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A late complication of aortic dissection is the dilatation of the weakened aortic wall. The only urgent endovascular alternative to high-risk open surgery in the treatment of postdissection aneurysms is branched endovascular aortic repair (BEVAR), which is extremely difficult due to the intimal membrane in the aorta lumen and the compressed true lumen. In this case report, we present the first application of BEVAR for aortic dissection in Hungary. Our 76-year-old male patient underwent type B aortic dissection 13 years before, for which supraaortic debranching was followed by thoracic stent graft implantation. The patient was admitted with acute chest pain associated with a con-tained rupture of a ten centimetre dilatation of the thoracoabdominal aorta. Our aortic team recommended endo-vascular surgery due to the extremely high risk of open surgery, which the patient accepted. Following selective embolization of the proximal segment of the left subclavian artery, a complex aortic intervention was performed. A new thoracic stent graft was started from the in situ thoracic graft, followed by a branched thoracoabdominal graft, the four branches of which were connected to the celiac trunk, the superior mesenteric artery and the two renal arter-ies. We also implanted a bifurcation graft under the branched graft and a left iliac bifurcation graft due to the complex dissection of the left iliac artery system. After an uneventful procedure, the patient was discharged home on the fourth postoperative day.

Összefoglaló. Az aortadissectio krónikus stádiumában kialakuló thoracoabdominalis tágulatok megoldása multidiszciplináris megközelítést, nagy felkészültséget és fejlett technológiát igényel. A jellemzően többlépcsős műtétsorozat mortalitása és morbiditása az endovascularis technológia fejlődésével csökkent, de még mindig jelentős. A fenesztrált endovascularis aortaműtét a thoracoabdominalis nyitott műtét alternatívája, mely kisebb mortalitással és morbiditással, rövidebb kórházi tartózkodással jár. Aortadissectio esetén történő alkalmazása az aorta lumenében lévő membrán miatt kihívást jelent. Esetbemutatásunkban egy 56 éves nőbeteget demonstrálunk, aki tíz évvel korábban A-típusú dissectio miatt aorta ascendens rekonstrukción esett át. A követés során csaknem a teljes aorta tágulata alakult ki, melynek megoldása három lépésben történt. Az első lépésben a disszekált aortaív nyitott műtétjét végeztük 'frozen elephant trunk' technikával, majd az aorta descendens tágulatának endovascularis kezelése történt sztentgraft-implantációval. A műtétsorozat záró lépése egy fenesztrált endovascularis aortaműtét volt, mely egyben ezen technikának az aortadissectio esetében történt első hazai alkalmazását jelenti. Orv Hetil. 2021; 162(31): 1260-1264. Summary. Thoracoabdominal aortic aneurysms developing in the chronic phase of an aortic dissection require multidisciplinary approach, experienced operators and advanced technology. The mortality and morbidity rate of these multistage operations were reduced with the latest technical achievements in endovascular repair, but they are still significant. Fenestrated endovascular aortic repair, an alternative of thoracoabdominal open repair, is associated with less mortality and morbidity, shorter hospital stay. Using fenestrated devices in aortic dissection is usually technically demanding due to the dissection membrane. We report the case of a 56-year-old woman, who underwent ascending aortic repair due to type A aortic dissection. During the follow-up, a large thoracoabdominal aneurysm developed involving also the arch. We performed a three-stage operation starting with the open repair of the aortic arch using a 'frozen elephant trunk' device followed by a thoracic endovascular aortic repair of the descending aorta. The final stage was a fenestrated endovascular aortic repair, which is the first use of this technique in aortic dissection in Hungary. Orv Hetil. 2021; 162(31): 1260-1264.

Introduction: A new era has begun in the last two decades with the advent of endovascular methods in the therapy of blunt thoracic aorta injuries. Our experiences with the endovascular interventions of blunt aortic trauma in the Cardiovascular Center of Semmelweis University are summarised here., Methods: We included those patients who underwent endovascular intervention due to blunt aortic trauma in a university hospital between 1998 and 2014. The statistical analysis was performed with the use of Excel., Results: 41 patients were selected from our database. There were 34 males, the average age was 47 years (±17 years). Among the 41 patients 15 underwent an acute procedure (12 ruptures) and 26 patients received delayed treatment (in 4 cases due to growing of the pseudoaneurysm). There was only one early postoperative death. Late mortality was 22.5% and 7.5% was related to the aortic injury., Conclusion: Our late mortality and complication rates were similar to other studies, which reinforces international experiences. In the cases when delayed treatment is feasible, the patient can be stabilized and the CTA images can be analyzed for precise stentgraft planning. The treatment of blunt thoracic aorta injured patients should take place in specialized centers capable of such endovascular interventions.

Case Report: The first case was a 77-year-old man with 5.6 cm juxtarenal abdominal aortic aneurysm who presented with multiple comorbidities. The patient had a single left kidney. A custom-made, single fenestrated stent graft was implanted successfully. The one-month follow-up showed a patent left renal fenestration without evidence of any endoleaks. Four months after the operation the patient was admitted with acute uremia. Imaging studies revealed an occluded left renal stent, which was successfully reopened. The second case was a 71-year-old man with 8.0 cm juxtarenal aneurysm. He presented with severe coronary artery disease among other multiple comorbidities in his medical history. He was successfully treated with a 3-vessel custom-made fenestrated stent graft to the renal and the superior mesenteric arteries. The one-month CT imaging revealed patent fenestrations without endoleaks., Discussion: With the development of fenestrated endograft technology, complex aneurysms with visceral artery involvement can be treated with complete endovascular approaches. The first fenestrated endovascular case in Hungary was treated in the Heart and Vascular Center of Semmelweis University, Budapest. The short and middle-term results are offering improved clinical results when compared with conventional surgery, but the long-term outcomes are difficult to ascertain from the current published series.

