Pavel Elias

Detailed evaluation of 2959 allogeneic and xenogeneic dense connective tissue grafts (fascia lata, pericardium, and dura mater) used in the course of 20 years for duraplasty in neurosurgery

SummarySurgical experience with 2959 allogeneic and xenogeneic dense connective tissue grafts (1767 of fascia lata, 909 of pericardium, and 283 of dura mater), used in 2665 neurosurgical operations performed in the course of 20 years (1976 to 1995) is reported.Duraplasty using either allogeneic or xenogeneic grafts has had a similar, and favourable clinical outcome. Nevertheless, the pliable deep frozen fascia lata grafts, which could be used in any location, have been reserved for sella turcica plugging, anterior cranial base plasty, aneurysmal wrapping, and surgery of lipomyelomeningocele. Pericardium and dura mater grafts were in the majority of cases used over the brain convexity and posterior cranial fossa. Ovine pericardium proved to be superior to bovine and allogeneic pericardia because of its workability, flexibility, reduced thickness, and better transparency.Postsurgical complications occurred in 7.3%, and they were: 1) cerebrospinal fluid fistulas in 2.8%; 2) meningites in 2.3% (aseptic 1.4%, bacterial 0.8%, and tumoural 0.1% meningites); 3) pseudomeningoceles in 2.2%; 4) wound infections in 0.6%; 5) malresorptive hydrocephalus in 0.5%; and 6) adhesions to nerve tissue in 0.5%. The majority of complications healed without surgery. Forty-eight grafts (1.6%) failed to fulfil the requirements of the surgeon, and 46 of them were re-operated upon. Though another thirty-nine grafts healed successfully, 39 shunts (1.5%) had to be performed for malresorptive hydrocephalus (0.9%), and/or for a big pseudomeningocele (0.6%). So, the pure complication rate in 2665 duraplasties was 3.1%.The complex evaluation of the allogeneic and xenogeneic grafts (fascia, pericardium, and dura mater), used for duraplasty in neuro-surgery during the last 20 years proved them, as remarkably good, with a success rates of 96.9%.

Catheterobronchial fistula due to vena cava superior thrombosis as a late complication of ventriculoatrial shunt

A case of a catheterobronchial fistula as a rare late complication of a ventriculoatrial shunt is reported. The ventriculoatrial shunt was implanted in a 4-monthold boy suffering from extreme postinfectious hydrocephalus. During the following years, twelfth nerve palsy on the right, vertebralgias, and salty taste sensations in the mouth associated with intermittent coughing and swelling of the neck and supraclavicular region on the right side developed. Valvography established a diagnosis of fistula 12 years after the implantation of a shunt. Ultrasonography of the neck and mediastinum and contrast-enhanced dynamic computed tomographic scanning demonstrated a catheterobronchial fistula to the subsegmental bronchus of the anterior segment of the right upper lung lobe, a thrombosis of the right internal jugular and both right and left brachiocephalic veins and the superior vena cava, and an extensive collateral venous system mainly draining into the azygos vein. Normalization of cerebrospinal fluid and blood flow and pressure allowed extraction of the “atrial” catheter without complications. One year after surgery the boy is in good health and without signs of shunt dependence.

Chronic thromboembolic pulmonary hypertension after the first episode of pulmonary embolism? How often?

BACKGROUND Surviving pulmonary embolism (PE) brings a risk of thromboembolic disease chronicity. Chronic thromboembolic pulmonary hypertension (CTEPH) develops as a result of one or multiple pulmonary embolic events. It is an incapacitating long-term complication of thromboembolic disease with a negative impact on the patients quality of life and prognosis. Contemporary pharmacological and especially surgical treatment possibilities offer hope for the patients full recovery, but an early diagnosis is crucial for success. METHODS In a prospective study cohort of 97 consecutive patients with a proven diagnosis of PE as the first documented thromboembolic event we tried to estimate the incidence of CTEPH during a 2-year follow-up. RESULTS Four individuals from our study population developed CTEPH, which represents an incidence of 4.2%. CONCLUSION Chronic thromboembolic pulmonary hypertension in pulmonary embolism survivors is a not uncommon complication deserving the attention of clinicians. Patients at risk of CTEPH can be identified for effective follow-up according to echocardiographic finding of elevated pulmonary artery systolic pressure and NT-proBNP levels at the time of hospital discharge.

Computed tomography pulmonary embolism residua index (CTPER-index): a simple tool for pulmonary embolism residua description

Objective: Chronic thromboembolic pulmonary hypertension (CTEPH) is a relatively common long-term complication of acute pulmonary embolism (PE) with severely negative impact on the patient’s quality of life and prognosis. The aim of our study was to assess morphological changes, with respect to CTEPH development, in the pulmonary artery vascular bed 6 months after diagnosis of acute PE as the first thromboembolic event in the patient`s history. Methods: Our prospective study included a population of 87 consecutive patients with proven PE. Multidetector computer tomography pulmonary arteriography (CTA) was performed 6 months after acute PE to assess residua of thrombi and abnormalities supporting the presence of pulmonary hypertension. To quantify the individual totality of morphological abnormalities, a computer tomography pulmonary embolism residua index (CTPER-index) was constructed and groups of patients with and without CTEPH were compared. The study follow-up was 24 months, with echocardiography performed 6, 12, and 24 months after PE. Results: Morphological abnormalities corresponding to thrombi residua or pulmonary hypertension on CTA were found in 68% of patients. The CTPER-index reached significantly higher values in patients with CTEPH during a 2-year follow-up. A CTPER-index value ≥4 equates to a 12-fold higher risk of CTEPH development (p=0.013) with sensitivity 0.80 (95% CI 0.31; 0.989) and specificity 0.79 (95% CI 0.754; 0.799). Conclusion: Our CTPER-index may provide useful information for a clinician performing CTA for differential diagnosis of dyspnea in a patient with a history of PE.