Endovascular treatment of thoracic aortic diseases.

BACKGROUND/AIM: Endovascular treatment of thoracic aortic diseases is an adequate alternative to open surgery. This method was firstly performed in Serbia in 2004, while routine usage started in 2007. Aim of this study was to analyse initial experience in endovacular treatment of thoracic aortic diseses of three main vascular hospitals in Belgrade - Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia, Clinic for Vascular Surgery of the Military Medical Academy, and Clinic for Vascular Surgery of the Institute for Cardiovascular Diseases "Dedinje". METHODS: Between March 2004. and November 2010. 41 patients were treated in these three hospitals due to different diseases of the thoracic aorta. A total of 21 patients had degenerative atherosclerotic aneurysm, 6 patients had penetrating aortic ulcer, 6 had posttraumatic aneurysm, 4 patients had ruptured thoracic aortic aneurysm, 1 had false anastomotic aneurysm after open repair, and 3 patients had dissected thoracic aneurysm of the thoracoabdominal aorta. In 15 cases the endovascular procedure was performed as a part of the hybrid procedure, after carotid-subclavian bypass in 4 patients and subclavian artery transposition in 1 patient due to the short aneurysmatic neck; in 2 patients iliac conduit was used due to hypoplastic or stenotic iliac artery; in 5 patients previous reconstruction of abdominal aorta was performed; in 1 patient complete debranching of the aortic arch, and in 2 patients visceral abdominal debranching were performed. RESULTS: The intrahospital mortality rate (30 days) was 7.26% (3 patients with ruptured thoracic aneurysms died). Endoleak type II in the first control exam was revealed in 3 patients (7.26%). The patients were followed up in a period of 1-72 months, on average 29 months. The most devastating complication during a followup period was aortoesofageal fistula in 1 patient a year after the treatment of posttraumatic aneurysm. Conversion was performed with explantation of stent-graft and open aortic in situ recontruction, followed by esophagectomy and the creation of cervical and gastrical stoma. CONCLUSION: Having in mind initial results of the 3 main vascular clinics in Belgrade, Serbia, economical situation in our country, as well as the published international results, endovascular treatment of thoracic aortic diseases is indicated in hemodinamicaly unstable patients with acute traumatic aneurysm, or in stabile patients older than 65, as well as in case of chronic diseases of the thoracic aorta in patients with significant comorbid conditions or in patients older than 65 years. Endovascular procedures on the thoracic aorta could be performed, hower, only in high-volume centers with experience in routine open surgery of thoracic aorta.

[Intrathrombus embolization of giant mesenteric inferior artery to prevent type II endoleak].

INTRODUCTION: One of the most common complications of endovascular repair of abdominal aortic aneurysm is type II endoleak - retrograde branch flow. CASE REPORT: A 76-year-old man with abdominal aortic aneurysm, 7.1 cm in diameter and aneurysm of the right common iliac artery, 3.2 cm in diameter was admitted to our Department with abdominal pain. The patient had no chance of having open repair of abdominal aortic aneurysm because of high perioperative risk (cardiac ejection fraction of 23%, chronic pulmonary obstructive disease). Multislice computed angiography also revealed a large inferior mesenteric artery, 6mm in diameter with the origin in thrombus of aneurysm. We decided to repair abdominal aortic aneurysm with GORE EXCLUDER stent-graft with crossed right hypogastric, but first we decided to embolize the inferior mesenteric artery. Angiography was performed through the right femoral approach and the good Riolan arcade was found. After that the inferior mesenteric artery was embolized with two coils, 5 mm in diameter, at the origin of artery in aneurysm thrombus. At the end of procedure, abdominal aortic aneurysm was repaired with GORE stent-graft, and the control angiography was performed. There was no endoleak, and the Riolan arcade was very good. The patient was discharged after 5 days. There were no signs of ischemia of the left colon, and peristaltic was excellent. Control multislice computed angiography was done after 1 and 3 months. There were no signs of endoleak. On the control colonoscopy there were no signs of ischemia of the colon. CONCLUSION: Endovascular repair of symptomatic abdominal aortic aneurysm in high risk patients with preoperative embolization of large branch is the best choice to prevent rupture of abdominal aortic aneurysm and to prevent type II endoleak.

[Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm].

INTRODUCTION: According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. CASE REPORT: We presented a 75-years-old man, with elective visceral hybrid reconstruc tion of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patient's vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. CONCLUSION: Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemic-reperfusion injury of the body is reduced to a minimum.

Inverse production of IL-6 and IL-10 by abdominal aortic aneurysm explant tissues in culture.

BACKGROUND: Abdominal aortic aneurysm is considered an atherosclerosis-related disease, but the mechanisms underlying abdominal aortic aneurysm remain poorly defined. Despite the large number of cytokines identified in an aneurysm sample, the relative importance of particular cytokines in aneurysm formation is unknown. We have studied the production of interleukin-6 and interleukin-10 cytokines in plasma and cultures of abdominal aortic aneurysm explant samples obtained from patients subjected to elective surgery and their correlation with cellular composition. MATERIALS AND METHODS: Inflammatory cells from the abdominal aortic aneurysm samples were phenotypically characterized using specific monoclonal antibodies (anti-CD3, -CD4, -CD8, -CD19, -CD38, -CD68, -HLA-DR) by means of immunocytochemistry staining. Production of interleukin-6 and interleukin-10 in culture supernatants of abdominal aortic aneurysm explant samples expanded in vitro for 24 h was measured by enzyme-linked immunosorbent assay. RESULTS: We showed that the levels of interleukin-6 and interleukin-10 in supernatants of abdominal aortic aneurysm sample cultures were higher by 73 and 86 times compared to their levels in plasma, respectively. In individual abdominal aortic aneurysm explant cultures, a negative correlation between interleukin-6 and interleukin-10 production was observed. Such inverse correlation was not detected in plasma. Based on these results, we divided abdominal aortic aneurysm into two cytokine-producing groups and showed that the interleukin-6(hi)/interleukin-10(lo) group contained higher percentages of granulocytes, HLA-DR(+), and CD68(+) cells but lower percentages of lymphocytes and plasma cells compared to the interleukin-6(lo)/interleukin-10(hi) group. Exogenously added interleukin-10 suppresses the production of interleukin-6 by abdominal aortic aneurysm explants. CONCLUSION: These results suggest that interleukin-6 and interleukin-10 may have a different role in the pathogenesis of abdominal aortic aneurysm.

[Elective reconstruction of thoracoabdominal aortic aneurysm type IV by transabdominal approach].

INTRODUCTION: Thoracoabdominal aortic aneurysm (TAAA) type IV represents an aortic dilatation from the level of the diaphragmatic hiatus to the iliac arteries branches, including visceral branches of the aorta. In the traditional procedure of TAAA type IV repair, the body is opened using thoractomy and laparotomy in order to provide adequate exposure of the descending thoracic and abdominal aorta for safe aortic reconstruction. CASE REPORT: We reported a 71-year-old man with elective reconstruction of the TAAA type IV performed by transabdominal approach. Computed tomography scans angiography revealed a TAAA type IV with diameter of 62 mm in the region of celiac trunk andsuperior mesenteric artery branching, and the largest diameter of 75 mm in the infrarenal aortic level. The patient comorbidity included a chronic obstructive pulmonary disease and hypertension, therefore he was treated for a prolonged period. In preparation for the planned aortic reconstruction asymptomatic carotid disease (occlusion of the left internal carotid artery and subtotal stenosis of the right internal carotid artery) was diagnosed. Within the same intervention percutaneous transluminal angioplasty with stent placement in right internal carotid artery was made. In general, under endotracheal anesthesia and epidural analgesia, with transabdominal approach performed aortic reconstruction with tubular dakron graft 24 mm were, and reimplantation of visceral aortic branches into the graft performed. Postoperative course was uneventful, and the patient was discharged on the postoperative day 17. Control computed tomography scan angiography performed three months after the operation showed vascular state of the patient to be in order. CONCLUSION: Complete transabdominal approach to TAAA type IV represents an appropriate substitute for thoracoabdominal approach, without compromising safety of the patient. This approach is less traumatic, especially in patients with impaired pulmonary function, because there is no thoracotomy and any complications that could follow this approach.

