Background: In patients with vertebral artery origin (VAO) stenosis and concomitant stenoses of other cerebral feeding arteries, data on the risk of percutaneous transluminal angioplasty (PTA) alone and with stent placement (PTAS) for VAO stenosis are limited. We aimed to determine how the presence of polystenotic lesions in other cerebral feeding arteries and concomitant carotid artery stenting (CAS) affect the periprocedural risk and long-term effect of PTA/S for atherosclerotic VAO stenosis. Methods: In a retrospective descriptive study, consecutive patients treated with PTA/S for ≥70% VAO stenosis were divided into groups with isolated VAO stenosis and multiple stenoses. We investigated the rate of periprocedural complications in the first 72 h and the risk of restenosis and ischemic stroke (IS)/transient ischemic attack (TIA) during the follow-up period. Results: In a set of 66 patients aged 66.1 ± 9.1 years, polystenotic lesions were present in 56 (84.8%) patients. 21 (31.8%) patients underwent endovascular treatment for stenosis of one or more other arteries in addition to VAO stenosis (15 underwent CAS). During the periprocedural period, no patient suffered from an IS or died, and, in the polystenotic group with concomitant CAS, there was one case of TIA (1.6%). During a mean follow-up period of 36 months, we identified 8 cases (16.3%) of ≥50% asymptomatic VA restenosis, and, in the polystenotic group, 4 (8.9%) cases of IS. Conclusion: The presence of severe polystenotic lesions or concomitant CAS had no adverse effect on the overall low periprocedural risk of PTA/S of VAO stenosis or the risk of restenosis during the follow-up period.

Objectives Transjugular intrahepatic portosystemic shunt (TIPS) is regularly used in treatment of clinically significant portal hypertension. Liver transplant recipients are, however, rarely indicated for the procedure. The study retrospectively examines the results of TIPS placement in 6 patients after OLT. Methods 4 males and 2 females (aged 36 to 62 years), treated with TIPS between 2007 a 2018, were included in the study. 5 patients had previously undergone liver transplantation for liver graft cirrhosis, 1 patient for Budd-Chiari syndrome. The piggyback caval reconstruction technique was selected in 4/6 cases. PH developed after OLT due to the recurrence of underlying liver condition and sinusoidal obstruction syndrome in half of the cases, respectively. Indications for TIPS were refractory ascites in 4 cases and variceal bleeding in 2 cases. Results Standard TIPS technique was used and technical success was achieved in all cases with a procedure-related complication in 1 patient. One patient died shortly after TIPS placement. The remaining patients all reported regression of clinically significant PH. Late complications appeared in 2 patients. Liver retransplantation after TIPS creation was performed in 1 case. Median TIPS patency was 55 months. 2/6 patient continue to thrive with a patent shunt. Conclusions Transjugular intrahepatic portosystemic shunt in OLT recipients is technically feasible. Favorable clinical outcomes were reported particularly in patients treated for sinusoidal obstruction syndrome who were indicated to TIPS for refractory ascites.

Background Endovascular aneurysm repair (EVAR) has created new possibilities for patients with abdominal aortic aneurysms (AAAs), and in recent years it has become tremendously popular. Use of EVAR in selected groups of patients allows mortality and morbidity to be reduced in comparison to open repair. However, complications such as endoleaks (ELs) can be of great concern and warrant urgent therapy to prevent sac rupture. Case presentation The case report presents urgent endovascular treatment of a high-risk type IA EL in a polymorbid 68-year-old patient 7 years after primary EVAR. The principle of treatment was parallel implantation of the proximal SG extension with the renal SG into the right renal artery (chimney technique). The subsequent type II collateral EL was treated by direct transabdominal AAA sac puncture and thrombin embolization. Conclusion EL can be a cause for urgent intervention, but specific anatomic features often require specialized SG types which are not readily available. The chimney technique allows the use of immediately available stent grafts to address endoleak in the setting of impending abdominal aneurysm rupture.

