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

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

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Background: Despite the proven clinical effect of oral antiplatelet drugs, a considerable number of patients do not have an adequate response to clopidogrel. The aim of our study was to determine the influence of CYP2C19*2 loss-of-function variant allele on clopidogrel responsiveness in patients with carotid artery stenosis. Methods: One hundred and twelve patients with carotid artery stenosis undergoing endarterectomy were included in this one-year prospective study. All of them received clopidogrel (75 mg daily) for at least 30 days after the intervention. They were followed from the moment of hospital admission. CYP2C19*2 genotyping was performed by TaqMan Assay. The influence of c Yp 2C 19*2 variant allele on clopidogrel platelet reactivity was determined using multiple-electrode aggregometry (MEA). Results: Genotyping results showed that 82 (73.2% ) patients were homozygous for wild type, 29 (25.9%) were heterozygous for the CYP2C19*2 allele and 1 (0.9%) was CYP2C19*2 homozygous. After 24 hours, among those with the wild type 29.3% were clopidogrel responders, and in those with the CYP2C19*2 alleles 10%. In the wild type group, 74.4% were clopidogrel responders after 7 days of taking the drug; 82.9% after 30 days of clopidogrel introduction, respectively. In patients with the CYP2C19*2 alleles the number of responders increased up to 46.7% after 7 days; 53.3% after 30 days of taking the drug, respectively. The risk for being a low-responder is higher for the patients heterozygous for the c Yp 2C 19*2 allele vs. wildtype (OR 4.250, 95% CI 1.695 -10.658 , P< 0.01). Conclusions: The CYP2C19*2 loss-of-function variant allele has significant influence on clopidogrel response in patients with carotid artery stenosis undergoing endarterectomy.

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

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

Background/Aim. Some oligoelements are now investigated as possibly having a role in atherosclerosis. The aim of this study was to compare the concentrations of copper and zinc in the serum and carotid plaque and parameters of lipid metabolism in patients with different morphology of carotid atherosclerotic plaque. Methods. Carotid endarterectomy due to the significant atherosclerotic stenosis was performed in 91 patients (mean age 64 ± 7). The control group consisted of 27 patients (mean age 58 ± 9), without carotid atherosclerosis. Atheroscletoric plaques were divided into four morphological groups, according to ultrasonic and intraoperative characteristics. Copper and zinc concentrations in the plaque, carotid artery and serum were measured by atomic absorption spectrophotometry. Results. Serum copper concentrations were statistically significantly higher in the patients with hemorrhagic in comparison to those with calcified plaque (1.2 ± 0.9 μmol/L vs 0.7 ± 0.2 μmol/L, respectively; p = 0.021). Zinc concentrations were statistically significantly lower in plaques of the patients with fibrolipid in comparison to those with calcified plaques (22.1 ± 16.3 μg/g vs 38.4 ± 25.8 μg/g, respectively; p = 0.024). A negative significant correlation was found for zinc and triglycerides in the serum in all the patients (r = -0.52, p = 0.025). In the control group we also demonstrated a positive significant correlation for low-density lipoprotein cholesterol and copper in the serum (r = 0.54, p = 0.04). Conclusion. The data obtained in the current study are consistent with the hypothesis that high copper and lower zinc levels may contribute to atherosclerosis and its sequelae as factors in a multifactorial disease. Further studies are necessary in order to conclude whether high concentration of copper and zinc in the serum could be risk factors for atherosclesrosis.

Introduction Vascular network of dental pulp is supplied through common and external carotid artery and terminal dental branches that supply each pulp tissue. Age related changes of pulp tissue influence pulpal vascularization as well. The aim of this study was to compare and correlate pulpal and common and external carotid artery blood flow in young and middle age individuals of general population. Material and Methods Two groups of 10 participants were included in the study, young (20-25 years) and middle age (50-55 years) group. Pulpal blood flow (PBF) measurements on intact right and left upper central incisors were performed using laser Doppler flowmetry (LDF) method. Carotid arteries blood flow was assessed using carotid ultrasonography. Results PBF levels were significantly higher in young (3.11±0.67 and 3.46±1.11, right and left upper central incisors, respectively) compared to middle age (1.93±0.47 and 2.30±0.64, right and left upper central incisors, respectively) participants (independent sample t test; p