[Early inflammatory response following elective abdominal aortic aneurysm repair: a comparison between endovascular procedure and conventional, open surgery].

BACKGROUND/AIM: Abdominal aorta aneurysm (AAA) represents a pathological enlargment of infrarenal portion of aorta for over 50% of its lumen. The only treatment of AAA is a surgical reconstruction of the affected segment. Until the late XX century, surgical reconstruction implied explicit, open repair (OR) of AAA, which was accompanied by a significant morbidity and mortality of the treated patients. Development of endovascular repair of (EVAR) AAA, especially in the last decade, offered another possibility of surgical reconstruction of AAA. The preliminary results of world studies show that complications of such a procedure, as well as morbidity and mortality of patients, are significantly lower than with OR of AAA. The aim of this paper was to present results of comparative clinical prospective study of early inflammatory response after reconstruction of AAA be tween endovascular and open, conventional surgical technique. METHODS: A comparative clinical prospective study included 39 patients, electively operated on for AAA within the period of December 2008 - February 2010, divided into two groups. The group I counted 21 (54%) of the patients, 58-87 years old (mean 74.3 years), who had been submited to EVAR by the use of excluder stent graft. The group II consisted of 18 (46%) of the patients, 49-82 (mean 66.8) years, operated on using OR technique. All of the treated patients in both groups had AAA larger than 50 mm. The study did not include patients who have been treated as urgent cases, due to the rupture or with simptomatic AAA. Clinical, biochemical and inflamatory parameters in early postoperative period were analyzed, in direct postoperative course (number of leucocytes, thrombocytes, serum circulating levels of cytokine--interleukine (IL)-2, IL-4, IL-6 and IL-10). Parameters were monitored on the zero, first, second, third and seventh postoperative days. The study was approved by the Ethics Commitee of the Military Medical Academy. RESULTS: The study showed a statistically significantly shorter time of treatment in the EVAR group (average 90 min) compared to the OR group (average 136 min). Also, there was a statistically significantly less blood loss in the patients operated on by the use of EVAR surgery (average 60 mL) as compared to the patients treated with OR techinique (average 495 mL), as well as a shorter postoperative hospitalization of patients in the EVAR group (average 4 days) compared to the OR group (average 8 days). The OR group was detected with a statistically significant increase of leucocytes and statistically significant fall of the number of thrombocytes in comparison with the EVAR group in all the investigated terms. A significant concentration rise of IL-2 in the OR group and concentration rise of IL-6 in the EVAR group was shown 24 hours after the procedure, whereas on the second postoperative day there was detected a significant fall of IL-6 in the EVAR group. IL-4 concentration in the OR group was significantly higher as of the third postoperative day in comparison to the EVAR group. There was no significant difference in IL-10 concentration between the groups. CONCLUSION: The EVAR techinique is a safer and less invasive and less traumatic procedure for patients than the OR of AAA. Following the EVAR, there are less inflammatory reactions in the early postoperative period as compared to the OR and therefore less possibility of the development of systemic inflammatory respons syndrome in patients treated.

Epidemiology of nosocomial colonization/infection caused by Acinetobacter spp. in patients of six surgical clinics in war and peacetime.

