Parkes Weber syndrome-Diagnostic and management paradigms: A systematic review

Objectives Parkes Weber syndrome is a congenital vascular malformation which consists of capillary malformation, venous malformation, lymphatic malformation, and arteriovenous malformation. Although Parkes Weber syndrome is a clinically distinctive entity with serious complications, it is still frequently misdiagnosed as Klippel-Trenaunay syndrome that consists of the triad capillary malformation, venous malformation, and lymphatic malformation. Methods We performed a systematic review investigating clinical, diagnostic, and treatment modalities of Parkes Weber syndrome (PubMed/MEDLINE, Embase, and Cochrane databases). Thirty-six publications (48 patients) fulfilled the eligibility criteria. Results The median age of patients was 23 years (IQR, 8-32), and 24 (50.0%) were males. Lower extremity was affected in 42 (87.5%) and upper extremity in 6 (12.5%) patients; 15 (31.3%) patients developed high-output heart failure; 12 (25.0%) patients had chronic venous ulcerations, whereas 4 (8.3%) manifested distal arterial ischemia. The spinal arteriovenous malformations were reported in six (12.5%) patients and coexistence of aneurysmatic disease in five (10.4%) patients. The most frequently utilized invasive treatments were embotherapy followed by amputation and surgical arteriovenous malformation resection, and occasionally stent-graft implantation. All modalities showed clinical improvement. However, long follow-up and outcome remained unclear. Conclusion A diagnosis of Parkes Weber syndrome should be made on the presence of capillary malformation, venous malformation, lymphatic malformation, and arteriovenous malformation (as main defect) in overgrowth extremity. Arteriovenous malformation presents the criterion for distinguishing Parkes Weber syndrome from Klippel-Trenaunay syndrome, which is substantial for treatment strategy. The primary management goal should be patient's quality of life improvement and complication reduction. Embolization alone/combined with surgical resection targeting occlusion or removal of arteriovenous malformation "nidus" reliably leads to clinical improvement.

9p21 locus rs10757278 is associated with advanced carotid atherosclerosis in a gender-specific manner

Single nucleotide polymorphisms from the chromosome locus 9p21 are reported to carry a risk for various cardiovascular diseases. One of the lead single nucleotide polymorphisms, rs10757278, was mostly investigated in association with coronary artery disease but rarely with carotid atherosclerosis. In this study, we aimed to analyze the association of rs10757278 A/G polymorphism with carotid plaque presence in advanced carotid atherosclerosis. The study included 803 participants, 486 patients with high-grade stenosis (>70%) who were undergoing carotid endarterectomy and 317 controls from Serbian population. Genotypes were determined using the real-time polymerase chain reaction. According to the recessive model of inheritance, GG genotype was significantly and independently associated with carotid plaque in females only (odds ratio 2.42, CI = 1.20-4.90, P = 0.013). Odds ratio was adjusted for age, body mass index, hypertension, TC, LDLC, HDLC and TG, and P value was corrected for multiple comparisons. Our preliminary findings suggest a gender-specific association of rs10757278 polymorphism with carotid plaque. Further studies on larger sample and in genetically and environmentally similar populations are needed.

Giant Posttraumatic Cervical Hematoma: Acute Presentation of Papillary Thyroid Carcinoma in an Adolescent

OBJECTIVE

To describe a rare case of acute presentation of papillary thyroid carcinoma (PTC).

CLINICAL PRESENTATION AND INTERVENTION

A 19-year-old male presented with an expanding cervical mass following blunt trauma. A computed tomography scan revealed a mass suspected to be hematoma that was compressing the vessels and thereby deviating the trachea. Immediate surgery was performed. Neither vascular injury nor active bleeding was seen; instead, a solid, hematoma-like tumefaction in the right thyroid lobe was revealed. A total thyroid lobectomy was performed. A histologic paraffin section confirmed a PTC that was permeated by hematoma.

CONCLUSION

This was a unique case of an acute, life-threatening presentation of previously asymptomatic PTC in an adolescent.

Incidence and relevance of groin incisional complications after aortobifemoral bypass grafting

BACKGROUND

Aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AIOD) is traditionally accompanied by substantial groin incisional morbidity, which poses a threat to an underlying prosthetic graft. We performed a study to investigate the frequency and define the clinical course and significance of such problems.

METHODS

One hundred twenty consecutive patients undergoing primary elective ABFB for AIOD were enrolled in a prospective study. The healing of groin wounds was systematically assessed, the occurrence of incisional complications of any type noted, and their clinical course and economic consequences documented and analyzed.

RESULTS

Early postoperative complications (30 days) affected 35 (15%) groin wounds in 29 (24.8%) patients. Lymph fistulas/lymphoceles were observed in 15 (6.4%), infection in 11 (4.7%), and noninfectious wound dehiscence in 9 (3.8%) of groin incisions. The only significant predictor of groin healing impairment was preoperative length of stay. Groin incision-related morbidity significantly increased the duration and cost of hospitalization. Sixty percent of groin healing problems were diagnosed after discharge and they represented the most common cause for early readmissions.

CONCLUSIONS

The incidence of groin wound complications after ABFB is considerable, their financial impact significant, and delayed onset frequent. Femoral incisional morbidity after ABFB still represents an unremitting nuisance, necessitating further improvements in preventive strategies and techniques and strict adherence to conventional ones, including the minimization of preoperative length of stay.

Indirect surgical management of a penetrating vertebral artery injury

Introduction

Vertebral artery injury caused by penetrating neck trauma is a rare occurrence. Direct surgical repair is difficult due to anatomy and exposure. Proximal and distal ligation or/and embolization represent the most common management in cases which require intervention.

Case report

A young man accidentally stabbed in the neck was admitted to the emergency department with active arterial bleeding from the wound. Immediate surgical exploration revealed an isolated injury of the left vertebral artery intraosseous segment. Lesion was managed by proximal segment ligature and distal Fogarty catheter balloon-tamponade. Postoperative angiography excluded the need for further interventions. Balloon-catheter was successfully extracted after 72 hours and patient discharged neurologically intact on postoperative day 7. Fourteen months later, there are no signs of vascular or neurologic complications.

Conclusion

Balloon-tamponade is a valuable technical adjunct in either temporizing or definitive management of surgically inaccessible vascular trauma.

Endovascular aortic repair: first twenty years

Endovascular aortic/aneurysm repair (EVAR) was introduced into clinical practice at the beginning of the nineties. Its fast development had a great influence on clinicians, vascular surgeons and interventional radiologists, educational curriculums, patients, industry and medical insurance. The aim of this paper is to present the contribution of clinicians and industry to the development and advancement of endovascular aortic repair over the last 20 years. This review article presents the development of EVAR by focusing on the contribution of physicians, surgeons and interventional radiologists in the creation of the new field of vascular surgery termed hybrid vascular surgery, and also the contribution of technological advancement by a significant help of industrial representatives--engineers and their counselors. This article also analyzes studies conducted in order to compare the successfulness of EVAR with up-to-now applied open surgical repair of aortic aneurysms, and some treatment techniques of other aortic diseases. During the first two decades of its development the EVAR method was rapidly progressing and was adopted concurrently with the expansion of technology. Owing to large randomized studies, early and long-term results indicate specific complications of this method, thus influencing further technological improvement and defining risk patients groups in whom the use of the technique should be avoided. Good results are insured only in centers, specialized in vascular surgery, which have on their disposal adequate conditions for solving all complications associated with this method.

Appearance of femoropopliteal segment aneurysms in patients with abdominal aortic aneurysm

BACKGROUND/AIM

To promote better treatment outcome, as well as economic benefit it is very important to find out patients with simultaneous occurrence of both aortic and arterial aneurysms. The aim of this prospective study was to determine the frequency and factors affecting femoropopliteal (F-P) segment aneurysms appearance in patients with abdominal aortic aneurysms (AAA).

METHODS

This study included 70 patients who had underwent elective or urgent surgery of AAA from January 1, 2006 to December 31, 2007. After ultrasonographic examination of F-P segment, all the patients were divided into two groups--those with adjunctive F-P segment aneurysm (n = 20) and the group of 50 patients witho no adjunctive F-P segment aneurysm. In both groups demographic characteristics (gender, age), risk factors (diabetes mellitus, elevated serum levels of cholesterol and triglycerides, arterial hypertension, smoking, obesity) and cardiovascular comorbidity (cerebrovascular desease, ischemic heart desease) were investigated.

