Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies.

OBJECTIVE: This study aimed to analyse the influence of different methods of monitoring cerebral perfusion (MCP) on stroke, death, and use of intraluminal shunt during carotid endarterectomy (CEA). METHODS: A systematic review and network meta-analysis was conducted and registered in the PROSPERO registry (CRD42021246360). Medline, Embase, CENTRAL, and Web of Science were searched. Randomised controlled trials (RCTs) and cohort studies with > 50 participants that compared clinical outcomes for different MCP in patients undergoing CEA were included. Papers reporting one or a combination of two of the following MCPs were included in the analysis: awake testing (AT), near infrared spectroscopy (NIRS), electroencephalography (EEG), somatosensory evoked potential (SSEP), motor evoked potential (MEP), transcranial Doppler (TCD), and stump pressure (SP). A random effects network meta-analysis was performed using a binomial likelihood function with a specified logit link for peri-operative stroke or death and shunting as outcomes. Near infrared spectroscopy was excluded due to the lack of studies that could be used for statistical analysis. RESULTS: Of 1 834 publications, 17 studies (15 cohort studies and two RCTs) including 21 538 participants were incorporated in the quantitative analysis. Electroencephalography was used in the largest number of participants (7 429 participants, six studies), while AT was used in the highest number of studies (10 studies). All monitoring modalities had worse outcomes with respect to stroke or death when compared with AT, with ORs ranging between 1.3 (95% credible interval [CrI] 0.2 - 10.9) for SSEP + MEP and 3.1 (CrI 0.3 - 35.0) for patients monitored with a combination of EEG and TCD. However, the wide CrI indicated that there is no statistically significant difference between the monitoring methods. Patients monitored with a combination of EEG and TCD had the lowest odds of being shunted, while SP had the highest odds of being shunted, also with no statistically significant difference. CONCLUSION: There is a lack of high quality data on this topic in the literature. The present study showed no significant difference between monitoring methods investigated in the network meta-analysis.

Recurrent deep venous thrombosis of lower extremities as a result of compression of large horseshoe kidney cysts in double inferior vena cava - Successfully treatment with sclerotherapy.

BACKGROUND: Horseshoe kidney is a well-known congenital anomaly and the most common anomaly of the upper urinary tract. This condition is rarely associated with anomalous inferior vena cava (IVC). Polycystic horseshoe kidney is a very rare occurrence and however IVC anomalies common with polycistic disease are an increasingly recognized risk factor for iliofemoral deep venous thrombosis. METHOD: We present a case of 75-year-old patient with recurrent deep vein thrombosis (DVT) of right leg as a result of compression of large horseshoe kidney cysts in double inferior vena cava. RESULTS: Large renal cyst were successful treated percutaneously punctured for the relief of compression and received injection of acidic solutions of 95% ethanol under ultrasound guidance for prevention against re-accumulation of cyst fluid. CONCLUSION: Percutaneous aspiration with ultrasound guidance with injection of sclerosing solutions as a relatively simple procedure and can be the method of choice for treatment of renal cysts. Also, any recurrent deep vein thrombosis on lower extremity requires additional evaluation in the form of an ultrasound or multidetector computed tomography examination of the abdomen.

Preoperative Anxiety is Associated With Postoperative Complications in Vascular Surgery: A Cross-Sectional Study.

BACKGROUND: Preoperative anxiety is associated with increased morbidity and/or mortality in surgical patients. This study investigated the incidence, predictors, and association of preoperative anxiety with postoperative complications in vascular surgery. METHODS: Consecutive patients undergoing aortic, carotid, and peripheral artery surgery, under general and regional anesthesia, from February until October 2019 were included in a cross-sectional study. Anesthesiologists assessed preoperative anxiety using a validated Serbian version of the Amsterdam Preoperative Anxiety and Information Scale. Patients were divided into groups with low/high anxiety, both anesthesia- and surgery-related. Statistical analysis included multivariate linear logistic regression and point-biserial correlation. RESULTS: Of 402 patients interviewed, 16 were excluded and one patient refused to participate (response rate 99.7%). Out of 385 patients included (age range 39-86 years), 62.3% had previous surgery. High-level anesthesia- and surgery-related anxieties were present in 31.2 and 43.4% of patients, respectively. Independent predictors of high-level anesthesia-related anxiety were having no children (OR = 0.443, 95% CI: 0.239-0.821, p = 0.01), personal bad experiences with anesthesia (OR = 2.294, 95% CI: 1.043-5.045, p = 0.039), and time since diagnosis for ≥ 4 months (OR = 1.634, 95% CI: 1.023-5.983, p = 0.04). The female sex independently predicted high-level surgery-related preoperative anxiety (OR = 2.387, 95% CI: 1.432-3.979, p = 0.001). High-level anesthesia-related anxiety correlated with postoperative mental disorders (rpb = 0.193, p = 0.001) and pulmonary complications (rpb = 0.104, p = 0.042). Postoperative nausea (rpb = 0.111, p = 0.03) and postoperative mental disorders (rpb = 0.160, p = 0.002) correlated with high-level surgery-related preoperative anxiety. CONCLUSIONS: Since preoperative anxiety affects the postoperative course and almost every third patient experiences anxiety preoperatively, routine screening might be recommended in vascular surgery.

