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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

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.

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

INTRODUCTION Despite the progress in surgical and anesthetic management decreased renal function is still observed after abdominal infrarenal aortic surgery and remains an important problem in postoperative period. Although data regarding the efficacy of perioperative renal protection are conflicting, it is widely believed that renal protection before aortic cross-clamping is beneficial and therefore is commonly used. The aim of this study was to evaluate the impact of renal protection in patients undergoing elective infrarenal aortic surgery (1 ARS). PATIENTS AND METHODS We have prospectively studied 80 patients undergoing elective infrarenal aortic surgery from October 1996 to May 1998 in the Clinical Center of Serbia because of aorto-occlusive disease or aortic aneurysm. Patients were excluded from the study for three reasons: prior renal dysfunction suprarenal aortic cross-clamping and ruptured aortic aneurysm. We have randomized the patients in two groups: without renal protection- group A (n = 40) and with renal protection- group V (n = 40). Preanaesthetic medication consisted of midazolam (5 mg i.m).Anesthesia was induced with etomidat 0.3 mg/kg, fentanyl 0.05-0.1 mg and succinil-holin Img/kg. Ventilation was controlled using 50% of nitrous oxide and oxygen. Supplemental anesthesia consisted of isofluran and fentanyl, in order to maintain the mean arterial pressure and heart rate ± 20% regarding preoperative values. In all patients two peripheral vein and radial artery catheters were cannulated before anesthesia. Central venous catheter and Foley urinary bladder catheter were inserted after the induction of anesthesia. Two-lead electrocardiograms were recorded. All patients in group V were given intravenously mannitol (0.3 g/kg) before aortic cross-clamping (ACC). After aortic cross-clamping, these patients received furosemide (20-40 mg) or dopamine (1-3 pg/kg/min) to the end of surgery (Table 1). In 8 time points (preoperatively, after induction during ACC, 2 and 8 hours after ACC, on day 1, 2 and 3 postoperatively) haemodynamic parameters (mean arterial and central venous pressure), volume load, urinary output, creatinine and free-water clearance, serum electrolytes, BUN, creatinine, plasma and urine osmolality and ACC time were analyzed in each patient. Renal complications were classified as transient or persistent. Transient renal dysfunction was defined as a greater rise Belgrade than 20% rise in peak serum creatinine level over baseline serum creatinine level, with a peak of at least 168 pmol/L. Persistent renal insufficiency was defined as a greater rise than 20% rise in discharge serum creatinine level over baseline serum creatinine level, with a peak of at least 168 umol/L. Moreover, renal insufficiency was defined as a free-water clearance greater than -15 ml/h. Aortic cross-clamping time was defined as a period in which the proximal inflow was occluded. The results were expressed as means ± SD. Statistical difference detected with Student's t-test, with p < 0.05 being considered significant. RESULTS Patients in groups A and V were similar regarding the age (64.32 vs. 62.00), sex (males 35, females vs. males 34, females 6) and preoperative diseases. (Tab. 2) No difference was found between groups regarding any of the parameters (BUN, serum creatinine electrolytes, volum load, creatinine and free-water clearance, haemodynamic parameters, plasma and urine osmolality). Urinary output was higher in group V during and 2 hours after ACC. (Graph 1) ACC time was similar in two groups (24.1 min vs 24.5 min). (Graph. 2) Only one patient in group V revealed transitory renal insufficiency, not requiring special treatment. These data indicate that renal protection did not influence renal function. Short ACC time may have impact on the obtained results. Our results suggest that renal protection should not be considered as mandatory for elective infrarenal aortic surgery. Because of the short ACC time observed in this study (in comparision to other studies), further studies of renal protection in patients with longer ACC time are needed.

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 Centre 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%, aorto-caval 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, aorto-iliac 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 < 0.05). Intraoperative systolic tension value influenced the outcome in patients; it was significantly higher in survivors (p < 0.01). Interposition of tubular graft gave better results compared with aorto-iliac and aorto-femoral reconstruction (p < 0.01). Duration of surgery was significantly higher in patients with lethal outcome (p < 0.05), as well as intraoperative blood loss (p < 0.05). Intraoperative diuresis was significantly lower in patients with lethal outcome (p < 0.05). Ruptured abdominal aortic aneurysm still remains one of the most dramatic surgical states with very high mortality. Important intraoperative factors that influence the outcome of surgical treatment can be defined. Therapeutic efforts should be concentrated on those factors that are possible to correct, which would hopefully lead to better survival of patients. Nevertheless, screening for abdominal aortic aneurysm and elective surgical intervention before rupture occurs should be the best solution for this complex problem.

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

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 (P < 0.05). Also, 'in situ' bypass proved to be better than 'reversed' only in patients with one patent crural artery (P < 0.01). Diabetes and preoperative smoking did not significantly affect late patency regarding this technique (P > 0.05). However, continuous smoking after the operation significantly decreased late patency rate in both groups of patients (P < 0.01). There was no significant difference in the early thrombectomy rate between groups with 'reversed' and 'in situ' bypasses (P > 0.05). The early thrombectomy, however, significantly reduced late patency rate in both groups (P < 0.01). 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.

Introduction: The aorto-enteric fistula (AEF) is a direct communication between aorta and intestinal lumen. There are primary and secondary forms. Primary AEFs are usually due to erosion of an aortic aneurysm (AAA) into the intestine, while secondary forms are caused by reconstructive procedures on the abdominal aorta. The incidence of primary AEF ranges from 0.1 to 0.8%, and secondary from 0.4% to 2.4% [2-4]. The mortality rate after surgical treatment of secondary AEFs is from 14% to 70% [5]. Therefore, they are of great medical importance. The aim of this paper is the presentation of 9 new cases., Methods: Over a 33-year period (1966-1999) a retrospective analysis of patients' records identified 9 patients with AEFs. All were males with average age of 66.62 (51-70) years. In Tables 1 and 2 are presented data on our cases. Of the total number of 9 patients, there were 4 primary and 5 secondary AEFs. All primary fistulas were caused by AAA rupture. Secondary AEFs developed after aortic abdominal surgery in the period between one and seven years after the operation. In 7 cases fistula involved the duodenum, in one the sigmoid and in one the transversal colon. The dominant manifestation of fistulas was gastrointestinal bleeding: melaena--8 (89%); haematemesis and melaena--2 (22%); proctorrhagia--1 (11%). In cases of primary AEFs gastrointestinal bleeding was followed by low back pain and haemorrhagic shok, while in cases of secondary AEFs by sepsis (fever, increased leucocytes count, sedimentation). In two cases the final diagnosis was established by gastrography and colonoscopy, while in two patients Duplex ultrasonographic examination suspected AEF. In all other cases the diagnosis was established intraoperatively (Figure 1). After aneurysmal resection in cases of primary AEFs, revascularization of the lower limbs was performed with extra-anatomic axillo-bifemoral bypass graft (one case) and with "in situ" graft placement (three cases) (Figure 2). The duodenal defect was closed transversally with standard two layers suture techniques in two patients without fistula excision, and in two cases after fistulas excision. In one case associated gastero-entero and entero-entero anastomosis was performed. In all cases with secondary AEFs, after removing of the previously implanted aortic graft, the aorta was closed just below the renal arteries root, and wrapped with a vascularized pedicle of omentum, to separate it from the bowel and the contained area. The duodenal defect was closed after fistulas excision using two layers transversal suture technique in two cases, and in one patient with large fistula a partial duodenectomy and Roux's procedure were necessary. In two patients in whom AEFs involved the transversal and sigmoid colon colostoma was performed. In three cases an extra-anatomic axillo-bifemoral bypass graft was performed for lower limbs revascularization, and in one patient bypass from the ascendent aorta to the femoral artery, using retroperitoneal route was carried out. In one patient the revascularization of the lower limbs was not done because of intraoperative death of the patient., Results: Seven of our patients died during the first 15 postoperative days. One died during the operation after massive acute myocardial infarction. In other six cases the mortality causes were: MOFS-3 cases, and secondary enteric fistula-3 cases. Two of our patients survived. One has been followed-up for 15 years, and his axillo-bifemoral bypass is patent. The other with bypass from the ascendent aorta to the femoral artery died 7 years after the operation, also with patent graft. More details are given in Table 3., Discussion: Sir Astley Cooper was the first who described primary AEFs caused by AAA rupture in 1817 [6], and Brock in 1953, first described secondary AEF developed 6 months after aortic homograft implantation [8]. In 1957, Haberer successfully treated primary AEF by suture of the duodenal defect and aneurysmorrhaphy [9]. In our country Stojanovitsh and Vujadinovitsh in 1966, first treated primary AEF [16]. Their patient died due to MOFS. However, in 1984 and 1985, Lotina successfully treated two patients with secondary AEFs [11] (Figure 3, Sheme 1). The authors also analyzed literature data on the aetiology, pathogenesis, clinical manifestations, diagnosis and treatment of AEFs. In conclusion, the authors suggest: 1. "Omega" extra-anatomic bypass from supraceliac artery trough retroperitonely to femoral arteries; 2. "In situ" replacement of the abdominal aorta using cadaveric homografts; 3. Intraoperative control of bleeding with endoluminal balloon occlusive aortic catheter.

