Bacterial Species Involved in Venous Leg Ulcer Infections and Their Sensitivity to Antibiotherapy-An Alarm Signal Regarding the Seriousness of Chronic Venous Insufficiency C6 Stage and Its Need for Prompt Treatment.

BACKGROUND: Venous leg ulcers (VLUs) are a common chronic wound condition susceptible to infection by various bacterial species. Understanding bacterial presence and antibiotic sensitivity is crucial for effective treatment. Methodsː Medical records of 60 patients diagnosed with the C6 chronic venous insufficiency stage were analyzed retrospectively. The patients were divided into an active recurrent VLU group (33 cases) and a first-onset active VLU group (27 cases). Bacterial identification, antibiotic sensitivity, and laboratory markers were assessed. Resultsː Pseudomonas aeruginosa was the most prevalent bacterial species in both the study (72.72%) and control (37.03%) groups, along with other common bacteria such as Proteus mirabilis, Enterococcus sp., Staphylococcus aureus, Acinetobacter baumannii, Klebsiella spp., and Escherichia coli. Furthermore, uncommon bacteria, including Providencia rettgeri, Group B Streptococcus, and Salmonella Paratyphi B, and a fungal infection with Candida albicans, were identified only in the study group, while Morganella morganii was found exclusively in the control group. Pseudomonas aeruginosa showed significant sensitivity to several antibiotics, particularly Amikacin and Meropenem. Nonspecific laboratory markers, such as CRP, fibrinogen, ESR, WBC, CK, neutrophils, and lymphocytes, revealed statistically significant differences between groups, indicating their potential as biomarkers for monitoring recurrent VLUs. Conclusionsː These results highlight the need for comprehensive diagnostic approaches to effectively manage VLU infections and improve patient outcomes. Further research is warranted to explore factors influencing the presence of uncommon bacteria and to develop targeted interventions for VLU management.

Impact of haemoglobin A1c on wound infection in patients with diabetes with implanted synthetic graft.

OBJECTIVE: The aim of this study was to assess the relationship between haemoglobin A1c (HbA1c) values and operative wound infection. METHOD: During the period from 2013-2016, consecutive patients with type 2 diabetes were prospectively evaluated. Data were retrospectively analysed. All included patients were admitted for an elective surgical procedure, requiring the use of prosthetic graft in a groin wound. The patients were divided into two groups according to their preoperative HbA1c values. The main outcome was groin wound infection. The association between preoperative long-term glycoregulation and wound infection was evaluated, as well as the impact of postoperative glycaemic values, regardless of the level of HbA1c. RESULTS: Of the 93 participating patients, wound infection occurred in 20 (21.5%). Wound infection occurred in 28.2% of patients with uncontrolled diabetes (HbA1c >7%) and 16.7% of patients with controlled diabetes (HbA1c <7%); however, the difference did not reach statistical significance (p=0.181). In regression modelling, operative time (p=0.042) was a significant predictor of wound infection, while patients' age (p=0.056) was on the borderline of statistical significance. Females had a higher probability for wound infection (odds ratio (OR): 1.739; 95% confidence interval (CI):0.483-6.265), but there was no statistical significance (p=0.397). Patients with elevated levels of HbA1c had a higher chance of wound infection compared with patients with controlled diabetes (OR: 2.243; 95% CI: 0.749-6.716), nevertheless, this was not statistically significant (p=0.149). CONCLUSION: We found no statistically significant correlation between elevated values of preoperative HbA1c and postoperative groin wound infection.

Case study scrub nurse role in aorto-bifemoral reconstruction with transbrachial balloon endoclamping technique.

INTRODUCTION: Aortoiliac arterial disease is a chronic progressive disease which is characterized by steno-occlusive changes in the aorta and iliac arteries. The gold standard for the treatment of patients with the advanced stage of the disease is aorto-bifemoral reconstruction. Patients with circumferential juxtarenal calcifications of the aorta bear a high risk of intraoperative complications, due to difficult cross-clamping in such zones. CASE REPORT: We present a case of a 73-year-old patient who has been admitted due to left leg rest pain and second toe ulceration. Multislice computed tomography showed significant stenosis of the aortoiliac segment with a circumferentially calcified abdominal aorta. Aortobifemoral reconstruction was performed featuring endoluminal occlusion of the aorta using a balloon catheter which was placed through the left brachial artery. The procedure and the postoperative course were uneventful, and the patient was discharged on the sixth postoperative day. CONCLUSION: The hybrid endovascular and open surgery technique presented emerged as a valid alternative for selected high-risk patients. Scrub nurses should be familiarized with endovascular techniques and tools and be aware of the measures to be protected from the harmful effects of ionizing radiation.

