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Introduction. Endovascular treatment of chronic total occlusion (CTO) represents a true challenge even for experienced interventional radiologists. We are presenting a case of hidden antegrade dissection of the external iliac artery (EIA) after a failed attempt to recanalize CTO of the common femoral artery (CFA). Case outline. A 52-year-old male patient was admitted for multidetector computed tomography (CT) angiography. Left common iliac artery (CIA) stenting was performed, followed by “crossover” attempt of recanalization of right CFA CTO that failed. The next day, left femoral superficial artery angioplasty was performed and after one month, angioplasty of the left popliteal and the bellow-knee arteries. A month later, the patient was readmitted for surgical reconstruction of the CFA. After desobstruction, excellent inflow was obtained and a Dacron graft was inserted. A few hours postoperatively, Fogarty catheter thrombectomy was performed. The next morning, pulsations were weakened again and CT angiography showed antegrade dissection of the EIA. Stenting of the EIA was performed with two stents and a favorable outcome was achieved. After a detailed analysis of the CT, hidden thrombosed antegrade dissection of the EIA was noted in the lateral view, which was not seen in the posterior/anterior view and was presented as fibrous plaque with mural thrombosis. Dissection occurred after failed attempt of CFA recanalization and was clinically silent until flow was established triggering opening of the false lumen and the release of thrombotic masses. Conclusion. In patients with failed angioplasty of CTO of the CFA and CT characteristics of fibrous plaque proximal to the site of attempted angioplasty, thrombosed antegrade dissection should be considered.

Introduction. Infection of synthetic graft in the groin is a rare but devastating complication. When it occurs, several possibilities of treatment are available. Extra-anatomic reconstruction and in-situ implantation of new, infection resistant grafts are associated with high mortality and morbidity. Therefore, more conservative approach is needed in some cases. Negative-pressure wound therapy is one of the options in treating such patients. Objective. The aim of this study was to assess the outcome for deep groin vascular graft infection treated with negative-pressure wound therapy. Methods. Seventeen patients (19 wounds), treated for Szilagyi grade III groin infections between October 2011 and June 2014, were enrolled into this observational study. Results. Majority of the wounds (11/19) were healed by secondary intention, and the rest of the wounds (8/19) were healed by primary intention after initial negative-pressure wound therapy and graft substitution with silver-coated prostheses or autologous artery/vein implantation. No early mortality was observed. Minor bleeding was observed in one patient. Reinfection was noted in three wounds. Only one graft occlusion was noted. Late mortality was observed in three patients. Conclusion. Negative-pressure wound therapy seems to be safe for groin vascular graft infections and comfortable for both patient and surgeon. However, the rate of persistent infection is high. This technique, in our opinion, can be used as a “bridge” from initial wound debridement to definitive wound management, when good local conditions are achieved for graft substitution, either with new synthetic graft with antimicrobial properties or autologous artery/vein. In selected cases of deep groin infections it can be used as the only therapeutic approach in wound treatment.

Introduction. The stump wound complications after above-knee amputation lead to other problems, such as prolonged rehabilitation, delayed prosthetic restoration, the increase in total treatment cost and high mortality rates. Objective. To evaluate the safety and outcomes of negative-pressure wound therapy (NPWT) using Vacuum-Assisted Closure (VACR) therapy in patients with stump complication after above-knee amputation (AKA). Methods. From January 2011 to July 2014, AKA was performed in 137 patients at the University Cardiovascular Clinic. Nineteen (12.4%) of these patients (mean age 69.3 Ѓ} 9.2 years) were treated with NPWT. The following variables were recorded: wound healing and hospitalization time, rate of NPWT treatment failure, and mortality. Results. AKA was performed in 17 (89.5%) patients after the vascular or endovascular procedures had been exhausted, while urgent AKA was performed in two (10.5%) patients due to uncontrolled infection. The time before NPWT application was 3.1 Ѓ} 1.9 days and the duration of the NPWT use ranged from 15 to 54 days (mean 27.95 Ѓ} 12.1 days). During NPWT treatment, operative debridement was performed in 12 patients. All the patients were kept on culture-directed intravenous antibiotics. The average hospital length of stay was 34.7 days (range 21-77 days). There were four (20.9%) failures during the treatment which required secondary amputation. During the treatment, one (5.3%) patient died due to multi-organ failure after 27 days. Conclusions. The use of NPWT therapy in the treatment of AKA stump complication is a safe and effective procedure associated with low risk and positive outcome in terms of wound healing time and further complications.

Introduction. An extracranial carotid artery aneurysm is a rare clinical entity with potentially debilitating consequences. Our aim is to present a case of a large internal carotid artery aneurysm combined with medial internal carotid artery (ICA) kinking successfully treated by resection with an end-to-end anastomosis. Case outline. A 34-year-old female patient was admitted to our hospital due to dizziness and frequent non-specific headaches. On admission, routine echocardiography showed an aneurysm of the atrial septum. Multislice computed tomography of the supraaortic branches showed medial kinking of the right ICA with a 15 mm aneurysm localized on the vertex of the angulation. Kinking was present on the left ICA as well, with a small aneurysm of 5 mm in diameter. The right ICA aneurysm was resected and the artery was reconstructed with an end-to-end anastomosis. The postoperative course was uneventful and the patient was symptom-free after a one-year follow-up. Conclusion. We showed that surgery of an aneurysm and kinking of the carotid artery in the medial segment of the ICA is possible and safe to perform. Detailed preoperative preparation, precise surgical technique, and short clamping time all contributed to a good final outcome.