A 16 patients with 20 vascular TOS have been evaluated at the our Institute. Fourteen of them were female, and 2 male patients, with average age of 33.1 (18-44) years. 19 of them had congenital, and one acquired TOS after trauma at neck-shoulder region. 13 cases had arterial, and 7 venous TOS. In 10 cases a cause of TOS was cervical rib, in one scar tissue after clavicle fracture, while in 9 soft tissue anomalies. Eight cases with arterial TOS had a hand ischemia, one TIA and 5 periodical symptoms only during the arm hyperabduction. Two cases with venous TOS also had symptoms and signs during arm hyperabducrtion only, while five patients had axillary-subclavian deep venous thrombosis (DVT). All patients underwent CW-Doppler, Duplex-ultrasonographic and angiographic examination in normal position of the arm and during the hyperabduction. The four aneurysms of the subclavian artery, two poststenotic dilatation of the subclavian artery were found as well as one thrombosis of the axillary artery and 8 brachial artery embolism. The operative treatment consists from decompression and vascular procedure. A decompression procedure include 10 resections of the cervical rib, three transaxilary and 6 supraclavcular resection of the first rib, as well as one scalenectomy. A vascular procedures included 8 transbrachial thrombembolectomy and 4 resection and replacement of subclavian artery aneurysms. Four early complications were noticed: two partial pneumothorax, and two transiet medianus nerve paresis. The follow-up period was between one and six years (mean 3 years). In this period one (12.5%) late arterial occlusion was found. The vascular TOS is more rare than neurogenic, however in mostly cases requires surgical management.

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

Introduction: Pseudo-occlusion of femoro-popliteal/crural (F-P/Cr) bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow [1]. The aim of this paper is the presentation of 24 new cases which, as far as we know, have not been published in Yugoslav medical literature., Case Report: The group consisted of 20 men and 3 women (aged 28 to 71 years, mean 61.95) with 24 cases of "pseudo-occlusion" of the F-P/Cr bypass. More details are presented in Tables 1 and 2. Saphenous vein graft was used for the reconstruction in 19 patients, and Dacron in 5 subjects. "Pseudo-occlusion" was symptomatic in all 24 patients. Fifteen patients had pain at rest, seven presented disabling claudication, and 2 foot gangrene. The mean time interval between primary operation and occurrence of new symptoms was 25.41 (4-84) months (Table 2). In 15 patients control angiography showed hemodynamically significant lesions in inflow tract, and in 9 subjects in outflow tract. Of the total number of inflow tract lesions, there were 3 late occlusions of previously implanted aorto-femoral graft (1, 3 and 17, Table 1), and in other 21 patients lesions of the native aorto-iliac segment. In 8 patients with changes in outflow tract, a distal progression of atherosclerotic disease was found, while one patient (number 8) had intraoperative lesion of the popliteal artery with vascular clamp. All 24 patients were treated operatively. The early postoperative result was favourable in all 24 (100%) patients. Patients were followed-up from 3 months to 5 years (mean 29.625 months). In this period one (4.1%) late graft occlusion was followed by major limb amputation. Four (16.6%) patients died with patent graft., Conclusion: 1. Pseudo-occlusion of the F-P/Cr bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow. 2. Pseudo-occlusion may be provoked by changes in inflow and outflow tract. 3. Pseudo-occlusion is not associated only with saphenous vein graft. 5. Recurrence of symptoms, loss of previously palpable distal pulses and reduction of Doppler indices in a previously patent F-P/Cr bypass graft, can indicate pseudo-occlusion. Early diagnosis provides a simple and safe treatment.

Introduction: The Subclavian artery aneurysms are not a commonly seen peripheral aneurysm [1-5]-. We present the experience of the Institute of Cardiovascular Diseases of the Serbian Clinical Centre, Belgrade., Patients and Methods: Eight cases of subclavian artery aneurysms are presented. There were 3 male and 5 female patients, average age 51 (32-65) years. Of them 3 aneurysms were of atherosclerotic origin, 4 developed due to thoracic outlet syndrome (TOS), and one developed after intra-arterial drug injection. More details about our cases are presented in Table 1. One of our patients had intra-thoracal aneurysm (Case 3), and 7 had extra-thoracal aneurysm (Figure 1). Two aneurysms appeared as an asymptomatic pulsatile mass in supraclavicular space, and two with compression in the brachial plexus (Figure 2). Our patient 3 manifested skin necrosis and haemorrhage in supraclavicular region (Figure 3). The other 3 patients manifested acute hand ischaemia due to partial aneurysmal thrombosis and distal embolization. In these patients all distal arterial pulses were absent (Figures 4 and 5). In patient 8, besides hand ischaemia, transitory ischaemic attack (TIA) with contralateral hemiparesis also occurred. The reason was microembolization of ipsilateral carotid artery due to retrograde thrombo propagation. The diagnosis was established by selective angiography of the subclavian artery, and in 4 patients Duplex ultrasonography was also used. All patients were treated surgically. In 7 patients supraclavicular approach to subclavian artery was used, and in case 3 we used a combined trans-sternal and supraclavicular approach. In 7 patients a complete aneurysmal resection was performed, and in patient 5 due to infection aneurysm was excluded by proximal and distal arterial ligations. In this case arterial flow was reestablished by extra-atomic carotid axillary bypass with saphenous vein graft. In three patients with TOS, after aneurysmal resections, end-to-end anastomosis was performed. In patient 2 in whom aneurysm was also caused by TOS, saphenous vein graft was used for reconstruction. In all 4 patients with TOS, some kind of decompressive procedure at the thoracic outlet was also performed (two cervical and two first-rib resections using supraclavicular approach). In 3 patients with atherosclerotic subclavian artery aneurysms, PTFE graft was used for reconstruction (Figures 6 and 7)., Results: One early postoperative complication occurred. It was embolism of the brachial artery which has been successfully treated by transbrachial embolectomy. The early patency rate was 88%. The patients were controlled using physical and Doppler ultrasonographic examinations 1, 3, 6, 12 months, and then every year postoperatively. The mean follow-up period was 3.6 (1-8) years. In that period one (13%) late complication was observed. It was thrombosis of the saphenous vein graft true aneurysm in our patient 2. This aneurysm was resected and replaced with PTFE graft. Postoperative histological examination showed connective tissue disorder of the vein wall. The long-term patency rate was 88%., Discussion: In most cases the true subclavian artery aneurysms are of atherosclerotic origin [1-4, 6, 7, 12]. We had 3 such cases. TOS is also often caused by subclavian artery true aneurysms [5, 13-17]. We had 4 such cases. Fibromuscular dysplasia [1, 18], cystic idiopathic medionecrosis [1, 19, 20], infection [1, 21, 22] and congenital disorders [23, 24], are rare causes of subclavian artery true aneurysms. Subclavian artery pseudoaneurysms can develop after different reconstructive vascular procedures [5, 28-41]. Subclavian artery aneurysms can rupture, thrombosis, embolize, or cause symptoms by local compression [6, 12, 41]. We had two cases with compression on brachial plexus. The compression on the trachea, oesophagus, laryngeal nerve, ganglion stellatum were also described [6, 12, 25, 42, 43]. Most subclavian artery aneurysms present ischaemic symptoms of

