Publications by authors named "Marko Dragas"

64 Publications

Influence of perioperative risk factors on the development of transmural colonic ischemia after open repair of ruptured abdominal aortic aneurysm.

J Cardiovasc Surg (Torino) 2021 Jul 8. Epub 2021 Jul 8.

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

Background: Development of colonic ischemia (CI) after ruptured abdominal aortic aneurysm (RAAA) treatment is a lethal complication with perioperative mortality reported to be high as 50%. Therefore, the main goal of this study was to identify pre-, intra- and postoperative risk factors associated with CI in patients undergoing open repair (OR) due to RAAA, that might help to select patients who are more prone to develop CI.

Methods: This was a single-center prospective cohort study on patients with RAAA undergoing OR between January 1st 2018 and July 1st 2019, at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia. During this period 89 patients were treated due to RAAA and all were included in the study. The primary endpoint was grade III CI, or transmural necrosis, diagnosed by laparotomy.

Results: Out of 89 patients operated due to RAAA, CI was diagnosed in 14 (15.73%). During the operation, patients with CI had a longer duration of hypotension (42.86±35.82 vs 24.13±23.48, p=.021) and more common significant hypotension (54.54% vs 14.66%, p=.024). In the postoperative course, patients with CI had more common signs of abdominal compartment syndrome (71.42% vs 25.33%, p=.001) and higher mortality rate (78.57% vs 29.33%, p=.001). The univariate regression model showed that one of the most significant factors that were associated with CI were age higher than 75 years, significant hypotension lasting more than one hour, organ lesion, development of abdominal compartment syndrome and higher potassium values on third and fourth quartile.

Conclusions: Grade III colon ischemia (transmural) remains the important cause of mortality after ruptured abdominal aortic aneurysm repair. We identified pre- and intraoperative and postoperative risk factors that could improve the selection of patients for primary open abdomen treatment or early exploratory laparotomy in order to prevent or timely diagnose colon ischemia.
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http://dx.doi.org/10.23736/S0021-9509.21.11861-0DOI Listing
July 2021

Open Surgical Treatment of Acute Spontaneous Isolated Abdominal Aortic Dissection.

Ann Vasc Surg 2021 Apr 6. Epub 2021 Apr 6.

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

Background: The aim of this paper is to report our single-center experience in the open surgical treatment of acute spontaneous infrarenal isolated abdominal aortic dissection (siIAAD).

Methods: This was a single center retrospective study. Between January 2015 and 2020 ten patients were treated due to acute siIAAD with open surgery. There were no patients treated for chronic siIAAD in this time period. Patients who had concomitant thoracic aortic involvement were excluded from this report.

Results: The group consisted of 7 male and 3 female patients. History of hypertension was present in nine patients and six were active smokers. The abdominal/back pain was described in 9 patients, two had acute limb ischemia and three had aortic rupture. Median dissection length was 91 mm (65.7 - 106), median distance from the lowest renal artery was 30 mm (20.7 - 49.3) and median abdominal aortic diameter was 58.5 mm (32.5 - 66.2). Supracoeliac clamp was used in three cases with a ruptured aorta and suprarenal in two patients. The mean duration of proximal clamping time was 24.3 ± 7.49 min. One patient died of postoperative acute myocardial infarction, one suffered nonfatal pulmonary embolism and one had deep venous thrombosis. No aortic-related deaths and/or reinterventions occurred during the median follow-up of 32 months.

Conclusions: Acute siIAAD is a rare event which affects mostly male smokers with hypertension. Open surgery is a technically demanding procedure with acceptable complication rates and should be performed in specialized high-volume centers for the treatment of aortic disease. Future efforts to establish a multicenter registry to evaluate the prevalence of the disease and treatment options could provide better and more comprehensive guidelines for the treatment of acute siIAAAD.
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http://dx.doi.org/10.1016/j.avsg.2021.02.035DOI Listing
April 2021

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis.

Eur J Vasc Endovasc Surg 2020 02 6;59(2):255-264. Epub 2020 Jan 6.

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

Objective: Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding.

Methods: A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality.

Results: After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group.

Conclusion: The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.
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http://dx.doi.org/10.1016/j.ejvs.2019.10.013DOI Listing
February 2020

Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center.

Int Angiol 2019 Jun 15;38(3):250-255. Epub 2019 Apr 15.

Faculty of Medicine, University of Belgrade, Belgrade, Serbia.

Background: Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity.

Methods: Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas.

Results: There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency.

Conclusions: Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.
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http://dx.doi.org/10.23736/S0392-9590.19.04124-5DOI Listing
June 2019

An Isolated Aneurysm of the Abdominal Aorta in a Patient with Marfan Syndrome-A Case Report.

Ann Vasc Surg 2020 Feb 11;63:454.e1-454.e4. Epub 2019 Feb 11.

Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia; School of Medicine, University of Belgrade, Serbia.

We present a case of successfully treated abdominal aortic aneurysm in a 24-year-old patient with Marfan syndrome. After initial physical and ultrasound examination, the multislice computed tomography (MSCT) scan revealed infrarenal aortic aneurysm of 6 cm in diameter, 10 cm long, along with slightly dilated iliac arteries. However, dimensions of aortic root, aortic arch, and descending suprarenal aorta were within normal limits. Further on, because the patient presented with signs of impending rupture, an urgent surgical intervention was performed. The patient was discharged in good general medical condition 7 days after surgery. After 6 months of follow-up, the patient's condition was satisfying and no MSCT signs of further aortic dissection/aneurysm were identified. To the best of our knowledge, a case of successful management of a patient with Marfans syndrome and truly isolated infrarenal and symptomatic abdominal aortic aneurysm has not been described in the literature before.
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http://dx.doi.org/10.1016/j.avsg.2018.11.019DOI Listing
February 2020

Impact of diabetes mellitus on early outcome of carotid endarterectomy.