RESULTS

Twenty (28.57%) patients who had been operated on because of AAA, had adjunctive aneurysmal desease of F-P segment. Diabetes was no statistically significantly more present among the patients who, beside AAA, had adjunctive aneurismal desease of F-P segment (chi2 = 0.04; DF = 1; p > 0.05). Also, in both groups there was no statistically significant difference in gender structure (chi2 = 2.05; DF = 2; p > 0.05), age (chi2 = 5.46; DF = 1; p > 0.05), total cholesterol level (chi2 = 0.89; DF = 1; p > 0.05) and triglyceride (chi2 = 0.89; DF = 1; p > 0.05) levels, the presence of arterial hypertension (chi2 = 1.38; DF = 2; p > 0.05), smoking (chi2 = 1.74; DF = 1; p > 0.05), obesity (chi2 = 1.76; DF = 1; p > 0.05) and presence of cerebrovascular desease (chi2 = 2.34; DF = 1; p > 0.05). Conversly, ischemic heart desease was statistically significantly more present among the patients who, beside AAA, had adjunctive aneurismal desease of F-P segment (chi2 = 5.45; DF = 1; p < 0.05).

CONCLUSION

Twenty patients, beside AAA, had adjunctive F-P segment aneurysm. The results of this study suggest the necessity of preforming ultrasonographic examination of F-P segment in all patients with proven AAA.

Portal hypertension caused by postoperative superior mesenteric arteriovenous fistula

INTRODUCTION

Arteriovenous fistula of the superior mesenteric blood vessels is a rare complicaton in abdominal surgery.

CASE REPORT

We presented a 49-year-old man with cramp-like abdominal pain, abdominal distension and weight loss symptoms, with a history of previous small bowel resection and right colectomy, due to Crohn disease, 16 years ago. Clinical examination revealed a paraumbilical pulsation with systolic murmur and thrill. Ultrasonography and computed tomography revealed cystic dilatation of the superior mesenteric vein, hepatomegaly and ascites. Upper endoscopy revealed grade I esophageal varices with portal hypertensive gastropathy. The diagnosis of arteriovenous fistula between superior mesenteric artery and vein was confirmed by angiogram of the superior mesenteric vessels and resection of the fistula was performed. Control examination after nine months showed no signs of portal hypertension.

CONCLUSION

Early diagnosis and treatment of mesenteric blood vessel arteriovenous fistula prevents portal hypertension development and its complications.

Repair of abdominal aortic aneurysms in the presence of the horseshoe kidney

AIM

Horseshoe kidney is the most common congenital kidney anomaly, occurring in 0.15-0.25% of all newborns. A medial fusion of the kidneys, mostly anteriorly to the aorta, is the main characteristic of this anomaly. The co-existence of abdominal aortic aneurysm (AAA) and horseshoe kidney is rare, occurring only in 0.12% of patients. The aim of this paper is to define the optimal management of patients with AAA associated with the horseshoe kidney.

METHODS

This paper presents the analysis of patients operated at the Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia in Belgrade due to AAA associated with the horseshoe kidney as well as the analysis of the previously published literature data regarding this topic.

RESULTS

Between 1985 and 2011, data were collected retrospectively on 25 patients with the horseshoe kidney who underwent aortic surgery. Out of them, 6 patients had aortoiliac occlusive disease and 19 patients had aortic aneurysm. More detailed analysis of the aneurysmatic group was performed. Among them there were 16 male and three female patients, with the average age of 63.8 (50-76) years. Two patients had type IV of thoracoabdomial aortic aneurysm (TAA) according to Crawford-Saffi classification, while 17 had infrarenal abdominal aortic aneurysms. There were 15 elective and four urgent procedures due to aneurismal rupture. The presence of the horseshoe kidney was detected in 16 patients before surgery (84.2%) by means of Duplex ultrasonography, angiography, computed tomography and intravenous urography. Multiple renal arteries were presented in 12 (63.2%) cases. A transperitoneal approach was used in 16 cases with abdominal aortic aneurysm, while left retroperitoneal approach with partial extrapleural removal of the 11th rib was performed in two cases of thoracoabdominal aneurysm and in one patient with AAA. In 18 cases, kidney tissue transection was successfully avoided with vascular graft placement beneath the horseshoe kidney. In one case only, the division of the renal isthmus was performed. In all 12 cases with detected anomalous renal arteries, their reattachment into vascular graft has been performed. Two patients (10.5%) died during perioperative period. One of them had ruptured type IV TAA. Seventeen patients who survived were followed from one to twenty years (mean 6.6 years). During the follow up period we lost track of 4 patients. In this period there were no signs of graft occlusion, or renal failure.

CONCLUSION

Repair of an abdominal aortic aneurysm in the presence of the horseshoe kidney is a truly particular surgical challenge. It is associated with three main problems: choice of the surgical approach; the procedure regarding kidney isthmus preservation as well as recognition and reattachment of all significant anomalous renal arteries.

The association of ACE I/D gene polymorphism with severe carotid atherosclerosis in patients undergoing carotid endarterectomy

Introduction: The ACE I/D polymorphism was mostly investigated in association with intima-media thickness, rarely with severe atherosclerotic phenotype.

Materials and methods: We investigated the association of I/D polymorphism with severe carotid atherosclerosis (CA) (stenosis > 70%) in asymptomatic and symptomatic patients undergoing carotid endarterectomy. The 504 patients subjected to endarterectomy and 492 healthy controls from a population in Serbia were investigated as a case-control study.

Results: The univariate logistic regression analysis revealed ACE DD as a significant risk factor for severe CA (odds ratio [OR] = 1.3, 95% confidence interval [CI] 1.0–1.7, p = 0.04). After adjustment for the common risk factors (age, hypertension, smoking, and HDL) ACE was no longer significant. However, we found a significant independent influence of DD genotype on plaque presence in a normotensive subgroup of patients (OR 1.8, CI 1.2–3.0, p = 0.01, corrected for multiple testing). In symptomatic patients D allele carriers were significantly more frequent compared with asymptomatic patients (OR 1.6 CI 1.0–2.6, p = 0.05).

Conclusions: Our data suggests that ACE I/D is not an independent risk factor for severe CA. On the other hand, a significant independent genetic influence of ACE I/D appeared in normotensive and symptomatic patients with severe CA. This should be considered in further research toward resolving the complex genetic background of severe CA phenotype.

The role of duplex ultrasonography in surgical treatment of acute progressive thrombophlebitis of great saphenous vein

AIM

The aim of this paper was to determine the role of ultrasonographic examination in acute progressive thrombophlebitis (APT) of great saphenous vein (GSV) and its impact in considering indications for urgent surgical treatment. MEHODS: In this retrospective study, out of 141 consecutive patients operated due to APT of GSV above the knee, 63 were examined by ultrasonography prior surgery.

RESULTS

Out of 63 operated patients, in 38 duplex ultrasonography (DUS) revealed that proximal level of phlebitic process was more than 5 cm higher than the one found during physical examination (60.3%). In this group, the mean difference between DUS and clinical finding was 8.5±3.5 cm. In 25 patients there were no differences greater than 5 cm found between DUS and physical examination (39.7%). There was statistically highly significant difference between DUS and physical examination findings (χ2=6.5, P<0.01).

CONCLUSION

This study revealed significant difference between ultrasonographic and physical findings in patients with APT of GSV. DUS presented as reliable diagnostic method in examining, course-following and making decision for operative treatment of these patients.

Blunt injury of the innominate artery and left innominate vein

Injuries to the branches of the aortic arch are rare and may be caused by blunt, penetrating, blast or iatrogenic trauma. Innominate vascular injury is a rare entity, particularly in blunt trauma. It is estimated that 71% of patients with innominate injuries die before arrival at the hospital. We report here a successfully managed case of a combined blunt trauma of the innominate artery and transection of the left innominate vein after blunt injury to the chest.

[Abdominal aortic surgery and renal anomalies]

INTRODUCTION

Kidney anomalies present a challenge even for the most experienced vascular surgeon in the reconstruction of the aortoilliac segment. The most significant anomalies described in the surgery of the aortoilliac segment are a horse-shoe and ectopic kidney.

