Treatment of visceral artery aneurysms: retrospective study of 35 cases.

BACKGROUND: Visceral artery aneurysms (VAA) represent a rare clinical entity with possible life-threatening complications. The presentation, diagnosis and management vary accordingly to the artery involved and the underlying pathology. PATIENTS AND METHODS: During a 25-year period (1980-2005), 35 patients (25 males + 10 females, age range 36-73 years-median 59.2 years) with VAA were treated at two tertiary vascular surgery centers in Belgrade. All data were retrospectively collected from the patient's records. RESULTS: On presentation, 19/35 patients were symptomatic, and 3/35 had ruptured VAA. Surgery was performed in 28 cases; most commonly involved arteries were splenic (11), hepatic (5), celiac trunk (5), superior mesenteric (3), inferior mesenteric (3) and gastroduodenal (1). Fatal rupture occurred in two patients. In 5 patients abdominal aortic aneurysm was associated with VAA, and in 4 patients multiple aneurysms of the involved artery were noted. Successful embolization was performed in 3 patients. Overall, four patients were treated medically. In the surgically treated patients, perioperative mortality and morbidity were 11% (3/28) and 40% (10/25) respectively. Of 25 patients included in the long-term follow up, six died. CONCLUSION: Since VAA have considerable tendency to rupture, an active approach is necessary. Based on our experience, surgical treatment could be recommended for any VAA patient with symptoms. In addition, we believe that the choice of the therapeutic procedure should be made on an individual basis.

Cardiac events after combined surgery for coronary and carotid artery disease.

OBJECTIVE: To evaluate serious cardiac events after combined (either single or two stage) coronary artery surgery (CAS) and carotid endarterectomy (CEA) for concomitant coronary and carotid artery disease. METHODS: We have analyzed our 15 year experience (January 1981-September 1996) with 201 consecutive patients operated on using both approaches. Group A consisted of 48 patients with the single-stage procedure, while in group B (153 patients), two stage procedure was carried out, either as carotid endarterectomy (CEA), followed by coronary artery bypass surgery (CAS) (group B1- 103 patients), or as CAS followed by CEA (group B2- 50 patients). Five patients from B1 group died after the CEA procedure, but were included, despite the fact they never reached the second stage. Left main coronary artery disease was found in 41 patients (20.4%), poor left ventricular function in 49 (24.4%) previous MI in 133 (66.2%), while 136 (67.7%) were in NYHA functional class III or IV. Bilateral carotid involvement was present in 61 patients (30.3%). Unstable angina was more prevalent in groups A and B2 (P < 0.0001). NYHA class III/IV in group A (versus B1, P = 0.001 and versus B2, P = 0.02), low ejection fraction in groups A and B2 (P < 0.0001), bilateral carotid stenosis in group B1 (versus A, P = 0.003 and versus B2, P < 0.0001), and ulcerated plaque in group B1 (P < 0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management. RESULTS: Early mortality for the entire group was 5.5% (11/201) 6.2% in group A, 7.8% in group B1 and 0% in group B2, respectively; (P > 0.05). Serious morbidity occurred in 7.5% of patients (8.3% in group A, 7.8% in group B1 and 6% in group B2, respectively; P > 0.05). Univariate analysis revealed only bilateral carotid stenosis to influence early outcome (P = 0.04). CONCLUSION: Patients with concomitant coronary and carotid artery disease have relatively good immediate operative results, providing all existing lesions are corrected. Despite it did not reach the statistical significance, cardiac events were less frequent in groups A and B2 indicating possible protective effect of prior CAS in patients with concomitant disease.

"Kissing-balloon" technique for abdominal aorta angioplasty. Initial results and long term outcome.

We evaluated results after angioplasty of the distal abdominal aorta using "kissing-balloon" technique. MATERIALS AND METHODS. From 1981 through 1993, 14 patients (12 women and 2 men, average age 52.4 years), underwent balloon angioplasty of the distal segment of the abdominal aorta. In 8 patients stenosis involved one or both iliac arteries as well. In all cases double balloon technique was used. Follow-up was based on clinical, angiographical and duplex scanning examinations. RESULTS. The initial success rate was 85% (12/14). In one case there was residual stenosis of 20% (redilated successfully 1 month later), and in one case there was acute thrombosis of the right iliac artery (successfully relieved surgically). Long-term follow-up (6-143 months) showed good patency of the dilated segment in all patients (including patients that initially failed). At follow-up, all patients were asymptomatic. CONCLUSION. Dilatation of the distal abdominal aorta using "kissing-balloon" technique is a safe and efficient modality of treatment, with acceptable initial and excellent long-term results.

[Hepatobiliary scintigraphy in evaluation of liver transplant function].

