The role of kinesitherapy and electrotherapeutic procedures in non-operative management of patients with intermittent claudications.

PURPOSE: To examine the effects of physical therapy (kinesitherapy and electrotherapeutic procedures) on the course of peripheral arterial occlusive disease by monitoring the changes in values of claudication distance and ankle-brachial indexes. METHODS: Prospective randomized study included 47 patients with peripheral arterial occlusive disease manifested by intermittent claudications associated with ankle-brachial indexes values ranging from 0.5 to 0.9. Patients from the first group (25 pts) were treated with medicamentous therapy, walking exercises beyond the pain threshold, dynamic low-burden kinesi exercises and electrotherapeutic ageneses (interference therapy, diadynamic therapy, and electromagnetic field), while the second group of patients (22 pts) was treated with "conventional" non-operative treatment - medicamentous therapy and walking exercises. The values of newly established absolute claudication distance and ankle-brachial indexes were measured. FINDINGS: Significant increase of absolute claudication distance in both groups of patients was registered, independently of therapeutic protocol applied (p < 0.001), as well as the increase in the claudication distance interval in the physical therapy group. There was no significant increase in ankle-brachial indexes values in both groups of patients. CONCLUSION: Methods of physical therapy presented valuable supplement in non-operative treatment of peripheral arterial occlusive disease patients, improving their functional ability and thus postponing surgical treatment. However, further investigations including larger number of patients are needed.

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center.

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial.

BACKGROUND: Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 microg) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0-10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. RESULTS: Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0-60] vs 60 [0-160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9-15.6] vs 3.1 [1.0-11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9-18] vs 15 [9-18] minutes, respectively; P = 0.18). CONCLUSIONS: The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center.

BACKGROUND: Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity. METHODS: Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas. RESULTS: There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency. CONCLUSIONS: Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.

Unusual forms of ruptured abdominal aortic aneurysms.

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

[Splanchnic artery aneurysms].

INTRODUCTION: Splanchnic artery aneurysms are uncommon but important vascular entity because nearly 25% of all cases present as surgical emergency. OBJECTIVE: The purpose of our study was to present nine patients operated on at the Institute of cardiovascular diseases, as well as literature review of clinical presentation of the disease. METHOD: There were three splenic artery aneurysms, two celiac trunk aneurysms, and one aneurysm of the hepatic, superior mesenteric, inferior mesenteric and gastroduodenal artery. All patients were males, mean aged 67.5 years (60-73). In four patients, splanchnic artery aneurysm was discovered accidentally during routine ultrasonographic and angiographic examinations of the abdominal aorta. At that time, arteriovenous fistula was diagnosed in a patient No 1; it was formed after rupture of the splenic artery aneurysm into the splenic vein. Three aneurysms were manifested by abdominal pain and palpable pulsating abdominal mass. Two patients were admitted as urgent cases in the state of hemorrhagic shock and signs of intraabdominal bleeding due to rupture of the splenic and hepatic arteries. In 7 cases, diagnosis was made preoperatively by means of ultrasonography and angiography; in two patients, accurate diagnosis was confirmed during surgery. RESULTS: Proximal and distal ligation of the artery was performed in a patient with rupture of the splenic aneurysm into the splenic vein that caused arteriovenous fistula. Gastroduodenal artery aneurysm was treated by trans-aneurysmatic ligation of its "entering" and "exiting" branches. Aneurysms of distal part of the superior mesenteric and splenic artery were resected without further reconstruction. Partial resection of the aneurysm and endoaneurysmorrhaphy was carried out in one case of celiac trunk aneurysm, and in another, after aneurysm resection, the restoration of blood flow through the hepatic and lienal artery was achieved by Dacron grafts. In a patient with the inferior mesenteric artery aneurysm, the resection of aneurysm was followed by reimplantation of medial part of the artery into bifurcated Dacron graft which replaced abdominal aorta. In 5 patients, some of additional surgical procedures were performed. There were 4 reconstructive procedures of abdominal aorta and one splenectomy. The patient with ruptured hepatic artery aneurysm died during surgery due to uncontrolled hemorrhage. In other patients, there was neither morbidity nor mortality in the early postoperative period (first 30 days after surgery). Mean follow up was 1 to 5 years (mean 3.4 years). One patient died after 5 years due to myocardial infarction. CONCLUSION: Although the introduction of precise diagnostic procedures (computerized tomography, magnetic resonance imaging, spiral scan) make diagnosis easier, the splanchnic artery aneurysms are still difficult to detect due to their uncommon clinical presentations.

[Anastomotic pseudoaneurysms].