Anterior circulation stroke (ACS) is associated with typical symptoms, while posterior circulation stroke (PCS) may cause a wide spectrum of less specific symptoms. We aim to assess the correlation between the initial presentation of acute ischemic stroke (AIS) symptoms and the treatment timeline. Using a retrospective, observational, single-center study, the set consists of 809 AIS patients treated with intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). We investigate the impact of baseline clinical AIS symptoms and the affected vascular territory on recanalization times in patients treated with IVT only and EVT (±IVT). Regarding the IVT-only group, increasing the National Institutes of Health Stroke Scale (NIHSS) score on admission and speech difficulties are associated with shorter (by 1.59 ± 0.76 min per every one-point increase; p = 0.036, and by 24.56 ± 8.42 min; p = 0.004, respectively) and nausea/vomiting with longer (by 43.72 ± 13.13 min; p = 0.001) onset-to-needle times, and vertigo with longer (by 8.58 ± 3.84 min; p = 0.026) door-to-needle times (DNT). Regarding the EVT (±IVT) group, coma is associated with longer (by 22.68 ± 6.05 min; p = 0.0002) DNT, anterior circulation stroke with shorter (by 47.32 ± 16.89 min; p = 0.005) onset-to-groin time, and drooping of the mouth corner with shorter (by 20.79 ± 6.02 min; p = 0.0006) door-to-groin time. Our results demonstrate that treatment is initiated later in strokes with less specific symptoms than in strokes with typical symptoms.

Aim: The aim was to assess the dependency of the 90-day clinical outcome on the initial symptoms of ischemic stroke (IS) in patients treated with intravenous thrombolysis (IVT) and/ or endovascular therapy (EVT). Materials and methods: In a retrospective, observational, one-center study, we assessed the effect of initial IS symptoms, achieved times and degree of recanalization on a 90-day clinical outcome in a set of 809 IS patients treated with IVT and/ or EVT. Results: In the IVT group, age (odds ratio [OR] = 0.94, 95% confidence interval [CI]: 0.91-0.96), baseline neurological deficit (OR = 0.91, 95% CI: 0.86-0.96), and the presence of limb paresis (OR = 0.51, 95% CI: 0.25-0.97) were identified as significant negative predictors of a good 90-day clinical outcome. In the EVT (+/- IVT) group, age (OR = 0.93, 95% CI: 0.91-0.95) and initial neurological deficit (OR = 0.84, 95% CI: 0.80-0.89) were identified as significant negative predictors and successful recanalization (OR = 4.31, 95% CI: 2.44-7.81) as a significant positive predictor of a good 90-day clinical outcome (P < 0.05 in all cases). Conclusions: Our results showed that the presence of limb paresis was associated with a worse clinical outcome in patients treated with IVT alone, while the presence of other IS symptoms did not affect a 90-day clinical outcome in patients treated with recanalization therapy.

Aim: To assess the procedural risk of carotid endarterectomy (CEA) in relation to its timing after ischemic stroke and to define the reasons that delay surgery beyond the recommended time interval. Materials and methods: A retrospective analysis was performed using prospectively collected data from all consecutive patients with symptomatic internal carotid artery stenosis who underwent CEA during the period from January 2013 to August 2019. The patients were divided into four groups according to the timing of CEA: group 1 - CEA within 2 days; group 2 - CEA between 3-7 days; group 3 - CEA between 8-14 days; and group 4 - CEA between 15-180 days. The primary outcome measure was the combined perioperative rate of any stroke or death within 30 days. Results: A total of 246 patients were included in the study. The median time interval between stroke and CEA was 8 days. A total of 191 patients (77.6%) underwent CEA within the recommended 14-day period from ischemic stroke, whereas 55 patients (22.4%) underwent CEA more than 14 days after stroke. Medical reasons were the cause of CEA delay in only 18 out of these 55 patients. For the entire cohort, the overall 30-day rate of any stroke or death was 3.7% (9 patients out of 246). The procedural risk was 5.9% (3 patients out of 51) in group 1, 1.5% (1 patient of 68) in group 2, 5.6% (4 patients out of 72) in group 3, and 1.8% (1 patient out of 55) in group 4 (P = 0.477). Conclusion: In this study, the time interval between the stroke and CEA was not associated with significant increase of procedural risk of any stroke or death.

