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Introduction: Fingolimod, a sphingosine-1-phosphate receptor agonist used for the treatment of multiple sclerosis (MS). Our goal was to assess the impact of fingolimod on quality of life in patients with relapsing-remitting multiple sclerosis (RRMS) after 2 years of treatment in this real-world study., Patients and Methods: This was a 2-year, prospective, observational study conducted in Bulgaria in RRMS patients treated with fingolimod. Quality of life was assessed using the Bulgarian-language version of the MSQoL-54 scale. The primary endpoint was the change from baseline in the MSQoL-54 score after 2 years of treatment. Secondary endpoints included the change from baseline in the MSQoL-54 score after one year of treatment, furthermore the assessment of depression level using the Hamilton D-17 score., Results: A total of 87 eligible patients were included in the study with a mean age of 38.7 ± 8.45 years. The median Expanded Disability Status Scale (EDSS) score was 3.5 points. We found statistically significant improvement in 10 subscales at month 12 and in seven subscales at month 24. The mental health composite score increased from 64.0 ± 16.69 points to 67.5 ± 15.94 points at month 24 (p = 0.012). The physical health composite score increased from 61.7 ± 17.61 to 66.3 ± 16.70 (p = 0.001). Depression level measured by the HAM-D17 decreased significantly by month 12 and month 24. The EDSS score decreased or remained stable in more than half of the patients (61.6%). We detected better quality of life in patients with a lower EDSS score., Conclusions: Quality of life scores and the depression level are improved in RRMS patients treated with fingolimod over 2 years in real-life setting.

The abdominal aneurysm imposes prominent epidemiological impact due to its high incidence and life threatening complications. The first steps in endovascular treatment of abdominal aneurysms in Bulgaria are herein described. Five bifurcated and one straight stent-grafts were implanted in the ,,St.Ekaterina" University Hospital for the period from February till May 2004. Satisfactory therapeutic result was achieved in all cases. The continuing follow-up of the patients proved favorable tolerability. The good therapeutic response, lack of perioperative mortality, and low complication rate provide evidence that endovascular repair can have beneficial implication in patients with abdominal aneurysms and high operative risk.

We operated 51 patients with chronic arterial occlusions of the bellow knee arteries in 2002 and 2003. Sixteen patients had foot lesions, and 8 of them had bones involved (most frequently--the toes). The rest had only skin and soft tissue involvement in the lesions. In most of the cases surgery (toe amputation or debridement) of those lesions was performed as a second stage procedure following the arterial reconstruction. The lesions of the skin and soft tissue are treated with wet to dry antiseptic dressings, and in three cases systemic antibiotic therapy was applied, because of clinical signs for severe infection. In cases of extensive necrotic lesions, they are debrided at the time of arterial surgery, in an effort to limit the risk of systemic sepsis and graft contamination.

We present a case of traumatic pseudoaneurysm of the anterior tibial artery in a 74-years-old male. The patient had history of a trauma on his left calf--a penetrating wound caused by a knife. The primary surgical treatment in a traumatological ward resulted in a good non-ischemic condition without signs of bleeding. Ten days after the operation a pulsating mass occurred at the treated place. An angiography was performed demonstrating pseudoaneurysm of the anterior tibial artery, followed by a revision of the lesion by a vascular surgeon (V.C.). A pseudoaneurysm and excessive coagula were found. The presence of a wound infection suggested ligature of the artery, without vascular reconstruction. Peroneal and posterior tibial arteries were patent. The final postoperative result was satisfactory, absence of significant ischemia of the left lower extremity, and healed operative incision.

The study involves 70 patients for the period from 1990 till 2001. Male are 60 of them and female are 10 patients. A total of 77 surgical procedures were performed on these patients with highest number per year are 1990 and 2001. Results are as follows: patent reconstruction--47, graft thrombosis not requiring immediate amputation--18, graft thrombosis requiring immediate amputation--11, and death in one case. Fifty five patients had grafts to the bellow the knee popliteal artery, and 23 of them received grafts to a tibial or peroneal artery. The stage distribution of patients is as follows: stage II--5 patients, stage III--50 patients, and stage IV--22 patients. Rethrombosis rate increased with the higher stages of the disease. In six cases ipsilateral deep venous thrombosis was diagnosed by duplex ultrasound study. Synthetic grafts were used in 24 of patients, nine of them received composed grafts, and in 38 cases venous conduits were employed. Diabetes mellitus was a comorbid condition in 13 patients. Thirty one (40.26%) of the grafts thrombosed.