Correlation Between Proteolytic Activity and Abdominal Aortic Aneurysm Wall Morphology with Intraluminal Thrombus Volume.

BACKGROUND: The aim of this study was to examine the influence of intraluminal thrombus (ILT) volume on the level of proteolytic activity and the content of abdominal aortic aneurysm (AAA) wall. METHODS: The research was designed as a cross-sectional study at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in the period from April 2017 to February 2018. During this period, a total of 155 patients with asymptomatic AAA underwent open surgical treatment and 50 were included in the study based on inclusion and exclusion criteria. Before surgery, patients included in the study were examined by MRI. During the operation, samples of ILT and AAA wall were taken for biochemical analysis. RESULTS: A statistically significant correlation was found between the volume of the ILT and largest AAA diameter (ρ = 0.56; P < 0.001). The correlation of the ILT volume on the anterior wall and the concentration of MMP-9, MMP-2 and NE/ELA in the wall did not find statistical significance. Also, no statistically significant association was found between the volume of ILT and the concentration of ECM proteins (collagen type 3, elastin, proteoglycan) in the corresponding part of the wall. The association of ILT volume with MDA was also of no statistical significance. There was a positive statistical significance found in correlation of volume of ILT and catalase activity in the wall of AAA (ρ = 0.28, P = 0.049). CONCLUSIONS: The volume of ILT in the aneurysmal sac seemed not to affect the level of proteolytic activity and the content of the aneurysm wall. However, a positive correlation was found between the ILT and the catalase activity. The effect of ILT on the aneurysm wall and its role in the progression of aneurysmal disease should be examined in future studies.

Identification of Risk Factors and Development of Predictive Risk Score Model for Mortality after Open Ruptured Abdominal Aortic Aneurysm Repair.

Background and Objectives: Despite the relatively large number of publications concerning the validation of these models, there is currently no solid evidence that they can be used with absolute precision to predict survival. The goal of this study is to identify preoperative factors that influenced 30-day mortality and to create a predictive model after open ruptured abdominal aortic aneurysm (RAAA) repair. Materials and Methods: This was a retrospective single-center cohort study derived from a prospective collected database, between 1 January 2009 and 2016. Multivariate logistic regression analysis was used to identify all significant predictive factors. Variables that were identified in the multivariate analysis were dichotomized at standard levels, and logistic regression was used for the analysis. To ensure that dichotomized variables were not overly simplistic, the C statistic was evaluated for both dichotomized and continuous models. Results: There were 500 patients with complete medical data included in the analysis during the study period. Of them, 37.6% were older than 74 years, and 83.8% were males. Multivariable logistic regression showed five variables that were predictive of mortality: age > 74 years (OR = 4.01, 95%CI 2.43−6.26), loss of consciousness (OR = 2.21, 95%CI 1.11−4.40), previous myocardial infarction (OR = 2.35, 95%CI 1.19−4.63), development of ventricular arrhythmia (OR = 4.54, 95%CI 1.75−11.78), and DAP < 60 mmHg (OR = 2.32, 95%CI 1.17−4.62). Assigning 1 point for each variable, patients were stratified according to the preoperative RAAA mortality risk score (range 0−5). Patients with 1 point suffered 15.3% mortality and 3 points 68.2% mortality, while all patients with 5 points died. Conclusions: This preoperative RAAA score identified risk factors readily assessed at the bedside and provides an accurate prediction of 30-day mortality after open repair of RAAA.

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

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 (χ2 = 36.60, DF = 1, P < 0.01, log-rank test) and the worst primary graft patency (χ2 = 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.

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

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.

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

Background: 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). Patients and methods: 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. Results: 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. Conclusions: 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.

Early and long-term results of open repair of inflammatory abdominal aortic aneurysms: Comparison with a propensity score-matched cohort.

