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INTRODUCTION Acute lower limb ischaemia (ALI) is the sudden onset of decreased arterial perfusion with imminent threat to limb viability. Contrast induced acute kidney injury (CI-AKI) is one of the complications that increases mortality in patients who undergo contrast imaging in coronary procedures. The goal of this study is to evaluate the impact of chronic kidney disease (CKD) and CI-AKI on long-term clinical outcomes in patients with ALI undergoing lower limb revascularisation. METHODS A total 1017 consecutive patients with acute lower limb ischaemia who were admitted between July 1, 2006, and January 1, 2017, were retrospectively reviewed. Patients who had end stage renal disease, those who had end stage heart and malignant disease and died within 7 days of limb revascularisation, and those who did not undergo angiography were excluded. Thus 546 patients were included in the final analysis. Patients were classified as with or without CKD and were then subdivided according to the presence or absence of the development of CI-AKI, defined as an increase in serum creatinine of ≥0.5 mg/dL or by ≥25% from the baseline value within the first 72 h after contrast exposure. The primary end point was all cause mortality and secondary major adverse limb event (MALE). RESULTS Both CKD and CI-AKI were associated with the highest rate of all cause mortality (chi square = 55.77, d.f. = 1, p

Abstract. Background: The effect of atmospheric pressure (AP) on the onset of abdominal aorta aneurysm rupture (RAAA) remains an unanswered question. We have investigated the seasonal variation and the effect of AP dynamics on RAAA by analysing the largest series of intraoperatively confirmed RAAA. Patients and methods: To realize this study we have performed a retrospective analysis of 546 patients with RAAA, operated within 503 days at the Clinic for vascular and endovascular surgery CCS between 1.1.2003 and 31.12.2012. AP data for Belgrade city were obtained from meteorological yearbooks published by the Republic Hydrometeorological Service of Serbia measured at the hydrometeorological station “Belgrade Observatory”. Only patients with a residence within the extended Belgrade region, exposed to the similar AP values, were included in the analysis of the AP effect on RAAA. Results: RAAA were observed more frequently during winter and autumn months but without significant difference in comparison to other seasons. Months with higher AP values were associated with a higher RAAA rate (p = 0.0008, R2 = 0.665). A similar trend was observed for the monthly AP variability (p = 0.0311, R2 = 0.374). Average AP values did not differ between days with and without RAAA. However, during the three and seven days periods preceding RAAA AP variability parameters were greater and AP was rising. Conclusions: Although these pressure differences are very small, higher AP values over longer periods of time as well as greater variability are associated with RAAA. The exact mechanism behind this association remains unclear. The postulation that low AP may precipitate RAAA based on the Laplace law should be discarded.

Introduction : Acute aortic type III dissection is one of the most catastrophic events, with in-hospital mortality ranging between 10% and 12%. The majority of patients are treated medically, but complicated dissections, which represent 15% to 20% of cases, require surgical or thoracic endovascular aortic repair (TEVAR). For the best outcomes adequate blood transfusion support is required. Interest in the relationship between blood type and vascular disease has been established. The aim of our study is to evaluate distribution of blood groups among patients with acute aortic type III dissection and to identify any kind of relationship between blood type and patient’s survival. Material and methods : From January 2005 to December 2014, 115 patients with acute aortic type III dissection were enrolled at the Clinic of Vascular and Endovascular Surgery in Belgrade, Serbia and retrospectively analyzed. Patients were separated into two groups. The examination group consisted of patients with a lethal outcome, and the control group consisted of patients who survived. Results : The analysis of the blood groups and RhD typing between groups did not reveal a statistically significant difference (p = 0.220). Conclusions : Our results indicated no difference between different blood groups and RhD typing with respect to in-hospital mortality of patients with acute aortic dissection type III.

Introduction Dementia is a prevalent condition in older adults associated with decline in cognitive and functional abilities and substantial burden. This study assessed the prevalence and impact of subjective memory impairment in the United States. Methods The 2011 to 2014 National Health and Nutrition Examination Survey, a population‐based, nationally representative survey, was analyzed. Data included medical examinations, self‐reported cognitive and functional limitations, and health care utilization over 1 year. Participants were aged ≥65 years and completed both interview and medical examination components. Descriptive analyses of patient characteristics were performed, and complex survey regression models were used to test associations. Results Of 2431 survey participants included, 53.1% had no memory impairment, 40.1% had early‐stage memory impairment, and 6.6% had late‐stage memory impairment. In adjusted analyses, late‐stage versus no impairment was associated with more functional limitations (odds ratio [OR] = 7.26, P

Summary Introduction The diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. The use of new renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and the prevention or minimization of definitive renal damage. Objective The aim of the study was to investigate a selection of promising biomarkers of renal injury with the intention of evaluating and comparing their profile with clinically based decisions for surgical intervention of infants with congenital obstructive uropathies. Study design The first-year profile of renal biomarkers, serum creatinine (sCr), serum and urine cystatin C (CyC), neutrophil gelatinase–associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-β1), retinol-binding protein (RBP), and microalbuminuria (μALB), was analyzed in a cohort of 37 infants with congenital UTO, divided into three subgroups, 14 cases with grade III unilateral hydro(uretero)nephrosis, 13 cases with grade III bilateral hydro(uretero)nephrosis, and 10 cases with low urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. Serum and urine samples were stored at −70 °C and thereafter analyzed by quantitative enzymatic immunoassay. Results Compared with the control group (Figure), all renal biomarker values were significantly increased in patients (P ≤ 0.02). In the unilateral hydronephrosis and LUTO group, RBP (P ≤ 0.043), NGAL (P ≤ 0.043), KIM-1 (P ≤ 0.03), and TGF-β1 (P ≤ 0.034) values dropped significantly after surgery. Neutrophil gelatinase–associated lipocalin alone and in combination with urine and serum CyC demonstrated the best performance in determining the need for surgery (area under the curve, 0.801 and 0.881, respectively). Biomarker profile analysis was suggestive of surgical intervention in 55.4% (7/13) of non-operated cases, and most of the biomarker values were above the cutoff levels within at least 3 months before the clinically based surgical decision in 58% (14/24) of all operated patients. Discussion To the best of the authors' knowledge, this is the first study to present the clinical use of selected group of serum and urinary biomarkers in the setting of UTO to distinguish between patients who would benefit from surgery intervention. The most promising results were obtained using NGAL, RBP, TGF-β1, and KIM-1, especially in the unilateral hydro(uretero)nephrosis and LUTO subgroups when compared with the control group. Conclusions Urine biomarkers, alone and in combination, demonstrated high potential as a non-invasive diagnostic tool for identifying infants who may benefit from earlier surgical intervention. Download : Download high-res image (117KB) Download : Download full-size image Figure . Comparative analysis of pre-operative values of the urine biomarkers in operated patients and control participants at the age of 12 months. The significance of all values was verified by the Student t-test for paired data and by the ¶) Wilcoxon signed-rank test for paired data. The median for urine biomarker sampling was 7 (3–59) days before surgery, in operated patients. KIM-1, kidney injury molecule-1; NGAL, neutrophil gelatinase–associated lipocalin; RBP, retinol-binding protein; TGF-β1, transforming growth factor beta-1; uCyC, urine cystatin C; μALB, microalbuminuria; uCr, urine creatinine.