Enhancing predictive accuracy of the cardiac risk score in open abdominal aortic surgery: the role of left ventricular wall motion abnormalities.

Background: Open abdominal aortic surgery carries many potential complications, with cardiac adverse events being the most significant concern. The Vascular Study Group Cardiac Risk Index (VSG-CRI) is a commonly used tool for predicting severe cardiac complications and guiding clinical decision-making. However, despite the potential prognostic significance of left ventricular wall motion abnormalities (LVWMAs) and reduced LV ejection fraction (LVEF) for adverse outcomes, the VSG-CRI model has not accounted for them. Hence, the main objective of this study was to analyze the added value of LV wall motion on the discriminatory power of the modified VSG-CRI in predicting major postoperative cardiac complications. Methods: A prospective study was conducted involving 271 patients who underwent elective abdominal aortic surgery between 2019 and 2021. VSG-CRI scores were calculated, and preoperative transthoracic echocardiography was conducted for all patients. Subsequently, a modified version of the VSG-CRI, accounting for reduced LVEF and LVWMAs, was developed and incorporated into the dataset. The postoperative incidence of the composite endpoint of major adverse cardiac events (MACEs), including myocardial infarction, clinically relevant arrhythmias treated with medicaments or by cardioversion, or congestive heart failure, was assessed at discharge from the index hospitalization, with adjudicators blinded to events. The predictive accuracy of both the original and modified VSG-CRI was assessed using C-Statistics. Results: In total, 61 patients (22.5%) experienced MACEs. Among these patients, a significantly higher proportion had preoperative LVWMAs compared to those without (62.3% vs. 32.9%, p < 0.001). Multivariable regression analysis revealed the VSG-CRI [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.21-1.77; p < 0.001] and LVWMA (OR 2.76; 95% CI 1.46-5.23; p = 0.002) as independent predictors of MACEs. Additionally, the modified VSG-CRI model demonstrated superior predictability compared to the baseline VSG-CRI model, suggesting an improved predictive performance for anticipating MACEs following abdominal aortic surgery [area under the curve (AUC) 0.74; 95% CI 0.68-0.81 vs. AUC 0.70; 95% CI 0.63-0.77; respectively]. Conclusion: The findings of this study suggest that incorporating preoperative echocardiography can enhance the predictive accuracy of the VSG-CRI for predicting MACEs after open abdominal aortic surgery. Before its implementation in clinical settings, external validation is necessary to confirm the generalizability of this newly developed predictive model across different populations.

Analysis of Lower Extremity Amputations from the SerbVasc Registry.

