Search

Objectives Parkes Weber syndrome is a congenital vascular malformation which consists of capillary malformation, venous malformation, lymphatic malformation, and arteriovenous malformation. Although Parkes Weber syndrome is a clinically distinctive entity with serious complications, it is still frequently misdiagnosed as Klippel-Trenaunay syndrome that consists of the triad capillary malformation, venous malformation, and lymphatic malformation. Methods We performed a systematic review investigating clinical, diagnostic, and treatment modalities of Parkes Weber syndrome (PubMed/MEDLINE, Embase, and Cochrane databases). Thirty-six publications (48 patients) fulfilled the eligibility criteria. Results The median age of patients was 23 years (IQR, 8-32), and 24 (50.0%) were males. Lower extremity was affected in 42 (87.5%) and upper extremity in 6 (12.5%) patients; 15 (31.3%) patients developed high-output heart failure; 12 (25.0%) patients had chronic venous ulcerations, whereas 4 (8.3%) manifested distal arterial ischemia. The spinal arteriovenous malformations were reported in six (12.5%) patients and coexistence of aneurysmatic disease in five (10.4%) patients. The most frequently utilized invasive treatments were embotherapy followed by amputation and surgical arteriovenous malformation resection, and occasionally stent-graft implantation. All modalities showed clinical improvement. However, long follow-up and outcome remained unclear. Conclusion A diagnosis of Parkes Weber syndrome should be made on the presence of capillary malformation, venous malformation, lymphatic malformation, and arteriovenous malformation (as main defect) in overgrowth extremity. Arteriovenous malformation presents the criterion for distinguishing Parkes Weber syndrome from Klippel-Trenaunay syndrome, which is substantial for treatment strategy. The primary management goal should be patient's quality of life improvement and complication reduction. Embolization alone/combined with surgical resection targeting occlusion or removal of arteriovenous malformation "nidus" reliably leads to clinical improvement.

Introduction: Nutcracker syndrome is defined as a set of signs and symptoms secondary to compression of the left renal vein (LRV) in the acute anatomic angle between the aorta and its superior mesenteric branch., Case Report: A 38-year old woman with asymptomatic and “idiopathic” gross hematuria came to the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade. Hematuria was documented by cystoscopy and was found to be unilateral, located to the left urethral orifice. The contrast-enhanced multidetector computed tomography (MDCT) scan showed a stenotic LRV due to the extrinsic compression in the angle formed by the ventral aorta and superior mesenteric artery (MSA), with a jet of contrast through the lumen. Considering the negative investigations for more common causes of hematuria, its incapacitating nature, and above mentioned imaging findings suggestive of the nutcracker syndrome, an indication for the open surgical correction of the LRV entrapment was established. The patient underwent reimplantation of the LRV into the more distal inferior vena cava (IVC), to relocate it out of the constrictive aortomesenteric space. Intraoperative findings were notable for blood flow turbulence in the LRV and hypertrophy of its tributaries, which were ligated. We presented the first published case in the Serbian literature on nutcracker syndrome with hematuria resolved by renocaval reimplantation., Conclusion: This case report demonstrates that renocaval reimplantation, as the open surgery technique, could be the adequate method for resolving gross hematuria in patients with nutcracker syndrome.