Vasa 2019 Mar 7;48(2):148-156. Epub 2018 Sep 7.

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

Background: Diabetes mellitus increases the risk of ischaemic stroke in the general population but its impact on early outcome after the carotid endarterectomy (CEA) is controversial with conflicting results.

Patients And Methods: This prospective study includes 902 consecutive CEAs. Patients were divided into non-diabetic and diabetic groups and subsequently analysed. Early outcomes in terms of 30-day stroke and death rates were then analysed and compared.

Results: There were 606 non-diabetic patients. Among 296 diabetic patients, 83 were insulin-dependent. The cumulative TIA/stroke rate was statistically higher in the diabetic group (2.6 vs. 5.7 %, P = 0.02). Stroke was more frequent in the diabetic group (2.0 vs. 4.4 %, P = 0.04) comparedto TIA (0.7 vs. 1.4 %, P = 0.45). Mortality was statistically more frequent in diabetic patients (0.2 vs. 1.7 %, P = 0.01). The 30-day stroke/death rate (2.6 vs. 5.7 %, P = 0.02) was also statistically higher in the diabetic group. Factors that were identified to increase risk of death and stroke in multivariate analysis were: use of insulin for blood glucose control (OR = 2.47, 95 % CI 1.61-4.68, P = 0.01), higher low-density lipoprotein cholesterol value (OR = 1.52, 95 % CI 1.15-2.22, P < 0.01), presence of coronary disease (OR = 2.04, 95 % CI 1.40-3.31, P = 0.03), peripheral artery disease (OR = 2.14, 95 % CI 1.34-3.65, P = 0.02), complicated plaque (OR = 1.77, 95 % CI 1.11-3.68, P = 0.03), contralateral carotid artery occlusion (OR = 2.37, 95 % CI 1.25-4.74, P = 0.02), shunt use (OR = 3.46, 95 % CI 1.18-7.10, P < 0.01), and among diabetic patients higher HbA1c levels (OR = 1.28, 95 % CI 1.05-1.66, P = 0.03). Clamp toleration was associated with lower risk of death and stroke rates (OR = 0.43, 95 % CI 0.23-0.76, P < 0.01).

Conclusions: In our study, perioperative neurological complications and mortality were statistically higher in diabetic patients compared to non-diabetic patients during CEA. Further research will have to show whether other treatment modalities of carotid artery stenosis and better glycaemia and dyslipidaemia controlling in diabetics can reduce this risk.
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http://dx.doi.org/10.1024/0301-1526/a000737DOI Listing
March 2019

Seat-Belt Abdominal Aortic Injury-Treatment Modalities.

Ann Vasc Surg 2018 Nov 4;53:270.e13-270.e16. Epub 2018 Aug 4.

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

Blunt abdominal aortic injuries are extremely rare, diagnosed in less than 0.05% of all trauma admissions. Aortic injury caused by a seat belt during a car accident is often referred as "seat-belt aorta". We present a case of an 18-year-old woman, restrained back passenger involved in a vehicular collision, sustaining vertebral column and multiple rib fractures, mesenterium and colonic injury, and infrarenal aortic contusion with localized dissection and partial thrombosis.
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http://dx.doi.org/10.1016/j.avsg.2018.05.047DOI Listing
November 2018

Combined Impact of Chronic Kidney Disease and Contrast Induced Acute Kidney Injury on Long-term Outcomes in Patients with Acute Lower Limb Ischaemia.

Eur J Vasc Endovasc Surg 2018 07 7;56(1):78-86. Epub 2018 Apr 7.

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

Introduction: Acute lower limb ischaemia (ALI) is the sudden onset of decreased arterial perfusion with imminent threat to limb viability. Contrast induced acute kidney injury (CI-AKI) is one of the complications that increases mortality in patients who undergo contrast imaging in coronary procedures. The goal of this study is to evaluate the impact of chronic kidney disease (CKD) and CI-AKI on long-term clinical outcomes in patients with ALI undergoing lower limb revascularisation.

Methods: A total 1017 consecutive patients with acute lower limb ischaemia who were admitted between July 1, 2006, and January 1, 2017, were retrospectively reviewed. Patients who had end stage renal disease, those who had end stage heart and malignant disease and died within 7 days of limb revascularisation, and those who did not undergo angiography were excluded. Thus 546 patients were included in the final analysis. Patients were classified as with or without CKD and were then subdivided according to the presence or absence of the development of CI-AKI, defined as an increase in serum creatinine of ≥0.5 mg/dL or by ≥25% from the baseline value within the first 72 h after contrast exposure. The primary end point was all cause mortality and secondary major adverse limb event (MALE).

Results: Both CKD and CI-AKI were associated with the highest rate of all cause mortality (chi square = 55.77, d.f. = 1, p < .01, log rank test) and MALE (chi square = 79.07, d.f. = 1, p < .01, log rank test). The presence of CKD and CI-AKI were significant risk factors associated with long-term all cause mortality (HR = 2.61, p < .01) and MALE (HR = 2.87, p < .01).

Conclusion: In patients with ALI undergoing lower limb revascularisation, both CKD and CI-AKI were significantly associated with poor long-term outcomes compared with either CKD or CI-AKI alone. Further studies are required to assess this association and to confirm the combined effect of CKD and CI-AKI on long-term clinical outcomes.
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http://dx.doi.org/10.1016/j.ejvs.2018.03.008DOI Listing
July 2018

Late Complication after Thoracic Endovascular Aortic Repair: What Is the Role of an Open Surgical Conversion?