Background Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to propose the most rationale strategy during open repair (OR) of RAAA in the presence of HK. Methods We identified and analyzed all patients treated at the clinic due to RAAA and HK. An extensive search was performed on all articles published up to August of 2017 describing open and endovascular repair of RAAA with concomitant horseshoe kidney. The following data were extracted and analyzed: patient number, number of renal arteries, Crawford classification of horseshoe kidney vascularization, type of aortic reconstruction, management with renal arteries, 30-day kidney failure and outcome. Results Transperitoneal approach followed by supraceliac aortic cross clamping without the division of the renal isthmus occurred in all our six cases. Four of them required additional procedures with accessory renal arteries after aortic replacement. Three of patients (50%) died during the first 30 postoperative days, while one developed transitory renal insufficiency. The renal isthmus was preserved in 43.90% and divided in 46.34% of cases. Crawford type I of HK vascularization was presented in 21.95% of cases, type II also in 39.02%, while the type III in 19.51% of cases. In 46.33% of cases a procedure with renal arteries was necessary. In 26.82% accessory renal arteries were ligated, while in 19.51% preserved (reattachment or aorto-renal bypass). Thirty-day mortality was 21.95%, while the incidence of postoperative renal failure was also 21.95%. There was not significant correlation between the renal artery ligation and the postoperative renal failure (r=-0.81, P=0.59). Conclusions Transperitoneal approach should be preferred during urgent OR of RAAA with concomitant HK. A supraceliac aortic cross clamping and the placement of occlusive Fogarty catheters into both iliac arteries are recommended for proximal and distal bleeding control. Preservation of accessory renal arteries that are larger than 3 mm in diameter or supply more than 30% of renal parenchima is recommended. The division of the renal isthmus should be avoided if vascularized. It seems that renal arteries could be covered in emergency EVAR without any implications on postoperative kidney function, allowing broader aplication of endovascular treatment for thesse patients.

This article provides rationale for recommendations on how to initiate aripiprazole once-monthly 400 mg (AOM 400), an injectable suspension, in patients with schizophrenia, supported by pharmacokinetic (PK) data and based on clinical studies.An overview of data from a PK study, PK simulations, controlled clinical trials, and a naturalistic study is presented.Pharmacokinetic data support 400 mg as the starting and maintenance dose of AOM; the plasma concentration profile of aripiprazole after initiating AOM 400 was consistent with therapeutic concentrations observed with oral aripiprazole 10 to 30 mg/d. PK simulations and observed data from a single-dose clinical trial indicate that median aripiprazole plasma concentrations reach therapeutic levels within 7 days of initiating AOM 400. Because of interpatient variability, a 14-day overlap with oral aripiprazole or another antipsychotic medication is considered sufficient to ensure therapeutic concentrations. In clinical studies, when patients initiated AOM 400 with concomitant oral aripiprazole (10-15 mg/d based on stabilized dose) or continued their previous antipsychotic for ≤14 days, mean aripiprazole plasma concentration after 4 weeks (93 to 112 ng/mL) was in range of the therapeutic window established for aripiprazole (94.0-534.0 ng/mL). In clinical studies, the 400-mg starting dose of AOM was efficacious and well tolerated. Across studies of variable duration and design, 1296/1439 (90.1%) patients initiated AOM 400 and required no dose change. Overall rates of discontinuation due to lack of efficacy across clinical studies were low in patients treated with AOM 400 (range, 2.3%-10.0%). In a post hoc analysis from a naturalistic study, cross-titration from other oral antipsychotic therapies to oral aripiprazole before initiating AOM 400 was better tolerated with a1- to 4-week cross-titration period versus a ≤1-week period, as evidenced by lower rates of discontinuation due to adverse events during cross-titration (2.7% [7/239] vs 10.4% [5/48]). The efficacy and safety of AOM 400 in the month after initiation in the pivotal maintenance studies were comparable between subpopulations of patients previously stabilized on 10- or 30-mg doses of oral aripiprazole.Findings from PK data, PK simulations, and clinical studies all support that 400 mg is the appropriate initiation dose of AOM for patients with schizophrenia. When switching to oral aripiprazole before initiating AOM 400, tapering the prior oral antipsychotic while titrating up the oral aripiprazole dose (target dose 10-30 mg/d) over1 to 4 weeks may be an effective strategy. The efficacy, safety, and tolerability of AOM 400 were comparable regardless of whether patients were previously stabilized on oral aripiprazole 10 or 30 mg/d or other antipsychotic therapy and continued to receive the same oral antipsychotic for the first 14 days after initiating AOM 400.

BACKGROUND: To present outcomes following an operative approach of extracranial carotid artery aneurysm (ECAAs) based on anatomic types and associated kinks. METHODS: This study represents retrospective analysis of anatomic type based approach to operative repair of 84 patients with ECAA from 1994 to 2011, 28 (33.3%) with associated kinking. Patients were followed for neurological ischemic events, hematoma, cranial nerve injury, myocardial infarction, neurological, and overall mortality. The results are presented as early, within 30 days after the surgery, and long term during the follow-up. RESULTS: In the early postoperative period, there were no strokes or mortalities, cranial nerve injury rate was 2.4% while 1 patient had myocardial infarction (1.2%). During the follow-up, 4 patients (4.8%) had stroke, out of which 2 patients died (2.3%), while overall mortality was 4.6%. The average 5-year survival rate was 96 +/- 3%. CONCLUSION: Excellent outcomes can be obtained with surgical repair of ECAA, which should be tailored to the anatomic types and presence of kinks. (C) 2014 Elsevier Inc. All rights reserved.

Introduction. Graft infection is rightly considered one of the severest complications of vascular reconstruction. Treatment is non­standardized 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, meanaged 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 (χ² test, p

The clinical spectrum of internal carotid artery occlusion ranges from being a completely asymptomatic occlusion to a devastating stroke or death. The prevalence of asymptomatic internal carotid artery occlusion is unknown, particularly for bilateral occlusion. The distal branches of the external carotid artery anastomose with distal branches of the internal carotid artery provide important sources of collateral circulation to the brain. Stenosis of the external carotid artery with ipsilateral/bilateral internal occlusion may result in ischemic sequelae. Coiling or kinking of the vertebral artery is a rare morphological entity that is infrequently reported because it remains asymptomatic and has no clinical relevance. Currently, there is little evidence to support management strategies for this disease entity and no official recommendations for asymptomatic bilateral carotid artery occlusion. We present a case of a 62-year-old female with asymptomatic bilateral internal carotid artery occlusion, bilateral external carotid artery stenoses, and bilateral kinking of the vertebral artery at the V2 segment, who has been successfully managed conservatively for over 5 years. An individualized approach to management of patients with bilateral internal carotid artery occlusion, especially in combination with external carotid artery stenosis and elongation malformations of the vertebral artery is key to a successful strategy.

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.

One of the rare forms of abdominal aortic aneurysm (AAA) rupture is the rupture into great abdominal veins such as the inferior vein cava (IVC), the iliac veins, or the left renal vein, with the formation of direct or indirect aorto-caval fistula (ACF). The purpose of the present study was to summarize 20 years of experience at a single referral center for vascular surgery in a developing country, and to discuss the clinical presentation, diagnosis, treatment options, and outcome of patients with spontaneous aorto-venous fistulas (AVF) caused by ruptured aortic aneurysms.Retrospective database review identified 50 patients treated in our institution for aorto-venous fistulas (AVF) caused by spontaneous AAA rupture in the 20 years 1991-2010. Pulsating abdominal mass and low back pain were the leading symptoms on admission in our patients. Signs of shock, congestive heart failure, or pelvic and lower extremity venous hypertension were present in 48%, 26%, and 75% of the patients, respectively. Diagnosis of AVF was based on physical examination, duplex ultrasonography, conventional angiography, or multislice computed tomography (MSCT). In 40% of the patients the presence of AVF has not been recognized before surgery. All patients were treated with open surgery.After proximal and distal bleeding control the fistula was closed with direct suture (92%) or patch angioplasty (8%). Aortic reconstruction followed with tubular (22%) or bifurcated (78%) synthetic graft. Six (12%) patients died. The causes of death were excessive intraoperative blood loss, myocardial infarction, left colon gangrene and multiple organ failure.Spontaneous AVFs caused by aneurysmal rupture are not uncommon, and they require prompt surgical or endovascular treatment. Routine use of multislice CT in patients with acute aortic syndrome is probably the best way to the correct diagnosis of aorto-venous fistulas and planning of the optimal treatment.