Background: Mortality after open repair of ruptured abdominal aortic aneurysms (RAAAs) remains high. The purpose of this study is to present the results of open RAAA treatment observing 2 different 10-year periods in a single high-volume center and to consider the possibilities of result improvement in the future., Methods: Retrospective analysis of 729 RAAA patients who were treated through 1991-2001 (229 patients, Group A) and 2002-2011 (500 patients, Group B) was performed. Variables significantly associated with mortality were defined and analyzed., Results: Overall 30-day mortality in Group A was 53.7% (123/229 patients) with intraoperative mortality of 13.5% (31/229 patients), while in Group B it was 37.4% (187/500 patients) with intraoperative mortality of 12.4% (62/500 patients). Overall 30-day mortality was significantly lower in Group B (P = 0.012). There was no difference regarding intraoperative mortality (P = 0.797). Preoperative severe hemodynamic instability (P < 0.01, P < 0.001), cardiac arrest (P < 0.01, P < 0.001), consciousness deterioration (P < 0.05, P < 0.001), renal malfunction (P < 0.01, P < 0.001), and significant anemia (P < 0.01, P < 0.001) were associated with increased mortality in both A and B groups, respectively. Aortic cross-clamping level in Group A was predominantly infrarenal (68%) while in Group B it was mostly supraceliac (53%) (P < 0.001). Cross-clamping time, duration of surgery, and type of aortic reconstruction had no influence on survival in Group B (P > 0.05). Intraoperative hemodynamic instability (P < 0.01, P < 0.001), significant bleeding (P < 0.05, P < 0.01), and low urine output (P < 0.05, P < 0.001) remained parameters that favored lethal outcome in both A and B groups, respectively. Cell saving was used only in Group B. The multivariate logistic regression applied on the complete sample of patients presented several significant predictors of lethal outcome: congestive heart failure on admission (odds ratio [OR] 1.954, 95% confidence interval [CI] 1.103-3.460), intraperitoneal rupture (OR 3.009, 95% CI 1.771-5.423), aortofemoral reconstruction (OR 1.928, 95% CI 1.044-3.563), and total operative time (OR 1.005, 95% CI 1.001-1.010). Postoperative multisystem organ failure (P < 0.01, P < 0.001), respiratory (P < 0.01, P < 0.001) and renal (P < 0.05, P < 0.001) failure, postoperative bleeding (P < 0.05), and cerebrovascular incidents (P < 0.05, P < 0.01) significantly increased mortality in both A and B groups., Conclusions: Although unselective, aggressive surgical approach in RAAA performed by teams experienced in open repair can improve patient's survival. Short admission/surgery time, supraceliac aortic cross-clamping, and the use of intraoperative cell saving are recommended., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Endovascular stent-graft placement has emerged as a minimally invasive alternative to open surgery for the treatment of aortic aneurysms and dissections. There are few reports of stent graft infections and aortoenteric fistula after endovascular thoracic aortic aneurysm repair, and the first multicentric study (Italian survey) showed the incidence of about 2%., Case Report: We presented a 69-year-old male patient admitted to our hospital 9 months after thoracic endovascular aortic repair, due to severe chest pain in the left hemithorax and arm refractory to analgesic therapy. Multislice computed tomography (MSCT) showed a collection between the stent graft and the esophagus with thin layers of gas while gastroendoscopy showed visible blood jet 28 cm from incisive teeth. Surgical treatment was performed in collaboration of two teams (esophageal and vascular surgical team). After explantation of the stent graft and in situ reconstruction by using Dacron graft subsequent esophagectomy and graft omentoplasty were made. After almost four weeks patient developed hemoptisia as a sign of aorto bronchial fistula. Treatment with implantation of another aortic cuff of 26 mm was performed. The patient was discharged to the regional center with negative blood culture, normal inflammatory parameters and respiratory function. Three months later the patient suffered deterioration with the severe weight loss and pneumonia caused by Candida albicans and unfortunately died. The survival time from the surgical treatment of aortoesophageal fistula was 4 months, Conclusion: Even if endovascular repair of thoracic aortic diseases improves early results, risk of infection should not be forgotten. Postoperative respiratory deterioration and finally hemoptisia could be the symptoms of another fistula.

Background: The angiotensin II type 2 receptor (AT2R) -1332 A/G polymorphism has been denoted as functional and associated with certain cardiovascular disease phenotypes. However, there are no studies considering the association of this gene polymorphism with carotid atherosclerosis (CA) and cerebrovascular events. Therefore, the aim of our study was to investigate a possible association of the AT2R -1332 A/G polymorphism with the occurrence of carotid plaques (CPs) and history of cerebrovascular insult (CVI) in advanced CA., Methods: The study group included 381 controls and 509 patients with CA consecutively admitted for endarterectomy. Genotyping was determined by polymerase chain reaction-restriction fragment length polymorphism method. The association was analyzed separately for males and females because the AT2R gene is located on the X chromosome., Results: The AT2R -1332 GG genotype was associated with the advanced CA in the female study group (recessive model of inheritance, AA+AG versus GG; adjusted odds ratio [OR] = 2.25; 95% confidence interval [CI] 1.17-4.33; P = .01). In the male subgroup of patients with CA, the significant overrepresentation of G/- hemizygote was detected in patients with CVI compared to male patients without this event (crude OR = 2.05, 95% CI 1.20-3.50, P = .008)., Conclusions: This study suggests a gender-specific association between the AT2R -1332 A/G polymorphism and the occurrence of CP and the history of CVI in advanced CA, but further replication studies are needed., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Single nucleotide polymorphisms from the chromosome locus 9p21 are reported to carry a risk for various cardiovascular diseases. One of the lead single nucleotide polymorphisms, rs10757278, was mostly investigated in association with coronary artery disease but rarely with carotid atherosclerosis. In this study, we aimed to analyze the association of rs10757278 A/G polymorphism with carotid plaque presence in advanced carotid atherosclerosis. The study included 803 participants, 486 patients with high-grade stenosis (>70%) who were undergoing carotid endarterectomy and 317 controls from Serbian population. Genotypes were determined using the real-time polymerase chain reaction. According to the recessive model of inheritance, GG genotype was significantly and independently associated with carotid plaque in females only (odds ratio 2.42, CI = 1.20-4.90, P = 0.013). Odds ratio was adjusted for age, body mass index, hypertension, TC, LDLC, HDLC and TG, and P value was corrected for multiple comparisons. Our preliminary findings suggest a gender-specific association of rs10757278 polymorphism with carotid plaque. Further studies on larger sample and in genetically and environmentally similar populations are needed., (© 2016 by the Society for Experimental Biology and Medicine.)

