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Cardiovascular disease is the most frequent cause of death in kidney transplant patients. High-flow arteriovenous fistula (AVF) increases cardiac output and may contribute to hyperkinetic heart failure. AVF follow-up is not implemented in kidney transplant patients. The aim of this study was to reduce AVF blood flow in a group of patients with a high-flow AVF following kidney transplantation to reduce cardiac strain.This prospective study was performed in kidney transplant patients who had a vascular access created before transplantation. The AVF of these patients was examined by ultrasound with a focus on AVF flow and brachial artery size. If high-flow AVF was detected, flow reduction was performed in the indicated group of patients.The study examined 164 patients, of whom 24 had a hyperfunctional AVF (14.8%). A total of 16 AVF flow reductions were performed, which led to an average decrease in cardiac index by 0.77 L/min/m2. Primary patency of the reconstructions was 93.33% after 12 months. All patients experienced a subjective improvement in dyspnea.Reduction in AVF flow leads to an improvement in the quality of life of kidney transplant patients. Maintaining a functional AVF is beneficial, especially for patients after repeated surgeries, where the option of creating an autologous AVF is limited.

The aim of the paper was to determine the causes of varicose vein recurrence and, when neovascularisation is suspected, to confirm or exclude its presence and to establish its contribution to the recurrence of varicose veins.A retrospective analysis of a set of 217 legs reoperated in our department over a period of 17 years with a two-year prospective histological and histochemical (nestin) analysis of resected veins.Reflux as a cause of varicose vein recurrence was identified in 93% of the limbs. It was most commonly found in the area of the saphenofemoral junction, followed by the area of the saphenopopliteal junction. Reflux in the perforating veins was almost invariably linked to that in the saphenofemoral junction or saphenopopliteal junction; an isolated damage to the perforating veins was only present in three limbs. Histological and histochemical analysis was performed for the samples of eleven veins in which neovascularisation was suspected based on preoperative duplex ultrasonography evaluation. Neovascularisation was confirmed in none of these veins and none of them was the cause of recurrence.The major cause of varicose vein recurrence is a reflux left unresolved during the primary surgery, particularly in the area of the saphenofemoral junction. A less common cause is progression of the disease and the occurrence of a new reflux. Neovascularisation is of no importance for the recurrence of varicose veins.

Revascularization of occlusion of the femoropopliteal region in patients with critical limb ischaemia (CLI) may be performed following the standard surgical approach using bypass with the saphenous vein graft (FP bypass). Unfortunately, up to 40% of these patients do not have a suitable saphenous vein. In these patients, revascularization may be performed surgically using bypass with prosthesis, allograft vein or by interventional radiological methods. An endovascular alternative is represented by subintimal recanalization (SIR).Our prospective analysis evaluated mid-term results of revascularization using FP bypass or SIR in patients with occlusion of the femoropopliteal region and CLI. Our aim was to answer the question whether SIR can fully replace FP bypass in certain indications. From January 2010 to December 2012, 59 revascularizations of the CLI (Rutherford 5-6) with comparable SFA occlusion were performed. We monitored the immediate postoperative course, technical and clinical success and the process of healing of the defect.Healing of the defect was achieved in 78.6% of patients with FP bypass using the saphenous vein, in 62.5% of patients with FP bypass using prosthesis and in 64.9% of patients with SIR (P=0.578). When comparing the bypass group, which was subdivided into a group with revascularization using autologous vein and a group with revascularization using ePTFE prosthesis, with the SIR group, primary patency was evaluated. The results for vein 78.0% after 6, 12, 24 and 36 months, for prosthesis 74.5%, 55%, 55% after 6, 12 and 24 months, and for the SIR group 78%, 60%, 51.3% and 50.7% after 6,12,24 and 36 months. When comparing the results of the groups, no statistically significant difference was found (P =0.625).As expected, the most successful method of choice is revascularization by FPB using the saphenous vein. SIR and FP bypass using prosthesis had similar results with respect to healing of the defects.

