Tomasz Ostrowski

Long-term results of endovascular treatment for May-Thurner syndrome

May-Thurner syndrome is a rare condition caused by compression of the left common iliac vein (LCIV) by the overlying right common iliac artery. This syndrome was shown to occur most frequently between the second and fourth decade of life, more often in women, with a prevalence of 2–5% in the general population. The syndrome was first described by R. May and J. Thurner in 1957. Compression of the LCIV causes disability of blood outflow from the left lower extremity, which results in unilateral LCIV thrombosis, chronic venous insufficiency, and the creation of multiple collaterals crossing the pelvis. Seven women, aged from 22 to 60 (mean 38) years were operated in our Department, and the consecutive mean follow-up period was 25.7 (12–36) months. In the preoperative period, in four cases a critical stenosis of LCIV (from 2 to 3 mm) was diagnosed, while in three other patients the stenosis was accompanied by a distal iliac vein thrombosis. In all cases endovascular therapy was performed. Access to the left common femoral vein or popliteal vein — in the case of iliac deep vein thrombosis — was achieved. After initial predilatation and catheter-based aspiration (in patients with iliac vein thrombosis), intravenous stent placement was performed. For this procedure four Veniti, two Zilver Vena, and one Sinus Venous stent/s (14–18 mm × 60–140 mm) was/were used. Three months after stent implantation duplex Doppler ultrasound revealed stent stenosis in the proximal part of LCIV in three patients. In all those cases re-interventions were conducted. Because of the poor radial strength of previously implanted stents, which was insufficient to compensate for the compression by LCIV, additionally 12–20-mm diameter Wallstents were used. This allowed restoration of blood through LCIV in further observations. Directly after the angioplasty procedure, all patients were given clopidogrel 1 × 75 mg and rivaroxaban (initially 2 × 15 mg, thereafter 1 × 20 mg). Such therapy was advocated for six months, and after that period only antiplatelet drugs were used. The follow-up ultrasound examination, to evaluate stent patency, was performed after three months and subsequently every six months. In four cases angio-computed tomography examinations were done from 18 to 24 months after angioplasty, which confirmed the patency of all implanted stents and good blood flow (Figs. 1–3). Endovascular therapy should be considered as a good method of treatment for May-Thurner syndrome, which prevents severe disablement in the patient — left leg chronic venous insufficiency with all its consequences. In addition, the development of collateral circulation may lead to pelvic congestion syndrome, which should be treated as well. We observed such a necessity in one patient after left iliac vein recanalisation, in whom wide pelvic veins were closed by embolisation coils during endovascular procedure.

Peripheral ARtery Atherosclerotic DIsease and SlEep disordered breathing (PARADISE) trial — protocol for an observational cohort study

BACKGROUND Peripheral arterial disease (PAD) is in fact a group of disease entities with different symptoms and course but a common underlying cause, i.e. atherosclerosis. Atherosclerosis is known to be aggravated by several cardiovascular risk factors, including obstructive sleep apnoea (OSA). AIM Following paper is a protocol for the Peripheral ARtery Atherosclerotic DIsease and SlEep disordered breathing (PARADISE) trial, which aims to describe the prevalence of OSA in PAD patients scheduled for revascularisation, and to determine the effect of OSA on the procedure outcomes. METHODS The PARADISE study is an observational cohort trial. It plans to include 200 consecutive patients hospitalised for revascularisation due to PAD. In every patient an overnight sleep study will be performed to diagnose sleep disorders. Accord¬ing to the results of the test, patients will be divided into two groups: group A - patients with OSA, and group B - patients without OSA (control group). All patients will also be screened for classical and non-classical cardiovascular risk factors. In some of the patients, during surgery, a fragment of atherosclerotic plaque will be collected for further testing. Patients will be followed for one year for adverse events and end-points. Primary end-point of the study will be the failure of revascularisa¬tion defined as recurrence or new onset of the symptoms of ischaemia from the treated region, a need for re-operation or procedure revision, or recurrence of ischaemia signs on the imaging tests. DISCUSSION The data obtained will help determine the incidence of OSA in the population of patients with PAD. The au¬thors expect to show that, as with other cardiovascular diseases associated with atherosclerosis, also in patients with PAD the incidence of undiagnosed OSA is high and its presence is associated with elevated cholesterol, inflammatory markers, and higher prevalence of arterial hypertension and poor control of other cardiovascular risk factors. In addition, due to increased oxidative stress and vascular endothelial injury associated with OSA, patients afflicted with this condition will not only have more advanced atherosclerotic lesions, but also in their histopathological examination their atherosclerotic plaque will exhibit evidence of greater instability and adverse morphology. We also expect to show that in patients with OSA, achieving cor¬rect control of cardiovascular risk factors will be more difficult. The study may improve PAD control through assuring better multispecialty care in PAD patients.