Introduction. Although intervention in patients with symptomatic carotid disease is generally accepted as beneficial, the management of asymptomatic disease is still controversial. We wanted to introduce and discuss treatment options in a patient with asymptomatic carotid stenosis and high embolic potential lesions of common and internal carotid artery detected by multidetector computed tomography (MDCT). Case Outline. A 78-year-old female patient was admitted to our institution for diagnostics and surgical treatment of asymptomatic high-grade carotid stenosis. Upon admission, color duplex ultrasonography of the carotid arteries revealed the left common carotid artery (CCA) stenosis of 50% and the ipsilateral internal carotid artery (ICA) stenosis of 60%, while the right CCA was narrowed by 60% and the ipsilateral ICA by 80%. Because of the left subclavian artery (LSA) occlusion, also described by ultrasonography, MDCT angiography was performed to assess arterial morphology for possible angioplasty. In addition to LSA occlusion, MDCT angiography surprisingly revealed significant left CCA (>80%) and ICA (>70%) narrowing by ulcerated plaques with high embolic potential. Surgical treatment of the left CCA and ICA was indicated and Dacron® tubular graft interposition was performed. The postoperative course was uneventful and the patient was discharged from the Institute on the third postoperative day. After the six-month follow-up the patient was doing well with well-preserved graft patency. Conclusion. Although color duplex ultrasonography is reliable and safe imaging modality in carotid stenosis diagnosis, MDCT angiography plays a significant role in patients with asymptomatic carotid stenosis since plaques with high embolic potential could be detected, which, if left untreated, could have severe neurological ischemic consequences. [Projekat Ministarstva nauke Republike Srbije, br. 41002]

Introduction. Acute lower limb ischemia results from thrombosis or embolization of diseased native artery or previously implanted bypass graft. When this occurs, several options are available to restore blood flow: catheter-directed thrombolysis, mechanical thrombectomy or open surgery. Fundamental reasons to apply percutaneous interventions are avoiding open procedures in high risk patients, and avoiding difficult dissection through scar tissue. Case Outline. A 67-year-old male was admitted at our Institution for critical limb ischemia. After performed angiography the diagnosis of occluded femoropopliteal graft was established. Occlusion was resolved by catheter-directed thrombolysis with plasmin. Culprit lesions were treated by angioplasty. Conclusion. Our patient underwent a successful thrombolysis of occluded femoropopliteal graft with locally-delivered human plasmin.

Introduction. Severe extremity ischemia and the presence of the “blue-toe” syndrome are rarely the first complications of the present abdominal aortic aneurysm. We report two interesting cases of this rare entity. Outline of Cases. A 61-year-old man presented with the rest pain of his toes accompanied with digital ischemia of both feet. Physical examination confirmed regular arterial pulses at lower extremities accompanied with palpable pulsate mass in the abdomen. Vascular ultrasound and multidetector tomography (MDCT) of blood vessels revealed small abdominal aortic aneurysm (37 mm in diameter), filled with the irregular, ulcerated, heterogeneous thrombotic masses. Aneurysm sac resection was performed with an aorto-bi-iliac bypass reconstruction. A week later, it was mandatory to amputate the fifth toe on the left foot because of the advanced gangrenous process. The second case was a 77-year-old woman with 7-day history of severe feet pain. Abdominal examination revealed pulsatile mass paraumbilical to the left. Performed abdominal ultrasonography and MDCT angiography confirmed coexistence of the infrarenal aortic aneurysm, 40.5 mm in diameter, covered by significant mobile mural thrombus and ulcerations. Surgical reconstruction was mandatory and patient underwent aneurysm sac resection and aortobifemoral reconstruction. Conclusion. Embolic phenomenon and peripheral embolic occlusion from the mural thrombus within the abdominal aortic aneurysm are relatively rare events, but associated with tissue loss. Thorough diagnostic examinations and prompt management are required regardless of the aneurysm size once these signs occurred.

Introduction. Leiomyosarcomas of the inferior vena cava are rare malignant tumors. A limited number of these cases have been described so far. Only few of them have intracardiac propagation and surgery is rarely undertaken for their treatment. Case Outline. We present a 52-year-old female patient in whom leiomyosarcoma of the inferior vena cava with intracardiac propagation was diagnosed. The patient underwent successful surgical treatment with complete removal of the tumor and direct suture of the inferior vena cava. No additional modalities of therapy were undertaken. Conclusion. Surgery, without radiation therapy can be a successful option for the treatment of inferior vena cava leiomyosarcoma with a good short-term result.

Introduction. Hybrid procedures represent staged or simultaneous endovascular and open surgical techniques in the treatment of complex pathologies of the thoracic and abdominal aorta. We are presenting a patient with previous abdominal aortic surgery in whom hybrid vascular procedure for descending aorta and left subclavian artery aneurysm was performed. Case Outline. A 63-year-old female patient was admitted for computed tomography angiography. Descending aorta aneurysm (7.6 cm) as well as aneurysm of the left subclavian artery (LSA) was noted. Eight years ago she underwent abdominal aortic aneurysm resection and aortoiliac bypass. Standard TEVAR (thoracic endovascular aortic repair) procedure couldn’t be done due to small dimensions of previous “Y” graft (12.6 mm), so first we did LSA transposition and after three days hybrid procedure. After “Y” graft exposure, anastomosis between the corps of “Y” graft and tubular graft 10 mm was created and through this conduit thoracic stent-graft was placed followed by complete “Y” graft replacement. After 6 months angiography showed regular postoperative findings. Conclusion. Combined surgical and endovascular procedures in thoracic aorta pathology treatment could be useful solutions with favorable outcome. [Projekat Ministarstva nauke Republike Srbije, br. 41002]

Introduction. Cardiovascular diseases, especially heart disease and stroke are the cause of more than a half of the total number of deaths in Serbia. Objectives. The aim of the present study was to determine sex differences of atherosclerotic risk factors in patients with symptomatic carotid disease. Methods. The cross-sectional study, involving 657 consecutive patients with verified carotid atherosclerotic disease, was performed in Belgrade, Serbia. Sex differences of anthropometric parameters and atherosclerotic risk factors were analyzed by means of the univariate logistic regression. Results. In comparison with men, lower education and physical inactivity were significantly more frequent in women, and the frequency of metabolic syndrome (MetS), lower high-density cholesterol, abdominal obesity, body mass index ≥30.0 kg/m2, hypercholesterolemia and depression were also significantly higher in women. Smoking and high serum uric acid level were significantly more frequent in men than in women. Women had significantly higher number of MetS components per person, but there were no significant sex differences in the number of other risk factors. Out of all observed risk factors, including MetS components, physical inactivity and hypertension were most frequent in both sexes followed by ever smoking and low education in men and low education and dyslipidemia in women. Conclusion. There were significant sex differences in the distribution of some atherosclerotic risk factors, but not in their number per person. Only the number of MetS components was significantly higher in women. [Projekat Ministarstva nauke Republike Srbije, br. III41002]

