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The aim of this paper is to present extremely rare case of 77-year old woman with free floating thrombus (FFT) in abdominal aorta obliterating superior mesenteric and right renal artery. The patient developed acute renal dysfunction. FFT was entirely removed surgically from aorta, renal arteries and celiac arteries obtaining good outflows. Appropriate treatment based on in-depth patient’s condition evaluation prevented severe, potentially fatal complications.

Hereby, we present the rare case of ischemic stroke with left-sided paralysis as a complication of the pseudoaneurysm of the brachiocephalic trunk due to clavicular fracture. After angio-computed tomography (CT) diagnostics the reconstruction of brachiocephalic trunk by upper sternotomy was performed.

Background Coagulation system disorders in liver transplantation (ltx) patients are considered a serious issue. Liver cirrhosis leads to decreased synthesis of clotting factors and decreased elimination of waste products, including coagulation proteins. Platelet sequestration and dysfunction in an enlarged spleen additionally worsen these conditions. The resulting state, the most common pathology of the coagulation system, involves the reduction of clotting potential and hyperfibrinolysis. Objectives Tackling the problem of impaired hemostasis is a dynamic process. Throughout the whole procedure, consisting of the preanhepatic, the anhepatic and the neohepatic phases, consecutive pathomechanisms disrupt the very balance that anesthesia aims to preserve. Material and methods Rotational thromboelastometry (ROTEM), having been introduced in the Clinic of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Poland, enables the efficient and early diagnosis of clotting disorders. An additional major problem which occurs during ltx, namely blood loss, could be solved using a cell separator. Results In this study, we present the standards introduced to the Transplantology Department of the Vascular Surgery Clinic, Wroclaw Medical University, Poland, that describe blood treatment during ltx procedures. Conclusions We conclude that thromboelastometric examination and the use of a cell separator have significantly increased the safety of ltx procedures at our clinic. The introduction of thromboelastometry (TEM) and the implementation of the cell separator recovery method have enabled us to perform the dangerous and complicated surgical procedure of ltx in a much more stable and much safer manner than in the past.

Background One of the underestimated causes of chronic pelvic pain (CPP) in women may be pelvic congestion syndrome (PCS) that is defined as the presence of varicose of ovarian and pelvic veins associated with chronic pain in the region of the pelvis. This pain is present longer than 6 months and intensifies with prolonged standing, coitus and menstruation. The disease constitutes a diagnostic as well as therapeutic problem, thus posing a challenge for the clinician. Transcatheter ovarian vein embolization might be a safe and effective option for PCS treatment. Objectives The objective of this study was to evaluate the efficacy of ovarian vein embolization ovarian as a method of the PCS treatment. Material and methods Between 2002-2012, 11 embolization procedures were performed in 10 women (age range: 34-43; median age 39) with the diagnosis of PCS. One patient underwent embolization procedure twice. In 1 case the combined therapy of endovascular embolization and surgical phlebectomy of vulvar varices was performed. Results There were no major intrainterventional complications. In all the patients (100%) a significant improvement in the clinical status was noted. The procedure improved the quality of life in the patients. Three women (30%) had a mild recurrence of the symptoms at mid-term follow-up. Among 8 women who had complained of dyspareunia prior to embolization 6 patients reported complete pain relief, in other 2 cases the pain subsided partially. There was a significant decrease in the severity of symptoms associated with hemorrhoids. Conclusions We consider embolization of insufficient ovarian veins an effective and safe way of treatment in a well-selected group of patients with PCS.

The chronic lower limbs ischaemia is caused mainly by arteriosclerosis. After insufficient conservative treatment only the surgical intervention can salvage the limb. The revascularisation surgery can be performed by open surgery with implantation of the prosthetic bypass or by endovascular angioplasty with stent. This second method seems to be the best alternative for the patients with several concomitant systemic diseases. Nevertheless it is limited by presence of the long-distance arteriosclerotic lesions. The resolve of that problem is use of new generation of long endovascular covered stents. They can be succesfuly used in aorto-femoral and femoro-popliteal segment. Their efficiacy is simmilar to traditional prosthetic grafts.

