In situ revascularisation for femoropopliteal graft infection: ten years of experience with silver grafts.

PURPOSE: The purpose of this study was to analyze clinical outcome of patients for femoropopliteal graft infection who were treated by in situ reconstruction with a silver-coated prosthesis. BASIC METHODS: From December 2001 to December 2011, 27 patients were treated for femoropopliteal graft infection. Twenty patients (74%) were male and seven (26%) were female. Mean age was 65 years. The primary endpoint was recurrence of infection. Secondary endpoints were early and late mortality and morbidity, primary graft patency, major amputation rates and patient survival. PRINCIPAL FINDINGS: Early reinfection occurred in 11% and late in 8% of patients. Perioperative mortality was 7% and late was 4%. Above-knee amputation was performed in 4% of patients during early postoperative course and in 12% of patients during follow-up. Early and late graft patency was 96% and 72%, respectively. CONCLUSIONS: Results of in situ implantation of silver-coated grafts for femoropopliteal prosthesis infection are according to our opinion acceptable, but the risk of reinfection remains.

Body mass index and primary chronic venous disease--a cross-sectional study.

OBJECTIVES: This study aims to investigate whether overweight and obesity are related to the clinical (C) category of clinical, etiologic, anatomic and pathophysiologic (CEAP) classification of chronic venous disease (CVD). DESIGN: A cross-sectional study. MATERIALS AND METHODS: The study was conducted in Serbia, in the year 2011. Men and women aged >18 years, consecutively coming to venous specialists because of venous problems in the legs, were included in the study. Patients demographic, anthropometric and clinical data were collected. For the analysis, univariate and multivariate logistic regressions were used. RESULTS: The study comprised 1116 subjects with primary CVD, 384 (34.4%) men and 732 (65.6%) women. Among them 464 (41.6%) were normal-weight patients (body mass index (BMI) < 25.0 kg m(-2)), 476 (42.7%) were overweight (BMI = 25.0-29.9 kg m(-2)) and 176 (15.8%) were obese (BMI ≥ 30.0 kg m(-2)). According to multivariate analysis, the CEAP C category of CVD was significantly more advanced in overweight and obese patients, the association being more pronounced in obese. Compared groups did not differ in the presence of venous reflux. In univariate analysis, venous obstruction was related to overweight and obesity but this association did not substantially affect the relationship between obesity and CEAP C categories of CVD. CONCLUSION: The CEAP C categories of CVD were significantly related to overweight and obesity, and this association was independent of age, sex and some other postulated risk factors.

Anatomy and radiology of the variations of aortic arch branches in 1,266 patients.

BACKGROUND: The most reliable data about arterial variations, which are very important in surgery and radiology, can be obtained from a large series of patients. MATERIALS AND METHODS: We examined angiographic and multislice computerised tomography (MSCT) images in a group of 1,265 patients and in 1 dissected specimen. RESULTS: While in 946 (74.72%) of the patients a normal vascular pattern (type I) was noticed, in the remaining 320 (25.28%) patients variations of the branches of the aortic arch were found, which were classified into types II through VIII and a few subtypes. Type II (2.84%) comprised a common origin of the left commoncarotid and subclavian arteries. Type III (15.56%) was related to an origin of the left subclavian artery from the brachiocephalic trunk. Type IV (0.55%) included the aortic origin of both common carotid and subclavian arteries, with the right subclavian artery having a retroesophageal course. Type V (0.24%) included the same 4 supra-aortic branches, which, however, arose from a double or a right--sided aortic arch. Type VI (3.63%) comprised the aortic origin of the left vertebral artery, type VII (0.24%) the same origin of the right vertebral artery, and type VIII(2.22%) the aortic origin of the thyroideaima artery. A corresponding embryological background and clinical implications of the described aberrant vessels were presented. CONCLUSIONS: In more than one quarter of the cases, the branching pattern of the examined arteries did not follow the classical pattern. Detailed knowledge of aortic branch variations is of great significance in anatomy, embryology, and clinical medicine, especially in radiology and thoracic surgery.

Surgical reconstruction for unilateral iliac artery lesions in patients younger than 50 years.

