[Early results in the surgical treatment of Crawford type IV thoracoabdominal aneurysms].

OBJECTIVE: The aim of the study was to present the outcome of surgical treatment of patients with thoracoabdominal aortic aneurysm Crawford type IV, operated on between January 2001 and April 2004. METHODS: This study included 42 subsequent patients (40 males, 2 females, age 41-76 years). All patients underwent ultrasonography, angiography, computed tomography or magnetic resonance imaging (MRI). Surgical treatment was performed under combined anaesthesia (continuous thoracic epidural analgesia and general endotracheal anaesthesia). In two patients thoracophrenolumbotomy was performed at the level of X rib, while others were operated through left lumbotomy after the extra pleural resection of XI rib. We did not perform any spinal cord protection procedures in this type of aneurysm. Reconstruction included interposition of Dacron graft in 20 patients, aortobiiliac bypass in 18, and aortobifemoral bypass in 4 patients with different varieties of visceral branches reimplantation. RESULTS: Thirty-days mortality was 31% (13 patients, two of them intraoperatively). Causes of death were: pulmonary embolism--in 1 patient; haemorrhage--in 2; myocardial infarction--in 4 (two intraoperative); acute renal failure--in 2; multisystem organ failure (MSOF)--in 4 patients. Respiratory failure dominated in all cases of MSOF. One patient with acute renal failure had paraplegia also, and that was the only case of neurological complication in whole group. All female patients (2), all patients with ruptured aneurysm (4), acute myocardial infarction (4) and acute renal failure (2) have died. Advanced age (over 70 years) and the need for extensive operative procedure with bifurcated graft use significantly influenced their mortality (p < 0.01 and p < 0.05 respectively). CONCLUSIONS: Surgical treatment of thoracoabdominal aortic aneurysm Crawford IV type was successful in 69% of our patients. There was no need for spinal cord protection measures, and extra peritoneal approach with XI rib resection under the combined anaesthesia was preferred.

Aorto-caval fistulas: a review of eighteen years experience.

The operative treatment of 26 aorto-caval fistulas during the last 18 years is reviewed (24 male and two female patients; average of 65.3 year). Out of 1698 cases presenting an abdominal aortic aneurysm, 406 presented with rupture, and 26 had aorto caval fistula. In 24 cases (92.3%) it concerned an atherosclerotic aneurysm. One aneurysm with aorto-caval fistula was secondary to abdominal blunt trauma (3.8%), and one due to iatrogenic injury (3.8%). The time interval between first clinical signs of aorto-caval fistula and diagnosis, ranged from 6 hours to 2 years (average 57,3 days). Clinical presentation included congestive heart failure infive patients (11.5%), extreme leg edema in 13 (50.0%), hematuria in 2 (7.0%), renal insufficiency 2 (7.0%), and scrotal edema in six patients. Diagnosis was made by means of color duplex scan in eight patients (30.7%), CT in seven patients (27%), NMR in three patients (11.5%), and angiography in seven patients (27%). Most reliable physical sign was an abdominal bruit,present in 20 patients (77%). In ten patients (38.4%) correct diagnosis was not made prior to surgery. The operative treatment consisted of transaortic suture of the vena cava (25 pts-96.0%), and aneurysm repair. Five operative deaths occurred (19,2%), and for all of them it concerned a misdiagnosis. Cause of death was myocardial infarction (one patient-3.8%), massive bleeding (one patient-3.8%), MOF (two patients-7, 0%), and colon gangrene (one patient-3.8%). Follow-up period varied from six months to 18 years (mean 4 years and two months). Long term results showed a 96% patency rate. No postoperative lower extremity venous insufficiency nor pelvic venous hypertension was observed post-operatively.

Femoro-popliteal reconstructions: 'in situ' versus 'reversed' technique.

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.

[Aorto-enteric fistulas]. / Aorto-entericne fistule.

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.

[Long-term patency of reversed and in situ femoro-popliteal bypasses]. / Udaljena (kasna) protocnost femoro-poplitealnog bajpasa ucinjenog "reverznim" i "in situ" metodima.

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).

[Chronic rupture of abdominal aortic aneurysms]. / Hronicna ruptura aneurizme abdominalne aorte.

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)

Popliteal artery aneurysms.

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.

[Acute superficial thrombophlebitis--modern diagnosis and therapy]. / Akutni povrsni tromboflebitis--savremena dijagnostika i lecenje.

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.

[Dacron and polytetrafluoroethylene aorto-bifemoral grafts]. / Dakronski i politetrafluoretilenski aorto-bifemoralni graftovi.

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

Popliteal artery war injuries.

The early postoperative results of 44 surgically treated popliteal arterial injuries from the Yugoslav civil war are reported. Of these patients, 41 (93%) were males and three (7%) were females, average age was 28 (range 6-45) years. Twenty patients (45%) had gunshot wounds and 24 (55%) explosive wounds. Twelve (28%) suffered isolated vascular damage, while 32 (72%) suffered concomitant bone fractures. Isolated arterial lesions were found in 24 (55%) cases, and concomitant arterial and venous lesions in 20 (45%). Twenty-four (55%) had primary reconstructions after haemostasis in the initial war hospital, and 20 (45%) secondary reconstructions after inadequate primary reconstruction in a regional war hospital. Artery procedures included 19 reverse saphenous vein graft interpositions, 10 reverse saphenous vein bypasses, 12 'in situ' saphenous vein bypasses and five lateral subcutaneous saphenous vein bypasses. The early graft patency rate was 100%, and limb salvage 72%. Major amputation was performed in 28%. Concomitant bone fractures, secondary reconstructions, secondary haemorrhage from an infected graft, and explosion wounds significantly increased the amputation rate (P < 0.01). Eleven amputations were performed after an anatomic, and only one after an extra-anatomic reconstruction (P < 0.01). The authors recommend an in situ or lateral subcutaneous reconstruction in cases of complicated popliteal artery injuries, such as concomitant bone fractures accompanied by massive soft tissue damage, and this type of reconstruction should also be used if infection is present or the procedure is delayed.

