Publications by authors named "Ilijas Cinara"

24 Publications

  • Page 1 of 1

Impact of Bypass Flow Assessment on Long-Term Outcomes in Patients with Chronic Limb-Threatening Ischemia.

World J Surg 2021 07 17;45(7):2280-2289. Epub 2021 Mar 17.

Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Dr Koste Todorovica 8, 11000, Belgrade, Serbia.

Background: Transit time flow meter (TTFM) allows quick and accurate intraoperative graft assessment. The main study goal is to evaluate the influence of graft flow measurements on long-term clinical outcomes in patients with chronic limb-threatening ischemia (CLTI) undergoing bellow the knee (BTK) vein bypass surgery.

Methods: Between January 1st, 1999 and January 1st, 2006, 976 CLTI consecutive patients underwent lower extremity bypass surgery. When applying the exclusion criteria, 249 patients were included in the final analysis. Control measurements were performed at the end of the procedure. Patients were divided according to the mean (more/less than 100 ml/min) and diastolic graft flow (more/less than 40 ml/min) values in four groups. The primary endpoints were a major adverse limb event (male) and primary graft patency.

Results: After the median follow-up of 68 months, a group with the mean graft flow below 100 ml/min and the diastolic graft flow below 40 ml/min had the highest rates of male (χ = 36.60, DF = 1, P < 0.01, log-rank test) and the worst primary graft patency (χ = 53.05, DF = 1, P < 0.01, log-rank test).

Conclusion: In patients with CLTI undergoing BTK vein bypass surgery, TTFM parameters, especially combined impact of mean graft flow less than 100 ml/min and diastolic graft flow less than 40 ml/min, were associated with an increased risk of poor long-term male and primary graft patency.
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http://dx.doi.org/10.1007/s00268-021-06046-yDOI Listing
July 2021

Comparison of Long Term Outcomes After Endovascular Treatment Versus Bypass Surgery in Chronic Limb Threatening Ischaemia Patients with Long Femoropopliteal Lesions.

Eur J Vasc Endovasc Surg 2021 02 15;61(2):258-269. Epub 2020 Dec 15.

Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Serbia.

Objective: There are currently two treatments available for patients with chronic limb threatening ischaemia (CLTI): open surgical bypass (OSB) and percutaneous transluminal angioplasty with/without stenting (PTA/S). The aim of this study was to compare short and long term outcomes between PTA/S and OSB in CLTI patients with long (GLASS grade III and IV) femoropopliteal disease.

Methods: This was a two centre retrospective study including all consecutive patients with CLTI undergoing first time lower extremity intervention at two distinct vascular surgical centres. Between 1 January 2012 and 1 January 2018, 1 545 CLTI consecutive limbs were treated for femoropopliteal GLASS grade III and IV lesions at two vascular surgical centres. Using covariables from baseline and angiographic characteristics, a propensity score was calculated for each limb. Thus, comparable patient cohorts (235 in PTA/S and 235 in OSB group) were identified for further analysis. The primary outcomes were freedom from re-intervention in the treated extremity and major amputation. Secondary outcomes were all hospital complications among the two patient groups.

Results: Total overall complication rates were significantly higher in the OSB group (20.42% vs. 5.96%, p < .001), especially wound infection/seroma rate that required prolonged hospitalisation and further treatment (7.65% vs. 0%, p < .001). After the median follow up of 61 months, re-intervention rates were significantly higher in the PTA/S group (log rank test, 44.68% vs. 29.79%, p = .002), but there was no significant difference in terms of major amputation rates between the two group of patients (log rank test, PTA/S 27.23% vs. OSB 22.13%, p = .17).

Conclusion: Bypass surgery seems to be superior to PTA/S for GLASS grade III and IV femoropopliteal lesions in patients with CLTI in terms of long term re-intervention rates, but with considerably higher rates of post-operative complications. A larger cohort of patients in currently ongoing randomised trials, as well as prospective cohort studies are necessary to confirm these findings.
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http://dx.doi.org/10.1016/j.ejvs.2020.11.009DOI Listing
February 2021

Abdominal Aortic Surgery in the Presence of Inferior Vena Cava Anomalies: A Case Series.

