Gloviczki, Péter

Background: Hybrid debranching repair of pararenal and thoracoabdominal aortic aneurysms was initially designed as a better alternative to standard open repair, addressing the limitations of endovascular repair involving the visceral aorta. We reviewed the collective outcomes of hybrid debranching repairs using extra-anatomic, open surgical debranching of the renal-mesenteric arteries, followed by endovascular aortic stenting. Methods: Data from patients who underwent hybrid repair in 14 North American institutions during 10 years were retrospectively reviewed. Society of Vascular Surgery scores were used to assess comorbidity risk. Early and late outcomes, including mortality, morbidity, reintervention, and patency were analyzed. Results: A total of 208 patients (118 male; mean age, 71±8 years old) were treated by hybrid repair with extraanatomic reconstruction of 657 renal and mesenteric arteries (mean 3.2 vessels/patient). Mean aneurysm diameter was 6.6±1.3 cm. Thoracoabdominal aortic aneurysms were identified in 163 (78%) patients and pararenal aneurysms in 45 (22%). A single-stage repair was performed in 92 (44%) patients. The iliac arteries were the most common source of inflow (n=132; 63%), and most (n=150; 72%) had 3 or more bypasses. There were 30 (14%) early deaths, ranging widely across sites (0%–21%). A Society of Vascular Surgery comorbidity score >15 was the primary predictor of early mortality ( P <0.01), whereas mortality was 3% in a score ≤9. Early complications occurred in 140 (73%) patients and included respiratory complications in 45 patients (22%) and spinal cord ischemia in 22 (11%), of whom 10 (45%) fully recovered. At 5 years, survival was 61±5%, primary graft patency was 90±2%, and secondary patency was 93±2%. The most significant predictor of late mortality was renal insufficiency ( P <0.0001). Conclusions: Mortality after hybrid repair and visceral debranching is highly variable by center, but strongly affected by preoperative comorbidities and the centers’ experience with the technique. With excellent graft patency at 5 years, the outcomes of hybrid repair done at centers of excellence and in carefully selected patients may be comparable (or better) than traditional open or even totally endovascular approaches. However, in patients already considered as high-risk for surgery, it may not offer better outcomes.

Background: Repair of thoracoabdominal aortic aneurysms (TAAAs) continues to be a challenging task. Hemorrhagic shock, cardiac arrest and multisystem organ failures are the most frequent causes of death, and paraplegia and renal failure are the most devastating complications. Methods: Flawless surgical technique and the use of adjuncts to protect key organs including the brain, heart, spinal cord, liver and kidneys affect outcome. Perfection in exposure and suturing technique decreases bleeding complications, shortens cross-clamp time and assures optimal, visceral, renal and lower extremity perfusion. Technical details include retroperitoneal abdominal aortic exposure, double thoracotomy for Type I and Type II aneurysms, and preservation of the diaphragm. The kidneys are protected by perfusion of iced lactated Ringers; visceral ischemia in Type 1 and Type II, aneurysms is diminished by using pulmonary vein-femoral artery pump with sequential clamping. Spinal cord protection is attempted by spinal fluid pressure monitoring and drainage, moderate general hypothermia, selective left heart bypass, reimplantation of critical intercostal arteries, monitoring somatosensory and somatomotor evoked potentials and epidural cooling of the spinal cord. Results: Outcome in 203 patients (Group I) who underwent repair of TAAAs without epidural cooling was compared with outcome in 97 patients, 27 with thoracic aortic aneurysms and 70 with TAAA (Group II) who underwent repair using epidural cooling. In Group II paraplegia/parapesis occurred in 11.6%. not different from the 8.9% in Group I. Thirty day mortality for elective cases decreased from 14.6% (Group I) to 7.2% (Group II, P<0.05). Conclusions: Open surgical repair of TAAA carries elevated mortality and complication rates. The etiology of ischemic and reperfusion injury to the spinal cord is multifactorial and its prevention remains a formidable and as yet unresolved task. To select patients for surgical repair, the risk of TAAA rupture should be balanced against risks of perioperative mortality, paraplegia and renal failure.

