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Background and objectives: The objective of this study was to assess the value of a whole-body bone scintigraphy using 99m technetium labelled-methyl diphosphonate (99mTc-MDP) for the diagnosis and the assessment of grades of muscle damage after prolonged acute or chronic obstruction of the main arteries in lower extremities. Material and Methods: Fifty consecutive patients were selected for the study. The patients’ condition had not improved after primary peripheral arterial reconstruction operation or limb amputation and after conservative treatment. The clinical suspicion was of arterial obstruction and muscle necrosis. All the patients underwent whole-body scintigraphy with 99mTc-MDP. Muscle necrosis was identified as an increased soft tissue uptake of 99mTc-MDP. Results: Forty-five patients had gross muscle necrosis detected on whole-body scintigraphy with 99mTc-MDP and were histologically confirmed after repeated surgery (necrectomy or amputation) or by muscle biopsy, if only fasciotomy was performed. The location and extent of muscle injury were assessed preoperatively and the findings were confirmed in all 45 patients. Twelve patients with clinically suspected minor muscle damage, which was confirmed as relatively minor muscle necrosis on 99mTc-MDP scintigraphy, were treated conservatively. The clinical outcome of all 50 patients was favorable. The 99mTc-MDP scintigraphy, in detection of muscular necrosis, demonstrated sensitivity, specificity, and accuracy of 97.3% (95% confidence interval (CI) 85.4 to 99.3%), 30.77% (95% confidence interval (CI) 9.09 to 61.43%), and 80% (95% confidence interval (CI) 66.28 to 89.97%), respectively. Conclusion: The 99mTc-MDP scintigraphy is a valuable tool in the detection of muscular necrosis. It is able to define location, extent, and grade of involvement. Therefore, it has a clinical impact in patient management, allowing clinicians to select adequate treatment policy and specify the scope of necrectomy.

Reikšmingi žodžiai: ortotopinė kepenų transplantacija, pradinė kepenų transplantato funkcija, komplikacijos po transplantacijos. Tikslas. Kepenų transplantacija yra rutininis kepenų terminalinio funkcijos nepakankamumo gydymo būdas Vilniaus universiteto ligoninės Santariškių klinikose (VUL SK). Labai svarbi yra pradinė persodintų kepenų funkcija, nes pagal ją galime spręsti apie tolesnę pasveikimo eigą. Pastebėta, kad po kepenų transplantacijos žymiai keičiasi kepenų fermentų koncentracijos kraujyje. Šiuo straipsniu siekiama apžvelgti VUL SK transplantacijų centro recipientų laboratorinių rodiklių kitimą po transplantacijos ir įvertinti juos atsižvelgiant į veiksnius, kurie galėjo turėti įtakos persodinto organo funkcijai. Tyrimo medžiaga ir metodai. Atlikta retrospektyvinė 57 pacientų laboratorinių tyrimų rezultatų analizė po ortotopinių kepenų transplantacijų, kurios buvo atliktos VUL SK nuo 2005 metų liepos iki 2014 m. rugpjūčio mėnesio. Pooperacinis sergamumas buvo vertintas pagal tai, ar pooperacinis laikotarpis komplikavosi hematoma, tulžies latakų nesandarumu, kraujagyslių tromboze arba ankstyva mirtimi. Taip pat buvo atsižvelgta į konservanto kiekį, panaudotą transplantatui plauti, kraujo netektį, šaltos ir šiltos išemijos laiką, MELD rodiklį. Vertinimas vyko naudojant ASAT, ALAT, ŠF, GGT, LDH, laktatų, bilirubino (tiesioginio, netiesioginio) ir protrombino aktyvumo rodiklius pirmomis septyniomis pooperacinėmis dienomis. Buvo siekiama nustatyti statistiškai reikšmingą šių duomenų vertės kitimą, siejamą su pooperacinėmis komplikacijomis ir kitais minėtais veiksniais. Rezultatai. Lyginant recipientų grupių ASAT ir LDH koncentracijas, kurie po transplantacijos turėjo komplikacijų ir kurie jų neturėjo, rastas statistiškai patikimas skirtumas nuo 2 paros po operacijos. Tarp konservanto kiekio, naudojamo plauti, ir kepenų fermentų dinamikos koreliacijos nerasta. Tačiau pacientų grupėje, kurioje buvo naudota ≤11 litrų skysčių – tulžies latakų nesandarumo atvejų buvo 4,3 karto mažiau ir kitos komplikacijos buvo retesnės. Šalta ir šilta išemija neturi statistiškai patikimos koreliacijos su fermentų dinamika. Pacientų grupėje, kurių transplantato šaltoji išemija truko

