Publications by authors named "Milos Sladojevic"

27 Publications

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Hybrid repair of aortic arch with zone zero endografting-Case series with review of the literature.

J Card Surg 2021 Jul 15. Epub 2021 Jul 15.

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

Introduction: We present single-institution results of types I and II hybrid procedures for aortic arch disease with 30-day and long-term results and review of the literature.

Materials And Methods: This is a retrospective study of all patients that underwent zone 0 endografting and open bypass from ascending aorta to the arch vessels at our institution between January 2013 and 2020. The following data for the systematic review were extracted from eligible studies: 30-day/in-hospital mortality, stroke rate, spinal cord ischemia (SCI) rate, renal failure requiring dialysis, development of retrograde dissection, early (<30 days) types I and III endoleak, follow-up length, late (>30 days) endoleak, and late (>30 days) mortality.

Results: Twelve patients underwent hybrid aortic arch treatment in our institution. The most common aortic arch pathology was degenerative aortic aneurysm. The rate of retrograde dissection and SCI was 8.33%. Regarding the literature data, a total of 768 patients undergoing types I and II hybrid aortic arch debranching procedure. The pooled rate of 30-day/in-hospital mortality was 10.96% (95% confidence interval [CI], 8.21-14.06), SCI pooled rate was 2.91% (95% CI, 1.76%-4.33%), and retrograde dissection pooled rate was 3.22% (95% CI, 1.99-4.72).

Conclusion: Hybrid arch techniques provide safe alternative to open repair with acceptable short- and midterm results.
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http://dx.doi.org/10.1111/jocs.15811DOI Listing
July 2021

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

Predictors of in-hospital mortality and complications in acute aortic occlusion: a comparative analysis of patients with embolism and in-situ thrombosis.

J Cardiovasc Surg (Torino) 2021 Apr 4;62(2):146-152. Epub 2020 Sep 4.

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

Background: Acute aortic occlusion (AAO) represents potentially fatal acute vascular emergency that requires prompt diagnosis and intervention. Clinical condition of patients with AAO is frequently severely devastated when surgical intervention is questionable. Our objective was to retrospectively review our institutional experience with AAO and assess predictors of intrahospital mortality and morbidity.

Methods: This is a retrospective single-center cohort study with prospectively collected data between January 1, 2005 and January 1, 2018. The total number of 28 consecutive patients with AAO were included in our analysis. Patients with acute aortic thrombosis manifested by bilateral acute limb ischemia were divided in two groups based on potential caues of AAO (embolism or in-situ thrombosis) differentiated according to condition of aortoilical segment.

Results: We identified 28 patients with AAO. All of them underwent either aortobifemoral bypass (N.=20, 71%) or bilateral trans-femoral thrombectomy (N.=8, 29%). The overall in-hospital mortality was 36%. Factors that influenced in-hospital mortality were: paralysis (OR=4.41, 95% CI: 1.88-21.78) and higher lactate values on admission (OR=1.23, 95% CI: 1.09-1.83), postoperative development of severe acute kidney injury (OR=3.08, 95% CI: 1.42-14.66), hemodialysis (OR=10.74, 95% CI: 1.64-109.78) and bowel ischemia (OR=5.19, 95% CI: 1.58-55.63).

Conclusions: Paralysis, higher lactate values, development of acute kidney injury, hemodialysis and bowel ischemia are predictors of worse outcome and may be used for risk stratification of patients with acute aortic occlusion and improve counseling patients and their families about expected postoperative outcomes. Patients with embolism and malignant disease have worse outcome; however, this should be tested in future studies on larger sample.
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http://dx.doi.org/10.23736/S0021-9509.20.11247-3DOI Listing
April 2021

Ruptured Abdominal Aortic Aneurysm in a Patient with Right Pelvic Kidney and Previous Left Nephrectomy.

Eur J Vasc Endovasc Surg 2020 Oct 24;60(4):593. Epub 2020 Jul 24.

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

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http://dx.doi.org/10.1016/j.ejvs.2020.05.044DOI Listing
October 2020

Influence of preoperative statins and aspirin administration on biological and magnetic resonance imaging properties in patients with abdominal aortic aneurysm.

Vasa 2021 Feb 16;50(2):116-124. Epub 2020 Jul 16.

School of Medicine, University of Belgrade, Serbia.