Ann Vasc Surg 2018 Feb 8;47:238-246. Epub 2017 Sep 8.

Division of Vascular Surgery, University Hospital of Zurich, Zurich, Switzerland; Faculty of Medicine, University of Zurich, Zurich, Switzerland.

Background: The aim was to evaluate the causes of thoracic endovascular aortic repair (TEVAR) failure and conversion to open surgery (COS) in a vascular center with high-volume open surgery and low-volume TEVAR procedures.

Methods: A total of 8 patients (6 men; mean age, 55.14 years) underwent COS after TEVAR. The indications for COS, intraoperative strategy, and early postoperative and mid-follow-up results were analyzed.

Results: The indications for COS were persistent proximal type I endoleak with progressive aneurysm enlargement in 2 patients, type III endoleak in 1 patient, progressive aneurysm enlargement with no endoleak in 1 patient, stent-graft migration in 2 patients, secondary aortoesophageal fistula in 1 patient, secondary aortoesophageal and aortobronchial fistula in 1 patient, and distal progression of the aneurysmal disease in 2 patients. In all but one patient, thoracic stent grafts were explanted, and replacement with a Dacron graft was performed using left partial cardiopulmonary bypass. In the remaining patients with disconnection of the distal component and unfavorable anatomy, the proximal stent graft was recycled, and the Dacron prosthesis was sewn to it. Patients with secondary aortobronchial and aortoesophageal fistulas required additional bronchial and esophageal repair. The in-hospital mortality rate was 50% (4 patients). Four (50%) patients were followed up between 7 and 24 months (mean, 16.75 months) without mortality.

Conclusions: COS after TEVAR has a high mortality rate, and endovascular techniques should be considered as the first line of treatment. Those procedures should be performed by surgeons experienced in open repair which one might expect to be a challenging problem in the era of endovascular therapy.
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http://dx.doi.org/10.1016/j.avsg.2017.08.034DOI Listing
February 2018

Evaluation of the renal function using serum Cystatin C following open and endovascular aortic aneurysm repair.

Vascular 2018 Apr 23;26(2):132-141. Epub 2017 Aug 23.

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

Objectives Controversies regarding renal function impairment after open and endovascular aortic aneurysm repair still exist. The purpose of this study was to evaluate the renal function following open repair and endovascular aneurysm repair using Cystatin C. Methods This prospective, observational case-control study was conducted in tertiary referral centre over 3 years, starting from 2012. In total, 60 patients operated due to infrarenal AAA either by means of open repair (30 patients) or endovascular aneurysm repair (30 patients) were included in the study. Biochemical markers of renal function (sCr, urea, potassium) were recorded pre-operatively and at these specific time points, immediately after the operation and at discharge, home (third postoperative day, endovascular aneurysm repair group) or from intensive care unit (third postoperative day, open repair group). Multivariate and propensity score adjustments were used to control for the baseline differences between the groups. Results Creatinine levels in serum remained unchanged during the hospital stay in both groups without significant differences at any time point. Cystatin C levels in endovascular aneurysm repair patients significantly increased postoperatively and restored to values comparable to baseline at the discharge (0.865 ± 0.319 vs. *0.962 ± 0.353 vs. 0.921 ± 0.322, * p < 0.001). Cystatin C levels in patients treated with the open surgery was decreasing over time but not statistically significant comparing to Cystatin C values at the admission. However, decrease in Cystatin C serum levels in patients treated with conventional surgery resulted in statistically significant lower values compared to endovascular aneurysm repair patients both postoperatively and at the time of discharge (0.760 ± 0.225 vs. 0.962 ± 0.353, p < 0.05; 0.750 vs. 0.156, p < 0.05). Both multivariate linear regression models and propensity score adjustment confirm that, even after correction for previously observed intergroup differences, type of surgery, i.e. endovascular aneurysm repair is independently associated with the higher levels of Cystatin C both postoperatively and at the discharge. Conclusions Dynamics of Cystatin C levels have been proven as a more vulnerable marker of renal dysfunction. Endovascular aneurysm repair is associated with higher levels of kidney injury markers.
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http://dx.doi.org/10.1177/1708538117717348DOI Listing
April 2018

Morphological and Biomechanical Features in Abdominal Aortic Aneurysm with Long and Short Neck-Case-Control Study in 64 Abdominal Aortic Aneurysms.

Ann Vasc Surg 2017 Nov 28;45:223-230. Epub 2017 Jun 28.

Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia.

Background: Both, open and endovascular, procedures are related to higher complication rate in abdominal aortic aneurysm (AAA) with shorter neck. Previous study showed that long-neck AAA might have lower risk of rupture. Estimation of biomechanical forces in AAA improves rupture risk assessment. The aim of this study was to compare morphological features and biomechanical forces in the short- and long-neck AAA with threshold of 15 mm.

Methods: Digital Imaging and Communication in Medicine images of 64 aneurysms were prospectively collected and analyzed in a case-control study. Using commercially available software, Peak wall Stress (PWS) and Rupture Risk Equivalent Diameter (RRED) were determined. Difference between the maximal aneurysm diameter (MAD) and RRED was calculated and expressed as an absolute and relative (percentage of the MAD) value. In addition, volume of intraluminal thrombus (ILT) was calculated and expressed relative to AAA volume.

