Totally implantable central venous catheters of the port-a-cath type: complications due to its use in the treatment of cancer patients.

PURPOSE: A multidisciplinary approach to the treatment of patients with malignant diseases requires adequate venous access in order to safely administer chemotherapy, blood transfusion and blood products, antibiotics, rehydratation and total parenteral nutrition. The insertion of the central venous catheter (CVC), its use and its maintenance can be accompanied by multiple complications. METHODS: Fifty cancer patients were retrospectively enrolled in this study. The obligatory inclusion criterion was an implanted CVC of the port-a-cath type, inserted for chemotherapy administration. This study included patients who had their catheters inserted in the period from 2001 to 2012. RESULTS: The median patient age was 44 years (range 28- 68). Thirty five patients (70%) were female and 15 (30%) male. The port-a-cath had been used from 1 to 40 months (16.8 ± 9 months on average). Breast cancer was the most frequent malignancy (18 patients, 36%). The overall incidence of reported complications was 38%. The most common complications were infections and thromboembolic events, each with an incidence of 10 %. The malposition and disconnection of the port-a-cath were in second place, each with an incidence of 6%. CONCLUSION: Insertion of the CVC carries the possibility of serious complications (thrombosis, infections, occlusions). However, correct implantation and handling performed by experienced and trained surgical and other medical staff significantly decrease the incidence of these complications. The use of the CVC has greatly improved the quality of life and also decreased the morbidity and mortality of the cancer patients in our study.

Endovascular repair of mycotic aneurysm of the descending thoracic aorta: diagnostic and therapeutic dilemmas-two case reports with 1-year follow-up.

A mycotic aneurysm of the thoracic aorta is a rare diagnosis with high mortality. We present two cases of endovascular reconstruction of mycotic descending thoracic aorta. Specific or nonspecific bacterial or other infectious agent in serial samples of blood, urine, cerebrospinal fluid, and pleural puncture was not detected in the first case, but we found in sputum sample Mycobacterium tuberculosis in the second patient. We empirically began by administering broad-spectrum intravenous antibiotics in the first case, with preoperative antibiotic prophylaxis and antituberculotic drugs therapy in the second case, and continued with the same medication for 4 months after endovascular repair. Control computed tomographic scans 6 months after reconstruction showed no endoleak in both patients. Repair of mycotic descending thoracic aortic aneurysms by endoluminal stent graft is reasonable alternative to open surgical intervention. A broad-spectrum antibiotic therapy has a high significance in the treatment of patients with mycotic aneurysm.

Correlation between climatic and biochemical parameters in etiopathogenesis of unprovoked deep vein thrombosis of the lower limbs.

AIM: Beside the intention of early detection and optimal treatment of deep venous thrombosis (DVT), the aim of this study was to investigate the influence of chronobiological rhythms on the etiopathogenesis of unprovoked deep vein thrombosis of the lower limbs with monitoring of seasonal variations in biochemical parameters. PATIENTS AND METHODOLOGY: The prospective clinical trial included all consecutive hospitalized patients and outpatients diagnosed with DVT at the Vascular Surgery Clinic of the Clinical Center in Nis, starting from January 2013 to December 2014. RESULTS: There was no statistically significant difference in correlation between the distribution of the incidence of DVT of the lower limbs (p = 0.582), sex (p = 0.350), age (p = 0.385) and localization (p = 0.886) and the seasons. Creatinine levels were significantly higher in patients who developed DVT in spring than in those who developed DVT in winter (p < 0.05), while LDL cholesterol levels were significantly higher in patients diagnosed with DVT in winter than in those diagnosed with DVT in autumn (p < 0.05). CONCLUSION: According to the results of the study, it can be concluded that in the territory of South Serbia, the seasons are not significantly related to the incidence, sex, age and localization of unprovoked DVT of the lower limbs. Creatinine levels were significantly higher in patients who developed DVT in spring than in those who developed DVT in winter, while LDL cholesterol levels were significantly higher in patients during winter than during autumn.

Aortobifemoral reconstruction and renal transplantation in a patient with abdominal aortic aneurysm and occlusion of iliac arteries: A case report.

