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Introduction: Graft infection is rightly considered one of the severest complications of vascular reconstruction. Treatment is non-standardized and associated with high mortality and morbidity rates. The choice of therapeutic modality depends upon variety of factors. One increasingly used option is in situ replacement of the infected prosthesis with the arterial allograft., Objective: The aim of this prospective nonrandomized study was to evaluate the effectiveness and durability of fresh arterial allograft as in situ substitute for the infected vascular prosthesis., Methods: During period of 2002-2005, 18 patients with the synthetic vascular graft infection underwent partial or complete prosthesis removal and secondary in situ reconstruction using the fresh arterial allograft, preserved under hypothermic conditions in buffered saline solution with an addition of antibiotics., Results: In 14 male and 4 female patients, mean-aged 62 years, 8 aortic and 10 peripheral arterial infected prostheses were partially or completely replaced with the allograft. Operative mortality was 27.8% and amputation rate was 22.2%. Systemic sepsis at initial presentation and highly virulent nature of causative microorganisms were identified as significant negative prognostic factors (chi2 test, p < 0.05). During the long-term follow-up (mean 47 months), allograft aneurysm developed in three patients, requiring allograft explantation, followed in two cases by tertiary prosthetic reconstruction., Conclusion: Substitution of the infected prosthesis with the arterial allograft could be successful if used selectively--for less virulent and localized infections of extracavitary grafts. Close follow-up is mandatory for timely diagnosis of late homograft lesions and its eventual replacement with more durable prosthetic material.

Breast cancer is really one from tumor with highest mortality in this country as well as in the word. For early detection of the loco-regional breast cancer and disease confirmation, many diagnostic procedures were recommended with aims to help in decision for surgery treatment. This comparative study reported data by clinical analyses, ultra-sonography, mammography and histological findings obtained after ex tempore biopsy, in 59 women with breast cancer aged from 16 to 69. The highest incidence of cancer was obtained in women over 61 years of age, although high rate of breast cancer was found in aging between 21 to 50 years. The fibroadenoma were founded in 40.68%, while malignant carcinoma ductale in 13.55% of all cases. Correlation between applied analyses for fibroadenoma was found in 86.05% cases, while in malignant lesions this percentage was highest (93.33%). Apart of these methods applied for early diagnosis in general hospital and obtained statistical significance in diagnosis, new techniques based on molecular level (hormone receptor status) must be used.

Between 1991-2001 total number of 1058 patients was operated at the Institute of Cardiovascular Diseases of Serbian Clinical Centre due to abdominal aortic aneurysm. Of this number, 288 patients underwent urgent surgical treatment because of ruptured abdominal aortic aneurysm. The aim of this retrospective study was to show results of the early outcome of the surgical treatment of patients with ruptured abdominal aortic aneurysm, and to define relevant preoperative factors that influenced their survival. There were 83% male and 17% female patients in the study, mean aged 67 years. Intrahospital mortality that included intraoperative and postoperative deaths was 53.7%. Therefore, 46.3% patients survived surgical treatment and were released from hospital. Intraoperative mortality was 13.5%. Statistics showed that the gender and the age did not have any influence on mortality of our patients, as well as their co morbid conditions (p > 0.05). Clinical parameters at admission in hospital such as state of consciousness, systolic blood pressure, cardiac arrest and diuresis significantly influenced the outcome of treatment, as well as laboratory findings such as levels of hematocrit, hemoglobin, white blood cells, urea and creatinin (p < 0.05; p < 0.01). Ruptured abdominal aortic aneurysm still remains one of the most dramatic surgical states with very high mortality reported. We assume that important preoperative factors that influence the outcome of surgical treatment can be defined, but there is no single parameter which can certainly predict the lethal outcome after surgery. Also, the presence of co morbid conditions does not significantly influence the outcome of treatment in these patients. Therefore, urgent operation should not be withheld in most of the patients with ruptured abdominal aortic aneurysm.