Ann Vasc Surg 2017 Feb 22;39:137-142. Epub 2016 Sep 22.

Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia.

Background: Left-sided inferior vena cava (LIVC) and duplicated inferior vena cava (DIVC) are rare asymptomatic congenital abnormalities. Unrecognized, these anomalies can be the source of major injuries and cause serious life-threatening bleeding complications especially during abdominal aortic surgery.

Methods: Retrospective data for patients with 2 major inferior vena cava (IVC) anomalies that underwent aortic surgery over a 13-year period were collected. Patient demographics, type of aortic disease and caval anomaly, surgical approach, type of aortic reconstruction associated with procedure on caval vein, postoperative complications, and in-hospital mortality were recorded.

Results: There were 9 patients with inferior vena cava (IVC) anomalies who underwent aortic surgery. All of them were men, with a median age of 66.2 years. Seven had an LIVC and 2 had DIVC. Five patients were operated on due to abdominal aortic aneurysm and 4 due to aortoiliac occlusive disease. In all patients, a midline transperitoneal aortic approach was performed. In 5 cases, the left IVC had to be temporarily resected and later reconstructed, and in the other 4 it was just mobilized. There were no postoperative complications except in one patient who developed deep vein thrombosis in the left calf; this was successfully treated with anticoagulant therapy.

Conclusion: Due to favorable results and low incidence of perioperative complications and in the absence of other associated abdominal pathology, we propose the midline transperitoneal approach with mobilization or temporary resection of LIVC.
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http://dx.doi.org/10.1016/j.avsg.2016.06.022DOI Listing
February 2017

Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome.

Neurosurg Rev 2017 Apr 30;40(2):241-249. Epub 2016 May 30.

Innovation Centre of the Faculty of Technology and Metallurgy, University of Belgrade, Belgrade, Serbia.

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.
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http://dx.doi.org/10.1007/s10143-016-0755-2DOI Listing
April 2017

Splenic Artery Aneurysms: Two Cases of Varied Etiology, Clinical Presentation and Treatment Outcome.

Srp Arh Celok Lek 2015 May-Jun;143(5-6):326-31

Introduction: Splenic artery aneurysms are potentially lethal lesions. We report two illustrative cases and discuss etiology, diagnosis and treatment of these aneurysms.

Outline Of Cases: Both patients, age 31 and 80 years, were biparous women.The younger woman, otherwise healthy, was referred from a local hospital 3 weeks after she underwent a left subcostal laparotomy and exploration for symptomatic abdominal mass diagnosed by CT. Angiography established the diagnosis of a large, non-ruptured splenic artery aneurysm. Elective aneurysmectomy with splenectomy was performed using the approach through the upper median laparotomy and bursa omentalis. Postoperative course was uneventful. Histopathology demonstrated cystic medial necrosis with chronic dissection. The other patient, elderly woman, presented urgently with acute abdominal pain and syncope and was diagnosed by computed tomography with a huge, ruptured splenic artery aneurysm. She underwent immediate aneurysmectomy with splenectomy using the same, above-mentioned approach. External pancreatic fistula and pancreatic pseudocyst complicated the postoperative course, requiring open pseudocyst drainage and cystojejunostomy. After a protracted hospitalization patient eventually recovered. The pathological diagnosis was atherosclerotic aneurysm.

Conclusion: Splenic artery aneurysms are infrequent lesions, with varied etiology and clinical presentation. Timely diagnosis and adequate treatment prevent life-threatening rupture and lessen the risk of operative morbidity and mortality.
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http://dx.doi.org/10.2298/sarh1506326pDOI Listing
October 2015

[In situ replacement of infected vascular prosthesis with fresh arterial homograft: early and long-term results in 18 patients].

Srp Arh Celok Lek 2013 Nov-Dec;141(11-12):750-7

Clinic of Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia.