Renal (kidney) transplantation is now a routine and the most successful form of renal replacement therapy. There is a long tradition of renal transplantation in the Czech Republic, The first was performed as early as 1961 in Hradec Kralove, and the programme as such was launched in 1966 with the first successful transplantation at the Institute of Experimental Surgery (later Institute for Clinical and Experimental Medicine, Prague). At present, transplantations are being performed at 7 transplantation centres (IKEM Prague, Centre for Cardiovascular and Transplantation Surgery Brno, Faculty Hospitals Hradec Kralove, Plzen, Olomouc and Ostrava and Faculty Hospital Motol for children). From the programme launch until the end of 2010, 8,761 renal transplantations were performed, 364 in 2010 alone. One-year patient and cadaver renal allograft survival, transplanted in the CR between 2000 and 2009, is around 95% and 92%, respectively, and 5-year survival is 87% and 81%, respectively. As of 31st December 2009, a total of 3,771 patients lived with functional renal allograft in the Czech Republic and the proportion of patients with irreversible renal failure treated with transplantation has recently been around 40%.

To evaluate our experience with hybrid endovascular and open surgical treatment of thoracoabdominal aneurysms.Between 1996 and 2008 8 patients with thoracoabdominal aneurysm (6 Crawford type IV and 2 type V) from the total of 257 aortic aneurysms with elective endovascular repair were treated using hybrid procedure. A retrograde revascularisation of visceral and renal arteries through the open access and endovascular exclusion of aneurysms using a stent-graft were done.A primar technical success of the hybrid procedure was in all cases. There was no severe ischaemia of visceral organs, kidneys (no need of haemodialysis) or spinal cord (paraplegia). One patient died on an acute pancreatitis 14 postperative day. Further follow up (in range 16-52 months) showed henceforth a successful exclusion of all the aneurysms without evidence of endoleak and patency of all bypasses with a good function of revascularised organs.Owing to minimal haemodynamic load and technical simplicity with a short time of organ ischaemia hybrid procedure represents an acceptable possibility of type IV and V thoracoabdominal aneurysms repair.

The infected ePTFE prosthesis for hemodialysis threatens the patient with local complications such as occlusion, the tunnel infection and massive hemorrhage. These complications are associated with the loss of function of the fistula. Infected prosthesis can work as a source for metastatic infections (endocarditis, arthritis, pneumonia), and sepsis. In European countries, interposition of ePTFE graft usually represents the last option of angioaccess beside the catheterization of central venous system; hence attempts occur to maintain the fistula function despite the manifestation of infection. Authors evaluate the total graftectomy (TGE) and the partial graftectomy (PGE) on the basis of their knowledge and literature findings. They take a stand whether it is preferable to remove an infected graft according to experience or to proceed conservatively following the modern examinations (USG, microbiology, PET CT). According to the documented case-report they tend more to the solution based on experience. If the infection of graft is of gram-negative etiology the total graftectomy (TGE) is recommended.

The aim of the presented work was to assess the causes of injury to great nerves during varicose vein surgery and comment on the consequences.This was a retrospective study of 2344 patients operated on for primary varicose veins between the years 1980 and 2005.In three patients out of 2344 the peroneal nerve was injured. The three patients underwent neurosurgery. In the first patient transplantation of the sacral nerve was performed. In the second patient the nerve was released from ligatures, and in the third patient the nerve was first released from the cicatrice and the transposition of the tendon of the posterior tibial muscle followed. All three patients went through intensive rehabilitation. The first patient still wears peroneal splint, the limb is atrophic. In the second patient the function has been well restored and he is not disabled anymore. However, the restitution of the lower limb function is not sufficient for him to work as a teacher of physical education. The third patient still suffers from serious paresis of the peroneal nerve.Even a frequent and relatively simple intervention such as varicose vein surgery may be accompanied by serious complications affecting patients for the rest of their lives. Serious motor nerve injuries are encountered only in operations in the popliteal fossa and the fibula head. Complications are more frequent when operations are performed by young general surgeons than when they are performed by an experienced surgeon or an expert in vascular surgery. The affected patients should be referred for neurosurgery; however, results are unpredictable. In spite of an intensive rehabilitation and possible plastic surgery the patients are permanently affected.

The aim of the present work was to assess the new device for the small saphenous vein surgery.The authors described the device which has been used since 2003 without any complications.The primary objective of varicose veins surgery is to eliminate reflux in saphenofemoral junction and saphenopoplietal junction. In concurrent surgery of both long and small saphenous veins the patient must be rotated on the operation table. The authors describe their own mechanism supporting the elevated leg during the surgery so that it is not necessary to rotate the patient while the area of small saphenous vein is well accessible.The support for small saphenous vein (surgery appears to be a simple and effective device making the preparation in the area of fossa poplitea much easier and comfortable. The patient's position is not changed and, therefore, it is not necessary to disinfect and dressing anew the operation table. This allows to save time and money at the same time.