Objectives New therapies for complicated skin and skin structure infections (cSSSIs) are needed because of significant morbidity and increasing antimicrobial resistance. Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of cSSSIs. Ceftaroline fosamil, a novel parenteral cephalosporin with excellent in vitro activity against Gram-positive pathogens, including MRSA, and many Gram-negative pathogens, was evaluated as therapy for cSSSIs in a multinational Phase III study. The primary study objective was to determine non-inferiority [lower limit of 95% confidence interval (CI), -10%] in the clinical cure rate of ceftaroline fosamil monotherapy to that achieved with vancomycin plus aztreonam combination therapy in the clinically evaluable (CE) and modified intent-to-treat (MITT) analysis populations. Methods Adult patients with cSSSIs requiring intravenous therapy received 600 mg of ceftaroline fosamil every 12 h or 1 g of vancomycin plus 1 g of aztreonam every 12 h for 5-14 days (randomized 1 : 1). Clinical and microbiological response, adverse events (AEs) and laboratory tests were assessed. Registration number NCT00423657 (http://clinicaltrials.gov/ct2/show/NCT00423657). Results The study enrolled 694 patients, 348 of whom received ceftaroline fosamil and 346 of whom received vancomycin plus aztreonam. The treatment groups had comparable baseline characteristics. Clinical cure rates for the ceftaroline fosamil and vancomycin plus aztreonam groups were similar in the CE (92.2%, 271/294 versus 92.1%, 269/292; 95% CI, -4.4, 4.5) and MITT (85.1%, 291/342 versus 85.5%, 289/338; 95% CI, -5.8, 5.0) populations, respectively. MRSA cSSSIs were cured in 91.4% (64/70) of patients in the ceftaroline fosamil group and 93.3% (56/60) of patients in the vancomycin plus aztreonam group. The microbiological success rate in the microbiologically evaluable population was 92.9% and 95.0% for ceftaroline fosamil and vancomycin plus aztreonam, respectively. Ceftaroline fosamil and vancomycin plus aztreonam had similar rates of AEs, serious AEs and discontinuations because of an AE. The most common AEs for ceftaroline fosamil and vancomycin plus aztreonam included diarrhoea (6.5% versus 4.4%), nausea (6.2% versus 5.6%), headache (5.3% versus 5.3%) and pruritus (3.8% versus 8.3%), respectively. Conclusions Ceftaroline fosamil demonstrated high clinical cure and microbiological success rates, was efficacious against cSSSIs caused by MRSA and other common cSSSI pathogens and was generally well tolerated. Monotherapy with ceftaroline fosamil has the potential to provide an alternative treatment for cSSSIs.

Implantation of the vascular prosthesis below renal artery when the neck of the aneurysm is short, carries the risk of the appearance of the endoleak type I. At such patients one ought to make allowance for with the necessity of the single-stage or two-stage-supply of the endoleak with banding method that is to say with the tightening of the neck of the aneurysm on the stentgraft with the open method. This method consisting in to the compression of the neck of the aneurysm on stentgraft at the use of ribbons or the wide belt from the dacron net. In this paper one represented 3 patients operated with banding method. In the face the massive endoleak type I and the threat of the ruptum of the aneurysm one decided on the realization of the surgical correction with the open method with banding.

The critical limb ischemia is diagnosed when the rest pain and/or distal necrosis or ishemic ulceration occur and last for more than two weeks. Critical limb ischemia requires immediate revascularisation due to the risk of amputation. The most common cause of this state is the arteriosclerosis located on femoropopliteal level. The surgery consists of endarterectomy or implantation of the bypass graft or the percutaneous, intravascular procedure. The best material for the graft is the autologous saphenous vein but sometimes the artificial graft should be used. Some trials have proven that the heparin-bonded polytetrafluoroethylene graft could be the best resolution for patients without possibilities of use of the autologous vein.

Every foreign body injected into an organism causes an inflammatory condition. Among other things leukocytes take part in it. The healing of a vascular prosthesis means gradual subsiding of an inflammatory condition. The process can be monitored with the series of scintigraphy following decrease of an area of concentrating of Technetium-labeled leukocytes. The purpose of work was an appraisal of the healing of both types of prostheses in cases of patients operated because of aneurism of abdominal aorta.In three years 64 patients have been examined. They were divided into two equal groups: I-patients after (stent-graft) being implanted because of abdominal aneurysm, II-patients after aortobifemoral prosthesis being implanted of the same reason. The scintigraphy was done in 3-4 day, in 3-, 6- and 12 after a surgery. A surface of concentrating of leucocytes was counted in a computer programme which allows manual marking of a contour. The results were put through a statistical processing.During a period after surgery an intensified inflammatory condition has been stated in a group of patients operated in classic way. In both groups a decreasing of an inflammatory condition has been observed. After 12 months an area of concentrating of leucocytes took up to 10 percent of initial values.The decreasing of an area of concentrating of leucocytes was observed independently of a type of vascular prosthesis. The higher reaction was where the classic prostheses were used. The scintigraphy shows only a cellular part of an inflammatory answer and it cannot be an independent way of a monitoring of the healing of the prostheses.

BACKGROUND This study focuses on the cytokine genes expression after brain-death, ischemia-reperfusion injury, and during allograft rejection. METHODS A total of 49 needle core biopsies from kidney transplant recipients, performed before and during transplantation procedures were studied. The first biopsy was taken during procurement of the organ, the second after cold ischemia, and the third after approximately 30 min of reperfusion. We also assessed 34 allograft biopsies obtained during acute rejection. Tubular and glomerular expression of interferon (IFN)-gamma, transforming growth factor (TGF)-beta1, platelet-desired growth factor-B (PDGF-B), interleukin (IL)-2, IL-6, IL-10 mRNA was analyzed with reverse-transcription polymerase chain reaction (RT-PCR) in situ technique, which allows to detect a few copies of the target gene without destruction of the tissue architecture. RESULTS Compared with normal kidney tissue from living donor, high gene expression of IFN-gamma, TGF-beta1, PDGF-B, IL-2, IL-6, and IL-10 was detected in all procurement specimens. After reperfusion gene expressions of IL-2, IL-6, and IL-10 were significantly upregulated in renal tubules compared to biopsies taken after cold ischemia. The gene expression of IFN-gamma, TGF-beta1, and PDGF-B remained stable after organ procurement, during cold ischemia, and after reperfusion. Gene expression of IFN-gamma, IL-2, IL-6, IL-10, and PDGF-B in procurement biopsies, as well as in those taken after cold ischemia and reperfusion, were significantly higher than during the period of acute rejection. CONCLUSION The data presented herein strongly point out the importance of the immunological and morphological injury that occurs before and during transplantation. The increase of inflammatory response after brain death is important for further stimulation of the immune response and long-term kidney survival.

