Symptom improvements were noted in 25 patients (93 %). One patient (4 %) referred to persistent pain despite successful revascularization, although during follow-up period weight gain was observed. At 71 months, freedom from recurrent symptoms, restenosis, and reinterventions was 78 % ± 13.9 %.ConclusionsSurgery for CMI can be safely performed with retrograde approach and single vessel anastomosis. Mortality rates and long-term survival compare favorably with other surgical approaches to treatment of CMI.

Acute mesenteric ischemia caused by isolated dissection of the superior mesenteric artery and thrombotic occlusion of its major branches: treatment by systemic thrombolysis with recombinant tissue plasminogen activator (rtPA)

Introduction. Isolated superior mesenteric artery (SMA) dissection, without associated aortic dissection, is relatively uncommon. Therefore, there are insufficient data to support a particular therapeutic option in the specific setting of isolated SMA dissection associated with thrombotic complications. Case report. In this article we describe the diagnosis and treatment of a patient who presented to the Emergency Department with the clinical picture of an acute abdomen and signs suggestive of acute occlusion of the SMA. Diagnostic studies showed an isolated SMA dissection with acute thrombotic occlusion of its main branches. The patient was successfully treated with systemic recombinant tissue plasminogen activator (rtPA) thrombolysis. To the best of our knowledge, this is the first description of a case of isolated SMA dissection associated with thrombotic occlusion of its main branches. Conclusion. In patients presenting with persistent abdominal pain and unspecific clinical findings, rare causes should be considered because of their life threatening complications. Systemic thrombolysis is a feasible technique for the treatment of isolated SMA dissection associated with thrombotic complications in the absence of bowel necrosis. CASE REPORT SIGNA VITAE 2010; 5(2): 40 42