Introduction: Venous aneurysm (VA) is a rare condition that can be presented in both superficial and deep venous system. Secondary VAs as well as pseudoaneurysms are usually caused by external spontaneous or iatrogenic trauma. They are often misdiagnosed and inadequately treated. Complications include thrombosis, phlebitis, eventual pulmonary embolism and rupture., Case Report: We presented a case of secondary VA of the great saphenous vein developed in a young addict following chronic intravenous drug application in the groin region. Aneurysm required urgent surgical treatment due to bleeding complication as it was previously misdiagnosed for hematoma (or abscess) and punctuated by a general surgeon. Complete resection of VA with successful preservation of continuity of the great saphenous vein was performed. Postoperative course was uneventful. Regular venous flow through the great saphenous vein was confirmed on control ultrasound examination., Conclusion: VAs are uncommon, among them secondary VA being extremely rare. In cases with a significant diameter or threatening complications surgical treatment is recommended.

Background and Aims: The principal biologic effects of the renin-angiotensin system are mediated by activation of the AT1R receptor. The microRNA miR-155 regulates AT1R expression, with both its, and AT1R's activity, linked to atherosclerosis. Target sites for miR-155 lie within the 3' UTR of the human AT1R gene, and include the AT1R A1166C polymorphism. Thus far, only levels of circulating miR-155 have been investigated with respect to A1166C genotypes. We hypothesized that the A1166C polymorphism could correlate with different, ultra-sonographically defined plaque phenotypes, as well as with an altered expression of AT1R mRNA and protein in human carotid plaques (CP), and altered expression of miR-155 in patients with advanced atherosclerosis., Methods: Our study cohort comprised 411 patients with advanced carotid atherosclerosis (298 hyperechoic; 113 hypoechoic plaques). PCR analyses identified A1166C genotypes; quantitative real-time PCR determined AT1R and miR-155 expression levels, with AT1R protein expression evaluated by western blot., Results: Genotypes containing the C allele bore a significant association with the hypoechoic plaque phenotype (adjusted OR 1.87, 95% CI 1.16-3.00, p = 0.01). The expression of AT1R mRNA and miR-155 were significantly up-regulated in the CPs of CC genotype carriers compared to the AA/AC genotypes (p = 0.032, p = 0.015, respectively). AT1R protein expression was also significantly higher for CC genotypes (p < 0.01)., Conclusion: Our results indicate that the AT1R A1166C polymorphism impacts an ultrasonographically-defined human plaque phenotype, with intra-plaque AT1R and miR-155 expression altered in advanced carotid atherosclerosis. Validation and replication of these data should contribute to an improved personalized therapy with which to prevent carotid atherosclerosis., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Unlabelled: BACKGROUND/AIM. Surgical and chronic wounds in vascular patients might contribute to limb loss and death. Vacuum-assisted closure (VAC)--Kinetic Concepts, Inc. (KCI), has been increasingly used in Western Europe and the U.S.A. clinical practice for 15 years. Advantages of this method are faster wound healing, wound approximation, lower wound related treatment costs and improved quality of life during treatment. Evidence related to the usage of VAC therapy in vascular patients and cost effectiveness of VAC therapy in a developing country are lacking. The aim of this study was to explore results of VAC therapy in vascular surgery comparing to conventional methods and to test cost effects in a developing country like Serbia., Methods: All patients with wound infection or dehiscence operated at the tertiary vascular university clinic in the period from January 2011-January 2012, were treated with VAC therapy. The primary endpoint was wound closure, while secondary endpoints were hospital stay, the number of weekly dressings, costs of wound care, working time of medical personnel. The patients were divided into groups according to the wound type and location: wound with exposed synthetic vascular implant (25%), laparotomy (13%), foot amputation (29%), major limb amputation (21%), fasciotomy (13%). The results of primary and secondary endpoint were compared with the results of conventional treatment during the previous year., Results: There was one death (1/42, 2.38%) and one limb loss (1/12, 2.38%) in the VAC group, and 8 deaths (8/38, 21.05%) and 5 (5/38, 13.15%) limb losses in the patients treated with conventional therapy. In the VAC group there was one groin bleeding (1/12, 2.38%), one groin reinfection (1/12, 2.38%) and one resistance to therapy with a consequent limb loss. Costs of hospital stay (p < 0.001) and nursing time (p < 0.001) were reduced with VAC therapy in the group with exposed graft., Conclusion: VAC therapy is the effective method for care of complicated wounds in vascular surgery. Patients with infection of wound with the exposed synthetic graft significantly benefit form this therapy. Cost effectiveness of VAC therapy is applicable to a developing country scenario, however cautious selection of patients contributes to the effectiveness.

Objective: To describe a rare case of acute presentation of papillary thyroid carcinoma (PTC)., Clinical Presentation and Intervention: A 19-year-old male presented with an expanding cervical mass following blunt trauma. A computed tomography scan revealed a mass suspected to be hematoma that was compressing the vessels and thereby deviating the trachea. Immediate surgery was performed. Neither vascular injury nor active bleeding was seen; instead, a solid, hematoma-like tumefaction in the right thyroid lobe was revealed. A total thyroid lobectomy was performed. A histologic paraffin section confirmed a PTC that was permeated by hematoma., Conclusion: This was a unique case of an acute, life-threatening presentation of previously asymptomatic PTC in an adolescent., (© 2016 S. Karger AG, Basel.)