Objective. Arteriovenous malformations (AVMs) are an uncommon vascular pathology that remains challenging to accurately diagnose and successfully treat. This study introduces a novel way to evaluate AVM treatment outcomes using transarterial lung perfusion scintigraphy (TLPS) and reports our treatment results. Material and Methods. The patients treated for extracranial AVMs were studied retrospectively. Diagnosis and outcomes were based on clinical data, ultrasonography, magnetic resonance imaging, computed tomography, angiography, and TLPS studies. The influence of gender; location, form, and stage of AVMs; first attempt at treatment; and treatment modalities was analyzed. Outcomes were defined as positive (cure, improvement, and remission) or negative (no remission and aggravation). Results. Of the 324 patients with congenital vascular malformations, 129 (39.8%) presented with AVMs, and the data of 56 treated patients with AVMs were analyzed. Of the 29 patients in the endovascularly treated group, 15 in the surgically treated group, and 12 in the combined treatment group, 24 (82.8%), 14 (93.3%), and 10 patients (83.3%), respectively, had positive outcomes (P>0.05). All outcomes were positive in surgically treated patients with extratruncular limited AVMs, and these patients were more likely to be cured as compared with those who had other forms of AVMs (OR, 5.8; 95% CI, 1.1–29; P=0.02). The patients with more advanced AVMs (stages III and IV) and with AVMs in the gluteal and pelvic region were more likely to have the worst outcomes than those with stage II AVMs (OR, 8.2; 95% CI, 1–72; P=0.03) and with AVMS in other locations (OR, 5.8; 95% CI, 1.1–29; P=0.02), respectively. Gender and age did not significantly influence treatment results (P>0.05). The TLPS data of 17 patients showed AV shunting ranging from 0% to 92%, which combined with other results helped identify 9 patients who needed further interventions, 6 who were treated successfully, and 2 who had insignificant shunting. Conclusions. The best outcomes were achieved in surgically treated patients with localized lesions and less advanced AVMs. For the first time in Lithuania, a modified TLPS method has been introduced that enhances a hemodynamic assessment of AV shunting and provides with a more accurate evaluation of AVMs to better serve in planning future treatments.

We reported a case of 68-year-old man, with a previous history of hypertension. Patient was admitted to our institution for evaluation of a severe, constant, tearing anterior chest pain radiated to the neck with suspicion of acute aortic dissection. A multidetector computed tomography scan of thorax and abdomen demonstrated a dissection starting from the middle part of aortic arch and extending downward to the descending aorta till the middle part of the thoracic aorta. The dissection was classified as Stanford A, De Bakey I. Surgical treatment of patient was started with bypass graft from the right common carotid artery to the left common carotid with subsequent revascularization of left subclavian artery. Lower parts of above-mentioned arteries were ligated. At the second stage an emergent prosthetic stent-graft was placed distally from the truncus brachiocephalicus up to the proximal part of the descending aorta. We reported a case report to present diagnostic and possible interventional treatment for patient with acute aortic type A dissection. © Copyright 2012 Gediminas Rackauskas et al.

Liver transplantation has become the treatment of choice for chronic and acute end-stage liver failure as well as for selected cases of malignancies and metabolic disorders. We report our first experience of the orthotopic liver transplantation.Between 2005 and 2008 16 cadaveric orthotopic liver transplantations in 16 adults (12 males, 4 females, mean age 44 years) were performed. Main indications for orthotopic liver transplantation were cholestatic liver disease (31%), viral-induced cirrhosis (25%), alcoholic liver disease (19%), hepatocellular carcinoma associated with hepatitis virus infection (13%), autoimmune cirrhosis (6%), cryptogenic acute liver failure (6%). Mean follow-up was 15 month (range: 4 days - 43 month).Intraabdominal haemorrhage was observed in 6 patients (37.5%). Vascular complications were observed in 3 patients (18.75%). Biliary complication were observed in 3 patients (18.75%). Overall 1 year patient survival was 87,5%. Four (25%) patients died during follow-up. All patients died because of sepsis and multiorgan system failure.Our first results showed that secret of successful liver transplantation is perfect interdisciplinary team approach, including selection of the recipient and timing of transplantation, the operative procedure itself, prevention and treatment of complications, the perioperative anaesthesiological and intensive-care management, and careful follow up after transplantation.