Introduction: The aim of this study was to investigate how "run off", diabetes, cigarette smoking and early reinterventions influence long-term patency of the "reversed" and "in situ" femoro-popliteal (F-P) bypass grafts., Patients and Methods: The study included 1991 patients with "reversed" F-P and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass and in the group with "in situ" bypass there were 78 (78.8%) male and 21 (21.2%) female patients. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.4%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and 80 (80.8%) in the group with "in situ" bypass. In Table 1 patients according to Fontain's classification of occlusive arterial disease are presented. On the basis of angiographic examination all patients were divided into four groups (with patent all 3 crural arteries, with patent 2 crural arteries, with patent one crural artery and without patent crural arteries) (Table 2). All patients were controlled using physical and Doppler ultrasonographic examinations immediately after the operation; after 1, 3, 6 months and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiography has also been carried out. Statistical analysis of the results was performed using chi 2 and Fisher's test., Results: The patients were followed-up from 3 to 10 years. In cases with patent all 3 crural arteries there was no significant difference in long-term patency between "reversed" and "in situ" bypasses (Fisher's test, P = 0.66; p > 0.05) (Graph 1). In cases with patent two crural arteries, there was no significant difference between groups with "reversed" and "in situ" bypasses chi 2 = 0.25, p > 0.05) (Graph 2). The long-term patency was significantly better in the group with "in situ" bypass if only one crural artery was patent (chi 2 = 4.96, p < 0.05) (Graph 3). In cases with occluded all three crural arteries there was no significant difference in long-term patency between the two examined groups (Fisher's test, P = 0.29; p > 0.05) (Graph 4). There was no significant difference between groups with "reversed" and "in situ" bypasses in patients with diabetes mellitus (chi 2 = 0.01; p > 0.05) (Graph 5). There was also no statistically significant difference between the two examined groups regarding the preoperative cigarette smoking (chi 2 = 0.94; p > 0.05) (Graph 6). However, in both groups postoperative cigarette smoking showed a statistically significant decrease in long-term patency (chi 2 = 66.71; p < 0.01) (Graph 7). The early REDO operations statistically significantly decreased long-term patency in both groups (chi 2 = 34.89; p < 0.01) (Graph 8). The late graft occlusions were found in 60 patients with "reversed" and 23 patients with "in situ" F-P bypasses. Table 3 shows causes of late graft occlusions., Conclusion: In some cases with pure "run off" "in situ" bypass technique showed better long-term patency. We preferred this technique when "run off" was pure, when diameter of the saphenous vein was small, and when bypass was "long". Diabetes mellitus had no significant influence on long-term graft patency in both groups, as well as regarding preoperative cigarette smoking. However, postoperative cigarette smoking and early REDO operations, statistically significant by decreased long-term graft patency in both groups. The reason was that cigarette smoking was not permitted postoperatively, while in cases with early reinterventions physical screening and ultrasonographic examinations were necessary.

Introduction: The small choice of graft materials is one of the greatest problems in femoro-popliteal (F-P) bypass reconstructions. Besides all biosynthetics(2-5) and synthetics(6) graft materials, there is no right alternative for autologous saphenous vein graft in F-P reconstructions. There are two main techniques for F-P reconstructions: "reversed" and "in situ". The aim of this study is the comparison of the long-term patency between "reversed" and "in situ" F-P bypasses., Patients and Methods: In the study were included 191 patients with "reversed" and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass, and 78 (78.78%) male and 21 (21.22%) female patients in the group with "in situ" bypass. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.43%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and as 80 (80.8%) in the group with "in situ" bypass. In Table 1 the Fontain classification of occlusive diseases in operated patients is presented. The early proximal reconstructions were performed in 49 patients with "reversed" and 16 patients with "in situ" bypasses (Table 2). The associated proximal reconstructions were performed in 21 patients with "reversed" and in 14 patients with "in situ" bypasses (Table 3). All patients were controlled by physical and Doppler ultrasonographic examination immediately after the operation, after 1, 3, 6 months, and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiographic examinations was also performed. The statistical analysis of the results was done using "Life table" analysis., Results: The patients were followed-up from 3 to 10 years. The results of "life-table" analysis are presented in Tables 4-8 and Graph 1. The "in situ" technique showed statistically significant better long-term patency compared to "reversed" technique, after 2 and 10 years (p < 0.05). The immediate patency in cases with "reversed" bypass was 98.96%, while limb salvage was 97.91%. In the same group long-term patency was 72.8% and limb salvage 73.9%. In the group with "in situ" bypasses the immediate patency as well as limb salvage were 96.97%. In the same group long-term patency was 73.8% and limb salvage 77.2%. In Table 5 potential advantages of the "in situ" F-P bypass technique are shown (16-21). However, there are controversial data on clinical results of both bypasses. Some authors described better long-term results of the "in situ" F-P bypass technique (28-30), while according to other data there are no significant differences between these two bypass groups (31-33). Most authors emphasized the two advantages of "in situ" bypasses in F-P reconstructions: a small diameter of the saphenous vein; in cases with pure run off (34-36).

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.

Introduction: Adventitial cystic disease of the popliteal artery (PA) is an uncommon and unique entity characterized by a mucinous cyst located in the arterial adventitia. As the cyst enlarges, it provokes vascular compression with stenosis or occlusion, the first only during the knee flexion, and then in all leg position. Atkins and Key (1946) were the first who described this disease in the external iliac artery [1]. Eirup and Hiertonn (1956) described the disease in the PA, which is the place of its most common localization. The aim of the paper is the presentation of our 10 cases of PA adventitial cystic disease., Patients and Methods: Ten patients with PA adventitial cyst were treated at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade, over the period between 1978 and 1997. There were 9 males and one female patient, average age 42.7 years (31-62). Two patients were smokers, while all other atherosclerotic risk factors, including heart disease, were absent. The diagnosis was established using Doppler ultrasonography and angiography. The postoperative histological examination revealed PA adventitial cyst in all patients (Figure 1). In Table 1 are presented our patients. The patients 3 and 4 were admitted for acute ischaemia of the leg. In patient 3 Doppler indexes were 0.0, and transfemoral arteriography revealed segmental occlusion of the PA. All other arteries were unchanged. These findings suggested an unusual disease of the PA. During the operation the posterior approach to the PA was used, and intraoperatively the adventitial cyst was found. In patient 4 the tibioperoneal trunk, posterior tibial artery and PA were occluded. Therefore, the medial approach to the PA was used. After thrombectomy of the crural vessels, the popliteo-popliteal bypass procedure was performed. The PA resection by this approach was not possible. The ringed 6 mm PTFE graft was used for reconstruction because of inadequate saphenous vein. The patients 1, 2, 5-10 were admitted with disabling claudication discomforts. In patients 1, 2, 5, 6, 8, 9 popliteal and pedal pulses were absent, and Doppler indexes decreased. In patients 7 and 10 pedal pulses were palpable and decreased during the normal knee position, while absent during the knee flexion. During some maneuvers Doppler indexes significantly decreased. Transfemoral arteriography in patients 1, 2, 5, 6, 8, 9 showed segmental stenosis or occlusion of the PA, and for this reason the posterior approach to the PA was used. The PA adventitial cyst was found in all cases (Figure 2). In patient 7 angiography revealed a "hourglass" deformity of the PA, while in patient 10 "scimitar" sign was found. Both angiographic findings are characteristic of PA adventitial cyst. The posterior approach was carried out in all patients. In patient 2 only cyst aspiration has been performed, while in patients 7, 8, 9 aspiration and resection of the changed PA adventitia (Figure 3a, figure 3b). In patients 1, 3, 5, 6, 10 an occluded arterial segment was resected. The restoration of the flow observed after the end-to-end anastomosis in patient 1, and after interposition of the saphenous graft in other patients. After the operation, the contralateral leg was examined using Doppler ultrasonography in all patients. The Doppler indexes were significantly decreased in patients 1 and 5 during the knee flexion, but the patients refused the angiographic examination. The control examination consisted of physical examination, Doppler ultrasonography and sometimes angiography; it was carried out after 1, 3, 6 and 12 months, and then every year after the operation., Results: There was no mortality among our patients in the early post-operative period. In patients in whom cyst aspiration was performed, claudication discomfort was decreased, and Doppler indexes were significantly increased. In patients with arterial resection and reconstruction (1, 3, 4, 5, 6, 10) the effect of the operation was simi