The surgical technique of the arterial reconstructions to the leg vessels is of critical importance for the outcome of those delicate procedures. The anatomic surgical exposures to the potentially target leg arteries are described. Infrapopliteal reconstructions are performed when popliteal artery is unsuitable for a distal anastomosis. Posterior tibial artery is exposed through a medial approach as an extension of the bellow knee popliteal artery exposure. Anterior tibial artery is accessible through the medial approach only in its ostial section, distal segments of it can be exposed using antero-lateral approach between tibia and fibula. Peroneal artery can also be exposed using medial approach in its proximal third, and for distal exposure resection of the fibula is required. All patients receive venous antibiotic, and Heparin 100 IU/kg or the corresponding doses low-molecular Heparin. All patients with thrombosed by-passes within 30 days undergo reoperation. Suggested is treatment of skin and soft tissue foot lesions. "Failing graft" should be diagnosed and treated properly, since assisted primary patency is higher than secondary patency. Intraoperative fluoroscopy has the potential to provide valuable information before, during and at completion of the procedure. Mortality is mainly due to myocardial infarction.

Restoration of blood flow to severely ischemic limbs may produce compartment and revascularization syndrome. It may require fasciotomies to be performed to decompress leg compartments. In cases when the skin edges are not close to each other skin grafting is a method of choice to close the defect without functional muscular and nerve deficit.

Congenital vascular malformations present a difficult therapeutic challenge. Phlebectasias are abnormally large veins found supra or/and subfascially most often involving lower extremities. There might be a communication with the arterial system or not. Asymptomatic and mildly symptomatic lesions do not require treatment. Absolute indications for treatment include hemorrhage, secondary ischemic complications, and congestive heart failure from arteriovenous shunting. Relative indications include pain, functional impairment, and cosmetic deformity, including limb asymmetry associated with extremity lesions. We present a surgical approach indicated for symptomatic patients for whom supportive measures do not provide relief of symptoms. It includes total excision of the involved skin and underlying fatty tissue with the abnormal vessels. A special device for obtaining a split skin graft is used and autotransplantation is performed.

Although not very often diagnosed, the acute and chronic mesenterial ischemia is advancing and life threatening condition. When associated with multivascular pathology compromising the perfusion and causing multiple organ failure the choice of treatment is a challenge. In such cases the radical surgical treatment is associated with high morbidity and mortality. In recent years endovascular methods of treatment (angioplasty and stenting) are gaining popularity in the treatment of these patients. We report a case of chronic mesenteric ischemia that caused abdominal angina and weight loss in a 63-year-old man with renovasal hypertension, renal insufficiency and peripheral vascular disease. Angiographic study revealed multivascular pathology including total occlusion of the superior mesenteric artery, 90% stenosis of the celiac trunk, bilateral high grade renal stenoses and obstructive pathology of both iliac arteries. One stage successful endovascular treatment was performed in the three vascular territories. In the Celiac trunk, left renal artery and right common iliac artery were implanted stents. A double right renal artery was treated successfully with kissing balloon. A clinical follow-up demonstrated success with no recurrence of abdominal pain, body weight gain, better control of the hypertension and improvement of the renal function. This is the first reported case of one stage endovascular treatment of a visceral artery, bilateral renal arteries and iliac artery. This case report illustrates the value of endovascular treatment in a patient with atherosclerotic narrowing of multiple abdominal visceral arteries.

Percutaneous peripheral and coronary interventions as well as surgical procedures can be complicated by dissections and traumatic lesions of peripheral arteries. Posttraumatic peripheral dissections can be threatening for the extremities and often their management might be a challenge. Open surgery requires wide exposure and dissection of posttraumatic tissues. Endovascular techniques using selfexpandable stents gains popularity because of high efficiency, safety and good results. This technique is associated with decreased trauma, no requirements for anesthesia, short hospital stay. We present two cases of posttraumatic iliac dissections treated with self expandable stents.