Introduction. Obesity, particularly visceral obesity, is considered one of major risk factors for cardiovascular events. Objectives. The aim of the present study was to investigate relationship between abdominal obesity and other cardiovascular risk factors. Methods. The cross-sectional study involved 657 consecutive patients with verified carotid atherosclerosis. Carotid atherosclerosis was estimated by high resolution B-mode ultrasonography. Abdominal obesity was defined as waist circumference >102 cm in men and >88 cm in women. Results. Abdominal obesity was present in 324 (49.3%) participants. Multivariate analyses showed that abdominal obesity was significantly positively associated with female sex, increased Baecke ’s Work Index of physical activity at work, years of school completed

Carotid endarterectomy has been established as the preferred treatment for symptomatic and asymptomatic high-grade carotid stenosis. Internal carotid artery restenosis is defined as a specific entity with a great clinical significance in carotid surgery due to accompanied increased future cerebral ischemic events risk. Carotid restenosis is the result of neointimal hyperplasia in the early postoperative period (within 36 months) or recurrent atherosclerotic lesions at a later date. While the restenotic lesions caused by neointimal hyperplasia are determined by ultrasound as smooth lesions, atherosclerotic carotid stenosis has almost the same ultrasound and angiographic characteristics as primary atherosclerotic lesions. Some authors believe that patients with internal carotid artery restenosis have insignificant risk of stroke or progression to total occlusion, and suggest conservative treatment only. On the other hand, many surgeons have more aggressive attitude towards the treatment of asymptomatic carotid stenosis and indicate surgical treatment in asymptomatic patients with carotid restenosis above 80%. The aim of our paper was to present a review of literature available data concerning etiology, pathophysiology, clinical significance and treatment of carotid restenosis following endarterectomy. Numerous studies have reported satisfactory results of redo endarterectomy and carotid angioplasty as treatment options of carotid restenosis. Carotid angioplasty for primary atherosclerotic lesions treatment is accompanied by a high carotid restenosis rate and therefore its role in primary carotid symptomatic and asymptomatic stenosis treatment is still the issue of numerous debates and the subject of extensive ongoing clinical studies worldwide.

Introduction. Carotid angioplasty and internal carotid artery stenting is the therapeutic method of choice in the treatment of carotid restenosis, but when it is not technically feasible (expressed tortuosity of supraaortic branches, calcifications, presence of pathological elongation of very long lesions) a redo surgery is indicated. Objective. The aim of our study was to examine the benefits and risks of redo surgery in patients with symptomatic and asymptomatic significant internal carotid artery restenosis and its impact on early and late morbidity and mortality. Methods. The study included 45 patients who were surgically treated for a hemodynamically significant internal carotid artery restenosis from January 2000 to December 2009. Surgical techniques included redo endarterectomy with direct suture, redo anderectomy with a patch plastic and resection with Dacron tubular graft interposition. The patients were followed for postoperative neurological ischemic events (transient ischemic attack (TIA), stroke), local surgical complications and lethal outcome after one month, six months, one year and after two years). Results. In the early postoperative period (up to 30 days) there were no lethal outcomes. TIA was diagnosed in four patients (8.8%), minor stroke in one patient (2.2%) and one patient (2.2%) also had cranial nerve injury. After two years two patients died (4.4%) due to fatal myocardial infarction, three patients (6.5%) had ipsilateral stroke and one patient developed graft occlusion (2%). Conclusion. In the case of symptomatic and asymptomatic carotid restenosis that cannot be treated by carotid percutaneous angioplasty, redo surgical treatment is therapeutic option with an acceptable rate of early and late postoperative complications.

Introduction. Peripheral arterial disease (PAD) is a severe atherosclerotic condition. The relationship between various risk factors and severity of PAD, measured by Ankle Brachial Index (ABI), has been the subject of a relatively small number of studies. Objective. The aim of the present study was to investigate whether there was any relationship between severity of PAD, expressed as ABI, and anthropometric, clinical and biochemical characteristics of patients, including inflammatory markers. Methods. The cross-sectional study, involving 388 consecutive patients with verified PAD, was performed at the Dedinje Vascular Surgery Clinic in Belgrade. The diagnosis of PAD was defined by Doppler sonography as ABI

Introduction. Congenital coarctation of the thoracic aorta at the ligamentum arteriosum or the aortic arch is well recognized. But a much less common variety (0.5-2.0%) of aortic coarctation is located in the distal thoracic aorta or abdominal aorta or both and is often called 'middle aortic syndrome' or 'midaortic dysplastic syndrome'. This represents serious pathological condition and indicates multidisciplinary therapy approach. Outline of Cases. From 1996 to 2007, at the Vascular Surgery Clinic of the Institute for Cardiovascular Diseases 'Dedinje', Belgrade, three patients were treated due to abdominal aorta coarctation, two females aged 55 and 50 and a 4-year-old child. The patients were treated surgically (by-pass with a prosthetic graft and patch angioplasty) and endovascular-percutaneous transluminal angioplasty (PTA) with and without a stent. The follow-up period was 3-70 months. In the 50-year-old patient, angiography showed severe narrowing of the suprarenal segment of the abdominal aorta. Thoraco-abdominal bypass with a 16 mm dacronic tubular graft was performed. In the 4-year-old patient angiography also showed a suprarenal aorta narrowing. In the first act patch angioplasty was performed and after PTA of the visceral arteries was done on several occasions. In the 55-year-old patient, after diagnostic angiography, infrarenal aorta coarctation was registered. PTA was performed with stent placement. All patients were asymptomatic on control check-ups. Conclusion. Abdominal coarctation is a pathological disease which is seldom found in vascular surgery. Angiography is of major importance for setting the diagnosis and for the control of the results of surgical and nonsurgical treatment. The combination of surgical and endovascular treatment in our patients showed very good results in the studied period.