Introduction: 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.

Objective: 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.

Methods: 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.

Results: 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.

Conclusion: 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.
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http://dx.doi.org/10.2298/sarh1312750pDOI Listing
October 2015

Influence of the chronic abdominal aortic occlusion on the femoral artery disease pattern.

Vascular 2014 Feb;22(1):28-34

We design a study to evaluate whether patients with chronic aortic occlusion have a different pattern of femoral artery atherosclerosis than patients with other forms of aortoiliac disease as well as to discuss potential causal mechanisms. From January 2008 to January 2010, 467 patients with aortoiliac occlusive disease were enrolled at Clinic of Vascular and Endovascular Surgery in Belgrade, Serbia. Among them 60 patients were divided into two groups, patients with chronic aortic occlusion (COA) and diffuse aortoiliac occlusive disease (AIOD, Leriche type II). Each group consisted of 30 patients. Those two groups were compared according to symptomatology, ABI values, femoral artery pressure gradient, atherosclerosis level in the femoral region and predictors of atherosclerosis.Patients with AIOD had severe atherosclerosis unlike patients with COA. Also, high elevation of postoperative ABIs in patients with an early atherosclerosis (0, I, II and III) was noted suggesting patent distal arterial tree. FAP gradient was significantly higher in COA group comparing with AIOD group (left: t=-10.963, P<0.01;right: t=-8.962, P<0.01). In conclusion, our data demonstrate that older patients have had more time to develop multilevel disease (AOID) and those with CAO have more isolated aortic disease chronic aortic occlusion.
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http://dx.doi.org/10.1177/1708538112472284DOI Listing
February 2014

Endovascular aortic repair: first twenty years.

Srp Arh Celok Lek 2012 Nov-Dec;140(11-12):792-9

School of Medicine, University of Belgrade, Belgrade, Serbia.

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.
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March 2013

[Factors influencing early results of femoro-femoral crossover bypass].

Srp Arh Celok Lek 2011 Mar-Apr;139(3-4):143-8

Introduction: Femoro-femoral crossover bypass is an extraanatomic reconstruction used for revascularization of lower limb with contralatateral femoral artery as an inflow vessel, and the graft placed in the suprapubic region. We perform this procedure when anatomic reconstruction is not possible or is contraindicated.

Objective: To analyze the influence of different risk factors on early patency of femoro-femoral crossover bypass.

Methods: This retrospective study analyzed the results of 88 femoro-femoral bypass grafting during an 11-year period. There were 66 (75%) males and 22 (25%) females of average age 64.93 years (42-79 years). In 76 patients the operations were performed due to critical limb ischemia. Revascularization was urgent in 12 patients, while 76 patients were elective. Dacron prosthesis was used in 81 patients, while PTFE was used in 7 patients. Statistical analysis was made by logistic regression.

Results: During hospitalisation the graft remained patent in 82 patients, and graft thrombosis occurred in 6 patients. Limb salvage rate was 90.91%. Early morbidity rate (within the first postoperative month) was 13.64%, while early mortality rate was 4.55%. Using logistic regression we established that early graft patency was statistically more significant in males (p < 0.05). Age (p = 0.07) and hypertension (p = 0.08) appeared to be predicting influence of the graft patency on the border of the accepted statistical significance level.

Conclusion: Femoro-femoral crossover bypass is a good alternative for revascularization in high risk patients for standard anatomic reconstructions due to comorbid conditions or local problems.
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http://dx.doi.org/10.2298/sarh1104143dDOI Listing
June 2011

Twenty years of experience in the treatment of spontaneous aorto-venous fistulas in a developing country.

World J Surg 2011 Aug;35(8):1829-34

Clinic for Vascular Surgery, Clinical Centre of Serbia, 8, Koste Todorovica st., Belgrade, Serbia.

Background: 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.

Materials And Methods: 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.

Results: 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.

Conclusions: 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.
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http://dx.doi.org/10.1007/s00268-011-1128-1DOI Listing
August 2011

The benefits of internal thoracic artery catheterization in patients with chronic abdominal aortic occlusion.

