Single-center prospective, randomized analysis of conventional and eversion carotid endarterectomy.

AIM: Several studies, comparing early and long-term results of the conventional carotid endarterectomy (CEA) and eversion carotid endarterectomy (EEA), were conducted for past 10 years. Nevertheless, it still remaining difficult to choose optimal endarterectomy technique. Choice yet mainly depends of experience of attending surgeon. The aim of this study was the comparison early and long-term results of the EEA and CEA. METHODS: Randomly, 103 patients were operated on in the eversion, and 98 patients in the conventional technique; 97 (48.3%) patients were asymptomatic and 104 (51.7%) had symptomatic lesions. All patients underwent preoperative cervical duplex scanning and neurological examination. The surgical procedure was carried out under general anesthesia. In cases with retrograde blood pressure less than 20 mmHg shunt was used; 78.6% of all CEA were finished up with ''patch'' angioplasty and 21.4% by primary suture. The primary outcomes were perioperative and late mortality, perioperative and late central neurological complications, a long-term survival rate and late restenosis incidence. RESULTS: The mean follow-up was 38 months. Mortality and long-term survival rate were similar in compared groups. The perioperative central neurological complications incidence were comparable in study groups (3.9% vs 12.1% , odds ratio 3.45, 95% confidence interval 1.1-11.1; P=0.029). The late restenosis incidence was significantly lower in eversion group (0.0% vs 6.1%). CONCLUSION: EEA has an advantage over the conventional procedure. The authors recommend CEA in cases when retrograde pressure indicated the use of the intraluminal shunting.

Heart and renal failure in renovascular hypertension caused by giant cell arteritis--case report.

We report a case of a male teenager with severe heart and acute renal failure as the dominant clinical manifestations of renovascular hypertension (RVH) caused by atypical giant cell arteritis (GCA). Unrecognized RVH and treatment of the consequent heart failure by angiotensin-converting enzyme inhibitors (ACEI) probably contributed to progression of renovascular disease to bilateral renal artery occlusion. Recurrent "flash" pulmonary edemas could not be prevented until surgical revascularization of the only functioning right kidney was achieved by an aortorenal bypass. Prompt post-operative normalization of heart function and arterial hypertension occurred despite the histopathological finding of the resected renal artery compatible with GCA and 4-year duration of significant renovascular disease. At the last check-up, the patient was asymptomatic, with normal arterial pressure on the prescribed treatment: carvedilol, hydrochlorothiazide, prednisolone 20 mg daily and aspirin. Subsequent follow-up is necessary to observe the evolution of GCA as an exceptionally rare cause of RVH.

Ex vivo repair of renal artery aneurysm associated with repairing of abdominal aortic aneurysm. Case report.

A case of right renal artery distal aneurysm associated with juxtarenal abdominal aortic aneurysm in a 75-year-old male, who presented with abdominal and back pain and chronic renal failure, is reported. The abdominal aortic aneurysm was repaired with a bifurcated Dacron graft. The right kidney was simultaneously explanted, ex vivo reconstruction of the renal artery with PTFE graft was performed, followed by autotransplantation of the kidney into the right iliac fossa. In the postoperative course the renal function returned to normal.

Aorto-caval fistulas: a review of eighteen years experience.

The operative treatment of 26 aorto-caval fistulas during the last 18 years is reviewed (24 male and two female patients; average of 65.3 year). Out of 1698 cases presenting an abdominal aortic aneurysm, 406 presented with rupture, and 26 had aorto caval fistula. In 24 cases (92.3%) it concerned an atherosclerotic aneurysm. One aneurysm with aorto-caval fistula was secondary to abdominal blunt trauma (3.8%), and one due to iatrogenic injury (3.8%). The time interval between first clinical signs of aorto-caval fistula and diagnosis, ranged from 6 hours to 2 years (average 57,3 days). Clinical presentation included congestive heart failure infive patients (11.5%), extreme leg edema in 13 (50.0%), hematuria in 2 (7.0%), renal insufficiency 2 (7.0%), and scrotal edema in six patients. Diagnosis was made by means of color duplex scan in eight patients (30.7%), CT in seven patients (27%), NMR in three patients (11.5%), and angiography in seven patients (27%). Most reliable physical sign was an abdominal bruit,present in 20 patients (77%). In ten patients (38.4%) correct diagnosis was not made prior to surgery. The operative treatment consisted of transaortic suture of the vena cava (25 pts-96.0%), and aneurysm repair. Five operative deaths occurred (19,2%), and for all of them it concerned a misdiagnosis. Cause of death was myocardial infarction (one patient-3.8%), massive bleeding (one patient-3.8%), MOF (two patients-7, 0%), and colon gangrene (one patient-3.8%). Follow-up period varied from six months to 18 years (mean 4 years and two months). Long term results showed a 96% patency rate. No postoperative lower extremity venous insufficiency nor pelvic venous hypertension was observed post-operatively.

Incidence of and indications for conversion of cervical plexus block to general anesthesia in patients undergoing carotid surgery: a single center experience.

AIM: He aim of this paper was to investigate the incidence of and the indications for conversion to general anesthesia (GA) in a large single-center series of patients undergoing carotid surgery under cervical plexus block (CPB). METHODS: With IRB approval we retrospectively analyzed the medical records of all patients who underwent carotid surgery under CPB from November 2007 to October 2010. Cervical plexus was blocked at both the superficial and deep levels. An intraluminal shunt was inserted in patients who demonstrated signs of inadequate cerebral perfusion upon carotid clamping (CC). Propofol was given to patients reporting pain or discomfort throughout the procedure. The primary outcomes were the number and percentage of conversions to GA as well as the indications for this intervention. The secondary outcome was the incidence of partial cervical block failure, defined as the need for supplemental propofol administration for pain relief during surgery. RESULTS: In total, 1464 carotid surgical procedures were performed under CPB in 1305 consecutive patients during the investigated period. Conversion to GA was required in 17 (1.2%) patients. The most common reason for conversion to GA was persisting neurological deterioration upon CC and intraluminal shunt insertion, which was recorded in 8/17 (47.1%) procedures. Other indications to convert were systemic toxicity of local anesthetics, pain, general discomfort and restlessness during surgery, and acute myocardial infarction. CONCLUSION: Cervical plexus block for carotid surgery is associated with a low rate of conversions to GA. Neurological deterioration upon carotid clamping and local anesthetic toxicity are identified as the most common indications for such intervention.