BackgroundMost recent publications have shown that the recombinant form of activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsværd, Denmark) induces excellent hemostasis in patients with severe intractable bleeding caused by trauma and major surgery. The purpose of this study was to determine the influence of rFVIIa on the treatment of intractable perioperative bleeding in vascular surgery when conventional hemostatic measures are inadequate.Materials and MethodsThere were two groups of patients: the NovoSeven group (group N), 10 patients with ruptured abdominal aortic aneurysms (RAAAs) and 14 patients operated on due to thoracoabdominal aortic aneurysms (TAAAs); the control group (group C), 14 patients with RAAAs and 17 patients with TAAAs. All patients suffered intractable hemorrhage refractory to conventional hemostatic measures, while patients from group N were additionally treated with rFVIIa.ResultsPostoperative blood loss was significantly lower in group N treated with rFVII (P < .0001). Postoperative administration of packed red blood cells, fresh frozen plasma, and platelets was lower in patients from group N, (P < .0001). Successful hemorrhage arrest was reported in 21 patients (87.5%) treated with rFVIIa, and in 9 patients (29.03%) in group C (P < .001). Thirty-day mortality in these two groups significantly differed. The mortality rate was 12.5% (3 patients) in group N and 80.65% (25 patients) in group C (P < .0001).ConclusionOur findings suggest that rFVIIa may play a role in controlling the intractable perioperative and postoperative bleeding in surgical patients undergoing a repair of RAAAs and TAAAs. Certainly, prospective randomized trials are necessary to further confirm the efficacy and cost-effectiveness of rFVIIa in these patients.

Introduction. Intramural haematoma (IMH) and penetrating aortic ulcers (PAU) are the frequent cause of acute aortic syndrome that is disclosed with a rising frequency due to the development of new diagnostic methods. Different symptoms contribute to clinical misdiagnosis, while changeable locations and unpersuasive diameter can lead the radiologists to underestimate such changes. The outcome of PAU and IMH differs, and for the time being there are no data on prognostic factors. The diversity of symptoms and disease course is presented in four cases with different manifestations, treatment and outcome. Outline of Cases. Two patients with IMH were treated conservatively due to the process extensiveness and its morphology. One patient had a complete restitution, while the other had progression of the disease. Other two patients with PAU were treated by surgery (stent graft implantation) according to the morphology and diameter of the aorta. Conclusion. IMH and PAU should be suspected in patients with unclear clinical presentation (back and abdominal pains). Although outcome and complications of these diseases are well known, their incidence has not been fully studied. Endovascular treatment is less invasive and followed by a potentially lower rate of complications. However, usage of this method is justifiable only in patients with associated complications.

Fleet enemas are hypertonic solutions with an osmotic action and a high concentration of phosphate. When retained in the human body they have a great toxic potential, causing severe hydro-electrolyte disorders in children, especially in newborns. We report the case of a previously healthy 8-day-old newborn who needed neonatal intensive care treatment after the inadvertent administration of an osmotically active hypertonic phosphate enema. Taking into account that phosphate removal by peritoneal dialysis (PD) strongly depends on total dialysate turnover, we chose continuous flow PD (CFPD) as the treatment option, with a successful outcome. Clinical experience with this dialytic modality is limited to a few case reports in pediatric and adult patients. To the best of our knowledge, we report here the first description of CFPD in the setting of acute phosphate nephropathy in the neonatal period. The modality of PD described here has potential as an alternative management option as it is a highly efficient, methodologically simple, and low-cost method without any need for sophisticated equipment. Physicians and parents should be aware of the adverse effects of a hypertonic phosphate enema and should never use these medications in infants and newborns.

Lessons Learned OPB-111077 is a novel inhibitor of STAT3 and mitochondrial oxidative phosphorylation that exhibited promising anticancer activity in preclinical models. In this first-in-human phase I study of OPB-111077 in unselected advanced cancers, treatment-emergent adverse events, most frequently nausea, fatigue, and vomiting, were generally mild to moderate in intensity and could be medically managed. Overall, only modest clinical activity was observed after OPB-111077 given as monotherapy. Notable antitumor activity was seen in a subject with diffuse large B-cell lymphoma. Background OPB-111077 is a novel inhibitor of STAT3 and mitochondrial oxidative phosphorylation with promising anticancer activity in preclinical models. Methods Open-label, phase I trial of OPB-111077 in advanced cancers with no available therapy of documented benefit. Initial dose escalation in unselected subjects was followed by dose expansion. Patients received oral OPB-111077 daily in 28-day cycles until loss of clinical benefit. Results Eighteen subjects enrolled in dose escalation, and 127 in dose expansion. Dose-limiting toxicities were observed at 300 mg and 400 mg QD; maximum tolerated dose was defined as 250 mg QD. Frequently reported treatment-emergent adverse events (TEAEs) included nausea, fatigue, and vomiting. TEAEs were generally mild to moderate and could be medically managed. OPB-111077 reached micromolar drug concentrations, had an elimination half-life of approximately 1 day, and reached steady-state by day 8. A durable partial response was observed in one subject with diffuse large B-cell lymphoma. Seven subjects with diverse tumor types had stable disease or minor responses for at least eight treatment cycles (224 days). Conclusion OPB-111077 is generally well tolerated, and its pharmacokinetic profile is sufficient for further clinical development. Notable clinical activity was observed in a subject with diffuse large B-cell lymphoma. Overall, modest efficacy was observed against unselected tumors.

Introduction. Endovascular aneurysm repair (EVAR) has been introduced into clinical practice at the beginning of the 90's of the last century. Because of economic, political and social problems during the last 25 years, the introduction of this procedure in Serbia was not possible. Objective. The aim of this study was to present preliminary experiences and results of the Clinic for Vascular Surgery of the Serbian Clinical Centre in Belgrade in endovascular treatment of thoracic and abdominal aortic aneurysms. Methods. The procedure was performed in 33 patients (3 female and 30 male), aged from 42 to 83 years. Ten patients had a descending thoracic aorta aneurysm (three atherosclerotic, four traumatic - three chronic and one acute as a part of polytrauma, one dissected, two penetrated atherosclerotic ulcers), while 23 patients had the abdominal aortic aneurysm, one ruptured and two isolated iliac artery aneurysms. The indications for EVAR were isthmic aneurismal localisation, aged over 80 years and associated comorbidity (cardiac, pulmonary and cerebrovasular diseases, previous thoracotomy or multiple laparotomies associated with abdominal infection, idiopatic thrombocitopaenia). All of these patients had three or more risk factors. The diagnosis was established using duplex ultrasonography, angiography and MSCT. In the case of thoracic aneurysm, a Medtronic-Valiant? endovascular stent graft was implanted, while for the abdominal aortic aneurysm Medtronic-Talent? endovascular stent grafts with delivery systems were used. In three patients, following EVAR a surgical repair of the femoral artery aneurysm was performed, and in another three patients femoro-femoral cross over bypass followed implantation of aortouniiliac stent graft. Results. During procedure and follow-up period (mean 1.6 years), there were: one death, one conversion, one endoleak type 1, six patients with endoleak type 2 that disappeared during the follow-up period, one early graft thrombosis. No other complications, including aneurysm expansion, collapse, deformity and migration of the endovascular stent grafts, were registered. Conclusion. According to all medical and economic aspects, we recommend EVAR to treat acute traumatic thoracic aortic aneurysm, as well as in elderly and high-risk patients with abdominal or thoracic aneurysms, when open surgery is related to a significantly higher mortality and morbidity.

This retrospective study covers the period from 1991 to 2002, during which 3,623 patients were operated on because of aneurysmal or occlusive disease of aortoiliac and femoropopliteal segments. Among them, 87 patients (2.4%) developed a false anastomotic aneurysm in the 12-year follow-up period and were treated operatively. Most frequently, in 53 patients (6.9%), a false anastomotic aneurysm developed after aortobifemoral bypass performed owing to aortoiliac occlusive disease. The cause of false anastomotic aneurysm was infection in 21 cases (24.7%); resection and revascularization were performed with a Dacron graft in 46 cases (52.9%), with a polytetrafluoroethylene graft in 10 cases (11.5%), and with the great saphenous vein in 16 cases (18.4%). Homograft implantation in 4 patients (4.6%) or extra-anatomic bypasses in 11 cases (12.6%) were performed when graft infection was suspected. Of 87 patients who underwent surgery, 74 (85.5%) had good early results without infection, reintervention, limb loss, and mortality. The presence of infection as a cause of false anastomotic aneurysm and comorbidity increased the mortality rate significantly after the reoperation, whereas the type of graft used in treatment had no influence on early results.