Endovascular grafts are transluminally implanted vascular devices that combine a vascular stent with a "prosthetic cover" and are designed for use as a less invasive treatment of vascular disease. Indications include aneurysms, arteviovenous fistulas, dissections, traumatic vascular lesions, and vascular occlusions. High risk patients with severe co morbidities are candidates for endoluminal grafting. Specific complications peculiar to stent-grafts have been described. Early and midterm results demonstrate that endovascular grafting is a safe and promising treatment modality. Concurrent comparative studies, randomized trials and registries will be needed to evaluate long-term efficacy of those devices.

Unlabelled: The stroke is one of the major causes for death and invalidization in the modern society. In about 30% of the cases the stroke is attributed to stenosis of a supraaortic vessel. In the last few years the percutaneous angioplasty and stenting is an alternative method of the classical surgical treatment--the carotid thrombendarterectomy. Crucial moment in the evolution of the method is the introduction in the practice of the systems for distal embolic protection of the brain and the routine implantation of stents with new design. One of the main conditions for successful and noncomplicated stenting is the respect of a strict procedural protocol. In the article we present the results of 17 cases with angioplasty and stenting of supraaortic vessels performed in our Clinic in the period 07.02.2001-01.07.2001. The immediate success rate is 100%. No major complications (stroke, myocardial infarction and death) were registered. In the midterm follow-up there were no thrombosis and restenosis of the implanted stents. We present four interesting case reports: 1. One stage stenting of right coronary artery and right internal carotid artery, 2. Stenting of a subocclusive right internal carotid stenosis with balloonexpandable stent and 3. Stenting of a vertebral artery as the unique brain supplying vessel and 4. Stenting of subocclusive aortoostial lesion of the brachiocephalic trunk in a patient with totally occluded contralateral internal carotid artery., Conclusions: Stenting of supraaortic vessels is a safe and reliable method when performed by experienced operator and when are applied the ultimate methods of cerebral protection and the new stent designs. The carotid stenting is a reliable alternative of the surgery and gains more and more popularity.

Retroperitoneal tumors engaging large vessels require vascular reconstruction when surgically removed. We present a case of retroperitoneal rhabdomiosarcoma in a child, which required inferior vena cava (IVC) grafting, creating a new bifurcation of IVC, and an A-V fistula between greater saphenous vein and femoral artery as well as grafting of right common iliac artery.

Renal artery hypoplasia is a relatively rare condition in childhood causing renovascular hypertension. We present a case of hypoplasia of the proximal two thirds of the right renal artery, and almost normal distal third of the renal artery as well as normal parenchymal branches managed with hypogastric autoarterial conduit. We discuss conduit options and technical considerations when dealing with this delicate condition in paediatric population.

Aorto-caval fistula is a rare complication of infrarenal abdominal aortic aneurysm /AAA/, and it occurs when the aneurysm ruptures into inferior vena cava. Literature indicates that such a communication is present in less than 2% of the elective AAA resections and in 3%-6.97% of the cases of AAA ruptures. From 1986 and 2000 in the University Hospital "St. Ekaterina" 207 elective AAA cases and 43 ruptured AAA cases underwent surgery. In 2 cases (4.65% of the ruptured AAA) we encountered aorto-caval communication. We report a patient with infrarenal AAA having significant oedema of lower extremities bilaterally, treated in another hospital for iron deficiency anemia and vegetative disorders. Patient presented for consultation and abdominal Echo showed AAA. The angiogram performed demonstrated aorto-caval fistula. At surgery bifurcated graft was implanted successfully. This is the first case of diagnosed prior to surgery aorto-caval fistula followed by successful surgery reported in Bulgaria.