Intraarterial perfusion of prostaglandin E1 after lumbar sympathectomy or reconstruction on femoropopliteal segment.

Out of 100 patients treated by intraarterial perfusion of prostaglandin E1 we selected 36 cases who have been treated after a lumbar sympathectomy or reconstruction on the femoro-popliteal segment. The patients were in the III and IV stage of occlusive diseases by Fontain. All patients were divided into four groups: (a) prostaglandin E1 after a lumbar sympathectomy (20); (b) prostaglandin E1 after failed femoro-popliteal bypass (8); (c) prostaglandin E1 with patent femoro-popliteal bypass and distal progression of the occlusive disease (3); (d) prostaglandin E1 with previously femoro-popliteal reconstruction and poor run off (5). After intraoperative introduction of a catheter into the superficial femoral artery, profunda femoral artery (a, b), a patent graft (c) or just implanted graft (d), a continuous intraarterial perfusion of prostaglandin E1 was applied, in doses 10 nanograms/kg body weight/minute, in total doses 3000 nanograms. The perfusion time was 48-72 h. The patients were controlled immediately after treatment as well as 1, 3, 6 and 12 months after. Our early and late results of the intraarterial perfusion of prostaglandin E1 proved as a very successful limb salvage procedure.

[Aneurysms of the subclavian artery]. / Aneurizme potkljucne arterije.

INTRODUCTION: The Subclavian artery aneurysms are not a commonly seen peripheral aneurysm [1-5]-. We present the experience of the Institute of Cardiovascular Diseases of the Serbian Clinical Centre, Belgrade. PATIENTS AND METHODS: Eight cases of subclavian artery aneurysms are presented. There were 3 male and 5 female patients, average age 51 (32-65) years. Of them 3 aneurysms were of atherosclerotic origin, 4 developed due to thoracic outlet syndrome (TOS), and one developed after intra-arterial drug injection. More details about our cases are presented in Table 1. One of our patients had intra-thoracal aneurysm (Case 3), and 7 had extra-thoracal aneurysm (Figure 1). Two aneurysms appeared as an asymptomatic pulsatile mass in supraclavicular space, and two with compression in the brachial plexus (Figure 2). Our patient 3 manifested skin necrosis and haemorrhage in supraclavicular region (Figure 3). The other 3 patients manifested acute hand ischaemia due to partial aneurysmal thrombosis and distal embolization. In these patients all distal arterial pulses were absent (Figures 4 and 5). In patient 8, besides hand ischaemia, transitory ischaemic attack (TIA) with contralateral hemiparesis also occurred. The reason was microembolization of ipsilateral carotid artery due to retrograde thrombo propagation. The diagnosis was established by selective angiography of the subclavian artery, and in 4 patients Duplex ultrasonography was also used. All patients were treated surgically. In 7 patients supraclavicular approach to subclavian artery was used, and in case 3 we used a combined trans-sternal and supraclavicular approach. In 7 patients a complete aneurysmal resection was performed, and in patient 5 due to infection aneurysm was excluded by proximal and distal arterial ligations. In this case arterial flow was reestablished by extra-atomic carotid axillary bypass with saphenous vein graft. In three patients with TOS, after aneurysmal resections, end-to-end anastomosis was performed. In patient 2 in whom aneurysm was also caused by TOS, saphenous vein graft was used for reconstruction. In all 4 patients with TOS, some kind of decompressive procedure at the thoracic outlet was also performed (two cervical and two first-rib resections using supraclavicular approach). In 3 patients with atherosclerotic subclavian artery aneurysms, PTFE graft was used for reconstruction (Figures 6 and 7). RESULTS: One early postoperative complication occurred. It was embolism of the brachial artery which has been successfully treated by transbrachial embolectomy. The early patency rate was 88%. The patients were controlled using physical and Doppler ultrasonographic examinations 1, 3, 6, 12 months, and then every year postoperatively. The mean follow-up period was 3.6 (1-8) years. In that period one (13%) late complication was observed. It was thrombosis of the saphenous vein graft true aneurysm in our patient 2. This aneurysm was resected and replaced with PTFE graft. Postoperative histological examination showed connective tissue disorder of the vein wall. The long-term patency rate was 88%. DISCUSSION: In most cases the true subclavian artery aneurysms are of atherosclerotic origin [1-4, 6, 7, 12]. We had 3 such cases. TOS is also often caused by subclavian artery true aneurysms [5, 13-17]. We had 4 such cases. Fibromuscular dysplasia [1, 18], cystic idiopathic medionecrosis [1, 19, 20], infection [1, 21, 22] and congenital disorders [23, 24], are rare causes of subclavian artery true aneurysms. Subclavian artery pseudoaneurysms can develop after different reconstructive vascular procedures [5, 28-41]. Subclavian artery aneurysms can rupture, thrombosis, embolize, or cause symptoms by local compression [6, 12, 41]. We had two cases with compression on brachial plexus. The compression on the trachea, oesophagus, laryngeal nerve, ganglion stellatum were also described [6, 12, 25, 42, 43]. Most subclavian artery aneurysms present ischaemic symptoms of

[Cystic degeneration of the tunica adventitia of the popliteal artery]. / Cisticna degeneracija tunike adventicije poplitealne arterije.

