Successful Hybrid Approach Treatment of a Large Persistent Sciatic Artery Aneurysm-A Case Report.

Background and Objectives: Persistent sciatic artery (PSA) is a rare congenital vascular anomaly that is often asymptomatic, but can be associated with aneurysm formation and potential complications, such as thromboembolism or aneurysm rupture in some cases. We present a case of a 75-year-old woman with a symptomatic thrombus-containing aneurysm of the left PSA. Materials and Methods: The treatment of the PSA aneurysm involved a successful hybrid approach, which included open surgical bypass and endovascular embolization. The open surgical bypass was performed from the left common femoral artery to the left above-the-knee popliteal artery using a synthetic graft, while the aneurysm exclusion was achieved through endovascular plug embolization. Results: Control angiography revealed complete exclusion of the PSA aneurysm. At the 1-month follow-up, there were no palpable pulsatile masses in the left gluteal region, and the patient reported no symptoms. Conclusions: Given the high incidence of limb- and life-threatening complications associated with a PSA aneurysm, accurate diagnosis and appropriate treatment are crucial. In this case, a combination of open surgical and endovascular techniques resulted in a favorable outcome for the patient, highlighting the effectiveness of the hybrid approach in managing PSA aneurysms. Further studies are warranted to explore and refine treatment strategies for these complex vascular anomalies.

Transesophageal Echocardiography-Guided Thrombectomy of Level IV Renal Cell Carcinoma without Cardiopulmonary Bypass.

Advanced renal cell carcinoma accompanied by tumor thrombus in the venous system is present in up to 10% of cases. Extension of tumor thrombus above the diaphragm or into the right atrium represents level IV disease. Level IV tumors are typically treated with sterno-laparotomy approach with or without deep hypothermic circulatory arrest and veno-venous bypass. In this case report, the surgical technique for the resection of advanced RCC were described, with the concomitant use of transesophageal echocardiography for thrombus extraction without the veno-venous or cardiopulmonary bypass.

[High rate of native arteriovenous fistulas: how to reach this goal?].

The types of vascular accesses for hemodialysis (HD) include the native arteriovenous fistula (AVF), arteriovenous graft (AVG) and central venous catheter (CVC). Adequately matured native AVF is the best choice for HD patients and a high percentage of its presence is the goal of every nephrologist and vascular surgeon. This paper analyses the number and type of vascular accesses for HD performed over a 10-year period at the Clinical Center of Serbia, and presents the factors of importance for the creation of such a high number of successful native AVF (over 80%). Such a result is, inter alia, the consequence of the appointment of the Vascular Access Coordinator, whose task was to improve the quality of care of blood vessels in the predialysis period as well as of functional vascular accesses, and to promote the cooperation among different specialists within the field. Vascular access is the "lifeline"for HD patients. Thus, its successful planning, creation and monitoring of vascular access is a continuous process that requires the collaboration and cooperation of the patient, nephrologist, vascular surgeon, radiologist and medical personnel.

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

INTRODUCTION: Posterior knee joint dislocation associated with injury of the popliteal artery in children is an extremely rare condition. Rapid diagnosis and treatment are essential for limb salvage and function. CASE REPORT: We reported a 14-year-old boy who suffered traumatic displacement of the right knee and contusion of the popliteal artery during motorcycle accident. The diagnosis was confirmed using Doppler and duplex ultrasonography and digital substraction transfemoral arteriography. The urgent surgical procedure was performed using posterior approach to the popliteal artery. During the surgical exploration, rupture of the posterior cruciate ligament associated with thrombosed popliteal artery have been found. The damaged popliteal artery was resected and replaced with autologous saphenous vein graft. The last stage of the procedure was a transosseous femoral fixation of posterior circuate ligament. A 3-year-follow-up after the surgery demonstrated intact arterial perfusion and very good function of the knee with a minimal difference as compared with the contralateral knee. CONCLUSION: Combined orthopedic and vascular injuries are very rare in children. They require combined treatment.

Transesophageal echocardiography-guided thrombectomy of level iv renal cell carcinoma without cardiopulmonary bypass

Abstract Advanced renal cell carcinoma accompanied by tumor thrombus in the venous system is present in up to 10% of cases. Extension of tumor thrombus above the diaphragm or into the right atrium represents level IV disease. Level IV tumors are typically treated with sterno-laparotomy approach with or without deep hypothermic circulatory arrest and veno-venous bypass. In this case report, the surgical technique for the resection of advanced RCC were described, with the concomitant use of transesophageal echocardiography for thrombus extraction without the veno-venous or cardiopulmonary bypass.

[In situ replacement of infected vascular prosthesis with fresh arterial homograft: early and long-term results in 18 patients].