Aorto-enteric fistula (AEF) is a very rare entity. Any direct or indirect communication between the arterial tree and the intestine represents a life threatening situation. Major symptom is gastro-intestinal bleeding with varying longevity and gravity. Preoperative diagnosis is difficult and this is why higher level of suspicion is necessary. Presence of Abdominal Aortic Aneurysm (AAA) or aorto-iliac grafts makes the diagnosis more likely. AEF are: primary, predominantly a complication of ruptured AAA, and secondary, after aorto-iliac reconstruction. The most frequent location of AEF is the end part of tue duodenum. In the group of secundary AEF the paraprosthetic type represents the most frequent morphological findings. Preoperative confirmation of an AEF however proved difficult despite the improvement in endoscopic and imaging technology. Diagnostic modality of choice is enhanced computed tomography. Management is surgical only. The choice of surgical repair is still controversial. Every effort must be made to prevent its occurrence by separating bowel and artery at the first aortic operation. Our experience in diagnosis and treatment of AEF is based on 3 cases with aorto-duodenal fistulas. Pathogenesis, clinical features and therapeutic aspects are presented and discussed.

The objective of this study was to define the perioperative risk of simultaneous operations in patients with abdominal aortic aneurysm (AAA) associated with coronary artery disease (CAD). The hospital data of 30 patients with coexistent severe symptomatic AAA and significant CAD, who underwent one stage surgery of the abdominal aorta and the coronary arteries was retrospectively analysed. Most of the pts.--28 were male and only 2 female. The average age consisted 57.7 years. Infrarenal AAA (diameter over 5 cm) was presented in 25 patients and suprarenal extension was in presented in 5 pts, while all patients with coexisting CAD had three vessels disease and significant impairment of left ventricular function (23 pts with ejection fraction (EF) < 50% and 10 pts < 30% EF). The resections of AAA in pts. undergoing simultaneous coronary artery procedure were performed on cardiopulmonary bypass (CPB) and moderate hypothermia. There were 2 early postoperative deaths (6.66%) and 5 major nonfatal postoperative complications (16.6%). Our experience with simultaneous surgery of coexistent huge AAA and CAD demonstrated that: a) Combined procedure can be performed safely in patients with significant AAA and CAD. b) The overall early operative mortality and morbidity after combined surgery compare favourably with the results after CABG of patients with impaired left ventricular function. c) Simultaneous operation seems to be more favourable in patients with coexistent AAA and CAD regarding the high risk of aneurysmal rupture, saving them also the potential morbidity and eventually fatal complications associated with the second procedure. d) Even the management of suprarenal and huge infrarenal AAA can be carried out easier and with less risk of complications under the protection of CPB.

We present our experience in treatment of patients with carotid-jugular fistulas for a three years period. Three of those patients had congenital fistulas and one had acquired (posttraumatic) fistula. Signs and symptoms include: pulsatile neck mass, systolic murmur, thrill, dilated superficial veins. Diagnosis was confirmed with Duplex ultrasonography and angiography. Patients were treated by open surgery (ligation and resection) and endovascular procedures (conventional and laser embolization). In cases of single A-V communication ligation and resection gives excellent results. In cases of multiple communications recurrence in the same or neighbouring vascular area is more likely and second stage surgery or/and endovascular procedures (embolization) may be needed.

We discuss vascular surgical problems in 59 kidney transplantations using alive donors. From April 96 till May 99 we harvested 59 kidneys from relatives (44 women and 15 men), mean age 54.33 years. Those kidneys were transplanted to 37 men (mean age 55.71 years), and 22 women (mean age 36.85 years). Preoperative dialysis was performed for a period of 5.015 years (mean). Thirty eight of the kidneys are right, and 21 of them are left. Six kidneys have two renal veins (10.16%), and 5 of them have two renal arteries (8.47%). We prefer end-to-end anastomosis between the donor renal artery and the recipient hypogastric artery. It ensures best regional hemodynamics, long-term patency and best positioning of the kidney avoiding vascular compression. The venous anastomosis is performed end-to-side to the iliac vein of the recipient. In 7 cases of short renal artery of the donor kidney greater saphenous vein is used as arterial conduit to ensure tension-free anastomoses. Only 1 patient (1.74%) of 59 cases (71 venous anastomoses) suffered thrombosis of the iliac vein, which caused kidney rupture. We had 5 cases of postoperative bleeding (8.47%), three of them were from the kidney hilus, and two from exposure sites. After reexploration all of them have normal function. Vascular anomalies and/or vascular disease do not preclude the procedure. Atraumatic harvesting of the kidney is critical.