Treatment Algorithm of Peripancreatic Arteries Aneurysm Coexisting with Coeliac Artery Lesion: Single Institution Experience

Introduction True aneurysms of peripancreatic arterial arcades (PAAAs) coexisting with celiac axis lesion are often asymptomatic. However, they may rupture regardless of their size and cause life-threatening hypovolemia. No treatment guidelines exist to date. We present a series of 21 patients and our management algorithm. Material and Methods For ruptured aneurysms we preformed endovascular embolization. Further treatment was dependent on patients condition and control studies. In case of unruptured aneurysms, we assessed collateral circulation between superior mesenteric artery and celiac axis in angio-CT. If there was a pathway free from aneurysms, endovascular approach was chosen. Otherwise, surgical or combined treatment was favored. Results Endovascular treatment was performed in 14 patients with no complications. Follow-up studies revealed incomplete occlusion of the aneurysms in two cases. Surgical or combined treatment was performed in 7 patients with three serious perioperative complications. They were managed conservatively in two cases and surgically in one. Follow-up studies showed aneurismal dilatation and stenosis of a renohepatic by-pass in one case. Conclusion We present our management algorithm of PAAAs. Our results support the leading role of endovascular treatment. We present its limitations favoring surgical or combined treatment. All patients should be carefully followed.

Critical limb ischemia caused by adductor canal compression syndrome — case report with the review of the literature

We report a case of a 55-year-old male who was diagnosed with the adductor canal compression syndrome – a rarely described nontraumatic disorder of the lower limb resulting from the external compression of the superficial femoral artery in the adductor canal, that may present with the symptoms ranging from intermittent exercise-induced claudication up to arterial obstruction and critical limb ischemia.

A hybrid treatment of Kommerell diverticulum saccular aneurysm in a patient with subclavian steal syndrome

Kardiologia Polska Copyright

Hybrid treatment of the infected carotid-subclavian graft complicated by the septic haemorrhage

The paper presents combined method of treatment to 90-year-old female, admitted with the hemorrhage from the chronic purulent fistula in her left neck in the incision post left carotid to subclavian artery bypass in 1971. In the vascular center where she was operate on (outside of Poland) it was suggested, that she should undergo graft excision because of the possibility of graft blow and subsequent exsanguinations as the most severe complication but finally she gave up. In the new circumstances, in the face of no-indirect threat to life, there was urgent need for surgical treatment. Being aware of multiple risk factors from age, general condition and changes in local, developed the concept of radical, yet more saving, to-step procedure. At first by percutaneous means covered stents were implanted into the places of vascular anastomoses, followed by angioplasty of the narrowed origin of left subclavian artery. In the second phase, after a few days, the infected prosthesis was excised and the cavities in the arterial walls of the two arteries were provided. Before, during and after surgery targeted antibiotics were used with classic antiplatelet therapy regimen. Post-operative course was uneventful. The wound healed properly. Which currently consisting of 93 years, as for her age, she in excellent condition overall. There were no signs of infection recurrence observed.

Life Threatening Complication during Treatment of Erysipelas due to Undiagnosed Ischemia of the Calf.

Erysipelas is a superficial skin infection due to streptococci strains, which usually responds well to conservative treatment. Coexisting undiagnosed ischemia of the extremity may lead to severe complications. 57-year-old man developed large, circumflex ulceration of his right calf within two weeks before the admission after three-month treatment of erysipelas. Computer angiography showed chronic occlusion of the superficial femoral artery and the above knee popliteal artery. Rapid debridement of the wound took control over the infection. Patient required complex vascular procedure which allowed to prepare the ulcer for meshed skin grafts. Patient was discharged home on 64th hospital day with completely healed ulcer.