[Show abstract][Hide abstract] ABSTRACT: Short article summary
“Excellent outcomes could be obtained with surgical repair of extracranial carotid aneurysms, which should be tailored to the anatomic types and presence of kinks”.
To present outcomes following an operative approach of extracranial carotid artery aneurysms (ECAA) based on anatomic types and associated kinks.
Material and methods
This study represents retrospective analysis of anatomic type based approach to operative repair of 84 patients with ECAA from 1994 till 2011, 28 (33.3%) with associated kinking. Patients were followed for neurological ischemic events, hematoma, cranial nerve injury, myocardial infarction, neurological and overall mortality. The results are presented as early, within 30 days after the surgery and long-term, during the follow-up.
In the early postoperative period there were no strokes or mortalities, cranial nerve injury rate was 2.4% while one patient had myocardial infarction - 1.2%. During the follow-up 4 patients (4.8%) had stroke, out of which 2 patients died (2.3%) while overall mortality was 4.6%. The average five-year survival rate was 96±3%.
Excellent outcomes can be obtained with surgical repair of ECAA, which should be tailored to the anatomic types and presence of kinks.
American journal of surgery 08/2014; · 2.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: He aim of this paper was to investigate the incidence of and the indications for conversion to general anesthesia (GA) in a large single-center series of patients undergoing carotid surgery under cervical plexus block (CPB).
With IRB approval we retrospectively analyzed the medical records of all patients who underwent carotid surgery under CPB from November 2007 to October 2010. Cervical plexus was blocked at both the superficial and deep levels. An intraluminal shunt was inserted in patients who demonstrated signs of inadequate cerebral perfusion upon carotid clamping (CC). Propofol was given to patients reporting pain or discomfort throughout the procedure. The primary outcomes were the number and percentage of conversions to GA as well as the indications for this intervention. The secondary outcome was the incidence of partial cervical block failure, defined as the need for supplemental propofol administration for pain relief during surgery.
In total, 1464 carotid surgical procedures were performed under CPB in 1305 consecutive patients during the investigated period. Conversion to GA was required in 17 (1.2%) patients. The most common reason for conversion to GA was persisting neurological deterioration upon CC and intraluminal shunt insertion, which was recorded in 8/17 (47.1%) procedures. Other indications to convert were systemic toxicity of local anesthetics, pain, general discomfort and restlessness during surgery, and acute myocardial infarction.
Cervical plexus block for carotid surgery is associated with a low rate of conversions to GA. Neurological deterioration upon carotid clamping and local anesthetic toxicity are identified as the most common indications for such intervention.
The Journal of cardiovascular surgery 04/2014; · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aneurysm of the persistent sciatic artery is a rare cause of limb ischemia, which is a challenge for both diagnosis and treatment. After successful diagnosis adequate treatment may require skills in open and endovascular surgery. We present a patient with the aneurysm of the persistent sciatic artery treated by bypass procedure with PTFE graft using posterior approach. We named this procedure "dorsal bypass". Detailed explanation of clinical presentation, diagnosis and the surgical procedure is given in this paper.
[Show abstract][Hide abstract] ABSTRACT: The infection in vascular surgery is a nightmare of every vascular surgeon. There are numerous ways of treatment but neither one is definitive. We present the case of the patient with infectious limb following aortobifemoral reconstruction treated by partial graft extirpation and with re-implantation of the superficial femoral artery into deep femoral artery.
[Show abstract][Hide abstract] ABSTRACT: Graft infection is rightly considered one of the severest complications of vascular reconstruction. Treatment is non-standardized and associated with high mortality and morbidity rates. The choice of therapeutic modality depends upon variety of factors. One increasingly used option is in situ replacement of the infected prosthesis with the arterial allograft.
The aim of this prospective nonrandomized study was to evaluate the effectiveness and durability of fresh arterial allograft as in situ substitute for the infected vascular prosthesis.
During period of 2002-2005, 18 patients with the synthetic vascular graft infection underwent partial or complete prosthesis removal and secondary in situ reconstruction using the fresh arterial allograft, preserved under hypothermic conditions in buffered saline solution with an addition of antibiotics.
In 14 male and 4 female patients, mean-aged 62 years, 8 aortic and 10 peripheral arterial infected prostheses were partially or completely replaced with the allograft. Operative mortality was 27.8% and amputation rate was 22.2%. Systemic sepsis at initial presentation and highly virulent nature of causative microorganisms were identified as significant negative prognostic factors (chi2 test, p < 0.05). During the long-term follow-up (mean 47 months), allograft aneurysm developed in three patients, requiring allograft explantation, followed in two cases by tertiary prosthetic reconstruction.
Substitution of the infected prosthesis with the arterial allograft could be successful if used selectively--for less virulent and localized infections of extracavitary grafts. Close follow-up is mandatory for timely diagnosis of late homograft lesions and its eventual replacement with more durable prosthetic material.