The Mallory-Weiss Syndrome is a rare complication of endoscopic examination. Upper gastrointestinal bleeding due to the Mallory-Weiss Syndrome usually stops spontaneously. The gastroscopy is an effective procedure (method) of diagnosis and treatment of the syndrome. Presented in this paper is a case of 49-year old woman with an upper gastrointestinal bleeding due to the Mallory-Weiss after biliary prosthesis removal. The choledocholithiasis was the primary reason for the initial insertion of prostheses. The cause of gastrointestinal bleeding was determined on the basis of performed gastroscopy in the early stage of prostheses removal forced by bleeding. The bleeding was effectively stopped with endoclips.

Critical lower limb ischemia is a term used to define those patients with chronic ischemic pain at rest, ulcerations or limb necrosis caused by confirmed atherosclerotic lesions of the arteries. In this paper to evaluate of the clinical usefulness of silver coated prostheses in critical lower limb ischemia was presented. The use of the vascular artificial prostheses (dacron, dacron with velour, dacron albumin coated, polytetrafluoroethylene, dacron gentamicin/ryfampicin coated) in the critical ischemia limbs threatened is her contagion. In cases of potentially threatened a contagion is indicated the use of vascular prostheses about enlarged resistance on the contagion, e.g. the silver/collagen coated prosthesis. A foundation of the use of such prostheses are antibacterial proprieties of polyester fibers salts of the silver. An aim of many works is estimation of healing of the silver prostheses of grafted in lower limb at ill with the critical ischemia where infecting of the synthetic material is extremely probable. The healing of the silver prosthesis rated is most often at the use of the scintigraphy with Technetium 99. One attends that such research will make possible the estimation of the usefulness of the vascular silver prostheses in reconstructive operations in the vascular surgery, particularly in cases threatened with the infection of used synthetic material.

The paper presents the results of our hybrid gene-cell therapy in case of critical lower limb ischemia. Eighteen patients with critical limb ischemia were enrolled to the study. The bone marrow from each patient was harvested. It had been incubated with VEGF165 gene plasmid for two hours before it was administrated intramuscularly into patient's lower limb.In the study we evaluated: safety, clinical outcomes of the therapy, venous blood VEGF protein concentration before and after (at: 7th, 14th, 28th and 90th day) administration of the stem cells. We obtained samples of muscles from the patients who underwent the limb amputation, which were examined histological and by PCR (Polymerase Chain Reaction) for detection of plasmid genes.We observed very good clinical outcomes of the therapy. In ten of eighteen patients (-55%) critical lower limb ischemia symptoms subsided--they saved their limbs. The serum VEGF concentration was higher than in healthy controls (p0.05). We observed the increase of the concentration of the cytokine at the 14th day an decrease at the 90th day after administration of cells with plasmid. We found expression of plasmid VEGF in transfected stem cells and in tissues taken from amputated limbs. However histological examination did not reveal any sings of new blood vessels formation in the samples taken from ischemic limbs.The therapy is safe and effective. We observed significant improvement in patient's clinical state. The therapy needs further investigations.

The abdominal aortic aneurysm is a dilatation of infrarenal part of aorta. Its ethiology is still unknown. An infection and congenital disorders of conjunctive tissue are regarded as the main risc factors. Other factors could be a perimural thrombus and elastin and colagen degradation. It's not proved that atheromatosis is a risc factor. The disease concerns mainly the old males. Not treated aneurysm grows until rupture. The aneurysms are usually asympthomatic. Majority of them are found incidentally. Ultrasonography and computed tomography are used to extended diagnosis. The open surgery or endovascular surgery are only possible ways of treatment. The aneurysm with diameter over 55 milimeters, sympthomatic or rupted is an indication for surgery. The aim of the open surgery is implantation of the vascular prosthesis into retroperitoneal space. Endovascular method consist in placement of stent-graft in the lumen of aneurysm through small incision in a peripherial vessel. Stent-graft consists of metal chassis covered by classic vascular prosthesis. This method still requires the long-term assessment.

Extra hepatic bile ducts with the gallbladder are the center place for many disease processes. In extreme cases of significant strictures of bile ducts and impairment of bile flow, obstructive jaundice occurs. There are benign and malignant biliary strictures. The treatment of obstructive jaundice depends on the removal of blockage using endoscopic and surgical methods which return the efficient bile flow to the digestive tract. The endoscopic treatment from Vater's papilla access using plastic and metal stents is the method of choice. The choice of proper prosthesis depends on the reason for biliary strictures. The plastic stents (straight, pigtail) are applied the most. Due to their low cost, easy insertion to biliary ducts and exchangeability, they are applied in benign and malignant strictures. However, metal stents (Wallstent, Diamond, Z-stent, InStent), due to the wide diameter after expansion and no possibility of removal, are applied only in malignant strictures. Endoscopic insertion of biliary endoprostheses can be burdened with complications. There have been reports of occlusion, migration with duodenal wall injury and hemorrhaging.