Results: Study included 64 AAA divided in group with long (36, 56.25%), and short (28, 43.75%) neck. There was no correlation between neck length and MAD, PWS, and RRED (P = 0.646, P = 0.421, and P = 0.405, respectively). Relative ILT volume was greater in the short-neck aneurysms (P = 0.033). Relative difference between RRED and MAD was -4% and -14.8% in short- and long-neck aneurysms, respectively (P = 0.029). The difference between RRED and MAD was positive in 14/28 patients (50%) with short neck and in 6/35 patients (17.14%) with long neck (P = 0.011).

Conclusions: Based on our biomechanical analysis, in AAA with neck longer than 15 mm rupture risk might be lower than the risk estimated by its diameter. It might be explained with lower relative volume of ILT.
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http://dx.doi.org/10.1016/j.avsg.2017.06.054DOI Listing
November 2017

Open Surgical Treatment of Secondary Aortoesophageal and Aortobronchial Fistula after Thoracic Endovascular Aortic Repair and Esophagocoloplasty in a Second Procedure.

Ann Vasc Surg 2017 Oct 11;44:417.e11-417.e16. Epub 2017 May 11.

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

Aortoesophageal (AEF) and aortobronchial fistula (ABF) after thoracic endovascular aortic repair (TEVAR) are rare complications with catastrophic consequences without treatment. In this case report, we presented a patient with AEF and ABF after TEVAR successfully treated with endograft explantation and replaced by Dacron graft followed by esophagectomy and left principal bronchus repairing. We report a patient with AEF and ABF after TEVAR who was evaluated due to dysphagia and chest pain followed by hematemesis and hemoptysis. Endoscopic examination revealed lesion of the esophageal wall with chronic abscess formation and stent-graft protrusion into the cavity. Patient was operated on with extracorporeal circulation. AEF and ABF were confirmed intraoperatively. Endograft was explanted and in situ reconstruction of thoracic aorta was carried out with tubular Dacron 22-mm prosthesis wrapped with omental flap. After aortic reconstruction, esophageal mucosal stripping was performed with cervical esophagostomy, pyloromyotomy, and Stamm-Kader gastrostomy for nutrition. In addition, omentoplasty of the defect in the left principal bronchus was performed. To re-establish peroral food intake esophagocoloplasty was carried out 8 months after previous surgery utilizing transversosplenic segment of the colon and retrosternal route. In very selective cases, stent-graft explantation and in situ reconstruction with Dacron graft covered by omental flap followed by esophagectomy and bronchus repairing permit adequate debridement reducing the risk of mediastinitis and graft infection and allow a safe esophageal reconstruction in a second procedure.
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http://dx.doi.org/10.1016/j.avsg.2017.01.019DOI Listing
October 2017

Transient Acute Leg Ischemia in a Professional Athlete Caused by Isolated Popliteal Artery Dissection Mimicking Popliteal Entrapment Syndrome.

Ann Vasc Surg 2017 Aug 4;43:316.e15-316.e20. Epub 2017 May 4.

Clinic for vascular and endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia.

Exertional leg pain includes a broad range of conditions induced by different vascular, musculoskeletal, and neurological disorders. We report a case with isolated popliteal artery dissection as a cause of a transient acute lower limb ischemia. We report a patient with popliteal artery dissection which occurred during squatting exercise. After initial signs of transient acute limb ischemia, physical and ultrasound examination pointed to entrampment syndrome as a likely cause. However, digital subtraction angiography showed possible dissection of popliteal artery, which was confirmed intraoperatively. Popliteal artery was resected and reversed saphenous vein bypass was performed. Isolated popliteal artery dissection in professional athletes is a rare entity, which can be manifested with exertional leg pain. Clinical findings can sometimes be similar to those of popliteal entrapment syndrome. Clinical suspicion and timely patient referral to a vascular specialist are crucial for optimal treatment of this limb-threatening condition.
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http://dx.doi.org/10.1016/j.avsg.2017.04.015DOI Listing
August 2017

Treatment of a Patient with Abdominal Aortic Aneurysm and Hepatocellular Carcinoma.

Ann Vasc Surg 2017 Apr 24;40:295.e1-295.e4. Epub 2016 Nov 24.

Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia; Belgrade Medical School, University of Belgrade, Belgrade, Serbia.

Background: The surgical tactics in cases of abdominal aortic aneurysms (AAA) and intra-abdominal malignancy are not uniform in the literature and are still a matter of debate. In this case report, we present a patient with coexisting AAA and primary liver cancer managed by simultaneous open AAA repair and liver resection After laparotomy and intraoperative liver ultrasonography that confirmed resectability of the tumor, aneurysm repair was performed with aorto-aortic tube grafting after interrenal cross-clamping Radiofrequency-assisted liver transection was performed to complete an anterior anatomic resection of liver segments VI and VII. The postoperative course was uneventful and the patient was discharged on a postoperative day 10.

Methods: This was prospective follow up of one patient.

Results: The patient is free from disease at 18-month follow-up.

Conclusions: The best treatment strategy for patients with AAA and malignant disease is still not clearly defined. Strategy selection is made individually according to the risk of rupture of AAA, general condition of the patient, experience of the teams that should perform the procedure and estimated life expectancy after resection of malignant disease.
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http://dx.doi.org/10.1016/j.avsg.2016.07.075DOI Listing
April 2017

Carotid replacement with Dacron graft in 292 patients.

Vascular 2016 Dec 19;24(6):580-589. Epub 2016 Jan 19.

Faculty of Medical, University of Belgrade, Serbia.