BACKGROUND: Peripheral arterial disease (PAD) and diabetes are the major causes of lower extremity amputations (LEAs) worldwide. Morbidity and mortality in patients with LEAs are high with an associated significant burden on the global health system. The aim of this article is to report the overall morbidity and mortality rates after major and minor LEAs from the Serbian Vascular Registry (SerbVasc), with an analysis of predictive factors that influenced adverse outcomes. MATERIALS AND METHODS: SerbVasc was created in 2019 as a part of the Vascunet collaboration that is aiming to include all vascular procedures from 21 hospitals in Serbia. Prevalence of diabetes among patients with LEAs, previous revascularization procedures, the degree and the type of foot infection and tissue loss, and overall morbidity and mortality rates were analyzed, with a special reference to mortality predictors. RESULTS: In the period from January 2020 to December 2022, data on 702 patients with LEAs were extracted from the SerbVasc registry, mean age of 69.06±10.63 years. Major LEAs were performed in 59%, while minor LEAs in 41% of patients. Diabetes was seen in 65.1% of the patients, with 44% of them being on insulin therapy. Before LEA, only 20.3% of patients had previous peripheral revascularization. Soft tissue infection, irreversible acute ischemia, and Fontaine III and IV grade ischemia were the most common causes of above-the-knee amputations while diabetic foot was the most common cause of transphalangeal and toe amputations. The infection rate was 3.7%, the re-amputation rate was 5.7%, and the overall mortality rate was 6.9%, with intrahospital mortality in patients with above-the-knee amputation of 11.1%. The most significant intrahospital mortality predictors were age >65 years (p<0.001), chronic kidney disease (CKD) (p<0.001), ischemic heart disease (IHD) (p=0.001), previous myocardial revascularization (p=0.017), emergency type of admission (p<0.001), not using aspirin (p=0.041), using previous anticoagulation therapy (p=0.003), and postoperative complications (p<0.001). CONCLUSIONS: The main predictors of increased mortality after LEAs from the SerbVasc registry are age >65 years, CKD, IHD, previous myocardial revascularization, emergency type of admission, not using aspirin, using previous anticoagulation therapy, and postoperative complications. Taking into account high mortality rates after LEAs and a small proportion of previous peripheral revascularization, the work should be done on early diagnosis and timely treatment of PAD hopefully leading to decreased number of LEAs and overall mortality. CLINICAL IMPACT: Mortality after lower limb amputation from the SerbVasc register is high. A small number of previously revascularized patients is of particular clinical importance, bearing in mind that the main reasons for above-the-knee amputations were irreversible ischemia, Fontaine III and Fontaine IV grade ischemia. Lack of diagnostics procedures and late recognition of patients with PAD, led to subsequent threating limb ischemia and increased amputation rates. The work should be done on early diagnosis and timely treatment of PAD in Serbia, hopefully leading to an increased number of PAD procedures, decreased number of LEAs, and lower overall mortality.

Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System.

Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.

Todd's paralysis due to hyperperfusion syndrome after carotid endarterectomy mimicking postoperative stroke.

Todd's paralysis is a neurological deficit that is observed in <10% of patients following epileptic seizures. Cerebral hyperperfusion syndrome (CHS) is a rare complication following carotid endarterectomy (CEA), seen in 0-3% of the patients, characterized by focal neurological deficit, headache, disorientation, and sometimes seizures. In this case report, we present a case of CHS after CEA followed by seizures and Todd's paralysis that mimicked postoperative stroke. A 75-year-old female patient was admitted for CEA of the right internal carotid artery, following a transient ischemic attack two months prior. Four hours after CEA with graft interposition, the patient suffered a temporary weakness of the left arm and leg followed by generalized spasms within a few seconds. CT angiography showed regular patency of the carotid arteries and the graft, and brain CT showed no sign of oedema, ischemia or hemorrhage. However, left-sided hemiplegia occurred following the seizure, and the patient suffered four more seizures over the next 48 hours, with persisting hemiplegia. On the second postoperative day, the motor skills of the left side fully recovered, and the patient was communicative, and of orderly mental status. Brain CT performed on the third postoperative day showed entire right hemisphere oedema. A moderate hemiparesis with seizures as a consequence of CHS after CEA has been described, however in all cases with seizures and hemiplegia, the underlying cause was always a verified stroke or intracerebral hemorrhage. This case highlights the importance of considering Todd's paralysis in patients with seizures after CEA due to CHS and prolonged periods of hemiplegia after the seizures.

Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery.

BACKGROUND: The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. METHODS: From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. RESULTS: The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. CONCLUSION: The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.

Carotid Restenosis Rate After Stenting for Primary Lesions Versus Restenosis After Endarterectomy With Creation of Risk Index.