Srpski arhiv za celokupno lekarstvo 01/2013; 141(11-12):750-7. · 0.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The increased number of carotid endarterectomies performed worldwide in recent years is associated with a greater need for carotid restenosis evaluation. Carotid restenosis rate ranges from 0.6% to 3.6% in symptomatic patients and from 8.8% to 19% in asymptomatic patients. Carotid angioplasty and stenting is a preferable therapeutic choice for carotid restenosis treatment, but whenever it is not technically feasible (tortuosities of supra-aortic branches, calcifications, pathological elongation, or very extensive lesions), redo surgical treatment is indicated. The aim of our study was to examine outcome of redo surgical treatment in patients with symptomatic and asymptomatic carotid restenosis, in whom carotid angioplasty could not be done, and its impact on early and late morbidity and mortality.
The study included 52 patients who were surgically treated for significant carotid restenosis from January 2000 to December 2008 in two high-volume vascular surgery university clinics. Surgical techniques included redo eversion endarterectomy, standard endarterectomy with Dacron patch closure, and Dacron tubular graft interposition. The patients were followed for significant events (transient ischemic attack, stroke, cranial nerve injuries, surgical site hematoma, the occurrence of carotid re-restenosis, or occlusion), and mortality after 1 month, 6 months, 1 year, and annually afterward.
In the early postoperative period (within 30 days), there were no lethal outcomes. Transient ischemic attack was diagnosed in four patients (7.6%), minor stroke in two patients (3.8%), and cranial nerve injury in four patients (7.6%). After 4 years, three patients died (5.7%), two due to a fatal myocardial infarction (3.8%) and one after a major stroke (1.9%); four patients (7.6%) had ipsilateral stroke; and graft occlusion was verified in one patient (1.9%).
Carotid angioplasty might be a primary option for carotid restenosis treatment, but whenever it cannot be performed, redo surgical treatment is indicated, owing to its acceptable rate of early and late postoperative complications.
Annals of Vascular Surgery 06/2012; 26(6):783-9. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Srpski arhiv za celokupno lekarstvo 01/2012; 140(11-12):792-9. · 0.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
International angiology: a journal of the International Union of Angiology 12/2011; 30(6):534-40. · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: One of the rare forms of abdominal aortic aneurysm (AAA) rupture is the rupture into great abdominal veins such as the inferior vein cava (IVC), the iliac veins, or the left renal vein, with the formation of direct or indirect aorto-caval fistula (ACF). The purpose of the present study was to summarize 20 years of experience at a single referral center for vascular surgery in a developing country, and to discuss the clinical presentation, diagnosis, treatment options, and outcome of patients with spontaneous aorto-venous fistulas (AVF) caused by ruptured aortic aneurysms.
Retrospective database review identified 50 patients treated in our institution for aorto-venous fistulas (AVF) caused by spontaneous AAA rupture in the 20 years 1991-2010. Pulsating abdominal mass and low back pain were the leading symptoms on admission in our patients. Signs of shock, congestive heart failure, or pelvic and lower extremity venous hypertension were present in 48%, 26%, and 75% of the patients, respectively. Diagnosis of AVF was based on physical examination, duplex ultrasonography, conventional angiography, or multislice computed tomography (MSCT). In 40% of the patients the presence of AVF has not been recognized before surgery. All patients were treated with open surgery.
After proximal and distal bleeding control the fistula was closed with direct suture (92%) or patch angioplasty (8%). Aortic reconstruction followed with tubular (22%) or bifurcated (78%) synthetic graft. Six (12%) patients died. The causes of death were excessive intraoperative blood loss, myocardial infarction, left colon gangrene and multiple organ failure.
Spontaneous AVFs caused by aneurysmal rupture are not uncommon, and they require prompt surgical or endovascular treatment. Routine use of multislice CT in patients with acute aortic syndrome is probably the best way to the correct diagnosis of aorto-venous fistulas and planning of the optimal treatment.
World Journal of Surgery 04/2011; 35(8):1829-34. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Most recent publications have shown that the recombinant form of activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsværd, Denmark) induces excellent hemostasis in patients with severe intractable bleeding caused by trauma and major surgery. The purpose of this study was to determine the influence of rFVIIa on the treatment of intractable perioperative bleeding in vascular surgery when conventional hemostatic measures are inadequate.
There were two groups of patients: the NovoSeven group (group N), 10 patients with ruptured abdominal aortic aneurysms (RAAAs) and 14 patients operated on due to thoracoabdominal aortic aneurysms (TAAAs); the control group (group C), 14 patients with RAAAs and 17 patients with TAAAs. All patients suffered intractable hemorrhage refractory to conventional hemostatic measures, while patients from group N were additionally treated with rFVIIa.
Postoperative blood loss was significantly lower in group N treated with rFVII (P < .0001). Postoperative administration of packed red blood cells, fresh frozen plasma, and platelets was lower in patients from group N, (P < .0001). Successful hemorrhage arrest was reported in 21 patients (87.5%) treated with rFVIIa, and in 9 patients (29.03%) in group C (P < .001). Thirty-day mortality in these two groups significantly differed. The mortality rate was 12.5% (3 patients) in group N and 80.65% (25 patients) in group C (P < .0001).