Introduction: Splenic artery aneurysms are potentially lethal lesions. We report two illustrative cases and discuss etiology, diagnosis and treatment of these aneurysms., Outline of Cases: Both patients, age 31 and 80 years, were biparous women.The younger woman, otherwise healthy, was referred from a local hospital 3 weeks after she underwent a left subcostal laparotomy and exploration for symptomatic abdominal mass diagnosed by CT. Angiography established the diagnosis of a large, non-ruptured splenic artery aneurysm. Elective aneurysmectomy with splenectomy was performed using the approach through the upper median laparotomy and bursa omentalis. Postoperative course was uneventful. Histopathology demonstrated cystic medial necrosis with chronic dissection. The other patient, elderly woman, presented urgently with acute abdominal pain and syncope and was diagnosed by computed tomography with a huge, ruptured splenic artery aneurysm. She underwent immediate aneurysmectomy with splenectomy using the same, above-mentioned approach. External pancreatic fistula and pancreatic pseudocyst complicated the postoperative course, requiring open pseudocyst drainage and cystojejunostomy. After a protracted hospitalization patient eventually recovered. The pathological diagnosis was atherosclerotic aneurysm., Conclusion: Splenic artery aneurysms are infrequent lesions, with varied etiology and clinical presentation. Timely diagnosis and adequate treatment prevent life-threatening rupture and lessen the risk of operative morbidity and mortality.

Introduction: The study included application of liners and dental composites in to cavities of six experimental animals-rabbits (Oryctolagus cuniculus). OBJECTIVE The aim of the study was to investigate rabbit dental pulp response to different liners. Methods Cavity preparation for class V were made on the maxillary central incisors and one lower incisor, while the second lower incisor served as a control tooth. These teeth were restored with the use of one of the following liners--Calcimol LC, ANA Liner and Fuji II LC Improved, and Ceram-X mono dental composite. After an observation period of five days animals were sacrificed and prepared for histological analysis.The existence and degree of the pulp inflammation was determined by using a light microscope., Results: Results showed that the used liners do not cause distortion of the structure and continuity of the odontoblastic layer. Inflammation was not registered in the control group, while in each group of tested materials one tooth with mild signs of hyperemia was registered. Results showed that all three tested liners demonstrated favorable effects on the pulp of the tooth and did not lead to inflammatory reactions., Conclusion: Histological analysis of the dental pulp of experimental animals suggests that the liners used in this study do not compromise the integrity of the odontoblastic layer, if it is applied over a thin layer of dentin. In each group of tested materials one tooth with mild signs of hyperemia and vasodilation was registered.

Aim: Chemokine CXC ligand 16 (CXCL16) has chemoattractive, adhesive and scavenging properties and may play a role in the formation of atherosclerotic lesions. However, studies of CXCL16 polymorphisms in patients with atherosclerosis are scarce. The missense polymorphisms I123T and A181V are potentially important factors in the regulation of presentation and shedding of the CXCL16 chemokine domain. The aim of this study was to analyze the association between I123T and A181V polymorphism haplotypes and the accumulation of carotid plaque as well as the effect of the haplotype on the CXCL16 mRNA expression in carotid plaques in patients with advanced atherosclerosis. Additionally, we performed a bioinformatic prediction analysis of the impact of CXCL16 protein sequence variation on CXCL16-CXCR6 interactions and analyzed the soluble CXCL16 plasma levels according to the CXCL16 haplotype., Methods: This study evaluated a total of 733 participants, including 283 controls and 450 patients with carotid atherosclerosis (CA) undergoing endarterectomy. Analyses of the polymorphisms and the gene expression were performed using real-time PCR. The soluble CXCL16 levels were measured with ELISA., Results: The missense allele haplotype, T123V181, was found to be significantly and independently associated with the occurrence of CA plaque (OR=1.27;1.02-1.57, p=0.03). This haplotype was predicted to significantly change the CXCL16-CXCR6 interaction, compared to I123A181. Neither the CXCL16 mRNA expression in the human plaques nor the soluble CXCL16 plasma levels differed according to the haplotype., Conclusions: These results indicate that the CXCL16 T123V181 haplotype is a moderate genetic risk factor for the development of carotid plaque. Further functional and replication studies are needed to clarify the mechanisms by which this combination of alleles promotes advanced CA and validate its impact on disease progression.