PURPOSE: Carotid artery stenting (CAS) is an option for carotid restenosis (CR) treatment with favorable outcomes. However, CAS has also emerged as an alternative to carotid endarterectomy (CEA) for the management of patients with primary carotid stenosis. This study aimed to report CR rates after CAS was performed in patients with primary lesions versus restenosis after CEA, to identify predictors of CR, and to report both neurological and overall outcomes. MATERIALS AND METHODS: From January 2000 to September 2018, a total of 782 patients were divided into 2 groups: The CAS (prim) group consisted of 440 patients in whom CAS was performed for primary lesions, and the CAS (res) group consisted of 342 patients with CAS due to restenosis after CEA. Indications for CAS were symptomatic stenosis/restenosis >70% and asymptomatic stenosis/restenosis >85%. A color duplex scan (CDS) of carotid arteries was performed 6 months after CAS, after 1 year, and annually afterward. Follow-up ranged from 12 to 88 months, with a mean follow-up of 34.6±18.0 months. RESULTS: There were no differences in terms of CR rate between the patients in the CAS (prim) and CAS (res) groups (8.7% vs 7.2%, χ2=0.691, p=0.406). The overall CR rate was 7.9%, whereas significant CR (>70%) rate needing re-intervention was 5.6%, but there was no difference between patients in the CAS (prim) and CAS (res) groups (6.4% vs 4.7%, p=0.351). Six independent predictors for CR were smoking, associated previous myocardial infarction and angina pectoris, plaque morphology, spasm after CAS, the use of FilterWire or Spider Fx cerebral protection devices, and time after stenting. A carotid restenosis risk index (CRRI) was created based on these predictors and ranged from -7 (minimal risk) to +10 (maximum risk); patients with a score >-4 were at increased risk for CR. There were no differences in terms of neurological and overall morbidity and mortality between the 2 groups. CONCLUSIONS: There was no difference in CR rate after CAS between the patients with primary stenosis and restenosis after CEA. A CRRI score >-4 is a criterion for identifying high-risk patients for post-CAS CR that should be tested in future randomized trials.

Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience.

The primary aim of the presented study is to analyze and compare the rate of carotid restenosis in patients after eversion carotid endarterectomy (eCEA), primary carotid angioplasty and stenting (CASp), and stenting for carotid artery restenosis after previous eCEA (CASr). The secondary aim is to compare clinical outcomes in patients with carotid restenosis. The total number of patients with evident carotid restenosis was 223 (24.8%). In patients with eCEA, significant carotid restenosis rate was 12.7%, in the CASp group 18.7%, and CASr 6.7%. Patients with carotid restenosis were asymptomatic in 95.1% of cases. Patients in the CASp group experienced transient ischemic attack more than patients with eCEA (P = .007), while no difference was observed regarding cerebrovascular insult (CVI). The incidence of carotid restenosis was higher in CASp patients, and increased during the follow-up. The majority of patients are asymptomatic post-procedural and the degree of carotid restenosis does not correlate with the occurrence of postoperative symptoms. High low-density lipoprotein cholesterol (LDL-C) levels, low high-density lipoprotein cholesterol (HDL-C) levels, smoking, and a history of vascular surgery correlate with higher degrees of carotid restenosis. The most important factor in the prevention of carotid restenosis is risk factor control as well as adequate pharmacological therapy.

Body mass index and early outcomes after carotid endarterectomy.

As the existing data on the correlation of adiposity with adverse outcomes of carotid endarterectomy (CEA) are inconsistent, the aim of the present study is to examine the correlation of an increased body mass index with 30-day complications after carotid endarterectomy. The cohort study comprises 1586 CEAs, performed at the Clinic for Vascular Surgery in Belgrade, from 2012-2017. Out of them, 550 CEAs were performed in patients with normal body mass index (18.5-24.9), 750 in overweight (25.0-29.9), and 286 in obese (≥30) patients. The association of overweight and obesity with early outcomes of carotid endarterectomy was assessed using univariate and multivariate logistic regression analysis. Overweight patients, in whom CEAs were performed, were significantly more frequently males, compared to normal weight patients-Odds Ratio (OR) 1.51 (95% confidence interval- 1.19-1.89). Moreover, overweight patients significantly more frequently had non-insulin-dependent diabetes mellitus-OR 1.44 (1.09-1.90), and more frequently used ACEI in hospital discharge therapy-OR 1.41 (1.07-1.84) than normal weight patients. Additionally, the CEAs in them were less frequently followed by bleedings-OR 0.37 (0.16-0.83). Compared to normal weight patients, obese patients were significantly younger-OR 0.98 (0.96-0.99), and with insulin-dependent and non-insulin-dependent diabetes mellitus-OR 1.83 (1.09-3.06) and OR 2.13 (1.50-3.01) respectively. They also more frequently had increased triglyceride levels-OR 1.36 (1.01-1.83), and more frequently used oral anticoagulants in therapy before the surgery-OR 2.16 (1.11-4.19). According to the results obtained, overweight and obesity were not associated with an increased death rate, transient ischemic attack (TIA), stroke, myocardial infarction, or with minor complications, and the need for reoperation after carotid endarterectomy. The only exception was bleeding, which was significantly less frequent after CEA in overweight compared to normal weight patients.