Introduction: Rupture of abdominal aortic aneurysms (RAAA) can take place in one of the 4 following ways: 1. "Open" rupture in the free peritoneal cavity; 2. "Closed" rupture with formation of retroperitoneal haematoma; 3. Rupture into surrounding cavity structures, such as veins and bowels; 4. In rare cases rupture is effectively "sealed of" by the surrounding tissue reaction, and retroperitoneal haematoma is "chronically" contained [1]. The terms "sealed" [2], "spontaneously healed" [3], "leakig" [4] RAAA, were also used in the previous papers connected to this situation. The "sealed" rupture was first described by Szilagyi and associates in 1961 [2]. In their case the rupture was small and haemorrhage was effectively encircled by the tissue surrounding the aortic wall. The slow rate of blood loss contributed to the patient's haemodinamically stable condition. Christenson et al. reported a case of "spontaneously healed" RAAA [3]. Rosenthal and associates described 2 patients who had aortic aneuryms that ruptured several months before repair and contributed to the term "leaking AAA" [4], while Jones et al. introduced the term "chronic contained rupture" [1]. The aim of this paper is the presentation of 5 such patients., Case Report: Between December 1, 1988 and May 30, 1997 411 patients with abdominal aortic aneurysms (AAA) have been operated at our institute. Of this number 137 (33%) had RAAA, while 5 patients (12%) had a contained RAAA (CRAAA). CRAAA were found in 3 male and two female patients, average age 62 years. All of them had a previously proved AAA and initial symptoms lasted for days or months before the admission. In all patients haematocrit, pulse rate and arterial tension during the admission, were normal. All typical signs of RAAA were absent in these patients. Patient 1. A 56-year-old man, smoker, with previous history of arterial hypertension had an isolated episode of abdominal pain and collapse 30 days before the admission. Physical examination revealed a pulsatile abdominal mass. Doppler ultrasonography identified an infrarenal AAA, with right lobular extraaneurysmal mass which displaced the inferior vena cava (ICV). Angiographically (Figure 1a) an unusual saccular intrarenal AAA was detected, while simultaneous cavography (Figure 1b) confirmed the-dislocated inferior vena cava to the right. The intraoperative finding showed infrarenal CRAAA with organized retroperitoneal haematoma between AAA, ICV and duodenum. After aortic cross clamping and aneurysmal opening, the rupture at the right posterior aneurysmal wall was discovered. The partial aneurysmactomy and aortobilliar bypass procedure with bifurcated knitted Dacron graft (16 x 8 mm), were performed. The patient recovered very well. After a 4-year follow-up period the graft is still patent. Patient 2. A 72-year-old woman with low back pain, fever and disuric problems was urgently admitted to the Institute of Urology and Nephrology. The standard urological examination (X-ray, intravenous pyelography, retrograde urography, kidney Duplex ultrasonography) excluded urological diseases. However, intrarenal AAA an a giant aneurysm of the right common iliac artery, were found. The proximal dilatation of the right excretory urinary system was also found by retrograde urography. The patient was transported to our Institute 20 days after the initial symptoms. Translumbar aortography (Figure 3) showed the right common iliac artery aneurysm and gave the false negative picture of normal abdominal aorta because of parietal thrombosis of AAA. The intraoperative finding showed chronic rupture of the posterior wall of the right common artery aneurysm. The retroperitoneal haematoma compressed the right ureter. Both aneurysm have been resected and replaced by bifurcated Dacron graft (16 x 8 mm). The patient recovered successfully. After a 2-year period of follow-up the graft is still patent. Patient 3. (ABSTRACT TRUNCATED)

Introduction: Gluteal artery pseudoaneurysms are very rare [1]. They mostly occur after gunshot and stub wounds [2]. However, gluteal artery pseudoaneurysms can be caused by pelvic fracture [1]. Also, they can be isolated or associated with trauma of the pelvic and abdominal viscera [3]. The authors present two cases of gluteal artery pseudoaneurysms. Case 1. A 30-year-old man was treated for large swelling of the left buttock. One month previously he manifested a gunshot wound in the gluteal region. He also had symptoms of lumboischialgia with peroneal nerve paresis. The physical examination revealed a large pulsatile mass over the left buttock with an associated overlying bruit. Selective angiography of the internal iliac artery (Figure 1) revealed a large inferior gluteal artery pseudoaneurysm that caused dislocation of both external and internal iliac arteries. The patient was operated under epidural anaesthesia by the combined abdominal (extraperitoneal) and gluteal approach. By extraperitoneal approach the internal iliac artery was identified and ligated. After the closure of the wound, the patient was placed on the abdomen, and pseudoaneurysm was opened by an incision made between gluteus maximus and medius muscles. After evacuation of the parietal thrombus and pseudocapsule resection, nutrient vessels were ligated. The postoperative recovery was good, and the patient was free of neurologic symptoms two days after the operation. The late result (after 4 years) is also good. Case 2. A-53-year-old man was treated for small haematoma pulsans (Figure 2) in the right buttock. Fifteen days previously he was treated in the regional hospital by intramuscular "antirheumatic cocktails". The physical examination revealed a small pulsatile mass over the right buttock associated with overlying bruit. The selective angiography of the internal iliac artery demonstrated a small inferior gluteal artery pseudoaneurysm. The patient was operated by the procedure described. The postoperative recovery and the late result (after 6 months) were good., Discussion: According to our knowledge, only 8 cases of gluteal artery pseudoaneurysms are reported in literature in the last 11 years (including the first three months of this year) [4-8]. The lesions of the gluteal arteries, especially pseudoaneurysms, have no specific symptoms and signs. usually, they appear as haematoma pulsans and neurologic deficiency due to compression. (One of our patients). The gluteal abscess can be a differential diagnostic problem. Duplex ultrasonography, CT and selective angiography can be used in the diagnosis [5]. The standard surgical treatment of gluteal artery pseudoaneurysms consists of the ligature of the internal iliac artery (using transperitoneal or extraperitoneal approach) and pseudoaneurysmal resection and ligation of nutrient vessels by gluteal approach [9]. The second procedure is the temporary clamping of the internal iliac artery and transgluteal ligation of the nutrient vessels [7]. The microcatheter embolization of the nutrient vessels using standard invasive radiologic approaches via femoral artery is the method of choice in the treatment of gluteal artery pseudoaneurysms [10]. A buttock pulsatile mass and neurological deficiency in a patient with history of penetrating gluteal trauma, suggest the existence of gluteal artery pseudoaneurysm and require diagnostic evaluation.

Introduction: The title "Thoracic Outlet Syndrome" (TOS) was introduced by Peet in 1956 [1]. In 1958 Charles Rob defined TOS as a "set of symptoms that may exist due to compression on the brachial plexus and on subclavian vessels in the region of the thoracic outlet" [2]. Compression due to cervical rib was first described by Galenus and Veaslius in the 2nd century A.D. The first unsuccessful resection of the cervical rib in patients with TOS was performed by Coote in 1861 [4]. In 1905 Murphy first made a successful resection of the cervical rib in patients with TOS and subclavian artery aneurysm [5]. He also removed the normal first rib in patients with TOS using the supraclavicular approach for the first time [6]. In 1920 Law described ligaments and other structures originating in soft tissue associated with TOS [8], while Adson and Coffey in 1927 emphasized the role of the scalene anticus muscle in TOS [3]. Ochsner, Gage and DeBakey in 1935 named it the "scalenus anticus syndrome", and made the first successful resection of the anterior scalene muscle [9]. In 1966 David Ross introduced the transaxillary resection of the first rib to relieve TOS [11]. The aim of the paper is to describe the treatment of patients with vascular TOS., Material and Methods: Over a six-year-period (1990-1997) 12 patients with vascular TOS were evaluated at our Centre. Seven (58%) were female and 5 (42%) male patients, average age 33.1 years. Eleven of them had congenital TOS, and one acquired TOS after trauma at neck-shoulder region. Seven patients had arterial and 5 venous TOS. Two patients with arterial TOS had ischaemia of the upper extremity due to embolism of the brachial artery. In one of them axillary artery was completely thrombosed, and in the other postenotic dilatation of the subclavian artery was present. The other 5 patients with arterial TOS demonstrated only hand pain and radial puls during hyperabduction of the arm. One of our patients with venous TOS had also symptoms and signs of hand oedema during hyperabduction, while four patients had axillary-subclavian deep venous thrombosis (DVT). All patients underwent CW-Doppler and Duplex-ultrasonographic examination. The results were positive in all patients with arterial TOS. The angiographic (selective arteriography of the subclavian artery) examination showed the same results. Diagnostic procedures were performed in normal position of the arm and during hyperabduction. The angiography also revealed: one aneurysm of the subclavian artery, one poststenotic dilatation of the subclavian artery with brachial artery embolization, and one thrombosed axillary artery with brachial artery embolization (Figure 1). In five patients the angiogram was normal in normal position of the arm, but showed arterial flow obstruction at the thoracic outlet during hyperabduction (Figures 2a and 2b). In patients with venous TOS Duplex ultrasonographic examination was performed. The cervical rib caused TOS in four of our patients and clavicle fracture calus in one case. In 7 patients bone anomalies were not found (Figure 3). The operative treatment was carried out in 3 patients with venous and 7 patients with arterial TOS. In two patients with DVT of the axillary-subclavian segment, 6 months after standard anticoagulant therapy, decompressive procedures were performed (one resection of the cervical rib, and one transauxillary resection of the first rib). In the case of venous TOS without DVT, a supraclavicular resection of the first rib was performed immediately after diagnosis. In 5 patients with arterial TOS without morphologic changes on the arterial system, a decompressive procedure was done. The following procedures were carried out: one scalenotomy, one supraclavicular and three transaxillary resections of the first rib. (ABSTRACT TRUNCATED)

Methods: The authors present the surgical treatment of 20 post-traumatic arteriovenous fistulas and 33 arterial pseudoaneurysms that have been treated in the last 5 years in the Centre for Vascular Surgery of the Institute for Cardiovascular Diseases, Clinical Centre of Serbia in Belgrade. Five women and 45 men (mean age 31.7 years) were examined. There were 28 war and 22 non-combatant injuries. In most cases superficial femoral artery and vein were involved. The average time elapsed from the moment of injury until the operation started, was 9 months in patients with AV fistulas, and one month for patients with pseudoaneurysms., Results: In all of the patients with AV fistulas, arterial and venous reconstructions were performed, except in 4 cases where the veins were ligated. Surgical reconstruction was performed in 26 patients with pseudoaneurysms, while in 7 cases the artery was ligated. There were no cases of postoperative ischemia in patients due to arterial ligation. Patients were followed for 2 years and 2 months postoperatively. As far as the reconstructive operations are concerned, the postoperative patency rate was 100%, while limb salvage was achieved in 96.9%. Namely, one amputation was done in spite of high arterial patency rate, which was indicated by massive bone-muscle tissue loss, occurring during mine explosive injury., Conclusions: Because of the rapid disease progress, the authors suggest that the operative treatment of post-traumatic AV fistulas and pseudoaneurysms should be performed as soon as possible. This was supported by good follow-up results in operatively treated patients.