Introduction: In case of highly atherosclerotic carotid process, carotid graft replacement might be a potential solution for successful procedure. Many studies evaluated the results of vein and polytetrafluorethilen (PTFE) graft usage at the carotid bifurcation, while the experience on the Dacron graft due to extensive atherosclerotic process is missing. The aim of our study was to evaluate 30-day and long-term results of the Dacron graft on carotid artery used in patients with extensive atherosclerotic disease.

Material And Methods: This retrospective study analysed early and long-term neurological outcome as well as Dacron graft patency in patients operated with carotid reconstruction. Early results were confirmed by follow-up clinical examination, whereas late results were assessed by follow-up clinical examination as well as duplex sonographic examination at least 1 year after the surgery. As for statistical methods we used descriptive analysis tests, Chi-square test, and logistic regression.

Results: Carotid graft replacement was performed in 292 patients, before endarterectomy in 155 (53.09%), or after already attempted unsuccessful eversion endarterectomy in 137 (46.91%). Nineteen (6.5%) patients had a stroke due to ipsilateral and contralateral ischaemia or haemorrhagic in 17 (5.8%), 1 (0.3%) and 1 (0.3%) patients, respectively. Significantly higher rate of strokes occurred when the graft reconstruction was used after the failure of endarterectomy (8.5% vs. 3.5%, p = 0.029). Stroke and death rate was 7.19%. Factors that increased risk of early stroke were the length of plaque in the internal carotid artery measured intraoperatively (p = 0.025) and the surgical tactic to perform graft reconstruction after attempted extensive endarterectomy (p = 0.029).

Conclusion: Low number of patients with carotid stenosis has extensive atherosclerotic process longer than 4 cm that might jeopardise eversion endarterectomy. Carotid graft replacement with Dacron graft provide early results that are comparable with other conduits; however, in such patients reconstruction should be selected individually based on surgical experience and anatomical distribution of stenotic disease. Due to high risk of stroke, only symptomatic patients with such extensive atherosclerotic disease should be operated.
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http://dx.doi.org/10.1177/1708538115627576DOI Listing
December 2016

Open Repair of AAA in a High Volume Center.

World J Surg 2017 Mar;41(3):884-891

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

Objective: To assess results of open repair (OR) of AAA in a single high volume center.

Methods: We analyzed prospectively collected data of 450 patients who underwent elective OR of AAA at the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre in the period between January 2013 and September 2014.

Results: Postoperative death occurred in seven patients (1. 55%) during the first 30 postoperative days. The mortality was caused by: uncontrolled bleeding-1, acute myocardial infarction-1, ischemic colitis-2, MOFS-2, sepsis due to infection and dehiscence of laparotomy wound-1. Coronary artery disease (OR 3.89; CI 0.85-17.7; p = 0.0058), postoperative acute myocardial infarction (OR 29.9; CI 2.56-334.95; p = 0.0053), chronic renal failure (OR 7.5; CI 1.35-8.5; p = 0.0073), colonic necrosis (OR 88.2; CI 4.77-1629.69; p = 0.0026), occlusion of the both hypogastric arteries and the inability to preserve at least one hypogastric artery (OR 17.4; CI 1.99-178.33; p = 0.0230), aortobifemoral reconstruction (OR 9.06; CI 1.76-46.49; p = 0.016), significant perioperative bleeding (>2 L) (OR 7.32; CI 1.31-10.79; p = 0.0001), hostile abdomen (OR 5.25; CI 1.3-21.1; p = 0.0055), inflammatory aneurysm (OR 13.99; CI 2.88-65.09; p = 0.0002), supraceliac aortic cross-clamping (OR 18.7; CI 3.8-90.6; p = 0.0003), prolonged aortic cross-clamping (>60 min) (OR 14.25; CI 2.75-64.5; p = 0.0003), the intraoperative hypotension (OR 6.61; CI 0.71-61.07; p = 0.0545), the prolonged operation (>240 min) (OR 8.66; CI 0.91-81.56; p = 0.0585) and complete dehiscence of the laparotomy (OR 44.1; CI 3.39-572.78; p = 0.0396) increased the 30-day mortality in our study.

Conclusions: Early mortality after open repair of AAA in high volume center might be very low due to experienced multidisciplinary team. Centralized open aortic surgery might be solution for effective treatment of patients with unsuitable anatomy or for young patients with long life expectancy.
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http://dx.doi.org/10.1007/s00268-016-3788-3DOI Listing
March 2017

Treatment strategies for carotid artery aneurysms.

J Cardiovasc Surg (Torino) 2016 Dec 28;57(6):872-880. Epub 2014 May 28.

Faculty of Medicine, University of Belgrade, Belgrade, Serbia -

Background: The aim of this paper was to present single centre experience in the treatment of extra cranial carotid artery aneurysms (ECCA) and to analyze results discussing different treatment modalities.

Methods: The study analyzed 60 patients with 62 ECCA treated surgically at the Clinic for vascular and endovascular surgery, Serbian Clinical Center (Belgrade) in the period between 1985 and 2013. Treatment strategy was individually selected and demographic, morphologic, intraoperative and postoperative data were collected.

Results: Thirty-day operative mortality was 3.3% and completely stroke related. Besides two fatal strokes one additional was registered making total number of 3 (4.8%) postoperative strokes. Only one (1.6%) early graft thrombosis has been found. The 30-day-patency rate was 98.4%. During the same period seven local complications were found: three (4.8%) hemorrhage and four (6.4%) cranial nerves injuries. In all cases of hemorrhage successful re-intervention was performed without any consequences. Cranial nerves injuries included transient contusions of hypoglossal (2) and superior laryngeal nerve (2).