Between 1978 and 1990, 32 patients (15 men and 17 women; mean age 48 (range 15–83) years) underwent 35 operations for renal artery aneurysm (4.2% of 829 renal artery repairs). Eleven patients presented with acute symptoms (nine with hematuria, eight with abdominal pain, two with acute hypertension). Twenty-eight of the 32 patients had chronic hypertension. The diagnosis was confirmed by angiography in all but two. The mean diameter of the renal artery aneurysm was 1.7 (range 0.7–9.0) cm. Seventeen patients had concomitant renal artery stenosis; none of the aneurysms ruptured. Nephrectomy was performed in seven patients and excision of the aneurysm without reconstruction in five. Twenty patients underwent 23 reconstructions using lateral suture (three procedures), vein patch (three), saphenous vein (13), Dacron (three) or composite (vein and hypogastric artery) graft (one). Seven patients underwent ex vivo renal artery repair. There was no perioperative death or secondary nephrectomy. One postoperative graft occlusion was successfully revised. Hypertension improved in 50% of patients. The presence of hypertension, enlargement of a renal artery aneurysm, solitary kidney, bilateral involvement, acute hematuria or potential loss of kidney or renal function may be indications for surgical treatment of an aneurysm > 1.5 cm in diameter. A renal artery aneurysm of any size should be repaired in women who may become pregnant. Where there is branch involvement, ex vivo repair is the procedure of choice for renal salvage.

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German–Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients. The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German–Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German–Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

Objectives To assess the ability of the current classification system for popliteal entrapment syndrome to accurately capture all patients, and if not, to design an all-inclusive new classification. Methods Retrospective review of all interventions performed for popliteal entrapment syndrome between 1994 and 2013 at our institution was performed. Preoperative imaging and intraoperative findings were used to establish the compressive morphology of popliteal entrapment syndrome. Patients were categorized, when possible, into six types of the current classification system (Rich classification, modified by Levien) and into seven types of a new classification. Results Sixty-seven limbs of 49 patients were operated on for unilateral (31) or bilateral (18) popliteal entrapment syndrome. The current classification system captured the anatomy of only 43 (64%) of 67 limbs with popliteal entrapment syndrome. Compressive morphologies without a defined class included aberrant insertion of the lateral head of gastrocnemius muscle, muscle slip originating from the lateral head of gastrocnemius or hamstrings, hypertrophied hamstring muscle, abnormal fibrous bands, perivascular connective tissue, and prominent lateral femoral condyle. The new classification captured 100% of the limbs with popliteal entrapment syndrome. Conclusions Current classification of popliteal entrapment syndrome is inadequate as more than one-third of the cases reviewed fell outside of the standard classification system. Consideration of a more inclusive new anatomic classification system is warranted.