Introduction: Most frequently, abdominal aortic aneurysm (AAA) ruptures into retroperitoneal space. The rupture of AAA into inferior vena cava is an uncommon event. The incidence of this complication of AAA is 2 to 10%. Surgeons' awareness of this rare entity is the most important factor for the early diagnosis and treatment. In this paper we report two cases of AAA rupture into inferior vena cava. As to our knowledge, in domestic literature such cases have not been previously reported., Case Report: Patient 1. A 65-year-old man was admitted to the hospital because of low back pain and haemorrhagic shock. He was anaemic with haemoglobin of 80 g/l, systemic blood pressure was 70 mmHg, pulse rate 100/min, and central venous pressure 12 cm H2O. Pulsatile abdominal mass with continuous bruit and thrill and leg oedema were present. Physical examination revealed global heart failure. The patient was anuric. Because of the critical condition and evident clinical signs of ruptured AAA, the patient was operated on immediately without any other diagnostic procedure. Transperitoneal approach was used. Intraoperative findings were consistent with the rupture of the frontal aneurysmal wall into retroperitoneal space, with large retroperitoneal haematoma and aorto-caval (AC) fistula on the posterior aneurysmal wall, large 2 cm in diameter. Using digital compression for venous bleeding control, the fistula was closed with interrupted polypropylene 2-0 sutures with patches. After closure of the fistula, the urine flow resumed. Then, the aneurysm was replaced with bifurcated Dacron graft. The postoperative recovery was successful. The patient has a 13-year follow-up, without any sign of cardiac or renal failure as well as arterio-venous insufficiency of legs. Patient 2. A 62-year-old man was admitted to the Zemun Clinical Hospital Cenre because of suddenly occurred tachycardia, dyspnea and low back pain. Abdominal ultrasound examination revealed the existence of a possible fistula between the abdominal aorta and inferior vena cava. The patient was immediately transported to our institute. At admission, he was anaemic (haemoglobin was 85 g/l), with systolic blood pressure of 100 mmHg, pulse rate of 100/min and central venous pressure of 20 cm H2O. Also, he had pulsatile abdominal mass with continuous bruit and thrill, as well as legs and scrotal oedema. He was oliguric and haematuric. Translumbar aortography showed AAA with AC fistula (Figure). Transperitoneal approach was used for the operation. Intraoperatively, a small retroperitoneal haematoma without retroperitoneal rupture was found. After aneurysmal opening, a massive venous bleeding started, followed with cardiac arrest. The bleeding was controlled using digital compression and cardiopulmonary resuscitation was successful. AC fistula, large 3 cm in diameter, was on the posterior aneurysmal wall, and it connected the inferior vena cava and the left common iliac vein with AAA. The fistula was closed with interrupted polypropylene 2-0 sutures with patches. The aneurysm was replaced with impregnated tubular Dacron graft 16 mm. The postoperative recovery was successful. The patient was followed-up for 2.5 years, and there were no signs of cardiac or renal failure and arterio-venous insufficiency of legs., Discussion: AC fistula as a complication of ruptured AAA was reported for the first time by Syme in 1831. The first attempt to repair this lesion was done by Lehman in 1935, but it was unsuccessful. In 1954, the first successful repair was performed by Cooley. According to Matsubara, by the end of 1989, 250 cases of this lesion were reported in England, German and French literature, and only 25 in Japanese. In 1991, Brewster et al. reported 14 new cases, while Italian authors reported 36 new cases in 1994. Retroperitoneal and intraperitoneal ruptures of AAA have different clinical presentation comparing with the rupture of AAA into inferior vena cava. (ABSTRACT TRUNCATED)

Acute superficial thrombophlebitis of the lower extremities is one of the most common vascular diseases affecting the population. Although it is generally considered as a benign disease, it can be extended to the deep venous system and pulmonary embolism. We examined 50 patients (22 males and 28 females), mean age 52.5 years. These patients were surgically treated due to acute superficial thrombophlebitis of the lower limbs that affected great saphenous vein above the knee. The diagnosis was made by palpable subcutaneous cords in the course of great saphenous vein or its tributaries in association with tenderness, erythema and oedema. Of these 50 patients, 26 were examined by duplex ultrasonography before the operation. In 20 patients duplex scanning confirmed that the process was greater than we supposed after clinical examination (77%) and in 6 patients there were no differences (23%) (Figures 1 and 2). The operation included crossectomy, ligation and resection of the proximal part of the great saphenous vein. Intraoperative findings in 38 patients showed that the level of the phlebitic process was higher than the clinical level (76%). There was no difference in 12 patients (24%). Deep vein thrombosis and pulmonary embolism were noted in 14 patients (28%) (Tables 1 and 2). Both complications were found in two patients, and 12 had one of these complications. Generally, there were 12 patients with deep venous thrombosis and 4 patients with pulmonary embolism. Only in one patient deep venous thrombosis appeared postoperatively, while all other complications occurred before surgical intervention (Scheme 1 and Table 3). The most common risk factor was the presence of varicose veins (86%). Obesity, age over 60 years, cigarette smoking are listed in decreasing order of frequency. Patients under 60 years were more likely to have complications while older patients usually followed a benign clinical course (Tables 4 and 5). There was no intrahospital mortality. Average hospitalization was 5.7 days. It was 4 days in patients without complications. After thes urgent operation that practically removed the risk of potentially fatal consequences, the patients were dismissed from hospital. New hospitalization was recommended after two weeks when the second act of surgical treatment was performed. It included stripping of the great saphenous vein and extirpation of varicose veins in the area without acute inflammation. The findings of this study confirm the general opinion that acute superficial thrombophlebitis is a very common vascular disease with usually "benign" clinical course. In its ascending form that affects the great saphenous vein above the knee it can be associated with deep venous thrombosis and pulmonary embolism. The level of phlebitic process is usually much higher than can be palpated clinically. Duplex scanning was a highly reliable, precise, fast non-invasive diagnostic method that is necessary in examining, following and making decision for operative treatment of acute superficial thrombophlebitis. If suspected complications an urgent surgical intervention should be performed. It is short and efficient, contributing to the fast recovery of the patients and their return to normal activities.

Introduction: The carotid body tumour was first described by von Haller in 1743. The first two, unsuccessfully surgically treated carotid body tumours, were done by Reinger in 1880 (his patient died), and by Maydel in 1886 (his patient developed hemiplegia). Scudder made the first successful surgical removal of the carotid body tumour in 1903. Using data from the Cologne (Germany) Medline Research Centre, surgical treatment of carotid body tumour was not reported in Yugoslav medical literature. The aim of this study is to present 6 surgically treated carotid body tumours., Material and Methods: Over the period from 1982 to the end of 1996, 6 patients with carotid body tumours were operated on in the Centre of Vascular Surgery of the institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade. Four of them were female and two male patients, average age 43.4 years. In all cases the tumour was an asymptomatic neck mass. Color-Duplex ultrasonography and selective carotid arteriography were used to establish the diagnosis in 5 cases. The pathohistological examination of all 6 patients revealed the benign character of tumors. Patient 1. A 52-year old man. The suspicion of symptomatic carotid artery aneurysm, was the indication for urgent operation. The intraoperative finding showed a carotid body tumour which compressed carotid arteries. The subadventitial removal of the tumour was done. The patient was followed for 14 years without signs of local recidivation. Patient 2. A 38-year old man. During the operation the tumour was removed subadventitially, without clamping or injuring the carotid arteries. The patient was followed for 8 years and 3 months, and there were no signs of local recidivation. Patient 3. A 48-year old woman. Intraoperative findings showed an infiltration of the carotid arteries and tumour was removed together with parts of internal and external carotid arteries. The internal carotid artery was reconstructed using saphenous vein graft. The follow-up period was 4 years and 6 months, without signs of local recidivation. Patient 4. A 61-year old woman was operated on (neck exploration) in other hospital 4 years before the admission to our Centre. During the primary operation, an internal carotid artery was ligated without neurological consequences. Also, histological examination was performed. We removed a tumour together with the ligated internal carotid artery without its reconstruction. Three years after the operation the patient was without signs of local recidivation. Patient 5. A 40-year old woman. After subadventitial surgical removal of the tumor without clamping or injuring the carotid arteries, the patient was followed-up for 2 years and 2 months, and was without signs of local recidivation. Patient 6. A 30-year old woman was operated on (neck exploration only) in other hospital two months before the admission to our Centre. Intraoperative findings showed tumour infiltration to the carotid arteries, and therefore, internal and external carotid arteries were removed together with the tumour. The internal carotid artery reconstruction was performed using aaphonous vein graft. The early postoperative period was unremarkable. However, 48 hours after the operation cerebrovascular insult developed with hemiplegia. There was no sign of graft thrombosis. The patient was followed-up for 2 years postoperatively. There were no signs of local recidivation. The same patient had also a small asymptomatic tumour at the other side of the carotid arteries., Discussion: The carotid body tumour originates from the paraganglious tissue at the carotid artery bifurcation. There are angiomatous and adenomatous forms. All of our 6 cases had adenomatous form. It grows slowly, and can compress and/or infiltrate carotid arteries and nerves. Three of our 6 cases showed signs of carotid artery compression and 3 showed infiltration to the carotid arteries. Malignant alteration of this tumour is uncommon. (ABSTRACT T