Introduction: Aortoiliac occlusive disease and abdominal aortic aneurysm in patients with renal insufficiency on hemodialysis can significantly influence the success of renal transplantation. In the recent past, advanced atherosclerosis was considered as contraindication for renal transplantation. Complicated creation of vascular anastomoses and progression of occlusive or aneurysmal disease were the main reasons. Case report: We presented a 52-year-old man with a 5-year history of end-stage renal disease on haemodialysis. The patient was previously excluded from renal transplantation program because of severe aortoiliac atherosclerosis and abdominal aortic aneurysm. Resection of abdominal aortic aneurysm with occlusion of the iliac arteries and reconstruction with aortobifemoral synthetic grafts was performed and followed by cadaveric renal transplantation. Conclusion: Advanced atherosclerotic disease in aortoiliac segment requires elective vascular surgical reconstruction, as part of preparation for renal transplantation in patients with end-stage renal disease.

Influence of open surgical and endovascular abdominal aortic aneurysm repair on clot quality assessed by ROTEM® test.

Introduction/Aim: The disturbances in hemostasis are often in open surgical repair (OR) and endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA). These changes may influence the perioperative and early postoperative period inducing serious complications. The aim of this study was to compare the impact of OR and EVAR of AAA on clot quality assessed by rotational thromboelastometry (ROTEM®) tests. Methods: The study included 40 patients who underwent elective AAA surgery and were devided into two groups (the OR and the EVAR group - 20 patients in each group). The ROTEM ® test was performed in 4 points: point 1 - 10 min before starting anesthesia in both groups; point 2 - 10 min after aortic clapming in the OR group and 10 min after the stent-graft trunk release in the EVAR group; point 3 - 10 min after the releasing of aortic clamp in the OR group and 10 min after stentgraft placement and releasing the femoral clamp in the EVAR group; point 4 - one hour after the procedure in both groups. Three ROTEM® tests were performed as: extrinsically activated assay with tissue factor (EXTEM), intrinsically activated test using kaolin (INTEM), and extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (FIBTEM). All tests included the assessment of the maximum clot firmness (MCF) and the platelet component of clot strength was presented as maximal clot elasticity (MCE). Results: No significant difference in age, gender and diameter of AAA between groups was found. The time required for the procedure was significantly longer and loss of blood was greater in the OR group than in the EVAR group (p < 0.001). The significant deviation of MCF values in EXTEM test was found mainly in the point 3 (p ≤ 0.004) with significant difference between groups (p < 0.001). A significant difference of MCF values in INTEM test between groups was found in the points 3 and 4 (p < 0.001), which were dose-dependent by heparin sulfate. The MCF values in FIBTEM test were more prominent in the OR group than in the EVAR group without significant difference. The significant changes of MCF values in the FIBTEM test were found during time in both groups (p < 0.001). The values of MCE were lower in both groups, but without significant changes and difference between groups (p = 0.105). Conclusion: The disorders of hemostatic parameters assessed by ROTEM® tests are present in both the OR and the EVAR groups being more prominent in OR of AAA. Vigilant monitoring of hemostatic parameters evaluated by ROTEM® tests could help in administration of the adequate and target therapy in patients who underwent EVAR or OR of AAA.

Endovascular treatment of the subclavian artery aneurysm in high-risk patient - a single-center experience.

We present our first experience with endovascular treatment of 6 subclavian artery aneurysms (SAA) occurring in five male and one female patient. All patients, in our studies, according to ASA classification were high risk for open repair of SAA. The etiology of the all aneurysms was atherosclerosis degeneration of the artery. Two aneurysms were of intrathoracic location, then the other were extrathoracic. Symptoms related to subclavian artery aneurysms were present in two patients, compression and chest pain in one, and hemorrhage shock in second, while the remaining patients were asymptomatic. We preferred the Viabhan endoprosthesis for endovascular repair in 5 cases. In one patient with ruptured of subclavian artery aneurysm who was high-risk for open repair we made combined endovascular procedure. First at all, we covered the origin of left subclavian artery with thoracic stent graft and after that we put two coils in proximal part of subclavian artery. There was no operative mortality, and the early patency rate was 100%. The follow-up period was from 3 months to 3 years. During this period, one patient died of heart failure and one patient required endovascular reoperation due to endoleak type I. Endovascular treatment is recommended for all patients with subclavian artery aneurysm whenever this is possible due to anatomical reasons especially in high-risk patient with intrathoracic localization of aneurysm, to prevent potential complications.

