State of the art of stem cell therapy for ischaemic cardiomyopathy. Part 2. / Ispol'zovanie stvolovykh kletok pri ishemicheskoi kardiomiopatii. Chast' 2.

Ischemic cardiomyopathy is becoming a leading cause of morbidity and mortality in the whole world. Stem cell-based therapy is emerging as a promising option for treatment of ischemic cardiomyopathy. Several stem cell types, including cardiac-derived stem cells, bone marrow-derived stem cells, mesenchymal stem cells, skeletal myoblasts, CD34+ and CD133+ stem cells have been used in clinical trials. Clinical effects mostly depend on transdifferentiation and paracrine factors. One important issue is that a low survival and residential rate of transferred stem cells blocks the effective advances in cardiac improvement. Many other factors associated with the efficacy of cell replacement therapy for ischemic cardiomyopathy mainly including the route of delivery, the type and number of stem cell infusion, the timing of injection, patient's physical conditions, the particular microenvironment onto which the cells are delivered, and clinical conditions remain to be addressed. Here we provide an overview of modern methods of stem cell delivery, types of stem cells and discuss the current state of their therapeutic potential.

State of the art of stem cell therapy for ischaemic cardiomyopathy. Part 1. / Ispol'zovanie stvolovykh kletok pri ishemicheskoi kardiomiopatii. Chast' 1.

Ischemic cardiomyopathy is becoming a leading cause of morbidity and mortality in the whole world. Stem cell-based therapy is emerging as a promising option for treatment of ischemic cardiomyopathy. Several stem cell types, including cardiac-derived stem cells, bone marrow-derived stem cells, mesenchymal stem cells, skeletal myoblasts, CD34+ and CD133+ stem cells have been used in clinical trials. Clinical effects mostly depend on transdifferentiation and paracrine factors. One important issue is that a low survival and residential rate of transferred stem cells blocks the effective advances in cardiac improvement. Many other factors associated with the efficacy of cell replacement therapy for ischemic cardiomyopathy mainly including the route of delivery, the type and number of stem cell infusion, the timing of injection, patient's physical conditions, the particular microenvironment onto which the cells are delivered, and clinical conditions remain to be addressed. Here we provide an overview of modern methods of stem cell delivery, types of stem cells and discuss the current state of their therapeutic potential.

Seat-Belt Abdominal Aortic Injury-Treatment Modalities.

Blunt abdominal aortic injuries are extremely rare, diagnosed in less than 0.05% of all trauma admissions. Aortic injury caused by a seat belt during a car accident is often referred as "seat-belt aorta". We present a case of an 18-year-old woman, restrained back passenger involved in a vehicular collision, sustaining vertebral column and multiple rib fractures, mesenterium and colonic injury, and infrarenal aortic contusion with localized dissection and partial thrombosis.

Validation of an assessment tool for pre-operative EVAR planning.

INTRODUCTION: Current methods of teaching endovascular aortic aneurysm repair (EVAR) planning involve non-criteria-based observations that lack validity. The primary aim of this study was to validate an EVAR Planning Objective Structured Assessment of Skill (EpOSAS) tool for the assessment of pre-operative EVAR planning skills. METHODS: Content analysis was performed in order to inform the formulation of EpOSAS domains. Thirty-five participants planned two cases of infra-renal abdominal aortic aneurysm for EVAR, using the OsiriX 7 platform. EVAR planning measurements, with accompanying screenshots, were uploaded onto an electronic data collection sheet. Performance was assessed by three blinded assessors using the EpOSAS tool. Construct and concurrent validity were evaluated. RESULTS: Inter-observer reliability for the three assessors for total EpOSAS scores was high (Cronbach's α 0.89). There were statistically significant differences in total EpOSAS scores between the different experience groups, demonstrating construct validity (Novice (5.3, IQR 5-5.3), Intermediate (15.3, IQR 14.8-16.8) and Experts (17.5, IQR 17-17.7), p<0.001). A statistically significant correlation was found between total EpOSAS scores and percentage error in measurements, demonstrating concurrent validity (Spearman's rank correlation coefficient: R=-0.250, p<0.001). Receiver-operator characteristics analysis established a cut-off point of 16 out of 18 for determining competence. CONCLUSION: We have developed and validated a tool that can be used for the assessment of pre-operative EVAR planning skills.

Predictions and Outcomes of Atrial Fibrillation in the Patients with Acute Myocardial Infarction.