Cardiovasc Intervent Radiol 2011 Apr 8;34(2):396-400. Epub 2010 Jun 8.

Clinic of Vascular and Endovascular Surgery, Clinical Center Serbia, Belgrade, Serbia.

Occlusion of the abdominal aorta may be caused by an embolic lesion, but more commonly by thrombotic disease at the aortoiliac area, progressing retrograde. However, the visualization of the distal run-off via internal thoracic-epigastric inferior artery collateral channel may be a very important diagnostic tool, especially in countries with poor technical equipment. This study was designed to show the benefit of the selective internal thoracic angiography in cases with complete aortic occlusion. We present 30 patients with chronic aortic abdominal occlusion who were submitted to the transaxillary aortography and selective ITA angiography with purpose of distal run off evaluation. Angiographic evaluation was performed by two independent radiologists according to previously defined classification. Good angiographic score via internal thoracic angiography by first observer was achieved in 19 (63.3%) patients and in 18 (60%) by a second observer. Transaxillary aortography showed inferior results: good angiographic score by the first observer in six (20%) patients and by the second observer in three (3%) patients. Low extremity run-off is better visualized during internal thoracic angiography than during transaxillary aortography.
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http://dx.doi.org/10.1007/s00270-010-9907-xDOI Listing
April 2011

[Endovascular repair of aortic aneurysm--preliminary results].

Srp Arh Celok Lek 2009 Jan-Feb;137(1-2):10-7

Introduction: Endovascular aneurysm repair (EVAR) has been introduced into clinical practice at the beginning of the 90's of the last century. Because of economic, political and social problems during the last 25 years, the introduction of this procedure in Serbia was not possible.

Objective: The aim of this study was to present preliminary experiences and results of the Clinic for Vascular Surgery of the Serbian Clinical Centre in Belgrade in endovascular treatment of thoracic and abdominal aortic aneurysms.

Methods: The procedure was performed in 33 patients (3 female and 30 male), aged from 42 to 83 years. Ten patients had a descending thoracic aorta aneurysm (three atherosclerotic, four traumatic--three chronic and one acute as a part of polytrauma, one dissected, two penetrated atherosclerotic ulcers), while 23 patients had the abdominal aortic aneurysm, one ruptured and two isolated iliac artery aneurysms. The indications for EVAR were isthmic aneurismal localisation, aged over 80 years and associated comorbidity (cardiac, pulmonary and cerebrovasular diseases, previous thoracotomy or multiple laparotomies associated with abdominal infection, idiopathic thrombocitopaenia). All of these patients had three or more risk factors. The diagnosis was established using duplex ultrasonography, angiography and MSCT. In the case of thoracic aneurysm, a Medtronic-Valiant endovascular stent graft was implanted, while for the abdominal aortic aneurysm Medtronic-Talent endovascular stent grafts with delivery systems were used. In three patients, following EVAR a surgical repair of the femoral artery aneurysm was performed, and in another three patients femoro-femoral cross over bypass followed implantation of aortouniiliac stent graft.

Results: During procedure and follow-up period (mean 1.6 years), there were: one death, one conversion, one endoleak type 1, six patients with endoleak type 2 that disappeared during the follow-up period, one early graft thrombosis. No other complications, including aneurysm expansion, collapse, deformity and migration of the endovascular stent grafts, were registered.

Conclusion: According to all medical and economic aspects, we recommend EVAR to treat acute traumatic thoracic aortic aneurysm, as well as in elderly and high-risk patients with abdominal or thoracic aneurysms, when open surgery is related to a significantly higher mortality and morbidity.
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http://dx.doi.org/10.2298/sarh0902010dDOI Listing
May 2009

[Surgical treatment of abdominal tumours closely related to major blood vessels].

Srp Arh Celok Lek 2008 May-Jun;136(5-6):241-7

Introduction: Radical operative treatment of abdominal tumours closely related to major blood vessels often demands complex vascular procedures.