Our findings suggest that rFVIIa may play a role in controlling the intractable perioperative and postoperative bleeding in surgical patients undergoing a repair of RAAAs and TAAAs. Certainly, prospective randomized trials are necessary to further confirm the efficacy and cost-effectiveness of rFVIIa in these patients.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2011; 53(4):1032-7. · 3.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aortic diseases associated with renal anomalies can present special challenges during surgery of the abdominal aorta. The aim of this paper is evaluation of morbidity and definition of optimal management according to the clinical histories of 30 patients with horseshoe and ectopic kidneys who underwent surgical procedures on the abdominal aorta over a 20-year period. Twenty-two of them had horseshoe kidney and eight had ectopic kidney. Indications for surgery included aortic aneurysms in 25 patients and aortoiliac occlusive disease in 5. Preoperative diagnostics were performed in all cases by means of computed tomography and angiography (except in the cases with ruptures) associated with duplex ultrasonography. In patients with ectopic kidney a Carrel patch technique was used for the reimplantation of the renal arteries into the body of the bifurcated (four cases) or tubular (four cases) Dacron graft in five (62.5%) cases whereas aortorenal bypass with Dacron graft was obtained in three cases (37.5%). Sixteen patients from the horseshoe kidney group required renal revascularization (reimplantation using Carrel patch in 10 patients and aortorenal bypass using Dacron graft in 6 patients). Two patients, both with ruptured abdominal aortic aneurysms died after the operation. In other cases the average follow up period was 6.2 years (6 months to 17 years). In one case control, angiography after 6 months revealed an occluded left renal artery that was reimplanted by Carrel patch but without repercussions on the renal function. Aortic surgery in patients with renal anomalies can be safely performed without increased mortality.
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to identify factors influencing surgical treatment outcome following upper extremity arterial injuries.
This 15-year study (January 1992 to December 2006) included 167 patients with 189 civilian, iatrogenic or military upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into a vascular trauma database and retrospectively analysed.
The most frequently damaged vessel was the brachial artery (55% of injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Three primary amputations (1.8%) were performed because of extensive soft-tissue destruction and signs of irreversible ischaemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft-tissue and nerve damage. Fasciotomy was required in 9.6% of cases. Operative mortality was 2.4% (four deaths). Early graft failure, compartment syndrome, associated skeletal and brachial plexus damage and a military mechanism of injury were found to be significant risk factors for limb loss (p<0.01).
Although careful physical examination should diagnose the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Prompt reconstruction is essential for optimal results. Nerve trauma is the primary cause of long-term functional disability.
[Show abstract][Hide abstract] ABSTRACT: This retrospective study covers the period from 1991 to 2002, during which 3,623 patients were operated on because of aneurysmal or occlusive disease of aortoiliac and femoropopliteal segments. Among them, 87 patients (2.4%) developed a false anastomotic aneurysm in the 12-year follow-up period and were treated operatively. Most frequently, in 53 patients (6.9%), a false anastomotic aneurysm developed after aortobifemoral bypass performed owing to aortoiliac occlusive disease. The cause of false anastomotic aneurysm was infection in 21 cases (24.7%); resection and revascularization were performed with a Dacron graft in 46 cases (52.9%), with a polytetrafluoroethylene graft in 10 cases (11.5%), and with the great saphenous vein in 16 cases (18.4%). Homograft implantation in 4 patients (4.6%) or extra-anatomic bypasses in 11 cases (12.6%) were performed when graft infection was suspected. Of 87 patients who underwent surgery, 74 (85.5%) had good early results without infection, reintervention, limb loss, and mortality. The presence of infection as a cause of false anastomotic aneurysm and comorbidity increased the mortality rate significantly after the reoperation, whereas the type of graft used in treatment had no influence on early results.
[Show abstract][Hide abstract] ABSTRACT: 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.
Annals of Vascular Surgery 02/2007; 21(1):23-9. · 0.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: DJORDJEVIC, M., et al.: Circadian Variations of Heart Rate and STIM-T Interval: Adaptation for Nighttime Pacing. In order to determine the optimal pacing rate for pacemaker patienfs at night, 150 normal subjects with regular sinus rhythm and free of manifest heart disease, were studied using 24-hour Rolter monitoring. Minimum and average heart rates were analyzed on an hourly basis. The study group was divided into six age groups, 25 subjects each, ranging from 20–29 years to 60–69 years. The minimum heart rate during the night was found to be lower than 65 ppm for all groups. The youngest subjects showed the largest variation in the minimum heart rate. The results suggest that an automatic lowering of the pacing rate during the night would allow for longer periods of sinus rhythm, thereby improving hemody-namic performance and reducing pacemaker power consumption. Suitable sensors for automatic lowering of the pacing rate include inbuilt 24-hour clock systems and the QT interval that lengthens during sleep.