Anastomotic pseudoaneurysm is a form of false aneurysm, whose wall does not consist of all normal layers of arterial wall. Given the rising number of reconstructive vascular procedures, the increase of anastomotic pseudoaneurysm cases is expected. Therefore, identification of causes, clinical manifestations as well as factors which affect the outcome of operative treatment of anastomotic pseudoaneurysms is of great practical value. This retrospectively-prospective study included 87 surgically treated cases of anastomotic pseudoaneurysms in the period from 1991 to 2002. The most often localization of anastomotic pseudoaneurysms was the inguinal region (68-86.2%). In the majority of cases, they were caused by arterial degeneration in the anastomotic region--56 cases (65.9%) and infection--21 cases (24.7%). The most frequent manifestations of anastomotic pseudoaneurysms were bleeding due to rupture in 26 cases (29.9%) and chronic limb ischaemia in 22 cases (25.3%). An acute limb ischaemia was present in 17 cases (19.5%), the symptoms caused by local compression to the surrounding structures--in 9 cases (10.3%), and in 12 cases (13.8%), the only manifestation of anastomotic pseudoaneurysm was asymptomatic pulsatile mass. In 32 cases (36.8%), surgical treatment involved the resection of anastomotic pseudoaneurysm and graft interposition, whereas in 39 cases (44.8%), bypass procedure had to be performed after the resection. Comorbidity significantly increased mortality in the first 30 days. The use of Dacron graft in primary operation significantly improved early results of operative treatment. Absence of infection as the cause of anastomotic pseudoaneurysm is a statistically important prognostic factor of operative treatment, considering the graft patency, limb salvage, infection, need for reintervention and mortality.

[Primary varicose veins: frequency, clinical significance and surgical treatment]. / Primarni varikoziteti--ucestalost, klinicki znacaj i hirursko lecenje.

INTRODUCTION: According to the definition of the World Health Organization, varicose veins represent abnormally enlarged superficial veins having baggy or cylindrical shape. The most frequent cause of primary varicose veins is the insufficiency of long saphenous vein (LSV), but especially the basin of its connection with femoral vein and perforating veins. OBJECTIVE: The objectives of these investigations were: the determination of insufficiency incidence of SSV in cases of LSV insufficiency; the establishment of association of insufficiency of perforating veins of the basin of LSV and SSV; the study of the results of surgical treatment of insufficiency and varicosity of both short and long saphenous veins. METHODS: In this study, 100 patients (66 women and 34 men), average age 52.1 years, with clinical symptoms showing the insufficiency and varicosity of long saphenous vein with no change of deep vein system were examined. Ultrasonographic examinations were made using Color Doppler probes--7.5 and 3.75 MHz (Toshiba Corevison SSA 350 A); the development of incompetence of long saphenous vein (LSV) and short saphenous vein (SSV) at the level of the junction as well as other incompetent valves were examined. The reflux was defined as a retrograde flow of the duration longer than 0.5 seconds. RESULTS: The insufficiency of short saphenous vein was determined by ultrasonographic examination in 34%, while the insufficiency of perforating veins in 80% of patients. 40% of patients were operated (33.3% of females, and 52.9% of males). The most frequent indications for surgical treatment of superficial veins insufficiency were: strong varicosities, clear symptoms and signs, superficial thrombophlebitis and conditions after superficial thrombophlebitis. Surgical treatment was applied in 16% of patients due to recurrence in the basin of long saphenous vein, and in 6% of cases because of the recurrence in the basin of short saphenous vein. Data analysis failed to discover any statistically significant difference between the age of patients and varicosities in the basin of long saphenous vein as well as in the basin of short saphenous vein (51.98 +/- 9.97 years; 54.50 +/- 31.82 years; t=0.36; p>0.05), or any significant difference of BMI value, with regard to the obesity of patients and varicosities in the basin of long saphenous vein as well as in the basin of short saphenous vein (28.02 +/- 4.61 kg/m2; 24.50 +/- 6.36 kg/m2; t=0.50; p>0.05). No statistically significant correlation was found between Color Duplex findings of insufficiency of both long saphenous vein and short saphenous vein (p=-0.21; p>0.05), nor any significant correlation of Color Duplex findings of perforating veins insufficiency in the basin of long saphenous vein and short saphenous vein (p=-0.115; p>0.05). CONCLUSION: The incidence of insufficiency is significant: approximately every third patient has short saphenous vein insufficiency, while three third of patients have perforating veins insufficiency. Color Duplex limb's veins ultrasonography is highly reliable method for the examination and study of superficial veins diseases, which is very important for preoperative decision-making and selection of surgical technique as well as for postoperative follow-up.