Endovascular repair of ruptured abdominal aortic aneurysm.

INTRODUCTION: Rupture of an abdominal aortic aneurysm (AAA) is a potentially lethal state. Only half of patients with ruptured AAA reach the hospital alive. The alternative for open reconstruction of this condition is endovascular repair (EVAR). We presented a successful endovascular reapir of ruptured AAA in a patient with a number of comorbidities. CASE REPORT: A 60-year-old man was admitted to our institution due to diffuse abdominal pain with flatulence and belching. Initial abdominal ultrasonography showed an AAA that was confirmed on multislice computed tomography scan angiography which revealed a large retroperitoneal haematoma. Because of patient's comorbidites (previous surgery of laryngeal carcinoma and one-third laryngeal stenosis, arterial hypertension and cardiomyopathy with left ventricle ejection fraction of 30%, stenosis of the right internal carotid artery of 80%) it was decided that endovascular repair of ruptured AAA in local anaesthesia and analgosedation would be treatment of choice. Endovascular grafting was achieved with aorto-bi-iliac bifurcated excluder endoprosthesis with complete exclusion of the aneurysmal sac, without further enlargment of haemathoma and no contrast leakage. The postoperative course of the patient was eventless, without complications. On recall examination 3 months after, the state of the patient was well. CONCLUSION: The alternative for open reconstruction of ruptured AAA in haemodynamically stable patients with suitable anatomy and comorbidities could be emergency EVAR in local anesthesia. This technique could provide greater chances for survival with lower intraoperative and postoperative morbidity and mortality, as shown in the presented patient.

Visceral hybrid reconstruction of thoracoabdominal aortic aneurysm after open repair of type A aortic dissection by the Bentall procedure with the elephant trunk technique--a case report.

INTRODUCTION: Reconstruction of chronic type B dissection and thoracoabdominal aortic aneurysm (TAAA) remaining after the emergency reconstruction of the ascending thoracic aorta and aortic arch for acute type A dissection represents one of the major surgical challenges. Complications of chronic type B dissection are aneurysmal formation and rupture of an aortic aneurysm with a high mortality rate. We presented a case of visceral hybrid reconstruction of TAAA secondary to chronic dissection type B after the Bentall procedure with the 'elephant trunk' technique due to acute type A aortic dissection in a high-risk patient. CASE REPORT: A 62 year-old woman was admitted to our institution for reconstruction of Crawford type I TAAA secondary to chronic dissection. The patient had had an acute type A aortic dissection 3 years before and undergone reconstruction by the Bentall procedure with the 'elephant trunk' technique with valve replacement. On admission the patient had coronary artery disease (myocardial infarction, two times in the past 3 years), congestive heart disease with ejection fraction of 25% and chronic obstructive pulmonary disease. On computed tomography (CT) of the aorta TAAA was revealed with a maximum diameter of 93 mm in the descending thoracic aorta secondary to chronic dissection. All the visceral arteries originated from the true lumen with exception of the celiac artery (CA), and the end of chronic dissection was below the origin of the superior mesenteric artery (SMA). The patient was operated on using surgical visceral reconstruction of the SMA, CA and the right renal artery (RRA) as the first procedure. Postoperative course was without complications. Endovascular TAAA reconstruction was performed as the second procedure one month later, when the 'elephant trunk' was used as the proximal landing zone for the endograft, and distal landing zone was the level of origin of the RRA. Postoperatively, the patient had no neurological deficit and renal, liver function and functions of the other abdominal organs were normal. Control CT after 6 months showed full exclusion of the aneurysm from the systemic circulation without endoleak and good flow through visceral anastomosis. CONCLUSION: In patients with comorbidities, like in the presented case, visceral hybrid reconstruction of chronic dissection type B with TAAA could be the treatment of choice.

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

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

An aortoduodenal fistula as a complication of immunoglobulin G4-related disease.