: Main objective of this study was to evaluate the influence of statins and/or acetylsalicylic acid on biochemical characteristics of abdominal aortic aneurysm (AAA) wall and intraluminal thrombus (ILT). : Fifty patients with asymptomatic infrarenal AAA were analyzed using magnetic resonance imaging on T1w sequence. Relative ILT signal intensity (SI) was determined as a ratio between ILT and psoas muscle SI. Samples containing the full ILT thickness and aneurysm wall were harvested from the anterior surface at the level of the maximal diameter. The concentration of enzymes such as matrix metalloproteinase (MMP) 9, MMP2 and neutrophil elastase (NE/ELA) were analyzed in ILT and AAA wall; while collagen type III, elastin and proteoglycan 4 were analyzed in harvested AAA wall. Oxidative stress in the AAA wall was assessed by catalase and malondialdehyde activity in tissue samples. : Relative ILT signal intensity (1.09 ± 0.41 vs 0.89 ± 0.21, p = 0.013) were higher in non-statin than in statin group. Patients who were taking aspirin had lower relative ILT area (0.89 ± 0.19 vs 1.13. ± 0.44, p = 0.016), and lower relative ILT signal intensity (0.85 [0.73-1.07] vs 1.01 [0.84-1.19], p = 0.021) compared to non-aspirin group. There were higher concentrations of elastin in AAA wall among patients taking both of aspirin and statins (1.21 [0.77-3.02] vs 0.78 (0.49-1.05) ng/ml, p = 0.044) than in patients who did not take both of these drugs. : Relative ILT SI was lower in patients taking statin and aspirin. Combination of antiplatelet therapy and statins was associated with higher elastin concentrations in AAA wall.
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http://dx.doi.org/10.1024/0301-1526/a000895DOI Listing
February 2021

Vascular Injuries in Intravenous Drug Addicts-A Single-Center Experience.

Ann Vasc Surg 2020 Aug 23;67:185-191. Epub 2020 Apr 23.

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

Background: Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients.

Methods: A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality.

Results: During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%.

Conclusions: The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss.
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http://dx.doi.org/10.1016/j.avsg.2020.02.041DOI Listing
August 2020

Magnetic resonance imaging assessment of proteolytic enzyme concentrations and biologic properties of intraluminal thrombus in abdominal aortic aneurysms.

J Vasc Surg 2020 09 14;72(3):1025-1034. Epub 2020 Feb 14.

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

Objective: The aim of the study was to determine whether magnetic resonance imaging (MRI) can be used in assessment of biologic activity of intraluminal thrombus (ILT) and proteolytic processes of the abdominal aortic aneurysm wall.

Methods: Using MRI, 50 patients with asymptomatic infrarenal abdominal aortic aneurysm were analyzed at the maximum aneurysm diameter on T1-weighted images in the arterial phase after administration of contrast material. Relative ILT signal intensity (SI) was determined as the ratio between ILT SI and psoas muscle SI. During surgery, the full thickness of the ILT and the adjacent part of the aneurysm wall were harvested at the maximal diameter for biochemical analysis. The concentrations of matrix metalloproteinase 9 and neutrophil elastase (NE/ELA) were analyzed in harvested thrombi, and the concentrations of collagen type III, elastin, and proteoglycans were analyzed in harvested aneurysm walls.

Results: A significant positive correlation was found between the NE/ELA concentration of the ILT and the relative SI (ρ = 0.309; P = .029). Furthermore, a negative correlation was observed between the elastin content of the aneurysm wall and the relative SI (ρ = -0.300; P = .034). No correlations were found between relative SI and concentration of matrix metalloproteinase 9, NE/ELA, collagen type III, or proteoglycan 4 in the aneurysm wall.

Conclusions: These findings indicate a potential novel use of MRI in prediction of thrombus proteolytic enzyme concentrations and the extracellular matrix content of the aneurysm wall, thus providing additional information for the risk of potential aneurysm rupture.
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http://dx.doi.org/10.1016/j.jvs.2019.11.032DOI Listing
September 2020

Late open conversion after endovascular abdominal aortic aneurysm repair: experience of three-high volume centers.

J Cardiovasc Surg (Torino) 2020 04 18;61(2):183-190. Epub 2019 Nov 18.

Unit of Vascular and Endovascular Surgery, San Martino University Hospital IRCCS, University of Genoa, Genoa, Italy.