[Post-traumatic arteriovenous fistulae and pseudoaneurysms]. / Posttraumatske arteriovenske fistule i pseudoaneurizme.

The surgical treatment of 13 posttraumatic arteriovenous (AV) fistulae and 32 pseudoaneurysmae (PsAn) treated in the last 5 years in the Center of vascular surgery of the institute of cardiovascular diseases, Clinical center of Serbia (Belgrade) was presented. Three women and 42 men (mean age 31.7 years) were examined. Twenty-one injuries occurred in a war, while 24 injuries occurred in the peacetime. In most of the cases the superficial femoral artery was involved. The average time elapsed from the moment of injury till surgery, was 9 months in patients suffering from AV fistulae, while in patients suffering from PsAn the elapsed time was one month. In all of those with AV fistulae, some reconstructions of artery and vein were performed, except in 2 cases where the vein was ligated. In twenty-six patients suffering from PsAn the arterial reconstruction was performed, while in 6 cases the artery was ligated. Considering the type of artery, none of the patients suffered from postoperative ischemia. Patients were followed up for 2 years and 2 months on the average after the operation. As far as the reconstructive operations were concerned, 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, but it was indicated by massive bone-muscle tissue loss, that occurred after an injury by the land-mine. Due to the rapid progress of the disease the authors suggested that the operative treatment of posttraumatic AV fistulae and PsAn should start as soon as possible. This was supported by good follow-up results in operatively treated patients.

[Factors determining late patency of aortobifemoral bypass graft]. / Cinoici koji odredjuju dugotrajniju protocnost aorto-bifemoralnog bajpasa.

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.

Post-traumatic AV fistulas and pseudoaneurysms.

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.

[Ruptured abdominal aortic aneurysms]. / Rupturirane aneurizme abdominalne aorte.

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.

[Aneurysms of the popliteal artery]. / Aneurizme poplitealne arterije.

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.

Intraarterial perfusion of prostaglandin E1 after lumbar sympathectomy or reconstruction on femoropopliteal segment.

Out of 100 patients treated by intraarterial perfusion of prostaglandin E1 we selected 36 cases who have been treated after a lumbar sympathectomy or reconstruction on the femoro-popliteal segment. The patients were in the III and IV stage of occlusive diseases by Fontain. All patients were divided into four groups: (a) prostaglandin E1 after a lumbar sympathectomy (20); (b) prostaglandin E1 after failed femoro-popliteal bypass (8); (c) prostaglandin E1 with patent femoro-popliteal bypass and distal progression of the occlusive disease (3); (d) prostaglandin E1 with previously femoro-popliteal reconstruction and poor run off (5). After intraoperative introduction of a catheter into the superficial femoral artery, profunda femoral artery (a, b), a patent graft (c) or just implanted graft (d), a continuous intraarterial perfusion of prostaglandin E1 was applied, in doses 10 nanograms/kg body weight/minute, in total doses 3000 nanograms. The perfusion time was 48-72 h. The patients were controlled immediately after treatment as well as 1, 3, 6 and 12 months after. Our early and late results of the intraarterial perfusion of prostaglandin E1 proved as a very successful limb salvage procedure.

[Indications for surgical treatment of acute superficial thrombophlebitis]. / Indikacije za operaciono lecenje akutnog povrsnog tromboflebitisa.

The acute superficial thrombophlebitis (AST) which may be considered as an "aseptic local inflammatory reaction to vein thrombosis" is a very common disease. The diagnosis of this illness is simple, and usually consists of anamnesis and physical examination. This is due to the fact that typical external signs of inflammation are always present. In such cases the conservative treatment was usually recommended and it included rest, elevation, alcoholic compresses, antipyretic and analgetic drugs. The operative treatment was carried out only if the process developed near the deep vein system, or if a suppurative inflammation was present. We believe that wider indications for operative treatment should be considered. We base this statement on the following facts: the operative finding always shows that the process is greater than we suppose after physical examination, and the operation is easier to perform before scar tissue has been formed at sites of inflammation. The following indications are considered for conservative treatment: AST of the upper limbs; AST of the lower limbs where the great saphaenous vein is not included; AST of the lower limbs including the great saphaenous vain on the level above the knee; Suppurative forms of AST. We plead for one act operation which shortens the time of hospitalisation and includes: Crosseectomia; Ligature, resection and extirpatin of the great saphaenous vein (Vasalve).

[The St. Jude biopolymeric graft in reconstruction of peripheral arteries]. / St. Jude biopolymeric graft u rekonstrukciji perifernih arterija.

The authors present their preliminary results of St. Jude Bio Polymeric graft application in the periphery arteries reconstruction. This biograft like all the previous ones (Soleo, CB.S., human umbilical veins) was introduced with the aim of creating a better substitute for autovenous Graft, which has been irreplacible ever before, especially in cases of crural reconstruction. The operated patients were classified into the II stadium of occlusive disease (claudication) and indications for surgery have been based on Doppler sonography and arteriography. In three cases crural femoro-popliteal reconstruction was carried out, because of an occlusion of the superficial femoral artery, in one case a femoro-femoro cross over bypass due to an occlusion of the iliac artery. Postoperative follow-up ranged from 6 to 12 months and the control of the graft passage by. Doppler sonography and arteriography confirmed patency of all grafts. I.e. the preliminary results are excellent.