BACKGROUND: To evaluate safety, short and long-term graft patency, clinical success rates, and factors associated with patency, limb salvage and mortality after surgical reconstruction in patients younger than 50 years of age who had undergone unilateral iliac artery bypass surgery. PATIENTS AND METHODS: From January 2000 to January 2010, 65 consecutive reconstructive vascular operations were performed in 22 women and 43 men of age < 50 years with unilateral iliac atherosclerotic lesions and claudication or chronic limb ischemia. All patients were followed at 1, 3, 6, and 12 months after surgery and every 6 months thereafter. RESULTS: There was in-hospital vascular graft thrombosis in four (6.1 %) patients. No in-hospital deaths occurred. Median follow-up was 49.6 ± 33 months. Primary patency rates at 1-, 3-, 5-, and 10-year were 92.2 %, 85.6 %, 73.6 %, and 56.5 %, respectively. Seven patients passed away during follow-up of which four patients due to coronary artery disease, two patients due to cerebrovascular disease and one patient due to malignancy. Limb salvage rate after 1-, 3-, 5-, and 10-year follow-up was 100 %, 100 %, 96.3 %, and 91.2 %, respectively. Cox regression analysis including age, sex, risk factors for vascular disease, indication for treatment, preoperative ABI, lesion length, graft diameter and type of pre-procedural lesion (stenosis/occlusion), showed that only age (beta - 0.281, expected beta 0.755, p = 0.007) and presence of diabetes mellitus during index surgery (beta - 1.292, expected beta 0.275, p = 0.026) were found to be significant predictors of diminishing graft patency during the follow-up. Presence of diabetes mellitus during index surgery (beta - 1.246, expected beta 0.291, p = 0.034) was the only variable predicting mortality. CONCLUSIONS: Surgical treatment for unilateral iliac lesions in patients with premature atherosclerosis is a safe procedure with a low operative risk and acceptable long-term results. Diabetes mellitus and age at index surgery are predictive for low graft patency. Presence of diabetes is associated with decreased long-term survival.

Dacron or ePTFE graft for above-knee femoropopliteal bypass reconstruction. A bi-centre randomised study.

BACKGROUND: The objective of this study was to compare polyester (Dacron) and expanded polytetrafluorethilene (ePTFE) grafts for above-knee femoropopliteal bypass. PATIENTS AND METHODS: Eighty five patients with disabling claudications or limb threatening ischemia suitable for above-knee femoropopliteal reconstruction were randomized into two groups. In the first group the surgery was performed using 8 mm Dacron graft, whereas the patients in the second group were operated using ePTFE grafts. RESULTS: The primary patency rates for Dacron and ePTFE were 100 %, and 88.37 % (p < 0.05), while secondary patency rates were 83.3 % and 75 % (p > 0.05) respectively. The early limb salvage rates for Dacron and ePTFE were 100 % and 97.7 % (p > 0.05). Early (30-day) complications (bleeding 2.38 % and 2.32 %; wound infection 11.9 % and 11.63 %) occurred in both groups with similar frequency (p > 0.05). The patients were followed up over a period of 6 to 12 months (mean 8.3 +/- 3.6 months). The overall mortality rate in the follow-up period was 2.38 % (one patient) for Dacron and 6.98 % (three patients) for ePTFE group (p > 0.05). Late graft infection was noted in three patients (7.1 %) in Dacron, and two patients (4.65 %) in ePTFE group (p > 0.05). Primary patency rates were not significantly influenced by obesity, diabetes, hypertension, hyperlipidemia, cigarette smoking, (p > 0.05). However, poor run-off (only one crural artery patent on preoperative angiography) significantly decreased patency of both grafts and favored the use of ePTFE graft (p < 0.05). CONCLUSIONS: This study confirms that both materials are suitable for above-knee femoropopliteal reconstructions. Above-knee femoropopliteal bypass does not have a good long-term prognosis in the presence of poor run-off.

Clinical efficacy of once-daily micronized purified flavonoid fraction 1000 mg tablet in patients with symptomatic chronic venous disease.

AIM: To investigate the clinical efficacy of micronized purified flavonoid fraction (MPFF) 1000 mg given as a single 1000 mg tablet once daily in patients suffering from chronic venous disease (CVD) vs MPFF 500 mg twice daily. METHODS: In an international, randomized, double-blind, parallel-group study, patients classified C0s to C4 according to Clinical Etiological Anatomic Pathophysiologic [CEAP] classification and with leg pain graded as superior to 4 cm on a 10-cm visual analog scale (VAS), were treated for 8 weeks with either MPFF 1000 mg once daily or MPFF 500 mg twice daily. The present post-hoc analysis focuses on the effect of treatment over time in patients randomized to the MPFF 1000 mg group. Leg pain was assessed at each follow-up visit by VAS. VAS scores over time were compared between each visit using paired Student t-tests. RESULTS: In total, 87 patients out of 174 were randomized to the MPFF 1000 mg group. Mean age ± SD was 49.1 ± 12.2 years, most of the patients were female (81.6%), the main CEAP classes of the most affected leg were C1 (20.7%), C2 (39.1%), C3 (33.33%), and the mean duration of CVD was 14.6 ± 10.9 years. Patients with previous CVD treatment represent 27.6% of the patients. A MPFF 1000 mg tablet once daily was associated with a significant and continuous reduction in leg pain throughout the treatment period: -1.54 cm (±1.45) from baseline to week 2 (p < .01), -1.11 cm (±1.06) from week 2 to week 4 (p < .01), -1.57 cm (±1.05) from week 4 to week 8 (p < .01). CONCLUSIONS: The new MPFF 1000 mg dose regimen in once daily tablets was associated with a rapid and continuous reduction in leg pain throughout the 8-week treatment period.