Introduction. Measurement of vessel stenosis using ultrasonography or magnetic resonance is still the principal method for determining the severity of carotid atherosclerosis and need for endarterectomy. Case Outline. A 56-year-old male was admitted to the Cardiovascular Institute 'Dedinje' due to a clinically asymptomatic restenosis of the operated left internal carotid artery (ICA). Angiography and magnetic resonance angiography (MRA) in previous hospitalization had revealed occluded right ICA. However, routine duplex ultrasonography revealed a highgrade restenosis (85%) of the left ICA and subocclusion of the right ICA by an ulcerated plaque (confirmed on repeated MRA). Conclusion. Selective arteriography examination could misrepresent the degree of stenosis especially in patents with the ICA that seems to be occluded. MRA is considered the method of choice for identifying pseudo-occlusions of ICA.

The American otolaryngologist Eagle was the first to describe styloid syndrome in 1937. Stylohyoid complex is composed of styloid process, stylohyoid ligament and a lesser horn of the hyoid bone. Embriologicaly, these anatomical structures originate from Reichert's cartilage of the second brachial arch. In the general population, the frequency of the elongated styloid process is estimated to be 4%, of which only 4% show clinical manifestations suggesting that the incidence of styloid syndrome is 0.16% (about 16,000 persons in Serbia). The styloid process deviation causes external or internal carotid impingement and pains which radiate along the arterial trunk. Classical stylohyoid syndrome is found after tonsillectomy and is characterized by pharyngeal, cervical, facial pain and headache. Stylo-carotid syndrome is the consequence of the pericarotid sympathetic fibres irritation and compression on the carotid artery. Clinical manifestations are found most frequently after head turning and neck compression. The diagnostic golden standard for styloid syndrome is 3D CT reconstruction. Sagital CT angiography has a leading role in the radiological diagnosis of the stylo-carotid syndrome. Differential diagnosis requires the differentiation of the styloid syndrome from numerous cranio-facio-cervical painful syndromes. If conservative treatment (analgesics, anticonvulsants, antidepressants, and local infiltration with steroids or anaesthetic agents) has no effect, surgical treatment is applied. Styloid syndrome is underrepresented in neurological literature. The syndrome is considered important, because it is clinically similar to many other painful cranio-facial syndromes; it is difficult to be recognized, and the patient should be treated adequately.

Procedures used in treatment of carotid stenosis are endarterectomy, PTA with stent implantation, resection with graft interposition and by-pass procedure. Segmental lesions are found more often and treated by the first two mentioned procedures. In case of longer lesions and extension to the greater part of the common carotid artery, the other two procedures are performed. For the past few years, the main dilemma has been whether to perform carotid endarterectomy or PTA with stent implantation. Both early and long-term results speak in favour of carotid endarterectomy, regardless of an increased number of PTA and carotid stenting. At the same time, PTA and carotid stenting are more expensive procedures. Both methods have their defined and important roles in treatment of segmental occlusive carotid lesions. Severe cardiac, pulmonary and renal conditions, which increase the risk of general anaesthesia, are not an absolute indication for PTA and stenting, since endarterectomy can be done in regional anaesthesia. Main indications for PTA with stent implantation are: surgically inaccessible lesions (at or above C2; or subclavian); radiation- induced carotid stenosis; prior ipsilateral radical neck dissection; prior carotid endarterectomy (restenosis).

INTRODUCTION The sciatic artery represents the earliest embryological blood supply to the lower extremity. It regresses after the 3rd month of embryologic development. The proximal part of the sciatic artery eventually persists as the inferior gluteal artery. Rarely, however, it persists into adulthood when it is frequently associated with numerous possible complications (aneurysm formation, embolism, nerve compression, rupture, thrombosis). CASE OUTLINE In March 1996, a 48-year-old male was admitted for angiography of the blood vessels of the right inferior extremity, before an elective orthopaedic procedure. Arteriography of the right leg was done in a usual manner through the right common femoral artery in order to get an angiogram of the popliteal trifurcation and crural arteries. However, on the first field we noticed a hypoplastic superficial femoral artery, as well as a huge persistent sciatic artery (PSA) originating from the internal iliac artery running distally and overlapping the deep femoral artery. There were no aneurysm and stenotic changes of PSA. CONCLUSION If clinical condition is stable, follow-ups at 12 months intervals should be done by means of ultrasound. The therapeutic decisions also depend on complete or incomplete PSA.

INTRODUCTION The American otolaryngologist Eagle was the first to describe styloid syndrome in 1937 and the syndrome was named after him (Eagle's syndrome). The original description of two separate syndromes is connected with his name: classical syndrome, which almost constantly occurs after tonsillectomy and carotid artery syndrome, which occurs without tonsillectomy and also in cases when stylohyoid complex compresses the carotid segments and perivascular sympathetic fibers. In the following years, two more syndromes were defined: stylohyoid and pseudostylohyoid, which according to their manifestations, correspond to the genuine classical form. CASE OUTLINE A 40-year old male is presented, with a history of 3-year duration of pains in the upper part of the left side of the neck, in the left eye and its surroundings. Pain occurrences were not regular. Throbbing pains were most often provoked by sudden head movements and neck compression. He was healthy until the onset of these problems. The findings of all examinations were normal. The applied prophylactic therapy, typical for cluster headache, was without any effect. On 64-MSCT (multislice computed tomography), the neck arteries did not show any intraluminal pathology. The styloid processes were of normal length. On the left side, the styloid process tip pressed the internal carotid artery disturbing its longitudinal axis. CONCLUSION In our presentation, the defined lengths of the styloid processes were normal. The medial angulation of the left styloid process was more expressed reaching 63.5 degrees (the right side angulation was normal). Persistent and throbbing pain in the region of the left eye with backward projection suggested compression on the internal carotid artery. Pains were most frequently provoked by head turning and neck compression. 64-MSCT diagnostics enabled us to determine the characteristics of styloid processes and their relation to the internal carotid artery. Improvement was achieved by administration of anti-epileptic (gabapentin) and antidepressant (amitriptyline) drugs.