The aim of the study was to assess relationship between the pharmacokinetics of mycophenolic acid (MPA) and the risk of developing acute rejection within 6 months after renal transplantation.MPA concentrations were measured using validated HPLC. Venous blood samples for assay of MPA plasma concentrations were evaluated before (trough level; C) and 40 minutes, 1, 2 and 4 hours after mycophenolate mofetil (MMF) oral administration. The study included adult kidney cadaveric graft recipients: 26 patients treated with CsA, MMF and prednisone. MPA AUC was determined using the linear trapezoidal rule. Statistical significance was assessed using ANOVA Statistica.A total of 13 patients experienced biopsy proven rejection. Patients with acute rejection had lower GFR, lower serum albumin and were younger. There was statistically significant difference for MPA AUC(0-4), C40, C(max) between patients with acute rejection and patients with uneventful outcomes: mean MPA AUC(0-4): 11,4 +/- 7,23 microg x h/ml versus 34,0 26,8 microgxh/ml (p 0,01). Recipients with MPA AUC(0-4)20 g x h/ml had a greater risk of acute rejection.MPA AUC(0-4) was a useful predictor of outcome in renal recipients within first 6 months after renal transplantation.

The aim of the study was to evaluate the effect of brain death, ischemia-reperfusion injury and alloreactivity of some cytokines on intragraft mRNA expression.We have examined 49 needle core biopsies of kidney allografts from cadaveric donors. Samples were taken before harvesting, after cold ischemia and approximately after 20-30 minutes of reperfusion. We have also assessed 56 allograft biopsies taken after transplantation. Tubular and glomerular expression of IL-2, IL-6, IL-10, IFN-gamma, TGF-beta 1 and PDGF-B mRNA was assessed using semiquantitative evaluation of the RT-PCR in situ on paraffin tissue sections.In all pre-procurement specimens high glomerular and tubular IL-2, IL-6, IL-10, TGF-beta 1, PDGF-B and IFN-gamma mRNA expression was detected. After reperfusion an increase of IL-2, IL-6, and IL-10 mRNA expression was observed in all specimens and was limited only to tubules. Biopsies samples with borderline changes exhibited the lowest levels of cytokine gene expression close to the intensity in control specimens. An intense, comparing to normal kidney, tubular and glomerular all examined cytokines gene expression was also noticed during acute rejection. No significant differences between acute cellular and vascular rejection were noticed. The mRNA expression of IFN-gamma and IL-2, IL-6, IL-10 in chronic rejection did not differ from acute rejection. The tubular expressions of mRNA for IL-6 and TGF-gamma 1 in biopsies with acute rejection obtained from patients treated with MMF were significantly lower than in biopsies obtained from patients treated with azathioprine.

In this paper the surgical treatment of thoracic outlet syndrome (TOS) is presented.The investigation of 74 patients treated for vascular complications of the TOS the Paget-Schroetter syndrome and postthrombotic syndrome (27 patients), as well as upper limb ischemia and/or the subclavian artery aneurysm (14 patients) and for neurological complications of the TOS (33 patients) was performed. In case of venous thrombosis the treatment consisted of thrombolytic therapy and decompressive procedures that included transaxillary first rib resection and other surgical procedures that excise different anomalies in the region of the thoracic outlet. In case of complications associated with compression of the subclavian artery the operation consisted of resection of the first rib and accessory osseous and muscular pathological elements using supraclavicular and/or infraclavicular approach with implantation of vascular bypass were performed. In the neurological syndrome of TOS the operation consisted of transaxillary first rib resection and other surgical procedures that excise different anomalies in the region of the thoracic outlet. The therapy results were estimated with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire of the American Academy of Orthopedic Surgeons.In case of venous complications the thrombolytic therapy was successful in all cases the restoration of complete patency was obtained. In all patients first rib was resected via transaxillary approach. The DASH questionnaire revealed the full return of upper limb function in most of patients. Improvement was obtained the in the cases with postthrombotic syndrome. In case of upper limb ischemia the improvement of blood flow was obtained after the subclavian-brachial bypass implantation (5 patients). In this group the DASH score showed return to full activity. In case of subclavian artery aneurysm surgery (9 patients) the DASH scale revealed worsening of limb function in 4 patients during the follow-up period. In the neurological syndrome of TOS the restoration of complete activity of limb was observed. The DASH scale revealed worsening of limb function in 4 patients during the follow-up period.The optimal therapy of vascular complications is multimodal treatment (thrombolysis or reconstructive vascular procedure with decompressive surgery). The surgical treatment of neurological TOS halts degradation of brachial splice. The decompression of neurovascular bundle in vascular TOS should include the first rib resection in each case.

Complete situs inversus (SI) is a very rare anomaly characterized by the total inversion of all abdominal and thoracic organs. SI has been traditionally considered an absolute contraindication for liver and heart transplantation. We report a case of a donor with complete SI diagnosed at the time of organ recovery and we review the literature concerning this anomaly and organ transplantation.