Unlabelled: The incidence of deep venous thrombosis (DVT) is high in numerous surgical and medical diseases [1]. There are increasing data on higher incidence of DVT in patients with malignant and other diseases [2]. The diagnosis of DVT is not always simple since there are subclinical and asymptomatic forms of the disease [3]. Besides, there are numerous pathological conditions that imitate deep venous thrombosis [4]., Methods: We present the results of a retrospective study over the period of January 1, 1996--June 30, 1998 at the Department of Vascular Surgery. Over that period we treated 113 patients (64 females, 49 males, average aged 60.3 +/- 7.5 years) with clinical picture of deep venous thrombosis. All patients underwent duplex scanning examinations (Toschiba SSA-100 A, 3.5 MHz and 8 MHz probes) [5, 6]. Special examinations such as angiography (8 patients), computerised tomography or nuclear magnetic resonance (27 patients) were performed in cases with unclear findings., Results: True DVT was established in 91 (80.3%) patients (Fig. 1). Seven of these patients had asymptomatic phlebothrombosis. Of 12 (10.6%) patients in 9 other pathologic conditions were found (Fig. 2). This symptomatic DVT was caused by malignant diseases (5 sarcomas, 2 metastatic carcinomas, 1 lymphoma); aneurysms of common femoral artery (2) and popliteal artery (2 patients). Ten patients (8.9%) with clinical picture of DVT established by special examinations had no evidence of the presence of intravenous thrombs (Fig. 3). This pseudo DVT was caused by calf haemathoma (3), Baker's cyst (2), popliteal artery aneurysm (1), lipoma of thigh (1), psoas abscess (1), gluteal abscess (1) and acute arthritis of the knee (1). The treatment of these groups of patients was different: surgical thrombectomy, use of streptokinase or heparine (true deep vein thrombosis), tumour extraction (Fig. 4) or another surgical treatment (symptomatic phlebothrombosis) and special decompression measures (Fig. 5) (pseudophlebothrombosis)., Discussion: Aetiopathogenesis of true DVT is determined by Virchov's triad [3, 4, 7, 8]. The incidence of DVT in medical and surgical patients is high (30-75%). Initially true DVT may be asymptomatic in 35-70% of patients [1, 3, 8] and depended on detection methods [1, 6, 7, 9, 10]. DVT may be only a symptom of other pathological conditions [2, 3, 7]. This symptomatic DVT is mostly caused by malignant diseases [2]. Pseudo DVT or primary deep vein obstruction may be caused by external abnormalities (right common iliac artery; compression of the left common iliac vein, malignant disease, retroperitoneal fibrosis, internal iliac compression of the external iliac vein, latent femoral hernia compression of the femoral vein, masses in the thigh (large tumours, true or false aneurysms, popliteal masses/aneurysms, large Baker's cysts), changes in the wall or within the lumen of a vein as aplasia, primary tumours, intraluminal spurs [7].