Introduction: The objective of the study was to analyse the causes of injury, surgical approaches, outcome, and complications with vascular trauma in patients operated on over a period between 1986-2006., Material and Methods: In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 30 cases. In 8 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were complicated by concomitant bone fractures,and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%) crural (22.6%),and ulnar and radial (13.2%) arteries., Results: In 132 cases operation had to be performed. Direct suture 26, interposition in arterial injuries 26, interposition in venous injuries 5, end to end anastomosis in 12 cases, venous patches in 7 cases were the operation method. In 28 cases non-reconstructive operation was carried out, and there were 4 endovascular procedures. Five secondary amputations were performed and five patients died. The limb salvage rate was 95%., Discussion: Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues.

In most cases of vascular repair a graft implantation is needed. Homografts have been proven to be suitable conduits when no autogenous graft is available. High viability index of vein homograft was confirmed during long term refrigerated storage in tissue culture medium, however there was no data of successful implanted cases. We report two cases of great saphenous vein (GSV) homograft implantation with excellent early results. In the first case graft-popliteal bypass was performed with vein homograft after septic ilio-femoral Dacron graft explantation and aorto-bifemoral Silver bypass procedure. Septic crossover synthetic bypass was replaced with GSV homograft in the second case. Long term storage of vein allografts at 4 C is a valuable and cost-effective option for revascularization and we propose wide-scale introduction of this method.

Authors reviewed the records of a patient with a 6 year long history of severing abdominal complaints, correct diagnosis came only in the state of acute abdomen for ileus. He underwent numerous radiological exams and gastroscopies in the course of repeated check-ups in other institute. Due to these results his complaints were managed as gastro esophageal reflux. After years of ineffective therapy his parents and physician suggested him to apply for psychiatric treatment. Finally, for the symptoms and radiological results of mechanical upper small bowel obstruction he underwent urgent laparotomy. Approximately a 40 cm long jejunal invagination was found caused by a large jejunal polyp. Segmental small bowel resection was carried out. Histologic examination of the resected specimen proved Grade I. adenocarcinoma. One year after an uneventful postoperative period the patient is free of complaints and symptoms. The differential diagnosis between upper small bowel obstruction and severe vomiting of esophago-gastro-duodenal origin is relatively difficult. For this we recommend utilizing all the recent diagnostic methods in case of hesitancy or ineffective therapy.

We lose more than 3000 patients a year in Hungary as a result of colorectal cancer. Our aim was to determine how the last 20 years' development of surgical techniques and related specialties has affected the outcome in this patient group at our Department. This retrospective study shows a significant increase in the resectability of colorectal cancer, while there has been a substantial decrease in perioperative mortality.

We analysed the clinical value of the procalcitonin quick test (PCT-Q; BRAHMS Diagnostica, GmbH, Berlin) in infected pancreatic necrosis verified by guided fine-needle aspiration (FNA). In a prospective, controlled study the results of 24 patients were evaluated during 2001. PCT-Q test was performed in patients with necrosis verified on CT scan and/or septic symptoms. If PCT-Q test was positive or septic complication (infected necrosis or abscess) developed CT or US guided fine-needle aspiration was performed with Gram staining and bacterial culture of the sample. Positive FNA result was indication for surgery with repeated staining and bacterial culture of the surgical specimen. Septic complications of pancreatic origin developed in 12 patients. Comparing the results fine-needle aspiration was more authentic with a sensitivity of 92% and a specificity of 100%, while the sensitivity of the PCT-Q test remained 75% and its specificity 83%. Comparing abscess and infected necrosis, significantly higher procalcitonin values were detected in patients with necrosis. These results show that PCT-Q test can be a possible non-invasive method besides fine-needle aspiration. Elevated levels of procalcitonin (higher than 2 ng/ml) clearly suggest infection of the necrosis, while lower values do not exclude the possibility of local septic progression.

Spontaneous rupture of liver hemangiomas is exceptional, they rarely increase in size. Elective surgery of liver hemangiomas is safe and effective. In our teaching hospital during a 5-year period 9 patients underwent elective surgery for giant liver hemangiomas, one more patient required urgent operation for spontaneous rupture. Indications for elective surgery were: abdominal pain in 5 patients, enlargement in 1 patient, and 3 patients were worried about the risk of rupture or having a tumor left in situ. The average age of our four male and six female patients was 44.5 years (30-58). The median largest dimension of the lesions was 8.5 cm (5.5-14); six of them located in the right, four in the left lobe. Enucleation was performed in most patients (8, mostly of them in the right lobe); anatomical resections were performed only in two cases (left lobectomy). There was no postoperative mortality, the only complication was mild pneumonia in one patient. Elective surgery is indicated only in a small number of patients with hemangiomas, it should be limited to giant, symptomatic tumors or those with a documented tendency to increase in size. The type of resection depends on the site and the size of the lesion. Enucleation can be performed rapidly and safely in most patients and as such it is preferable to anatomical resection.

We present six cases of successfully resected primary tumors of the distal part of duodenum (third and fourth segment). Average age of the four male and two female patients was 59 years (47-80). Distal segmental resection were performed in four, pylorus-preserving pancreatoduodenectomy in two cases. Histologically the tumors were five adenocarcinomas, and one gastrointestinal stromal tumor. This tumor causing massive bleeding. In two patients, local lymph nodes were tumor positive, and in one patient synchronous metastasis of the greater omentum was excised during a palliative resection. There was no operative mortality. During a mean follow-up period of 17 months two patients died. Our results support the fact, that radical surgical resection of these tumors, even by segmental resection, provides a more favorable prognosis for duodenal carcinoma than for pancreatic tumors.