This multicentric Serbian study presents the treatment of 91 extracranial carotid artery aneurysms in 76 patients (13 had bilateral lesions). There were 61 (80.3%) male and 15 (19.7%) female patients, with an average age of 61.4 years. The aneurysms were caused by atherosclerosis in 73 cases (80.2%), trauma in six (6.6%), previous carotid surgery in six (6.6%), tuberculosis in one (1.1%), and fibromuscular dysplasia in five (5.5%). The majority (61 cases or 67%) of the aneurysms involved the internal carotid artery, 29 (31.9%) the common carotid artery bifurcation, and one (1.1%) the external carotid artery. Forty-five (49.4%) aneurysms were fusiform, while 46 (50.6%) were saccular. Twenty-nine (31.9%) cases were totally asymptomatic at the time of diagnosis. The remainder presented with compression in 14 (15.4%) cases, stroke in 11 (12.1%) cases, transient ischemic attack in 33 (36.3%) cases, and rupture in four (4.4%) cases. In cases where the aneurysm involved the internal carotid artery, four surgical procedures were performed: aneurysmectomy with end-to-end anastomosis in 30 (33.0%) cases, aneurysmectomy with vein graft interposition in 20 (22.0%) cases, aneurysmectomy with anastomosis between external and internal carotid artery in eight (8.8%) cases, and aneurysmectomy followed by arterial ligature in three cases. One case of external carotid artery aneurysm also was treated by aneurysmectomy and ligature. Aneurysm replacement with Dacron graft was performed in 29 (31.9%) cases where common carotid artery bifurcation was involved. Two (2.2%) patients died after the operation due to a stroke. They had ruptured internal carotid artery aneurysm treated by aneurysmectomy and ligature. Including these, a total of five (5.5%) postoperative strokes occurred. In two (2.2%) cases, transient cranial nerve injuries were found. Excluding the five patients who were lost to follow-up, 69 other surviving patients were followed from 2 months to 12 years (mean 5 years and 3 months). In this period, there were no new neurological events and all reconstructed arteries were patent. Three patients died more than 5 years after the operation, due to myocardial infarction. Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurological sequelae. Because of their varied etiology, location, and extension, different vascular procedures have to be used during repair of extracranial carotid artery aneurysms. In all of these procedures, an aneurysmectomy with arterial reconstruction is necessary.

Objective BETA was designed to evaluate the overall effectiveness of aripiprazole in patients with schizophrenia or schizoaffective disorder treated in a general psychiatry outpatient practice setting. Methods In this 8-week, multicenter, open-label study, 1599 outpatients with schizophrenia or schizoaffective disorder were randomly assigned to receive either aripiprazole (n = 1295) or another antipsychotic medication (safety control [SC] group; n = 304). Aripiprazole was initiated at 15 mg/d with the option to adjust between 10–30 mg/d. The SC medication was specifically selected for each patient by the clinician and dosed according to prescribing guidelines for that medication. The primary effectiveness measure was the Clinical Global Impression–Improvement (CGI–I) score of the aripiprazole group at study end point. Secondary measures included response rates and preference of medicine (POM) ratings by patients and caregivers. Results Sixty-five percent of aripiprazole patients completed the study. The mean aripiprazole dose at end point was 19.9 mg/d, with approximately 39% of patients starting and remaining at 15 mg/d. At end point, the mean CGI–I score of 2.77 demonstrated that aripiprazole was minimally to moderately effective; the mean CGI–I score for the SC group was 3.59 indicating minimally effective to no change. Fifty-three percent of aripiprazole patients responded to treatment (CGI–I score of 1 or 2; last-observation-carried-forward [LOCF]), and approximately 71% of patients and caregivers rated aripiprazole as better than the prestudy medication on the POM (LOCF). Incidence and severity of adverse events (AEs) were similar to those reported in double-blind, randomized, placebo-controlled aripiprazole clinical trials. The most frequent AE in the aripiprazole group was insomnia (24%). Conclusions Aripiprazole was effective for the treatment of schizophrenia and schizoaffective disorder in a general psychiatry outpatient practice setting. Overall, aripiprazole was found to be effective by the treating clinician and well accepted by patients and caregivers over the 8-week treatment course.

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury ( p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery ( p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Objective: The aim of the study was to present the outcome of surgical treatment of patients with thoracoabdominal aortic aneurysm Crawford type IV, operated on between January 2001 and April 2004. Methods: This study included 42 subsequent patients (40 males, 2 females, age 41-76 years). All patients underwent ultrasonography, angiography, computed tomography or magnetic resonance imaging (MRI). Surgical treatment was performed under combined anesthesia (continuous thoracic epidural analgesia and general endotracheal anesthesia). In two patients thoracophrenolumbotomy was performed at the level of X rib, while others were operated through left lumbotomy after the extra pleural resection of XI rib. We did not perform any spinal cord protection procedures in this type of aneurysm. Reconstruction included interposition of Dacron graft in 20 patients, aortobiiliac bypass in 18, and aortobifemoral bypass in 4 patients with different varieties of visceral branches reimplantation. Results: Thirty - days mortality was 31% (13 patients, two of them intraoperatively). Causes of death were: pulmonary embolism - in 1 patient; hemorrhage - in 2; myocardial infarction - in 4 (two intraoperative); acute renal failure - in 2; multi system organ failure (MSOF) - in 4 patients. Respiratory failure dominated in all cases of MSOF. One patient with acute renal failure had paraplegia also, and that was the only case of neurological complication in whole group. All female patients (2), all patients with ruptured aneurysm (4), acute myocardial infarction (4) and acute renal failure (2) have died. Advanced age (over 70 years) and the need for extensive operative procedure with bifurcated graft use significantly influenced their mortality (p

Horseshoe kidney presents a special challenge during surgery of the abdominal aorta. The aim of this study was to evaluate the morbidity and define optimal management based on clinical histories of 15 patients with horseshoe kidney who underwent surgical procedures on the abdominal aorta over a 20-year period. There were 2 female and 13 male patients with an average age of 62.66 (50-75) years. The indications for surgery included aortic aneurysms in 10 patients and aortoiliac occlusive disease in 5. The horseshoe kidney was detected before surgery in 12 patients (80%) by ultrasonography, angiography, computed tomography (CT) or excretory urography. Angiography revealed multiple or anomalous renal arteries in 8 of 12 patients studied preoperatively. At surgery, 10 patients (66.6%) were found to have multiple or anomalous renal arteries. Five patients (33.41%) were without multiple or anomalous renal arteries. Ten required renal revascularization (reimplantation with a Carrel patch in 7 patients and aortorenal bypass in 3). Two patients, both with ruptured abdominal aortic aneurysms, died postoperatively. In the other 10 cases the average follow-up period was 5.3 years (6 months to 17 years). During this period there were no signs of graft occlusion, renovascular hypertension, or renal failure. From these results we conclude that aortic surgery can be performed safely in patients with horseshoe kidney without increased mortality. These patients require exact preoperative diagnosis (ultrasonography, CT scan, angiography), reimplantation of anomalous renal arteries, and preservation of the renal isthmus.

We present the treatment of 17 extracranial carotid artery aneurysms in 16 patients (1 patient had bilateral lesions). There were 15 (93.75%) male patients and 1 (6.25%) female patient, with an average age of 64.8 years. Two (11.8%) aneurysms involved the common carotid artery and 15 (88.2%) the internal carotid artery. Two (11.8%) aneurysms presented with rupture, 3 (17.6%) as an asymptomatic mass, 2 (11.8%) with cranial nerve compression, 6 (35.3%) with transient ischemic attack, and 4 (23.5%) with stroke. The following surgical procedures were performed: extirpation with 8 mm Dacron graft replacement, 5 (29.4%) cases; extirpation with end-to-end anastomosis, 8 (47.1%) cases; extirpation with saphenous vein graft replacement, 3 (17.6%) cases; and ligature of the internal carotid artery, 1 (5.9%) case. One (5.9%) patient died postoperatively owing to stroke. Including this case, 3 (17.6%) patients had a postoperative stroke, whereas 2 (11.8%) patients had transient cranial nerve damage. Sixteen surviving patients were followed from 2 months to 15 years (mean 5 years, 3 months). During this period, 1 patient died 5 years postoperatively owing to a myocardial infarction, whereas all other patients were alive and free of neurologic symptoms. Extracranial carotid artery aneurysms are rare. However, they are of medical importance because of their location, differential diagnosis, natural history, complications, and treatment.