Direct Ischemic Postconditioning After Carotid Endarterectomy in the Prevention of Postoperative Cerebral Ischemic Complications-Observational Case-Control Study.

INTRODUCTION: Ischemic postconditioning (IPCT) represents one of the several therapeutic strategies to attenuate ischemic reperfusion injury (IR) after carotid endarterectomy (CEA). We here present the first in-human study of IPCT in carotid surgery. METHODS: The study represents an observational case-control study, with the data collected in our Institution carotid database. From December 2015 to December 2020, a total of 300 patients were included in our study; IPCT group consisted of 148 patients in whom ischemic postconditioning was performed while control group consisted of 152 patients in whom IPCT was not performed. Indications for IPCT technique were: severe unilateral internal carotid artery (ICA) stenosis (>90%), severe bilateral ICA stenosis (>80%), severe ICA stenosis (>80%) with contralateral ICA occlusion and ICA subocclusion. IPCT was performed by applying 6 cycles of 30 sec reperfusion (declamping of ICA)/30 sec ischemia (clamping of ICA) after finishing the procedure and initial declamping. Two groups of patients were compared in terms of occurrence of intrahospital and early postoperative stroke, TIA (transient ischemic attack) and neurologic morbidity. RESULTS: Cumulative incidence of intrahospital postoperative stroke or TIA was significantly higher in the control group (5.3% vs 0.7%, P = .036). According to carotid plaque characteristics, patients in the IPCT group had significantly more frequent presence of heterogenous plaque, as well as ulcerated plaque, which was associated with the absence of postoperative stroke and significantly lower cumulative rate of TIA/stroke when compared to the control group (43.9% vs 8% and 47.3% vs 1.5%). During the follow-up period of 1 month after the surgery, there were no cases of stroke, TIA and deaths due to neurological causes in both groups of patients. CONCLUSION: Our results showed that IPCT significantly reduced the incidence of postoperative cerebral ischemic complications after CEA in high-risk patients for IR injury when compared to the control group.

Long-term results after simultaneous carotid and coronary revascularisation.

BACKGROUND: The revascularisation strategy for concomitant carotid and coronary disease is unknown. Simultaneous or stage coronary artery stenting and carotid endarterectomy are the most common revascularisation approach in the CABG population. This study aimed to evaluate long-term results after simultaneous carotid artery stenting or carotid endarterectomy in patients who underwent coronary artery bypass surgery. METHODS: This is a prospective cohort non-randomised single-institution study. During the period from 2012 to 2015, sixty consecutive patients (65.9 ± 7.41 mean) underwent simultaneous carotid artery stenting and coronary artery bypass surgery (n = 30) or simultaneous carotid endarterectomy and coronary artery bypass surgery (n = 30). The primary endpoints were short- and long-term rates of adverse events (transient ischemic attack, stroke, myocardial infarction, and death). The mean follow-up was 62.05 ± 11.12 months. RESULTS: In-hospital mortality was insignificantly higher in the carotid endarterectomy, and coronary artery bypass surgery group (6.6% vs. 0%), the rate of stroke and myocardial infarction was similar (13.3% and 0% in the carotid endarterectomy and coronary artery bypass surgery group vs. 6.6% and 3.3% in the carotid artery stenting and coronary artery bypass surgery group, respectively). The intensive care unit readmission was significantly higher in the surgical revascularisation approach; it was an independent predictor of hospital mortality. The overall mortality during the follow-up period was 14.28% in both groups. Freedom of the composite adverse outcomes (stroke, myocardial infarction, and death) was 78.55%. CONCLUSION: Comparing two revascularisation strategies is not straightforward due to different anatomical indications for carotid artery stenting and endarterectomy. We consider that each technique has an essential role in carotid revascularisation. Good selection of patients, according to indications, contributes to satisfactory short- and long-term results.

Transcatheter Aortic Valve Implantation: A Report on Serbia's First Systematic Program.