Összefoglaló. A thoracoabdominalis aortakirekesztés okozta gerincvelő ischemia súlyos neurológiai következményeit számos klinikai és kísérleti tanulmány bizonyítja. E nehezen kiszámítható, súlyos szövődmény megelőzésének érdekében régi törekvés megfelelő intra- és posztoperatív monitorizálás kifejlesztése, ami előre jelzi a gerincvelő-funkció romlását, illetve a kialakuló celluláris károsodást. A legelterjedtebb, a klinikai gyakorlatban széles körben alkalmazott megoldás a gerincvelői kiváltott motoros potenciál (MEP) folyamatos ellenőrzése. Ritkábban alkalmazott – bár ígéretes – eljárás a biokémiai változások nyomon követése, ami a sejtszintű károsodás markereit használja fel az ischemia okozta változások felismerésére. Korábbi dolgozatunkban kutyákon végzett kísérleteink azon eredményeit ismertettük, amelyekben a 60 perces thoracoabdominalis aortakirekesztés okozta neurológiai változások és a perfúzió adatainak összefüggéseit tárgyaltuk. Jelen tanulmányunkban a gerincvelői motoros (MEP) és szenzoros (SEP) kiváltott potenciálok változásait vizsgáljuk a neurológiai végállapot vonatkozásában. Megállapítottuk, hogy SEP változásai a neurológiai károsodás mértékével értékelhető összefüggést nem mutatnak. A MEP-amplitúdó és -latencia értékei biztonsággal jelzik a fenyegető gerincvelő ischemiát. A neurológiai deficit mélységét (Tarlov 2,1,0) a MEP-értékek változásai numerikusan nem értékelhetően követik. Summary. Severe neurological complications of the thoracoabdominal aortic clamping were published in numerous clinical and experimental studies. These hardly predictable, devastating consequences demanded to develop a monitoring system which might detect impending level of spinal cord ischemia in time – in order to introduce or enhance protective procedures and prevent permanent neurological deficit. The most widely used monitoring in clinical practice is the continuous surveillance of the motor evoked potentials (MEP) during and after thoracoabdominal aortic clamping. Much less used, but promising opportunity is to control the metabolic changes and cellular integrity utilizing specific markers like liquor lactate and neuron specific enolase (NSE) etc. In our earlier study we published data of our canine experiment related to coherencies between neurological outcome and specific perfusion of the spinal cord during and after one hour thoracoabdominal aortic clamping. In the present paper we investigate the behavior of motor evoked (MEP) and sensory evoked (SEP) potentials related to neurological changes. We conclude the behavior of SEP values hardly correlate with the neurologic outcome, meanwhile decrease of MEP amplitude provides reliable signal for developing spinal cord ischemia. We could not confirm a numeric correlation of these data and the level of the final neurologic outcome.

Összefoglaló. A thoracoabdominalis aorta kirekesztése a gerincvelő keringésének csökkenését okozza. Az ischemia klinikailag paraparesis, paraplegia formájában jelenik meg. Ez elsősorban nyitott műtétek során jelent aligha kiszámítható szövődményt, de a modern endovascularis technikák sem oldották meg teljes mértékben ennek biztonságos kivédését – bár arányát jelentősen mérsékelték. A javuló eredmények számos tényezőre vezethetők vissza, mint a keringés kirekesztési idejének csökkentése, a gerincvelő-funkció és metabolismus ellenőrzése. Mesterséges keringésjavító direkt és indirekt eljárások, liquor drainage, hűtés mellett a collateralis keringés javítását szolgáló prekondicionáló módszerek kerültek bevezetésre. Kísérletes munkánkban 25–30 kg testsúlyú kutyákon vizsgáltuk – más paraméterek mellett – a distalis perfusio növelésének, a liquornyomás csökkentésének, illetve ezek kombinációjának protektív hatását egyórás thoracoabdominalis aortakirekesztés során. Dolgozatunkban a kísérleti állataink neurológiai végállapotát a keringési paraméterek és szöveti perfusio és a reperfusio változásainak összefüggésein keresztül tárgyaljuk. Megállapítottuk, hogy distalis gerincvelő reperfusiós hyperaemiája szorosan összefügg a neurológiai károsodás mértékével. Summary. Clamping of the thoracoabdominal aorta reduces perfusion of the spinal cord significantly, which clinically may present as paraparesis or paraplegia – devastating and unpredictable complications of open thoracoabdominal aortic surgery. Introduction of monitoring of evoked potentials and/or biochemical markers, methods increasing distal arterial pressure, indirect procedures enhancing residual flow (like liquor drainage), drugs, and use of hypothermia contributed to achieve better outcome. Preconditioning of spinal cord circulation is also a promising method. New endovascular techniques for thoracoabdominal aortic aneurysms and dissections reduced surgical trauma significantly. Despite all these progressions spinal cord ischemic damage is still a significant risk. To address this problem we carried out an experimental work using a canine model focusing on the protective effect of distal arterial perfusion, spinal fluid drainage, and their combination in a one hour setting of thoracoabdominal aortic clamping. In this paper we publish our data of circulatory and specific perfusion parameters of the spinal cord during and after declamping in correlation of final neurologic outcome.

Background To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. Methods A review of our EVA database (1998–2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. Results 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46–018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69–0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. Conclusion Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30–90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6–12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.