OBJECTIVE

The aim of this retrospective study was to analyze experience on 40 patients with renal anomalies, who underwent surgery of the aortoilliac segment and to determine attitudes on conventional surgical treatment.

METHODS

In the period from 1992 to 2009, at the Clinic for Vascular Surgery of the Clinical Centre of Belgrade we operated on 40 patients with renal anomalies and aortic disease (aneurysmatic and obstructive). The retrospective analysis involved standard epidemiological data of each patient (gender, age, risk factors for atherosclerosis, type of anomaly, type of aortic disease, presurgical parameter values of renal function), type of surgical approach (laparatomy or retroperitoneal approach), classification of the renal isthmus, reimplantation of renal arteries and perioperative morbidity and mortality.

RESULTS

Twenty patients were males In 30 (70%) patients we diagnosed a horse-shoe kidney and in 10(30%) ectopic kidney. In the cases of ruptured aneurysm of the abdominal aorta the diagnosis was made by ultrasound findings. Pre-surgically, renal anomalies were confirmed in all patients, except in those with a ruptured aneurysm who underwent urgent surgery. In all patients we applied medial laparatomy, except in those with a thoracoabdominal aneurysm type IV, when the retroperitonal approach was necessary. On average the patients were under follow-up for 6.2 years (from 6 months to 17 years).

CONCLUSION

Under our conditions, the so-called double clamp technique with the preservation of the kidney gave best results in the patients with renal anomalies and aortic disease.

Perioperative fluid balance in patients with heart failure

Careful assessment of fluid balance is required in the perioperative period since appropriate fluid therapy is essential for successful patient outcomes. Volume status is frequently assessed by different hemodynamic variables that could be targeted as endpoints for fluid therapy and resuscitation. Goal directed fluid therapy is a method for correction of fluid status in individual patients that includes invasive hemodynamic monitoring and aggressive perioperative correction of hemodynamics. Heart failure is a syndrome of ventricular dysfunction. It is associated with a variety of patophysiological disturbances, hydro-electrolyte balance disorders and compensatory mechanisms. Heart failure indicates careful assessment of fluid balance in perioperative period. The aim of this article is to describe actual techniques of hemodynamic measurements as well as main principles of fluid therapy to maintain hydro-electrolyte balance in patients with heart failure.

Intraoperative Cell Salvage versus Allogeneic Transfusion during Abdominal Aortic Surgery: Clinical and Financial Outcomes

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS ( p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.

[Why carotid endarterectomy is method of choice in treatment of carotid stenosis]

Procedures used in treatment of carotid stenosis are endarterectomy, PTA with stent implantation, resection with graft interposition and by-pass procedure. Segmental lesions are found more often and treated by the first two mentioned procedures. In case of longer lesions and extension to the greater part of the common carotid artery, the other two procedures are performed. For the past few years, the main dilemma has been whether to perform carotid endarterectomy or PTA with stent implantation. Both early and long-term results speak in favour of carotid endarterectomy, regardless of an increased number of PTA and carotid stenting. At the same time, PTA and carotid stenting are more expensive procedures. Both methods have their defined and important roles in treatment of segmental occlusive carotid lesions. Severe cardiac, pulmonary and renal conditions, which increase the risk of general anaesthesia, are not an absolute indication for PTA and stenting, since endarterectomy can be done in regional anaesthesia. Main indications for PTA with stent implantation are: surgically inaccessible lesions (at or above C2; or subclavian); radiation-induced carotid stenosis; prior ipsilateral radical neck dissection; prior carotid endarterectomy (restenosis).

Carotid Artery Aneurysms: Serbian Multicentric Study

This multicentric Serbian study presents the treatment of 91 extracranial carotid artery aneurysms in 76 patients (13 had bilateral lesions). There were 61 (80.3%) male and 15 (19.7%) female patients, with an average age of 61.4 years. The aneurysms were caused by atherosclerosis in 73 cases (80.2%), trauma in six (6.6%), previous carotid surgery in six (6.6%), tuberculosis in one (1.1%), and fibromuscular dysplasia in five (5.5%). The majority (61 cases or 67%) of the aneurysms involved the internal carotid artery, 29 (31.9%) the common carotid artery bifurcation, and one (1.1%) the external carotid artery. Forty-five (49.4%) aneurysms were fusiform, while 46 (50.6%) were saccular. Twenty-nine (31.9%) cases were totally asymptomatic at the time of diagnosis. The remainder presented with compression in 14 (15.4%) cases, stroke in 11 (12.1%) cases, transient ischemic attack in 33 (36.3%) cases, and rupture in four (4.4%) cases. In cases where the aneurysm involved the internal carotid artery, four surgical procedures were performed: aneurysmectomy with end-to-end anastomosis in 30 (33.0%) cases, aneurysmectomy with vein graft interposition in 20 (22.0%) cases, aneurysmectomy with anastomosis between external and internal carotid artery in eight (8.8%) cases, and aneurysmectomy followed by arterial ligature in three cases. One case of external carotid artery aneurysm also was treated by aneurysmectomy and ligature. Aneurysm replacement with Dacron graft was performed in 29 (31.9%) cases where common carotid artery bifurcation was involved. Two (2.2%) patients died after the operation due to a stroke. They had ruptured internal carotid artery aneurysm treated by aneurysmectomy and ligature. Including these, a total of five (5.5%) postoperative strokes occurred. In two (2.2%) cases, transient cranial nerve injuries were found. Excluding the five patients who were lost to follow-up, 69 other surviving patients were followed from 2 months to 12 years (mean 5 years and 3 months). In this period, there were no new neurological events and all reconstructed arteries were patent. Three patients died more than 5 years after the operation, due to myocardial infarction. Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurological sequelae. Because of their varied etiology, location, and extension, different vascular procedures have to be used during repair of extracranial carotid artery aneurysms. In all of these procedures, an aneurysmectomy with arterial reconstruction is necessary.

[Splenic artery aneurysms]

Although the third most frequent aneurysm in the abdomen, after aneurysms of the aorta and iliac arteries, and most frequent aneurisms of visceral arteries, splenic artery aneurysms are rare, but not very rare. Thanks to the new imaging techniques, first of all ultrasonography, they have been discovered with increasing frequency. We present a series of 9 splenic artery aneurysms. Seven patients were female and two male of average age 49 years (ranging from 28 to 75 years). The majority of afected women were multiparae, with average 3 children (ranging from 1 to 6). One patient had a subacute rupture, and 2 had ruptures into the splenic vein causing portal hypertension. The spleen was enlarged in 7 out of 9 patients. The average size of aneurysms was 3,2 cm (ranging from 2 to 8 cm). The preoperative diagnosis of splenic artery aneurysm was established in 6 patients while in 3 patients aneurism was accidentally found during other operations, during splenectomy in 2, and during the excision of a retroperitoneal tumour in 1 patient. Aneurysmectomy was carried out in 7 patients, while a ligation of the incoming and outcoming wessels was performed in 2 patients with arteriovenous fistula. Splenectomy was performed in 6 patients, while pancreatic tail resection, cholecystectomy and excision of the retroperitoneal tumor were performed in 3 patients. Additional resection of the abdominal aortic aneurysm with reconstruction of aortoiliac segment was performed in 2 patients. There were no mortality and the postoperative recovery was uneventful in all patients.

[Effect of infusion of hypertonic-hyperoncotic solution on cardiovascular function in surgery of the abdominal aorta during the perioperative period]

INTRODUCTION

When blood flow is decreased, as in prolonged hypovolaemia and hypotension, or in the course of transversal clamping of the aorta during aortic reconstruction, nutritive tissue perfusion can also fall below the critical level.

AIM

The objective of this study was to analyse the effects of hypertonic-hyperoncotic solution on cardiovascular function during reconstruction of the abdominal aorta.

METHOD

This prospective randomised study included 40 patients. All patients underwent surgery of the abdominal aorta under general endotracheal anaesthesia. Based on the type of solution infused from the time of clamping to the moment of the removal of the transversal aortic clamp, the patients were divided into two groups of 20. The study group was infused with a small volume of hypertonic-hyperoncotic solution, while the controls were administered infusions of isotonic solution. Patients with a preoperative creatinine level over 130 micromol L(-1) and an ejection fraction of less than 40% were excluded from the study.