INTRODUCTION: Graft infection is rightly considered one of the severest complications of vascular reconstruction. Treatment is non-standardized and associated with high mortality and morbidity rates. The choice of therapeutic modality depends upon variety of factors. One increasingly used option is in situ replacement of the infected prosthesis with the arterial allograft. OBJECTIVE: The aim of this prospective nonrandomized study was to evaluate the effectiveness and durability of fresh arterial allograft as in situ substitute for the infected vascular prosthesis. METHODS: During period of 2002-2005, 18 patients with the synthetic vascular graft infection underwent partial or complete prosthesis removal and secondary in situ reconstruction using the fresh arterial allograft, preserved under hypothermic conditions in buffered saline solution with an addition of antibiotics. RESULTS: In 14 male and 4 female patients, mean-aged 62 years, 8 aortic and 10 peripheral arterial infected prostheses were partially or completely replaced with the allograft. Operative mortality was 27.8% and amputation rate was 22.2%. Systemic sepsis at initial presentation and highly virulent nature of causative microorganisms were identified as significant negative prognostic factors (chi2 test, p < 0.05). During the long-term follow-up (mean 47 months), allograft aneurysm developed in three patients, requiring allograft explantation, followed in two cases by tertiary prosthetic reconstruction. CONCLUSION: Substitution of the infected prosthesis with the arterial allograft could be successful if used selectively--for less virulent and localized infections of extracavitary grafts. Close follow-up is mandatory for timely diagnosis of late homograft lesions and its eventual replacement with more durable prosthetic material.

[Abdominal aortic surgery and renal anomalies].

INTRODUCTION: Kidney anomalies present a challenge even for the most experienced vascular surgeon in the reconstruction of the aortoilliac segment. The most significant anomalies described in the surgery of the aortoilliac segment are a horse-shoe and ectopic kidney. OBJECTIVE: The aim of this retrospective study was to analyze experience on 40 patients with renal anomalies, who underwent surgery of the aortoilliac segment and to determine attitudes on conventional surgical treatment. METHODS: In the period from 1992 to 2009, at the Clinic for Vascular Surgery of the Clinical Centre of Belgrade we operated on 40 patients with renal anomalies and aortic disease (aneurysmatic and obstructive). The retrospective analysis involved standard epidemiological data of each patient (gender, age, risk factors for atherosclerosis, type of anomaly, type of aortic disease, presurgical parameter values of renal function), type of surgical approach (laparatomy or retroperitoneal approach), classification of the renal isthmus, reimplantation of renal arteries and perioperative morbidity and mortality. RESULTS: Twenty patients were males In 30 (70%) patients we diagnosed a horse-shoe kidney and in 10(30%) ectopic kidney. In the cases of ruptured aneurysm of the abdominal aorta the diagnosis was made by ultrasound findings. Pre-surgically, renal anomalies were confirmed in all patients, except in those with a ruptured aneurysm who underwent urgent surgery. In all patients we applied medial laparatomy, except in those with a thoracoabdominal aneurysm type IV, when the retroperitonal approach was necessary. On average the patients were under follow-up for 6.2 years (from 6 months to 17 years). CONCLUSION: Under our conditions, the so-called double clamp technique with the preservation of the kidney gave best results in the patients with renal anomalies and aortic disease.

Unusual forms of ruptured abdominal aortic aneurysms.

Over 95% of abdominal aortic aneurysms (AAAs) rupture into the retroperitoneal space. Rare types of AAA ruptures comprise ruptures into the inferior vena cava with aortocaval fistula formation (ACF), ruptures into the duodenum with formation of a primary aortoduodenal fistula (ADF), and chronic contained ruptures (CCRs). This article presents a study of 41 cases with unusual forms of ruptured AAA of a series of 506 patients with AAA rupture treated within a 14-year period. There were 11 cases of CCR, 5 cases with ADF, and 25 cases with ACF. The correct preoperative diagnosis was established in 6 (of 11) cases of CCR, in 2 (of 5) cases of primary ADF, and in 13 (of 25) cases of ACF. AAA replacement was performed in 8 cases using a tube graft, whereas a bifurcated graft was used in 31 patients because of the distant extent of the atherosclerotic/aneurysmatic lesions engaging iliac arteries. Two patients had an axillobifemoral bypass. The overall 30-day mortality rate was 19% (8 of 41), with subgroup mortality rates of 0 (CCR), 60% (ADF), and 20% (ACF). Diagnosis and treatment are simplest in cases of CCR and the most complicated in cases of ADF.

[Effect of intraoperative parameters on survival in patients with ruptured abdominal aortic aneurysms]. / Uticaj intraoperacionih parametara na prezivljavanje bolesnika sa rupturom aneurizme abdominalne aorte.

Ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality that has not been changed in decades. Between 1991-2001 total number of 1058 patients was operated at the Institute for Cardiovascular Diseases of Clinical Centre of Serbia due to abdominal aortic aneurysm. Of this number, 288 patients underwent urgent surgical repair because of ruptured abdominal aortic aneurysm. The aim of this retrospective study was to show results of the early outcome of surgical treatment of patients with ruptured abdominal aortic aneurysm, and to define relevant intraoperative factors that influence their survival. There were 83% male and 17% female patients in the study, mean aged 67 years. Mean duration of surgical procedure was 190 minutes (75-420 min). Most common localization of aneurysm was infrarenal--in 74% of patients, then juxtarenal (12.3%). Suprarenal aneurysm was found in 6.8% of patients, as well as thoracoabdominal aneurysm (6.8%). Retroperitoneal rupture of aortic aneurysm was most common--in 65% of patients, then intraperotineal in 26%. Rare finding such as chronic rupture was found in 3.8%, aorto-caval fistula in 3.2% and aorto-duodenal fistula in 0.6% of patients. Mean aortic cross-clamping time was 41.7 minutes (10-150 min). Average intraoperative systolic pressure in patients was 106.5 mmHg (40-160 mmHg). Mean intraoperative blood loss was 3700 ml (1400-8500 ml). Mean intraoperative diuresis was 473 ml (0-2100 ml). Tubular graft was implanted in 53% of patients, aorto-iliac bifurcated graft in 32.8%. Aortobifemoral reconstruction was done in 14.2% of patients. These data refer to the patients that survived surgical procedure. Intrahospital mortality that included intraoperative and postoperative deaths was 53.7%. Therefore, 46.3% patients survived surgical treatment and were released from the hospital. Intraoperative mortality was 13.5%. Type of aneurysm had no influence on outcome of patients (p > 0.05), as well as type of rupture and level of aortic cross-clamping. Aortic cross-clamping time was significantly shorter in survivors, and longest in patients that died intraoperatively (p < 0.05). Intraoperative systolic tension value influenced the outcome in patients; it was significantly higher in survivors (p < 0.01). Interposition of tubular graft gave better results compared with aorto-iliac and aorto-femoral reconstruction (p < 0.01). Duration of surgery was significantly higher in patients with lethal outcome (p < 0.05), as well as intraoperative blood loss (p < 0.05). Intraoperative diuresis was significantly lower in patients with lethal outcome (p < 0.05). Ruptured abdominal aortic aneurysm still remains one of the most dramatic surgical states with very high mortality. Important intraoperative factors that influence the outcome of surgical treatment can be defined. Therapeutic efforts should be concentrated on those factors that are possible to correct, which would hopefully lead to better survival of patients. Nevertheless, screening for abdominal aortic aneurysm and elective surgical intervention before rupture occurs should be the best solution for this complex problem.

Carotid artery aneurysms.

We present the treatment of 17 extracranial carotid artery aneurysms in 16 patients (1 patient had bilateral lesions). There were 15 (93.75%) male patients and 1 (6.25%) female patient, with an average age of 64.8 years. Two (11.8%) aneurysms involved the common carotid artery and 15 (88.2%) the internal carotid artery. Two (11.8%) aneurysms presented with rupture, 3 (17.6%) as an asymptomatic mass, 2 (11.8%) with cranial nerve compression, 6 (35.3%) with transient ischemic attack, and 4 (23.5%) with stroke. The following surgical procedures were performed: extirpation with 8 mm Dacron graft replacement, 5 (29.4%) cases; extirpation with end-to-end anastomosis, 8 (47.1%) cases; extirpation with saphenous vein graft replacement, 3 (17.6%) cases; and ligature of the internal carotid artery, 1 (5.9%) case. One (5.9%) patient died postoperatively owing to stroke. Including this case, 3 (17.6%) patients had a postoperative stroke, whereas 2 (11.8%) patients had transient cranial nerve damage. Sixteen surviving patients were followed from 2 months to 15 years (mean 5 years, 3 months). During this period, 1 patient died 5 years postoperatively owing to a myocardial infarction, whereas all other patients were alive and free of neurologic symptoms. Extracranial carotid artery aneurysms are rare. However, they are of medical importance because of their location, differential diagnosis, natural history, complications, and treatment.

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

Abdominal aortic surgery and horseshoe kidney.

Horseshoe kidney presents a special challenge during surgery of the abdominal aorta. The aim of this study was to evaluate the morbidity and define optimal management based on clinical histories of 15 patients with horseshoe kidney who underwent surgical procedures on the abdominal aorta over a 20-year period. There were 2 female and 13 male patients with an average age of 62.66 (50-75) years. The indications for surgery included aortic aneurysms in 10 patients and aortoiliac occlusive disease in 5. The horseshoe kidney was detected before surgery in 12 patients (80%) by ultrasonography, angiography, computed tomography (CT) or excretory urography. Angiography revealed multiple or anomalous renal arteries in 8 of 12 patients studied preoperatively. At surgery, 10 patients (66.6%) were found to have multiple or anomalous renal arteries. Five patients (33.41%) were without multiple or anomalous renal arteries. Ten required renal revascularization (reimplantation with a Carrel patch in 7 patients and aortorenal bypass in 3). Two patients, both with ruptured abdominal aortic aneurysms, died postoperatively. In the other 10 cases the average follow-up period was 5.3 years (6 months to 17 years). During this period there were no signs of graft occlusion, renovascular hypertension, or renal failure. From these results we conclude that aortic surgery can be performed safely in patients with horseshoe kidney without increased mortality. These patients require exact preoperative diagnosis (ultrasonography, CT scan, angiography), reimplantation of anomalous renal arteries, and preservation of the renal isthmus.