Introduction: Vertebral artery injury caused by penetrating neck trauma is a rare occurrence. Direct surgical repair is difficult due to anatomy and exposure. Proximal and distal ligation or/and embolization represent the most common management in cases which require intervention., Case Report: A young man accidentally stabbed in the neck was admitted to the emergency department with active arterial bleeding from the wound. Immediate surgical exploration revealed an isolated injury of the left vertebral artery intraosseous segment. Lesion was managed by proximal segment ligature and distal Fogarty catheter balloon-tamponade. Postoperative angiography excluded the need for further interventions. Balloon-catheter was successfully extracted after 72 hours and patient discharged neurologically intact on postoperative day 7. Fourteen months later, there are no signs of vascular or neurologic complications., Conclusion: Balloon-tamponade is a valuable technical adjunct in either temporizing or definitive management of surgically inaccessible vascular trauma., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AIOD) is traditionally accompanied by substantial groin incisional morbidity, which poses a threat to an underlying prosthetic graft. We performed a study to investigate the frequency and define the clinical course and significance of such problems., Methods: One hundred twenty consecutive patients undergoing primary elective ABFB for AIOD were enrolled in a prospective study. The healing of groin wounds was systematically assessed, the occurrence of incisional complications of any type noted, and their clinical course and economic consequences documented and analyzed., Results: Early postoperative complications (30 days) affected 35 (15%) groin wounds in 29 (24.8%) patients. Lymph fistulas/lymphoceles were observed in 15 (6.4%), infection in 11 (4.7%), and noninfectious wound dehiscence in 9 (3.8%) of groin incisions. The only significant predictor of groin healing impairment was preoperative length of stay. Groin incision-related morbidity significantly increased the duration and cost of hospitalization. Sixty percent of groin healing problems were diagnosed after discharge and they represented the most common cause for early readmissions., Conclusions: The incidence of groin wound complications after ABFB is considerable, their financial impact significant, and delayed onset frequent. Femoral incisional morbidity after ABFB still represents an unremitting nuisance, necessitating further improvements in preventive strategies and techniques and strict adherence to conventional ones, including the minimization of preoperative length of stay., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Glutathione S-transferases (GSTs) carry out a wide range of functions in cells, such as detoxification of endogenous compounds, removal of reactive oxygen species, and even catalysis of reactions in metabolic pathways beyond detoxification. Based on previous research, GSTM1 and GSTT1 might modify the risk of atherosclerosis. The aim of our study was to analyze the possible association of GSTM1 and GSTT1 gene polymorphisms with the occurrence of carotid plaque (CP); and biochemical parameters of oxidative stress, lipid profile and inflammation, in 346 consecutive patients with advanced atherosclerosis that underwent endarterectomy. A multiplex polymerase chain reaction (PCR) method was used to detect the deletions in GSTM1 and GSTT1 genes in the genomic DNA in 346 patients and 330 controls. The adjusted OR for CP presence (adjusted for age, gender, smoking, hypertension, BMI, HDLC, TG) was 0.24, 95 %CI 0.08-0.7, p < 0.01 for GSTT1 null and 1.13, 95 %CI 0.62-2.07, p = 0.7 for GSTM1 null genotype. We found significantly lower plasma lipoprotein (a) (Lp(a)) levels in GSTT1 null compared to wild-type genotype carriers in patient group (20.68 ± 26.02 mg/dl vs. 40.66 ± 42.89 mg/dl, mean ± SD, p = 0.04). The serum interleukin-6 (IL-6) values were significantly influenced by both GST polymorphisms in patients with CP. Our results, showing the significant reduction of GSTT1 deletions in patients with CP, suggest involvement of GSTs in carotid atherosclerosis. This study shows additional view of the possible role of GSTs in advanced chronic inflammatory disease of vascular system, but the confirmation in a larger studies in different populations are needed.

Introduction: Posterior knee joint dislocation associated with injury of the popliteal artery in children is an extremely rare condition. Rapid diagnosis and treatment are essential for limb salvage and function., Case Report: We reported a 14-year-old boy who suffered traumatic displacement of the right knee and contusion of the popliteal artery during motorcycle accident. The diagnosis was confirmed using Doppler and duplex ultrasonography and digital substraction transfemoral arteriography. The urgent surgical procedure was performed using posterior approach to the popliteal artery. During the surgical exploration, rupture of the posterior cruciate ligament associated with thrombosed popliteal artery have been found. The damaged popliteal artery was resected and replaced with autologous saphenous vein graft. The last stage of the procedure was a transosseous femoral fixation of posterior circuate ligament. A 3-year-follow-up after the surgery demonstrated intact arterial perfusion and very good function of the knee with a minimal difference as compared with the contralateral knee., Conclusion: Combined orthopedic and vascular injuries are very rare in children. They require combined treatment.