RESULTS

Cardiac output increased from 5.67 +/- 2.95 to 7.05 +/- 3.39 L min(-1) in the study group, in comparison to the controls, where it increased from 4.98 +/- 2.06 to 5.99 +/- 3.02 L min(-1) (p = 0.004). Central venous pressure increased from 8.75 +/- 3.67 to 9.30 +/- 2.77 mm Hg in the study group, in comparison to the controls, where the values decreased from 6.84 +/- 2.73 to 6.45 +/- 2.50 mm Hg (p = 0.022). Diastolic pulmonary artery pressure increased from 15.92 +/- 5.61 to 16.65 +/- 6.53 mm Hg in the study group, in comparison to the controls, where it decreased from 12.65 +/- 4.28 to 11.85 +/- 3.91 mm Hg (p = 0.021). The amount of given crystalloids 24 hours after the removal of the aortic clamp totalled 2562.5 +/- 485.82 mL in the study group, versus 3350 +/- 727.29 mL in the control group (p = 0.000). The amount of given human albumins 24 hours after the removal of the aortic clamp totalled 30 +/- 49.74 mL in the study group versus 100 +/- 4.34 mL in the control group (p = 0.001). CONCLUSION Haemodynamic stability of patients and adequate organ perfusion during surgery are achieved through the infusion of hypertonic-hyperoncotic solution, which maintains optimal values of: cardiac output, mixed venous oxygen saturation, and delivery of oxygen, while reducing alveolo-arterial oxygen difference. The balance of fluids, 24 hours after the removal of the aortic clamp, was maintained with the aid of hypertonic-hyperoncotic solution, while isotonic solution produced an excess of over 1000 mL of fluid in the control patients. Hypertonic-hyperoncotic solution increases cardiac output considerably more than does isotonic solution, and its application significantly reduces the accumulation of crystalloid solutions and human albumins.

[Early results in the surgical treatment of Crawford type IV thoracoabdominal aneurysms]

OBJECTIVE

The aim of the study was to present the outcome of surgical treatment of patients with thoracoabdominal aortic aneurysm Crawford type IV, operated on between January 2001 and April 2004.

METHODS

This study included 42 subsequent patients (40 males, 2 females, age 41-76 years). All patients underwent ultrasonography, angiography, computed tomography or magnetic resonance imaging (MRI). Surgical treatment was performed under combined anaesthesia (continuous thoracic epidural analgesia and general endotracheal anaesthesia). In two patients thoracophrenolumbotomy was performed at the level of X rib, while others were operated through left lumbotomy after the extra pleural resection of XI rib. We did not perform any spinal cord protection procedures in this type of aneurysm. Reconstruction included interposition of Dacron graft in 20 patients, aortobiiliac bypass in 18, and aortobifemoral bypass in 4 patients with different varieties of visceral branches reimplantation.

RESULTS

Thirty-days mortality was 31% (13 patients, two of them intraoperatively). Causes of death were: pulmonary embolism--in 1 patient; haemorrhage--in 2; myocardial infarction--in 4 (two intraoperative); acute renal failure--in 2; multisystem organ failure (MSOF)--in 4 patients. Respiratory failure dominated in all cases of MSOF. One patient with acute renal failure had paraplegia also, and that was the only case of neurological complication in whole group. All female patients (2), all patients with ruptured aneurysm (4), acute myocardial infarction (4) and acute renal failure (2) have died. Advanced age (over 70 years) and the need for extensive operative procedure with bifurcated graft use significantly influenced their mortality (p < 0.01 and p < 0.05 respectively).

CONCLUSIONS

Surgical treatment of thoracoabdominal aortic aneurysm Crawford IV type was successful in 69% of our patients. There was no need for spinal cord protection measures, and extra peritoneal approach with XI rib resection under the combined anaesthesia was preferred.

[Surgical revascularisation of the heart in patients with chronic ischaemic cardiomyopathy and leftventricular ejection fraction of less than 30%]

INTRODUCTION

Patients suffering from chronic ischaemic cardiomyopathy and left ventricular ejection fraction (LVEF) lower than 30% represent a difficult and controversial population for surgical treatment.

OBJECTIVE

The aim of this study was to evaluate the effects of surgical treatment on the early and long-term outcome of these patients.

METHOD

The patient population comprised 50 patients with LVEF < 30% (78% male, mean age: 58.3 years, range: 42-75 years) who underwent surgical myocardial revascularisation during the period 1995-2000. Patients with left ventricular aneurysms or mitral valve insufficiency were excluded from the study. The following echocardiography parameters were evaluated as possible prognostic indicators: LVEF, fraction of shortening (FS), left ventricular systolic and diastolic diameters (LVEDD, LVESD) and volumes (LVEDV, LVESV), as well as their indexed values (LVESVI).

RESULTS

Fifteen patients (30%) died during the follow-up, 2/50 intraoperatively (4%). The presence of diabetes mellitus, previous myocardial infarction, main left coronary artery disease, and three-vessel disease, correlated significantly with the surgical outcomes. The patient's age, family history, smoking habits, hypertension, hyperlipidaemia, history of stroke, peripheral vascular disease, and renal failure, did not correlate with the mortality rate. A comparison of preoperative echocardiography parameters between survivors and non-survivors revealed significantly divergent LVEF, LVEDD, LVESD, LVEDV, LVESV, and LVESVI values. Preoperative LVESVI offered the highest predictive value (R = 0.595).

CONCLUSION

Diabetes mellitus, history of myocardial infarction, stenosis of the main branch, and three-vessel disease, significantly affected the perioperative and long-term outcome of surgical revascularisation in patients with ischaemic cardiomyopathy and LVEF < 30%. In survivors, LVEF, FS, and systolic and diastolic echocardiography parameters, as well as their indexed values, significantly improved after surgical revascularisation. LVESVI provided the highest predictive value for mortality.

Ruptured Abdominal Aortic Aneurysms: Factors Influencing Early Survival

In this study we aimed to define relevant prognostic predictors for the outcome of surgical treatment of ruptured abdominal aortic aneurysms. The study included 406 consecutive patients treated between January 1991 and December 2003. There were 337 (83%) male and 69 (17%) female patients aged 67 +/- 7.5 years. Fourteen (3.5%) patients had aortocaval fistula whereas 4 (0.98%) had primary aortorenteric fistula caused by aneurysm rupture into the inferior vena cava or duodenum. Reconstruction included interposition of a tube graft (215-53%), aortobiiliac bypass (134-33%), and aortobifemoral bypass (58-14.3%). Findings on admission that significantly correlated with both intraoperative (13.5%) and total operative mortality (48.3%) were systolic blood pressure <95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes >14 x 10(9)/L, hematocrit <0.29%, hemoglobin <100 g/L, urea> 11 mmol/L, and creatinine >180 micromol/L. Intraoperative determinants of increased mortality were aortic cross-clamping time >47 min, duration of surgery >200 min, intraoperative blood loss >3500 mL, diuresis <400 mL, arterial systolic pressure <97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were significantly associated with lethal outcome in the postoperative period. Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 51.7% of patients. Variables significantly associated with mortality were unconsciousness, low systolic blood pressure, cardiac arrest, low diuresis, high urea and creatinine levels, signs of blood loss, and the need for aortobifemoral reconstruction. Short aortic cross-clamping and the total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival. Therapeutic efforts should concentrate on intraoperative factors that are possible to correct, leading to better survival of these patients.

[Off-pump myocardial revascularization (OPCAB) in patients with post-infarction unstabile angina, low ejection fraction and renal disfunction]

The purpose of this study is to present our experience in off-pump myocardial revascularization in patients with post-infarction unstable angina, left ventricular low ejection fraction and renal dysfunction.

MATERIAL AND METHODS

From January 1998. until march 2002, at the Institute for Cardiovascular Diseases in Clinical Centre of Serbia, we have operated 20 patients with post infarction unstable angina, echocardiographicaly proved low ejection fraction (less than 30%) and renal dysfunction (Serum Creatinin 150 micrograms per liter) using this method. All patients were male and they were between 52 and 79 years old. Preoperative characteristics, surgical treatment and postoperative course are presented.