The incidence of vascular replacement infection is reported between 0.5-6.0%. The infection of aortal valve replacement is usually managed by its removal and axilofemoral reconstruction. Replacement removal and reconstruction in situ is another alternative. The aim of our work is to give the comparison of the results obtained with the extra-anatomic reconstruction and alternative techniques.Between January 1987 and August 2008 1324 abdominal aortal replacements were performed in our department. In 14 patients (1.05%) the infection of the replacement occurred; one of the patients was operated on in another hospital. In eight patients axilobifemoral/axilopoplietal by-pass was applied (Group A). In two patients the whole replacement was removed together with in situ reconstruction (ISR) using a new bifurcation replacement. In two patients a partial resection of the replacement and the resected part substitution or femoro-femoral cross-over by-pass was performed. Three patients were treated with a total or partial replacement removal without the following reconstruction.In Group A no haemorrhage from the aortal stub occurred. The mean value of surgical management due to the replacement infection was 3.5 (1-6). For Group B the number was 5 (1-16). In Group B there were three reinfections, in Group A none. In both Group A and B one patient died; one thigh amputation was necessary in Group A, two in Group B.The partial or total removal of the replacement followed with in situ reconstruction is considered a safe and good method solving the infection of the aortal replacement in some patients. The results are comparable to those obtained with extra-anatomic reconstruction that remains the method of choice in patients with virulent infections.

The subclinical rejection is defined as finding of histological signs of rejection on well functioning grafts. Its diagnostic domain remains protocol biopsy. The diagnostic value of ultrasound scaning in subclinical rejection has not been studied yet.The aim of our study was to detect the incidence of subclinical rejection in protocol biopsies in the first three months after kidney transplantation and to find out the ultrasound correlation to histological picture of subclinical rejection with special accent on ultrasound signs of parenchymal oedema, quantity and quality of perfusion emphasising their changes in process of time.Sixty six protocol graft biopsies were performed on 36 recipients of cadaveric renal transplants in Transplant Centrum Olomouc between July 1999 and September 2000. The biopsies were carried out 21 +/- 2 days and 90 +/- 5 days after transplantation. Subclinical rejection was defined as t2 i2 v0 (IA) rejection infiltrate by Banff 97 histological classification at the same time with serum creatinine in normal range and ultrasound signs of parenchymal oedema.In the group of subclinical rejection the ultrasound findings of graft parenchymal oedema correlated with 81% sensitivity and 90 % specificity with histological diagnosis. The duplex picture of parenchymal hyperaemia blush - had 100 % specificity but low sensitivity. The resistive indices were in the wide range 0,61 - 0,80 without diagnostic value.The high sensitivity and specificity of ultrasound prospective follow up was found in the subclinical rejection diagnosis. Parenchymal hyperaemia indicated high specificity but low sensitivity in evaluation of subclinical rejection. No benefit of resistive indices was found. Larger sample of patients has to be established to gain more exact review anyway.

One-day surgical methods lower the procedures costs as well the need for urgent beds in surgical clinics. The varix operation seem to be the optimal diagnosis suitable for the one-day surgical procedure.The aim of this work is to assess a feasibility of the one-day surgery for the low extremities varix operations.During the period starting in January until December 2003, 98 extremities were operated for varices. The surgical procedure was the same for the hospitalized as well as for the patients assigned to the one-day surgery programme. Each patient was examined with the duplex ultrasound prior to the surgery, after the surgery a compressive bandage was indicated.We operated 98 extremities in 96 patients suffering from varices during the period from January 2003 to December 2003. The trial group consisted of 67 females and 29 males aged 21-79 years of age (the average of 45.3 years). According to the CEAP classification, 57 extremities (58.2%) were assigned to the C2 category, 30 extremities (30.6%) to the C3 category, 6 extremities (6%) to the C4 category, 4 extremities (4%) to the C5 category and one extremity (1%) to the C6 category. 14 extremities in the group were operated due to the disease relapse. 62 patients (i.e. 65%) were released for the home-care on the day of the operation, 27 patients (28%) were released the following day. One patient was hospitalized for two days, three patients for three days, one patient for four days and two patients for five days. 91 out of the total 98 extremities (i.e. 93%) underwent the one-day surgery.Although some patients require hospitalization, the varix surgery is safe and suitable for the one-day surgery. A thorough preoperative examination as well each patient's cooperation are both very important.