INTRODUCTION: Adventitial cystic disease of the popliteal artery (PA) is an uncommon and unique entity characterized by a mucinous cyst located in the arterial adventitia. As the cyst enlarges, it provokes vascular compression with stenosis or occlusion, the first only during the knee flexion, and then in all leg position. Atkins and Key (1946) were the first who described this disease in the external iliac artery [1]. Eirup and Hiertonn (1956) described the disease in the PA, which is the place of its most common localization. The aim of the paper is the presentation of our 10 cases of PA adventitial cystic disease. PATIENTS AND METHODS: Ten patients with PA adventitial cyst were treated at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade, over the period between 1978 and 1997. There were 9 males and one female patient, average age 42.7 years (31-62). Two patients were smokers, while all other atherosclerotic risk factors, including heart disease, were absent. The diagnosis was established using Doppler ultrasonography and angiography. The postoperative histological examination revealed PA adventitial cyst in all patients (Figure 1). In Table 1 are presented our patients. The patients 3 and 4 were admitted for acute ischaemia of the leg. In patient 3 Doppler indexes were 0.0, and transfemoral arteriography revealed segmental occlusion of the PA. All other arteries were unchanged. These findings suggested an unusual disease of the PA. During the operation the posterior approach to the PA was used, and intraoperatively the adventitial cyst was found. In patient 4 the tibioperoneal trunk, posterior tibial artery and PA were occluded. Therefore, the medial approach to the PA was used. After thrombectomy of the crural vessels, the popliteo-popliteal bypass procedure was performed. The PA resection by this approach was not possible. The ringed 6 mm PTFE graft was used for reconstruction because of inadequate saphenous vein. The patients 1, 2, 5-10 were admitted with disabling claudication discomforts. In patients 1, 2, 5, 6, 8, 9 popliteal and pedal pulses were absent, and Doppler indexes decreased. In patients 7 and 10 pedal pulses were palpable and decreased during the normal knee position, while absent during the knee flexion. During some maneuvers Doppler indexes significantly decreased. Transfemoral arteriography in patients 1, 2, 5, 6, 8, 9 showed segmental stenosis or occlusion of the PA, and for this reason the posterior approach to the PA was used. The PA adventitial cyst was found in all cases (Figure 2). In patient 7 angiography revealed a "hourglass" deformity of the PA, while in patient 10 "scimitar" sign was found. Both angiographic findings are characteristic of PA adventitial cyst. The posterior approach was carried out in all patients. In patient 2 only cyst aspiration has been performed, while in patients 7, 8, 9 aspiration and resection of the changed PA adventitia (Figure 3a, figure 3b). In patients 1, 3, 5, 6, 10 an occluded arterial segment was resected. The restoration of the flow observed after the end-to-end anastomosis in patient 1, and after interposition of the saphenous graft in other patients. After the operation, the contralateral leg was examined using Doppler ultrasonography in all patients. The Doppler indexes were significantly decreased in patients 1 and 5 during the knee flexion, but the patients refused the angiographic examination. The control examination consisted of physical examination, Doppler ultrasonography and sometimes angiography; it was carried out after 1, 3, 6 and 12 months, and then every year after the operation. RESULTS: There was no mortality among our patients in the early post-operative period. In patients in whom cyst aspiration was performed, claudication discomfort was decreased, and Doppler indexes were significantly increased. In patients with arterial resection and reconstruction (1, 3, 4, 5, 6, 10) the effect of the operation was simi

[Pseudo-occlusion of the femoro-popliteal bypass]. / Pseudookluzije femoro-poplitealnog bajpasa.

INTRODUCTION: Pseudo-occlusion of femoro-popliteal/crural (F-P/Cr) bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow [1]. The aim of this paper is the presentation of 24 new cases which, as far as we know, have not been published in Yugoslav medical literature. CASE REPORT: The group consisted of 20 men and 3 women (aged 28 to 71 years, mean 61.95) with 24 cases of "pseudo-occlusion" of the F-P/Cr bypass. More details are presented in Tables 1 and 2. Saphenous vein graft was used for the reconstruction in 19 patients, and Dacron in 5 subjects. "Pseudo-occlusion" was symptomatic in all 24 patients. Fifteen patients had pain at rest, seven presented disabling claudication, and 2 foot gangrene. The mean time interval between primary operation and occurrence of new symptoms was 25.41 (4-84) months (Table 2). In 15 patients control angiography showed hemodynamically significant lesions in inflow tract, and in 9 subjects in outflow tract. Of the total number of inflow tract lesions, there were 3 late occlusions of previously implanted aorto-femoral graft (1, 3 and 17, Table 1), and in other 21 patients lesions of the native aorto-iliac segment. In 8 patients with changes in outflow tract, a distal progression of atherosclerotic disease was found, while one patient (number 8) had intraoperative lesion of the popliteal artery with vascular clamp. All 24 patients were treated operatively. The early postoperative result was favourable in all 24 (100%) patients. Patients were followed-up from 3 months to 5 years (mean 29.625 months). In this period one (4.1%) late graft occlusion was followed by major limb amputation. Four (16.6%) patients died with patent graft. CONCLUSION: 1. Pseudo-occlusion of the F-P/Cr bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow. 2. Pseudo-occlusion may be provoked by changes in inflow and outflow tract. 3. Pseudo-occlusion is not associated only with saphenous vein graft. 5. Recurrence of symptoms, loss of previously palpable distal pulses and reduction of Doppler indices in a previously patent F-P/Cr bypass graft, can indicate pseudo-occlusion. Early diagnosis provides a simple and safe treatment.

[Pseudoaneurysm of the gluteal artery: 2 case reports]. / Pseudoaneurizme glutealne arterije: prikaz dva bolesnika.

INTRODUCTION: Gluteal artery pseudoaneurysms are very rare [1]. They mostly occur after gunshot and stub wounds [2]. However, gluteal artery pseudoaneurysms can be caused by pelvic fracture [1]. Also, they can be isolated or associated with trauma of the pelvic and abdominal viscera [3]. The authors present two cases of gluteal artery pseudoaneurysms. Case 1. A 30-year-old man was treated for large swelling of the left buttock. One month previously he manifested a gunshot wound in the gluteal region. He also had symptoms of lumboischialgia with peroneal nerve paresis. The physical examination revealed a large pulsatile mass over the left buttock with an associated overlying bruit. Selective angiography of the internal iliac artery (Figure 1) revealed a large inferior gluteal artery pseudoaneurysm that caused dislocation of both external and internal iliac arteries. The patient was operated under epidural anaesthesia by the combined abdominal (extraperitoneal) and gluteal approach. By extraperitoneal approach the internal iliac artery was identified and ligated. After the closure of the wound, the patient was placed on the abdomen, and pseudoaneurysm was opened by an incision made between gluteus maximus and medius muscles. After evacuation of the parietal thrombus and pseudocapsule resection, nutrient vessels were ligated. The postoperative recovery was good, and the patient was free of neurologic symptoms two days after the operation. The late result (after 4 years) is also good. Case 2. A-53-year-old man was treated for small haematoma pulsans (Figure 2) in the right buttock. Fifteen days previously he was treated in the regional hospital by intramuscular "antirheumatic cocktails". The physical examination revealed a small pulsatile mass over the right buttock associated with overlying bruit. The selective angiography of the internal iliac artery demonstrated a small inferior gluteal artery pseudoaneurysm. The patient was operated by the procedure described. The postoperative recovery and the late result (after 6 months) were good. DISCUSSION: According to our knowledge, only 8 cases of gluteal artery pseudoaneurysms are reported in literature in the last 11 years (including the first three months of this year) [4-8]. The lesions of the gluteal arteries, especially pseudoaneurysms, have no specific symptoms and signs. usually, they appear as haematoma pulsans and neurologic deficiency due to compression. (One of our patients). The gluteal abscess can be a differential diagnostic problem. Duplex ultrasonography, CT and selective angiography can be used in the diagnosis [5]. The standard surgical treatment of gluteal artery pseudoaneurysms consists of the ligature of the internal iliac artery (using transperitoneal or extraperitoneal approach) and pseudoaneurysmal resection and ligation of nutrient vessels by gluteal approach [9]. The second procedure is the temporary clamping of the internal iliac artery and transgluteal ligation of the nutrient vessels [7]. The microcatheter embolization of the nutrient vessels using standard invasive radiologic approaches via femoral artery is the method of choice in the treatment of gluteal artery pseudoaneurysms [10]. A buttock pulsatile mass and neurological deficiency in a patient with history of penetrating gluteal trauma, suggest the existence of gluteal artery pseudoaneurysm and require diagnostic evaluation.