INTRODUCTION:The preferred treatment for acute cholecystitis is cholecystectomy, but for patients with precluded general anesthesia due to critical illness or multiple medical comorbidities it is not suitable. Cholecystostomy could be a minimally invasive therapeutic alternative.AIM:To retrospectively evaluate the indications, technical features, efficacy, complications, patients' development and relationships among monitored parameters of percutaneous computed tomography (CT)-guided cholecystostomies in cases of acute cholecystitis and find the role of this procedure in appropriate treatment selection.MATERIAL AND METHODS:Over the course of 10 years, 75 percutaneous cholecystostomy procedures in 69 patients were performed in cases with diagnosed acute cholecystitis, precluded general anesthesia and contraindicated cholecystectomy by an experienced surgeon and anesthesiologist. These interventions were done using only local anesthesia. The patients were men in 39 cases and women in 33 cases, aged 33 to 91 years.RESULTS:Technical success was achieved in all cases. The indications were sepsis in 34 (45.3%) cases, bridging acute gallbladder inflammatory status in 15 (20%) interventions, serious medical comorbidities in 8 (10.7%) cases, disseminated malignancy and cardiac failure in 6 cases each (both 8%) and neurological affections in 5 (6.5%) cases. Cholecystostomy was frequently the final solution in acalculous cholecystitis (79.3%). The 30-day mortality rate was determined at 10.7% and the overall complication rate was 21.3%, but all of these complications were managed conservatively or using minimally invasive treatment.CONCLUSIONS:Percutaneous CT-guided cholecystostomy is reserved for patients with a serious medical status for various reasons that preclude surgical treatment and general anesthesia. Simultaneously, technical success and efficacy are high and the complication rate is acceptable.

Background: Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (<= 48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE). Methods: A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE). Results: A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 +/- 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 +/- 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS <= 2). Conclusions: Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.

An aggressive periaortic lymphoma could very rarely invade the aortic wall. We present a unique case of a patient with symptomatic thoracic aneurysm and imminent rupture due to the periaortic lymphoma, in which endovascular treatment using stent graft was applied. After stabilization of the aorta and histological confirmation of aggressive B-cell lymphoma by computed tomography–guided biopsy, the antilymphoma therapy was initiated. Despite the full treatment, the patient died 12 months later.

Background: The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. Methods: A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14 days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30 days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. Results: A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2 days (range: 0-13). A subgroup of 6 patients underwent CEA within 24 hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P = 0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. Conclusions: Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.

BACKGROUNDThe composition of intra-arterial clots might influence the efficacy of mechanical thrombectomy (MT) in ischemic stroke (IS) due to the acute occlusions within large cerebral arteries. The aims were to assess the factors associated with blood clot structure and the impact of thromboembolus structure on MT using stent-retrievers in patients with acute large artery IS in the anterior circulation.Methods and Results:In an observational cohort study, we studied the components of intra-arterial clots retrieved from large cerebral arteries in 80 patients with acute IS treated with MT with or without i.v. thrombolysis (IVT). Histology of the clots was carried out without knowledge of the clinical findings, including the treatment methods. The components of the clots, their age, origin and semi-quantitative graded changes in the architecture of the fibrin components (e.g., "thinning") were compared via neuro-interventional, clinical and laboratory data. The most prominent changes in the architecture of the fibrin components in the thromboemboli were associated with IVT (applied in 44 patients; OR, 3.50; 95% CI: 1.21-10.10, P=0.02) and platelet count (OR, 2.94; 95% CI: 1.06-8.12, P=0.04).CONCLUSIONSIn patients with large artery IS treated with the MT using stent-retrievers, bridging therapy with IVT preceding MT and higher platelet count were associated with significant changes of the histological structure of blood clots.