Background: Accumulated endovascular aneurysm repair (EVAR) procedures will increase number of patients requiring conversion to open repair of abdominal aortic aneurysms (AAA). In most cases, patients undergo late open surgical conversion (LOSC), many months, or years, after initial EVAR. The aim of this study is to analyze results of LOSC after EVAR in elective and urgent setting, including presenting features, surgical techniques, as well as to review the clinical outcomes and their predictors.

Methods: Retrospective review of all consecutive patients undergoing LOSC after EVAR was performed at three distinct, high volume, vascular centers. Patients that required primary conversion within 30 days after EVAR have not been included in this study. Between January 1st 2010 and January 1st 2017 total of 31 consecutive patients were treated. LOSC were performed either in elective or in urgent setting, thus dividing patients in two groups. Primary outcome was 30-day mortality and secondary postoperative complications.

Results: LOSC rate after EVAR was 4.51%. Most common indication for LOSC was type I endoleak (N.=20, 64.51%). All patients that presented with ruptured AAA had some form of endoleak (type I endoleak was present in five from six cases). Most common site for aortic cross-clamping was infrarenal (51.61%). Stent-graft was removed completely in 18 patients (58.06%) and partially in 13 (41.93%). 30-day mortality rate was 16.12% (5 patients) and most common cause of death was myocardial infarction (60%). Following univariate factors were isolated as predictors for 30-day mortality: preoperative coronary artery disease, chronic obstructive pulmonary disease, urgent LOSC, prolonged time until LOSC, ruptured AAA, supraceliac clamp, higher number of red blood cell transfusion, postoperative myocardial infarction, and prolonged intubation (more than 48 hours).

Conclusions: LOSC seems to be safe and effective procedure when preformed in elective manner. On the other side, urgent LOSC after EVAR is associated with very high postoperative mortality and morbidity. Endoleak remains the main indication for open conversion. Further studies are necessary to standardize timing and treatment options for failing EVAR.
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http://dx.doi.org/10.23736/S0021-9509.19.10972-XDOI Listing
April 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

Selection of optimal open repair for popliteal aneurysms.

J Cardiovasc Surg (Torino) 2019 Feb;60(1):148-149

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

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http://dx.doi.org/10.23736/S0021-9509.18.10641-0DOI Listing
February 2019

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

Case report of gross hematuria in the nutcracker syndrome resolved by renocaval reimplantation.

Vojnosanit Pregl 2016 Dec;73(12):1178-80

Introduction: Nutcracker syndrome is defined as a set of signs and symptoms secondary to compression of the left renal vein (LRV) in the acute anatomic angle between the aorta and its superior mesenteric branch.

Case Report: A 38-year old woman with asymptomatic and “idiopathic” gross hematuria came to the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade. Hematuria was documented by cystoscopy and was found to be unilateral, located to the left urethral orifice. The contrast-enhanced multidetector computed tomography (MDCT) scan showed a stenotic LRV due to the extrinsic compression in the angle formed by the ventral aorta and superior mesenteric artery (MSA), with a jet of contrast through the lumen. Considering the negative investigations for more common causes of hematuria, its incapacitating nature, and above mentioned imaging findings suggestive of the nutcracker syndrome, an indication for the open surgical correction of the LRV entrapment was established. The patient underwent reimplantation of the LRV into the more distal inferior vena cava (IVC), to relocate it out of the constrictive aortomesenteric space. Intraoperative findings were notable for blood flow turbulence in the LRV and hypertrophy of its tributaries, which were ligated. We presented the first published case in the Serbian literature on nutcracker syndrome with hematuria resolved by renocaval reimplantation.

Conclusion: This case report demonstrates that renocaval reimplantation, as the open surgery technique, could be the adequate method for resolving gross hematuria in patients with nutcracker syndrome.
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http://dx.doi.org/10.2298/VSP150401132BDOI Listing
December 2016

Effects of atmospheric pressure dynamics on abdominal aortic aneurysm rupture onset.

Vasa 2018 Feb 4;47(2):137-142. Epub 2018 Jan 4.

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

Background: The effect of atmospheric pressure (AP) on the onset of abdominal aorta aneurysm rupture (RAAA) remains an unanswered question. We have investigated the seasonal variation and the effect of AP dynamics on RAAA by analysing the largest series of intraoperatively confirmed RAAA.

Patients And Methods: To realize this study we have performed a retrospective analysis of 546 patients with RAAA, operated within 503 days at the Clinic for vascular and endovascular surgery CCS between 1.1.2003 and 31.12.2012. AP data for Belgrade city were obtained from meteorological yearbooks published by the Republic Hydrometeorological Service of Serbia measured at the hydrometeorological station "Belgrade Observatory". Only patients with a residence within the extended Belgrade region, exposed to the similar AP values, were included in the analysis of the AP effect on RAAA.