OBJECTIVE: The aim of our study was to compare early and long-term results of open repair of patients with inflammatory abdominal aortic aneurysm (IAAA) with matched cohort of patients with abdominal aortic aneurysm (AAA). METHODS: This retrospective single-center cohort study used prospectively collected data from an institutional registry from 1786 patients between 2009 and 2015. Patients with IAAA and AAA were matched by propensity score analysis controlling for demographics, baseline comorbidities, and AAA parameters in a 1:2 ratio. Patients were followed for 5 years. RESULTS: There were 76 patients with IAAA and 152 patients with AAA. Patients with IAAA had more common intraoperative lesion of intraabdominal organs (P = .04), longer in-hospital (P = .035) and intensive care (P = .048) stays and a higher in-hospital mortality rate (P = .012). There were four patients (5.26%) with in-hospital lethal outcome in IAAA there were no deaths in the AAA group. During the follow-up, there was no difference in survival (χ2 = 0.07; DF = 1; P = .80) and overall aortic related complications (χ2 = 1.25; DF = 1; P = .26); however, aortic graft infection was more frequent in IAAA group (P = .04). CONCLUSIONS: Open repair of IAAA is challenging and comparing to AAA carries a higher perioperative risk and long-term infection rate, even in high-volume centers. The main causes of complications are intraoperative injury of adjacent organs, bleeding, and coronary events. Patients with AAA in a matched cohort showed equal long-term survival, which should be assessed in bigger registries.

The TAXINOMISIS Project: A multidisciplinary approach for the development of a new risk stratification model for patients with asymptomatic carotid artery stenosis.

INTRODUCTION: Asymptomatic carotid artery stenosis (ACAS) may cause future stroke and therefore patients with ACAS require best medical treatment. Patients at high risk for stroke may opt for additional revascularization (either surgery or stenting) but the future stroke risk should outweigh the risk for peri/post-operative stroke/death. Current risk stratification for patients with ACAS is largely based on outdated randomized-controlled trials that lack the integration of improved medical therapies and risk factor control. Furthermore, recent circulating and imaging biomarkers for stroke have never been included in a risk stratification model. The TAXINOMISIS Project aims to develop a new risk stratification model for cerebrovascular complications in patients with ACAS and this will be tested through a prospective observational multicentre clinical trial performed in six major European vascular surgery centres. METHODS AND ANALYSIS: The risk stratification model will compromise clinical, circulating, plaque and imaging biomarkers. The prospective multicentre observational study will include 300 patients with 50%-99% ACAS. The primary endpoint is the three-year incidence of cerebrovascular complications. Biomarkers will be retrieved from plasma samples, brain MRI, carotid MRA and duplex ultrasound. The TAXINOMISIS Project will serve as a platform for the development of new computer tools that assess plaque progression based on radiology images and a lab-on-chip with genetic variants that could predict medication response in individual patients. CONCLUSION: Results from the TAXINOMISIS study could potentially improve future risk stratification in patients with ACAS to assist personalized evidence-based treatment decision-making.

Primary Aorto-Appendicular Fistula Accompanied by Infected Penetrating Aortic Ulcer - Case Report.

Primary aorto-appendicular fistulas are extremely rare in clinical practice, and there are only 3 such cases reported in the available literature. The aim of this study is to present the case of a 68-year-old female patient with primary aorto-appendicular fistula accompanied by infected penetrating aortic ulcer (PAU). At the time of her hospital admission, the patient did not demonstrate any typical symptoms. Multidetector computed tomography imaging of aorta was performed during an additional preoperative examination and the PAU of the infrarenal aortic segment was detected. Other pathological changes were not found. The intraoperative findings confirmed the presence of the PAU firmly attached to the appendix and surrounding signs of inflammation. Appendectomy and partial resection of the PAU were performed, along with aortic reconstruction, using a Dacron tube graft and right renal artery reattachment. During the postoperative period, there were no complications, and the patient was discharged on the 10th postoperative day. Control medical examination and color duplex ultrasonography were performed 18 months after the surgery and they provided satisfactory results.

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

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.

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

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.

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.

Open Repair of AAA in a High Volume Center.

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.

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

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.

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.

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

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.

Reborn of Internal-External Carotid Artery Transposition as a Repair Method for Shotgun Injury of Neck Zone 2.

A 26-year-old male presented to the emergency center having been shot in the neck. Multislice computed tomography angiography revealed injury of the right internal carotid artery at level of the carotid bifurcation with hematoma and injury of right internal jugular vein. Under general anesthesia, transposition of internal carotid artery to external carotid artery, with ligation of internal jugular vein, was successfully performed. This case emphasizes the value of "old fashion" surgical treatment in modern endovascular age.