Most primary aortoduodenal fistulas occur in the presence of an aortic aneurysm, which can be part of immunoglobulin G4 (IgG4)-related sclerosing disease. We present a case who underwent endovascular grafting of an aortoduodenal fistula associated with a high serum IgG4 level. A 56-year-old male underwent urgent endovascular reconstruction of an aortoduodenal fistula. The patient received antibiotics and other supportive therapy, and the postoperative course was uneventful, however, elevated levels of serum IgG, IgG4 and C-reactive protein were noted, which normalized after the introduction of steroid therapy. Control computed tomography angiography showed no endoleaks. The primary aortoduodenal fistula may have been associated with IgG4-related sclerosing disease as a possible complication of IgG4-related inflammatory aortic aneurysm. Endovascular grafting of a primary aortoduodenal fistula is an effective and minimally invasive alternative to standard surgical repair.

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

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

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

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

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

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

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

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

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

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

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

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

[Abdominal aortic aneurysm--rupture of the anterior wall].

INTRODUCTION: An aneurysm is a focal dilatation of an artery (aorta), involving an increase in diameter of at least 50% as compared to the expected normal diameter (over 3 cm). Abdominal aortic aneurysms (AAA) cause thousands of deaths every year, many of which can be prevented with timely diagnosis and treatment. AAA can be asymptomatic for many years, but in one third of patients whose aneurysm ruptured, the mortality rate is 90%. In the past, palpation of the abdomen was the preferred method for identifyng AAA. However, diagnostic imaging techniques, such as ultrasonography and computed tomography are more accurate and offer opportunities for early detection of AAA. CASE REPORT: This paper is a case report of an 83-year-old female patient. She was admitted due to severe pain in the abdomen. We already knew about the AAA (from her medical history). After using all available diagnostic procedures, rupture or disection of the AAA were not comfirmed. The patient underwent emergency surgery. During the operation, rupture of the anterior wall of the aneurysm was found. The anterior wall was filled with parietal thrombus, which hermetically closed the perforation. The patient was successfully operated and recovered. CONCLUSION: The aim of this case report was to point out that our diagnostic procedures failed to confirm the rupture of AAA. We decided to apply surgical treatment, based on medical experience, clinical findings, ultrasonography and computed tomography and during operation rupture of AAA was confirmed Patients with an already diagnosed AAA, or patients with clinical picture of rupture or dissection, are in urgent need for surgery, no matter what diagnostic tools are being used.

[Use of presternal catheters for peritoneal dialysis in obese patients].

INTRODUCTION: Patients with terminal kidney failure represent an important socio-medical problem not only in our country, but also in most countries of the world. There are three options of treatment: transplantation, hemodialysis and peritoneal dialysis. Each of them has advantages and disadvantages. CASE REPORT: This is a case report of an extremely obese woman on peritoneal dialysis. Due to obesity, we decided to use a presternal catheter. We wished to report our dilemmas, opinions and experiences associated with this problem, as well as opinions from avaliable medical literature.

[Takayasu arteritis].

INTRODUCTION: Giovanni Battista Mlorgani reported the first case with Takayasu arteritis (TA) in 1761. The disease affects the aortic arch and large blood vessels. It is found in every race and in every age-group, predominantly in female population aged 20-40 years. There are four types of TA: type I affects blood vessels of aortic arch: Type II is syndrome of middle aorta (thoracal and abdominal aorta); Type III affects aortic arch and abdominal aorta; Type IV affects pulmonary artery. CLINICAL MANIFESTATIONS: TA has three phases: 1. weakness, fever, anemia, loss of appetite: 2. inflammation of blood vessels; 3. symptoms of stenosis and occlusive lesions. Pathoanatomical disorder includes inflammation of all three layers of blood vessels. CASE REPORT: This is a case report of a 41-year-old woman with TA. She suffered from chest pain, fatigue and pain in both legs, predominatly in the right. Clinical presentation of the disease varies whereas development of TA is unpredictable. Angiography is an important method in diagnosis of the disease and in planning surgical treatment. In our patient five arterial stenoses were established by angiography. ECHO Color Doppler angiography may be useful. Diagnostic criteria include: age under 40 years, occlusion of the right and left subclavian artery and nine minor criteria. Corticosteroid and antiinflammatory therapy is indicated. One third of patients needs surgery. DISCUSSION AND CONCLUSION: In our opinion surgical treatment should be delayed until acute phase is over. Surgical treatment in our patient included: aortobifemoral bypass and left carotid-axillary bypass grafting. Some patients need multiple surgical treatments, like our patient. They also need post-surgical controls.