Background/aim: Aortobifemoral (AFF) bypass is still the most common surgical procedure used in treatment of aortoiliac occlusive disease. One of the most common complications of AFF bypass procedure is long-term graft oclussion. The aim of this study was to determine the cause of long-term graft occlusion in AFF position, as well as the results of early treatment of this complication., Methods: This retrospective study, performed at the Clinic of Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade, involved 100 patients treated for long-term occlusion of bifurcated Dacron graft which was ensued at least one year after the primary surgical pro cedure., Results: The most common cause of the long-term graft occlusion was the process at the level of distal anastomosis or below it (Z = 3.8, p = 0.0001). End-to-end type of proximal anastomosis has been associated with a significantly increased rate of long-term graft occlusion (Z = 2.2, p = 0.0278). Five different procedures were used for the treatment of long-term graft occlusion: thrombectomy and distal anastomosis patch plasty (46% of the cases); thrombectomy and elongation (26% of the cases); thrombectomy and femoropopliteal bypass (24% of the cases); crossover bypass (2% of the cases) and a new AFF bypass (2% of the cases). The primary early graft patency was 87%. All 13 early occlusions occurred after the thrombectomy associated with patch plasty of distal anastomosis. Thrombectomy with distal anastomosis patch plasty showed a statistically highest percentage of failures in comparison to thrombectomy with graft elongation, or thrombectomy with femoro-popliteal bypass (Z = 2 984, p = 0.0028). Redo procedures were performed in all the cases of early occlusions. In a 30-day follow-up period after the secondary surgery, 90 (90%) patients had their limbs saved, and above knee amputation was made in 10 (10%) patients., Conclusion: Long-term AFF bypass patency can be obtained by proximal end-to-end anastomosis on the juxtarenal part of aorta and distal anastomosis on the bifurcation of the common femoral, or on the deep femoral artery.

Background/aim: Endovascular treatment of thoracic aortic diseases is an adequate alternative to open surgery. This method was firstly performed in Serbia in 2004, while routine usage started in 2007. Aim of this study was to analyse initial experience in endovacular treatment of thoracic aortic diseses of three main vascular hospitals in Belgrade - Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia, Clinic for Vascular Surgery of the Military Medical Academy, and Clinic for Vascular Surgery of the Institute for Cardiovascular Diseases "Dedinje"., Methods: Between March 2004. and November 2010. 41 patients were treated in these three hospitals due to different diseases of the thoracic aorta. A total of 21 patients had degenerative atherosclerotic aneurysm, 6 patients had penetrating aortic ulcer, 6 had posttraumatic aneurysm, 4 patients had ruptured thoracic aortic aneurysm, 1 had false anastomotic aneurysm after open repair, and 3 patients had dissected thoracic aneurysm of the thoracoabdominal aorta. In 15 cases the endovascular procedure was performed as a part of the hybrid procedure, after carotid-subclavian bypass in 4 patients and subclavian artery transposition in 1 patient due to the short aneurysmatic neck; in 2 patients iliac conduit was used due to hypoplastic or stenotic iliac artery; in 5 patients previous reconstruction of abdominal aorta was performed; in 1 patient complete debranching of the aortic arch, and in 2 patients visceral abdominal debranching were performed., Results: The intrahospital mortality rate (30 days) was 7.26% (3 patients with ruptured thoracic aneurysms died). Endoleak type II in the first control exam was revealed in 3 patients (7.26%). The patients were followed up in a period of 1-72 months, on average 29 months. The most devastating complication during a followup period was aortoesofageal fistula in 1 patient a year after the treatment of posttraumatic aneurysm. Conversion was performed with explantation of stent-graft and open aortic in situ recontruction, followed by esophagectomy and the creation of cervical and gastrical stoma., Conclusion: Having in mind initial results of the 3 main vascular clinics in Belgrade, Serbia, economical situation in our country, as well as the published international results, endovascular treatment of thoracic aortic diseases is indicated in hemodinamicaly unstable patients with acute traumatic aneurysm, or in stabile patients older than 65, as well as in case of chronic diseases of the thoracic aorta in patients with significant comorbid conditions or in patients older than 65 years. Endovascular procedures on the thoracic aorta could be performed, hower, only in high-volume centers with experience in routine open surgery of thoracic aorta.

Endovascular aortic/aneurysm repair (EVAR) was introduced into clinical practice at the beginning of the nineties. Its fast development had a great influence on clinicians, vascular surgeons and interventional radiologists, educational curriculums, patients, industry and medical insurance. The aim of this paper is to present the contribution of clinicians and industry to the development and advancement of endovascular aortic repair over the last 20 years. This review article presents the development of EVAR by focusing on the contribution of physicians, surgeons and interventional radiologists in the creation of the new field of vascular surgery termed hybrid vascular surgery, and also the contribution of technological advancement by a significant help of industrial representatives--engineers and their counselors. This article also analyzes studies conducted in order to compare the successfulness of EVAR with up-to-now applied open surgical repair of aortic aneurysms, and some treatment techniques of other aortic diseases. During the first two decades of its development the EVAR method was rapidly progressing and was adopted concurrently with the expansion of technology. Owing to large randomized studies, early and long-term results indicate specific complications of this method, thus influencing further technological improvement and defining risk patients groups in whom the use of the technique should be avoided. Good results are insured only in centers, specialized in vascular surgery, which have on their disposal adequate conditions for solving all complications associated with this method.