A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment. This study included 229 subsequent patients (83% males, 17% females, age 67.0 ± 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40–100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%). Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 × 109/l, hematocrit < 0.29%, hemoglobin 11 mmol/l, and creatinine > 180 µmol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period. Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.

INTRODUCTION Abdominal aortic aneurysm can be repaired by elective procedure while asymptomatic, or immediately when it is complicated - mostly due to rupture. Treating abdominal aneurysm electively, before it becomes urgent, has medical and economical reason. Today, the first month mortality after elective operations of the abdominal aorta aneurysm is less than 3%; on the other hand, significant mortality (25%-70%) has been recorded in patients operated immediately because of rupture of the abdominal aneurysm. In addition, the costs of elective surgical treatment are significantly lower. OBJECTIVE The objective of this study is to compare long-term survival of patients that underwent elective or immediate repair of abdominal aortic aneurysm (due to rupture), and to find out the factors influencing the long-term survival of these patients. MATERIAL AND METHODS Through retrospective review of prospectively collected data of the Institute for Cardiovascular Diseases of Clinical Center of Serbia, Belgrade, 56 patients that had elective surgery and 35 patients that underwent urgent operation due to rupture of abdominal aneurysm were followed up. Only the patients that survived 30 postoperative days were included in this review, and were followed up (ranging from 2 to 126 months). Electively operated patients were followed during 58.82 months on the average (range 7 to 122), and urgently operated were followed over 52.26 months (range 2 to 126). There was no significant difference of the length of postoperative follow-up between these two groups. RESULTS During this period, out of electively operated and immediately operated patients, 27 and 22 cases died, respectively. There was no significant difference (p>0,05a) of long-term survival between these two groups. Obesity and early postoperative complications significantly decreased long-term survival of both electively and immediately operated patients. Graft infection, ventral hernia, aneurysm of peripheral arteries and other vascular reconstructive procedures were the factors that significantly reduced long-term survival of patients operated immediately due to rupture. DISCUSSION This comprehensive study has searched for more factors than others had done before. The applied discriminative analysis numerically evaluated the influence of any risk factor of mortality. These factors were divided in three groups as follows: preoperative, operative and postoperative ones. Preoperative factors were sex, age, diabetes mellitus, arterial hypertension, obesity, COPD, and naturally, the indication for operative treatment of ruptured or non-ruptured abdominal aneurysm. Among all these factors, only obesity significantly reduced long-term survival of electively operated patients. It may be said that immediately operated patients who survived the first 30 postoperative days had quite good long-term survival. Operative factors such as type of operative procedure and vascular graft had no influence on long-term survival of patients in both groups. Postoperative risk factors were early postoperative complications, graft infection, symptomatic cerebrovascular disease, carotid endarterectomy, myocardial revascularization, ventral hernias, "other" non vascular operations, malignancy, mental disorders, peripheral aneurysms and occlusive vascular disease, and other vascular operations either due to aneurysm or peripheral occlusive disease. Early postoperative complications (even graft infection) had no significant effect on long-term survival. Ventral hernias and peripheral aneurysms were factors that significantly decreased long-term survival of patients operated for rupture of the abdominal aneurysm. CONCLUSION It is interesting that endarterectomy, myocardial revascularization or malignancy after repair of the abdominal aneurysm (ruptured or non-ruptured) had no effect on long-term survival.

INTRODUCTION Renal artery aneurysms is relatively uncommon with reported incidence ranges from 0.3% to 1%. However, considering all visceral artery aneurysms the percentage of renal artery aneurysms is relatively high between 15-25%. The distal forms of renal artery aneurysms sometimes require "ex vivo" reconstruction and kidney autotransplantation. CASE REPORT A 75-year-old male presented with the right abdominal and back pain. He suffered from a long history of arterial hypertension and chronic renal failure over the last few months (urea blood = 19.8 mmol/l; creatinine = 198 mmol/l). Duplex ultrasonography showed abdominal aortic aneurysm. Subsequent translumbarangiography revealed juxtarenal abdominal aortic aneurysm associated with distal right renal artery aneurysm. The operation was performed under combined thoracic epidural analgesia and general anesthesia using transperitoneal approach. After the laparotomy, the ascending colon was mobilized and reflected medially followed by Kocher maneuver. The result was visualization of the anterior aspect of the right kidney, the collecting system, ureter as well as the right renal vein and artery with large saccular aneurysm located distally. After mobilization of the renal vessels and careful dissection of the ureter, the kidney was explanted. The operation was continued by two surgical teams. The first team performed abdominal aortic aneurysm resection and reconstruction with bifurcated Dacron graft. The second team performed ex vivo reparation of renal artery aneurysm. All time during the explantation, the kidney was perfused by Collins' solution. The saccular right renal artery aneurysm 4 cm in diameter was located at the kidney hilus at the first bifurcation. Three branches originated from the aneurysm. The aneurysm was resected completely. The longest and widest of three branches arising from the aneurysmal sac was end-to-end anastomized with 6 mm PTFE graft. After this intervention, one of shorter arteries was implanted into the long artery, and another one into PTFE graft. After 30 minutes of explanation, autotransplantation of the kidney into the right iliac fossa was performed. The right renal vein was implanted into the inferior vein cava, and PTFE graft into the right limb of Dacron graft. Immediately following the completion of both anastomoses, large volume of urine was evident. Finally, ureteneocystostomy was performed with previous insertion of double "J" catheter. In the immediate postoperative period, renal function was restored to normal, while postoperative angiography revealed all patent grafts. DISCUSSION The most common causes of renal artery aneurysms are arteriosclerosis, as in our case, and fibro-muscular dysplasia. Very often, renal artery aneurysms are asymptomatic and discovered only during angiography in patients with aneurysmal and occlusive aortic disease. Other cases include: arterial hypertension, groin pain and acute or chronic renal failure. Due to relatively small number of evaluated cases, the risk of aneurysmal rupture is not known. According to some authors, the overall rupture rate of renal artery aneurysm is 5%, however, the rupture risk becomes higher in young pregnant woman. Several standard surgical procedures are available for the repair of renal artery aneurysms. These include saphenous vein angioplasty, bypass grafting, as well as ex vivo reconstruction with reimplantation or autotransplantation. Furthermore, interventional embolization therapy, as well as endovascular treatment with ePTFE covered stent, or autologous vein-coverage stent graft, have been also reported to be successful. CONCLUSION The major indications for surgical treatment of renal artery aneurysms are to eliminate the source of thromboembolism which leads to fixed renal hypertension and kidney failure, as well as prevention of aneurysmal rupture.

Ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality that has not been changed in decades. Between 1991-2001 total number of 1058 patients was operated at the Institute for Cardiovascular Diseases of Clinical Center of Serbia due to abdominal aortic aneurysm. Of this number, 288 patients underwent urgent surgical repair because of ruptured abdominal aortic aneurysm. The aim of this retrospective study was to show results of the early outcome of surgical treatment of patients with ruptured abdominal aortic aneurysm, and to define relevant intraoperative factors that influence their survival. There were 83% male and 17% female patients in the study, mean aged 67 years. Mean duration of surgical procedure was 190 minutes (75-420 min). Most common localization of aneurysm was infrarenal - in 74% of patients, then juxtarenal (12.3%). Suprarenal aneurysm was found in 6.8% of patients, as well as thoracoabdominal aneurysm (6.8%). Retroperitoneal rupture of aortic aneurysm was most common - in 65% of patients, then intraperotineal in 26%. Rare finding such as chronic rupture was found in 3.8%, aortocaval fistula in 3.2% and aorto-duodenal fistula in 0.6% of patients. Mean aortic cross-clamping time was 41.7 minutes (10-150 min). Average intraoperative systolic pressure in patients was 106.5 mmHg (40-160 mmHg). Mean intraoperative blood loss was 3700 ml (1400-8500 ml). Mean intraoperative diuresis was 473 ml (0-2100 ml). Tubular graft was implanted in 53% of patients, aortoiliac bifurcated graft in 32.8%. Aortobifemoral reconstruction was done in 14.2% of patients. These data refer to the patients that survived surgical procedure. Intrahospital mortality that included intraoperative and postoperative deaths was 53.7%. Therefore, 46.3% patients survived surgical treatment and were released from the hospital. Intraoperative mortality was 13.5%. Type of aneurysm had no influence on outcome of patients (p>0.05), as well as type of rupture and level of aortic cross-clamping. Aortic cross-clamping time was significantly shorter in survivors, and longest in patients that died intraoperatively (p