In the study we assessed the clinical and histological benefits of gene therapy in no-option patients with critical lower limb ischemia.We administrated VEGF165 (Vascular Endothelial Growth Factor) plasmid to 10 patients. The plasmid was injected intramuscularly into lower limb. In the study we evaluated: clinical outcomes, venous blood VEGF protein concentration before and after (7th, 14th, 28th and 90th day) administration of plasmid. From patients who required amputation we obtained samples of muscles, which were examined histological and by PCR (Polymerase Chain Reaction) for detection of plasmid genes.Only two patients from the group did not require amputation due to the therapy. In eight patients the operation was essential. Serum VEGF concentration was higher than in healthy controls (p0.05). We observed increase of the concentration of the cytokine on the 14th day an decrease on the 90th day after administration of plasmid (p0.05). Histological analysis did not reveal any sings of new blood vessels formation in the samples taken from amputated limbs. There was also no signs of expression of plasmid primers in PCR.The therapy is safe. We did not observe significant improvement in patient's clinical state. The therapy needs further investigations.

The authors present etiology, diagnosis and operative treatment of thoracoabdominal aneurysms based on their own experiences, especially in performing proximal anastomosis between vascular graft and aorta. The protheses are made of polytertafluoroethylene or dacron. They are impregnated with colagen or soaked with argentum or antibiotics. Spinal cord and visceral organ protection is described. The authors present also endovascular treatment of aorta. Internal chasis of vascular protheses (stentgrafts) is made of biologically neutral metal (like stainless stell, nitinol, other alloys). Its diameter is simmilar to abdominal or thoracic aorta dimension. The chasis is covered by material used also to produce classic vascular protheses (polytetrafluoroethylene, dacron). Thoracoabdominal aneurysms occur rarely, but they are the most difficult problem in vascular surgery. According to literature occurrence of aneurysms in this section value from 4% to 10%. Atherosclerotic process is a exciting cause of this type of aneurysms. According to modified Crawfords classification there are five basic types of thoracoabdominal aneurysms. For pioneer of thoracoabdominal aneurysms surgical treatment one should to recognize S. Etheredge, who in 1954 as a first performed human, aortal homograft implantation with using temporary by-pass. In 1973 E. S. Crawford proposed a new way of management depended on in situ anastomosis between arterial trunks with prosthesis, without use of temporary bypass. In Anglo-Saxon literature this technique gained descriptive qualification "clamp and sew". Using this method, thoracoabdominal aneurysms surgery stood himself decidedly shorter and safer for patients.

The purpose of this study is to evaluate of the use of and silver-coated medical prosthesis in cases of the massive vascular graft infection. In this paper the use of silver-coated medical prosthesis (29 patients) of massive dacron graft infection in Departament of Vascular, General and Transplantation Surgery In Wroclaw University of Medicine In the years 1999-2004 is presented. For lack of tissue material and because of the exclusion of extraanatomic bypass application, in situ replacement was attempted using silver-coated dacron vascular prosthesis more resistant to infection. Before and after the surgery in all patients imaging studies were performed. Duplex-Doppler Ultrasound demonstrated perigraft fluid collections and the scintigraphy with use of Technetium-labeled leukocytes revealed vast migration to the infected prosthesis. The remission of the symptoms of infection was obtained. In the postoperative follow up no perigraft fluid collections were observed. In the most cases positive clinical effect was obtained, the scintigraphy of implanted graft revealed its infection. Because the scintigraphy disclosed Technetium-labeled leukocytes vast migration to the implanted graft, the application of silver coated medical prosthesis should be very cautious and limited to the critical states.

In the article we present the latest knowledge about angiogenesis. We have divided the paper into three main parts, in which the involvement of the extracellular matrix, cells, and cytokines/growth factors in the growth of new blood vessels is described. In brief, the extracellular compartment plays a crucial role in the formation of new vasculature. Degradation of matrix is a very important and precisely controlled process performed mostly by a family of proteins called matrix metallproteinases (MMPs). The extracellular compartment, through the special transmembrane proteins integrins, transmit a wide variety of signals into the cells and thus influence such cell behavior as proliferation, invasion, shape, migration, and maturation. Many products of matrix degradation are potent (mostly negative) regulators of angiogenesis; this self-limiting system prevents excessive proteolysis of the matrix components. The cells involved in the process are endothelial progenitor cells (EPCs), which are derived from bone marrow. The major surface antigens of the cells are CD34+, CD133+, and VEGFR2+. It has been demonstrated that EPCs are responsible for maintaining the functional integrity of endothelium. The number of EPCs in peripheral blood samples inversely correlates with cardiovascular risk factors. In the last section of the article the role of cytokines/growth factors is described. VEGF, as a key regulator of the initial steps of angiogenesis, controls the mobilization and incorporation of EPCs into the site of ischemia. The most important cytokine that facilitates the mobilization of EPCs from bone marrow is SDF-1, which is the strongest chemoattractant for EPCs. Ang-1, on the other hand, controls new blood vessel maturation and stabilization.