Introduction: Embolism is one of the most frequent causes of lower limbs acute arterial occlusion [1]. Of the total number of peripheral embolism 56% of cases involve lower limbs arteries [2]. Inadequate and late treatment of the lower limbs embolism is associated with high morbidity and mortality rate. The aim of this paper was to study the aetiology of lower limbs embolism and to detect factors influencing early and late results after the operative treatment., Patients and Methods: The study included 204 patients with 224 lower limbs embolism, treated surgically at the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade in the period between 1993 and 1997. There were 107 (52.2%) female and 97 (47.8%) male patients. Thirty two (14.3%) patients were younger than 50 years, 64 (28.6%) were between 51 and 65, 101 (45.1%) between 66-75, while 27 patients (12.1%), were older than 75. Twenty (8.9%) patients were admitted less than 6 hours before the operation, 79 (33.3%) between 6 and 24 hours, and 125 (55.8%) more than 24 hours before the operation (Table 1). One hundred (53.6%) patients had motor and 133 (59.4%) sensor paralysis on admission. Table 2 shows arterial localization of the lower limbs embolism. The popliteal artery was involved in most cases. During the operation transfemoral arterial approach was used in 132 (58.9%) cases, while transpopliteal in 92 (41.1%) cases. Fourteen cases required bypass surgery, 43 fasciotomy, 2 intraoperative streptokinase and 4 intraoperative angiography. All patients were controlled using physical and CW Doppler ultrasonographic examinations immediately after the operation, and then one, six and 12 months, as well as every year., Results: In 173 (84.4%) patients cardiac causes of embolism were found, in 8 (3.9%) noncardiac, while in 8 (3.9%) the cause could not be established. Of all cardiac causes absolute arrhythmia was most frequent. Table 3 and Table 4 show the aetiology of the lower limb embolism. The early amputation rate was 23 (10.3%) cases, while limb salvage was recorded in 174 (77.7%) patients. Of all saved limbs complete recovery was noted in 162 (72.4%) cases and peroneal nerve paresis in 12 (5.3%) cases. The early postoperative mortality rate was 27 (12.0%). Table 5 shows early results of embolectomy. The early results (limb salvage, complete recovery, rethrombosis, early reoperations, amputations rate, morbidity and mortality rate) of embolectomy were statistically significant: worse in cases when the embolus was located in the abdominal aorta and popliteal artery; in cases with a long time interval before the operation as well as in patients with sensor-motoric paralysis on admission (Tables 6-8). Of the total number of patients in 87 (56.5%) cases a late control examination was carried out. Forty nine (31.8%) patients died before the late control, while 18 (11.7%) did not come to control examination. Late recidivation of embolism was found in 3 cases. In these patients the cause could not be found, and they were treated by anticoagulant drugs.

Introduction: The treatment of inoperable patients in terminal stages of chronic arterial occlusive disease is difficult and associated with high incidence of limb amputations and lethal outcomes [1]. Prostacyclin (Pgl2) is a strong vasodilator and the most potent endogenous platelet aggregation inhibitor in men [1-6]. Application of Pgl2 in such conditions is justifiable since it represents the exogenous substitution therapy [7, 8]., Material and Methods: An open blind study included 80 patients with inoperable peripheral arterial occlusion (Fontens stages III and IV) who were divided in two groups: Prostacyclin (PG) and Pentoxyfillyne (CG). Clinical characteristics of the groups were comparable (Table 1). Diagnosis of unreconstructable state was based on clinical and arteriographic results. Prostacyclin in the form of Epoprostenol sodium (Flolan) was used in doses of 5 ng/kg/h of continuous intravenous infusions during 24 h (9), 48 h (21) and 72 h (12). Pentoxyfillyne was also administered in continuous intravenous infusions during 24 h (2), 48 h (3) and 72 h (33) in daily dose of 300 mg. Duration of treatment was based on the subjective condition of the patients, i.e., when the patient reported the improvement the therapy was discontinued. Following the completion of infusion therapy, medicamentous therapy was initiated in all patients (Pentoxyfillyne 3 x 400 mg, Aspirin 100 mg). Routine laboratory tests (RBC, haemoglobin, haematocrit, platelet count, WBC, urea, glycaemia, Na, K, lipids, cholesterol, triglycerides), platelet aggregation (Collagen 60 mg/ml; ADP 1.5 mM/ml; RI-PA 1.5 mg/mL), BP, ABI (Doppler) indices and claudication distance were evaluated in all patients after day 1, 7 and 90 following the end of the therapy., Results: The infusion treatment led to subjective reduction or elimination of pain in 52 (32 PG, 20 CG) patients during the immediate course (up to 7 days). The therapy induced no significant changes in laboratory findings, platelet count and BP during the whole follow-up period. Significant decrease in platelet aggregation was recorded 24 hours and 7 days after the initiation of the study only in PG group, while after 3 months no significant decrease in aggregation was found (Table 2). Doppler index changes in both groups were not significant. Significant improvement in claudication distance was recorded 3 months after the infusion therapy: in PG for distance under 100 m (15 patients) and more than 100 m (17 patients), in CG for distance under 100 m (22 pts). In the course of infusion therapy the following complications were recorded: blushing (3 PG), tachycardia (2 PG, 1 CG) and nausea and vomiting (1 PG, 2 CG). Deceleration or temporary discontinuation of infusion led to the improvement of condition, and thus none of the patients was withdrawn from the study. Over a three-month follow-up period 4 lethal outcomes were recorded (2 PG, 2 CG). Causes of death (diabetic nephrosclerosis and renal insufficiency, septic endocarditis, heart insufficiency, CVI) could not have been related to infusion therapy. Due to the progression of gangrene, extremity amputation on different levels was performed in 27 patients (12 PG, 15 CG) of which 15 (7 PG and 8 CG) were performed during the immediate 7-day period while the other amputations were carried out 8-90 days after the treatment., Discussion: The use of prostacyclin leads to temporary and limited distant improvement in arterial flow in patients with occlusive diseases [1]. During the immediate course these effects are manifested by complete absence of pain at rest and initial demarcation of the gangrenous process [1, 4]. Doppler index values established in our series suggest that prostacyclin does not reduce vascular resistance in the major blood vessels; however, it expresses potent vasodilation, antiaggregation and disaggregation effects at the level of microcirculation flow [6, 7]. (ABSTRACT TRUNCATED)