INTRODUCTION Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously [1]. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons. OBJECTIVE The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass. METHODS The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity- in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with iatrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluo-roethlylene graft was used in three patients. Simultaneously, profundo-plastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done, x2 test was used for statistical evaluation and life table method was used for verification of late graft patency. RESULTS The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis -1, MOFS - 3, and infarct myocardium -1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was fpund in one patient. The other complications were - artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in three patients. Life table method has shown that cumulative rate of late graft patency is 80.39% after five years (Graph 1). DISCUSSION Our results were analyzed and compared with the results of the study on 283 patients who had undergone aortobifemoral bypass (AFF) operation due to the aortoiliac occlusive disease. This study was completed in 1995 (18). The results showed that there was no statistically significant differences between AxFF and AFF group (p>0.05), considering early mortality rate and late graft patency (Graph 2). The review of mortality and late patency rate after AxFF bypass grafting in a world well known studies has shown the similar results (Table 1). CONCLUSION The authors suggest that axilobifemoral bypass is indicated when there are contraindications or difficulties to perform anatomic reconstruction due to the abdomen condition (infection, adhesion, comorbidity) as well as in high risk patients with low life expectancy.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

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 preopera-tive 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

The authors present surgical techniques and distant results of the operative treatment in patients with occlusive lesions of the supraaortic branches. The study included 29 men (55.8 %) and 23 women (44.2 %), with the average age of 54 years. The majority of patients - 44 (84.6 %) had symptoms and signs of the upper extremities ischemia while 25 (48.1 %) had symptoms and signs of cerebral ischemia (the posterior circulation mainly). Among seven patients with isolated cerebral ischemia of the anterior circulation, four of them developed transient ischemic attack (TIA) and three had cerebrovascular insult (CVI). All patients were examined ultrasonographically and angiographically. Operative treatment was performed under general anesthesia. In eight cases the anatomic, and in 44 extraanatomic procedure was applied. Following reconstructive procedures were used: endarterectomy and patch of the brachiocephalic trunk - 2 bypass from ascending aorta - 7, carotid to subclavian bypass - 31 subclavian to carotid bypass - 7, subclavian artery transposition - 3 axillo-axillary bypass - 2. During the follow-up period (10-228 months) eight out of 52 patients exhibited the occlusion of the graft. Six occlusions developed after carotid-subclavian bypass: in two patients reconstructions were performed using Dacron grafts, in three using PTFE grafts and in one patient using autologous vein graft. Two occlusions developed after subclavio-carotid bypass. In both cases the vein graft was used: one was coming from the ipsilateral and the other one from the contralateral subclavian artery. The mean period from the operation to the occlusion of the graft (the mean lasting of the primary flow) was 14.72 years (SE=1.41; 95 % CI=11.96-17.48). There was no statistically significant difference in primary patency and survival without symptoms between patients treated with the anatomic and those treated with the extra anatomic approach. Practically, this means that both approaches were equally good, so that the decision about the approach should be made individually according to the loading factors of each patient. In the case of the carotid-subclavian bypass, according to our results, we recommend the use of the PTFE graft.

The infection of the previously implanted vascular graft at the groin, is associated with great mortality and morbidity rate [1]. The authors present a retrospective study in which they analyzed management of infected vascular prostheses at the groin, using obturator bypass in 26 cases, and "lateral" bypass in 15 cases. The indications for obturator bypass reconstructions included: 20 infections of aorto-femoral grafts, two infected pse udoaneurysms in the groin after RTA of the superficial femoral artery, and 4 infections of iliac-femoral grafts. The indications for lateral bypass reconstructions were: infections after aorto-femoral reconstructions - 8 cases; infection after femora-popliteal reconstructions - 4 cases; infection after iliac-femoral reconstruction - 2 patients, and one infected pseudoaneurysm in the groin after RTA of the superficial femoral artery. In 3 subjects obturator bypass was performed using extraperitoneal approach while in other 23 patients transperitoneal approach was done by donor's artery. The obturator bypass was performed using a PTFE graft in 3 cases and Dacron graft in 23. The donor's artery used for obturator bypass was a noninfected proximal part of aortofemoral graft in 20 cases, and iliac artery in 6 patients. The superfical femoral artery was recipient artery for obturator bypass in 3 cases, deep femoral artery in one case, and above the knee popliteal artery in 22 cases (Figure 1). In two patients transperitoenal approach to donors artery for "lateral" bypass has been used, and in 13 cases extraperitoneal. The proximal noninfected part of aorto femoral graft was used as a donor's artery for lateral bypass in 8 patients, while common iliac artery in 7 subjects. In 5 cases recon structions were performed using PTFE grafts, in 3 using autologous saphenous vein grafts, and in 7 using Dacron grafts. The recipient artery for "lateral" bypass was deep femoral in 8 cases, superficial femoral in three patients and above the knee popliteal artery in 4 subjects. After both types of reconstruction, extirpation of infected grafts from the groin was performed (Figure 2). The control examination was performed using physical and Doppler ultrasonographic examinations, one, 3, 6, 12 months, and then every year after the operation. In cases with suspected graft infection or thrombosis, control angography was also performed. One intraoperative perforation of the urinary bladder has been done accidentally during obturator bypass reconstruction. The mean follow-up period for patients with obturator bypasses was 2.3 years, while 2.1 years for patients with "lateral" bypasses. Comparing with "lateral" bypass, obturator bypass showed statistically significant lower (p < 0.05) 30- day mortality and early graft infection rate, as well as statistically significant better early and total limb salvage rate. There were no statistically significant differences (p > 0.05) between obturator and "lateral" bypass procedures having in mind, late graft infection rate, as well as early and late graft patency (Figures 3 and 4). In cases with infected vascular prostheses in the groin, the authors recommend obturator bypass comparing with "lateral" bypass.

This study examined 191 patients with 'reversed' and 99 patients with 'in situ' femoro-popliteal bypass technique. There were 85 diabetic patients (44.5%) in the group with 'reversed' bypass, and 43 patients (43.43%) in the 'in situ' group. There were 152 (79.68%) smokers in the 'reversed' bypass group, and 80 (80.8%) in the 'in situ' group. The graft patency was confirmed immediately after operation using CW Doppler and then followed up after 1, 6, l2 months and annually thereafter. The statistical analysis was performed using Pearsons chi-square test, Fischer's test and 'Life table' statistic methods. The patients were followed from 3 to 10 yr after surgery. 'In situ' bypass showed better patency than the 'reversed' bypass technique but only in the second and tenth follow-up year (P0.05). Also, 'in situ' bypass proved to be better than 'reversed' only in patients with one patent crural artery (P0.01). Diabetes and preoperative smoking did not significantly affect late patency regarding this technique (P0.05). However, continuous smoking after the operation significantly decreased late patency rate in both groups of patients (P0.01). There was no significant difference in the early thrombectomy rate between groups with 'reversed' and 'in situ' bypasses (P0.05). The early thrombectomy, however, significantly reduced late patency rate in both groups (P0.01). Therefore we suggest 'in situ' bypass in cases with poor run off, small-calibre vein and 'long' bypass. Also, we consider important more frequent physical and Doppler ultrasonographic control in patients who had early thrombectomy.

Intracardiac leiomyomatosis (ICL) is a rare and dangerous form of intravenous leiomyomatosis (IVL). The case of ICL presented here depicts some diagnostic and surgical difficulties that may arise from the rarity and complexity of this condition. Further, to our best knowledge, neither the mass nor the growth rate of the abdominal part of the presented ICL has been described in the available literature. Finally, this case and extensive literature search allowed us to clarify some important questions pertaining to this entity.

Aneurysm of the persistent sciatic artery is a rare cause of limb ischemia, which is a challenge for both diagnosis and treatment. After successful diagnosis adequate treatment may require skills in open and endovascular surgery. We present a patient with the aneurysm of the persistent sciatic artery treated by bypass procedure with PTFE graft using posterior approach. We named this procedure “dorsal bypass”. Detailed explanation of clinical presentation, diagnosis and the surgical procedure is given in this paper.