The aim of the study is evaluation of hepatocellular function, as well as morphology and patency of the biliary three of the liver transplants by dynamic hepatobiliary scintigraphy. The study was performed in 10 controls and 10 patients after orthotopic transplantation (up to two years). Sixty minutes dynamic acquisition (1 frame/min) was performed with scintillation camera after injection of 360 MBq 99mTc-diethyl- IDA. Hepatobiliary scintigrams were analysed for morphology, and parenchymal and hepatobiliary TA curves were generated and analysed as regard to the time to maximal acitivity (Tmax) and the time to half of maximum acitivity (T1/2). Uptake of the radiopharmaceutical was slightly but not significantly delayed (Tmax=18.5 +/- 2.9 min) in comparison to the controls (Tmax=14.2 +/- 3.4min), while excretion was significantly prolonged (T1/2=59.5 +/- 12.1 min) than physiological (Tmax=34.2 +/- 4.1min). Intrahepatic bile flow was nonsignificantly prolonged (Tmax=31.3 +/- 3.7 min) in comparison to the controls (Tmax=25.7 +/- 3.5 min) while extrahepatic one is high significantly prolonged (T1/2=89.0 +/- 14.3 min) than physiological (T1/2 =45.0 +/- 7.2 min). Biliary phase of hepatobiliary scintigraphy showed increased accumulation of radiopharmaceutical in the left (n=1) or right (n=2) hepatic duct. Radionuclide methods are noninvasive, and apear to be sensitive and valuable for the monitoring of liver transplants.

Effect of blood flow on the fate of venous grafts in the arterial circulation.

The paper deals experimentally with the influence of the blood flow on the long-term fate of venous grafts in the arterial circulation. Based on the results of experiments, and applying the laws of haemodynamics, the paper provides evidence that the blood flow has a decisive influence on the behavior of the implanted vein. Veins with a mean flow of 364.5 ml/min, dilate by 70% while the external diameter of veins with a mean flow of 65.4 ml/min. remain without major changes. This difference in the behaviour is statistically significant at the 1% level. From the results ensues that the vein is suited for reconstructions where a blood flow of 50--200 ml/min. may be expected.

[Contusion injury of the brachial artery]. / Kontuziona povreda brahijalne arterije.

We present a case of a successful repair of brachial artery after blunt trauma, almost five days after the injury. Autovenous graft (great saphenous vein) was used for the repair. The diagnosis was confirmed by angiography, and this method was indisposable in the postoperative course. Precise surgical technique is compulsory in obtaining optimal surgical revascularization.

[Axillo-femoral bypass--an emergency operation]. / Aksilo-femoralni bypass--operacija nuzde.

Our patient with peritonitis, chronical ileus and ileostoma has had the atherosclerotic occlusive changes in aorto-iliac area on both sides. Hypotensive crises must have made hemodynamic conditions worse, permitting thrombosis in the collateral circulation to cause acute ischemia of the right leg. Because of the bad general condition and infection on the anterior abdomen wall, the axillo-femoral bypass has been the only way for the arterial reconstruction and salvation of the leg.

Emergency surgery of acute traumatic arteriovenous fistulas.

The purpose of this report was to analyze the clinical presentation, diagnosis, surgical and non-surgical treatment and the outcome of patients with acute AVFs seen during the last 8years. During 1991-98 we treated 47 patients with traumatic AVFs. Among these patients 11 were classified as 'acute' AVF. All the patients were male and they ranged in age from 17 to 64yr (mean 25yr). The time from injury to admission to our two institutions varied from 4h to 17days. Emergency surgery was performed in unstable patients and in those with an expanding haematoma base on clinical assessment alone. The acute surgery group consisted of stable patients that were operated after angiography examination. A ??? murmur and thrill were present in seven patients, and peripheral pulses were absent in four patients. The main blood vessels were reconstructed using various techniques in eight patients and minor blood vessel were ligated in three patients. Two lower limb amputations had to be performed, both after reconstruction of popliteal AVFs. In the remaining nine patients reconstruction of the axial vessels was successful and no signs of ischemia developed in patients after ligation of minor vessels. No neurological deficit developed in two patients whose AVFs were vaporised in the neck. The average hospital stay was 8. 6days. Emergency surgery is safe in unstable patients with traumatic AVFs. A thrill and murmur are characteristic signs even in the acute setting, but the examiner must be persistent in looking for them whenever there is a suspicion of a blood vessel injury. Angiography is a reliable diagnostic tool in stable patients, but whether it is essential when there is an expanding pulsating hematoma remains debatable.

Single center experience on eversion versus standard carotid endarterectomy: a prospective non-randomized study.