The aim of the paper is the presentation of the treatment of aneurysms of the extracranial carotid artery and review of literature. Aneurysms of extracranial carotid arteries (common carotid artery, external carotid artery and cervical part of the internal carotid artery) are very rate [1, 2]. In 1979 McCollum from the Baylor University (Houston, Texas) reported 37 cases over a 21-year period [3]. Moreau from France reported 38 cases over a 24-year period [4]. Mayo clinic experience includes 25 cases in the 40-year period [5]. According to Schechter 835 extracranial carotid artery aneurysms were reported in literature until 1977. These and the other aneurysms of the extracranial carotid artery can be partially or completely thrombosed, can cause distal embolization, or compression of adjacent structures, and can be ruptured [4, 9]. Therefore, the mortality rate in non operated patients with carotid artery aneurysm is 70% [10]. Over the period from January 1, 1985 to December 31, 1996 at the Centre of Vascular Surgery within the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade, 12 patients with 13 extracranial carotid artery aneurysms were treated. Nine of them (75%) were males and 3 (25%) females, average age 58.22 (21-82) years. There were two traumatic (gunshot wounds) and one anastomotic (after carotid subclavian bypass with PTFE graft) pseudoaneurysms, and 10 true atherosclerotic aneurysm. Three (23%) aneurysms were on the common and 9 (77%) on the cervical part of the internal carotid artery. Two (15%) aneurysms were in the form of asymptomatic pulsatile neck mass, 7 (54%) with CVI or TIA, three (23%) with compression of the cranial nerves and one (8%) was ruptured. Twelve (92%) patients were treated surgically, while one asymptomatic aneurysm in a 82-year old female patient was not operated due to high risk. The intraoperative findings revealed one complete and 11 partial thromboses of the aneurysmal sac. In 3 patients with fusiform aneurysms, thrombectomy and aneurysmorrhaphy were performed. One traumatic pseudoaneurysm was treated with aneurysmectomy and lateral suture of the artery. In 3 patients aneurysmectomy and end to end anastomosis were done, while in three aneurysmectomy and saphenous vein graft interposition. In case of ruptured aneurysm of the internal carotid artery aneurysmetomy and arterial ligature were carried out, while in case of anastomotic pseudoaneurysm after carotid subclavian bypass, aneurysmectomy and new carotid subclavian bypass with PTFE graft, were performed. During the study no intrahospital mortality was recorded. One patient died 5 years after the operation due to myocardial infarction. The mean follow-up period was 4 years and 2 months (6 months to 11 years). The early and late potency rates were 100%. Two (17%) CVI and two transient cranial nerve paresies were noticed immediately after the operation. In literature male/female ration in patients with extracranial carotid artery aneurysms is 2:1 [2, 4, 7], but in our study it was 5:1. One (10%) of our patients had a bilateral carotid artery aneurysm. According to literature data the incidence of bilateral localization of extracranial carotid artery aneurysms with atherosclerotic origin is 21% [1]. Of 12 surgically treated aneurysms in our study, 9 were of atherosclerotic origin, two were traumatic and one anastomotic pseudoaneurysms. Today, most of true extracranial carotid artery aneurysms are of atherosclerotic origin [7, 20-25]. However, true extracranial carotid artery aneurysms can be developed due to: infection of the arterial wall (mycotic forms) [26-37]; nonspecific [23] or irradiation arteritis [38], fibromuscular dysplasia [4, 8, 15, 16, 39]. The most frequent types of false extracranial carotid artery aneurysms are traumatic pseudoaneurysms [32, 50-54] and anastomotic pseudoaneurysms [53, 59, 60]. There are also dissecting extracranial carotid artery aneurysms developed after isolated spontaneous d

Introduction: In reconstructive procedures of the abdominal aorta synthetic grafts are today mostly used. There are two types of bifurcated synthetic grafts: Dacron and polytetrafluorethilene (PTFE). In many papers these grafts are compared in aortobifemoral position. Karner 1988, and Lord 1988, found no significant difference between them after aortobifemoral reconstructions. In 1955. Paaske wrote about a new "stretch" bifurcated PTFE graft in aortobifemoral position. Comparing this material with standard Dacron graft, he only found a shorter operating time. The aim of this paper is to compare Dacron and PTFE bifurcated grafts in aortobifemoral position in patients with aortoiliac occlusive diseases., Material and Methods: This prospective study included 283 aortobifemoral reconstructions due to aortoiliac occlusive diseases operated between January 1st, 1984 and December 31st, 1992 at the Institute for Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade. Bifurcated PTFE grafts were used in 136 patients, and nonimpregnated knitted Dacron grafts in 147 subjects. There were 25 (8.8%) female and 258 (91.2%) male patients, average age 56.88 years. Ninety one (32.2%) patients had a claudication discomfort (Fonten stadium II), 91 (32.2%) disabling claudication discomfort (Fonten stadium IIB), 45 (15.9%) rest pain (Fonten stadium III), and 56 (19.8%) gangrene (Fonten stadium IV). In 45 (15.9%) patients previous vascular procedures were performed. Prior to operation, Doppler ultrasonography and translumbar aortography were carried out (Figure 1). Transperitoneal approach to abdominal aorta, and standard inguinal approach to femoral arteries were used. In 154 (54.4%) patients proximal anastomosis had an end to side (TL), and in 129 (45.6%) end to end (TT) form. In 152 (26.88%) cases distal anastomosis was done in the common femoral (AFC) artery, and in 414 (73.2%) cases in the deep femoral (APF) artery. In 7 patients the aorto-femoro-popliteal "jumping" bypass was done, and in 29 patients simultaneous sequential femoro-popliteal bypass graft. The patients were following-up over the period from one, six and twelve months after operation, and later once a year, using physical examination and Doppler ultrasonography. In patients with suspected graft occlusion, anastomotic stenosis, pseudoaneurysms, progression of distal arterial diseases, Duplex ultrasonography and angiography were also used, and leukoscintigraphy in patients with suspected infection. Statistical analysis was performed using Long Rank and Student t-test., Results: Inhospital mortality rate was 11 (7%). Distal reconstructions significantly increased the mortality rate when simultaneously performed with aortobifemoral bypass graft (p < 0.01). The follow-up period was from 2 months to 9.5 years (mean 3.6 years). The early patency rate was 97% from PTFE and 99.4% for Dacron grafts, while the late patency rate was 94.9% for PTFE and 96.6% for Dacron grafts. The type of the graft had no statistical influence on the early and late graft patency (p > 0.05) (Graphs 1, 2, 3). Six (2.1%) early unilateral limb occlusions were observed. Five patients had the PTFE and one the Dacron graft, without statistically significant difference (p > 0.05). The reasons for early graft occlusion were: stenosis of distal anastomosis in 3 patients, and pure run off in 3 patients. In 5 patients urgent reoperation (limb thrombectomy with profundoplasty or femoro-popliteal bypass graft above the knee) were done with complete recovery of legs. However, in one patient the above knee amputation was done. During the follow-up period, 14 (5.2%) late graft occlusions were recorded. There were 11 unilateral limb occlusions and 3 bilateral. All patients with bilateral occlusions had PTFE grafts but this was not statistically significant (p > 0.05) comparing two types of grafts. Taking into account all late occlusions, there were 7 PTFE and 7 Dacron grafts. There was no statistical difference betwe

