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A 53-year-old man presented with acute ischemic stroke, NIHSS score of 7, 28 days after traumatic subdural haematoma and 8 days after haemothorax surgery. The MRI, MRA, and cerebral angiography revealed a thrombotic occlusion of the left middle cerebral artery (MCA), M2 segment. A significant laboratory abnormality was platelet count of 784 x109/l. Endovascular treatment using Penumbra thrombectomy system and 500 mg aspirin was applied intra-arterially to enhance recanalization. Final TICI 2b/3 result was achieved and onset-to-recanalization time was 260 min. In our center, this was the first patient with acute cerebral artery occlusion treated successfully during neuro-intervention with intra-arterial application of 500 mg aspirin. On control MRI, DWI core area was not enlarged after the intervention. The patient was discharged on day 8, and on 90 days his NIHSS and mRS scores were 0. In the pathogenesis of this stroke, some non-traditional causes were discussed: post-traumatic subdural haematoma and haemothorax, surgery, as well as reactive thrombocytosis and hyperhomocysteinaemia. On 3rd month follow-up, the transcranial colour coded doppler examination detected abnormal blood flow velocities in the left MCA, M1 segment, consistent with moderate to high-grade intracranial stenosis, which was verified by cerebral CT angiography. Secondary stroke prevention of the patient was guided in accordance with clarified etiologic mechanisms and additional risk factors.

Purpose: To evaluate the safety of endovascular treatment of chronic cerebrovascular insufficiency (CCSVI) in patients with multiple sclerosis (MS)., Methods: In a 1-year period, 461 MS patients (261 women; mean age 45.4 years, range 21-79) with CCSVI underwent endovascular treatment of 1012 venous lesions during 495 procedures [34 (6.9%) reinterventions]. While balloon angioplasty was preferred, 98 stents were implanted in 76 patients for lesion recoil, restenosis, or suboptimal dilation. The procedures were analyzed for incidences of major adverse events (death, major bleeding, or clinical deterioration of MS), access site complications, procedure-related complications, and procedural safety-related variables (fluoroscopy and contrast times). The complication rates were compared to published data for similar endovascular methods., Results: There were no deaths, major bleeding events, or clinical deterioration of MS. Access site complications included limited groin hematoma (5, 1.0%); there were no arteriovenous fistulas or puncture site infections. Systemic complications included only rare cardiac arrhythmias (6, 1.2%). Procedure-related complications included vein rupture (2, 0.4%), vein dissection (15, 3.0%), acute in-stent/in-segment thrombosis (8, 1.6%), and acute recoil (1, 0.2%); there was no stent migration or fracture or distal embolization. Mean fluoroscopy time was 22.7 minutes, and mean contrast volume was 136.3 mL., Conclusion: Endovascular therapy appears to be a safe and reliable method for treating CCSVI. Innovations such as purpose-specific materials and devices are needed, as are case-controlled and randomized data to establish efficacy in ameliorating MS symptoms.

Aim: The aim of this study was to evaluate the prevalence of and risk factors for chronic venous disease (CVD) in the Bulgarian adult population seeking medical help from general practitioners., Methods: The design was a cross-sectional descriptive survey. Each general practitioner (GP) enrolled 50 consecutive patients aged 18 and over attending for a routine consultation. A subsample of these patients was reappraised by a group of specialists to confirm the GPs diagnosis., Results: A total of 576 GPs selected 26 785 subjects to participate in the survey. In the GP survey, 11 724 subjects (44%) were found to be suffering from CVD. Specialist reappraisal of a subset of 373 subjects confirmed the initial diagnosis in 91.2% of cases. CVD was more prevalent in females (51%) than in males (32%) (P<0.0001) and prevalence increased with age and body mass index., Conclusions: Heavy legs, pain in the legs, and a sensation of swelling were the most frequently reported symptoms. Varicose veins and telangiectasias were the most common signs in both males and females, but with a higher frequency of varicose veins in males and telangiectasias in females. Increasing age, pregnancy, and a positive family history were found to be risk factors for CVD.

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.

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.

Multifocal manifestation of atherosclerosis (ATS) is common for this pathology and demands special diagnostic and therapeutic approaches. The need of active screening of basic clinical forms of multifocal ATS--carotid, peripheral arterial disease (PAD), aortic abdominal aneurysms(AAA) and coronary (IHD) is mandatory along with precise indications of therapeutical strategy and operative tactics in cases when surgical treatment is needed. The aim of this study is the evaluation of our results in operative treatment of combined forms of ATS and proper indication for simultaneous or two staged surgical approach. Our experience dictates simultaneous operative strategy only in cases of: 1. Carotid stenosis > 70% even asympthomatic, or > 50% sympthomatic stenosis (group A) combined with coronary artery disease in III-IV stage and 2-3 main vessel disease and unstable angina. 2. AAA > 7 cm. (group B) associated with IHD. 3. PAD with critical limb ischemia associated with unstable IHD. The absence of this specific indications allows not so aggressive surgical approach--two staged procedures (coronary artery bypass surgery first and several months later arterial reconstructive surgery of carotid or abdominal aortic lesions.