The authors present early and late results of femoro-popliteal/crural reconstruction where "in situ" technic is used. Of 35 patients 10 had the third stage of occlusive disease by Fontain, and 25 were in the fourth stage. Therefore the reconstruction consisted of "limb salvage procedure". The aim of the study was to present the possibilities of this technique in cases with ischaemic extremities and poor "run off". The early potency of prosthesis within the first month was 97% (34 patients) and late (after one year) 91% (32 patients). In three patients, in early postoperative stage, AV fistulas were found and successfully surgically treated. AV fistulas were caused by non-ligated branches of the saphenous vein. Thus, a conclusion was drawn that intraoperative control angiography vas of great importance. Better potency of prosthesis, when compared to the quality of saphenous vein graft and when used "in situ", over the classical method was achieved thanks to the following facts: no damage of the intima caused by hydrostatic dilatation; possible use of a vein whose diameter is less than 4 mm; no damage of adventitia (vasa vasorum) due to the slower degenerative process of the vein wall; impossible graft torsion; low compliance level between the graft and the small artery, and small artery caused by the conic shape of graft.

Extra-anatomic bypass is a nonanatomic procedure of vascular graft from the donor to the recipient artery. The subclavian or axillary artery is very often used for the revascularization of the lower limbs (axillary-femoral bypass). The usage of the femoral artery for the arm or cerebral revascularization is seldom. The authors describe 74-year old woman with femoral-axillary bypass. The bypass was due to subclavian steel syndrome (cerebral and arm vascular insufficiency). Desobstruction and patch angioplasty of the subclavian artery or aorto-subclavian bypass after, transthoracic approach were a contraindication because of the patients advanced age and subcompensated cardiomyopathy. The authors made no typical extraanatomyc bypasses between branches of the aortic arch (carotidosubclavian, or subclavian-subclavian bypass) because of changes on these arteries (occlusion of the left common carotid artery and stenosis of the innominate artery). This is the reason why the femoroaxillary reconstruction was the only possibility of the cerebral and arm revascularization. The Doppler sonographic and angiographic control examination gave good early, and late results. This case is the confirmation of the good use of this unusual method in surgery of subclavian steel syndrome.

Preliminary results of the use of prostacyclin in 6 patients with peripheral arterial occlusive disease (IV stage) are presented. Diagnosis was supported by clinical signs, Doppler ultrasound and arteriography. There were 4 diabetics, one with Mb Bürger and the other with obliterant atherosclerosis. All patients were unsuccessful by treated with antiaggregants, vasodilators and haemorheological medicaments. The reconstructive vascular surgery was also impossible. However amputation was necessary. The patients treated by intra-venous and intra-arterial prostacyclin administration in the dose of 5 ng/kg b.w./min during different periods of time (24, 48, 72 h). During intrahospital treatment complete relief of pain and gangrene demarcation in all patients. One month later two patients manifested necrotic progression and amputation of a limb was necessary. The long-term clinical success was registered in 4 patients (1-16) months). Indications, doses, side effects of prostacyclin action are discussed.