BACKGROUND/AIM: Acinetobacter spp. has emerged as nosocomial pathogen during the past few decades in hospitals all over the world, but it has increasingly been implicated as a serious nosocomial pathogen in military hospitals. The aim of this study was to analyse and compare the surveillance data on Acinetobacter nosocomial colonization/infection (NCI) collected during the wartime with the data collected in peacetime. METHODS: We conducted a prospective study of incidence of Acinetobacter spp. colonization/infection. Also, the two nested case-control studies were conducted. The patients with nosocomial infection (cases) were compared with those with nosocomial colonization (controls) during the two different periods, wartime and peacetime. The patients with NCI by Acinetobacter spp. were identified by the case-based surveillance. The surveillance covered all the patients in 6 surgical clinics. RESULTS: During the study periods a total of 166 patients had cultures that grew Acinetobacter spp. and the pooled rates of Acinetobacter spp. colonization and infection were significantly higher in wartime. When patients with NCI in wartime were compared with those with NCI in peacetime significant differences were observed. In the war year, the patients were more significantly males (p < 0.000). In a period of peace, most of the colonization/infections were reported from patients with certain chronic diseases (p = 0.020) and the survival of patients was more significant (p = 0.049). During the peacetime, proportions of Acinetobacter isolates resistent to ciprofloksacin, imipenem and meropenem were significantly higher (p < 0.001). CONCLUSION: This study provides additional important information about the risk factors of nosocomial Acinetobacter spp. infections in a large cohort of surgical patients. This is also the first study that directly examines epidemiological differences between NCI caused by Acinetobacter spp. during the war and peace period.

Endovascular repair of posttraumatic multiple femoral-femoral and popliteal-popliteal arteriovenous fistula with Viabahn and excluder stent graft.

BACKGROUND: Traumatic arteriovenous (AV) fistula is considered to be a pathologic communication between the arterial and venous systems following injury caused mostly by firearms, sharp objects or blasting agents. Almost 50% of all traumatic AV fistulas are localized in the extremities. In making diagnosis, besides injury anamnesis data, clinical image is dominated by palpable thrill and auscultator continual sounds at the site of fistula, extremities edemas, ischemia distally of fistula, pronounced varicose syndrome, and any signs of the right heart load in high-flow fistulas. CASE REPORT: We presented a male 32-year-old patient self-injured the region of the right lower and upper leg by shotgun during hunting in 2005. The same day the patient was operated on in a tertiary traumatology health care institution under the diagnosis of vulnus sclopetarium femoris et cruris dex; AV fistula reg popliteae dex; fractura cruris dex. The performed surgery was ligatura AV fistulae; reconstructio a. popliteae cum T-T anastomosis; fasciotomia cruris dex. Postoperatively, in the patient developed a multiple AV fistula of the femoral and popliteal artery and neighboring veins. The patient was two more times operated on for closing the fistula but with no success. Three years later the patient was referred to the Clinic for Vascular Surgery, Military Medical Academy, Belgrade, Serbia. A physical examination on admission showed the right upper leg edema, pronounced varicosities and high thrill, signs of the skin induration and initial ischemia with ulceration in the right lower leg, as well as numerous scars in the inner side of the leg from the previously performed operations. Due to the right heart load there were also present easy getting tired, tachypnoea and tachycardia. CT and contrast angiography verified the presence of multiple traumatic AV fistulas in the surface femoral and popliteal artery and neighboring veins of the highest diameter being 1 cm. Also, numerous metallic balls--grains of shotgun were present. After the preoperative preparation under local infiltrative anesthesia, transfemoral endovascular reconstruction was done of the surface femoral and popliteal artery by the use of stent grafts Viabahn 6 x 50 mm and excluder PXL 161 007. Within the immediate postoperative course a significant reduction of the leg edema and disappearance of thrill occurred, and, latter, healing of ulceration, and disappearance of signs of the foot ischemia. Also, patient's both cardiac and breathing functions became normal. CONCLUSION: In patients with chronic traumatic AV fistulas in the femoropopliteal region, especially with multiple fistulas, the gold standard is their endovascular recon struction which, although being minimally traumatic and invasive, offers a complete reconstruction besides keeping integrity of both distal and proximal circulation in the leg.

[The influence of sepsis as a complication after trauma on immune response to injury].

INTRODUCTION: Mortality rate in trauma complicated with sepsis is exceeding 50%. Outcome is not determined only by infection or trauma, but also by the intensity of immuno-inflammatory response. OBJECTIVE: The aim of this study was to determine the influence of sepsis on the immuno-inflammatory response, in the group of 35 traumatized men, of which in 25 cases trauma was complicated with sepsis. METHODS: Cytokines were measured by ELISA test in plasma. Blood samples were drown on the first, third and fifth day after ICU admission. RESULTS: Proinflammatory cytokine IL-8 was 230-fold higher in trauma + sepsis group (1148.48 vs. 5.05 pg/ml; p < 0.01), and antiinflammatory cytokine IL-ra was 4-fold higher (1138.3 vs. 310.05 pg/ml; p < 0.01), whereas IL-12 and IL-4 showed no significant difference between the groups. CONCLUSION: We concluded that sepsis, as a complication after trauma, drastically enhances immuno-inflammatory response to insult, as indicated by IL-8 and IL-ra, but not IL-12 and IL-4.