INTRODUCTION Inflammatory abdominal aortic aneurysm accounts for 5% to 10% of all cases of abdominal aortic aneurysm and differs from typical atherosclerotic abdominal aortic aneurysm in many important ways. Although both inflammatory and atherosclerotic abdominal aortic aneurysms most commonly affect the infrarenal portion of the abdominal aorta, patients with the inflammatory variant are younger and usually symptomatic, chiefly from back or abdominal pain. Unlike patients with atherosclerotic abdominal aortic aneurysm, most with the inflammatory variant have an elevated erythrocyte sedimentation rate or abnormalities of other serum inflammatory markers. Computed tomography and magnetic resonance imaging are both sensitive for demonstrating the cuff of soft tissue inflammation surrounding the aneurysm that is characteristic of inflammatory abdominal aortic aneurysm. Inflammatory abdominal aortic aneurysm can be primarily infected by degenaration of an infected artery (in less than 1% of cases), or can become secondary infected in the already existing aneurysm. Secondary infection of the pre-existing aneurysm has big influence on treatment choice, but is also rare. Clinically non-symptomatic infection, also known as bacterial collonisation, can be very frequent, regarding a greatly increased number of positive intraoperative findings (10-15%). Prolonged intravascular catheterization, vascular grafting, repeated punctures with large bore needles, and decreased immune defense mechanism make uraemic patients undergoing hemodialysis more likely to develop Staphylococcus aureus bacteraemia and its complications. CASE OUTLINE The case shows a gigantic inflammatory aneurysm of the abdominal aorta, localized infrarenally, which was solved successfully by resection of the aneurysm of the abdominal aorta, and interposition of Dacron tubular graft 22 mm. Bacterial examination of the aneurysmal sac was positive: methicillin-resistent Staphylococcus aureus was detected. CONCLUSION There were no postoperative complications, and the final outcome was fully satisfactory. Control CT scans after 3, 6 and 12 months were regular, with signs of regression fibrosis of the retroperitoneum.

INTRODUCTION Although the incidence is low, infection of prosthetic vascular graft bears a high incidence of serious complications including 25-75% mortality rate and 40-75% limb loss. The standard treatment of vascular graft infection consists of excision of the prosthesis, wound debridement and extraanatomic revascularization. Conservative treatment might be an option in a limited number of patients. We present three cases of surgical and conservative treatment of vascular graft infection. CASE OUTLINE Case 1: A patient developed silver-coated graft infection after femorodistal arterial reconstruction performed because of critical limb ischemia. In the early postoperative period, massive skin and subcutaneous tissue necrosis developed, with the graft being exposed. After two months of persistent debridement and wound toilette, the defect was covered with a Thiersch skin graft. Case 2: PTFE graft infection in the right groin followed reconstruction of the isolated common femoral artery aneurysm. This graft was replaced with a silver-coated graft in situ. Reinfection of the proximal end of the implanted silver-coated graft occurred and the graft was exposed. After repeated debridement and wound toilette, the exposed prosthesis was covered with granulomatous tissue, and the wound healed. Case 3: A year after anastomotic pseudoaneurysm resection in the left groin, prosthesis was exposed following wound infection. This graft was substituted with a silver-coated graft in situ. The wound healed primarily. CONCLUSION These three cases demonstrate that under some circumstances vascular prosthesis infection can be successfully treated conservatively without graft removal, and also by in situ replacement using silver-coated graft.

Since antiquity, there has been a mystery about the cerebral circulation function. Scientific methods were introduced in research at the end of the nineteenth century. During the first half of the last century, the problem of occlusive carotid disease was defined and the basis for the surgical treatment of carotid disease was established. The first contemporary reconstructive surgical procedures were performed in the middle of the last century, the time when successful surgical treatment of carotid disease began. Today, carotid endarterectomy is one the most frequently performed vascular surgical procedures of all, followed by very low morbidity and mortality rates.

Introduction Transplantation is the method of choice in the treatment of terminal liver diseases with acute and structural damage of liver tissue and congenital liver diseases. Objective The aim of our study was to determine specificity and significance of vascular anastomosis in liver transplantation by postoperative evaluation of vascular anastomosis function. Method The study included 16 patients with 16 liver transplantations and one re-do liver transplantation. In all patients, preoperative angiography and postoperative duplex sonographic and angiographic evaluation of vascular anastomosis were performed. Results Preoperative angiographic evaluation did not reveal anomalies in liver blood vessels of transplant candidates. In one patient, we identified and angiographically confirmed stenosis on anastomosis of the hepatic artery on the 7th postoperative day. In another patient, we had artificial thrombosis of the hepatic artery branch due to the liver biopsy. Conclusion The successful performance of vascular anastomosis in liver transplantation is significant for adequate liver graft perfusion, good postoperative graft function and overall outcome of the liver transplantation.

Introduction: Hypersplenism is a common complication of portal hypertension. Cytopenia in hypersplenism is predominantly caused by splenomegaly. Distal splenorenal shunt (Warren) with partial spleen resection is an original surgical technique that regulates cytopenia by reduction of the enlarged spleen. Objective. The aim of our study was to present the advantages of distal splenorenal shunt (Warren) with partial spleen resection comparing morbidity and mortality in a group of patients treated by distal splenorenal shunt with partial spleen resection with a group of patients treated only by a distal splenorenal shunt. Method. From 1995 to 2003, 41 patients with portal hypertension were surgically treated due to hypersplenism and oesophageal varices. The first group consisted of 20 patients (11 male, mean age 42.3 years) who were treated by distal splenorenal shunt with partial spleen resection. The second group consisted of 21 patients (13 male, mean age 49.4 years) that were treated by distal splenorenal shunt only. All patients underwent endoscopy and assessment of oesophageal varices. The size of the spleen was evaluated by ultrasound, CT or by scintigraphy. Angiography was performed in all patients. The platelet and white blood cell count and haemoglobin level were registered. Postoperatively, we noted blood transfusion, complications and total hospital stay. Follow-up period was 12 months, with first checkup after one month. Results In the first group, only one patient had splenomegaly postoperatively (5%), while in the second group there were 13 patients with splenomegaly (68%). Before surgery, the mean platelet count in the first group was 51.6±18.3x109/l, to 118.6±25.4x109/l postoperatively. The mean platelet count in the second group was 67.6±22.8x109/l, to 87.8±32.1x109/l postoperatively. Concerning postoperative splenomegaly, statistically significant difference was noted between the first and the second group (p