RESULTS

There was no hospital mortality, as well as important morbidity. There was no worsening of the renal and myocardial function. Postoperative ICU stay was from 1 to 2 days. Postoperative hospital stay was between 3 and 7 days.

CONCLUSION

Off-pump myocardial revascularization is safe and effective procedure in all patients with left ventricular low ejection fraction and renal dysfunction.

[Effect of intraoperative parameters on survival in patients with ruptured abdominal aortic aneurysms]

Ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality that has not been changed in decades. Between 1991-2001 total number of 1058 patients was operated at the Institute for Cardiovascular Diseases of Clinical Centre of Serbia due to abdominal aortic aneurysm. Of this number, 288 patients underwent urgent surgical repair because of ruptured abdominal aortic aneurysm. The aim of this retrospective study was to show results of the early outcome of surgical treatment of patients with ruptured abdominal aortic aneurysm, and to define relevant intraoperative factors that influence their survival. There were 83% male and 17% female patients in the study, mean aged 67 years. Mean duration of surgical procedure was 190 minutes (75-420 min). Most common localization of aneurysm was infrarenal--in 74% of patients, then juxtarenal (12.3%). Suprarenal aneurysm was found in 6.8% of patients, as well as thoracoabdominal aneurysm (6.8%). Retroperitoneal rupture of aortic aneurysm was most common--in 65% of patients, then intraperotineal in 26%. Rare finding such as chronic rupture was found in 3.8%, aorto-caval fistula in 3.2% and aorto-duodenal fistula in 0.6% of patients. Mean aortic cross-clamping time was 41.7 minutes (10-150 min). Average intraoperative systolic pressure in patients was 106.5 mmHg (40-160 mmHg). Mean intraoperative blood loss was 3700 ml (1400-8500 ml). Mean intraoperative diuresis was 473 ml (0-2100 ml). Tubular graft was implanted in 53% of patients, aorto-iliac bifurcated graft in 32.8%. Aortobifemoral reconstruction was done in 14.2% of patients. These data refer to the patients that survived surgical procedure. Intrahospital mortality that included intraoperative and postoperative deaths was 53.7%. Therefore, 46.3% patients survived surgical treatment and were released from the hospital. Intraoperative mortality was 13.5%. Type of aneurysm had no influence on outcome of patients (p > 0.05), as well as type of rupture and level of aortic cross-clamping. Aortic cross-clamping time was significantly shorter in survivors, and longest in patients that died intraoperatively (p < 0.05). Intraoperative systolic tension value influenced the outcome in patients; it was significantly higher in survivors (p < 0.01). Interposition of tubular graft gave better results compared with aorto-iliac and aorto-femoral reconstruction (p < 0.01). Duration of surgery was significantly higher in patients with lethal outcome (p < 0.05), as well as intraoperative blood loss (p < 0.05). Intraoperative diuresis was significantly lower in patients with lethal outcome (p < 0.05). Ruptured abdominal aortic aneurysm still remains one of the most dramatic surgical states with very high mortality. Important intraoperative factors that influence the outcome of surgical treatment can be defined. Therapeutic efforts should be concentrated on those factors that are possible to correct, which would hopefully lead to better survival of patients. Nevertheless, screening for abdominal aortic aneurysm and elective surgical intervention before rupture occurs should be the best solution for this complex problem.

[Effect of preoperative factors on survival in patients with ruptured aneurysms of the abdominal aorta]

Between 1991-2001 total number of 1058 patients was operated at the Institute of Cardiovascular Diseases of Serbian Clinical Centre due to abdominal aortic aneurysm. Of this number, 288 patients underwent urgent surgical treatment because of ruptured abdominal aortic aneurysm. The aim of this retrospective study was to show results of the early outcome of the surgical treatment of patients with ruptured abdominal aortic aneurysm, and to define relevant preoperative factors that influenced their survival. There were 83% male and 17% female patients in the study, mean aged 67 years. Intrahospital mortality that included intraoperative and postoperative deaths was 53.7%. Therefore, 46.3% patients survived surgical treatment and were released from hospital. Intraoperative mortality was 13.5%. Statistics showed that the gender and the age did not have any influence on mortality of our patients, as well as their co morbid conditions (p > 0.05). Clinical parameters at admission in hospital such as state of consciousness, systolic blood pressure, cardiac arrest and diuresis significantly influenced the outcome of treatment, as well as laboratory findings such as levels of hematocrit, hemoglobin, white blood cells, urea and creatinin (p < 0.05; p < 0.01). Ruptured abdominal aortic aneurysm still remains one of the most dramatic surgical states with very high mortality reported. We assume that important preoperative factors that influence the outcome of surgical treatment can be defined, but there is no single parameter which can certainly predict the lethal outcome after surgery. Also, the presence of co morbid conditions does not significantly influence the outcome of treatment in these patients. Therefore, urgent operation should not be withheld in most of the patients with ruptured abdominal aortic aneurysm.

Ruptured Abdominal Aortic Aneurysm

BACKGROUND AND PURPOSE

A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment.

PATIENTS AND METHODS

This study included 229 subsequent patients (83% males, 17% females, age 67.0 +/- 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40-100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%).

RESULTS

Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 x 10(9)/l, hematocrit < 0.29%, hemoglobin < 100 g/l, urea > 11 mmol/l, and creatinine > 180 micro mol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period.

CONCLUSION

Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.

Comparation of influence general and regional anesthesia on basic haemodynamic parameters during carotid endarterectomy

Carotid endarterectomy (CEA) is a preventive operation to reduce the incidence of embolic and thrombotic cerebral stroke. CEA carries a significant perioeperartive mortality rate from stroke and myocardial infarction, which may even approach 5%. Thus, anesthetic and surgical techniques are constantly under scrutiny to try to reduce this relatively high incidence of morbidity and mortality. Anesthetic technique for CEA is divided to general (GA) and regional (RA) anesthesia, performed by cervical plexus block. The aim this study was to examine changes of basic haemodynamic parameters, which routinely fallows during CEA in condition of GA and RA. After obtaining institutional approval and informed consent, we randomized 50 patients scheduled for CEA (Tab.1) in two groups (GA and RA). We fallow blood pressure: systolic (BPs), mean (BPm), diastolic (BPd), heart rate (HR), and RPP index at the examined patients. The examination performed in six control times: before induction of anesthesia (T1), 10 minutes after beginning of operation (T2), 5 minutes after cross clamping of arteria carotis (T3), 5 minutes after declamping arteria carotis (T4), 10 minutes (T5) and 2 hours after operation (T6). The results of study shows significant changes of blood pressure (BPs and BPm) and RPP index in T2 time in patinets undergoing GA. The changes occurred under influence of induction agent thio- pental. These changes were in homeostatic range. In RA patinets, no haemodynamic changes registrated in control times. Therefore, from haemodynamic aspect RA was superior to GA.

[Renal protection during surgical procedures on the infrarenal aorta]

INTRODUCTION

Despite the progress in surgical and anaesthetic management, decreased renal function is still observed after abdominal infrarenal aortic surgery and remains an important problem in postoperative period. Although data regarding the efficacy of perioperative renal protection are conflicting, it is widely believed that renal protection before aortic cross-clamping is beneficial and therefore is commonly used. The aim of this study was to evaluate the impact of renal protection in patients undergoing elective infrarenal aortic surgery (1ARS).