Background Experimental studies have demonstrated that the intensity of alloreactivity against a transplanted organ results from an interaction of positive (CD40/CD40L and B.7/CD28) and inhibitory (B.7/CTLA-4) signals between antigen-presenting cells (APCs) and T lymphocytes. Methods We examined the CD40L, CD28, and both surface (s) and intracellular (i) CTLA-4 expressions on freshly drawn and anti-CD3+rIL-2-stimulated peripheral blood CD4+ T cells in groups of kidney transplant recipients in relation to distinct clinical course using the tri-color immunofluorescence method. Results The median proportions of freshly isolated CD3+/CD4+/CTLA-4+ and CD3+/CD4+/CD40L+ cells in all groups of graft recipients were higher than in control subjects. In patients with stable graft function (SGF), non-significantly higher sCTLA-4, significantly higher iCTLA-4 expression, and significantly lower CD40L expression on freshly drawn CD4+ T cells compared with recipients with chronic allograft nephropathy (CAN) were found. Moreover, CD4+ T cells from SGF patients showed a higher potential to express sCTLA-4 and CD40L molecules and to down-regulate the CD28 molecule in response to ex vivo stimulation than those from patients with CAN. In patients without acute graft rejection (NAGR), a markedly higher proportion of freshly drawn CD3+/CD4+/iCTLA-4+ cells compared with patients with acute graft rejection (AGR) and an up-regulation of the median percentage of CD3+/CD4+/CD40L+ cells after ex vivo stimulation was found. Conclusions In patients with SGF, peripheral blood CD4+ T cells exhibited a higher potential to express surface CTLA-4 and CD40L and to down-regulate CD28 costimulatory molecules in response to ex vivo stimulation, indicating a relationship between the expression patterns of both costimulatory and inhibitory molecules in CD4+ T cells and clinical course after renal transplantation.

An article is presented the treatment of vascular prosthetic grafts infections. An the graft infection treated by the replacement of infected prosthesis with autogenic venous material or with venous and arterial allograft harvested from brain-dead organ donors together with multiple organ procurement is presented. Autogenous material has an ability a better healing in infected tissues and used with absorbable sutures may lead to complete recovery from vascular graft infection - a severe and often lethal complication. An article is presented the treatment of vascular prosthetic grafts infections with the use of more resistant prostheses of infection - silver coated prosthesis, prosthesis with antibiotic and polytetrafluoroethylene prostheses.

In this paper the treatment of arterial complications of the Thoracic Outlet Syndrome (TOS) is presented. The investigation of 14 patients treated in the Department of Vascular, General and Transplantological Surgery of the Wroclaw Medical University for arterial complications of the TOS (as upper limb ischemia and/or the subclavian artery aneurysm in 14 patients) was performed. In case of complications associated with compression of the subclavian artery the operation consisted of resection of the first rib and accessory osseous and muscular pathological elements using supraclavicular and/or infraclavicular approach with implantation of externally supported ringed vascular polytetrafluoroethylene bypass (PTFE) were performed. The therapy results were estimated with use of The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire of American Academy of Orthopedic Surgeons.In case of upper limb ischemia the improvement of blood flow was obtained after the subclavian-brachial bypass implantation (5 patients). In this group the DASH score showed return to full activity. In case of subclavian artery aneurysm surgery (9 patients) the DASH scale revealed worsening of limb function in 4 patients during follow-up period. The optimal therapy of vascular complications is the multimodal treatment (reconstructive vascular procedure with decompressive surgery). The decompression of neurovascular bundle in vascular TOS should include the first rib resection in each case.

The aim of our study was to correlate intragraft mRNA expression of cytokines and growth factors with histopathologic features in renal allograft biopsies. Fifty-six core biopsies performed in 51 kidney transplant recipients were assessed by the Banff '97 classification. Tubular and glomerular expressions of IFN-gamma, TGF-beta1, and PDGF-B as well as IL-2, IL-6, and IL-10 mRNA were assessed using semiquantitative RT-PCR in situ. No significant differences were noted between acute cellular and vascular rejection with regard to the glomerular and tubular mRNA expression of cytokines examined. We observed a positive correlation between tubular and glomerular IL-10 and IFN-gamma mRNAs during acute rejection. In chronic rejection the mRNA expression levels of IFN-gamma and IL-2, IL-6, and IL-10 did not differ from those of acute rejection; moreover, the glomerular expression of mRNA for TGF-beta1 (P.05) and PDGF-B (P.1) was even lower than during acute rejection episodes. Both tubular and glomerular IL-2, TGF-beta1, and PDGF-B mRNA expression levels in biopsies with acute rejection were significantly higher than in acute tubular necrosis (ATN). Biopsy samples with borderline changes exhibited the lowest levels of cytokine gene expression and were close to the intensity of control specimens obtained from living donor kidney biopsies taken during organ harvest. Our data failed to show a dichotomy between Th1 and Th2 cytokine activation in biopsy specimens from kidney allograft recipients; both Th1- and Th2-derived cytokines were involved to similar extents in rejection processes.

The aim of the study was to assess the molecular background of the alloimmune response by the detection of low-abundance mRNA of cytokines in 34 core needle biopsies from kidney allografts with histopathological findings of acute rejection (AR). Recipients were immunosuppressed with a calcineurin inhibitor (CNI), cyclosporine or tacrolimus, and prednisone and azathioprine or mycophenolate mofetil (MMF). Tubular and glomerular expression of IL-2, IL-6, IL-10, IFN-gamma, TGF-beta1, and PDGF-B mRNA were assessed using semiquantitative evaluations of RT-PCR in situ on paraffin tissue sections. This procedure resulted in light microscopy visualization of granular precipitates at the sites of the corresponding mRNA chains. The tubular expression of mRNA for IL-6 and TGF-beta1 was significantly lower in biopsies with AR (n = 34) obtained from patients treated with MMF (n = 12) than in biopsies obtained from patients treated with azathioprine (n = 22) (P.02). Responsiveness to corticosteroids tended to be more frequent among the MMF group (11 of 12 recipients vs 15 of 22 recipients, P = ns). Moreover, 8 of 12 recipients in the MMF-treated group displayed serum creatinine levels equal or less than 167 mmol/L 1 year after biopsy compared to 7 of 22 recipients in the azathioprine-treated group. There was no significant difference between the groups that had or had not received corticosteroids or between those treated with each type of CNI. These results suggest stronger inhibition of humoral responses and down-regulation of fibrosis by MMF among recipients with AR.