The large epidemiological studies demonstrated that atrial fibrillation is correlated with high mortality and adverse events in patients with acute myocardial infarction. The aim of this study was to determinate predictors of atrial fibrillation develop during the hospital period in patients with acute myocardial infarction as well as short- and long-term mortality depending on the atrial fibrillation presentation. The 600 patients with an acute myocardial infarction were included in the study and follow-up 84 months. Atrial fibrillation develops during the hospital period was registered in 48 patients (8%). After adjustment by logistic regression model the strongest predictor of atrial fibrillation develop during the hospital period was older age, particularly more than 70 years (odds ratio 2.37, CI 1.23-4.58, p=0.010), followed by increased of Body Mass Index (odds ratio 1.17, CI 1.04-1.33, p=0.012), enlarged diameter of left atrium (LA) (odds ratio 1,18, CI 1,03-1,33, p=0,015) presentation of mitral regurgitation (odds ratio 3.56, CI 1.25-10.32, p=0.018) and B-type natriuretic peptide (odds ratio 2.12, CI 1.24-3.33, p=0.048).Patients with atrial fibrillation develop during the hospital period had a higher mortality during the hospital course (10.4% vs. 5.6%) p=0.179. as well as follow-up period of 84 months than patients without it (64.6% vs. 39.1%) p=0.569, than patients without it, but without statistically significance. Patients with AF develop during the hospital period had higher mortality during the hospital course as well as follow up period of 84 months than patients without it, but without statistically significance.

Blood groups and acute aortic dissection type III.

INTRODUCTION: Acute aortic type III dissection is one of the most catastrophic events, with in-hospital mortality ranging between 10% and 12%. The majority of patients are treated medically, but complicated dissections, which represent 15% to 20% of cases, require surgical or thoracic endovascular aortic repair (TEVAR). For the best outcomes adequate blood transfusion support is required. Interest in the relationship between blood type and vascular disease has been established. The aim of our study is to evaluate distribution of blood groups among patients with acute aortic type III dissection and to identify any kind of relationship between blood type and patient's survival. MATERIAL AND METHODS: From January 2005 to December 2014, 115 patients with acute aortic type III dissection were enrolled at the Clinic of Vascular and Endovascular Surgery in Belgrade, Serbia and retrospectively analyzed. Patients were separated into two groups. The examination group consisted of patients with a lethal outcome, and the control group consisted of patients who survived. RESULTS: The analysis of the blood groups and RhD typing between groups did not reveal a statistically significant difference (p = 0.220). CONCLUSIONS: Our results indicated no difference between different blood groups and RhD typing with respect to in-hospital mortality of patients with acute aortic dissection type III.

Bilateral Internal Carotid Artery Occlusion, External Carotid Artery Stenosis, and Vertebral Artery Kinking: May It Be Asymptomatic?

The clinical spectrum of internal carotid artery occlusion ranges from being a completely asymptomatic occlusion to a devastating stroke or death. The prevalence of asymptomatic internal carotid artery occlusion is unknown, particularly for bilateral occlusion. The distal branches of the external carotid artery anastomose with distal branches of the internal carotid artery provide important sources of collateral circulation to the brain. Stenosis of the external carotid artery with ipsilateral/bilateral internal occlusion may result in ischemic sequelae. Coiling or kinking of the vertebral artery is a rare morphological entity that is infrequently reported because it remains asymptomatic and has no clinical relevance. Currently, there is little evidence to support management strategies for this disease entity and no official recommendations for asymptomatic bilateral carotid artery occlusion. We present a case of a 62-year-old female with asymptomatic bilateral internal carotid artery occlusion, bilateral external carotid artery stenoses, and bilateral kinking of the vertebral artery at the V2 segment, who has been successfully managed conservatively for over 5 years. An individualized approach to management of patients with bilateral internal carotid artery occlusion, especially in combination with external carotid artery stenosis and elongation malformations of the vertebral artery is key to a successful strategy.

Vacuum erection device in treatment of organic erectile dysfunction and penile vascular differences between patients with DM type I and DM type II.