Introduction: The goal of modern carotid surgery is relief of symptoms, stroke prevention, improvement in quality of life, prevention of vascular dementia, and prolongation of lifetime. OBJECTIVE: The objective of this paper was to compare the outcome of carotid endarterectomy in cervical block vs. general anesthesia in patients with occluded contralateral internal carotid artery (ICA). METHOD: One hundred patients (76 male, 24 female, mean age 60.81 years) with occluded contralateral ICA were operated from 1997-2000. Neurological symptomatology, deficiency and stroke incidence were preoperatively analyzed in two groups. Duplex-scanning, angiograms and CT-scan confirmed the diagnosis. Risk factors analysis included hypertension, diabetes, lipid metabolism disorders, smoking and history of CAD, CABG and PAOD. Morbidity and mortality were used to compare the outcome of surgery in two groups. RESULTS There was no difference of age, gender and symptomatology between the groups. Paresis, TIA and dysphasia were most frequent. 70%-90% of ICA stenosis was seen in the majority of patients. Hypertension and smoking were dominant risk factors in these two groups. Eversion carotid end arterectomy was the most frequent technique used. In three cases out of nine that were operated under cervical block, the neurological symptoms developed just after clamping, so the intra-luminal shunt was placed. Postoperative morbidity was 12% and mortality was 8%. Conclusion: There was no difference of preoperative parameters, surgical technique and outcome in these two groups. Without other intraoperative monitoring, cervical block anesthesia might be an option in patients with the occlusion of the contralateral ICA. However, prospective studies involving more patients are needed.

INTRODUCTION Copper and zinc have significant antiatherogenic effect influencing activity of antioxidant enzyms (giutathion-peroxidase i superoxid-dismutase), mechanism of apoptosis and other mechanisms. Few studies showed increased copper and zinc concentration in atherosclerotic plaque in comparison to normal vascular tissue. AIM The aim of the study was to compare copper and zinc concentrations in carotid artery tissue without significant atherosclerotic changes and human ulcered atherosclerotic plaque. MATERIAL AND METHODS Study was conducted on 66 patients. Carotid endarterectomy due to the significant carotid atherosclerotic changes with cerebrovascular disorders was performed in 54 patients (81.8%). Control group consisted of 12 patients (18.2%) without carotid atherosclerotic changes operated due to the symptomatic kinking and coiling of carotid artery. Operated group consisted of 38 man (62.96%) and 16 woman (37.04%). Control group had the same number of patients: six men (50%) and six women (50%). Preoperatively, all patients were examined by vascular surgeon, neurologist and cardiologist. Duplex sonografy of carotid and vertebral arteries was performed by Aloca DSD 630 ultrasound with mechanical and linear transducer 7.7 MHz. Indication for surgical treatment was obtained according to non-invasive diagnostic protocol and neurological symptoms. Copper and zinc concentration in human ulcered atherosclerotic plaque and carotid artery segment were estimated by spectophotometry (Varian AA-5). RESULTS Average age of our patients was 59.8±8.1 years. For males average age was 76.1 ±9.8 years. And for females 42.4±5.8 years. In group with carotid endarterectomy female patients were significantly younger than male patients (p

INTRODUCTION Reversible Posterior Leukoencephalopathy Syndrome was introduced into clinical practice in 1996 in order to describe unique syndrome, clinically expressed during hypertensive and uremic encephalopathy, eclampsia and during immunosuppressive therapy [1 ]. First clinical investigations showed that leucoencephalopathy is major characteristic of the syndrome, but further investigations showed no significant destruction in white cerebral tissue [2, 3,4]. In majority of cases changes are localize in posterior irrigation area of the brain and in the most severe cases anterior region is also involved. Taking into consideration all above mentioned facts, the suggested term was Posterior Reversible Encephalopathy Syndrome (PRES) for the syndrome clinically expressed by neurological manifestations derived from cortical and subcortical changes localized in posterior regions of cerebral hemispheres cerebral trunk and cerebellum [5]. CASE REPORT Patient, aged 53 years, was re-hospitalized in Cardiovascular Institute "Dedinje" two months after succesfull aorto-coronary bypass performed in June 2001 due to the chest bone infection. During the treatment of the infection (according to the antibiogram) in September 2001, patient in evening hours developed headache and blurred vision. The recorded blood pressure was 210/120 mmHg so antihypertensive treatment was applied (Nifedipin and Furosemid). After this therapy there was no improvement and intensive headache with fatigue and loss of vision developed. Neurological examination revealed cortical blindness and left hemiparesis. Manitol (20%, 60 ccm every 3 hours) and iv. Nytroglicerin (high blood pressure). Brain CT revealed oedema of parieto-occipital regions of both hemispheres, more emphasized on the right. (Figure 1 a, b, c). There was no sign of focal ischemia even in deeper sections (Figure 1d, e, f). Following three days enormous high blood pressure values were registered. On the fourth day the significant clinical improvement occurred with lowering of blood pressure, better mental state and better vision. There was no sign of left hemiparesis on the 7th day. On the 9th day there were no symptoms or sign of disease. Control brain CT (15th day) was normal. ETHIOPATHOGENESIS Most common causes of PRES are hypertensive encephalopathy [6-8], pre-eclampsia/eclampsia [9-12] cyklosporin A administration [13-22] and uremic encephalopathy [23]. There are several theories about the mechanism for PRES in hypertensive encephalopathy (reversible vasospasm and hyperperfusion) and administration of cyclosporin A (neurotoxic effect). CLINICAL PICTURE Most common symptoms are headache, nausea, vomiting, confusion, behavioural changes, changes of conciousnes (from somnolencia to stupor), vision disturbances (blurred vision, haemianopsia, cortical blindness) and epileptic manifestations (mostly focal attacs with secondary generalization). Mental functions are characterised with decreased activity and reactivity, confusion, loss of concentration and mild type of amnesia. Lethargy is often initial sign, sometimes accompanied with phases of agitation. Stupor and coma rarely occurred. DIAGNOSIS In patients with hypertensive ecephalopathy and eclampsia high blood pressure is registered. Neurological examination revealed vision changes and damages of mental function as well as increased reflex activity. Today, brain MRI and CT are considered the most important diagnostic method for the diagnosis and follow-up of patients with PRES [6]. Brain MRI better detects smaller focal parenhim abnormalities than brain CT.The most often neuroradiological finding is relatively symetrical oedema of white cerebral tissue in parieto-occipital regions of both cerebral hemispheres. Gray cerebral tissue is sometimes involved, usually in mild form of disease. Diagnosis of this "cortical" form of PRES is possible by MR FLAIR (Fluid-Attenuated Inversion Recovery) technique [5]. TREATMENT Therapeutic strategy depends on the cause of PRES and clinical picture. Most important are blood pressure regulation (labetalol, nitroprusid, diuretici), control of epileptic attacs (phenytoin), anti-oedema therapy. (Manitol), induction of vaginal delivery in eclampsia and discontinuation of cyclosporin therapy. In most cases there are no neurological manifestations after the 7th day but some studies showed normalization of clinical finding after one year and more.