Introduction: Severe aortic stenosis, a highly-common valve disease in the elderly, has a poor prognosis if left untreated. To address the concern of effective procedures for severe aortic stenosis, a systematic TAVI program was established at the Dedinje Cardiovascular Institute (Belgrade, Serbia). Methods: Our cohort was composed of 56 patients (74±15 years old). The mean logistic EuroScore was 10.17%; the mean Society of Thoracic Surgeons score was 3.22%. One third of the patients were categorized as class III or IV of the New York Heart Association (NYHA). The valves selected for use were either self-expandable or balloon expandable (Evolut R, Medtronic; Acurate Neo, Boston Scientific and Myval, Meril). The choice of valve type was made by the Institute's Structural Heart Team, in accordance with the patient's native aortic valve, size and calcification of ilio-femoral vessels, as well as the need for alternative access. TAVI procedure was conducted according to current guidelines provided by the European Society of Cardiology. Results: The procedure success rate was 100%. Trans-femoral approach was achieved in 100% of patients; percutaneously in 87.5%, while a surgical cut was necessary in 12.5%. No patient showed moderate or severe aortic regurgitation after the procedure, although trace or mild regurgitation was recorded in 30.3%. Permanent pacemaker was implanted in one patient (1.78%), contrast induced acute kidney injury occured in one patient (1.78%), no stroke was recorded, and three pseudo-aneurysms which required surgical intervention occurred. Three patients required blood transfusions (5.33%). A 30-day all-cause mortality rate was 1.78%. Conclusion: The Dedinje Cardiovascular Institute spearheaded all efforts to establish a TAVI program in Serbia. Our initial TAVI results are promising, encouraging, and comparable with the results of previous large randomized trials. This initial experience opens the door for further development with a goal of our Institute to become a high-volume TAVI center.

Giant splenic artery aneurysm treated surgically with spleen and pancreas preservation.

Aneurysms of the splenic artery represent a rare clinical entity, even though they account for 60-70% of all visceral artery aneurysms. Splenic artery aneurysms larger than 5 cm are extremely rare, and they are considered to be giant. Possible causes of splenic artery aneurysm development include: trauma, hormonal and local hemodynamic changes in pregnancy, portal hypertension, arterial degeneration, infection and postsplenectomy occurrence. Surgical treatment of giant splenic artery aneurysms includes procedures that frequently require pancreatectomy and splenectomy. We present a case of a 10.2 cm giant splenic artery aneurysm, firmly adhered to the pancreas, which was treated surgically, with spleen and pancreas preservation. SIMILAR CASES PUBLISHED: Although many cases on treatment of giant splenic artery aneurysm have been published, the majority have described additional visceral resections associated with aneurysmectomy, which is in contrast with our report. Furthermore, aneurysms reaching 10 cm in size were extremely rare.

Midterm Results After Simultaneous Carotid Artery Stenting and Cardiac Surgery.

BACKGROUND: The presence of carotid artery disease is known risk factor for perioperative stroke in cardiac surgery. The optimal management of patients with concomitant heart and carotid artery disease is not known. Simultaneous or staged carotid endarterectomy has been proposed to prevent stroke. In an attempt to reduce perioperative morbidity and death, simultaneous carotid stenting and cardiac surgery were implemented (hybrid procedure). This study evaluated early and midterm results after the hybrid procedure. METHODS: From November 2012 through November 2018, 54 patients (36 men; an average age, 65.8 ± 7.3 years) underwent the hybrid procedure. The primary end points were the occurrence of perioperative cerebral stroke, transient ischemic attack (TIA), acute myocardial infarction, bleeding, or death. The mean follow-up period was 30 months. RESULTS: The 30-day mortality was 0%. Periprocedural incidence of stroke and transient ischemic attack were 1.9% and 7.6%, respectively, and acute myocardial infarction occurred in 1 patient (1.9%). No patients required repeat thoracotomy for bleeding. Four patients (7.6%) died during follow-up. The cause of death was stroke in 2 patients (3.8%), heart failure in 1 (1.9%), and multiorgan failure in 1 (1.9%). In-stent restenosis of the carotid artery occurred in 1 patient (1.9%). CONCLUSIONS: In this small group of patients, the hybrid procedure proved to be a safe and efficient treatment for patients with concomitant carotid and cardiac diseases. The low rate of perioperative complications and good midterm results are encouraging.