[Chronic rupture of abdominal aortic aneurysms]. / Hronicna ruptura aneurizme abdominalne aorte.

INTRODUCTION: Rupture of abdominal aortic aneurysms (RAAA) can take place in one of the 4 following ways: 1. "Open" rupture in the free peritoneal cavity; 2. "Closed" rupture with formation of retroperitoneal haematoma; 3. Rupture into surrounding cavity structures, such as veins and bowels; 4. In rare cases rupture is effectively "sealed of" by the surrounding tissue reaction, and retroperitoneal haematoma is "chronically" contained [1]. The terms "sealed" [2], "spontaneously healed" [3], "leakig" [4] RAAA, were also used in the previous papers connected to this situation. The "sealed" rupture was first described by Szilagyi and associates in 1961 [2]. In their case the rupture was small and haemorrhage was effectively encircled by the tissue surrounding the aortic wall. The slow rate of blood loss contributed to the patient's haemodinamically stable condition. Christenson et al. reported a case of "spontaneously healed" RAAA [3]. Rosenthal and associates described 2 patients who had aortic aneuryms that ruptured several months before repair and contributed to the term "leaking AAA" [4], while Jones et al. introduced the term "chronic contained rupture" [1]. The aim of this paper is the presentation of 5 such patients. CASE REPORT: Between December 1, 1988 and May 30, 1997 411 patients with abdominal aortic aneurysms (AAA) have been operated at our institute. Of this number 137 (33%) had RAAA, while 5 patients (12%) had a contained RAAA (CRAAA). CRAAA were found in 3 male and two female patients, average age 62 years. All of them had a previously proved AAA and initial symptoms lasted for days or months before the admission. In all patients haematocrit, pulse rate and arterial tension during the admission, were normal. All typical signs of RAAA were absent in these patients. Patient 1. A 56-year-old man, smoker, with previous history of arterial hypertension had an isolated episode of abdominal pain and collapse 30 days before the admission. Physical examination revealed a pulsatile abdominal mass. Doppler ultrasonography identified an infrarenal AAA, with right lobular extraaneurysmal mass which displaced the inferior vena cava (ICV). Angiographically (Figure 1a) an unusual saccular intrarenal AAA was detected, while simultaneous cavography (Figure 1b) confirmed the-dislocated inferior vena cava to the right. The intraoperative finding showed infrarenal CRAAA with organized retroperitoneal haematoma between AAA, ICV and duodenum. After aortic cross clamping and aneurysmal opening, the rupture at the right posterior aneurysmal wall was discovered. The partial aneurysmactomy and aortobilliar bypass procedure with bifurcated knitted Dacron graft (16 x 8 mm), were performed. The patient recovered very well. After a 4-year follow-up period the graft is still patent. Patient 2. A 72-year-old woman with low back pain, fever and disuric problems was urgently admitted to the Institute of Urology and Nephrology. The standard urological examination (X-ray, intravenous pyelography, retrograde urography, kidney Duplex ultrasonography) excluded urological diseases. However, intrarenal AAA an a giant aneurysm of the right common iliac artery, were found. The proximal dilatation of the right excretory urinary system was also found by retrograde urography. The patient was transported to our Institute 20 days after the initial symptoms. Translumbar aortography (Figure 3) showed the right common iliac artery aneurysm and gave the false negative picture of normal abdominal aorta because of parietal thrombosis of AAA. The intraoperative finding showed chronic rupture of the posterior wall of the right common artery aneurysm. The retroperitoneal haematoma compressed the right ureter. Both aneurysm have been resected and replaced by bifurcated Dacron graft (16 x 8 mm). The patient recovered successfully. After a 2-year period of follow-up the graft is still patent. Patient 3. (ABSTRACT TRUNCATED)

Aorto-caval fistulas.

The surgical repair of 16 aorto-caval (A-C) fistulas (15 male and one female patient; average age of 61.3 years) is reviewed. Fourteen fistulas were caused by aneurysm's erosion, one by iatrogenic injury, while one followed abdominal blunt trauma. The interval from presumed occurrence to diagnosis ranged from 6 h to 2 years. The presence of an abdominal bruit (87.5%) was the most reliable physical finding. Congestive heart failure was prominent in three (18.7%) cases, while severe lower extremity edema in five (31.2%). Two patients (12.5%) had hematuria, two (12.5%) renal insufficiency, while four (25%) scrotal edema. The diagnosis was not recognized before the surgery in five (31.2%) cases. In all 16 cases after transaortic suture of the fistula, aortic reconstructions were performed. Four operative deaths (25%) occurred, in patients who were not correctly diagnosed before surgery. In one case the cause of death was massive bleeding, and in three MOFS. All other patients were followed from 1 to 17 years (mean 4 years and 2 months). All grafts are patent, and there is no lower extremity venous insufficiency or pelvic venous hypertension. Surgical repair of A-C fistulas is mandatory to prevent serious complications.

Femoro-popliteal reconstructions: 'in situ' versus 'reversed' technique.