Introduction. Congenital interruption of the inferior vena cava is a rare entity. It can be associated with other organ and system malformations, especially the cardiovascular system. Usually, patients are asymptomatic and the anomaly is therefore diagnosed incidentally. In some cases it can be of clinical importance. Case Outline. A 22-year-old female was diagnosed during evaluation of cardiac symptoms. Clinical examination showed normal findings. CT angiography and cavography were used to establish the diagnosis of inferior vena cava interruption. Since there was no need for surgical intervention the patient was discharged in good condition. During a five year follow-up no significant health problems were noted with patient leading normal life. Conclusion. Diagnostic tools used to establish the diagnosis of inferior vena cava interruption are ultrasonography, as well as CT and MR angiography and phlebography. Mediastinal masses found on chest roentgenogram must raise suspicion of inferior vena cava interruption. Although the anomaly is rare, physicians should be aware of the infrahepatic interruption of the IVC, especially because it can present at any age.

Introduction. The natural course of abdominal aneurysms is progressive expansion, rupture, embolisation, thrombosis and compression of the visceral organs. The majority of papers report that inflammatory aortic and iliac aneurysms are associated with perianeurysmal and retroperitoneal fibrosis that ultimately results in the structural compromise of the urinary tract. Ureteral obstruction occurs in 20% to 71% of cases and approximately one half of these patients will present with obstructive uropathy. Most patients with inflammatory aneurysm are symptomatic, with elevated serum inflammatory markers, and characteristic multislice CT findings including a thickened aortic wall and a mass of periaortic inflammatory tissue. Case Outline. A 70-year-old man was admitted at the Vascular Surgery Clinic “Dedinje”, Belgrade, because of ultrasonically verified asymptomatic aortoiliac aneurysm. Multisclice CT findings showed left urethral dilatation and hydronephrosis secondary to extrinsic ureteral obstruction due to aortoiliac aneurysm. CT findings, laboratory tests and finally, histopathologic examination showed atherosclerotic aneurysm without inflammation and retroperitoneal fibrosis. The patient was successfully treated with surgical resection of the aneurysm and aortobiiliac reconstruction with “Y” prosthesis. Conclusion. We present a rare case of ureteral obstruction secondary to atherosclerotic aneurysm which, to our knowledge, has not been previously described in the domestic literature. A successful operative repair was performed. Postoperative course was uneventful and the patient was discharged on the seventh day after the surgery with normal vascular status and renal function.

Prevalence of asymptomatic carotid artery stenosis in patients with lower extremities atherosclerosis is relatively high. Limiting screening of specific subgroups for any demographic or medical characteristics is ineffective. Screening for asymptomatic carotid artery stenosis is indicated in all patients with lower extremities atherosclerosis except in whom prophylactic carotid endarterectomy is not recommended because of comorbid disease or extreme age.

Introduction. Internal carotid artery (ICA) kinking is a pathological malformation with angulation of the vessel’s axis of 90° or less. It is known that kinking causes the reduction of flow within the vessel that may be exacerbated by progressive head rotation up to the point that causes complete cessation of flow. In this article, we report on the case of acute reversible ischaemic deficit induced by internal carotid artery kinking and immediate neurological recovery following surgical reconstruction. Case Outline. A 64-year-old woman was admitted to Vascular Surgery Clinic due to severe dizziness, fainting and walking instability, suddenly arising a few days prior to admission. Two years before, the left ICA reconstruction was done for kinking, after which there was no cerebral ischaemia symptoms. Symptoms have been present perpetually, enhanced when resting and with head movement. CT angiography (MSCT) showed haemodynamic significant right ICA kinking. The left ICA postoperative finding was regular. Computerized tomography (CT) of the endocranium was done and no novel lessions were verified than those seen two years earlier. Resection, shortening and reimplantation of the right ICA were performed. A few hours following surgical reconstruction, there was no cerebral ischaemia symptoms, neither when resting nor with head movement. On the third postoperative day, the patient was discharged for home treatment. Conclusion. Surgical repair for symptomatic ICA kinking contributes to cerebral ischaemia symptoms reduction, improves cerebral perfusion and significantly prevents carotid thrombosis and stroke. In this paper, we have seen that in case of acute cerebral ischaemia symptoms and ICA kinking, surgical ICA treatment appears to be justified.