Hypothesis related to the regulation of inducible nitric oxide synthase during carotid endarterectomy.

Sudden occlusion of an artery caused by a thrombus or emboli is the most frequent cause of acute brain ischemia (ABI). Carotid endarterectomy (CEA) represents the gold standard for preventing strokes of carotid origin. However, neuronal damage caused by ischemia and/or reperfusion may contribute to a poor clinical outcome after CEA. In response to shear stress caused by hypoxic-ischemic conditions in patients undergoing CEA, stimulation of the hypothalamic-pituitaryadrenal axis leads to biological responses known as hypermetabolic stress, characterized by hemodynamic, metabolic, inflammatory and immunological changes. These changes maintain homeostasis and assist recovery, but an unregulated inflammatory response could lead to further tissue damage and death of neurons. Nitric oxide (NO) is an important signaling molecule involved in several physiological and pathological processes, including ABI. However, an excess of NO could have detrimental effects. We hypothesized that the hypoxic-ischemic state induced by carotid clamping leads to overexpression of inducible NO synthase and that uncontrolled production of NO could adversely affect outcome after CEA.

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

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

Relationship Between Pain and CEAP C Categories of Chronic Venous Disease.

In this study, we investigated whether the occurrence and intensity of leg pain are related to C class of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification for chronic venous disease (CVeD). This cross-sectional study, conducted in Serbia, included 2841 patients: 2027 (71.3%) women and 814 (28.7%) men with CVeD diagnosed by general practitioners. For the first time, the Numeric Rating Scale of 0 to 5 units was used to assess the intensity of pain. For the analysis, univariate and multivariate logistic and linear regressions were applied. Pain in the legs was reported by 90.5% of the patients. The occurrence of pain significantly (P < .001) increased with increasing C class. Of the patients who reported pain in the legs, 42.0% had moderate pain, 23.7% had moderate to severe pain, 22.8% had light pain, 11.2% had severe pain, and 0.3% had very severe pain. Severity of pain differed significantly (P < .001) according to C class. Light and moderate pain gradually decreased and severe pain gradually increased from C0 to C6 class. These associations remained significant after adjustment for age, body mass index, and family history of CVeD.

Iron concentrations in atherosclerotic plaque and serum in patients with carotid atherosclerosis.

The aim of this study was to investigate the iron concentrations in serum and carotid plaque in patients with different morphology of carotid atherosclerotic plaque and compared with other metal ions. Carotid endarterectomy due to the significant atherosclerotic stenosis was performed in 91 patients. Control group consisted of 27 patients, without carotid atherosclerosis. Atherosclerotic plaques were divided into four morphological groups, according to ultrasonic and intraoperative characteristics. Iron, copper and zinc concentration in plaque, carotid artery and serum were measured by spectrophotometry. Serum iron concentrations were higher in patients with hemorrhagic plaques in comparison to the control group (4.7 µmol/l ± 1.2 vs. 2.1 µmol/l ± 0.8, p < 0.05). Iron concentrations were higher in patients with hemorrhagic plaques in comparison to fibrolipid plaques (72.1 ± 14.3 µg/g vs. 39.3 ± 22.9 µg/g; p < 0.05). Negative significant correlation was found for zinc in serum and plaque iron concentration in patients (p < 0.05). We also demonstrated positive significant correlation for copper and iron in serum (p < 0.05). The data obtained in the current study are consistent with the hypothesis that high iron levels may contribute to atherosclerosis and its complications as factors in a multifactorial disease.

Doppler-based diagnosis of restenosis after femoropopliteal percutaneous transluminal angioplasty: sensitivity and specificity of the ankle/brachial pressure index versus changes in absolute pressure values.