PATIENTS AND METHODS

We have prospectively studied 80 patients undergoing elective infrarenal aortic surgery from October 1996 to May 1998 in the Clinical Centre of Serbia, because of aorto-occlusive disease or aortic aneurysm. Patients were excluded from the study for three reasons: prior renal dysfunction, suprarenal aortic cross-clamping and ruptured aortic aneurysm. We have randomized the patients in two groups: without renal protection--group A (n = 40) and with renal protection--group B (n = 40). Preanaesthetic medication consisted of midazolam (5 mg i.m.). Anaesthesia was induced with etomidat 0.3 mg/kg, fentanyl 0.05-0.1 mg and succinil-holin Img/kg. Ventilation was controlled using 50% of nitrous oxyde and oxygen. Supplemental anaesthesia consisted of isoflurane and fentanyl, in order to maintain the mean arterial pressure and heart rate +/- 20% regarding preoperative values. In all patients two peripheral vein and radial artery catheters were cannulated before anaesthesia. Central venous catheter and Foley urinary bladder catheter were inserted after the induction of anaesthesia. Two-lead electrocardiograms were recorded. All patients in group B were given intravenously mannitol (0.3 g/kg) before aortic cross-clamping (ACC). After aortic cross-clamping, these patients received furosemide (20-40 mg) or dopamine (1-3 micrograms/kg/min) to the end of surgery (Table 1). In 8 time points (preoperatively, after induction, during ACC, 2 and 8 hours after ACC, on day 1, 2 and 3 postoperatively) haemodynamic parameters (mean arterial and central venous pressure), volume load, urinary output, creatinine and free-water clearance, serum electrolytes, BUN, creatinine, plasma and urine osmolality and ACC time were analyzed in each patient. Renal complications were classified as transient or persistent. Transient renal dysfunction was defined as a greater rise than 20% rise in peak serum creatinine level over baseline serum creatinine level, with a peak of at least 168 mumol/L. Persistent renal insufficiency was defined as a greater rise than 20% rise in discharge serum creatinine level over baseline serum creatinine level, with a peak of at least 168 mumol/L. Moreover, renal insufficiency was defined as a free-water clearance greater than -15 ml/h. Aortic cross-clamping time was defined as a period in which the proximal inflow was occluded. The results were expressed as means +/- SD. Statistical difference detected with Student's t-test, with p < 0.05 being considered significant.

RESULTS

Patients in groups A and B were similar regarding the age (64.32 vs. 62.00), sex (males 35, females vs. males 34, females 6) and preoperative diseases. (Tab. 2) No difference was found between groups regarding any of the parameters (BUN, serum creatinine, electrolytes, volume load, creatinine and free-water clearance, haemodynamic parameters, plasma and urine osmolality). Urinary output was higher in group B during and 2 hours after ACC. (Graph 1.) ACC time was similar in two groups (24.1 min vs 24.5 min). (Graph. 2) Only one patient in group B revealed transitory renal insufficiency, not requiring special treatment. These data indicate that renal protection did not influence renal function. Short ACC time may have impact on the obtained results. Our results suggest that renal protection should not be considered as mandatory for elective infrarenal aortic surgery. Because of the short ACC time observed in this study (in comparison to other studies), further studies of renal protection in patients with longer ACC time are needed.

[The upper thoracic outlet vascular syndrome]

A 16 patients with 20 vascular TOS have been evaluated at the our Institute. Fourteen of them were female, and 2 male patients, with average age of 33.1 (18-44) years. 19 of them had congenital, and one acquired TOS after trauma at neck-shoulder region. 13 cases had arterial, and 7 venous TOS. In 10 cases a cause of TOS was cervical rib, in one scar tissue after clavicle fracture, while in 9 soft tissue anomalies. Eight cases with arterial TOS had a hand ischemia, one TIA and 5 periodical symptoms only during the arm hyperabduction. Two cases with venous TOS also had symptoms and signs during arm hyperabducrtion only, while five patients had axillary-subclavian deep venous thrombosis (DVT). All patients underwent CW-Doppler, Duplex-ultrasonographic and angiographic examination in normal position of the arm and during the hyperabduction. The four aneurysms of the subclavian artery, two poststenotic dilatation of the subclavian artery were found as well as one thrombosis of the axillary artery and 8 brachial artery embolism. The operative treatment consists from decompression and vascular procedure. A decompression procedure include 10 resections of the cervical rib, three transaxilary and 6 supraclavcular resection of the first rib, as well as one scalenectomy. A vascular procedures included 8 transbrachial thrombembolectomy and 4 resection and replacement of subclavian artery aneurysms. Four early complications were noticed: two partial pneumothorax, and two transiet medianus nerve paresis. The follow-up period was between one and six years (mean 3 years). In this period one (12.5%) late arterial occlusion was found. The vascular TOS is more rare than neurogenic, however in mostly cases requires surgical management.

[The popliteal artery entrapment syndrome]

The authors are presenting 8 patients with 9 cases of popliteal artery entrapment syndrome. There were one female, and 7 male patients with average age of 36.4 (25-54) years. Six cases were manifested with acute, 2 with chronic foot ischemia, while one case was asymptomatic. For diagnosis a combination of Doppler sonography and transfemoral angiography, was used. Eight cases were operated using posterior, while in one medial approach to the popliteal artery. The types I and IV of the popliteal artery entrapment syndrome were found in one case, type II in two cases, type III in 4 cases, while in one case a type of syndrome had not to be identified. During the operation the resection of the anomalous muscle and reconstruction of the popliteal artery, were done in 8 cases. In one case muscle resection or arterial reconstruction, were not necessary. The early potency rate and limb salvage, were 100%, while long term potency rate after mean follow up period of 6.3 years was 83.5%. The acute or chronic foot ischemia in health, young persons without typical atherosclerotical risk factors, suggests on popliteal artery entrapment syndrome.

[Arterial embolisms of the lower extremities]

INTRODUCTION

Embolism is one of the most frequent causes of lower limbs acute arterial occlusion [1]. Of the total number of peripheral embolism 56% of cases involve lower limbs arteries [2]. Inadequate and late treatment of the lower limbs embolism is associated with high morbidity and mortality rate. The aim of this paper was to study the aetiology of lower limbs embolism and to detect factors influencing early and late results after the operative treatment.

PATIENTS AND METHODS

The study included 204 patients with 224 lower limbs embolism, treated surgically at the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade in the period between 1993 and 1997. There were 107 (52.2%) female and 97 (47.8%) male patients. Thirty two (14.3%) patients were younger than 50 years, 64 (28.6%) were between 51 and 65, 101 (45.1%) between 66-75, while 27 patients (12.1%), were older than 75. Twenty (8.9%) patients were admitted less than 6 hours before the operation, 79 (33.3%) between 6 and 24 hours, and 125 (55.8%) more than 24 hours before the operation (Table 1). One hundred (53.6%) patients had motor and 133 (59.4%) sensor paralysis on admission. Table 2 shows arterial localization of the lower limbs embolism. The popliteal artery was involved in most cases. During the operation transfemoral arterial approach was used in 132 (58.9%) cases, while transpopliteal in 92 (41.1%) cases. Fourteen cases required bypass surgery, 43 fasciotomy, 2 intraoperative streptokinase and 4 intraoperative angiography. All patients were controlled using physical and CW Doppler ultrasonographic examinations immediately after the operation, and then one, six and 12 months, as well as every year.

RESULTS

In 173 (84.4%) patients cardiac causes of embolism were found, in 8 (3.9%) noncardiac, while in 8 (3.9%) the cause could not be established. Of all cardiac causes absolute arrhythmia was most frequent. Table 3 and Table 4 show the aetiology of the lower limb embolism. The early amputation rate was 23 (10.3%) cases, while limb salvage was recorded in 174 (77.7%) patients. Of all saved limbs complete recovery was noted in 162 (72.4%) cases and peroneal nerve paresis in 12 (5.3%) cases. The early postoperative mortality rate was 27 (12.0%). Table 5 shows early results of embolectomy. The early results (limb salvage, complete recovery, rethrombosis, early reoperations, amputations rate, morbidity and mortality rate) of embolectomy were statistically significant: worse in cases when the embolus was located in the abdominal aorta and popliteal artery; in cases with a long time interval before the operation as well as in patients with sensor-motoric paralysis on admission (Tables 6-8). Of the total number of patients in 87 (56.5%) cases a late control examination was carried out. Forty nine (31.8%) patients died before the late control, while 18 (11.7%) did not come to control examination. Late recidivation of embolism was found in 3 cases. In these patients the cause could not be found, and they were treated by anticoagulant drugs.

[Aorto-caval fistula due to abdominal aortic aneurysm rupture]

INTRODUCTION

Most frequently, abdominal aortic aneurysm (AAA) ruptures into retroperitoneal space. The rupture of AAA into inferior vena cava is an uncommon event. The incidence of this complication of AAA is 2 to 10%. Surgeons' awareness of this rare entity is the most important factor for the early diagnosis and treatment. In this paper we report two cases of AAA rupture into inferior vena cava. As to our knowledge, in domestic literature such cases have not been previously reported.