Narimantas Markevicius 1 , Gintaras Apanavicius 1 , Stanislovas Scerbinskas 2 , Marijus Gutauskas 1 , Vytautas Triponis 3 1 Vilniaus universiteto Kraujagyslių chirurgijos klinika, Vilniaus miesto universitetinės ligoninės I angiochirurgijos skyrius 2 Vilniaus universiteto Kraujagyslių chirurgijos klinika, Vilniaus miesto universitetinės ligoninės Rentgenoangiografinių tyrimų skyrius 3 Vilniaus universiteto Kraujagyslių chirurgijos klinika, Vilniaus miesto universitetinės ligoninės II angiochirurgijos skyrius Antakalnio g. 57, LT-10305 Vilnius El pastas: nmark@one.lt Įvadas Ūminės proksimalinės giliųjų venų trombozės (GVT) vėlyvosios komplikacijos – potrombozinio sindromo – gydymas yra viena aktualiausių siuolaikinės medicinos problemų. Taikant naujus perspektyvius gydymo metodus, galima sumažinti sio sindromo pasireiskimo dažnį. Darbe palygintas potrombozinio sindromo dažnis taikant skirtingus ūminės proksimalinės GVT gydymo metodus. Ligoniai ir metodai Vilniaus universiteto Kraujagyslių chirurgijos klinikoje nuo 1998 m. iki 2003 m. gydyta 150 ligonių, kuriems pasireiskė ūminė proksimaline GVT. 60 ligonių taikyta kateterizacinė trombolizė (I grupė), 90 ligonių gydyti tik antikoaguliantais (II grupė). Gydymo rezultatai vertinti po 1, 3, 9 ir 12 mėn. atliekant dvigubą skenavimą, po 6 mėn atliekant ascendentine ir descendentine venografijas. Po 16 mėn. nuo buvusios ūminės GVT atlikta visų ligonių anketinė apklausa, pateikiant jiems po 8 klausimus su sistemintais atsakymais. Buvo klausiama apie gydytų ligonių sveikatos, darbingumo, gyvenimo kokybės pokycius po persirgtos ūminės GVT, o jei pasireiskė potrombozinis sindromas, – ar kreipėsi į gydymo įstaigas ir kiek kartų jose gydėsi. Rezultatai Atliekant dvigubą skenavimą po 12 mėn. nuo ūminės GVT, giliųjų venų vožtuvų nepakankamumas pasireiskė 10 (18%) I grupės ligonių ir 83 (93%) – II grupės. Rekanalizacijos laipsnis I grupėje siekė 99%, II grupėje – 77% Po 16 mėn. nuo persirgtos ūminės proksimalinės GVT buvo issiųsta 150 anketų ir gauti 106 atsakymai (71%). Savo sveikatos būkle teigiamai įvertino 34 (56%) I grupės ligoniai ir 10 (11%) II grupės. Jokių kojos, kurios gilioji vena buvo užakusi, odos pokycių nenurodė 56 (93%) I grupės ligoniai ir 23 (26%) – II grupės. Gyvenimo kokybė pablogėjo 4 (7%) I grupės ligoniams ir 42 (47%) II grupės. Darbingumą prarado 6 (10%) I grupės ligoniai ir 39 (43%) II grupės. Dėl potrombozinio sindromo į gydytojus kreipėsi 5 (5%) I grupės ligoniai ir 41 (45%) II grupės. Stacionare potrombozinis sindromas gydytas 2 (3%) I grupės ligoniams ir 40 (44%) II grupės. Isvados Kateterizacinės trombolizės taikymas istikus ūminei proksimalinei GVT gerokai veiksmingiau apsaugo nuo potrombozinio sindromo negu gydymas tik antikoaguliantais. Tai ekonomiskai efektyvesnis metodas, kadangi vėlyvuoju laikotarpiu daug mažiau ligonių kreipiasi į gydymo įstaigas, gydosi stacionaruose. Kateterizacinė trombolizė daugumai ligonių padeda islaikyti buvusį iki ligos darbingumą ir gyvenimo kokybe. Reiksminiai žodžiai: giliųjų venų trombozė, potrombozinis sindromas A comparison between long term results of catheter-directed thrombolysis and anticoagulation in the treatment of acute iliofemoral deep vein thrombosis Narimantas Markevicius 1 , Gintaras Apanavicius 1 , Stanislovas Scerbinskas 2 , Marijus Gutauskas 1 , Vytautas Triponis 3 Background / objective The management of remote complications of acute proximal DVT such as post-thrombotic syndrome is considered to be one of the main problems of modern medicine. The new means of the treatment of post-thrombotic syndrome can contribute to reducing the incidence of this syndrome. The incidence of post-thrombotic syndrome under different measures of DVT treatment is compared. Patients and methods A total of 150 patients with acute proximal DVT were treated at Vilnius University Clinic of Vascular Surgery from 1998 to 2003. Sixty patients were treated by catheter-directed thrombolysis (the first group) and 90 patients by anticoagulation alone (the second group). Treatment results were assessed by duplex ultrasonography at 1, 3, 9 and 12 months and by ascending and descending venography at 6 months of treatment. Following 16 months after the onset of acute DVT, 8-item