Results: RAAA were observed more frequently during winter and autumn months but without significant difference in comparison to other seasons. Months with higher AP values were associated with a higher RAAA rate (p = 0.0008, R2 = 0.665). A similar trend was observed for the monthly AP variability (p = 0.0311, R2 = 0.374). Average AP values did not differ between days with and without RAAA. However, during the three and seven days periods preceding RAAA AP variability parameters were greater and AP was rising.

Conclusions: Although these pressure differences are very small, higher AP values over longer periods of time as well as greater variability are associated with RAAA. The exact mechanism behind this association remains unclear. The postulation that low AP may precipitate RAAA based on the Laplace law should be discarded.
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http://dx.doi.org/10.1024/0301-1526/a000681DOI Listing
February 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

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

Graft replacement as a method in treatment of symptomatic carotid in stent restenosis.

J Cardiovasc Surg (Torino) 2017 Feb;58(1):133-135

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

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http://dx.doi.org/10.23736/S0021-9509.16.09175-XDOI Listing
February 2017

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

Complete Immediate Paraplegia Reversal after Performing Aorto-Lumbar Bypass on the Patient who Underwent Aortoiliac Reconstruction.

Ann Vasc Surg 2016 Aug 26;35:203.e1-3. Epub 2016 May 26.

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

Although both internal iliac arteries were saved during operation, the patient developed paraplegia immediately after aortoiliac reconstruction due to the spinal cord ischemia. We report a successfully treated immediate postoperative paraplegia by performing second operation and creating bypass from the bifurcated Dacron graft to the previously detected nonpaired huge lumbar artery.
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http://dx.doi.org/10.1016/j.avsg.2016.01.028DOI Listing
August 2016

Open Treatment of Blunt Injuries of Supra-Aortic Branches: Case Series.

Ann Vasc Surg 2016 Feb 2;31:205.e5-205.e10. Epub 2015 Dec 2.

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

Background: Blunt injuries of the supra-aortic branches are rare entity, and majority of patients die before arrival at the hospital. Those who arrive alive require complex and fast procedure that requires sternotomy. We report 3 successfully managed cases.

Case Reports: We report 3 patients with injury of supra-aortic branches. One was treated urgently due to longitudinal rupture on the posterior wall of innominate artery after car accident, and another 2 had chronic false aneurysm located at the very orifice of the right subclavian and left common carotid artery. In first and second patient bypass grafting with a hand-made, Y-shaped, 8-mm Dacron graft from the ascending aorta to the right common carotid and proximal right subclavian artery were performed, whereas in last 1 bypass grafting from the ascending aorta to the cervical part of the left common carotid artery was performed. In our facility, there were no possibilities for any endovascular treatment.

Conclusions: When endovascular technology is not available, open surgical repair of blunt injuries of supra-aortic vessels can be performed without complications. No matter to that, endovascular and hybrid procedures should be considered whenever possible.
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http://dx.doi.org/10.1016/j.avsg.2015.07.049DOI Listing
February 2016

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

Popliteal artery injury following traumatic knee joint dislocation in a 14-year-old boy: a case report and review of the literature.

Vojnosanit Pregl 2014 Jan;71(1):87-90

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

Introduction: Posterior knee joint dislocation associated with injury of the popliteal artery in children is an extremely rare condition. Rapid diagnosis and treatment are essential for limb salvage and function.

Case Report: We reported a 14-year-old boy who suffered traumatic displacement of the right knee and contusion of the popliteal artery during motorcycle accident. The diagnosis was confirmed using Doppler and duplex ultrasonography and digital substraction transfemoral arteriography. The urgent surgical procedure was performed using posterior approach to the popliteal artery. During the surgical exploration, rupture of the posterior cruciate ligament associated with thrombosed popliteal artery have been found. The damaged popliteal artery was resected and replaced with autologous saphenous vein graft. The last stage of the procedure was a transosseous femoral fixation of posterior circuate ligament. A 3-year-follow-up after the surgery demonstrated intact arterial perfusion and very good function of the knee with a minimal difference as compared with the contralateral knee.