CASE REPORT

Patient 1. A 65-year-old man was admitted to the hospital because of low back pain and haemorrhagic shock. He was anaemic with haemoglobin of 80 g/l, systemic blood pressure was 70 mmHg, pulse rate 100/min, and central venous pressure 12 cm H2O. Pulsatile abdominal mass with continuous bruit and thrill and leg oedema were present. Physical examination revealed global heart failure. The patient was anuric. Because of the critical condition and evident clinical signs of ruptured AAA, the patient was operated on immediately without any other diagnostic procedure. Transperitoneal approach was used. Intraoperative findings were consistent with the rupture of the frontal aneurysmal wall into retroperitoneal space, with large retroperitoneal haematoma and aorto-caval (AC) fistula on the posterior aneurysmal wall, large 2 cm in diameter. Using digital compression for venous bleeding control, the fistula was closed with interrupted polypropylene 2-0 sutures with patches. After closure of the fistula, the urine flow resumed. Then, the aneurysm was replaced with bifurcated Dacron graft. The postoperative recovery was successful. The patient has a 13-year follow-up, without any sign of cardiac or renal failure as well as arterio-venous insufficiency of legs. Patient 2. A 62-year-old man was admitted to the Zemun Clinical Hospital Cenre because of suddenly occurred tachycardia, dyspnea and low back pain. Abdominal ultrasound examination revealed the existence of a possible fistula between the abdominal aorta and inferior vena cava. The patient was immediately transported to our institute. At admission, he was anaemic (haemoglobin was 85 g/l), with systolic blood pressure of 100 mmHg, pulse rate of 100/min and central venous pressure of 20 cm H2O. Also, he had pulsatile abdominal mass with continuous bruit and thrill, as well as legs and scrotal oedema. He was oliguric and haematuric. Translumbar aortography showed AAA with AC fistula (Figure). Transperitoneal approach was used for the operation. Intraoperatively, a small retroperitoneal haematoma without retroperitoneal rupture was found. After aneurysmal opening, a massive venous bleeding started, followed with cardiac arrest. The bleeding was controlled using digital compression and cardiopulmonary resuscitation was successful. AC fistula, large 3 cm in diameter, was on the posterior aneurysmal wall, and it connected the inferior vena cava and the left common iliac vein with AAA. The fistula was closed with interrupted polypropylene 2-0 sutures with patches. The aneurysm was replaced with impregnated tubular Dacron graft 16 mm. The postoperative recovery was successful. The patient was followed-up for 2.5 years, and there were no signs of cardiac or renal failure and arterio-venous insufficiency of legs.

DISCUSSION

AC fistula as a complication of ruptured AAA was reported for the first time by Syme in 1831. The first attempt to repair this lesion was done by Lehman in 1935, but it was unsuccessful. In 1954, the first successful repair was performed by Cooley. According to Matsubara, by the end of 1989, 250 cases of this lesion were reported in England, German and French literature, and only 25 in Japanese. In 1991, Brewster et al. reported 14 new cases, while Italian authors reported 36 new cases in 1994. Retroperitoneal and intraperitoneal ruptures of AAA have different clinical presentation comparing with the rupture of AAA into inferior vena cava. (ABSTRACT TRUNCATED)

[Carotid body tumor]

INTRODUCTION

The carotid body tumour was first described by von Haller in 1743. The first two, unsuccessfully surgically treated carotid body tumours, were done by Reinger in 1880 (his patient died), and by Maydel in 1886 (his patient developed hemiplegia). Scudder made the first successful surgical removal of the carotid body tumour in 1903. Using data from the Cologne (Germany) Medline Research Centre, surgical treatment of carotid body tumour was not reported in Yugoslav medical literature. The aim of this study is to present 6 surgically treated carotid body tumours.

MATERIAL AND METHODS

Over the period from 1982 to the end of 1996, 6 patients with carotid body tumours were operated on in the Centre of Vascular Surgery of the institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade. Four of them were female and two male patients, average age 43.4 years. In all cases the tumour was an asymptomatic neck mass. Color-Duplex ultrasonography and selective carotid arteriography were used to establish the diagnosis in 5 cases. The pathohistological examination of all 6 patients revealed the benign character of tumors. Patient 1. A 52-year old man. The suspicion of symptomatic carotid artery aneurysm, was the indication for urgent operation. The intraoperative finding showed a carotid body tumour which compressed carotid arteries. The subadventitial removal of the tumour was done. The patient was followed for 14 years without signs of local recidivation. Patient 2. A 38-year old man. During the operation the tumour was removed subadventitially, without clamping or injuring the carotid arteries. The patient was followed for 8 years and 3 months, and there were no signs of local recidivation. Patient 3. A 48-year old woman. Intraoperative findings showed an infiltration of the carotid arteries and tumour was removed together with parts of internal and external carotid arteries. The internal carotid artery was reconstructed using saphenous vein graft. The follow-up period was 4 years and 6 months, without signs of local recidivation. Patient 4. A 61-year old woman was operated on (neck exploration) in other hospital 4 years before the admission to our Centre. During the primary operation, an internal carotid artery was ligated without neurological consequences. Also, histological examination was performed. We removed a tumour together with the ligated internal carotid artery without its reconstruction. Three years after the operation the patient was without signs of local recidivation. Patient 5. A 40-year old woman. After subadventitial surgical removal of the tumor without clamping or injuring the carotid arteries, the patient was followed-up for 2 years and 2 months, and was without signs of local recidivation. Patient 6. A 30-year old woman was operated on (neck exploration only) in other hospital two months before the admission to our Centre. Intraoperative findings showed tumour infiltration to the carotid arteries, and therefore, internal and external carotid arteries were removed together with the tumour. The internal carotid artery reconstruction was performed using aaphonous vein graft. The early postoperative period was unremarkable. However, 48 hours after the operation cerebrovascular insult developed with hemiplegia. There was no sign of graft thrombosis. The patient was followed-up for 2 years postoperatively. There were no signs of local recidivation. The same patient had also a small asymptomatic tumour at the other side of the carotid arteries.

DISCUSSION

The carotid body tumour originates from the paraganglious tissue at the carotid artery bifurcation. There are angiomatous and adenomatous forms. All of our 6 cases had adenomatous form. It grows slowly, and can compress and/or infiltrate carotid arteries and nerves. Three of our 6 cases showed signs of carotid artery compression and 3 showed infiltration to the carotid arteries. Malignant alteration of this tumour is uncommon. (ABSTRACT T

[Aneurysms of the carotid arteries]