[Morbidity and mortality in the early postoperative course following elective reconstruction of abdominal aorta aneurysm using endovascular and open surgical techniques].

BACKGROUND/AIM: Surgical treatment is the only method of abdominal aorta aneurysm (AAA) treatment. According to data of the available literature, elective open, i.e., conservative, reconstruction (OR) is followed by 3%-5% mortality, as well as by numerous comorbide conditions inside the early postoperative course (the first 30 days after the surgery) that occur in 20%-30% of the operated on. The aim of the study was to present preliminar results of a comparative clinical retrospective study of early postoperative morbidity and mortality in AAA reconstruction using endovascular (EVAR) and open surgical techniques. METHOD: This comparative clinical retrospective study included 59 patients, electively operated on for AAA within the period January 2008-March 2009, divided into two groups. The group I counted 29 (49%) of the patients who had been submitted to EVAR by the use of Excluder stent. The group II consisted of 30 (51%) of the patients operated on using OR. All of the patients were males, 50-87 years old (mean 67.6 year in the group I, and 54-86 years (mean 68.3 years) in the group II. All tha patients had AAA larger than 50 mm, in the group I 50-105 mm (mean 68 mm), and in the group II 50-84 mm (mean 65 mm). Preoperative comorbide conditions of any patients were similar (coronary disease, obstructive lung disease, chronical renal insufficiency). Patients operated on as emergency cases due to rupture or due to symptomatic aneurysm (threthening rupture) were excluded. The analysed parameters were the duration of surgical operation, intraoperative and operative blood substitution, postoperative morbidity, the duration of postoperative hospitalization, and hospital mortality. RESULTS: The obtained results showed a statistically significantly shorter time taken by EVAR surgery (average 95 min, ranging 70-180 min) as compared to OR surgery (average 167 min, ranging 90-300 min). They also showed statistically significantly less blood loss in the patients operated on by the use of EVAR surgery (average blood compensation 130 mL, ranging 0-1050 mL) as compared to OR surgery (average blood compensation 570 mL, ranging 0-2.000 mL). Also, general complications as wound infection, no restoration of intestines peristalsis, febrility, proteinic and electolytic disbalance, lung and heart decompensation were statistically significantly less following EVAR than OR surgery. Postoperative hospitalization was also statistically significantly shorter after EVAR than after OR surgery (average 4.2 days, ranging 3-7 days; 10.6 days, ranging 8-35 days, respectively). Finally, within this 13-month study there was no mortality following EVAR surgery, while two patients died after OR surgery. CONCLUSION: In the patients with elective AAA reconstruction endovascular reconstruction is shown to be far more safer and minimally invasive procedure than open conventional aorta reconstruction.

Surgical site infections in a tertiary health care center: prospective cohort study.

PURPOSE: To investigate the incidence and risk factors associated with the development of surgical site infections (SSIs) using the National Nosocomial Infection Surveillance (NNIS). METHODS: A prospective cohort study was conducted at a tertiary health care center. Infection control personnel collected general and health care related data about patients. The NNIS risk index was calculated on the basis of data relating to the operation: wound contamination class, duration of surgery, and the American Society of Anesthesiologists (ASA) score. RESULTS: A total of 5109 surgical procedures were included in the study. The overall cumulative incidence rate was 6.3%. The incidence of SSIs was 2.3% (63.5% of operative procedures), 8.3% (29.7%), 34.6% (6.2%), and 43.3% (0.6%), in patients with 0, 1, 2, and 3 risk index, respectively. The length of hospital stay (OR: 1.0; 95% CI: 1.053-1.075), preoperative length of stay (odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.953-1.981), antibiotic prophylaxis (OR: 2.5; 95% CI: 1.421-4.628), drainage (OR: 1.7; 95% CI: 1.360-2.353), ASA score (OR: 1.5; 95% CI: 1.235-1.946), class of wound contamination (OR: 2.0; 95% CI: 1.745-2.003), and NNIS risk index (OR: 1.3; 95% CI: 1.063-1.7) were independently associated with an increased risk for SSIs. Staphylococcus aureus was the most frequently isolated microorganism, 64% of them being methicillin-resistant. CONCLUSION: The aim of this study was to investigate the most important risk factors associated with the development of surgical site infections (SSIs). Therefore, greater attention has been given to adherence to recommendations for the prevention and control of SSIs as well as to antibiotic prophylaxis protocols.