Introduction. Necrotizing fasciitis is a rare, progressive bacterial infection of superficial fascia followed by secondary subcutaneous tissue necrosis. We pressented a patient with massive fulminant lifethreatening necrotising fasciitis after bellow-knee femoro-popliteal vein bypass grafting successfully treated by antibiotics, surgical debridement and final skin reconstruction using the Tierch method. Case report. A 61-year-old patient was ad-mitted to the Vascular Surgery Clinic for below-knee femoro-popliteal bypass grafting. He complained of intermittent claudication in the left leg after 50 m, ankle brachial indexes were 0.45 on the left and 1.0 on the right side. Femoropopliteal below-knee bypass grafting was done using the autologous great saphenous vein. In the very next day, initial signs of skin infection appeared including local inflammation, erythema, swelling and cellulitis restricted to saphenectomy site. These changes had rapidly spread in the following days on the deep tissue of the whole upper and lower leg, including the groin and with clinical signs of life-threatening systemic infection. Immediate surgical debridement was done followed by extensive wound packing and wide spectrum antibiotics administration for the next 33 days when final skin reconstruction by the Tierch method was performed. Interesting point is that this entire time wound swab was sterile. Conclusion. In the presented case immediate surgical debridement, wide spectrum antibiotics administration and consistent wound packing gave satisfactory results in this life-threatening systemic infection. Wound swab is not always a reliable indicator of the infection while clinical findings and surgeons’ experience are of great significance in rapid reaction to this rare surgical complication. [Projekat Ministarstva nauke Republike Srbije, br. 41002]

Different internal jugular vein (IJV) abnormalities can be found in patients with multiple sclerosis (MS): stenoses, complete occlusion, distortions and intraluminal structures, such as membranes, webs and inverted valves. IJV duplication is a very rare phenomenon. We report a case of right IJV duplication as an incidental finding during IJV morphological and haemodynamic assessment in a patient with MS. A 55-year-old female patient was admitted to our Institute for IJV and vertebral veins morphological and haemodynamic assessment. During the last seven years she had been treated for MS. Colour Doppler ultrasonography in our patient did not reveal IJV or vertebral veins stenoses or abnormal valves, but instead right IJV duplication. This finding was confirmed using multislice computed tomography angiography and by selective phlebography. In conclusion, to our knowledge, a case of IJV duplication in a patient with MS has not been described yet. This further venous malformation can be assessed by the means of Doppler ultrasounds. [ABSTRACT FROM AUTHOR]

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

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

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

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

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

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

Bacground/Aim. Endovascular treatment of thoracic aortic diseases is an adequate alternative to open surgery. This method was firstly performed in Serbia in 2004, while routine usage started in 2007. Aim of this study was to analyse initial experience in endovacular treatment of thoracic aortic diseses of three main vascular hospitals in Belgrade - Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia, Clinic for Vascular Surgery of the Military Medical Academy, and Clinic for Vascular Surgery of the Institute for Cardiovascular Diseases “Dedinje”. Methods. Between March 2004. and November 2010. 41 patients were treated in these three hospitals due to different diseases of the thoracic aorta. A total of 21 patients had degenerative atherosclerotic aneurysm, 6 patients had penetrating aortic ulcer, 6 had posttraumatic aneurysm, 4 patients had ruptured thoracic aortic aneurysm, 1 had false anastomotic aneurysm after open repair, and 3 patients had dissected thoracic aneurysm of the thoracoabdominal aorta. In 15 cases the endovascular procedure was performed as a part of the hybrid procedure, after carotidsubclavian bypass in 4 patients and subclavian artery transposition in 1 patient due to the short aneurysmatic neck; in 2 patients iliac conduit was used due to hypoplastic or stenotic iliac artery; in 5 patients previous reconstruction of abdominal aorta was performed; in 1 patient complete debranching of the aortic arch, and in 2 patients visceral abdominal debranching were performed. Results. The intrahospital mortality rate (30 days) was 7.26% (3 patients with ruptured thoracic aneurysms died). Endoleak type II in the first control exam was revealed in 3 patients (7. 26%). The patients were followed up in a period of 1-72 months, on average 29 months. The most devastating complication during a followup period was aortoesofageal fistula in 1 patient a year after the treatment of posttraumatic aneurysm. Conversion was performed with explantation of stent-graft and open aortic in situ recontruction, followed by esophagectomy and the creation of cervical and gastrical stoma. Conclusion. Having in mind initial results of the 3 main vascular clinics in Belgrade, Serbia, economical situation in our country, as well as the published international results, endovascular treatment of thoracic aortic diseases is indicated in hemodinamicaly unstable patients with acute traumatic aneurysm, or in stabile patients older than 65, as well as in case of chronic diseases of the thoracic aorta in patients with significant comorbid conditions or in patients older than 65 years. Endovascular procedures on the thoracic aorta could be performed, hower, only in high-volume centers with experience in routine open surgery of thoracic aorta.