Prevalence, clinical characteristics, and predictors of peripheral arterial disease in hemodialysis patients: a cross-sectional study.

BACKGROUND: Peripheral arterial disease (PAD) is common in patients with end-stage renal disease on hemodialysis, but is frequently underdiagnosed. The risk factors for PAD are well known within the general population, but they differ somewhat in hemodialysis patients. This study aimed to determine the prevalence of PAD and its risk factors in patients on hemodialysis. METHODS: This cross-sectional study included 156 hemodialysis patients. Comorbidities and laboratory parameters were analyzed. Following clinical examinations, the ankle-brachial index was measured in all patients. PAD was diagnosed based on the clinical findings, ankle-brachial index < 0.9, and PAD symptoms. RESULTS: PAD was present in 55 of 156 (35.3%; 95% CI, 27.7-42.8%) patients. The patients with PAD were significantly older (67 ± 10 years vs. 62 ± 11 years, p = 0.014), more likely to have diabetes mellitus (p = 0.022), and anemia (p = 0.042), and had significantly lower serum albumin (p = 0.005), total cholesterol (p = 0.024), and iron (p = 0.004) levels, higher glucose (p = 0.002) and C-reactive protein (p < 0.001) levels, and lower dialysis adequacies (p = 0.040) than the patients without PAD. Multivariate analysis showed higher C-reactive protein level (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06; p = 0.030), vascular access by Hickman catheter (OR, 4.66; 95% CI, 1.03-21.0; p = 0.045), and symptoms of PAD (OR, 5.20; 95% CI, 2.60-10.4; p < 0.001) as independent factors associated with PAD in hemodialysis patients. CONCLUSION: The prevalence of PAD was high among patients with end-stage renal disease on hemodialysis. Symptoms of PAD, higher C-reactive protein levels, and Hickman vascular access were independent predictors of PAD in patients on hemodialysis.

Surgical Treatment of Proximal Segmental Occlusion of the Internal Carotid Artery.

PURPOSE: To present the feasibility, safety, and efficacy of carotid endarterectomy in patients with type II internal carotid artery occlusions, including the long-term outcomes. METHODS: From March 2008 to August 2015, 74 consecutive patients (48 men with a mean age of 65.1 ± 8.06 years) underwent carotid endarterectomy because of internal carotid artery (ICA) segmental occlusions. These were verified with preoperative carotid duplex scans (CDS) and CT angiography (CTA). Also, brain CT scanning was performed in all these patients. The indication for treatment was made jointly by a vascular surgeon, neurologist, and an interventional radiologist in a multidisciplinary team (MDT) context. After successful treatment, all the patients were followed-up at 1, 3, 6, and 12 months, then every 6 months thereafter. RESULTS: The most common symptom at presentation was transient ischaemic attack (TIA) in 49 patients (66.2%), followed by stroke in the past six months in the 17 remaining patients (23%). Revascularisation of the ICA with endarterectomy techniques was performed successfully in all the patients with an average clamp time of 11.9 min. All the procedures were performed under general anaesthesia in combination with a superficial cervical block. The early complication rate was 8.1% and included two cardiac events (2.7%) (one rhythm disorder and one acute coronary syndrome), three TIAs (4.1%), and one intracerebral hemorrhage (1.3%). Only one patient with the intracerebral hemorrhage died 5 days after surgery giving a postoperative mortality of 1.3% for this series. During the follow-up period (mean 50.4 ± 31.3 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 94.9%, 92.9%, and 82.9%, respectively. Likewise, the survival rates were 98.7%, 96.8%, 89%, and 77.6%, respectively. Ultrasound Doppler controls during follow-up detected 8 ICA restenoses; however, only 3 of these patients required further endovascular treatment. CONCLUSIONS: Carotid endarterectomy of internal carotid artery (ICA) segmental occlusion is a safe and effective procedure associated with acceptable risk and good long-term results. Therefore, the current guidelines which do not recommend carotid endarterectomy in this patient group should be reassessed, with the requirement for ongoing large-scale randomized controlled trials to compare CEA with best medical therapy in this patient cohort.