Objective: The aim of this paper was to present elementary principles and results of the complex procedures, based on 46 patients operated on at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, from January 1999 to July 2006.

Method: Primary localisation of the tumour was the kidney in 14 patients, the suprarenal gland in 2, the retroperitoneum in 23 and the testis in 7 patients. Histologically, the most frequent were the following: renal carcinoma in 14 patients, teratoma in 7, liposarcoma in 5, fibrosarcoma and lymphoma in 3 patients. The tumour compressed abdominal aorta occurred in 3 cases, vena cava inferior in 5 and both the abdominal aorta and vena cava inferior in 11 cases. In 4 cases the tumour infiltrated the abdominal aorta, in 11 the vena cava inferior and in 8 both of them. In two patients, the tumour compressed the vena cava inferior and infiltrated the aorta; in two patients the aorta was compressed and the vena cava was infiltrated. In three cases only the exploration was performed due to multiple abdominal organ infiltration. The ex tempore biopsy showed the type of tumour in which the radical surgical treatment did not improve the prognosis. In 20 cases of tumour compression, subadventitional excision was performed. In 23 cases of infiltration, the tumour excision and vascular reconstruction had to be performed. Intraoperative blood cell saving and autotransfusion were applied in 27 patients.

Results: The lethal outcome happened in 3 (6.5%) patients during hospitalization. In other patients all reconstructed blood vessels were patent during the postoperative hospitalization period.

Conclusion: Treatment of the abdominal tumours closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. Tumour reduction cannot improve long term prognosis, and has no major impact on life quality. There have been not many papers that analyse the long term results after such complex operations proving their appropriateness.
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http://dx.doi.org/10.2298/sarh0806241dDOI Listing
October 2008

[Preoperative factors influencing the early results of infrainguinal limb salvage procedures].

Srp Arh Celok Lek 2007 Jan-Feb;135(1-2):7-14

Introduction: The early results of 59 patients treated surgically for critical limb ischemia at the Institute of Cardiovascular Diseases were analyzed. Research was performed in a prospective manner, as an acute study, lasting for three months.

Objective: Our focus was on primary and secondary patency rate, and graft efficacy (quality accomplished by graft patency, improvement of clinical status of the leg, and quality of life).

Method: The influence of each variable on the outcome was analyzed (descriptive: sex, comorbidity, risk factors, clinical stage of disease, angiographic verification of pedal arch, previous vascular procedures; and numerical: gender, preoperative Doppler index, angiographic score by Bollinger), as well as their predictive value. Inferential statistics was used for establishing the significance of influence, and univariate regression analysis for predictive values.

Results: No influence of variables on the outcome was evident in the first three months, and their predictive value was not important considering the graft patency rates and efficacy (except for preoperative clinical status affecting the graft efficacy, presence of pedal arch, affecting both primary and secondary patency rates and graft efficacy, and finally Doppler index affecting the secondary patency rates).

Conclusion: When the surgeon needs to give an early prediction of graft destiny, he can rely on preoperative clinical status, earlier vascular operative procedures, presence of pedal arch, and values of Doppler index (in case of reintervention).
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http://dx.doi.org/10.2298/sarh0702007cDOI Listing
June 2007

[Anastomotic pseudoaneurysms].

