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A clinical series of five patients operated on for symptomatic cerebral blood flow deterioration is discussed. They presented with either hemispheral symptoms (hemiparesis, amaurosis fugax) or signs of diffuse cerebral hypoxia. In the presence of unilateral or bilateral internal carotid artery (ICA) occlusion a critical stenosis of the external carotid artery (ECA) was confirmed either by duplex ultrasound or angiography. In all these cases ECA was reconstructed by means of common vascular surgical techniques. The use of intraluminal (i.l.) shunt was mandatory. There were neither early nor late deaths in this group. In one patient a transient stroke occurred three days following standard carotid endarterectomy performed after ECA surgery on the contralateral side. After the mean follow-up of 46 months all patients remain neurologically asymptomatic. In selected cases the ECA reconstruction offers an effective and beneficial tool for surgical management of critical cerebral perfusion impairment.

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BACKGROUND: Elevated total homocysteine plasma levels are considered a significant factor of vascular damage. As they are encountered in more than half the patients with atherosclerotic vascular damage the importance as a lipid-dependent or lipid-independent risk factor in the promotion of pathophysiological processes is discussed. METHODS AND RESULTS: In a group of 100 healthy subjects and 529 patients with indication for an aortocoronary or peripheral arterial bypass and in patients from the lipid clinic the mutual relation between total plasma homocysteine levels and selected indicators of the lipid metabolism was investigated. The following results more obtained: for total cholesterol a correlation coefficient of r = 0.26, for HDL-cholesterol r = 0.20, for LDL-cholesterol r = 0.21, for triacylglycerols r = 0.29, apolipoprotein A-I r = 0.06, apolipoprotein B r = -0.12 and for Lp(a) r = -0.03. To ensure correct evaluation of the homocysteine levels simultaneously also folate levels were examined (correlation coefficient r = 0.28), vitamin B12 r = (0.03) and fibrinogen r = (0.09). CONCLUSIONS: The authors did not detect an unequovical relationship between the total homocysteine level and selected lipid indicators in any of the patient groups (p < 0.05).

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Embolization of end-stage kidneys using our own embolizing agent Vilanol (partially hydrolyzed polyvinyl acetate) was performed in 10 patients with hypertension refractory to conservative therapy. Native kidneys were embolized in 7 patients with chronic renal failure, nonfunctioning renal transplants in 2 patients, and a shrunken kidney in 1 patient. Five of the 10 patients had high (9.96-18.2 ng/ml/h) peripheral renin (PR) levels. The embolization was technically successful in 4 of these 5 patients and was immediately followed by a marked decrease in PR, and simultaneous improvement in blood pressure (BP). The other 5 patients had very low PR levels (0.07-0.65 ng/ml/h), and a reduction in BP was observed in 4 after embolization. One patient died following embolization from cardiac arrest due to hyperkalemia. Six patients (3 in each group) have been on follow-up for 2-5 years with sustained decrease in BP. We conclude that the new agent is effective for renal ablation and control of refractory hypertension.

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Patients with affections of the vascular system of the lower extremities at several levels present a complicated problem for vascular surgery. The authors submit their experience with a combination of vascular reconstruction and peroperative transluminal angioplasty. In 25 patients, mean age 64 years, they performed 29 of these combined operations, 10 times on account of claudications, 11 times on account of pain at rest, 8 times on account of trophic defects. The pelvic vessels were dilated 6 times; the dilated vessels as well as the reconstruction remained patent. Peroperative angioplasty of the superficial femoral artery was performed 6 times, occlusion occurred once. Twelve times they dilated the distal portion of the popliteal artery or the vessels of the leg, 3 times the dilated portion became occluded. None of the patients lost the limb, one patient died from acute myocardial infarction shortly after operation. The authors describe the technique of peroperative transluminal angioplasty, evaluate the results and discuss the advantages and disadvantages of this method.

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Based on their own experience and data in the literature, the authors recommend to use also in future palliative embolization of the kidney as part of comprehensive treatment of patients with inoperable tumours of the kidney. They describe their experience with a group of 20 patients. In one female patient after palliative embolization an unusually favourable effect was observed with macroscopic disappearance of the tumour and affection of the pleura, associated with prolonged survival.

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Percutaneous transluminal angioplasty (PTA) takes its stable position in the therapy of obliterating arterial diseases. Its indication areas considerably extend. The authors present a survey of their experience and the results of PTA of arteries supplying the brain and upper extremities. This surgery was made in 29 patients on 31 arteries. The authors consider PTA on a. subclavia as a method of choice. In the angioplasty on a. vertebralis there is a very low risk in correctly indicated cases. An atherosclerotic stricture of a. carotis interna is not considered suitable for PTA for the risk of embolism from the exulcerated plaques. However, the method may be used with advantage in the stenosis based on fibromuscular dysplasia and in some cases of early restenoses in a. carotis interna after previous endarterectomy. The authors arrive at the conclusion that PTA, if correctly indicated, is a safe method even in arteries supplying the brain and upper extremities. No complication was observed in the reported group.

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The authors describe their experience in two cases of mechanic desobliteration and subsequent percutaneous transluminal angioplasty in a chronically occluded renal artery. It has become obvious that although this surgery has been so far performed only rarely it is technically viable and may exert a favourable therapeutic effect on hypertension of renovascular etiology as well as angioplasty of stenosing lesion of kidney arteries. The paper also discusses a possibility of influencing renal function by this method. The authors arrive at the conclusion that recanalization of a chronic occlusion of renal artery extends the presently relatively stabilized indications for percutaneous transluminal angioplasty in this localization.

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The authors performed, in the period of 10/1980 to 12/1985, 102 PTA interventions in 95 patients in the peripheral region. The lasting clinical improvement of early and long-term duration was expressed by the Life-table method. In the whole cohort, 95% of patients proved to be improved clinically in the early period (3 months after the intervention), while 70% of patients were improved for long-term period (up to 66 months). The authors also compare the results reached in PTA of pelvis vascular bed and femoropopliteal region. In the PTA of pelvis vascular bed, improved clinical condition in the early period was reached in 95% of patients, long-term improvement was observed in 73% of individuals. In PTA of femoropopliteal region the early period showed improvement in 96% of patients, the long-term period indicated improvement in 52% of subjects.

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A total of 13 procedures of percutaneous transluminal angioplasty were performed in 11 kidney graft recipients with renal transplant artery stenosis. Nine procedures were technically successful in eight patients (one redilatation was necessary because of restenosis). Graft biopsy confirmed rejection nephropathy in all cases. The outcome could not be evaluated in one patient who died of a concomitant disease shortly after angioplasty. The remaining seven patients (eight percutaneous transluminal angioplasties) showed improvement in hypertension in 63% and in glomerular filtration rate in 50% of procedures, persisting for 6-13 months. A single major complication encountered was a loss of graft related to unsuccessful percutaneous transluminal angioplasty. The results suggest that percutaneous transluminal angioplasty may bring prolonged increase in effective renal plasma flow and glomerular filtration rate even in patients experiencing rejection nephropathy.

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Embolization of the renal arterial bed with embolization agent Vilan 500 was performed in 13 dogs. Embolized kidneys shrink after the procedure and the functional parenchyma is extinguished. Peripheral PRA values were followed to find out whether renin production by the embolized kidney is extinguished (the non-embolized kidney was surgically removed). In nine of the thirteen dogs peripheral PRA decreased below 0.5 ng/ml/h; this renin activity can be considered extrarenal. Embolization of the kidneys with Vilan 500 can thus substitute surgical nephrectomy in patients with secondary renal hypertension.

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