The use of original ex vivo immunoadsorption and "multi-manner" apheresis in ABO/H-mismatched kidney transplants--A phase II clinical study.

Anti-A/B depletion efficacy and clinical outcome for 22 ABO-incompatible kidney transplants were investigated. Preconditioning by anti-CD20 therapeutic plasma exchange (TPE) by Cobe-Spectra (CaridianBCT USA) and simplified extracorporeal immunoadsorption (ECIA) as well as triple immunosuppression (tacrolimus/mycophenolate-mofetil/steroid) were performed. The use of TPE with ECIA resulted in a high in vivo anti-A/B depletion, 94.23±4.2% for IgG and 95.26±3.2% for IgM. The mean anti-A/B titers on day 0 were: IgG=1.27±1.03 and IgM=2.20±1.47. One HLA cross-match positive patient (beside ABO-incompatibility) subjected to double-dose anti-CD20 and intensive TPE-treatment had no allograft rejection. The level of serum creatinine ranged from 100 to 156 µmol/L in the entire group of patients during postoperative follow-up (up to 36 months). One recipient (with sepsis and multi organ distress syndrome) lost kidney function in early posttransplant period. ABO-incompatible (n=2) and ABO-compatible (n=3) kidney recipients had severe anemia and bleeding episodes. They were efficiently treated using original "multi-manner" apheresis. Our study represents a clear demonstration that the combination of TPE with ECIA and anti-CD20 is effective in anti-A/B depletion. This therapeutic approach is feasible in clinical setting showing satisfactory short-term results although verification of long-term effects needs to be confirmed in a larger study. The rapid beneficial outcome of "multi-manner" apheresis strongly supports the future use of this therapeutic modality for efficient oxygenation and advanced engraftment.

Endovascular reconstruction of giant gastroduodenal artery aneurysm with stent graft: case report.

INTRODUCTION: Gastroduodenal artery (GDA) aneurysms are rare and mainly asymptomatic vascular diseases. Endovascular intervention can provide an alternative method of treatment for GDA aneurysms. REPORT: We present a case of endovascular repair of giant GDA aneurysm, with stent graft. A 56-year-old man, smoker, presented with nausea, acute worsening of chronic abdominal pain, and a large, tender, pulsating mass in his right upper abdomen with no previous medical history. Computed tomographic (CT) angiography was performed, and there was GDA aneurysm. Through the left brachial approach, we did the endovascular repair of GDA with Viabahn stent graft. DISCUSSION: Endovascular gastroduodenal aneurysm artery reconstruction with stent graft is a reasonable alternative to open surgical repair and it is safety option in carefully selected patients.

[Hyperbaric oxygenation effects determination in the therapy of chronic occlusive lower extremities arteries disease by the use of perfusion scintigraphy].