Introduction: Most of the patients with aortoiliac occlusive diseases have a multilevel localization of atherosclerotic diseases. In patients with aortoiliac occlusive diseases, the femoro-popliteal segment is involved in 28 to 66% of cases. These patients are usually old persons with many risk factors. Therefore, simultaneous proximal and distal reconstruction is often associated with a higher morbidity and mortality rates. In contrast, can proximal reconstruction help only patients with multilevel occlusive diseases? The aim of this paper is: definition of factors determining late patency rate of aortobifemoral bypass graft in patients with multilevel occlusive diseases; definition of factors determining clinical effects after aortobifemoral bypass procedures., Material and Methods: This prospective study included 283 aortobifemoral reconstructions due to aortoiliac occlusive diseases operated between January 1st, 1984 and December 31st, 1992 at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade. Bifurcated polytetrafluorethylene (PTFE) grafts were used in 136 patients, and standard nonimpregnated knitted Dacron grafts in 147 paetients. There were 25 (8.8%) female and 258 (91.2%) male patients, average age 56.88 years. Ninety one (32.2%) patients had claudication discomfort (Fonten stadium II), 91 (32.2%) disabling claudication discomfort (Fonten stadium IIb), 45 (15.9%) rest pain (Fonten stadium III), and 56 (19.8%) gangrene (Fonten stadium IV). In 45 (15.9%) patients previous vascular procedures were performed. Prior to operation Doppler ultrasonography and translumbar aortography were done. Isolated aortoiliac occlusive diseases with intact femoro-popliteal segment (Type I) were found in 83 (29.3%) patients; combined aorto-iliac and diseases of superficial femoral artery (Type II) in 170 (60%) patients; and combined aorto-iliac and femoro-popliteal diseases (Type III) in 30 (10.7%) individuals. Transperitoneal approach to abdominal aorta and standard inguinal approach to femoral arteries, were used. In 154 (54.4%) patients proximal anastomosis had an end to side (TL), while in 129 (45.6%) end to end (TT) form. In 152 (26.88%) patients distal anastomosis was found on the common femoral artery (AFC), while in 414 (73.2%) on the deep femoral artery (APF). In 7 patients the aorto-femoro-popliteal "jumping" bypass was performed, and in 29 subjects the simultaneous sequential femoro-popliteal bypass graft (Figures 1, 2, 3, 4a and 4b). The patients were followed-up over a period from one, six and twelve months after reconstruction, and later once a year, using physical examination and Doppler ultrasonography. In patients with suspected graft occlusion, anastomotic stenosis, pseudoaneurysms, progression of distal diseases, Duplex ultrasonography and angiography were also used, and leukoscintigraphy in patients with suspected graft infection. Statistical analysis was performed by Long Rank and Student's t-test., Results: Inhospital mortality rate was 11 (7%). Simultaneous distal reconstructions significantly increased the mortality rate (p< 0.01). The follow-up period was from 2 months to 9.5 years (mean 3.6 years). Configuration of proximal anastomosis showed no significant influence on graft patency (p>0.05) (Graphs 1, 2, 3). Location of distal anastomosis at the deep femoral artery contributed to statistically significant increase in graft patency (p < 0.01) (Graphs 4, 5, 6). Simultaneous distal bypass showed statistically significant increase in graft patency (p < 0.01), but also significant increase in inhopsital mortality rate (p < 0.01) (Graphs 7, 8, 9). The type of occlusive diseases had no statistically significant influence on graft patency (p > 0.05) (Graphs 10, 11, 12). Six (2.1%) early unilateral limb occlusions were observed. The reasons for early graft occlusions were: stenosis of distal anastomosis in 3 patients and pure run off in 3 subjects. In 5 patients urgent reoperations (limb thrombectomy and profundoplasty or femoro-popliteal bypass graft above the knee) were performed with complete recovery of patients. However, in one patient an above the knee amputation had to be done. During the follow-up period 14 (5.2%) late graft occlusions were recorded: 11 unilateral limb and 3 bilateral graft occlusions. The reasons for late graft occlusion were: distal progression of atherosclerotic diseases, distal anastomotic stenosis, proximal progression of atherosclerotic diseases and anastomotic neointimal hyperplasy. All patients with late graft occlusion underwent successful redo-operations. Next late redo-procedures had to be done: three new aorto-bifemoral bypass grafts (patients with bilateral occlusion), two limb thrombectomies, 6 limb thrombectomies with profundoplasty and 3 femoro-femoral "cross-over" bypass grafts. Configuration of proximal anastomosis and type of occlusive disease showed no statistically significant influence on the number of early and late graft occlusions (p > 0.05). Location of distal anastomosis at the deep femoral artery and simultaneous distal bypass, statistically significantly decreased the number of early and late graft occlusions (p < 0.05). "Small aorta syndrome" statistically significantly increased the number of late graft occlusions. Eleven distal anastomotic pseudoaneurysms were noted. In 8 patients pseudoaneurysms were infected and in 3 noninfected. In all patients new redo-operations were carried out. Graft infection was recorded in 5 (1.7%) patients. One (0.3%) secondary aortoduodenal fistula was found. During the follow-up period new disabling claudication discomforts were found in 46 patients. The causes were distal anastomotic stenosis in 30 patients and progression of distal arterial diseases in 16 subjects. Of the total number of 30 patients with distal anastomotic stenosis 14 were reoperated (profundoplasty) and 16 patients refused a new operation. Also, 16 patients with progression of distal atherosclerotic diseases were reoperated. The operation was a kind of femoropopliteal or crural bypass grafts. During the follow-up period 97 patients were asymptomatic, 128 showed significant improvement, 29 had disabling claudications, and 111 had amputations. Distal anastomosis at the deep femoral artery and patent superficial femoral artery, statistically significantly influenced the clinical course after operation (p 0.01), while configuration of proximal anastomosis and simultaneous distal bypass had no significant effects (p < 0.05)., Conclusions: (1) Only location of distal anastomosis has a statistically significant influence on the patency of aorto-bifemoral bypass graft. (2) The location of distal anastomosis and type of occlusive disease have a statistically significant influence on the clinical effect of the operation. (3) The simultaneous distal bypass had no influence on the late patency of aortobifemoral bypass graft and on the number of asymptomatic patients. Also, it increased inhospital mortality rate.

The authors are presenting 8 patients with 9 cases of popliteal artery entrapment syndrome. There were one female, and 7 male patients with average age of 36.4 (25-54) years. Six cases were manifested with acute, 2 with chronic foot ischemia, while one case was asymptomatic. For diagnosis a combination of Doppler sonography and transfemoral angiography, was used. Eight cases were operated using posterior, while in one medial approach to the popliteal artery. The types I and IV of the popliteal artery entrapment syndrome were found in one case, type II in two cases, type III in 4 cases, while in one case a type of syndrome had not to be identified. During the operation the resection of the anomalous muscle and reconstruction of the popliteal artery, were done in 8 cases. In one case muscle resection or arterial reconstruction, were not necessary. The early potency rate and limb salvage, were 100%, while long term potency rate after mean follow up period of 6.3 years was 83.5%. The acute or chronic foot ischemia in health, young persons without typical atherosclerotical risk factors, suggests on popliteal artery entrapment syndrome.

Adrenal cyst are rare disease. Bleeding, particularly massive, from these cysts is even rarer. The cyst causing spontaneous massive retroperitoneal bleeding in a 17 year old girl is presented. Adrenalectomy was successfully carried out. The patient stayed symptom free so far.