The aim of this study was to investigate the sensitivity and specificity of changes of the ankle/brachial pressure index (ABI) and changes in absolute ankle pressure values to detect restenosis in patients who underwent femoropopliteal percutaneous transluminal angioplasty (PTA). In total, 171 patients were followed up prospectively for 12 months; sensitivity and specificity of Doppler-based diagnosis were calculated with duplex scanning as the gold standard. The criteria for restenosis were: (1) a loss of 50% of the ABI increase or (2) loss of 50% of the absolute ankle systolic pressure, gained by PTA. For both criteria, different cut-off points (minimum increase of ABI or ankle pressure gained by PTA) were evaluated. The overall sensitivity and specificity of the ABI criterion was 67% and 80%, respectively. The introduction of cut-off points (the minimum ABI increase gained by PTA), ranging between > or = 0.13 and > or = 0.35, did not markedly improve the results. The overall sensitivity and specificity of the absolute ankle pressure criterion again was poor (59% and 81%). With the introduction of cut-off points (the minimum increase of absolute ankle pressure gained by PTA) ranging between > or = 15 mm Hg and > or = 20 mm Hg, the sensitivity and specificity of the criterion improved to acceptable 92% and 96%, respectively. It is concluded, that in the long-term follow-up of PTA patients, the "loss of 50% ankle pressure" criterion will detect restenosis with reasonable accuracy in those patients, in whom an increase in systolic ankle pressure > or = 20 mm Hg is warranted.

[Neoangiogenesis and human amniotic membrane. A clinico-instrumental study in phlebostatic ulcer of the lower extremities]. / Neoangiogénesis y membrana amniótica humana. Estudio clínico-instrumental en la úlcera flebostática de los miembros inferiores.

The present study was made in order to determine if granulation tissue development after treatment with Human Amniotic Membrane (HAM) is related with instrumental photoplethysmographically evidenced changes of the "ulcus layer". Daily, HAM fragments were disposed along the continuity solution of external patients with opened postthrombotic ulcus cruris. Instrumental examinations were made before, a week after and two weeks after treatment, and after the complete ulcus healing. Ulcus with a slight granulous or fibrogranulous layer developed a granulation tissue within the first week of treatment. On the contrary, in continuity solutions with necrotic layer, treatment with HAM failed. After the first week of treatment, a 84% of ulcus with slight granulation and fibrinogranulation, presented some sphygmic variations respect to baseline levels, like: raising in the amplitude and dicrotism appearing. Within the first week, all of the continuity solutions showed significant sphygmograms with a regular vascularization on the layer, this period of time concurred with the complete granulation phase of the ulcus. Long-preserved HAM stimulates in a significant way the appearing of the granulation tissue, within the first week of treatment. Sphygmic raisings are directly proportional with the amount of granulated tissue evidenced on the layer of the continuity solution.

[Reinterventions for the late failures of femoral-distal grafts]. / Reintervenciones para fallos posteriores de los injertos femorodistales.

In this retrospective study of 195 patients treated for late failure of a previous femoral-distal reconstruction, there were 178 men and 17 women ranging in age from 42 to 79 years. The graft material utilised for initial operation was an autogenous vein reversed saphenous vein (75), in situ (1), and arm veins (4) in 80, polytetrafluoroethylene in 51, Dacron in 46, Biografts in 12 and composite grafts in 6 patients. The previous site for distal anastomosis was above the knee in 79, and tibial or peroneal arteries in 18 cases. The most common cause of graft failure was late thrombosis (95), progression of the underlying disease (64), deterioration of the graft (15), pseudoaneurysms (8), and rarely perigraft reactions, hemodynamic insufficiency, late infection, etc. The aim of the reoperation was: graft extension for distal disease (68) desobstruction and patch angioplasty (21), thrombectomy (9) exchange of the graft (17), local repair of the graft (3). Seventeen patients required inflow procedures. Other reinterventions (sympathectomy, catheterisation and prostaglandin perfusion) were used in patients with no chance for reconstructive arterial surgery. Secondary reoperations were performed in 12, tertiary operations in 7 patients. Major amputations rate, operation mortality, wound morbidity and hemodynamic success rates with limb salvage in reoperated patients support usefulness of repeated revascularisation when femoro-distal bypass failure occurs.

[Reinterventions in late failures of femorodistal grafts]. / Reintervenciones en los fallos tardíos de los injertos femorodistales.