questionnaires containing organized answers were administered to all the patients. The questionnaire included the assessment of health distress, working performance and the quality of life. Furthermore, this questionnaire assessed whether the patient had been referred to medical institutions due to post-thrombotic syndrome and how many times. Results Duplex ultrasonography performed 12 months after acute DVT revealed development of valvular incompetence in 18% of patients in the first group and in 93% of patients in the second group. The degree of recanalization reached 99% in the first group and 77% in the second group. Following 16 months after acute proximal DVT, 150 questionnaires were dispatched;106 (71%) patients filled in the forms. 34 (56%) patients of the first and 10 (11%) of the second group evaluated their own state of health positively. 56 (93%) patients in the first and 23 (26%) in the second group did not indicate any post-thrombotic skin changes of the affected lower extremity. Quality of life disimproved in 4 (7%) patients in the first group and in 42 (47%) patients in the second group. Working disablement was identified in 6 (10%) and 39 (43%) patients in the first and in the second groups, respectively. 5 (5%) patients in the first group and 41 (45%) in the second group consulted doctors about developing post-thrombotic syndrome. Inpatient treatment for post-thrombotic syndrome was administered to 2 (3%) patients on catheter-directed thrombolysis versus 40 (44%) patients on anticoagulation. Conclusions Catheter-directed thrombolysis for acute proximal DVT has been demonstrated to be a more effective means of post-thrombotic syndrome prophylaxis as compared with anticoagulation alone. Catheter-directed thrombolysis offered a better maintenance of working performance, the quality of life and well-being. Keywords: deep venous thrombosis, posthrombotic syndrome

Nerijus Bickauskas, Gintaras Žukauskas, Gintaras Apanavicius, Marijus Gutauskas Vilniaus miesto universitetinės ligoninės Kraujagyslių chirurgijos skyrius Antakalnio g. 57, LT-10305 Vilnius El pastas: nnnb@post.omnitel.net Įvadas / tikslas Pasaito kraujagyslių rekonstrukcinės operacijos sudaro nedidele kraujagyslių rekostrukcinių operacijų dalį, stambiausiose klinikose – tik iki 0,5% rekonstrukcinių operacijų kiekio. Pagerėjus diagnostikai, lengviau sprendžiama operacijos tikslingumo problema, taciau kontroversiski lieka operacinės taktikos klausimai. Labiausiai paplitusios antegradinė ir retrogradinė kraujotakos atkūrimo operacijos. Antegradinė kraujotakos atkūrimo operacija turi pranasumų. Taciau jos apimtis yra gerokai didesnė. Retrogradinis kraujotakos atkūrimas yra lengvesnė operacija ir dėl to palankesnė senyviems ligoniams. Mūsų siūloma metodika atlikti suntą su lengvu linkiu yra optimali, leidžia isvengti sunto perlinkių, be to, anastomozė gula tolygiau, sugrąžinus žarnas į pirmine padėtį. Darbo tikslas – palyginti tiesaus sunto ir lenkto sunto efektą. Ligoniai ir metodai Nuo 1998 metų iki 2003 metų operuoti 29 ligoniai (17 vyrų ir 12 moterų). Is jų 18 atliktas lenktas suntas, 11 – tiesus suntas. Taikytas retrogradinis kraujotakos atkūrimo metodas. Vidutinis ligonių amžius – 68,7 metų. Visi ligoniai tirti ultragarsu ir angiografiskai. Ligonio operacijos taktiką pasirinkdavo pats chirurgas. Rezultatai Operacijos metu kraujotaka buvo atkuriama į geresnį kolateralių tinklą ar kelias pilvo visceralines sakas. Siuvama sunto medžiaga (protezas ar autovena ) abiejose grupėse buvo panasi. Pooperacinių mircių nebuvo. Stebint ankstyvuosius ir vėlyvuosius rezultatus paaiskėjo, kad I grupėje, kuriai buvo atliekamas lenktas suntas, vienam ligoniui pasireiskė restenozė, II grupėje, kuriai buvo siuvamas tiesus suntas, pasitaikė viena restenozė ir dvi sunto trombozės (1 ligonis operuotas skubos tvarka). Vėliau isgyvenamumas, klinikinis ir ultragarsinis efektas liko panasūs. Isvados Taikant ilgo lenkto sunto techniką, galima isvengti sunto perlinkio ir trombozės ar distalinės anastomozės susiaurėjimo, todėl naudojant sią techniką retrogradinė pilvo aortos visceralinių sakų kraujotakos atkūrimo operacija tampa gana veiksminga. Ji yra saugesnė, nei tradicinė tiesaus sunto technika. Prasminiai žodžiai: pasaito kraujagyslės, lėtinė žarnyno isemija, retrogradinė rekonstrukcija Retrograde mezenteric revascularisation for patients with chronic visceral ischemia Nerijus Bickauskas, Gintaras Žukauskas, Gintaras Apanavicius, Marijus Gutauskas Background / objective Occlusive disease of mezenteric vessels makes only a small part of all vascular surgical cases. According to literature, mezenteric revascularization makes about 0.5% of all reconstructive operations. Improvement of diagnostic procedures led to a more precise selection of the patients for surgery, while the surgical technique remains quite controversial. Most widely accepted is the antegrade and retrograde revascularization of mezenteric arteries. The main disadvantage of antegrade revascularization is a difficult, long and traumatic procedure. Retrograde revascularisation is significantly less traumatic, what is very important for elderly and severely sick patients. The disadvantage of this procedure – if the graft is positioned straight – is kinking of the graft, which can lead to thrombosis. The method proposed by us – positioning of the graft with a soft kinking – in our opinion, is optimal, as it allows to avoid sharp kinking and thrombosis of the graft, anastomosis is located in a more anatomic position, and the bowels are located in the most physiological position after surgery. Patients and methods From January 1998 till December 2003, 29 patients were treated by revascularization of mezenteric arteries – all by the retrograde method. In 18 cases bypass was performed with soft kinking (group I), and in 11 cases strait bypass was inserted (group II). The mean age of the patients was 68.7 years. There were 17 male and 12 female patients in the group. All patients were investigated by Dupplex-scan and aortography. Bypass was inserted to the artery with a better collateral network or to several visceral arteries. The use of graft material (autologous vein or prosthetic graft) was similar in both groups. The choice of the procedure was at the discretion of the operating surgeon. Results There was no deaths in the immediate postoperative period. In remote postoperative period we observed 1 restenosis in group I (retrograde revascularization with a soft graft kinking). In group II, where strait graft was inserted, we observed 1 restenosis, and in 2 cases thrombosis of the graft was observed (one of them was operated on on emergency basis). In the remote period, the survival rate, clinical and Dupplex-scan results were similar. Conclusions The advantages of retrograde revascularization are less operative trauma, possibility to perform simultaneously reconstruction of aorto-iliac as well as renal arteries. Positioning the graft with a soft kinking showed better postoperative results, allowing us to propose it as a method of choice for mezenteric reconstructive surgery. Keywords: mezenteric vessels, chronic visceral ischemia, mezenteric revascularisation

Extracranial congenital arteriovenous malformations (AVMs) are rare clinical entities that can be progressive in nature. The influence of pregnancy on lesion progression has been discussed in the past. This report presents an unusual case of 23-year-old primigravida woman who presented at 36 weeks' gestation with complicated necrotic ulceration and hemorrhage of the right gluteal region. A hyperpigmented mark with varicosities was initially noted at birth, but during pregnancy it showed remarkable progression and was first identified as an AVM. After hemorrhage control and induced delivery, the lesion was successfully treated with several embolizations. Complete wound healing was achieved, but because of partial recurrence at 3 years, repeat embolization was performed, with satisfactory clinical improvement and residual 25% arteriovenous shunting on transarterial lung perfusion scintigraphy study. AVM complications during pregnancy are uncommon, and this case supports the prior opinion that pregnancy can stimulate lesion progression. Especially in undiagnosed and previously untreated cases, this can lead to life-threatening complications for the mother and fetus. Long-term lesion management usually requires combined endovascular and surgical treatment.