Patients with decompensated heart failure, volume overload, and hyponatremia are challenging to manage. Relatively little has been documented regarding the clinical course of these patients during standard in-hospital management or with vasopressin antagonism.The Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan database was examined to assess the short-term clinical course of patients hospitalized with heart failure and hyponatremia and the effect of tolvaptan on outcomes. In the placebo group, patients with hyponatremia (serum Na(+)135mEq/L; n = 232), compared with those with normonatremia at baseline (n = 1785), had less relief of dyspnea despite receiving higher doses of diuretics (59.2% vs 69.2% improved; P.01) and worse long-term outcomes. In the hyponatremia subgroup from the entire trial cohort (n = 475), tolvaptan was associated with greater likelihood of normalization of serum sodium than placebo (58% vs 20% and 64% vs 29% for day 1 and discharge, respectively; P.001 for both comparisons), greater weight reduction at day 1 and discharge (0.7 kg and 0.8 kg differences, respectively; P.001 and P = .008), and greater relief of dyspnea (P = .03). Among all hyponatremic patients, there was no effect of tolvaptan on long-term outcomes compared with placebo. In patients with pronounced hyponatremia (130 mEq/L; n = 92), tolvaptan was associated with reduced cardiovascular morbidity and mortality after discharge (P = .04).In patients with decompensated heart failure and hyponatremia, standard therapy is associated with less weight loss and dyspnea relief, and unfavorable longer-term outcomes compared to those with normonatremia. Tolvaptan is associated with more favorable in-hospital effects and, possibly, long-term outcomes in patients with severe hyponatremia.

Background The increased number of carotid endarterectomies performed worldwide in recent years is associated with a greater need for carotid restenosis evaluation. Carotid restenosis rate ranges from 0.6% to 3.6% in symptomatic patients and from 8.8% to 19% in asymptomatic patients. Carotid angioplasty and stenting is a preferable therapeutic choice for carotid restenosis treatment, but whenever it is not technically feasible (tortuosities of supra-aortic branches, calcifications, pathological elongation, or very extensive lesions), redo surgical treatment is indicated. The aim of our study was to examine outcome of redo surgical treatment in patients with symptomatic and asymptomatic carotid restenosis, in whom carotid angioplasty could not be done, and its impact on early and late morbidity and mortality. Methods The study included 52 patients who were surgically treated for significant carotid restenosis from January 2000 to December 2008 in two high-volume vascular surgery university clinics. Surgical techniques included redo eversion endarterectomy, standard endarterectomy with Dacron patch closure, and Dacron tubular graft interposition. The patients were followed for significant events (transient ischemic attack, stroke, cranial nerve injuries, surgical site hematoma, the occurrence of carotid re-restenosis, or occlusion), and mortality after 1 month, 6 months, 1 year, and annually afterward. Results In the early postoperative period (within 30 days), there were no lethal outcomes. Transient ischemic attack was diagnosed in four patients (7.6%), minor stroke in two patients (3.8%), and cranial nerve injury in four patients (7.6%). After 4 years, three patients died (5.7%), two due to a fatal myocardial infarction (3.8%) and one after a major stroke (1.9%); four patients (7.6%) had ipsilateral stroke; and graft occlusion was verified in one patient (1.9%). Conclusion Carotid angioplasty might be a primary option for carotid restenosis treatment, but whenever it cannot be performed, redo surgical treatment is indicated, owing to its acceptable rate of early and late postoperative complications.

Aortic diseases associated with renal anomalies can present special challenges during surgery of the abdominal aorta. The aim of this paper is evaluation of morbidity and definition of optimal management according to the clinical histories of 30 patients with horseshoe and ectopic kidneys who underwent surgical procedures on the abdominal aorta over a 20-year period. Twenty-two of them had horsheshoe kidney and eight had ectopic kidney. Indications for surgery included aortic aneurysms in 25 patients and aortoiliac occlusive disease in 5. Preoperative diagnostics were performed in all cases by means of computed tomography and angiography (except in the cases with ruptures) associated with duplex ultrasonography. In patients with ectopic kidney a Carrel patch technique was used for the reimplantation of the renal arteries into the body of the bifurcated (four cases) or tubular (four cases) Dacron graft in five (62.5%) cases whereas aortorenal bypass with Dacron graft was obtained in three cases (37.5%). Sixteen patients from the horseshoe kidney group required renal revascularization (reimplantation using Carrel patch in 10 patients and aortorenal bypass using Dacron graft in 6 patients). Two patients, both with ruptured abdominal aortic aneurysms died after the operation. In other cases the average follow up period was 6.2 years (6 months to 17 years). In one case control, angiography after 6 months revealed an occluded left renal artery that was reimplanteted by Carrel patch but without repercusions on the renal function. Aortic surgery in patients with renal anomalies can be safely performed without increased mortality.

Fracture of the epidural lead (Pisces Quad 3487) is documented in four out of eight patients with an implanted Itrel pacing system for treatment of peripheral vascular disease. In two patients, lead fracture was established during x-ray fluoroscopy. In the remaining two patients, x-ray examination did not reveal any fracture, due to proximity of the fragments. Microscopic examination of the extracted lead, however, confirmed lead fracture, as well as the presence of tissue fluid and thrombus between the two ends of the spiral shaped lead, but no insulation defect was observed. A cross-sectional area on the fracture line of the broken lead was examined using scanning electron microscopy. It was found, by tracing the radial marks to their point of convergence, that the initial microcrack started from a large inclusion of the calcium-silicon type at the lead surface. The initial microcrack was propagated by the fatigue mechanism. The presence of a large inclusion at the surface suggests that the main cause of the failure of the investigated epidural leads could be improper fabrication of the material. The high incidence of epidural lead fracture in our group suggests that this complication should be considered as a possible cause of epidural spinal electrical stimulation pacing system dysfunction.

INTRODUCTION Radical operative treatment of abdominal tumors closely related to major blood vessels often demands complex vascular procedures. OBJECTIVE The aim of this paper was to present elementary principles and results of the complex procedures, based on 46 patients operated on at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, from January 1999 to July 2006. METHOD Primary localization of the tumor was the kidney in 14 patients, the suprarenal gland in 2, the retroperitoneum in 23 and the testis in 7 patients. Histologically, the most frequent were the following: renal carcinoma in 14 patients, teratoma in 7, liposarcoma in 5, fibrosarcoma and lymphoma in 3 patients. The tumor compressed abdominal aorta occurred in 3 cases, vena cava inferior in 5 and both the abdominal aorta and vena cava inferior in 11 cases. In 4 cases the tumor infiltrated the abdominal aorta, in 11 the vena cava inferior and in 8 both of them. In two patients, the tumor compressed the vena cava inferior and infiltrated the aorta; in two patients the aorta was compressed and the vena cava was infiltrated. In three cases only the exploration was performed due to multiple abdominal organ infiltration. The ex tempore biopsy showed the type of tumor in which the radical surgical treatment did not improve the prognosis. In 20 cases of tumor compression, subadventitional excision was performed. In 23 cases of infiltration, the tumor excision and vascular reconstruction had to be performed. Intraoperative blood cell saving and autotransfusion were applied in 27 patients. RESULTS The lethal outcome happened in 3 (6.5%) patients during hospitalization. In other patients all reconstructed blood vessels were patent during the postoperative hospitalization period. CONCLUSION Treatment of the abdominal tumors closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. Tumor reduction cannot improve long term prognosis, and has no major impact on life quality. There have been not many papers that analyze the long term results after such complex operations proving their appropriateness.

Objective The objective was to determine the effects of aripiprazole on hostility. Method A total of 1476 patients diagnosed with DSM-IV schizophrenia or schizoaffective disorder were the subjects in 5 short-term, double-blind studies comparing aripiprazole with placebo; 3 of these studies also included a comparison with haloperidol. The studies were conducted between December 1993 and January 2001. The Positive and Negative Syndrome Scale (PANSS) was the principal outcome measure in these studies. To determine the effect of aripiprazole on hostility, post hoc analyses of the hostility item from the PANSS were conducted for the first 4 weeks of treatment. Results Aripiprazole was superior to placebo and not significantly different from haloperidol in reducing hostility. Conclusion Aripiprazole is an effective treatment for hostility in patients with schizophrenia or schizoaffective disorder.