This study examined 191 patients with 'reversed' and 99 patients with 'in situ' femoro-popliteal bypass technique. There were 85 diabetic patients (44.5%) in the group with 'reversed' bypass, and 43 patients (43.43%) in the 'in situ' group. There were 152 (79.68%) smokers in the 'reversed' bypass group, and 80 (80.8%) in the 'in situ' group. The graft patency was confirmed immediately after operation using CW Doppler and then followed up after 1, 6, l2 months and annually thereafter. The statistical analysis was performed using Pearsons chi-square test, Fischer's test and 'Life table' statistic methods. The patients were followed from 3 to 10 yr after surgery. 'In situ' bypass showed better patency than the 'reversed' bypass technique but only in the second and tenth follow-up year (P < 0.05). Also, 'in situ' bypass proved to be better than 'reversed' only in patients with one patent crural artery (P < 0.01). Diabetes and preoperative smoking did not significantly affect late patency regarding this technique (P > 0.05). However, continuous smoking after the operation significantly decreased late patency rate in both groups of patients (P < 0.01). There was no significant difference in the early thrombectomy rate between groups with 'reversed' and 'in situ' bypasses (P > 0.05). The early thrombectomy, however, significantly reduced late patency rate in both groups (P < 0.01). Therefore we suggest 'in situ' bypass in cases with poor run off, small-calibre vein and 'long' bypass. Also, we consider important more frequent physical and Doppler ultrasonographic control in patients who had early thrombectomy.

[Factors which affect long-term patency in femoro-popliteal bypass]. / Faktori koji uticu na udaljenu (kasnu) protocnost femoro-poplitealnog bajpasa.

INTRODUCTION: The aim of this study was to investigate how "run off", diabetes, cigarette smoking and early reinterventions influence long-term patency of the "reversed" and "in situ" femoro-popliteal (F-P) bypass grafts. PATIENTS AND METHODS: The study included 1991 patients with "reversed" F-P and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass and in the group with "in situ" bypass there were 78 (78.8%) male and 21 (21.2%) female patients. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.4%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and 80 (80.8%) in the group with "in situ" bypass. In Table 1 patients according to Fontain's classification of occlusive arterial disease are presented. On the basis of angiographic examination all patients were divided into four groups (with patent all 3 crural arteries, with patent 2 crural arteries, with patent one crural artery and without patent crural arteries) (Table 2). All patients were controlled using physical and Doppler ultrasonographic examinations immediately after the operation; after 1, 3, 6 months and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiography has also been carried out. Statistical analysis of the results was performed using chi 2 and Fisher's test. RESULTS: The patients were followed-up from 3 to 10 years. In cases with patent all 3 crural arteries there was no significant difference in long-term patency between "reversed" and "in situ" bypasses (Fisher's test, P = 0.66; p > 0.05) (Graph 1). In cases with patent two crural arteries, there was no significant difference between groups with "reversed" and "in situ" bypasses chi 2 = 0.25, p > 0.05) (Graph 2). The long-term patency was significantly better in the group with "in situ" bypass if only one crural artery was patent (chi 2 = 4.96, p < 0.05) (Graph 3). In cases with occluded all three crural arteries there was no significant difference in long-term patency between the two examined groups (Fisher's test, P = 0.29; p > 0.05) (Graph 4). There was no significant difference between groups with "reversed" and "in situ" bypasses in patients with diabetes mellitus (chi 2 = 0.01; p > 0.05) (Graph 5). There was also no statistically significant difference between the two examined groups regarding the preoperative cigarette smoking (chi 2 = 0.94; p > 0.05) (Graph 6). However, in both groups postoperative cigarette smoking showed a statistically significant decrease in long-term patency (chi 2 = 66.71; p < 0.01) (Graph 7). The early REDO operations statistically significantly decreased long-term patency in both groups (chi 2 = 34.89; p < 0.01) (Graph 8). The late graft occlusions were found in 60 patients with "reversed" and 23 patients with "in situ" F-P bypasses. Table 3 shows causes of late graft occlusions. CONCLUSION: In some cases with pure "run off" "in situ" bypass technique showed better long-term patency. We preferred this technique when "run off" was pure, when diameter of the saphenous vein was small, and when bypass was "long". Diabetes mellitus had no significant influence on long-term graft patency in both groups, as well as regarding preoperative cigarette smoking. However, postoperative cigarette smoking and early REDO operations, statistically significant by decreased long-term graft patency in both groups. The reason was that cigarette smoking was not permitted postoperatively, while in cases with early reinterventions physical screening and ultrasonographic examinations were necessary.

[Aorto-enteric fistulas]. / Aorto-entericne fistule.

INTRODUCTION: The aorto-enteric fistula (AEF) is a direct communication between aorta and intestinal lumen. There are primary and secondary forms. Primary AEFs are usually due to erosion of an aortic aneurysm (AAA) into the intestine, while secondary forms are caused by reconstructive procedures on the abdominal aorta. The incidence of primary AEF ranges from 0.1 to 0.8%, and secondary from 0.4% to 2.4% [2-4]. The mortality rate after surgical treatment of secondary AEFs is from 14% to 70% [5]. Therefore, they are of great medical importance. The aim of this paper is the presentation of 9 new cases. METHODS: Over a 33-year period (1966-1999) a retrospective analysis of patients' records identified 9 patients with AEFs. All were males with average age of 66.62 (51-70) years. In Tables 1 and 2 are presented data on our cases. Of the total number of 9 patients, there were 4 primary and 5 secondary AEFs. All primary fistulas were caused by AAA rupture. Secondary AEFs developed after aortic abdominal surgery in the period between one and seven years after the operation. In 7 cases fistula involved the duodenum, in one the sigmoid and in one the transversal colon. The dominant manifestation of fistulas was gastrointestinal bleeding: melaena--8 (89%); haematemesis and melaena--2 (22%); proctorrhagia--1 (11%). In cases of primary AEFs gastrointestinal bleeding was followed by low back pain and haemorrhagic shok, while in cases of secondary AEFs by sepsis (fever, increased leucocytes count, sedimentation). In two cases the final diagnosis was established by gastrography and colonoscopy, while in two patients Duplex ultrasonographic examination suspected AEF. In all other cases the diagnosis was established intraoperatively (Figure 1). After aneurysmal resection in cases of primary AEFs, revascularization of the lower limbs was performed with extra-anatomic axillo-bifemoral bypass graft (one case) and with "in situ" graft placement (three cases) (Figure 2). The duodenal defect was closed transversally with standard two layers suture techniques in two patients without fistula excision, and in two cases after fistulas excision. In one case associated gastero-entero and entero-entero anastomosis was performed. In all cases with secondary AEFs, after removing of the previously implanted aortic graft, the aorta was closed just below the renal arteries root, and wrapped with a vascularized pedicle of omentum, to separate it from the bowel and the contained area. The duodenal defect was closed after fistulas excision using two layers transversal suture technique in two cases, and in one patient with large fistula a partial duodenectomy and Roux's procedure were necessary. In two patients in whom AEFs involved the transversal and sigmoid colon colostoma was performed. In three cases an extra-anatomic axillo-bifemoral bypass graft was performed for lower limbs revascularization, and in one patient bypass from the ascendent aorta to the femoral artery, using retroperitoneal route was carried out. In one patient the revascularization of the lower limbs was not done because of intraoperative death of the patient. RESULTS: Seven of our patients died during the first 15 postoperative days. One died during the operation after massive acute myocardial infarction. In other six cases the mortality causes were: MOFS-3 cases, and secondary enteric fistula-3 cases. Two of our patients survived. One has been followed-up for 15 years, and his axillo-bifemoral bypass is patent. The other with bypass from the ascendent aorta to the femoral artery died 7 years after the operation, also with patent graft. More details are given in Table 3. DISCUSSION: Sir Astley Cooper was the first who described primary AEFs caused by AAA rupture in 1817 [6], and Brock in 1953, first described secondary AEF developed 6 months after aortic homograft implantation [8]. In 1957, Haberer successfully treated primary AEF by suture of the duodenal defect and aneurysmorrhaphy [9]. In our country Stojanovitsh and Vujadinovitsh in 1966, first treated primary AEF [16]. Their patient died due to MOFS. However, in 1984 and 1985, Lotina successfully treated two patients with secondary AEFs [11] (Figure 3, Sheme 1). The authors also analyzed literature data on the aetiology, pathogenesis, clinical manifestations, diagnosis and treatment of AEFs. In conclusion, the authors suggest: 1. "Omega" extra-anatomic bypass from supraceliac artery trough retroperitonely to femoral arteries; 2. "In situ" replacement of the abdominal aorta using cadaveric homografts; 3. Intraoperative control of bleeding with endoluminal balloon occlusive aortic catheter.