BACKGROUND/AIM: Hyperbaric oxygenation (HBO) is a medical treatment of a patient with 100% oxygen inspiration under the pressure higher than atmospheric in a special unit designed to let the whole patient's body rest in a chamber. The aim of the study was to determine the effect of the application of HBO treatment on the patient's lower extremities with chonic inoperabile occlusive disease by measning the parameters of perfusion scintigraphy (perfusion reserve, relative perfusion). METHODS: This investigation included 22 patients (19 males and 3 famales). Following clinical assessment of lower extremities condition according to the skin appearance and its adnexa, claudication distance was performed. Clinical condition was graded by the use of 5-point nominal scale. In all of the patients 99mTc-tetraphosmine lower extremities scintigraphy was done ten days prior to the treatment start and ten days after the treatment with HBO. Lower legs were imaged from the posterior view. Prior to imaging the patients were obligatory lying approximately half an hour. RESULTS: In 18 (86%) of the patients there was an improvement manifested as better subjective condition and better skin and its adnexa appearance. Following HBO treatment there was a statistically significant change in collecting the radiopharmac at rest. This finding indicates an increased viability of muscles as well as an increased perfusion reserve. Perfusion reserve mean values increased from 39.99 to 50.86%, and from 38.46 to 49.33% for the right and the left lower leg, respectively. This parameter clearly indicates favorable effects of HBO treatment pertaining neoangiogenesis and, consequently, increased viability of the lower leg muscles. It was also obvious in visual analysis of the obtained images. CONCLUSION: The obtained results confirm that muscle perfusion measured by the parameters of perfusion scintigraphy using 9mTc-tetrophosmine (perfusion reserve, relative perfusion) in patients with inoperabile occlusive disease of the lower leg arteries significantly increases after the application of HBO treatment.

Polymorphisms of genes encoding tumor necrosis factor-alpha, interleukin-10, cluster of differentiation-14 and interleukin-1ra in critically ill patients.

PURPOSE: The aim of the study was to determine whether distributions of tumor necrosis factor (TNF)-α(308), interleukin (IL)-10(1082), CD14(159), and IL-1ra gene intron 2 genotypes in critically ill patients are associated with outcome, underlying cause of sepsis, and type of microorganism. MATERIALS AND METHODS: Blood samples from 106 critically ill white patients were genotyped by method based on polymerase chain reaction for TNF-α(308), IL-10(1082), CD14(159), and IL-1ra gene intron 2. RESULTS: All patients with TNF-α(308)AA genotype survived; relative risk (RR) of death in patients with AG was 3.250 and with GG, 1.923 (P < .01). In patients with Gram-positive sepsis, IL-10(1082)AA and then AG genotypes were the most frequent ones (odds ratio [OR], 18.67 and 7.20, respectively; P < .01). When comparing IL-10(1082)AA with AG, RR of pancreatitis was 1.80 and OR was 3.40. When AA and GG were compared, RR was 7.33 and OR was 20.00. In patients with GG, RR of peritonitis was 4.07 and OR was 5.88 (P < .01). In patients with Gram-positive sepsis, CD14(159)CT was the most frequent one with OR of 5.25. Distribution of 6 IL-1ra gene intron 2 genotypes showed no significant association. CONCLUSIONS: Distribution of TNF-α(308) genotypes is associated with outcome, IL-10(1082) with type of microorganism and underlying cause of sepsis, and CD14(159) with type of microorganism.

Living unrelated donor kidney transplantation--a fourteen-year experience.

BACKGROUND: In countries without a national organization for retrieval and distribution of organs of the deceased donors, problem of organ shortage is still not resolved. In order to increase the number of kidney transplantations we started with the program of living unrelated - spousal donors. The aim of this study was to compare treatment outcome and renal graft function in patients receiving the graft from spousal and those receiving ghe graft from living related donors. METHOD: We retrospectively identified 14 patients who received renal allograft from spousal donors between 1996 and 2009 (group I). The control group consisted of 14 patients who got graft from related donor retrieved from the database and matched than with respect to sex, age, kidney disease, immunological and viral pretransplant status, the initial method of the end stage renal disease treatment and ABO compatibility. In the follow-up period of 41 +/- 38 months we recorded immunosuppressive therapy, surgical complications, episodes of acute rejection, CMV infection and graft function, assessed by serum creatinine levels at the beginning and in the end of the follow-up period. All patients had pretransplant negative cross-match. In ABO incompatible patients pretransplant isoagglutinine titer was zero. RESULTS: The patients with a spousal donor had worse HLA matching. There were no significant differences between the groups in surgical, infective, immunological complications and graft function. Two patients from the group I returned to hemodialysis after 82 and 22 months due to serious comorbidities. CONCLUSION: In spite of the worse HLA matching, graft survival and function of renal grafts from spousal donors were as good as those retrieved from related donors.