Srp Arh Celok Lek 2006 Mar-Apr;134(3-4):114-21

Anastomotic pseudoaneurysm is a form of false aneurysm, whose wall does not consist of all normal layers of arterial wall. Given the rising number of reconstructive vascular procedures, the increase of anastomotic pseudoaneurysm cases is expected. Therefore, identification of causes, clinical manifestations as well as factors which affect the outcome of operative treatment of anastomotic pseudoaneurysms is of great practical value. This retrospectively-prospective study included 87 surgically treated cases of anastomotic pseudoaneurysms in the period from 1991 to 2002. The most often localization of anastomotic pseudoaneurysms was the inguinal region (68-86.2%). In the majority of cases, they were caused by arterial degeneration in the anastomotic region--56 cases (65.9%) and infection--21 cases (24.7%). The most frequent manifestations of anastomotic pseudoaneurysms were bleeding due to rupture in 26 cases (29.9%) and chronic limb ischaemia in 22 cases (25.3%). An acute limb ischaemia was present in 17 cases (19.5%), the symptoms caused by local compression to the surrounding structures--in 9 cases (10.3%), and in 12 cases (13.8%), the only manifestation of anastomotic pseudoaneurysm was asymptomatic pulsatile mass. In 32 cases (36.8%), surgical treatment involved the resection of anastomotic pseudoaneurysm and graft interposition, whereas in 39 cases (44.8%), bypass procedure had to be performed after the resection. Comorbidity significantly increased mortality in the first 30 days. The use of Dacron graft in primary operation significantly improved early results of operative treatment. Absence of infection as the cause of anastomotic pseudoaneurysm is a statistically important prognostic factor of operative treatment, considering the graft patency, limb salvage, infection, need for reintervention and mortality.
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http://dx.doi.org/10.2298/sarh0604114mDOI Listing
October 2006

Civil and war peripheral arterial trauma: review of risk factors associated with limb loss.

Vascular 2005 May-Jun;13(3):141-7

Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, Serbia.

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.
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http://dx.doi.org/10.1258/rsmvasc.13.3.141DOI Listing
September 2005

[Long-term results after elective and emergency surgery of abdominal aortic aneurysm].

Srp Arh Celok Lek 2004 Sep-Oct;132(9-10):306-12

Introduction: Abdominal aortic aneurysm can be repaired by elective procedure while asymptomatic, or immediately when it is complicated--mostly due to rupture. Treating abdominal aneurysm electively, before it becomes urgent, has medical and economical reason. Today, the first month mortality after elective operations of the abdominal aorta aneurysm is less than 3%; on the other hand, significant mortality (25%-70%) has been recorded in patients operated immediately because of rupture of the abdominal aneurysm. In addition, the costs of elective surgical treatment are significantly lower.

Objective: The objective of this study is to compare long-term survival of patients that underwent elective or immediate repair of abdominal aortic aneurysm (due to rupture), and to find out the factors influencing the long-term survival of these patients.

Material And Methods: Through retrospective review of prospectively collected data of the Institute for Cardiovascular Diseases of Clinical Center of Serbia, Belgrade, 56 patients that had elective surgery and 35 patients that underwent urgent operation due to rupture of abdominal aneurysm were followed up. Only the patients that survived 30 postoperative days were included in this review, and-were followed up (ranging from 2 to 126 months). Electively operated patients were followed during 58.82 months on the average (range 7 to 122), and urgently operated were followed over 52.26 months (range 2 to 126). There was no significant difference of the length of postoperative follow-up between these two groups.

Results: During this period, out of electively operated and immediately operated patients, 27 and 22 cases died, respectively. There was no significant difference (p>0.05a) of long-term survival between these two groups. Obesity and early postoperative complications significantly decreased long-term survival of both electively and immediately operated patients. Graft infection, ventral hernia, aneurysm of peripheral arteries and other vascular reconstructive procedures were the factors that significantly reduced long-term survival of patients operated immediately due to rupture.

Discussion: This comprehensive study has searched for more factors than others had done before. The applied discriminative analysis numerically evaluated the influence of any risk factor of mortality. These factors were divided in three groups as follows: preoperative, operative and postoperative ones. Preoperative factors were sex, age, diabetes mellitus, arterial hypertension, obesity, COPD, and naturally, the indication for operative treatment of ruptured or non-ruptured abdominal aneurysm. Among all these factors, only obesity significantly reduced long-term survival of electively operated patients. It may be said that immediately operated patients who survived the first 30 postoperative days had quite good long-term survival. Operative factors such as type of operative procedure and vascular graft had no influence on long-term survival of patients in both groups. Postoperative risk factors were early postoperative complications, graft infection, symptomatic cerebrovascular disease, carotid endarterectomy, myocardial revascularization, ventral hernias, "other" non vascular operations, malignancy, mental disorders, peripheral aneurysms and occlusive vascular disease, and other vascular operations either due to aneurysm or peripheral occlusive disease. Early postoperative complications (even graft infection) had no significant effect on long-term survival. Ventral hernias and peripheral aneurysms were factors that significantly decreased long-term survival of patients operated for rupture of the abdominal aneurysm.