The aim of this study is to investigate changes in the vascular system and hemodynamics between patients with organic erectile dysfunction (ED) (DM type I and II), as well as to compare the quality of sexual life between those two groups after the treatment with vacuum erection device (VED). Study enrolled 50 males with DM, aged from 35 to 67 years, who have attended the urologic clinic due to inability to attain and maintain an erection of the penis sufficient to permit satisfactory sexual intercourse. Patients were using VED and six months later were assessed for therapy results. The International Index of Erectile Function (IIEF) was used to quantify erectile dysfunction. Alprostadil injection test was also used, with Doppler color flow imaging system, to evaluate the peak systolic velocity (PSV) and diameter of cavernosal artery (DCA). Significantly higher values of PSV were obtained in patients with DM type II. Also, DCA showed significant difference between two groups of patients. There was significant improvement in three items of IIEF after six months of treatment among both groups of examinees. Patients with DM type I had more serious risk for development of arteriogenic ED. VED could be a good alternative therapy for patients who denied peroral therapy.

Open Repair of AAA in a High Volume Center.

OBJECTIVE: To assess results of open repair (OR) of AAA in a single high volume center. METHODS: We analyzed prospectively collected data of 450 patients who underwent elective OR of AAA at the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre in the period between January 2013 and September 2014. RESULTS: Postoperative death occurred in seven patients (1. 55%) during the first 30 postoperative days. The mortality was caused by: uncontrolled bleeding-1, acute myocardial infarction-1, ischemic colitis-2, MOFS-2, sepsis due to infection and dehiscence of laparotomy wound-1. Coronary artery disease (OR 3.89; CI 0.85-17.7; p = 0.0058), postoperative acute myocardial infarction (OR 29.9; CI 2.56-334.95; p = 0.0053), chronic renal failure (OR 7.5; CI 1.35-8.5; p = 0.0073), colonic necrosis (OR 88.2; CI 4.77-1629.69; p = 0.0026), occlusion of the both hypogastric arteries and the inability to preserve at least one hypogastric artery (OR 17.4; CI 1.99-178.33; p = 0.0230), aortobifemoral reconstruction (OR 9.06; CI 1.76-46.49; p = 0.016), significant perioperative bleeding (>2 L) (OR 7.32; CI 1.31-10.79; p = 0.0001), hostile abdomen (OR 5.25; CI 1.3-21.1; p = 0.0055), inflammatory aneurysm (OR 13.99; CI 2.88-65.09; p = 0.0002), supraceliac aortic cross-clamping (OR 18.7; CI 3.8-90.6; p = 0.0003), prolonged aortic cross-clamping (>60 min) (OR 14.25; CI 2.75-64.5; p = 0.0003), the intraoperative hypotension (OR 6.61; CI 0.71-61.07; p = 0.0545), the prolonged operation (>240 min) (OR 8.66; CI 0.91-81.56; p = 0.0585) and complete dehiscence of the laparotomy (OR 44.1; CI 3.39-572.78; p = 0.0396) increased the 30-day mortality in our study. CONCLUSIONS: Early mortality after open repair of AAA in high volume center might be very low due to experienced multidisciplinary team. Centralized open aortic surgery might be solution for effective treatment of patients with unsuitable anatomy or for young patients with long life expectancy.

Secondary venous aneurysm following intravenous drug abuse: A case report.

INTRODUCTION: Venous aneurysm (VA) is a rare condition that can be presented in both superficial and deep venous system. Secondary VAs as well as pseudoaneurysms are usually caused by external spontaneous or iatrogenic trauma. They are often misdiagnosed and inadequately treated. Complications include thrombosis, phlebitis, eventual pulmonary embolism and rupture. CASE REPORT: We presented a case of secondary VA of the great saphenous vein developed in a young addict following chronic intravenous drug application in the groin region. Aneurysm required urgent surgical treatment due to bleeding complication as it was previously misdiagnosed for hematoma (or abscess) and punctuated by a general surgeon. Complete resection of VA with successful preservation of continuity of the great saphenous vein was performed. Postoperative course was uneventful. Regular venous flow through the great saphenous vein was confirmed on control ultrasound examination. CONCLUSION: VAs are uncommon, among them secondary VA being extremely rare. In cases with a significant diameter or threatening complications surgical treatment is recommended.

Case report of gross hematuria in the nutcracker syndrome resolved by renocaval reimplantation.

