Distal venous arterialization and reperfusion injury: focus on oxidative status.

In patients with unreconstructable arterial occlusive disease distal venous arterialization (DVA) seems to be a promising option in the treatment. The goals of this prospective study were to assess clinical efficiency and possible impact of DVA on tissue damage by estimating oxidative status of patients with critical limb ischemia treated with this procedure. The subjects were 60 randomized patients: 30 were undergoing DVA and 30 were treated with antiaggregation therapy. During the mean follow-up period (6.13 ± 4.32 months for DVA vs. 6.74 ± 0.5 months for antiaggregation therapy) survival (p < 0.01), limb salvage (p < 0.001), pain relief (p < 0.001) and wound healing (p < 0.001) rates were significantly different between the two groups of patients in favor of the DVA group. Ten minutes after declamping we observed a decreasing trend in the lactate level in the blood of the deep venous system (p < 0.001). Also, on postoperative day 7 digital systolic pressure and digital-brachial index were higher than before the operation (p < 0.001). In blood samples collected immediately before and successively at 1, 3, 5 and 10 min postoperatively, prooxidative status (thiobarbituric acid reactive substances, O(2)(-), H(2)O(2) and nitric oxide) and antioxidative enzymes (superoxide dismutase, catalase and glutathione reductase) were determined spectrophotometrically. Using the nonparametric Friedman test, we noted statistically nonsignificant differences (p > 0.05) in values of both prooxidative parameters and enzymes of the antioxidative defense system, before and successively at 1, 3, 5 and 10 min after operation. These results indicate that there was no statistically significant reperfusion injury after revascularization, which could have been expected after this surgical procedure, thus confirming its validity in these patients.

[The upper thoracic outlet vascular syndrome]. / Vaskularni sindrom gornjeg torakalnog otvora.

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.

[Pseudo-occlusion of the femoro-popliteal bypass]. / Pseudookluzije femoro-poplitealnog bajpasa.

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.

[Factors which affect long-term patency in femoro-popliteal bypass]. / Faktori koji uticu na udaljenu (kasnu) protocnost femoro-poplitealnog bajpasa.

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.

[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)

[Treatment of the thoracic outlet vascular syndrome]. / Tretman vaskularnog sindroma gornjeg otvora grudnog kosa.

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)