Conclusions: The etiology, location, and morphology of an ECCA are determining selection of appropriate therapy. Large or tortuous aneurysms, as well as aneurysms involving common carotid or proximal internal carotid artery, are also absolutely indicated to open surgical therapy. Aneurysms which involve the distal internal carotid artery and false anastomotic aneurysms are best managed with endovascular techniques. The ligature is indicated for the treatment of external carotid aneurysms, mycotic aneurysms with local infection and in ruptured ECCA with uncontrolled bleeding.
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December 2016

Aortoesophageal and aortobronchial fistula caused by Candida albicans after thoracic endovascular aortic repair.

Vojnosanit Pregl 2016 Sep;73(9):684-7

Introduction: Endovascular stent-graft placement has emerged as a minimally invasive alternative to open surgery for the treatment of aortic aneurysms and dissections. There are few reports of stent graft infections and aortoenteric fistula after endovascular thoracic aortic aneurysm repair, and the first multicentric study (Italian survey) showed the incidence of about 2%.

Case Report: We presented a 69-year-old male patient admitted to our hospital 9 months after thoracic endovascular aortic repair, due to severe chest pain in the left hemithorax and arm refractory to analgesic therapy. Multislice computed tomography (MSCT) showed a collection between the stent graft and the esophagus with thin layers of gas while gastroendoscopy showed visible blood jet 28 cm from incisive teeth. Surgical treatment was performed in collaboration of two teams (esophageal and vascular surgical team). After explantation of the stent graft and in situ reconstruction by using Dacron graft subsequent esophagectomy and graft omentoplasty were made. After almost four weeks patient developed hemoptisia as a sign of aorto bronchial fistula. Treatment with implantation of another aortic cuff of 26 mm was performed. The patient was discharged to the regional center with negative blood culture, normal inflammatory parameters and respiratory function. Three months later the patient suffered deterioration with the severe weight loss and pneumonia caused by Candida albicans and unfortunately died. The survival time from the surgical treatment of aortoesophageal fistula was 4 months

Conclusion: Even if endovascular repair of thoracic aortic diseases improves early results, risk of infection should not be forgotten. Postoperative respiratory deterioration and finally hemoptisia could be the symptoms of another fistula.
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http://dx.doi.org/10.2298/VSP141209074KDOI Listing
September 2016

Secondary venous aneurysm following intravenous drug abuse: A case report.

Vojnosanit Pregl 2016 May;73(5):500-3

Introduction: Venous aneurysm (VA) is a rare condition that can be presented in both superficial and deep venous system. Secondary VAs as well as pseudoaneurysms are usually caused by external spontaneous or iatrogenic trauma. They are often misdiagnosed and inadequately treated. Complications include thrombosis, phlebitis, eventual pulmonary embolism and rupture.

Case Report: We presented a case of secondary VA of the great saphenous vein developed in a young addict following chronic intravenous drug application in the groin region. Aneurysm required urgent surgical treatment due to bleeding complication as it was previously misdiagnosed for hematoma (or abscess) and punctuated by a general surgeon. Complete resection of VA with successful preservation of continuity of the great saphenous vein was performed. Postoperative course was uneventful. Regular venous flow through the great saphenous vein was confirmed on control ultrasound examination.

Conclusion: VAs are uncommon, among them secondary VA being extremely rare. In cases with a significant diameter or threatening complications surgical treatment is recommended.
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http://dx.doi.org/10.2298/vsp140617026mDOI Listing
May 2016

The Rationale for Continuing Open Repair of Ruptured Abdominal Aortic Aneurysm.

Ann Vasc Surg 2016 Oct 6;36:64-73. Epub 2016 Jul 6.

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

Background: Mortality after open repair of ruptured abdominal aortic aneurysms (RAAAs) remains high. The purpose of this study is to present the results of open RAAA treatment observing 2 different 10-year periods in a single high-volume center and to consider the possibilities of result improvement in the future.

Methods: Retrospective analysis of 729 RAAA patients who were treated through 1991-2001 (229 patients, Group A) and 2002-2011 (500 patients, Group B) was performed. Variables significantly associated with mortality were defined and analyzed.

Results: Overall 30-day mortality in Group A was 53.7% (123/229 patients) with intraoperative mortality of 13.5% (31/229 patients), while in Group B it was 37.4% (187/500 patients) with intraoperative mortality of 12.4% (62/500 patients). Overall 30-day mortality was significantly lower in Group B (P = 0.012). There was no difference regarding intraoperative mortality (P = 0.797). Preoperative severe hemodynamic instability (P < 0.01, P < 0.001), cardiac arrest (P < 0.01, P < 0.001), consciousness deterioration (P < 0.05, P < 0.001), renal malfunction (P < 0.01, P < 0.001), and significant anemia (P < 0.01, P < 0.001) were associated with increased mortality in both A and B groups, respectively. Aortic cross-clamping level in Group A was predominantly infrarenal (68%) while in Group B it was mostly supraceliac (53%) (P < 0.001). Cross-clamping time, duration of surgery, and type of aortic reconstruction had no influence on survival in Group B (P > 0.05). Intraoperative hemodynamic instability (P < 0.01, P < 0.001), significant bleeding (P < 0.05, P < 0.01), and low urine output (P < 0.05, P < 0.001) remained parameters that favored lethal outcome in both A and B groups, respectively. Cell saving was used only in Group B. The multivariate logistic regression applied on the complete sample of patients presented several significant predictors of lethal outcome: congestive heart failure on admission (odds ratio [OR] 1.954, 95% confidence interval [CI] 1.103-3.460), intraperitoneal rupture (OR 3.009, 95% CI 1.771-5.423), aortofemoral reconstruction (OR 1.928, 95% CI 1.044-3.563), and total operative time (OR 1.005, 95% CI 1.001-1.010). Postoperative multisystem organ failure (P < 0.01, P < 0.001), respiratory (P < 0.01, P < 0.001) and renal (P < 0.05, P < 0.001) failure, postoperative bleeding (P < 0.05), and cerebrovascular incidents (P < 0.05, P < 0.01) significantly increased mortality in both A and B groups.