In order to study pathogenesis of vascular prosthesis healing process the following experiment was designed. 16 dogs underwent implantation of unilateral straight aorto-femoral teflon (PTFE, polytetrafluoroethylene) by-pass. After 6 months all dogs were killed, dissected and vascular prostheses with margin of adjacent aorta and femoral artery were collected for further study. Areas of proximal and distal anastomosis were examined immunohistochemically. Presence of coagulation factor VII, and C3 complement factor were studied. The obtained results were analyzed statistically by means of t-Student test. Factor VII as well C3 were found in areas of both proximal and distal anastomosis. Concentration of all two substances in proximal and distal anastomosis was compared. No statistically valid differences in factor VII concentration in proximal and distal anastomosis were found, whereas amounts of C3 factor as well as degree of extracellular matrix infiltration were markedly higher in distal anastomosis.

There is growing experimental evidence that Chlamydia pneumoniae is a risk factor and contribute to the development of atherosclerosis of carotid artery. This process might cause stenosis of carotid artery and TIA or stroke.Aim of this study was to evaluate the frequency of Ch. pneumoniae infection in carotid artery stenosis patients and in control group-healthy artery from multiorgan donors.From each of 84 patients undergoing carotid endarterectomy the samples were analyzed by nested PCR for Ch. pneumoniae DNA. Furthermore we determined DNA Ch. pneumoniae in carotid artery from 20 multiorgan donors.In control group-healthy artery the PCR for Ch. pneumoniae was negative in all samples. Ch. pneumoniae was detected in 57 patients (67.85%) with symptomatic carotid artery stenosis, however in 27 patients (32.15%) the PCR test was negative.We did not observe infection of Ch. pneumoniae in healthy carotid artery-control group. We noted great frequency of infection in patients with stenosis of carotid artery. Patients with stenosis of carotid artery can be candidates to antibiotic therapy, which can slow down the progression of artery stenosis.

We present in this paper application of haemostatic device TachoComb onto bleeding after vascular anastomosis of dacron vascular prosthesis (branch of aortobifemoral or bypass aortofemoral) with common femoral artery in the groin. Hemorrhagic complications have influence onto clinical status of operated patients. Haemostatic TachoComb dressing was applied at 30 cases and results were compared to control group consist of 25 cases, in which gas compresses were applied. Mean loss blood in group I with the usage of TachoComb was statistical characteristic (p0.003) smallest than in group II. Also mean time of hemostasis was shortest than in group II (p0.01). We proved that use of TachoComb limits bleeding from suture line connecting artery with vascular prosthesis.

The purpose of this study is to evaluate the use of immunosuppression in treatment of prosthetic graft infections with arterial transplantation.In this paper 29 cases of the massive aorto-ilio-femoral graft infection treated by the replacement of infected prosthesis with arterial homograft are presented. The arterial allograft was stored with application of cold ischemia method in preservation solution at 4 degrees C. During the follow up period the patients were divided into two groups: group received immunosuppressive regimen after surgery (n = 16) and group without immunosuppression (n = 13). The Duplex-Doppler ultrasound, the scintigraphy with use of Technetium-labeled leukocytes, bacteriological and antigenic examination and blood levels of Cyclosporin A were used in the diagnostic trial of infection and of the healing process of the homograft. In both groups there was performed evaluation of arterial wall by using the scanning electron microscopy.In the group with immunosuppression no complications due to the homograft's wall degradation and deficiency of cell mediated immunity in infections were noticed. In the group without immunosuppression there were observed complications related to the impairment of the allograft wall: in 3 cases--the graft rupture, in 2 cases--the graft true aneurysm and homograft thrombosis in 3 cases.The use of immunosuppression in transplantation of artery produces increase in survival rate and improves function of arterial graft.

The infection after synthetic vascular prosthetic graft implantation remains a serious complication of reconstructive vascular surgery. Surgical treatment consists of complete removal of the infected vascular graft with the preservation of the limb circulation. In this paper the case of aortofemoral by-pass infection limited to the distal part of the branches is presented. Because of the unsatisfactory results of conventional treatment the patients underwent the in situ replacement of infected prosthesis with the silver/collagen coated prosthesis. The postoperative check up (clinical examination, duplex-doppler ultrasound, scintigraphy of Technetium 99m-labeled leucocytes) revealed the complete remission of infection. The surgery can be limited to the replacement of infected segment of prosthesis with arterial homograft, but this therapeutic method requires further investigations and scrupulous observations.

In this paper we present influence of use of haemostatic dressing TachoComb, onto bleeding from surface of transplanted kidney. Kidney transplantation (KTX) seems to be main method of treatment of terminal renal failure. Enlarging number of KTX results in growing frequency of intra and postoperative complications. Hemorrhagic complications can impact clinical status of recipient and graft function. Haemostatic dressing was applied at 29 cases. Control group in which only gas compresses were used consisted of 25 patients. It was proved, that use of dressing from collagen mesh covered by fibrin glue TachoComb, after kidney transplantation diminished parenchymal bleeding and time necessary to get complete hemostasis.