In this retrospective study of 195 patients treated for late failure of a previous femoral-distal reconstruction, there were 178 men and 17 women ranging in age from 42 to 79 years. The graft material utilised for initial operation was an autoenous vein (reversed saphenous vein (75), in situ (1) and arm veins (4) in 80, polytetrafluoroethylene in 51, Dacron in 46, Biografts in 12 and composite grafts in 6 patients. The previous site for distal anastomosis was above the knee in 70 and tibial or peroneal arteries in 18 cases. The most common cause of graft failure was late thrombosis (95), progression of the underlying disease (64), deterioration of the graft (15), pseudoaneurysms (8), and rerelly perigraft reactions, hemodynamic insufficiency, late infection, etc. The aim of the reoperation was: graft extension for distal disease (68) desobstruction and patch angioplasty (21), thrombectomy (9) exchange of the graft (17), local repair of the graft (3). Seventeen patients required inflow procedures. Other reinterventions (sympathectomy, catheterisation and prostaglandin perfusion, were used in patients with no chance for reconstructive arterial surgery. Secondary reoperations were performed in 12, tertiary operations in 7 patients. Major amputations rate, operation mortality, wound morbidity and hemodynamic success rates with limb salvage in reoperated patients support usefulness of repeated revascularisation when femoro-distal bypass failure occurs.

[Treatment of complications of in situ saphenous by-pass]. / Tratamiento de las complicaciones del "by-pass" safeno "in situ".

The early and late (2-12 months) complications of in situ bypass for 24 patients (limb salvage procedures) were presented. The early complications were: 1. Overlook branches of saphenous vein developed into A-V fistulas which religated (2 patients). 2. Graft occlusions (2 patients). A successful thrombectomy was carried out on one patient, while an above knee amputation was performed on the other patient. 3. A deep venous thrombosis (one being crural, the other femoral) was treated with medication therapy. We recorded late complications: two graft occlusions (after 3 and 6 months) where redo surgery was impossible for distal progression of occlusion disease. The following procedures must be done: per-operative angiography, adequate technique of anastomoses and defects of the femoral vein, postoperative application of medication therapy, observation of patients in the later post-operative period and routine control with Doppler US (1, 3, 6, 12 months).

Copeptin level after carotid endarterectomy and perioperative stroke.

We evaluated the prognostic value of copeptin levels in a cohort of surgical patients after elective carotid endarterectomy (CEA). Twenty-one patients with perioperative stroke were prospectively recruited. The diagnosis of cerebrovascular event (CVE) was confirmed by computed tomography. Additionally, 21 patients with CEA without any complications (control patients) were enrolled. Blood samples were taken within 3 hours of the symptom onset. Circulating copeptin level was significantly higher in patients with CVE when compared to controls (P = .025), and significantly higher in nonsurvivors than in survivors (P = .030) after CVE. Plasma concentrations of interleukin 6 (IL-6) and C-reactive protein (CRP) were also elevated in patients with CVE (IL-6: P = .043; CRP: P = .002). We conclude that the activation of the stress axis in patients with CEA results with copeptin elevation, but more so in patients with perioperative stroke. Copeptin may be a helpful biomarker for stroke risk assessment in patients after CEA.

Duplication of the superior vena cava associated with atrial termination of the left hepatic vein.

Duplication of the superior vena cava (SVC), associated with an aberrant left hepatic vein (LHV), was found in one of the 58 dissected specimens. The right SVC virtually showed a typical appearance. The persistent left SVC, which drained into the right atrium via the enlarged coronary sinus, was formed by the persistence of the left anterior cardinal vein. The LHV opened into the right atrium, due to the persistent left hepatocardiac channel. The left common carotid artery arose from the brachiocephalic trunk as a consequence of a regression of the embryonic aortic sac. The revealed venous and arterial variations seem to be the first reported vascular combination of this type.

Internal jugular vein duplication: a further truncular malformation in a patient with multiple sclerosis.

Different internal jugular vein (IJV) abnormalities can be found in patients with multiple sclerosis (MS): stenoses, complete occlusion, distortions and intraluminal structures, such as membranes, webs and inverted valves. IJV duplication is a very rare phenomenon. We report a case of right IJV duplication as an incidental finding during IJV morphological and haemodynamic assessment in a patient with MS. A 55-year-old female patient was admitted to our Institute for IJV and vertebral veins morphological and haemodynamic assessment. During the last seven years she had been treated for MS. Colour Doppler ultrasonography in our patient did not reveal IJV or vertebral veins stenoses or abnormal valves, but instead right IJV duplication. This finding was confirmed using multislice computed tomography angiography and by selective phlebography. In conclusion, to our knowledge, a case of IJV duplication in a patient with MS has not been described yet. This further venous malformation can be assessed by the means of Doppler ultrasounds.