[Treatment of the thoracic outlet vascular syndrome]. / Tretman vaskularnog sindroma gornjeg otvora grudnog kosa.

INTRODUCTION: The title "Thoracic Outlet Syndrome" (TOS) was introduced by Peet in 1956 [1]. In 1958 Charles Rob defined TOS as a "set of symptoms that may exist due to compression on the brachial plexus and on subclavian vessels in the region of the thoracic outlet" [2]. Compression due to cervical rib was first described by Galenus and Veaslius in the 2nd century A.D. The first unsuccessful resection of the cervical rib in patients with TOS was performed by Coote in 1861 [4]. In 1905 Murphy first made a successful resection of the cervical rib in patients with TOS and subclavian artery aneurysm [5]. He also removed the normal first rib in patients with TOS using the supraclavicular approach for the first time [6]. In 1920 Law described ligaments and other structures originating in soft tissue associated with TOS [8], while Adson and Coffey in 1927 emphasized the role of the scalene anticus muscle in TOS [3]. Ochsner, Gage and DeBakey in 1935 named it the "scalenus anticus syndrome", and made the first successful resection of the anterior scalene muscle [9]. In 1966 David Ross introduced the transaxillary resection of the first rib to relieve TOS [11]. The aim of the paper is to describe the treatment of patients with vascular TOS. MATERIAL AND METHODS: Over a six-year-period (1990-1997) 12 patients with vascular TOS were evaluated at our Centre. Seven (58%) were female and 5 (42%) male patients, average age 33.1 years. Eleven of them had congenital TOS, and one acquired TOS after trauma at neck-shoulder region. Seven patients had arterial and 5 venous TOS. Two patients with arterial TOS had ischaemia of the upper extremity due to embolism of the brachial artery. In one of them axillary artery was completely thrombosed, and in the other postenotic dilatation of the subclavian artery was present. The other 5 patients with arterial TOS demonstrated only hand pain and radial puls during hyperabduction of the arm. One of our patients with venous TOS had also symptoms and signs of hand oedema during hyperabduction, while four patients had axillary-subclavian deep venous thrombosis (DVT). All patients underwent CW-Doppler and Duplex-ultrasonographic examination. The results were positive in all patients with arterial TOS. The angiographic (selective arteriography of the subclavian artery) examination showed the same results. Diagnostic procedures were performed in normal position of the arm and during hyperabduction. The angiography also revealed: one aneurysm of the subclavian artery, one poststenotic dilatation of the subclavian artery with brachial artery embolization, and one thrombosed axillary artery with brachial artery embolization (Figure 1). In five patients the angiogram was normal in normal position of the arm, but showed arterial flow obstruction at the thoracic outlet during hyperabduction (Figures 2a and 2b). In patients with venous TOS Duplex ultrasonographic examination was performed. The cervical rib caused TOS in four of our patients and clavicle fracture calus in one case. In 7 patients bone anomalies were not found (Figure 3). The operative treatment was carried out in 3 patients with venous and 7 patients with arterial TOS. In two patients with DVT of the axillary-subclavian segment, 6 months after standard anticoagulant therapy, decompressive procedures were performed (one resection of the cervical rib, and one transauxillary resection of the first rib). In the case of venous TOS without DVT, a supraclavicular resection of the first rib was performed immediately after diagnosis. In 5 patients with arterial TOS without morphologic changes on the arterial system, a decompressive procedure was done. The following procedures were carried out: one scalenotomy, one supraclavicular and three transaxillary resections of the first rib. (ABSTRACT TRUNCATED)

[Surgery of abdominal aorta with horseshoe kidney]. / Hirurski zahvati na aorti abdominalis kod bolesnika s potkovicastim bubregom.