Conclusions: Although unselective, aggressive surgical approach in RAAA performed by teams experienced in open repair can improve patient's survival. Short admission/surgery time, supraceliac aortic cross-clamping, and the use of intraoperative cell saving are recommended.
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http://dx.doi.org/10.1016/j.avsg.2016.02.037DOI Listing
October 2016

Simultaneous Endovascular Treatment of Tandem Internal Carotid Lesions: Case Report and Review of Literature.

Vasc Endovascular Surg 2016 Jul 2;50(5):359-62. Epub 2016 Jun 2.

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

The incidence of concomitant extracranial carotid artery stenosis and ipsilateral intracranial carotid aneurysm has been reported to vary between 2.8% and 5%. These complex lesions may present a challenge for treatment decision-making. This case report describes an asymptomatic male patient with severe carotid bifurcation stenosis, coupled with an unruptured supraclinoid internal carotid aneurysm. Both lesions were treated simultaneously. Patient underwent carotid stenting followed by aneurysm coiling in the same setting without any complication.
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http://dx.doi.org/10.1177/1538574416652246DOI Listing
July 2016

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

Med Princ Pract 2016;25(4):385-7. Epub 2016 Mar 2.

Department of Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.

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.
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http://dx.doi.org/10.1159/000445117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588419PMC
August 2017

Vacuum-assisted wound closure in vascular surgery--clinical and cost benefits in a developing country.

Vojnosanit Pregl 2016 Jan;73(1):9-15

Unlabelled: BACKGROUND/AIM. Surgical and chronic wounds in vascular patients might contribute to limb loss and death. Vacuum-assisted closure (VAC)--Kinetic Concepts, Inc. (KCI), has been increasingly used in Western Europe and the U.S.A. clinical practice for 15 years. Advantages of this method are faster wound healing, wound approximation, lower wound related treatment costs and improved quality of life during treatment. Evidence related to the usage of VAC therapy in vascular patients and cost effectiveness of VAC therapy in a developing country are lacking. The aim of this study was to explore results of VAC therapy in vascular surgery comparing to conventional methods and to test cost effects in a developing country like Serbia.

Methods: All patients with wound infection or dehiscence operated at the tertiary vascular university clinic in the period from January 2011-January 2012, were treated with VAC therapy. The primary endpoint was wound closure, while secondary endpoints were hospital stay, the number of weekly dressings, costs of wound care, working time of medical personnel. The patients were divided into groups according to the wound type and location: wound with exposed synthetic vascular implant (25%), laparotomy (13%), foot amputation (29%), major limb amputation (21%), fasciotomy (13%). The results of primary and secondary endpoint were compared with the results of conventional treatment during the previous year.

Results: There was one death (1/42, 2.38%) and one limb loss (1/12, 2.38%) in the VAC group, and 8 deaths (8/38, 21.05%) and 5 (5/38, 13.15%) limb losses in the patients treated with conventional therapy. In the VAC group there was one groin bleeding (1/12, 2.38%), one groin reinfection (1/12, 2.38%) and one resistance to therapy with a consequent limb loss. Costs of hospital stay (p < 0.001) and nursing time (p < 0.001) were reduced with VAC therapy in the group with exposed graft.

Conclusion: VAC therapy is the effective method for care of complicated wounds in vascular surgery. Patients with infection of wound with the exposed synthetic graft significantly benefit form this therapy. Cost effectiveness of VAC therapy is applicable to a developing country scenario, however cautious selection of patients contributes to the effectiveness.
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http://dx.doi.org/10.2298/vsp131222127kDOI Listing
January 2016

Regarding "Recurrent spinal cord ischemia after endovascular stent grafting for chronic traumatic aneurysm of the aortic isthmus".

J Vasc Surg 2016 Feb;63(2):567-8

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

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http://dx.doi.org/10.1016/j.jvs.2015.08.116DOI Listing
February 2016

The role of kinesitherapy and electrotherapeutic procedures in non-operative management of patients with intermittent claudications.

Vascular 2016 Jun 26;24(3):246-53. Epub 2015 Jun 26.

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

Purpose: To examine the effects of physical therapy (kinesitherapy and electrotherapeutic procedures) on the course of peripheral arterial occlusive disease by monitoring the changes in values of claudication distance and ankle-brachial indexes.

Methods: Prospective randomized study included 47 patients with peripheral arterial occlusive disease manifested by intermittent claudications associated with ankle-brachial indexes values ranging from 0.5 to 0.9. Patients from the first group (25 pts) were treated with medicamentous therapy, walking exercises beyond the pain threshold, dynamic low-burden kinesi exercises and electrotherapeutic ageneses (interference therapy, diadynamic therapy, and electromagnetic field), while the second group of patients (22 pts) was treated with "conventional" non-operative treatment - medicamentous therapy and walking exercises. The values of newly established absolute claudication distance and ankle-brachial indexes were measured.

Findings: Significant increase of absolute claudication distance in both groups of patients was registered, independently of therapeutic protocol applied (p < 0.001), as well as the increase in the claudication distance interval in the physical therapy group. There was no significant increase in ankle-brachial indexes values in both groups of patients.