Introduction. A right-sided aortic arch is a rare congenital defect of the aorta with incidence of 0.05% to 0.1% reported in published series. Usually it is associated with congenital heart anomalies and esophageal and tracheal compression symptoms. We present a case of a right-sided aortic arch of anomalous left subclavian artery origin, accidentally revealed during multislice CT (MSCT) supraaortic branches angiography. Case Outline. A 53-year-old female patient was examined at the Outpatients’ Unit of the Vascular Surgery University Clinic for vertigo, occasional dizziness and difficulty with swallowing. Physical examination revealed a murmur of the left supraclavicular space, with 15 mmHg lower rate of arterial tension on the left arm. Ultrasound of carotid arteries revealed 60% stenosis of the left subclavian artery and bilateral internal carotid artery elongation. MSCT angiography revealed a right-sided aortic arch with aberrant separation of the left subclavian artery that was narrowed 50%, while internal carotid arteries were marginally elongated. There was no need for surgical treatment or percutaneous interventions, so that conservative treatment was indicated. Conclusion. A right-sided aortic arch is a very rare anomaly of the location and branching of the aorta. Multislice CT angiography is of great importance in the diagnostics of this rare disease.

Introduction. Though surgical approach is common in arteriovenous (AV) fistula treatment, endovascular procedures such as stent-graft placement has become more popular in recent years. We aim to present a case of thrombosed femoral artery stent-graft which was placed one year earlier due to multiple AV fistulas following gunshot wounds. Case Outline. A 43-year-old patient was admitted to the Institute for Cardiovascular Diseases 'Dedinje', Belgrade, Serbia, for arteriography. Five years before, he had suffered from six gunshot wounds in his right leg and one year before, in the health centre in Vienna, stent-graft had been placed in the right superficial femoral artery due to multiple AV fistulas. Because of artery dilation proximal to AV fistula location, a large dimensional stent-graft had to be placed (24 mm). After admission, arteriography and Multislice CT (MSCT) angiography revealed thrombotic masses in the stent-graft with intraluminal stenosis of 50%. Extirpation of thrombosed stent-graft was performed followed by Dacron tubular graft 10 mm interposition. On the fifth postoperative day, the patient was discharged from the clinic, and after 3 months, the right leg vascularisation was well preserved. Conclusion. Large dimensional stent-graft placement in patients with mutiple AV fistulas and blood vessel dilation proximal to AV site of communication carries an increased risk of thrombotic events due to turbulent blood flow and parietal thrombosis occurrence. Though stent-graft placement can be a very useful solution in acute AV fistula treatment, the very same thrombosis should be thought of when surgical management is the only treatment choice.

INTRODUCTION Aneurysms of digital arteries are considered to be rarity. They could be true or false. False aneurysms are usually the result of penetrating trauma, while the causes of development of true aneurysms are various, such as blunt trauma, and rarely atherosclerosis, vasculitis and infection. Also, they can be idiopathic. Reviewing the literature we found 13 cases of previously described true aneurysms of digital arteries. None of them referred to the common digital artery aneurysm. CASE OUTLINE We report a case of an idiopathic true aneurysm of the common digital artery, with its clinical presentation and a corresponding multislice CT arteriogram. Surgical treatment by ligation and excision of the aneurysm was performed. CONCLUSION As mentioned above, true aneurysms of digital arteries are very rare, so they are of little clinical importance. The most common symptom of digital artery aneurysms is pain, with a tender pulsatile mass on examination. Since natural healing cannot be expected, surgical treatment of true digital artery aneurysms is recommended for pain relief and avoidance of complications which may occur and are related to the aneurysm presence. Aneurysm resection and ligation of a blood vessel can be performed. Also, artery reconstruction can be performed by primary end-to-end anastomosis or the placement of a reversed interposition vein graft.

Although the incidence of prosthetic infection is low (1%-6%), the consequences (limb loss or death) are dramatic for a patient, with high mortality rate (25%-75%) and limb loss in 40%-75% of cases. In case of Szilagyi's grade III infection, standard procedure consists of the excision of prosthesis and wound debridement. Alternative method is medical treatment. This is a case report of a patient with prosthetic infection of Silver-ring graft, used for femoropopliteal reconstruction, in whom an extreme skin necrosis developed in early postoperative period. This complication was successfully treated medically. After repeated debridement and wound-packing, the wound was covered using Thiersch skin graft.

Introduction: Peripheral arterial disease (PAD) is a severe atherosclerotic condition. The relationship between various risk factors and severity of PAD, measured by Ankle Brachial Index (ABI), has been the subject of a relatively small number of studies., Objective: The aim of the present study was to investigate whether there was any relationship between severity of PAD, expressed as ABI, and anthropometric, clinical and biochemical characteristics of patients, including inflammatory markers., Methods: The cross-sectional study, involving 388 consecutive patients with verified PAD, was performed at the Dedinje Vascular Surgery Clinic in Belgrade. The diagnosis of PAD was defined by Doppler sonography as ABI < 0.9, and by symptoms. Data on cardiovascular risk factors, anthropometric parameters, clinical and biochemical characteristics were collected for all participants. In the analysis, chi2 test, t-test and multivariate logistic regressions were used., Results: According to the results of multivariate analysis (the model of which included age, percentage of body fat, average value of uric acid, high sensitivity C-reactive protein--hsCRP > or = 3 mg/L, fibrinogen > or = 4 g/L, Baecke index of physical activity at work and Baecke index of leisure-time physical activity), the patients with more severe form of peripheral arterial disease (ABI < or = 0.40) had more frequently increased high sensitivity C-reactive protein (p = 0.002), lower Baecke index of physical activity at work (p = 0.050) and lower Baecke index of leisure-time physical activity (p = 0.024). Average value of body fat was significantly higher in the patients with a less severe form of disease (p = 0.006)., Conclusion: According to the results obtained, the increased values of hsCRP and physical inactivity are associated with a more severe form of PAD (ABI < or = 0.40).