Seventy one surgical procedures on abdominal aorta in patients with horseshoe kidney have been reported in literature until 1980. Bergan reviewed 30 operations of abdominal aortic aneurysms (AAA) in these patients until 1974. Of them 3 AAA were ruptured. Gutowitz noticed 57 surgically treated AAA in patients with horseshoe kidney until 1984. Over the period from 1991 to 1996 thirty nine new cases were reported , including 2 ruptured AAA. The surgery of the abdominal aorta in patients with horseshoe kidney is associated with the following major problems: -reservation of anomalous (aberrant) renal arteries; reservation of the kidney excretory system; approach to the abdominal aorta (especially in patients with AAA) and graft placement The aim of the paper is the presentation of 5 new patients operated for abdominal aorta with horseshoe kidney. Over the last 12 years (January 1, 1984 to December 31, 1996) at the Centre of Vascular Surgery of the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia, 5 patients with horseshoe kidney underwent surgery of the abdominal aorta. There were 4 male and one female patients whose average age was 57.8 years (50-70). Patient 1. A 50-year-old male patient was admitted to the hospital for disabling claudication discomforts (Fontan stadium IlI) and with significantly decreased Ankle-Brachial indexes (ABI). The translumbal aortography showed aorto-iliac occlusive disease and horseshoe kidney with two normal and one anomalous renal artery originating from infrarenal aorta (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. The aorto-bifemoral (AFF) bypass with Dacron graft was done with end-to-end (TT) proximal anastomosis just under the anomalous renal artery. The graft was placed behind the isthmus. During a 12-year follow-up renal failure, renovascular hypertension and graft occlusion were not observed. Patient 2. A 53-year-old male patient was admitted to the hospital for symptomatic AAA. Two years before admission the patient underwent coronary artery bypass grafting. The Duplex scan ultrasonography and translumbal aortography showed an infrarenal AAA, aneurysm of the right iliac artery and horseshoe kidney with two normal and one anomalous renal artery originating from the left iliac artery (Crawford type III). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy, the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the bifurcated graft was anastomosed with the common femoral artery and the left limb with left iliac artery just above the origin of the anomalous renal artery. The first day after operation thrombosis of the left common femoral artery with leg ischaemia was observed. (That artery was cannulated for ECC during coronary artery bypass grafting 2 years ago). The revascularisation of the left leg was done with femoro-femoral cross over bypass. During a 11-year follow-up period, the graft was patent and renal failure or revascular hypertension were not observed. Patient 3. A 66-year-old male patient was admitted to the hospital for rest pain (Fontan stadium III) and significantly decreased ABI. The patient had diabetes mellitus and myocardial infarction two months before admission. Translumbar aortography showed an aorto-iliac occlusive disease associated with horseshoe kidney with 5 anomalous renal arteries. (Crawford type III). Due to high risk, the axillo-bifemoral (AxFF) extra-anatomic bypass graft was performed. Five years after the operation the patient died due to new myocardial infarction. During the follow-up period the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 4. A 50-year old male patient was admitted to the hospital for high asymptomatic AAA. The diagnosis was established by Duplex scan and translumbal aortography. The large infrarenal AAA (transverse diameter 7 cm) associated with horseshoe kidney with two normal renal arteries (Crawford type I) were found. Intravenous pyelography and retrograde urogrpahy showed two separated ureters. After partial aneurysmectomy the tubular Dacron graft was placed behind the isthmus. During a 15-month follow-up the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 5. A 70-year-old female patient was admitted to the hospital for large asymptomatic AAA. The Duplex ultrasonography, CT scan, NMR and translumbal aortography showed an infrarenal AAA, aneurysms of the both common iliac arteries, aneurysm of the left hypergastric artery and horseshoe kidney with two normal and two anomalous renal arteries. One of the anomalous renal arteries originated from AAA, and the other from the left common iliac artery (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the graft was anastomosed (TT) with bifurcation of the common iliac artery and the left limb with the distal part of the common iliac artery (end-to-side) just above the origin of the second anomalous renal artery. The first anomalous renal artery that originated from AAA was removed from the aneurysm wall and anastomosed with graft using Carrel patch technique. During a 9-month follow-up the graft was patent and there were no signs of renovascular hypertension and renal failure. The horseshoe kidney is a rare anomaly of the urinary system. The incidence of this anomaly is from 1:1600 to 1:400 In 95% of cases the kidneys are connected with the lower poles, while in 5% with the upper poles In most cases, the isthmus structure is parenchimatous structure, and rarely it consists of the connective tissue. Usually the isthmus is located in front of the abdominal aorta and inferior vena cava, and very rarely behind them In two thirds of patients anomalous vascularization is present There are two classifications of anomalous vascularization: Papin's and Crawford's. According to Papin's classification, based on the number of renal arteries, there are three types of horseshoe kidney vascularization: Papin I (20%): There are two normal renal arteries only. (One of our 5 patients); Papin II (66%): There are 3-5 renal arteries. (Four of our 5 patients); Papin III (14%): There are more than 5 renal arteries. The Crawford's classification based on the origin of renal arteries, is of greater surgical importance than Papin's. According to it there are also three types of vascularization: Crawford I: There are two renal arteries with normal origin. (One of our 5 patients); Crawford II: Besides two normal, there are 1-3 anomalous renal arteries originating from the infrarenal aorta or iliac arteries (Three of our 5 patients); Crawford III: All renal arteries have an anomalous origin. (One of our 5 patients). The patients with horseshoe kidney can also have two separated, or one connected excretory urinary systems. All our 5 patients had two separated ureters. There is no specific clinical manifestation of the horseshoe kidney. Urinary infection or calculosis are very frequent as are in other urinary anomalies. The diagnosis of horseshoe kidney is established by Dupplex ultrasonography, CT scan, NMR, radionuclide scintigraphy and angiography. Very often the diagnosis is established occasionally during the examination of aneurysmal and occlusive diseases of the abdominal aorta. In cases of AAA or AIO associated with horseshoe kidney preoperative vascularization and condition of the excretory system should be established. Besides standard translumbar aortography selective renovasography is often neccessary. In some cases the intraoperative angiography or arterial identification, with metallic probe must be done. All renal arteries are "terminal" without significant anastomosis on the side of the kidney. Therefor its preservation is neccessary. There are three ways. The first is the location of anastomosis (3 of our patients). The second is an AxFF bypass, but only in patients with AIO (One of our patients and in the third reimplantation of the renal artery using Carrel patch technique was performed (One of our patients). The Isthmus of the kidney aggravates aortic preparation especially in patients with AAA. Sometimes isthmectomy is neccessary. In such cases there is danger of urinary fistula. Therefor many authors suggest the left extraperitoneal approach to abdominal aorta. In our patients, the transperitoneal approach was used, isthmectomy was not neccessary and graft was placed behind the isthmus. The operation of the abdominal aorta in patients with horseshoe kidney can be difficult due to anomalous renal arteries, anomalous excretory urinary system and is Ehmus. In these patients a more precise preoperative diagnosis is neccessary.

Popliteal artery aneurysms.

