Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms.

OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

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

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.

Carotid replacement with Dacron graft in 292 patients.

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.

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center.

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

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

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

Syndactylization as a technique in treatment of infectious limb following aortobifemoral reconstruction.

The infection in vascular surgery is a nightmare of every vascular surgeon. There are numerous ways of treatment but neither one is definitive. We present the case of the patient with infectious limb following aortobifemoral reconstruction treated by partial graft extirpation and with re-implantation of the superficial femoral artery into deep femoral artery.

Technical considerations for transabdominal aortic reconstruction with renal fusion and ectopia: case series.

Aortic diseases associated with renal anomalies can present special challenges during surgery of the abdominal aorta. The aim of this paper is evaluation of morbidity and definition of optimal management according to the clinical histories of 30 patients with horseshoe and ectopic kidneys who underwent surgical procedures on the abdominal aorta over a 20-year period. Twenty-two of them had horseshoe kidney and eight had ectopic kidney. Indications for surgery included aortic aneurysms in 25 patients and aortoiliac occlusive disease in 5. Preoperative diagnostics were performed in all cases by means of computed tomography and angiography (except in the cases with ruptures) associated with duplex ultrasonography. In patients with ectopic kidney a Carrel patch technique was used for the reimplantation of the renal arteries into the body of the bifurcated (four cases) or tubular (four cases) Dacron graft in five (62.5%) cases whereas aortorenal bypass with Dacron graft was obtained in three cases (37.5%). Sixteen patients from the horseshoe kidney group required renal revascularization (reimplantation using Carrel patch in 10 patients and aortorenal bypass using Dacron graft in 6 patients). Two patients, both with ruptured abdominal aortic aneurysms died after the operation. In other cases the average follow up period was 6.2 years (6 months to 17 years). In one case control, angiography after 6 months revealed an occluded left renal artery that was reimplanted by Carrel patch but without repercussions on the renal function. Aortic surgery in patients with renal anomalies can be safely performed without increased mortality.

[Comparative analysis of conventional and eversion carotid endarterectomy--prospective randomized study].

INTRODUCTION: Studies completed in the last decade of the 20th century showed benefits of carotid endarterectomy in the prevention of stroke in patients with a high-grade stenosis of the internal carotid artery. OBJECTIVE: The aim of this prospective, randomized study was the comparison of early and long-term results between the conventional and eversion carotid endarterectomy, and literature review. METHOD: By the method of random choice, 103 patients were operated on using the eversion carotid endarterectomy and 98 patients using the conventional technique. Operative treatment was carried out under general anaesthesia. Following the clammping of the carotid artery, retrograde blood pressure was determined by a direct puncture of the internal carotid artery above the stenotic lesions. In patients with retrograde pressure below 20 mm Hg intraluminal shunting was routinely performed. Early results were estimated (during the first seven postoperative days) based on mortality, central neurological complications (stroke, TIA) and cranial or cervical nerve lesions. Long-term results were estimated (after at least two years) based on long-term survival rate, central neurological complications (stroke,TIA) and the incidence of haemodynamically significant restenosis of the carotid artery treated by endarterectomy. RESULTS: The average time of clamming of the internal carotid artery in the eversion carotid anderectomy group was 5.36 minutes shorter than in the group treated by the conventional technique. Student's t-test showed a statistically highly significant difference in the time needed for clamming of the internal carotid artery between the two groups. The average duration of eversion endarterectomy (82 minutes) was most often 19 minutes shorter than the duration of the conventional endarterectomy (101 minutes). Student's t-test showed a statistically highly significant difference in the average length of surgeries. The distal intimal fixation was more often needed during the conventional carotid endarterectomy (34.7%) compared to eversion endarterectomy (3.9%). Chi 2-test showed a statistically highly significant difference. CONCLUSION: Eversion carotid endarectomy represents a statistically significantly shorter procedure. Distal intimal fixation demanded by this procedure is very rare, clammping of the internal carotid artery is significantly shorter, and it also has a lower rate of the early neurological complications. Based on the results of this study, as well as the opinions of other authors, it can be concluded that the eversion carotid endarterectomy has an advantage over the conventional procedure.We recommend conventional procedure only in cases when retrograde pressure indicates the use of the intraluminal shunting.

[Axillobifemoral bypass grafting]. / Aksilobifemoralni bajpas.

INTRODUCTION: Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons. OBJECTIVE: The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass. METHODS: The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity--in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with latrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluoroethlylene graft was used in three patients. Simultaneously, profundoplastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done. Chi2 test was used for statistical evaluation and life table method was used for verification of late graft patency. RESULTS: The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis--1, MOFS--3, and infarct myocardium--1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was found in one patient. The other complications were--artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in three patients. Life table method has shown that cumulative rate of late graft patency is 80.39% after five years (Graph 1). DISCUSSION: Our results were analyzed and compared with the results of the study on 283 patients who had undergone aortobifemoral bypass (AFF) operation due to the aortoiliac occlusive disease. This study was completed in 1995 (18). The results showed that there was no statistically significant differences between AxFF and AFF group (p > 0.05), considering early mortality rate and late graft patency (Graph 2). The review of mortality and late patency rate after AxFF bypass grafting in a world well known studies has shown the similar results (Table 1). CONCLUSION The authors suggest that axilobifemoral bypass is indicated when there are contraindications or difficulties to perform anatomic reconstruction due to the abdomen condition (infection, adhesion, comorbidity) as well as in high risk patients with low life expectancy.