In this study a method of elimination of the second warm ischemia is shown. The method is based on the application of a specially constructed polyethylene bag, in which the transplanted kidney is placed in the time course from a removal from ice to the reconstruction of vessel flow. The bag is built of polyethylene foil HDPE of low density produced under high pressure. Own construction of the bag (three spaces and polyethylene) enables the storage of a transplanted organ at the stable temperature +4 Celsius degrees. Thanks to the separation of containers for melting ice and for the kidney, possible becomes unrestrained performance of both venous and arterial anastomosis independently of existing operative conditions. Due to the applied method of the elimination of the second warm ischemia with the usage of own construction of polyethylene bag HDPE, one can expect better early renal function after transplantation--decrease in the number of cases and shortening of the time of acute tubular necrosis (ATN--Acute Tubular Necrosis).

Cases of massive purulent infection of vascular prosthesis are demonstrated in this study. Infected prosthesis was substituted by arterial homograft, harvested during multi-organ procurement, and stored by the cold ischaemia method. In the follow-up period, the patients were divided into two groups, those treated with immunosuppression (n = 16) and those treated without immunosuppressive drugs (n = 13). The patients underwent resurgery, during which a fragment of arterial wall was taken for electron microscopic examination. In the group with immunosuppression, the presence of the following structures was observed: endothelial cells, the intima, with a great number of elastic and collagen fibrils with fibrinogen inclusions, and active phagocyting myoblasts and myofibroblasts. In the group without immunosuppression electron microscopic examination showed the total destruction of the wall of the ruptured arterial homograft - absence of endothelium and sparse, damaged fibroblasts of the media or their degraded fragments, making a picture of cellular death. Morphological analysis of the arterial wall and the clinical state of the patient suggest the necessity of immunosuppressive treatment after fresh arterial homograft transplantation.

Author on the ground 124 of artificial grafts Dallon H grafted in years 2000--June 2002 in Department of Vascular, General and Transplantation Surgery in Wroclaw with protracted ischaemia of lower limbs, represents own experiences for observations of useful features this artificial graft. The hydrophility of these grafts, at maintenance all of other comparable features with grafts of westerly firms causes, that Dallon H I gained oneself large acknowledgement as many-sided artificial grafts alternative to vascular prosthesis of renowned westerly firms.

In this paper the use of silver-coated medical prosthesis of massive aorto-bifemoral and ilio-femoral dacron graft infection with hemorrhage is presented. To solve this problem in situ replacement was attempted using silver-coated dacron vascular prosthesis more resistant to infection. 9 patients with this therapeutic method is reported. Although positive clinical effect was obtained, the scintigraphy and Duplex Doppler Ultrasound of implanted graft revealed its infection. In our opinion therefore application of silver-coated medical prosthesis should be very cautious and limited to the critical states.

The varices of the lower limbs and its complications are very common Surgical procedure which consists of ligatur of the venous tranks or stripping of them, ligation of perforating veins are basic methods of the treatment. After surgery, veins compression prevents secondary bleeding and above all, the development or recurrence of thrombosis The purpose of this study was the assessment of graduated compression stockings in prophylaxis of varicose vein disease recurrency. The study included 120 patients who underwent phlebectomy due to varicose veins. The period of follow up lasts 3 years and has been carried out in two groups. The first one was agreed to use compression therapy following surgery. The second group did not get any physical support to their legs. Compression class I and II: calf, thigh, panty medical stockings and were used. The first group of 60 patients (102 legs) wearing medical stockings following surgery have no either subjective or objective signs of venous insufficiency in long period of time after surgery. Statistical analysis pointed out marked significance between both groups of patients p0.001.

In this paper the methods with synthetic vascular prosthesis used in surgical treatment of the secondary aorto-intestinal fistula are presented. 10 cases of 22 patients treated in the years 1993-2003 for secondary aorto-intestinal fistulas as a complication of vascular prosthesis infection are analysed. In all patients the abdominal CT, scintigraphy with technetium 99m labeled leucocytes and endoscopy were performed. The patients underwent the operation of infected dacron prosthesis' replacement with silver/collagen coated prosthesis or extraanatomic bypass (subclavian to femoral). To close the intestinal fistula the duodenectomy with gastroenterostomy was performed or the duodenum was sutured and protected with the use of pedicled omentum. In 4 patients extraanatomic subclavian-femoral of polytetrafluoroethylene (PTFE) bypass was used. In these cases the intestinal surgery was composed of the partial duodenectomy with fistula excision and duodenal stumps formation followed by antecolic gastrojejunostomy with the Braun's enteroanastomosis and pyloroplasty. In this group 2 patients (50%) died in the follow up period. There were two extraanatomic bypass thromboses in the 30 days follow up and one amputation (25%). The infected vascular prosthesis was replaced with silver/collagen coated prosthesis in the 6 patients. In these cases duodenal fistula was closed with two layers of stitches and additionally protected with pedicled fragment of the greater omentum, which was sewn on the duodenum. In this group 1 patients (16.7%) died in the follow up period. In one case (16.7%) in 9 months after operation reinfection od silver prosthesis was observed. There were no significative differences (p = 0.45) in terms of early mortality between both group of patients. The treatment of the fistula is a difficult and hazardous surgical procedure, results of which are unpredictable.