Background/aim: To promote better treatment outcome, as well as economic benefit it is very important to find out patients with simultaneous occurrence of both aortic and arterial aneurysms. The aim of this prospective study was to determine the frequency and factors affecting femoropopliteal (F-P) segment aneurysms appearance in patients with abdominal aortic aneurysms (AAA)., Methods: This study included 70 patients who had underwent elective or urgent surgery of AAA from January 1, 2006 to December 31, 2007. After ultrasonographic examination of F-P segment, all the patients were divided into two groups--those with adjunctive F-P segment aneurysm (n = 20) and the group of 50 patients witho no adjunctive F-P segment aneurysm. In both groups demographic characteristics (gender, age), risk factors (diabetes mellitus, elevated serum levels of cholesterol and triglycerides, arterial hypertension, smoking, obesity) and cardiovascular comorbidity (cerebrovascular desease, ischemic heart desease) were investigated., Results: Twenty (28.57%) patients who had been operated on because of AAA, had adjunctive aneurysmal desease of F-P segment. Diabetes was no statistically significantly more present among the patients who, beside AAA, had adjunctive aneurismal desease of F-P segment (chi2 = 0.04; DF = 1; p > 0.05). Also, in both groups there was no statistically significant difference in gender structure (chi2 = 2.05; DF = 2; p > 0.05), age (chi2 = 5.46; DF = 1; p > 0.05), total cholesterol level (chi2 = 0.89; DF = 1; p > 0.05) and triglyceride (chi2 = 0.89; DF = 1; p > 0.05) levels, the presence of arterial hypertension (chi2 = 1.38; DF = 2; p > 0.05), smoking (chi2 = 1.74; DF = 1; p > 0.05), obesity (chi2 = 1.76; DF = 1; p > 0.05) and presence of cerebrovascular desease (chi2 = 2.34; DF = 1; p > 0.05). Conversly, ischemic heart desease was statistically significantly more present among the patients who, beside AAA, had adjunctive aneurismal desease of F-P segment (chi2 = 5.45; DF = 1; p < 0.05)., Conclusion: Twenty patients, beside AAA, had adjunctive F-P segment aneurysm. The results of this study suggest the necessity of preforming ultrasonographic examination of F-P segment in all patients with proven AAA.

Introduction: Arteriovenous fistula of the superior mesenteric blood vessels is a rare complicaton in abdominal surgery., Case Report: We presented a 49-year-old man with cramp-like abdominal pain, abdominal distension and weight loss symptoms, with a history of previous small bowel resection and right colectomy, due to Crohn disease, 16 years ago. Clinical examination revealed a paraumbilical pulsation with systolic murmur and thrill. Ultrasonography and computed tomography revealed cystic dilatation of the superior mesenteric vein, hepatomegaly and ascites. Upper endoscopy revealed grade I esophageal varices with portal hypertensive gastropathy. The diagnosis of arteriovenous fistula between superior mesenteric artery and vein was confirmed by angiogram of the superior mesenteric vessels and resection of the fistula was performed. Control examination after nine months showed no signs of portal hypertension., Conclusion: Early diagnosis and treatment of mesenteric blood vessel arteriovenous fistula prevents portal hypertension development and its complications.

Introduction: The ACE I/D polymorphism was mostly investigated in association with intima-media thickness, rarely with severe atherosclerotic phenotype., Materials and Methods: We investigated the association of I/D polymorphism with severe carotid atherosclerosis (CA) (stenosis > 70%) in asymptomatic and symptomatic patients undergoing carotid endarterectomy. The 504 patients subjected to endarterectomy and 492 healthy controls from a population in Serbia were investigated as a case-control study., Results: The univariate logistic regression analysis revealed ACE DD as a significant risk factor for severe CA (odds ratio [OR] = 1.3, 95% confidence interval [CI] 1.0-1.7, p = 0.04). After adjustment for the common risk factors (age, hypertension, smoking, and HDL) ACE was no longer significant. However, we found a significant independent influence of DD genotype on plaque presence in a normotensive subgroup of patients (OR 1.8, CI 1.2-3.0, p = 0.01, corrected for multiple testing). In symptomatic patients D allele carriers were significantly more frequent compared with asymptomatic patients (OR 1.6 CI 1.0-2.6, p = 0.05)., Conclusions: Our data suggests that ACE I/D is not an independent risk factor for severe CA. On the other hand, a significant independent genetic influence of ACE I/D appeared in normotensive and symptomatic patients with severe CA. This should be considered in further research toward resolving the complex genetic background of severe CA phenotype.