The results of kidney transplantation from very young paediatric cadaveric donors up to five years, which were transplanted to adult recipients, are evaluated in the first retrospective study of all Czech transplantcentres. In general, 42 of these transplantations were carried out during 1994-2001. In 28 cases single kidney was transplanted, in 14 cases en bloc graft of both children kidneys was transplanted. The reasons of kidney failure by recipients are usual (in 42.9% glomerulonephritis). An average age of the donors was 34.7 months (median 39 months). An average age of the recipients during transplantation was 42.6 years (median 43.5 years). All the kidneys were placed into retroperitoneum. As long as only single kidney was transplanted, the rules, already propagated by Salvatiera in 1970, were respected. At the transplantation of en bloc graft, Kinne's method with possible vessels elongation of the graft and with uretero-uretero anastomoses (in so called Ostrava modification) was used. The higher occurrence of the primary graft non-function (as 50% losses of all grafts) was confirmed in the study. Its reason was an acute thrombosis of vessels or rotation of graft stem. One-, three- and five-years patients and grafts survival were 97.6-90.5-90.5% and 76.2-73.8-73.8% actually. Patients survival are very good while grafts survival are average, momentarily a bit worse than national data published by the Czech Transplant Society, which determines one-, three- and five-years grafts survival with 90.3-82.9-75.5% and 79.1-71.1-65% actually. The kidney transplantation from paediatric cadaveric donors to adult recipients is acceptable under present allocated criteria, in case that some principles are kept. The study confirms the international experiences about rather higher incidence of surgical complications and primary graft non-function. In conclusion, some general references for reduction of complications, as well as for improvement of these transplantation results are introduced.

Fourty eight patients with cadaveric kidney allografts treated by cyclosporin A (CSA) or tacrolimus (FK506) underwent protocol graft biopsies at 1, 3 and 12 months after transplantation, and 110 biopsy specimens were obtained. Histologic diagnosis was made according to the Banff scheme. The main cause of the graft instability at 1 and 3 months was acute clinical rejection, these biopsies showed all known histological patterns of tubulointersticial and vascular rejection. Acute tubular nephropathy was found in 13% and borderline changes or nephrotoxicity in 8.7% of instable grafts. Specifically, we focused on the occurRence of subclinical rejection and toxic reactions in stable renal allografts. Of these, 36.1% showed histological patterns of acute tubulointersticial and vascular rejection. The Banff score of subclinical rejection was significantly lower than in clinically apparent rejection. CSA and tacrolimus nephrotoxicity were seen in 14.2%, 19.5% and 27.2% of specimens at 1, 3 and 12 months, respectively. In over one half of the identified cases of nephrotoxicity neither increased level of immunosuppression nor features of allograft dysfunction were found. At 12 months, 45.5% of specimens showed mild chronic transplant nephropathy and 18.1% moderate chronic transplant nephropathy. Normal morphology was found in 36.4% of biopsies. We found a high prevalence of subclinical rejection and nephrotoxicity in the studied cohort. We conclude that protocol biopsy is a reliable method in the diagnosis of clinically silent, as well as clinically apparent, disorders of the transplanted kidney.

This prospective, randomized, multicentre study investigated the efficacy and safety of two tacrolimus-based regimens and their potential to withdraw steroids.In total 489 patients were randomised to receive either tacrolimus and MMF (n = 243) or tacrolimus and azathioprine (n = 246) concomitantly with steroids in both treatment groups. The initial oral dose of tacrolimus was 0.2 mg/kg/day, MMF dose was 1 g/day, azathioprine was administered at 1-2 mg/day. Steroids were tapered from 20 mg/day to 5 mg/day. From month 3 onwards, steroids were withdrawn in patients who were free from steroid-resistant rejection and who had serum creatinine concentrations160 mumol/L. Study duration was 6 months.Patient survival at month 6 was 98.3% (Tac/MMF/S) and 98.4% (Tac/Aza/S), graft survival at 6 month was 95.0% (Tac/MMF/S) and 93.5% (Tac/Aza/S). The 6-month incidences of biopsy-proven acute rejection were 18.9% (Tac/MMF/S) compared with 26.8% (Tac/Aza/S), p = 0.038. The 6-month incidences of steroid-resistant acute rejection were 2.1% (Tac/MMF/S) and 4.9% (Tac/Aza/S), p = ns. At the end of month 3, steroid withdrawal was performed in 60.5% (Tac/MMF/S) and 48.8% (Tac/Aza/S) of patients, p0.01. During months 4-6, 2.7% of patients in the Tac/MMF group had a biopsy-confirmed acute rejection compared with 0.8% of patients in the Tac/Aza group. In patients who continued to receive steroids, the incidences of biopsy-proven acute rejections during months 4-6 were 3.5% (Tac/MMF/S) and 7.1% (Tac/Aza/S). At study end, the steroid-free patients had an excellent kidney function, the median serum creatinine concentration was 119.5 mumol/L (Tac/MMF) and 115.1 mumol/L (Tac/Aza); the median serum creatinine of the total study group was 130.5 mumol/L (Tac/MMF/S) and 132.8 mumol/L (Tac/Aza/S).Both tacrolimus regimens are efficacious and safe. The combination of Tacrolimus and MMF achieved a lower rejection rate and permitted a higher proportion of steroid-free patients. The overall incidence of acute rejection was low and kidney function was good.