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

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

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Background/Aim. Doppler ultrasonography is now a reliable diagnostic tool for noninvasive examination of the morphology and hemodynamic parameters of extracranial segments of blood vessels that participate in the brain vascularisation. This diagnostic modality in recent years become the only diagnostic tool prior to surgery. The aim of the study was to determine hemodynamic status in symptomatic and asymtomatic patients with severe carotid stenosis prior to and after carotid endarterectomy (CEA). Methods. A total of 124 symptomatic and 94 asymptomatic patients who had underwent CEA at the Clinic for Cardiovasculare Disease “Dedinje” in Belgrade were included in this study. Doppler ultrasonography examinations were performed one day before CEA and seven days after it. The peak systolic velocity (PSV), end-dyastolic velocity (EDV), time-averaged maximum blood flow velocity (MV), resistance index (RI) and the blood flow volume (BFV) of the ipsilateral and the contralateral internal carotid artery (ICA) were measured. Results. Diabetes was the only risk factor found significantly more frequent in symptomatic patients. There were significantly more occluded contralateral ICAs in the group of symptomatic patients. There was a significant increase in PSV, EDV, MV and BFV of the ipsilateral ICA after CEA and a significant decrease in PSV, EDV, MV and BFV of the contralateral ICA after CEA. RI is the only hemodynamic parameter without significant changes after CEA in both groups of patients. Comparing the values of hemodynamic parameters after CEA between the group of symptomatic and the group of asymptomatic patients no significant differences were found. Conclusion. The occlusion of the contralateral ICA is an important factor differentiating between symptomatic and asymptomatic patients with severe carotid stenosis. Successful surgery provides good recovery of cerebral hemodynamics in both symtomatic and asymptomatic patients.

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Introduction. Combined endovascular interventions on carotid and coronary arteries are rare. Stenting of the unprotected coronary left main stem is a high risk procedure. We presented hemodynamically unstable patient with combined carotid artery and left main stem coronary artery stenting. Case report. A 78-year-old female patient was admitted to our institution for right carotid endaterectomy. The patient had 80% stenosis of the right carotid artery and occlusion of the left carotid artery. Coronary angiography revealed 70% ostial left main stenosis, occlusion of the right coronary artery and the left circumflex artery, and 80% stenosis of the left anterior descending artery. Simultaneous carotid artery endaterectomy and coronary artery by-pass grafting were considered. Due to high perioperative risk, surgery was rejected, and the patient was treated endovascularly with stenting of arteries occluded. The procedure was completed without complications and the patient was hemodynamically stabilised. Conclusion. This report illustrates simultaneous coronary and carotid stenting as a successfull lifesaving procedure.

Atherosclerosis represents a complex disease which encompasses all the components of the vascular wall. Nevertheless, according to all known theories of the pathogenesis of atherosclerosis, the key role in this process belongs to the endothelial cells, i.e. the changes that they are subjected to especially during the initial stage of the lesion. In this review we have attempted, according to the results of our continuous research and numerous data from available modern literature, to show the cytohistological characteristics of endothelial cells, as well as the changes they are subjected to in all stages of atherosclerosis. In the first part we have reviewed the ultrastructure, function and pathology of the endothelium, subcellular organization of the endothelial cells, their specific characteristics, micro compartments and intercellular junctions. In the second part we have described the morphological and functional changes of endothelial cells during atherosclerosis. Special attention is given to the role of endothelial cells in the development of the initial stage of lesion: endothelial dysfunction, factors that cause the increased expression of adhesion molecules in endothelial cells and mechanisms that cause leukocytes to migrate through the endothelial layer to subendothelial connective tissue in the early stage of atherosclerosis.

In this study we compared the effects of duration of cold ischemia (longer and shorter ischemia) on the yield, viability and preservation of the physiological function and insulin secretion of adult human pancreatic islets in short-term (seven days) culture. Based on the tested parameters, we established that there are no major differences between these two test groups and that the storage and transport of pancreatic tissue in physiological solution at 4oC gives quite satisfactory results.

[Projekat Ministarstva nauke Republike Srbije, br. III41002]

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

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

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

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

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

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

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

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

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

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

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

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