Carotid body tumors are rare, with a tendency of slow but progressive growth, giving rise to external compression and/or involvement of the carotid arteries, craniofacial nerves and other neighbouring structures. They are adequately vascularized, with surgery being the treatment of choice. Localization and vascularity require comprehensive understanding of the anatomy, and most likely, vascular surgeons with carotid experience and neurosurgeons would make the best teams. In certain cases the participation of craniofacial surgeon is likewise needed. Over the period 1989 through 1999, in the Department of Vascular Surgery, six patients presenting carotid body tumor are treated. There is not a single case with bilateral involvement, and all have negative family history for carotid body tumor. Two of them are subjected to explorative surgery elsewhere. Two patients only are asymptomatic. In 3 patients CT of the neck, and in one--MRI are used as diagnostic modalities. Five patients undergo carotid artery ultrasonography, and three--angiography. Internal carotid clamping is necessitated in one case only, undergoing explorative surgery at another hospital and presenting a big tumor, stage III (Shamblin). Postoperatively, the patients complain of slight deviation of the tongue and slurred speech. The check-up carotid ultrasound shows hemodynamically relevant stenosis of the internal carotid artery, 1 cm distally to the carotid bifurcation, without flow into the external carotid being detected. On follow-up, all patients are alive and free of local recurrences or metastases.

Reconstructive procedures of renal arteries are routinely advocated for patients presenting documented renovascular hypertension (RVH). It is the purpose of this study to analyze experience had to date, and the results of operative reconstruction of 52 arteries in forty-seven patients, covering a 10-year period. Twenty-seven patients are operated on for RVH. In fourteen patients simultaneous procedures are performed for occlusive disease of the abdominal aorta, three patients are operated simultaneously--ACB, and two--carotid arteries. Aorto-renal bypass is the procedure of choice. In 11 patients TEA is performed for renal artery stenosis. In 45 patients (95.7 per cent) there is a significant improvement of hypertension, and in none of them is renal function lost postoperatively. Hospitalization is prolonged because of postoperative bleeding--two cases, and diffuse peritonitis--one patient, dying in the early postoperative period. Experience with the operative management of RVH shows that operative reconstruction of renal arteries is a method of choice in selected patients, and its indications may be extended to patients undergoing vascular reconstruction of the abdominal aorta.

Abdominal aortic aneurysms (AAA) are a major problem in vascular surgery owing to their ever increasing incidence, asymptomatic course and disastrous complications. The positive postoperative results of elective treatment account for a lowered mortality rate, with life expectancy prolonged as much as twice. However, the results of the operative treatment of AAA on an emergency basis are still unsatisfactory. It is the purpose of this paper to describe hitherto experience and success of the clinic with AAA treatment, and inform the medical circles about the increased potentialities of the management of this unexplored, difficult but still curable disease. Seventy-three patients presenting AAA, operated on during the period 1989-1993, are analyzed. The clinical signs and associated diseases, frequency of clinical forms, preoperative factors influencing the risks of forthcoming operations and the long-term results are comprehensively discussed. An asymptomatic clinical form is observed in 60.5 per cent of the patients (Pt = 0.05). Operative lethality is significantly increased in the event of rupture of the aneurysm, its diameter, angina pectoris symptoms and hypertension (P = 0.01). A standard operative technique, described by Creech, is used. Haemonetics Cell Saver is also employed. Thus, the amount of donor blood is reduced by one third of the volume required without any accidents or fatalities. The causes of postoperative death include: ischemic colitis, myocardial infarction and bronchopneumonia. Thanks to the experience and skill of the surgical and anesthesiological teams, the last five years are marked by a low rate of mortality - 3.7 percent for the elective group, and 12.5 percent for the emergency cases.(ABSTRACT TRUNCATED AT 250 WORDS)