Changes of glomerular filtration after nephrectomy in living donor.

A possible complication after donor nephrectomy is a decrease in glomerular filtration rate. The goal of our investigation is to estimate the function of the remaining donor kidney in the first 6 months after nephrectomy using the equations Cockcroft-Gault, Modification of Diet in Renal Disease 1 (MDRD1) and MDRD2. In addition to basic age and sex data, we collected standard biochemical data from blood: creatinine, blood urea nitrogen, and albumin. Blood samples and diuresis were taken at -1, 0, 1, 2, 3, 7, and 14 days, and after 6 months. Our results show that glomerular filtration rate decreases after nephrectomy and stabilizes after 6 months in values significantly lower compared with predonation values. Both MDRD estimations show that these donors after nephrectomy are patients in the third degree of chronic kidney disease, and we can predict that older donors and those with comorbidities very soon will need a treatment for chronic kidney disease. For glomerular filtration rate estimation, we recommend the MDRD2 equation. All donors must have long-term follow-up and treatment, because there is a possibility of eventual cardiovascular and metabolic diseases.

[Therapeutic approach in patients undergoing percutaneous coronary interventions]. / Terapijski pristup kod pacijenata koji se podvrgavaju perkutanim koronarnim intervencijama.

While the performance of percutaneous coronary interventions remains the domain of interventional cardiologists, the management of these patients before, during, and after the procedure is in the domain of general cardiologists, internists and primary care physicians. Therefore, for optimal patient care it is crucial that all engaged physicians should understand the procedural risks, complications and optimal treatment strategy before, during and after the procedure. Before a percutanous coronary intervention, patients with known allergies to iodinated contrast dye should be pretreated with oral corticosteroids and H1-receptor blockers. Diabetic patients as well as patients with renal failure need special care. Hydration is crucial for patients with renal insufficiency in order to minimise the risk of contrast nephropathy. Metformin therapy should be discontinued before the procedure in patients with renal failure in order to avoid lactic acidosis, and it should be reinstituted after the procedure only when normal serum creatine level is confirmed. Double antiplatelet therapy (aspirin plus clopidogrel) should be initiated at least six hours before the procedure. While aspirin therapy after the procedure is life long, the duration of clopidogrel therapy depends on the type of implanted stent (in patients with bare stents implanted clopidogrel should be taken at least 3 - 4 weeks post procedural, and in patients with drug-eluting stents implanted clopidogrel should be taken at least 6 - 12 months after the procedure due to in-stent restenosis prevention). Patients who experience typical anginal pain in a period of one to eight month after percutaneous coronary revascularization are likely to have restenosis, and they should be reevaluated with stress echocardiography and/or repeated coronary angiography.

Predictive value of serum bicarbonate, arterial base deficit/excess and SAPS III score in critically ill patients.

Arterial base deficit/excess (BD/E) is commonly used marker of metabolic acidosis in critically ill patients, but requires an arterial puncture and blood gas analysis. We hypothesized that serum bicarbonate (HCO3), which can be routinely obtained, strongly correlates with arterial BD/E and provides equivalent predictive information. In addition, we evaluated predictive value of simplified acute physiology score III (SAPS III). Total of 152 critically ill surgical patients were included in retrospective analysis. On admission to intensive care unit sets of simultaneously obtained paired laboratory data, including an arterial blood gas and serum chemistry panel with serum HCO3 were obtained. Very strong correlation between BD/E and simultaneously measured serum HCO3 levels was found (r = 0.857, R(2) = 0.732, p < 0.01). The serum HCO3 level reliably identified a significant metabolic acidosis (AUC = 0.761, p < 0.05). BD and SAPS III were good predictors of mortality (AUCs 0.70 and 0.74, respectively). Serum HCO3 may be used as substitute to detect severe metabolic acidosis. BD and SAPS III score were good predictors of mortality.