Altogether 59 patients with 76 popliteal artery aneurysms were treated during the last 36 years. There were 50 (85%) male and 9 (15%) female patients with an average age of 61 years. Nineteen (32%) patients had bilateral aneurysms. The clinical manifestations of the aneurysms included ruptures 4 (5.3%); deep venous thrombosis 4 (5.3%); sciatic nerve compression 1 (1.3%); leg ischemia 52 (68.4%), and asymptomatic pulsatile masses 15 (19.7%). Seventy (92%) aneurysms were atherosclerotic, one (1.3%) mycotic, and four (5.3%) traumatic; one (1.3%) developed owing to fibromuscular displasia. Seven (9.2%) small, asymptomatic aneurysms were not operated on. Reconstructive procedures end-to-end anastomosis, graft interposition, bypass) after aneurysmal resection or exclusion using a medial or posterior approach were done in 59 cases. An autologous saphenous vein graft was used in 49 cases, polytetrafluoroethylene (PTFE) in 5, and heterograft in 2 cases. The in-hospital mortality rate was 2.9%, the early patency rate 93.3%, and limb salvage 95%. The long-term patency rate after a mean follow-up of 4 years was 78% and long-term limb salvage 89%. The total limb salvage was 73%, and the total amputation rate was 27%. The dangerous complications associated with popliteal artery aneurysms and the good results after elective procedures suggest that operative treatment is appropriate.

[Acute superficial thrombophlebitis--modern diagnosis and therapy]. / Akutni povrsni tromboflebitis--savremena dijagnostika i lecenje.

Acute superficial thrombophlebitis of the lower extremities is one of the most common vascular diseases affecting the population. Although it is generally considered as a benign disease, it can be extended to the deep venous system and pulmonary embolism. We examined 50 patients (22 males and 28 females), mean age 52.5 years. These patients were surgically treated due to acute superficial thrombophlebitis of the lower limbs that affected great saphenous vein above the knee. The diagnosis was made by palpable subcutaneous cords in the course of great saphenous vein or its tributaries in association with tenderness, erythema and oedema. Of these 50 patients, 26 were examined by duplex ultrasonography before the operation. In 20 patients duplex scanning confirmed that the process was greater than we supposed after clinical examination (77%) and in 6 patients there were no differences (23%) (Figures 1 and 2). The operation included crossectomy, ligation and resection of the proximal part of the great saphenous vein. Intraoperative findings in 38 patients showed that the level of the phlebitic process was higher than the clinical level (76%). There was no difference in 12 patients (24%). Deep vein thrombosis and pulmonary embolism were noted in 14 patients (28%) (Tables 1 and 2). Both complications were found in two patients, and 12 had one of these complications. Generally, there were 12 patients with deep venous thrombosis and 4 patients with pulmonary embolism. Only in one patient deep venous thrombosis appeared postoperatively, while all other complications occurred before surgical intervention (Scheme 1 and Table 3). The most common risk factor was the presence of varicose veins (86%). Obesity, age over 60 years, cigarette smoking are listed in decreasing order of frequency. Patients under 60 years were more likely to have complications while older patients usually followed a benign clinical course (Tables 4 and 5). There was no intrahospital mortality. Average hospitalization was 5.7 days. It was 4 days in patients without complications. After thes urgent operation that practically removed the risk of potentially fatal consequences, the patients were dismissed from hospital. New hospitalization was recommended after two weeks when the second act of surgical treatment was performed. It included stripping of the great saphenous vein and extirpation of varicose veins in the area without acute inflammation. The findings of this study confirm the general opinion that acute superficial thrombophlebitis is a very common vascular disease with usually "benign" clinical course. In its ascending form that affects the great saphenous vein above the knee it can be associated with deep venous thrombosis and pulmonary embolism. The level of phlebitic process is usually much higher than can be palpated clinically. Duplex scanning was a highly reliable, precise, fast non-invasive diagnostic method that is necessary in examining, following and making decision for operative treatment of acute superficial thrombophlebitis. If suspected complications an urgent surgical intervention should be performed. It is short and efficient, contributing to the fast recovery of the patients and their return to normal activities.

[Long-term patency of reversed and in situ femoro-popliteal bypasses]. / Udaljena (kasna) protocnost femoro-poplitealnog bajpasa ucinjenog "reverznim" i "in situ" metodima.

INTRODUCTION: The small choice of graft materials is one of the greatest problems in femoro-popliteal (F-P) bypass reconstructions. Besides all biosynthetics(2-5) and synthetics(6) graft materials, there is no right alternative for autologous saphenous vein graft in F-P reconstructions. There are two main techniques for F-P reconstructions: "reversed" and "in situ". The aim of this study is the comparison of the long-term patency between "reversed" and "in situ" F-P bypasses. PATIENTS AND METHODS: In the study were included 191 patients with "reversed" and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass, and 78 (78.78%) male and 21 (21.22%) female patients in the group with "in situ" bypass. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.43%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and as 80 (80.8%) in the group with "in situ" bypass. In Table 1 the Fontain classification of occlusive diseases in operated patients is presented. The early proximal reconstructions were performed in 49 patients with "reversed" and 16 patients with "in situ" bypasses (Table 2). The associated proximal reconstructions were performed in 21 patients with "reversed" and in 14 patients with "in situ" bypasses (Table 3). All patients were controlled by physical and Doppler ultrasonographic examination immediately after the operation, after 1, 3, 6 months, and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiographic examinations was also performed. The statistical analysis of the results was done using "Life table" analysis. RESULTS: The patients were followed-up from 3 to 10 years. The results of "life-table" analysis are presented in Tables 4-8 and Graph 1. The "in situ" technique showed statistically significant better long-term patency compared to "reversed" technique, after 2 and 10 years (p < 0.05). The immediate patency in cases with "reversed" bypass was 98.96%, while limb salvage was 97.91%. In the same group long-term patency was 72.8% and limb salvage 73.9%. In the group with "in situ" bypasses the immediate patency as well as limb salvage were 96.97%. In the same group long-term patency was 73.8% and limb salvage 77.2%. In Table 5 potential advantages of the "in situ" F-P bypass technique are shown (16-21). However, there are controversial data on clinical results of both bypasses. Some authors described better long-term results of the "in situ" F-P bypass technique (28-30), while according to other data there are no significant differences between these two bypass groups (31-33). Most authors emphasized the two advantages of "in situ" bypasses in F-P reconstructions: a small diameter of the saphenous vein; in cases with pure run off (34-36).