Introduction: Nutcracker syndrome is defined as a set of signs and symptoms secondary to compression of the left renal vein (LRV) in the acute anatomic angle between the aorta and its superior mesenteric branch. Case report: A 38-year old woman with asymptomatic and "idiopathic" gross hematuria came to the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade. Hematuria was documented by cystoscopy and was found to be unilateral, located to the left urethral orifice. The contrast-enhanced multidetector computed tomography (MDCT) scan showed a stenotic LRV due to the extrinsic compression in the angle formed by the ventral aorta and superior mesenteric artery (MSA), with a jet of contrast through the lumen. Considering the negative investigations for more common causes of hematuria, its incapacitating nature, and above mentioned imaging findings suggestive of the nutcracker syndrome, an indication for the open surgical correction of the LRV entrapment was established. The patient underwent reimplantation of the LRV into the more distal inferior vena cava (IVC), to relocate it out of the constrictive aortomesenteric space. Intraoperative findings were notable for blood flow turbulence in the LRV and hypertrophy of its tributaries, which were ligated. We presented the first published case in the Serbian literature on nutcracker syndrome with hematuria resolved by renocaval reimplantation. Conclusion: This case report demonstrates that renocaval reimplantation, as the open surgery technique, could be the adequate method for resolving gross hematuria in patients with nutcracker syndrome.

Reborn of Internal-External Carotid Artery Transposition as a Repair Method for Shotgun Injury of Neck Zone 2.

A 26-year-old male presented to the emergency center having been shot in the neck. Multislice computed tomography angiography revealed injury of the right internal carotid artery at level of the carotid bifurcation with hematoma and injury of right internal jugular vein. Under general anesthesia, transposition of internal carotid artery to external carotid artery, with ligation of internal jugular vein, was successfully performed. This case emphasizes the value of "old fashion" surgical treatment in modern endovascular age.

Open Surgical Repair of Aortoiliac Aneurysm, Left Pelvic Kidney and Right Kidney Malposition with Aberrant Vascularization, and Compressive Syndrome.

We present the case of a 65-year-old male patient with aortoiliac aneurysm associated with a congenital left pelvic kidney vascularized by left common iliac artery and right malposition kidney vascularized by 2 aberrant arteries, which sprout from the aneurysm. In addition, the patient had right iliacofemoral vein thrombosis caused by right iliac artery aneurysm compression. We faced the challenge of treating the patient while preserving renal function.

Multiple visceral artery aneurysms.

A 63-year-old woman patient was presented with 3 visceral artery aneurysms, which were identified accidentally at nuclear magnetic resonance imaging carried out because of small mass in the left adrenal gland, which was suspected by ultrasound. Computed tomography (CT) examination was indicated and showed fusiform aneurysm on splenic artery, saccular aneurysm of right renal artery, and saccular aneurysm of left segmental renal artery. Also, she experienced hypertension, cardiomyopathy, thyroid gland strum with normal hormone levels, osteoporosis, and rheumatoid arthritis. The patient was treated by open conventional surgery followed by end-to-end anastomosis reconstructions firstly of the right renal and then splenic artery. In 5 days, the patient was released from hospital in good condition. Control CT examination in 9 months did not show enlargement of remaining aneurysm. Histopathology confirmed just typical aneurysm degeneration based on atherosclerosis.

Cystic Adventitial Disease in Former Athlete.

In this paper we present a 39-year old former athlete complaining with pain in his legs during long walk resembling to intermittent claudication. Color duplex scan described a popliteal artery with 10 mm in diameter with mural thrombus that caused stenosis 75% of lumen. Digital subtraction angiography demonstrated a stenosis of right popliteal artery. The suspicion for Cystic adventitial disease was set. The patient was operated on by posterior direct approach. After incision, a yellowish viscous material was observed in adventitia. Partial resection of the affected popliteal artery and replacement by an autogenous great saphenous vein graft was performed. Patient was dismissed on the seventh postoperative day, in good condition and without any complication. Cystic adventitial disease of the popliteal artery should be considered in the differential diagnosis of intermittent claudication, especially in former sportsmen patients. Partial resection of the affected popliteal artery and replacement by an autogenous great saphenous vain graft produces excellent results.

Hepatic artery aneurysm developing after Billroth's operation.

In this report we review the unusual case of a patient with a common hepatic artery aneurysm presenting 30 years after a Billroth's II resection. A 65-year-old man with epigastric pain and 10 kg of weight loss in the previous 6 months was referred to our clinic. Computed tomography revealed the presence of an aneurysm of the common hepatic artery (HAA) of 35 mm. This HAA was surgically excluded by aneurysmectomy and prosthetic bypass. Intraoperatively we observed extensive peritoneal adhesions and connective tissue formation in the region of the hepatoduodenal and hepatogastric ligaments, and the outer wall of the HAA was tightly affixed to the root of the transverse mesocolon by connective adhesions. Retraction of the adhesions slowly brought about a continued stretching and thinning of the arterial wall likely caused the HAA.