BACKGROUND AND PURPOSE: The prospective studies that have compared the outcomes of eversion and standard longitudinal carotid endarcterectomy (CEA) have been few and small and available data to reach definitive conclusions are still scarce. This prospective, non-randomized study sought to compare eversion and standard CEA for early and late mortality and morbidity and the incidence of late restenosis. METHODS: Between 1992 and 1997, we performed 2806 CEAs in 2469 patients (2124 eversion CEAs in 1859 patients and 682 standard CEAs in 610 patients). All patients underwent preoperative neurological examination and cervical duplex scanning. Patients were followed up by neurological evaluation and duplex scanning at 1 and 6months after CEA, and yearly afterwards. RESULTS: Demographics and neurologic inidications for CEA were similar in both groups. Mean clamping time was shorter in the eversion CEA group (13.5+/-6.1 vs 19.9+/-19.1min, P<0.001). Early (30-day) postoperative mortality due to major stroke was lower after eversion CEA (10/2124 vs 9/682, P=0. 037), as well as total cardiovascular mortality (16/2124 vs 12/682, P=0.038). Early carotid occlusion was more frequent in standard CEA group (12/2124 vs 11/682, P=0.017), as well as total early morbidity (112/2124 vs 53/682, P<0.001). During follow-up (mean 56 months, range 6-92), restenosis rate was lower in the eversion CEA group (0. 5 vs 1.8%, P=0.006). CONCLUSIONS: Our data indicate that eversion CEA as compared to standard CEA technique is associated with lower total cardiovascular perioperative mortality and mortality due to major stroke, shorter clamping time, lower early occlusion rate, and lower late restenosis rate.

[Traumatic arteriovenous fistulas during a period of peace]. / Traumatske arteriovenske fistule u mirnodopskim uslovima.

The aim of the study was to point out the significance of clinical vascular examination and angiography in diagnosis setting, with the presentation of the patients treated for traumatic arteriovenous (AV) fistulas, so as the significance of timely treatment of that specific traumatic entity. In the period 1985-1996 11 patients with traumatic AV fistulas were treated. The most frequent causes of injury were bullet from firearms and blunt injury. The most frequent injury localization was in upper leg (4 cases). The interval from injury till registration and/or treatment of AV fistula was from 10 days to 33 years. Murmur was noticed in nine patients, thrill in eight, and weakened or absent arterial pulsations below the place of injury were observed in five patients. The diagnosis was confirmed by classic or cine-angiography. Major blood vessels were surgically reconstructed by various techniques, and non-major were ligated or percutaneous transluminal embolization was used. It was concluded that the noticing of murmur and thrill above the place of injury pointed out the existence of traumatic AV fistula, and angiography represented reliable diagnostic method and should be used for diagnostic, as well as therapeutic purposes. In the case of major blood vessel injury, surgical reconstruction is the method of choice.

[Partial resection of the spleen in the treatment of benign and traumatic lesions]. / Parcijalna resekcija slezine u lecenju benignih i traumatskih lezija.

It has been thought that the spleen is an organ without important functions, until recently. That is, why splenectomy has been the procedure of choice in a treatment of splenic diseases. Even now, when we know the functional [figure: see text] importance of the spleen, splenectomy is performed frequently, regardless of its complications. The need of spleen functions salvage, favours partial resection of the spleen as competitive in a treatment of its traumatic and benign lesions. Improvement in diagnostic procedures, surgical techniques, transfusiology and postoperative treatment, will promote it as a treatment of choice. The authors of this study have experience with 17 partial resections of the spleen for traumatic, 11 for benign lesions of the spleen, and one ectopic spleen with hypersplenism, without mortality and with insignificant complications.

[Partial resection of the spleen and spleno-renal shunt in the treatment of portal hypertension with splenomegaly and hypersplenism]. / Parcijalna resekcija slezine i spleno-renalni sant u lecenju portne hipertenzije sa splenomegalijom i hipersplenizmom.

Some of serious hepatic diseases with cirrhosis may be complicated by portal hypertension, splenomegaly and hypersplenism. Splenomegaly inhibits regenerative processes of the liver, and also intensifies sequestration of the cellular components of blood up to hypersplenism. Cytopenia caused by hypersplenism is aggravated by negative hepatic influence on bone marrow activity-hemathopoesis, and also by recurrent bleeding from oesophageal varices, and from the other site of gastrointestinal tract. This circle of pathologic conditions may be interrupted only by liver transplantation, until which patients are jeopardized by acute bleeding and chronic anemia. Partial resection of the spleen and splenorenal shunt may correct portal hypertension and hypersplenism, prevent gastrointestinal bleeding, and alleviate hepatic regenerative processes inhibition. In this study, 51 patients with partial resection of the spleen and splenorenal shunt, were analyzed.