Posttraumatic false aneUrysms can be life threatening and often their management might be a challenge, because of poor general condition as well as because of specific technical difficulties. Open surgery requires wide exposure and dissection of posttraumatic tissues. Endovascular techniques using stent-grafts gains popularity because of high efficiency, safety and good results. We present a case of posttraumatic false aneurysm of right subclavian artery treated with a stent-graft.

This study describes the methods of anesthesia and analgesia used in 296 limb amputations for vascular disease over a fifteen year period (1986-2000). The main type of anesthesia was general in 55%, epidural in 29% and spinal in 14%: there were no significant differences for ASA grade, age, or amputation level, nor any statistical differences in mortality for each method of anesthesia. The main methods of analgesia in the first 48 hours changed between 1986 and 1998, with decreasing intramuscular and oral opioids (from 42% to 1%, and from 14% to 1% respectively) while epidurals became the commonest method (2% in 1986 and 83% in 2000). Thirty-seven percent of patients were prescribed pethidine for phantom pain. There have been substantial changes in postoperative analgesia following amputation, and epidurals are now common practice, despite the controversy about their role in preventing phantom pain.

The aim of this study to evaluate comparatively the early and long-term outcome of end-to-end (E-E) vs end-to-side (E-S) anastomoses in arterial reconstructions for aorto-iliac occlusive disease (AIOD). The early and late postoperative results of 150 arterial reconstructions for AIOD are evaluated, covering the period 1990 through 1993. All patients present AIOD II-IV clinical stage, randomized in three groups according to type of arterial reconstruction/anastomosis. Group A consists of 60 patients (pts) undergoing aortobifemoral/biprofunda bypass grafting (Ao-2F/P), with all proximal and distal anastomoses performed in the classical E-S fashion. Group B (40 pts)--Ao-2F/P replacement grafting (RG), with all proximal and distal anastomoses performed E-E, and simultaneous reconstruction of at least one hypogastric artery and/or inferior mesenteric artery (AMI). Group C (50 pts)--Ao2F/P or unilateral aorto-femoral/profunda bypass grafting (Ao-F/P) with EO-S proximal and E-E all distal anastomoses. The aforementioned groups are then compared to 30 pts (group O) free of vascular diseases. All patients are subjected to 18 months average follow-up study (range 6 to 32 months). The postoperative effect, including evaluation of the complete and regional hemodynamics by clinical and Doppler ultrasonography (DS) methods, is assayed. In some cases control angiography is performed as well. The complication rate--restenoses, rethromboses, false aneurysms and amputations--is estimated in percents. Statistically significant higher restenosis and rethrombosis rate is found in group A pts (56 per cent), compared to B (20 per cent) and C (25 per cent) which correlates with the early postoperative results, referred to in the authors' previous study.(ABSTRACT TRUNCATED AT 250 WORDS)

A survey is made of the angiologic methods for ChAIE investigations. The role and the potentialities of some of the non-invasive present-day methods are discussed in details, implemented lately in the clinical practice: determination of muscular Xenon 133 clearance, venous obturation pletismography (VOP) and US Doppler flowmetry. VOP is one of the few methods, enabling the quantitative assessment of the functional state of peripheral circulation. US Doppler flowmetry, as a relatively easy to apply and adequate method for wide clinical application and for scientific investigations, gives a valuable diagnostic information about CHAIE and enables the accurate dynamic control of the vascular-reconcstructive and conservative therapy. An original classification system is proposed for the assessment of the potentialities of the various angiologic methods in ChAIE diagnosties.

The frequency of carotid pathology and of some risk factors in the genesis of atherosclerosis was studied in 189 patients. The patients were classified into two groups: group A--58 persons without clinical data for atherosclerosis (conditionally healthy persons); group B--131 patients with chronic arterial failure in the limbs. By means of Doppler sonography a low incidence of carotid pathology was established in group A (3.4%) and a significantly higher incidence in group B (38%). The results were confirmed angiographically. The risk factor were more frequent in group B than in group A. The atherosclerotic process affects simultaneously the peripheral, carotid and coronary arteries. This implies active screening of the carotid arteries in patients with clinically manifested chronic arterial failure in the limbs of with ischemic heart disease. The method of Doppler sonography is the most suitable for that.