Objective: Matrix metalloproteinases (MMPs) are involved in the remodeling of the extracellular matrix in the arterial wall. Collagen I is associated with vascular smooth muscle cell (VSMC) migration and monocyte differentiation. MMP-8 is expressed in atherosclerotic plaque and preferentially cleaves collagen type I. The aim of this study was to investigate the associations of two MMP-8 promoter polymorphisms, rs11225395 (-799C/T) and rs1320632 (-381 A/G), with carotid plaque occurrence, and the influence of these polymorphisms on MMP-8 mRNA expression in plaque tissue., Methods: The study included a total of 766 participants: 277 controls and 489 patients with carotid atherosclerosis undergoing endarterectomy. The two investigated polymorphisms were genotyped by PCR-RFLP. The gene expression analysis was performed by real-time PCR., Results: In females only, a significantly higher frequency of the -381G allele was found in patients with carotid atherosclerosis compared to controls (OR, 1.7; 95% CI 1.1-2.9; p = 0.001). Significant up-regulation of MMP-8 gene expression was observed in patients carrying the -381G allele compared to those with the AA genotype (mean factor, 3.54; S.E. range, 0.643-19.551; p = 0.007). Carotid plaque tissue of the haplotype G(-381)T(-799) showed a significantly higher mRNA level compared with the reference A(-381)C(-799) haplotype (p = 0.003)., Conclusion: Our preliminary results indicate that MMP-8 -381A/G and -799C/T gene polymorphisms could be risk factors for carotid atherosclerosis. Further validation and functional studies are needed to establish the potential regulatory role of these polymorphisms and their impact on susceptibility to carotid atherosclerosis., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Aim: Horseshoe kidney is the most common congenital kidney anomaly, occurring in 0.15-0.25% of all newborns. A medial fusion of the kidneys, mostly anteriorly to the aorta, is the main characteristic of this anomaly. The co-existence of abdominal aortic aneurysm (AAA) and horseshoe kidney is rare, occurring only in 0.12% of patients. The aim of this paper is to define the optimal management of patients with AAA associated with the horseshoe kidney., Methods: This paper presents the analysis of patients operated at the Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia in Belgrade due to AAA associated with the horseshoe kidney as well as the analysis of the previously published literature data regarding this topic., Results: Between 1985 and 2011, data were collected retrospectively on 25 patients with the horseshoe kidney who underwent aortic surgery. Out of them, 6 patients had aortoiliac occlusive disease and 19 patients had aortic aneurysm. More detailed analysis of the aneurysmatic group was performed. Among them there were 16 male and three female patients, with the average age of 63.8 (50-76) years. Two patients had type IV of thoracoabdomial aortic aneurysm (TAA) according to Crawford-Saffi classification, while 17 had infrarenal abdominal aortic aneurysms. There were 15 elective and four urgent procedures due to aneurismal rupture. The presence of the horseshoe kidney was detected in 16 patients before surgery (84.2%) by means of Duplex ultrasonography, angiography, computed tomography and intravenous urography. Multiple renal arteries were presented in 12 (63.2%) cases. A transperitoneal approach was used in 16 cases with abdominal aortic aneurysm, while left retroperitoneal approach with partial extrapleural removal of the 11th rib was performed in two cases of thoracoabdominal aneurysm and in one patient with AAA. In 18 cases, kidney tissue transection was successfully avoided with vascular graft placement beneath the horseshoe kidney. In one case only, the division of the renal isthmus was performed. In all 12 cases with detected anomalous renal arteries, their reattachment into vascular graft has been performed. Two patients (10.5%) died during perioperative period. One of them had ruptured type IV TAA. Seventeen patients who survived were followed from one to twenty years (mean 6.6 years). During the follow up period we lost track of 4 patients. In this period there were no signs of graft occlusion, or renal failure., Conclusion: Repair of an abdominal aortic aneurysm in the presence of the horseshoe kidney is a truly particular surgical challenge. It is associated with three main problems: choice of the surgical approach; the procedure regarding kidney isthmus preservation as well as recognition and reattachment of all significant anomalous renal arteries.

Aim: The aim of this paper was to determine the role of ultrasonographic examination in acute progressive thrombophlebitis (APT) of great saphenous vein (GSV) and its impact in considering indications for urgent surgical treatment. MEHODS: In this retrospective study, out of 141 consecutive patients operated due to APT of GSV above the knee, 63 were examined by ultrasonography prior surgery., Results: Out of 63 operated patients, in 38 duplex ultrasonography (DUS) revealed that proximal level of phlebitic process was more than 5 cm higher than the one found during physical examination (60.3%). In this group, the mean difference between DUS and clinical finding was 8.5±3.5 cm. In 25 patients there were no differences greater than 5 cm found between DUS and physical examination (39.7%). There was statistically highly significant difference between DUS and physical examination findings (χ2=6.5, P<0.01)., Conclusion: This study revealed significant difference between ultrasonographic and physical findings in patients with APT of GSV. DUS presented as reliable diagnostic method in examining, course-following and making decision for operative treatment of these patients.

Careful assessment of fluid balance is required in the perioperative period since appropriate fluid therapy is essential for successful patient outcomes. Volume status is frequently assessed by different hemodynamic variables that could be targeted as endpoints for fluid therapy and resuscitation. Goal directed fluid therapy is a method for correction of fluid status in individual patients that includes invasive hemodynamic monitoring and aggressive perioperative correction of hemodynamics. Heart failure is a syndrome of ventricular dysfunction. It is associated with a variety of patophysiological disturbances, hydro-electrolyte balance disorders and compensatory mechanisms. Heart failure indicates careful assessment of fluid balance in perioperative period. The aim of this article is to describe actual techniques of hemodynamic measurements as well as main principles of fluid therapy to maintain hydro-electrolyte balance in patients with heart failure.

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS (p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.