Conclusion: It is interesting that endarterectomy, myocardial revascularization or malignancy after repair of the abdominal aneurysm (ruptured or non-ruptured) had no effect on long-term survival.
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http://dx.doi.org/10.2298/sarh0410306kDOI Listing
May 2005

Ruptured abdominal aortic aneurysms: factors influencing early survival.

Ann Vasc Surg 2005 Jan;19(1):29-34

Department of Vascular Surgery, Institute for Cardiovascular Diseases, Clinical Center of Serbia, Belgrade, Serbia.

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.
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http://dx.doi.org/10.1007/s10016-004-0148-9DOI Listing
January 2005

Abdominal aortic surgery and horseshoe kidney.

Ann Vasc Surg 2004 Nov;18(6):725-8

Institute for Cardiovascular Diseases, Clinical Center of Serbia, 8, K. Todorovića Street, Belgrade, 11000, Serbia.

Horseshoe kidney presents a special challenge during surgery of the abdominal aorta. The aim of this study was to evaluate the morbidity and define optimal management based on clinical histories of 15 patients with horseshoe kidney who underwent surgical procedures on the abdominal aorta over a 20-year period. There were 2 female and 13 male patients with an average age of 62.66 (50-75) years. The indications for surgery included aortic aneurysms in 10 patients and aortoiliac occlusive disease in 5. The horseshoe kidney was detected before surgery in 12 patients (80%) by ultrasonography, angiography, computed tomography (CT) or excretory urography. Angiography revealed multiple or anomalous renal arteries in 8 of 12 patients studied preoperatively. At surgery, 10 patients (66.6%) were found to have multiple or anomalous renal arteries. Five patients (33.41%) were without multiple or anomalous renal arteries. Ten required renal revascularization (reimplantation with a Carrel patch in 7 patients and aortorenal bypass in 3). Two patients, both with ruptured abdominal aortic aneurysms, died postoperatively. In the other 10 cases the average follow-up period was 5.3 years (6 months to 17 years). During this period there were no signs of graft occlusion, renovascular hypertension, or renal failure. From these results we conclude that aortic surgery can be performed safely in patients with horseshoe kidney without increased mortality. These patients require exact preoperative diagnosis (ultrasonography, CT scan, angiography), reimplantation of anomalous renal arteries, and preservation of the renal isthmus.
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http://dx.doi.org/10.1007/s10016-004-0076-8DOI Listing
November 2004

[Axillobifemoral bypass grafting].

Srp Arh Celok Lek 2004 May-Jun;132(5-6):157-62

Introduction: Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons.

Objective: The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass.

Methods: The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity--in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with latrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluoroethlylene graft was used in three patients. Simultaneously, profundoplastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done. Chi2 test was used for statistical evaluation and life table method was used for verification of late graft patency.

Results: The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis--1, MOFS--3, and infarct myocardium--1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was found in one patient. The other complications were--artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in three patients. Life table method has shown that cumulative rate of late graft patency is 80.39% after five years (Graph 1).

Discussion: Our results were analyzed and compared with the results of the study on 283 patients who had undergone aortobifemoral bypass (AFF) operation due to the aortoiliac occlusive disease. This study was completed in 1995 (18). The results showed that there was no statistically significant differences between AxFF and AFF group (p > 0.05), considering early mortality rate and late graft patency (Graph 2). The review of mortality and late patency rate after AxFF bypass grafting in a world well known studies has shown the similar results (Table 1). CONCLUSION The authors suggest that axilobifemoral bypass is indicated when there are contraindications or difficulties to perform anatomic reconstruction due to the abdomen condition (infection, adhesion, comorbidity) as well as in high risk patients with low life expectancy.
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http://dx.doi.org/10.2298/sarh0406157dDOI Listing
November 2004

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

Srp Arh Celok Lek 2003 Nov-Dec;131(11-12):432-6

Clinic of Vascular Surgery, Institute of Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade.