The authors describe three patients with blunt injuries of the iliac artery. They mention the causes and mechanism of their development, symptomatology, diagnosis and treatment. They draw attention to early diagnosis and an active approach; they discuss the type of vascular prosthesis and mention alternative therapeutic procedures. In all patients surgical treatment (resection and prosthesis of the affected part) led to favourable long-term results.

Renal biopsy is nowadays considered a relatively safe and routine examination method in nephrology. Its development was made possible by extension of sonography and introduction of modern automatic bioptic sets. Relatively frequent complications of biopsy include macrohaematuria, perirenal haematomas and AV fistulae. The majority of complications is unimportant from the clinical aspect. Some 30% fistulae do not recede spontaneously and gradual remodelling of the circulation near the fistula may lead to the development of complications. In the submitted paper the authors inform on the case of a 55-year-old woman where 24 hours after biopsy of a renal graft a sonographically revealed arteriovenous fistula closed spontaneously within one month; the case of a 40-year-old woman where 5 days after biopsy progression of a subcapsular haematoma and manifestation of a fistula occurred, and a 35-year-old man who developed 6 years after biopsy gradually an arteriovenous fistula with uncontrollable hypertension, hypercirculation syndrome and functional deterioration of the transplanted kidney. Superselective embolization led to improvement of the circulatory sequelae of the vascular shunt but did not have a favourable impact on renal function. Analysis of hitherto assembled experience indicates that direct ultrasound control of biopsy is effective. Because the manifestation of possible complications of biopsy need not follow immediately after the operation ultrasound follow up of native and transplanted kidneys after biopsy is justified even after a longer time interval after the operation.

The period of six years is discussed by the authors during which 39 patients were confirmed having primary or secondary hyperparathyroidism. All of them finally underwent the surgical procedure. The possibility of immunoreactive PTH measurement has been highly appreciated. Despite that key position of the experienced surgeon remains of the utmost importance.

Isolated human hepatocytes (HH) are an accepted model for in vitro experiments for testing liver function and xenobiotic metabolism. Preferred over more traditional animal hepatocyte model used in toxicological studies, it is the model of choice when substances undergoing biotransformation in man are investigated. The aim of this study was to optimize isolation and culture conditions for HH primary culture with regard to cell yield, viability, and metabolic activity, and to evaluate the suitability of donor samples for toxicology experiments. Cell viability, total cytochrome P450 (CYP) content, CYP3A4, CYP1A2 activity, and finally mixed ethoxycoumarin-O-deethylase (ECOD) activity were parameters measured in order to characterize the isolated HH. The quality of the primary cultures, stable and functional for a seven-day period following 24 hour stabilization, was assessed by lactate dehydrogenase (LDH) leakage and response to the model toxin tert-butylhydroperoxide (tBH) and to silybinin, a model cytoprotective substance. Based on HH obtained from livers of five multiorgan donors (average age 44.8 years, three males and two females), the individual variability of donors needs to be considered in evaluating cultures focussing on clinical liver tests. Greater sensitivity to toxins and silybinin was found in the hepatocyte culture from one donor with higher aminotransferase activity. In another case, higher serum bilirubin appeared to be linked to higher ECOD activity. Our conclusion is that values of clinical liver tests ought to suggest a healthy organ thus eliminating previous hepatocyte damage, the crucial factor of primary culture stability and functioning.