Conclusion: Methods of physical therapy presented valuable supplement in non-operative treatment of peripheral arterial occlusive disease patients, improving their functional ability and thus postponing surgical treatment. However, further investigations including larger number of patients are needed.
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http://dx.doi.org/10.1177/1708538115593651DOI Listing
June 2016

[High rate of native arteriovenous fistulas: how to reach this goal?].

Srp Arh Celok Lek 2015 Mar-Apr;143(3-4):226-9

The types of vascular accesses for hemodialysis (HD) include the native arteriovenous fistula (AVF), arteriovenous graft (AVG) and central venous catheter (CVC). Adequately matured native AVF is the best choice for HD patients and a high percentage of its presence is the goal of every nephrologist and vascular surgeon. This paper analyses the number and type of vascular accesses for HD performed over a 10-year period at the Clinical Center of Serbia, and presents the factors of importance for the creation of such a high number of successful native AVF (over 80%). Such a result is, inter alia, the consequence of the appointment of the Vascular Access Coordinator, whose task was to improve the quality of care of blood vessels in the predialysis period as well as of functional vascular accesses, and to promote the cooperation among different specialists within the field. Vascular access is the "lifeline"for HD patients. Thus, its successful planning, creation and monitoring of vascular access is a continuous process that requires the collaboration and cooperation of the patient, nephrologist, vascular surgeon, radiologist and medical personnel.
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http://dx.doi.org/10.2298/sarh1504226jDOI Listing
October 2015

Female and obese patients might have higher risk from surgical repair of asymptomatic carotid artery stenosis.

Ann Vasc Surg 2015 Aug 22;29(6):1286-92. Epub 2015 May 22.

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

Background: To investigate the results after carotid endarterectomy performed for asymptomatic carotid stenosis (ACS) in a single high-volume center and define the factors that increase perioperative stroke and mortality rate.

Methods: This observational study that analyzes prospectively collected data includes 1,567 patients with ACS operated in the period between 2007 and 2012.

Results: Most patients were male, 1,037 (66.18%), with mean age of 63.6 years. Perioperative death rate was 0.38%. The most frequent causes of death were stroke and myocardial infarction. The total perioperative stroke/transient ischemic attack rate was 2.81%. Logistic regression analysis confirmed that females (P = 0.028) and obese (P = 0.060) patients have higher risk of perioperative stroke after surgical repair of ACS with odds ratio (OR) of 2.008 and 2.342. The early mortality was significantly higher in candidates for coroanary artery bypass grafting (P = 0.018). Stroke and mortality are related to obesity and ischemic heart disease with OR of 2.407 and 2.097, respectively.

Conclusions: According to our results, female and obese patients are prone to stroke after carotid endarterectomy. Further study of the effects of female gender and obesity on surgical outcomes is warranted before medical therapy is considered the preferred treatment for these patients.
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http://dx.doi.org/10.1016/j.avsg.2015.03.032DOI Listing
August 2015

Fluctuations of serum neuron specific enolase and protein S-100B concentrations in relation to the use of shunt during carotid endarterectomy.

PLoS One 2015 10;10(4):e0124067. Epub 2015 Apr 10.

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

Objective: To evaluate the changes in serum neuron specific enolase and protein S-100B, after carotid endarterectomy performed using the conventional technique with routine shunting and patch closure, or eversion technique without the use of shunt.

Materials And Methods: Prospective non-randomized study included 43 patients with severe (>80%) carotid stenosis undergoing carotid endarterectomy in regional anesthesia. Patients were divided into two groups: conventional endarterectomy with routine use of shunt and Dacron patch (csCEA group) and eversion endarterectomy without the use of shunt (eCEA group). Protein S-100B and NSE concentrations were measured from peripheral blood before carotid clamping, after declamping and 24 hours after surgery.

Results: Neurologic examination and brain CT findings on the first postoperative day did not differ from preoperative controls in any patients. In csCEA group, NSE concentrations decreased after declamping (P<0.01), and 24 hours after surgery (P<0.01), while in the eCEA group NSE values slightly increased (P=ns), accounting for a significant difference between groups on the first postoperative day (P=0.006). In both groups S-100B concentrations significantly increased after declamping (P<0.05), returning to near pre-clamp values 24 hours after surgery (P=ns). Sub-group analysis revealed significant decline of serum NSE concentrations in asymptomatic patients shunted during surgery after declamping (P<0.05) and 24 hours after surgery (P<0.01), while no significant changes were noted in non-shunted patients (P=ns). Decrease of NSE serum levels was also found in symptomatic patients operated with the use of shunt on the first postoperative day (P<0.05). Significant increase in NSE serum levels was recorded in non-shunted symptomatic patients 24 hours after surgery (P<0.05).

Conclusion: Variations of NSE concentrations seemed to be influenced by cerebral perfusion alterations, while protein S-100B values were unaffected by shunting strategy. Routine shunting during surgery for symptomatic carotid stenosis may have the potential to prevent postoperative increase of serum NSE levels, a potential marker of brain injury.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0124067PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393266PMC
April 2016

Images in vascular medicine. Graft angulation due to the shortening of a body stature - an (un)predictable late complication of axillobifemoral bypass grafting.

Vasc Med 2014 Dec 9;19(6):508-9. Epub 2014 Sep 9.

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

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http://dx.doi.org/10.1177/1358863X14550853DOI Listing
December 2014

Isolated true aneurysm of the superficial temporal artery: a truly enigmatic lesion.

Vasa 2014 Sep;43(5):380-4

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

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http://dx.doi.org/10.1024/0301-1526/a000379DOI Listing
September 2014
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