Conclusion: Combined orthopedic and vascular injuries are very rare in children. They require combined treatment.
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http://dx.doi.org/10.2298/vsp1401087cDOI Listing
January 2014

A deceitful case of spinal cord malperfusion presented as an acute limb ischemia.

Ann Vasc Surg 2014 Jul 16;28(5):1318.e11-2. Epub 2014 Jan 16.

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

We present an interesting case of a patient with spinal cord ischemia presented with physical and angiographic findings of acute right leg ischemia 6 days after abdominal aortic aneurysm open repair. After unsuccessful transpopliteal thrombectomy, patient was treated with spinal cord drainage. Cause of this complication might be ischemic lumbal plexopathy.
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http://dx.doi.org/10.1016/j.avsg.2013.11.010DOI Listing
July 2014

Long-term graft occlusion in aortobifemoral position.

Vojnosanit Pregl 2013 Aug;70(8):740-6

Clinic for Special Surgical Skills, Clinical Center Banja Luka, Banja Luka, Bosnia and Herzegovina.

Background/aim: Aortobifemoral (AFF) bypass is still the most common surgical procedure used in treatment of aortoiliac occlusive disease. One of the most common complications of AFF bypass procedure is long-term graft oclussion. The aim of this study was to determine the cause of long-term graft occlusion in AFF position, as well as the results of early treatment of this complication.

Methods: This retrospective study, performed at the Clinic of Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade, involved 100 patients treated for long-term occlusion of bifurcated Dacron graft which was ensued at least one year after the primary surgical pro cedure.

Results: The most common cause of the long-term graft occlusion was the process at the level of distal anastomosis or below it (Z = 3.8, p = 0.0001). End-to-end type of proximal anastomosis has been associated with a significantly increased rate of long-term graft occlusion (Z = 2.2, p = 0.0278). Five different procedures were used for the treatment of long-term graft occlusion: thrombectomy and distal anastomosis patch plasty (46% of the cases); thrombectomy and elongation (26% of the cases); thrombectomy and femoropopliteal bypass (24% of the cases); crossover bypass (2% of the cases) and a new AFF bypass (2% of the cases). The primary early graft patency was 87%. All 13 early occlusions occurred after the thrombectomy associated with patch plasty of distal anastomosis. Thrombectomy with distal anastomosis patch plasty showed a statistically highest percentage of failures in comparison to thrombectomy with graft elongation, or thrombectomy with femoro-popliteal bypass (Z = 2 984, p = 0.0028). Redo procedures were performed in all the cases of early occlusions. In a 30-day follow-up period after the secondary surgery, 90 (90%) patients had their limbs saved, and above knee amputation was made in 10 (10%) patients.

Conclusion: Long-term AFF bypass patency can be obtained by proximal end-to-end anastomosis on the juxtarenal part of aorta and distal anastomosis on the bifurcation of the common femoral, or on the deep femoral artery.
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http://dx.doi.org/10.2298/vsp110404002vDOI Listing
August 2013

Vascular graft thrombosis secondary to activated protein C resistance: a case report and literature review.

Vascular 2014 Feb 13;22(1):71-6. Epub 2013 May 13.

Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, 11000 Belgrade, Serbia.

Hypercoagulability is a well-documented and prominent risk factor for venous thromboembolism. The role of thrombophilia in arterial thrombotic events is less well defined. A 52-year-old male patient with multiple atherogenic risk factors was admitted for non-healing pedal ulcer and absent distal pulses. Based on the clinical presentation, Doppler ultrasound and angiography findings, the patient underwent elective in situ bypass arterial reconstruction. The saphenous vein graft was of satisfactory quality and the procedure went routinely. Acute graft thrombosis on postoperative day 0 was recognized immediately and prompted an emergent surgical revision. No technical errors or anatomical/mechanical causes for failed reconstruction were found and the graft was successfully thrombectomized using a Fogarty balloon-catheter. Graft rethrombosis, however, ensued after several hours. Considering the absence of threatening limb ischemia and the idiopathic recurrent thrombosis, raising suspicion of prothrombotic state, conservative treatment was pursued. Postoperative thrombophilia testing proved positive for activated protein C resistance, mandating introduction of chronic oral anticoagulation. Six months later, the operated extremity is viable. Inexplicable vascular graft thrombosis, particularly if early and recurrent, should raise suspicion of underlying thrombophilia. If confirmed by laboratory testing, long-term secondary antithrombotic prophylaxis may be required.
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http://dx.doi.org/10.1177/1708538113478414DOI Listing
February 2014
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