Seventy one surgical procedures on abdominal aorta in patients with horseshoe kidney have been reported in literature until 1980. Bergan reviewed 30 operations of abdominal aortic aneurysms (AAA) in these patients until 1974. Of them 3 AAA were ruptured. Gutowitz noticed 57 surgically treated AAA in patients with horseshoe kidney until 1984. Over the period from 1991 to 1996 thirty nine new cases were reported , including 2 ruptured AAA. The surgery of the abdominal aorta in patients with horseshoe kidney is associated with the following major problems: -reservation of anomalous (aberrant) renal arteries; reservation of the kidney excretory system; approach to the abdominal aorta (especially in patients with AAA) and graft placement The aim of the paper is the presentation of 5 new patients operated for abdominal aorta with horseshoe kidney. Over the last 12 years (January 1, 1984 to December 31, 1996) at the Centre of Vascular Surgery of the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia, 5 patients with horseshoe kidney underwent surgery of the abdominal aorta. There were 4 male and one female patients whose average age was 57.8 years (50-70). Patient 1. A 50-year-old male patient was admitted to the hospital for disabling claudication discomforts (Fontan stadium IlI) and with significantly decreased Ankle-Brachial indexes (ABI). The translumbal aortography showed aorto-iliac occlusive disease and horseshoe kidney with two normal and one anomalous renal artery originating from infrarenal aorta (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. The aorto-bifemoral (AFF) bypass with Dacron graft was done with end-to-end (TT) proximal anastomosis just under the anomalous renal artery. The graft was placed behind the isthmus. During a 12-year follow-up renal failure, renovascular hypertension and graft occlusion were not observed. Patient 2. A 53-year-old male patient was admitted to the hospital for symptomatic AAA. Two years before admission the patient underwent coronary artery bypass grafting. The Duplex scan ultrasonography and translumbal aortography showed an infrarenal AAA, aneurysm of the right iliac artery and horseshoe kidney with two normal and one anomalous renal artery originating from the left iliac artery (Crawford type III). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy, the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the bifurcated graft was anastomosed with the common femoral artery and the left limb with left iliac artery just above the origin of the anomalous renal artery. The first day after operation thrombosis of the left common femoral artery with leg ischaemia was observed. (That artery was cannulated for ECC during coronary artery bypass grafting 2 years ago). The revascularisation of the left leg was done with femoro-femoral cross over bypass. During a 11-year follow-up period, the graft was patent and renal failure or revascular hypertension were not observed. Patient 3. A 66-year-old male patient was admitted to the hospital for rest pain (Fontan stadium III) and significantly decreased ABI. The patient had diabetes mellitus and myocardial infarction two months before admission. Translumbar aortography showed an aorto-iliac occlusive disease associated with horseshoe kidney with 5 anomalous renal arteries. (Crawford type III). Due to high risk, the axillo-bifemoral (AxFF) extra-anatomic bypass graft was performed. Five years after the operation the patient died due to new myocardial infarction. During the follow-up period the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 4. A 50-year old male patient was admitted to the hospital for high asymptomatic AAA. The diagnosis was established by Duplex scan and translumbal aortography. The large infrarenal AAA (transverse diameter 7 cm) associated with horseshoe kidney with two normal renal arteries (Crawford type I) were found. Intravenous pyelography and retrograde urogrpahy showed two separated ureters. After partial aneurysmectomy the tubular Dacron graft was placed behind the isthmus. During a 15-month follow-up the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 5. A 70-year-old female patient was admitted to the hospital for large asymptomatic AAA. The Duplex ultrasonography, CT scan, NMR and translumbal aortography showed an infrarenal AAA, aneurysms of the both common iliac arteries, aneurysm of the left hypergastric artery and horseshoe kidney with two normal and two anomalous renal arteries. One of the anomalous renal arteries originated from AAA, and the other from the left common iliac artery (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the graft was anastomosed (TT) with bifurcation of the common iliac artery and the left limb with the distal part of the common iliac artery (end-to-side) just above the origin of the second anomalous renal artery. The first anomalous renal artery that originated from AAA was removed from the aneurysm wall and anastomosed with graft using Carrel patch technique. During a 9-month follow-up the graft was patent and there were no signs of renovascular hypertension and renal failure. The horseshoe kidney is a rare anomaly of the urinary system. The incidence of this anomaly is from 1:1600 to 1:400 In 95% of cases the kidneys are connected with the lower poles, while in 5% with the upper poles In most cases, the isthmus structure is parenchimatous structure, and rarely it consists of the connective tissue. Usually the isthmus is located in front of the abdominal aorta and inferior vena cava, and very rarely behind them In two thirds of patients anomalous vascularization is present There are two classifications of anomalous vascularization: Papin's and Crawford's. According to Papin's classification, based on the number of renal arteries, there are three types of horseshoe kidney vascularization: Papin I (20%): There are two normal renal arteries only. (One of our 5 patients); Papin II (66%): There are 3-5 renal arteries. (Four of our 5 patients); Papin III (14%): There are more than 5 renal arteries. The Crawford's classification based on the origin of renal arteries, is of greater surgical importance than Papin's. According to it there are also three types of vascularization: Crawford I: There are two renal arteries with normal origin. (One of our 5 patients); Crawford II: Besides two normal, there are 1-3 anomalous renal arteries originating from the infrarenal aorta or iliac arteries (Three of our 5 patients); Crawford III: All renal arteries have an anomalous origin. (One of our 5 patients). The patients with horseshoe kidney can also have two separated, or one connected excretory urinary systems. All our 5 patients had two separated ureters. There is no specific clinical manifestation of the horseshoe kidney. Urinary infection or calculosis are very frequent as are in other urinary anomalies. The diagnosis of horseshoe kidney is established by Dupplex ultrasonography, CT scan, NMR, radionuclide scintigraphy and angiography. Very often the diagnosis is established occasionally during the examination of aneurysmal and occlusive diseases of the abdominal aorta. In cases of AAA or AIO associated with horseshoe kidney preoperative vascularization and condition of the excretory system should be established. Besides standard translumbar aortography selective renovasography is often neccessary. In some cases the intraoperative angiography or arterial identification, with metallic probe must be done. All renal arteries are "terminal" without significant anastomosis on the side of the kidney. Therefor its preservation is neccessary. There are three ways. The first is the location of anastomosis (3 of our patients). The second is an AxFF bypass, but only in patients with AIO (One of our patients and in the third reimplantation of the renal artery using Carrel patch technique was performed (One of our patients). The Isthmus of the kidney aggravates aortic preparation especially in patients with AAA. Sometimes isthmectomy is neccessary. In such cases there is danger of urinary fistula. Therefor many authors suggest the left extraperitoneal approach to abdominal aorta. In our patients, the transperitoneal approach was used, isthmectomy was not neccessary and graft was placed behind the isthmus. The operation of the abdominal aorta in patients with horseshoe kidney can be difficult due to anomalous renal arteries, anomalous excretory urinary system and is Ehmus. In these patients a more precise preoperative diagnosis is neccessary.

The 45 patients with popliteal artery aneurysms have been treated at the Institute for Cardiovascular Diseases from Belgrade, during the last 36 years. Four of them were women and 41 men, with average age of 61 years. The incidence of bilateral localization was 28%. The aneurysms have been presented with the rupture in 6 cases, with deep popliteal venous thrombosis in 3 cases, with sciatic nerve compression in one case, and with acute or chronic leg ischemia in 38 cases. Seven small asymptomatic aneurysms have not been operated. The primary major leg amputation had to be done in 8 cases due to irreversible ischemic changes. Any form of reconstructive procedures has been done in 48 cases (total or partial aneurysmal resection with graft interposition, an aneurysmal exclusion and bypass procedures). The autologous saphenous vein graft has been used in 42 cases, PTFE in 5 cases and Bovin solco graft in one case. Three patient died intraoperatively due to massive myocardial infarction. The early patency rate was 91%, and limb salvage 93%. The follow-up period was between 2 months to 16 years (men 3 years). The long term patency rate was 86%, and limb salvage 97%. The surgical treatment is the method of choice in case of popliteal artery aneurysm, due to good results, and possible complications.

Eighty two aortic replacements of ruptured abdominal aortic aneurysms have been performed during the last 6 years. There were 72 male and 10 female patients, and the average age was 71.33 years. Hemorrhagic shock on the admission was observed in 45 patients, and 13 have been operated urgently without any diagnostic procedures. The transperitoneal approach have been used for the operation. Two aorto duodenal and one aorto caval fistulas, have been found. Only exploration (three patients died immediately after laparotomy and 6 after cross clamping) has been done in 9 cases, and the aortic replacement in 70 cases (27 with tubular, and 43 with bifurcated graft). In 3 cases and axillobifemoral bypass had to be done. During the operation eleven patients died, and 30 in postoperative period, during the period between one and 40 days. Total intrahospital mortality rate was 50%, compared with 3.5% for 250 electively operated patients with abdominal aortic aneurysms in same period. In postoperative period the most important cause of death was multiple organs failures. Statistically significant greater mortality rate (p > 0.01%) was found in cases of late operative treatment, hemorrhagic shock, intra-operational bleeding, ruptured front wall, suprarenal cross clamping and in patients older than 75 year. In complicated cases such as juxtarenal aneurysm, 3 sutures parachute technique for proximal anastomosis, a temporary transection of the left renal vein, and intraaortal balloon occlusive catheter for proximal bleeding control are recommended.

The aim of this clinical prospective study was to determine the effect of indobufen upon synthetic graft patency in femoral-popliteal/crural position. 15 operated patients were observed during the three-month period. One day prior to operation patients were given 400 mg of indobufen perorally. The same daily dose was continued on the first postoperative day as well as during the following three months. Blood levels of 6-keto-prostaglandin (PG) F1alpha (stable metabolite of PGI2) and thromboxane (Tx) B2 (stable metabolite of TxA2) were determined by RIA before indobufen administration, i.e., one day and three months postoperatively. The three-month patency of grafts was achieved in 86% of cases. Plasma levels in all observed time periods showed significantly reduced TxB2, increased 6-keto-PGF1alpha, and higher PGI2 levels compared with TxA2 that could suggest the normalization of aggregation/antiaggregation process.