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.
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http://dx.doi.org/10.2298/sarh0312432mDOI Listing
May 2004

Ruptured abdominal aortic aneurysm. Predictors of survival in 229 consecutive surgical patients.

Herz 2004 Feb;29(1):123-9

Department of Vascular Surgery, Institute for Cardiovascular Diseases, Clinical Center of Serbia, Belgrade, Serbia and Montenegro.

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.
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http://dx.doi.org/10.1007/s00059-004-2540-1DOI Listing
February 2004

[An obturator or "lateral" bypass in infected vascular prostheses in the groin?].

Srp Arh Celok Lek 2002 Jan-Feb;130(1-2):27-32

Institute of Cardiovascular Diseases, Serbian Clinical Centre, Belgrade.

The infection of the previously implanted vascular graft at the groin, is associated with great mortality and morbidity rate [1]. The authors present a retrospective study in which they analyzed management of infected vascular prostheses at the groin, using obturator bypass in 26 cases, and "lateral" bypass in 15 cases. The indications for obturator bypass reconstructions included: 20 infections of aorto-femoral grafts, two infected pseudoaneurysms in the groin after PTA of the superficial femoral artery, and 4 infections of iliac-femoral grafts. The indications for lateral bypass reconstructions were: infections after aorto-femoral reconstructions--8 cases; infection after femoro-popliteal reconstructions--4 cases; infection after iliac-femoral reconstruction--2 patients, and one infected pseudoaneurysm in the groin after PTA of the superficial femoral artery. In 3 subjects obturator bypass was performed using extraperitoneal approach, while in other 23 patients transperitoneal approach was done by donor's artery. The obturator bypass was performed using a PTFE graft in 3 cases, and Dacron graft in 23. The donor's artery used for obturator bypass was a noninfected proximal part of aortofemoral graft in 20 cases, and iliac artery in 6 patients. The superficial femoral artery was recipient artery for obturator bypass in 3 cases, deep femoral artery in one case, and above the knee popliteal artery in 22 cases (Figure 1). In two patients transperitoneal approach to donors artery for "lateral" bypass has been used, and in 13 cases extraperitoneal. The proximal noninfected part of aorto femoral graft was used as a donor's artery for lateral bypass in 8 patients, while common iliac artery in 7 subjects. In 5 cases reconstructions were performed using PTFE grafts, in 3 using autologous saphenous vein grafts, and in 7 using Dacron grafts. The recipient artery for "lateral" bypass was deep femoral in 8 cases, superficial femoral in three patients and above the knee popliteal artery in 4 subjects. After both types of reconstruction, extirpation of infected grafts from the groin was performed (Figure 2). The control examination was performed using physical and Doppler ultrasonographic examinations, one, 3, 6, 12 months, and then every year after the operation. In cases with suspected graft infection or thrombosis, control angiography was also performed. One intraoperative perforation of the urinary bladder has been done accidentally during obturator bypass reconstruction. The mean follow-up period for patients with obturator bypasses was 2.3 years, while 2.1 years for patients with "lateral" bypasses. Comparing with "lateral" bypass, obturator bypass showed statistically significant lower (p < 0.05) 30-day mortality and early graft infection rate, as well as statistically significant better early and total limb salvage rate. There were no statistically significant differences (p > 0.05) between obturator and "lateral" bypass procedures, having in mind, late graft infection rate, as well as early and late graft patency (Figures 3 and 4). In cases with infected vascular prostheses in the groin, the authors recommend obturator bypass comparing with "lateral" bypass.
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http://dx.doi.org/10.2298/sarh0202027dDOI Listing
August 2002
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