This study compared the efficacy, safety, and tolerability of aripiprazole, a novel antipsychotic, with placebo in patients with psychosis associated with Alzheimer's Disease (AD). This 10-week, double-blind, multicenter study randomized 208 outpatients (mean age, 81.5 years) with AD-associated psychosis to aripiprazole (n = 106) or placebo (n = 102). The initial aripiprazole dose of 2 mg/d was titrated upwards (5, 10, or 15 mg/d) according to efficacy and tolerability. Evaluations included Neuropsychiatric Inventory (NPI) Psychosis subscale and Brief Psychiatric Rating Scale (BPRS), adverse event (AE) reports, extrapyramidal symptoms (EPS) rating scales, and body weight. Overall, 172 patients (83%) completed the study. Mean aripiprazole dose at end point was 10.0 mg/d. The NPI Psychosis subscale score showed improvements in both groups (aripiprazole, -6.55; placebo, -5.52; P = 0.17 at end point). Aripiprazole-treated patients showed significantly greater improvements from baseline in BPRS Psychosis and BPRS Core subscale scores at end point compared with placebo. AEs were generally mild to moderate in severity and included (aripiprazole vs. placebo): urinary tract infection (8% vs. 12%), accidental injury (8% vs. 5%), somnolence (8% vs. 1%), and bronchitis (6% vs. 3%). Somnolence was mild and not associated with falls or accidental injury. There were no significant differences from placebo in EPS scores, or clinically significant ECG abnormalities, vital signs, or weight. In conclusion, aripiprazole showed similar improvements to placebo in psychotic symptoms as assessed by NPI Psychosis subscale scores, but significantly greater effects on BPRS Core and Psychosis assessments in community-living AD patients with psychosis. Aripiprazole was safe and well tolerated in this patient population.

We present the results and respective determinant factors of 283 consecutive aortobifemoral bypasses. This prospective study included 283 patients with aortoiliac atherosclerotic occlusive disease treated by aortobifemoral reconstructions. Polytetrafluoroethylene (PTFE) grafts were used in 136 patients and Dacron® grafts in 147 patients. The 30-day mortality rate was 11 patients (3.9%). Perioperative (< 30 days) graft failure occurred in 6 patients (2.1%), whereas in 14 (5.25%) patients, it occurred during the follow-up period. There were 3 (1.05%) distal anastomotic pseudoaneurysms and 5 (1.7%) graft infections, with no statistical difference between the two types of grafts. The type of prosthesis did not influence cumulative graft patency. The end-to-end configuration of proximal anastomosis and a simultaneously performed femoropopliteal bypass significantly increased the graft patency ( p < .05). The associated occlusion of the superficial femoral and popliteal arteries decreased the cumulative graft patency in comparison with that of the patients without artery disease ( p < .05). Our results showed that in the aortobifemoral position, there was no significant difference in the patency, anastomotic pseudoaneurysms, and graft infection between PTFE and Dacron grafts. However, the PTFE grafts had a significantly higher rate ( p < .05) of distal anastomotic stenosis, which was mostly caused by neointimal hyperplasia.

Objective To evaluate efficacy and safety of aripiprazole once-monthly 400mg (AOM-400mg), an extended release injectable suspension of aripiprazole, in obese (BMI =30kg/m 2 ) and non-obese (BMI 2 ) patients with schizophrenia. Methods Data from a 38-week, double-blind, active-controlled, non-inferiority study (NCT00706654); randomisation (2:2:1) to AOM-400mg, oral aripiprazole (10-30mg/day) (ARI), or aripiprazole once-monthly 50mg (AOM-50mg) assessing the efficacy and safety of AOM in patients requiring chronic antipsychotic treatment were used for this post-hoc analysis. We report the overall relapse rates in the 38-week randomized phase. Comparisons of overall relapse rates were analyzed using the Chi-squared test. Results 662 patients were randomized to: AOM-400mg (n=265); ARI (n=266); or AOM-50mg (n=131). Of these, the following were obese: AOM- 400mg: n=95; ARI: n=95; AOM-50mg: n=43. In the obese patients, the overall relapse rate was significantly (p=0.0012) lower with AOM-400mg (7.4%) than with AOM-50mg (27.9%). The difference between AOM-400mg and ARI (8.4%) was not significantly different. In the non-obese patients, the overall relapse was significantly (p=0.0153) lower with AOM-400mg (8.8%) than with AOM-50mg (19.3%). The difference between AOM-400mg and ARI (7.6%) was not significantly different. For patients treated with AOM-400mg, the most common TEAEs (>10% in any group) are presented in Table 1. Table 1 . TEAE: AOM-400mg Obese Non-obese Insomnia 12.6% 11.2% Headache 12.6% 8.2% Injection site pain 11.6% 5.3% Akathesia 10.5% 10.6% Upper respiriatory tract infection 10.5% Weight increase 10.5% 8.2% Weight decrease 6.3% 11.8% Conclusions The efficacy and tolerability of aripiprazole once-monthly 400mg were similar in both the obese and non-obese subgroups. Disclosure Supported by Otsuka Pharmaceutical Development & Commercialization, Inc. , and H. Lundbeck A/S

Altogether 59 patients with 76 popliteal artery aneurysms were treated during the last 36 years. There were 50 (85%) male and 9 (15%) female patients with an average age of 61 years. Nineteen (32%) patients had bilateral aneurysms. The clinical manifestations of the aneurysms included ruptures 4 (5.3%); deep venous thrombosis 4 (5.3%); sciatic nerve compression 1 (1.3%); leg ischemia 52 (68.4%), and asymptomatic pulsatile masses 15 (19.7%). Seventy (92%) aneurysms were atherosclerotic, one (1.3%) mycotic, and four (5.3%) traumatic; one (1.3%) developed owing to fibromuscular displasia. Seven (9.2%) small, asymptomatic aneurysms were not operated on. Reconstructive procedures end-to-end anastomosis, graft interposition, bypass) after aneurysmal resection or exclusion using a medial or posterior approach were done in 59 cases. An autologous saphenous vein graft was used in 49 cases, polytetrafluoroethylene (PTFE) in 5, and heterograft in 2 cases. The in-hospital mortality rate was 2.9%, the early patency rate 93.3%, and limb salvage 95%. The long-term patency rate after a mean follow-up of 4 years was 78% and long-term limb salvage 89%. The total limb salvage was 73%, and the total amputation rate was 27%. The dangerous complications associated with popliteal artery aneurysms and the good results after elective procedures suggest that operative treatment is appropriate.

A total of 46 patients with syncopal episodes after VVI pacemaker implantation were studied. Of these, 92% had one to three syncopal episodes and 8% more than three. All underwent a thorough clinical examination, which included chest X ray, echocardiogram, neurological exam, and the following protocol: 24-hour Holter monitoring, EEG, blood pressure (BP) measurement in three positions, Doppler exam of the carotid vessels, fasting blood glucose, and head-up tilt table test (60 minutes, 60 degrees). Holter monitoring showed exit block in two patients (4.3%) and failed sensing in one (2.1%). In two patients there was unilateral slowing on EEG. Orthostatic hypotension was found in four patients (8.6%), and hypoglycemia in three insulin-dependent diabetics. An occlusive atherosclerotic plaque in the carotid artery was found in three patients (6.5%). Syncope was induced in 17 patients (36.9%) by the tilt table test, after a mean standing time of 47 +/- 11 minutes. The mean resting systolic BP of these patients was 140 +/- 24 mmHg, and fell to a mean level of 56 +/- 8 mmHg (mean systolic BP drop was 79 +/- 8 mmHg). Sixteen of these 17 patients with positive tilt table were being paced at the time of syncope and one had a spontaneous heart rate of 73 beats/min. In 14 cases (30.4%) the cause of syncopal episodes after this extensive workup remained unexplained. These results indicate that pacemaker dysfunction is not a major cause of syncopal episodes in pacemaker patients and that these are most often due to vasovagal syncope. Long-term follow-up is warranted to determine the prognostic significance of various types of syncope in pacemaker patients.