Uvod: Prehepatalni portalni hypertenze (PHPH) je kromě jaterni cirhozy a solidnich nadorů nejcastěji způsobena trombozou v portalnim řecisti (TP). Tromboza v portalnim řecisti se projevuje buď akutně bolestmi břicha s hrozici infarzaci střevni, nebo probiha nepozorovaně a v reakci na zvýsený portalni tlak se tvoři jicnove a žaludecni varixy. V lecbě trombozy porty se řidime novým doporuceni spolecnosti EASL z roku 2016. Cilem teto prace je popsat soubor nemocných lecených pro trombozu v portalnim řecisti ve Fakultni nemocnici Hradec Kralove (FNHK) a porovnat uživane terapeuticke postupy s nově doporucovanou lecbou. Metoda: Retrospektivni popis vsech nemocných lecených s výse zminěnou trombozou porty ve FNHK, ktere se podařilo identifikovat v elektronicke dekumentaci. Výsledky: Soubor se sklada z 52 nemocných, 27 mužů a 25 žen, 44 nemocných s chronickou TP, 6 s akutni TP a 2 se subakutni TP. Vsichni nemocni leceni s akutni nebo subakutni TP dostavali antikoagulacni terapii. Nad to byl u 5 nemocných užit TIPS, z toho ve 4 připadech s lokalni trombolýzou. Nemocni s chronickou TP byli leceni jako pacienti s PH a jaterni cirhozou. Soucasně bylo u těchto nemocných provedeno 6 splenorenalnich spojek, 9 splenektomii, 7 azygoportalnich dekonexi, 4x TIPS, 1x mesenterikokavalni zkrat, 1x embolizace sleziny. Diskuze: Terapie nemocných v nasem souboru splňuje lecebne ukoly z noveho doporuceni, v některých připadech bylo nutne užit i dalsi postupy. Zavěr: K lecbě akutni TP je doporuceno neprodleně zahajit antikoagulacni terapii. U nemocných s chronickou TP je doporuceno v terapii postupovat jako u nemocných s PH při jaterni cirhoze. Komplikovane připady si mohou vyžadovat i dalsi terapeuticke přistupy.

Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA).

Cil: Praskle břisni a panevni výdutě patři mezi nejzavažnějsi život ohrožujici situace s vysokou mortalitou mezi 40–80 %. Retrospektivně jsme analyzovali výsledky endovaskularni lecby u těchto urgentnich stavů. Material/metodika: V obdobi unora 2009 až listopadu 2014 jsme endovaskularně lecili 12 pacientů (12 mužů, průměrný věk 75,2 let) s prasklou aortoilickou nebo panevni výduti. Vsichni pacienti vzhledem k ostatnim komorbiditam byli rizikovi ke standardni operacni lecbě. Jednalo se 7 × o rupturu degenerativni aortoilicke výdutě (rAAA), 3 × rupturu výdutě vnitřni ilicke tepny (AII), 2 × rupturu výdutě spolecne ilicke tepny (AIC). Celkem jsme použili u 7 nemocných bifurkacni stentgraft, u 4 nemocných tubularni stentgraft a jeden pacient byl lecen pouze embolizaci AII (okluder a akrylatove lepidlo). Výsledky: Průměrna doba od přijeti do ukonceni endovaskularni lecby byla 73 minut (rozmezi 45–180 minut). Dvakrat se po lecbě rozvinul břisni kompartment syndrom, který si vyžadal chirurgicke řeseni s drenaži retroperitonealniho hematomu. Třicetidenni letalita v nasem souboru byla 0 %, jednorocni letalita 16,7 % (2/12) a celkova letalita souboru pak 25 % (3/12). V průběhu sledovaneho obdobi se nevyskytly žadne komplikace ci umrti souvisejici s výkonem ci zakladnim onemocněnim (median sledovani 15 měsiců, rozsah 4–48). Zavěr: Akutni endovaskularni lecba prasklých aortoiliackých a panevnich výduti je v nasem centru organizacně proveditelna a dosahuje slibných výsledků. Podle specifickeho protokolu stratifikuje nemocne k endovaskularni ci operacni lecbě. Při dodrženi zakladnich předpokladů planujeme pokracovat v endovaskularni lecbě prasklých aortoilických a panevnich výduti.