The aim of the paper is the presentation of the treatment of aneurysms of the extracranial carotid artery and review of literature. Aneurysms of extracranial carotid arteries (common carotid artery, external carotid artery and cervical part of the internal carotid artery) are very rate [1, 2]. In 1979 McCollum from the Baylor University (Houston, Texas) reported 37 cases over a 21-year period [3]. Moreau from France reported 38 cases over a 24-year period [4]. Mayo clinic experience includes 25 cases in the 40-year period [5]. According to Schechter 835 extracranial carotid artery aneurysms were reported in literature until 1977. These and the other aneurysms of the extracranial carotid artery can be partially or completely thrombosed, can cause distal embolization, or compression of adjacent structures, and can be ruptured [4, 9]. Therefore, the mortality rate in non operated patients with carotid artery aneurysm is 70% [10]. Over the period from January 1, 1985 to December 31, 1996 at the Centre of Vascular Surgery within the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade, 12 patients with 13 extracranial carotid artery aneurysms were treated. Nine of them (75%) were males and 3 (25%) females, average age 58.22 (21-82) years. There were two traumatic (gunshot wounds) and one anastomotic (after carotid subclavian bypass with PTFE graft) pseudoaneurysms, and 10 true atherosclerotic aneurysm. Three (23%) aneurysms were on the common and 9 (77%) on the cervical part of the internal carotid artery. Two (15%) aneurysms were in the form of asymptomatic pulsatile neck mass, 7 (54%) with CVI or TIA, three (23%) with compression of the cranial nerves and one (8%) was ruptured. Twelve (92%) patients were treated surgically, while one asymptomatic aneurysm in a 82-year old female patient was not operated due to high risk. The intraoperative findings revealed one complete and 11 partial thromboses of the aneurysmal sac. In 3 patients with fusiform aneurysms, thrombectomy and aneurysmorrhaphy were performed. One traumatic pseudoaneurysm was treated with aneurysmectomy and lateral suture of the artery. In 3 patients aneurysmectomy and end to end anastomosis were done, while in three aneurysmectomy and saphenous vein graft interposition. In case of ruptured aneurysm of the internal carotid artery aneurysmetomy and arterial ligature were carried out, while in case of anastomotic pseudoaneurysm after carotid subclavian bypass, aneurysmectomy and new carotid subclavian bypass with PTFE graft, were performed. During the study no intrahospital mortality was recorded. One patient died 5 years after the operation due to myocardial infarction. The mean follow-up period was 4 years and 2 months (6 months to 11 years). The early and late potency rates were 100%. Two (17%) CVI and two transient cranial nerve paresies were noticed immediately after the operation. In literature male/female ration in patients with extracranial carotid artery aneurysms is 2:1 [2, 4, 7], but in our study it was 5:1. One (10%) of our patients had a bilateral carotid artery aneurysm. According to literature data the incidence of bilateral localization of extracranial carotid artery aneurysms with atherosclerotic origin is 21% [1]. Of 12 surgically treated aneurysms in our study, 9 were of atherosclerotic origin, two were traumatic and one anastomotic pseudoaneurysms. Today, most of true extracranial carotid artery aneurysms are of atherosclerotic origin [7, 20-25]. However, true extracranial carotid artery aneurysms can be developed due to: infection of the arterial wall (mycotic forms) [26-37]; nonspecific [23] or irradiation arteritis [38], fibromuscular dysplasia [4, 8, 15, 16, 39]. The most frequent types of false extracranial carotid artery aneurysms are traumatic pseudoaneurysms [32, 50-54] and anastomotic pseudoaneurysms [53, 59, 60]. There are also dissecting extracranial carotid artery aneurysms developed after isolated spontaneous d

Popliteal artery war injuries

The early postoperative results of 44 surgically treated popliteal arterial injuries from the Yugoslav civil war are reported. Of these patients, 41 (93%) were males and three (7%) were females, average age was 28 (range 6-45) years. Twenty patients (45%) had gunshot wounds and 24 (55%) explosive wounds. Twelve (28%) suffered isolated vascular damage, while 32 (72%) suffered concomitant bone fractures. Isolated arterial lesions were found in 24 (55%) cases, and concomitant arterial and venous lesions in 20 (45%). Twenty-four (55%) had primary reconstructions after haemostasis in the initial war hospital, and 20 (45%) secondary reconstructions after inadequate primary reconstruction in a regional war hospital. Artery procedures included 19 reverse saphenous vein graft interpositions, 10 reverse saphenous vein bypasses, 12 'in situ' saphenous vein bypasses and five lateral subcutaneous saphenous vein bypasses. The early graft patency rate was 100%, and limb salvage 72%. Major amputation was performed in 28%. Concomitant bone fractures, secondary reconstructions, secondary haemorrhage from an infected graft, and explosion wounds significantly increased the amputation rate (P < 0.01). Eleven amputations were performed after an anatomic, and only one after an extra-anatomic reconstruction (P < 0.01). The authors recommend an in situ or lateral subcutaneous reconstruction in cases of complicated popliteal artery injuries, such as concomitant bone fractures accompanied by massive soft tissue damage, and this type of reconstruction should also be used if infection is present or the procedure is delayed.

[Post-traumatic arteriovenous fistulae and pseudoaneurysms]

The surgical treatment of 13 posttraumatic arteriovenous (AV) fistulae and 32 pseudoaneurysmae (PsAn) treated in the last 5 years in the Center of vascular surgery of the institute of cardiovascular diseases, Clinical center of Serbia (Belgrade) was presented. Three women and 42 men (mean age 31.7 years) were examined. Twenty-one injuries occurred in a war, while 24 injuries occurred in the peacetime. In most of the cases the superficial femoral artery was involved. The average time elapsed from the moment of injury till surgery, was 9 months in patients suffering from AV fistulae, while in patients suffering from PsAn the elapsed time was one month. In all of those with AV fistulae, some reconstructions of artery and vein were performed, except in 2 cases where the vein was ligated. In twenty-six patients suffering from PsAn the arterial reconstruction was performed, while in 6 cases the artery was ligated. Considering the type of artery, none of the patients suffered from postoperative ischemia. Patients were followed up for 2 years and 2 months on the average after the operation. As far as the reconstructive operations were concerned, postoperative patency rate was 100%, while limb salvage was achieved in 96.9%. Namely, one amputation was done in spite of high arterial patency rate, but it was indicated by massive bone-muscle tissue loss, that occurred after an injury by the land-mine. Due to the rapid progress of the disease the authors suggested that the operative treatment of posttraumatic AV fistulae and PsAn should start as soon as possible. This was supported by good follow-up results in operatively treated patients.

[The effect of indobufen on patency in femoro-popliteal/crural bypass using artificial grafts]

The aim of this clinical prospective study was to determine the effect of indobufen upon synthetic graft patency in femoral-popliteal/crural position. 15 operated patients were observed during the three-month period. One day prior to operation patients were given 400 mg of indobufen perorally. The same daily dose was continued on the first postoperative day as well as during the following three months. Blood levels of 6-keto-prostaglandin (PG) F1alpha (stable metabolite of PGI2) and thromboxane (Tx) B2 (stable metabolite of TxA2) were determined by RIA before indobufen administration, i.e., one day and three months postoperatively. The three-month patency of grafts was achieved in 86% of cases. Plasma levels in all observed time periods showed significantly reduced TxB2, increased 6-keto-PGF1alpha, and higher PGI2 levels compared with TxA2 that could suggest the normalization of aggregation/antiaggregation process.

[Intra-arterial administration of prostaglandin E1 in occlusive arterial diseases]

The authors present their result of a two-year follow-up of 106 patients to whom an intra-arterial perfusion of prostaglandin E1 was administered, as limb salvage procedure. The patients were in the IIIrd and IVth stage of occlusive diseases by Fountain, and surgical reconstructions were not possible. All patients were divided into five groups: A--diabetic angiopathy (5), B--distal form of atherosclerosis (40), C--diabetic angiopathy and atherosclerosis (45), D--Burger disease (10) and E--adjuvant therapy in reconstruction with poor run-off (6). The Doppler sonographic and angiographic measurements were performed. After transcutaneous (16 cases), or intraoperative (90 cases) introduction of the catheter into superficial of profunda femoral artery, a continuous intraarterial administration of prostaglandin E1 was carried out in a dose of 10 nanograms/kg body weight/minute (total dosage 3000 nanograms). The patients were controlled immediately after the treatment, as well as 1, 3, 6, 12, 24 and 36 months after the treatment. In efficiency of the treatment was estimated on the following basis: elimination of rest pain, healing of trophic ulceration and demarcation of gangrenous processes. Our late results of intra-arterial administration of prostaglandin E1 proved to be a very successful limb salvage procedure. The treatment was more successful in a connections between the upper knee arterial net and pedal arterial arches were preserved.

[Femoro-popliteal bypass in situ]

The authors present early and late results of femoro-popliteal/crural reconstruction where "in situ" technic is used. Of 35 patients 10 had the third stage of occlusive disease by Fontain, and 25 were in the fourth stage. Therefore the reconstruction consisted of "limb salvage procedure". The aim of the study was to present the possibilities of this technique in cases with ischaemic extremities and poor "run off". The early potency of prosthesis within the first month was 97% (34 patients) and late (after one year) 91% (32 patients). In three patients, in early postoperative stage, AV fistulas were found and successfully surgically treated. AV fistulas were caused by non-ligated branches of the saphenous vein. Thus, a conclusion was drawn that intraoperative control angiography vas of great importance. Better potency of prosthesis, when compared to the quality of saphenous vein graft and when used "in situ", over the classical method was achieved thanks to the following facts: no damage of the intima caused by hydrostatic dilatation; possible use of a vein whose diameter is less than 4 mm; no damage of adventitia (vasa vasorum) due to the slower degenerative process of the vein wall; impossible graft torsion; low compliance level between the graft and the small artery, and small artery caused by the conic shape of graft.