Aim . To evaluate the long-term effect of rheohemapheresis (RHF) treatment of age-related macular degeneration (AMD) on photoreceptor IS/OS junction status. Methods . In our study, we followed 24 patients with dry AMD and drusenoid retinal pigment epithelium detachment (DPED) for a period of more than 2.5 years. Twelve patients (22 eyes) were treated by RHF and 12 controls (18 eyes) were randomized. The treated group underwent 8 RHF standardized procedures. We evaluated best-corrected visual acuity, IS/OS junction status (SD OCT), and macular function (multifocal electroretinography) at baseline and at 2.5-year follow-up. Results . RHF caused a decrease of whole-blood viscosity/plasma viscosity at about 15/12%. BCVA of treated patients increased insignificantlyP=0.187from median 74.0 letters (56.2 to 81.3 letters) to median 79.0 letters (57.3 to 83.4 letters), but it decreased significantly from 74.0 letters (25.2 to 82.6 letters) to 72.5 letters (23.4 to 83.1 letters) in the control groupP=0.041. The mfERG responses in the region of eccentricity between 1.8° and 7° were significantly higher in treated patientsP=0.04. Conclusions . RHF contributed to sparing of photoreceptor IS/OS junction integrity in the fovea, which is assumed to be a predictive factor for preservation of visual acuity.

BACKGROUND: Budd-Chiari Syndrome (BCS) is characterized by obstruction of blood flow in hepatic veins. The aim of the study was to analyze diagnosis, etiology and management of BCS.METHODS: We analyzed 44 patients (32 females, 12 males, the mean age <35y of age) treated with TIPS. Ascites was found in 35 patients as the most frequent symptom. The median of total follow-up was 52 months. Non-covered (bare) or covered stent was inserted to all patients. Diagnosis of myeloproliferative neoplasm (MPN) was based on WHO criteria. Other inherited or acquired thrombophilia were assessed as well. Therapy of BCS was with regard to the etiology.RESULTS: The etiology of BCS was identified in 38 cases. Ph- MPN was found as the most common risk factor (50%, N.=22),especially polycythemia vera. JAK2V617F mutation was detected in the most of 22 MPN cases (82.5%). The second most common etiologic factor was inherited thrombophilia (18%, N.=8). In the non-covered (bare) stent group, a primary patency rates 52.9% in 1 year and 20% in 5 years after TIPS (Portasystemic Shunt, Transjugular Intrahepatic) creation. In the covered stent group the 1-year and 5-year primary patency rates were was 80% and 33.3% respectively. The average 5-year re-intervention rate per patient was 1.65 procedures in the bare stent group and 0.67 in the covered stent group. Re-interventions were more frequent in MPN patients. All patients were anticoagulated with heparin at the beginning, switched to vitamin K antagonist. On top of TIPS, anticoagulant and a vigorous therapy of underlying disorder are necessary.CONCLUSION: BCS is a serious and life-threatening disorder in MPD is a major cause of morbidity and mortality. Therapy requires a multidisciplinary approach. Insertion of TIPS dedicated covered stent is a very effective treatment in cases resistant to conservative approach with lower dysfunction rate and the number of re-interventions.

Osteochondromas (exostoses) are the most common benign bone tumours. In most cases, osteochondroma occurs as a solitary lesion. Hereditary multiple osteochondromatosis is an autosomal dominant disorder manifested by multiple exostoses most commonly located at the metaphyses of long bones, the iliac crest, the ribs, the vertebral borders, and scapulas. Vascular complications of multiple osteochondromatosis are very rare, most frequently affecting the popliteal artery. The authors report the case of a 27-year-old female patient with hereditary multiple osteochondromatosis that was complicated by femoropopliteal deep vein thrombosis and giant popliteal artery pseudoaneurysm.