Endovascular or open surgical treatment of high-risk patients with infrainguinal peripheral arterial disease and critical limb ischemia.

Aim To determine preferable type of treatment in our clinical circumstances by following two groups of patients with critical limb ischemia (CLI), who were treated endovascularly and surgically. Methods Research was carried out in the form of a prospective study of 80 patients with CLI and Trans-Atlantic Inter-Society Consensus (TASC) C or D type of arterial disease, with American Society of Anesthesiology (ASA) class III risk, who were randomly divided in two groups as per the treatment they received, surgical and endovascular. Patients were followed during 28 months using clinical examination and Duplex Ultrasound (DUS) in accordance with prescheduled control visits. Results There was a statistical difference between surgical and endovascular group in two years patency (82.5% vs. 55%; p=0.022) but it did not result in the difference in amputation free survival (AFS) (95% vs. 85%; p=0.171) or two-year freedom from major adverse limb events (MALE) (87.5 vs. 77.5; p=0.254). Also, there was no difference in the overall survival of patients (100% vs. 97.5%; p=0.317). Conclusion Initial endovascular treatment is a preferred form of the treatment for selected patient population.

Does the new vascular management of acute limb ischemia have effective results with lower treatment costs.

Aim To compare hospital costs of acute limb ischemia treatment in two periods of time and to show evidence of long-term repercussions on reducing costs during successful treatment. Methods Retrospective analysis of data obtained from 100 patients' medical history in the period 2000-2016 at the Clinic of Vascular Surgery Sarajevo: group A - 60 patients with acute limb ischemia in the period 2005-2016 and group B - 40 patients with acute limb ischemia (ALI) in the period 2000-2005. From 2000 to 2005 conservative treatment method was used, invasive diagnostic and surgical procedures were often delayed for a shorter or longer period of time. During the period from 2005 to 2016, the management model and safe practice included emergency diagnostic procedures, colour-Doppler, arteriography, emergency surgery (embolectomy by Fogharty and if necessary, vascular by-pass). Results Better health service for the patients with acute limb ischemia was offered in the period 2005-2016, which relied on proven medical treatment trends. The largest share of the total costs of each patient included costs of hospital bed with significant difference between the period 2005-2016 and 2000-2005, mean of 1398.71 KM and 2480.45KM, respectively (p<0.0001), indicating rationalization of time that patients spend at the Vascular Clinic. Conclusion This trend of money/fund savings is an example of good practice, effectiveness and efficiency in the treatment of ALI and as such was used in patients with other vascular diseases.

Is 64-Row Multi-Detector Computed Tomography Angiography Equal to Digital Subtraction Angiography in Treatment Planning in Critical Limb Ischemia?

BACKGROUND: Critical limb ischemia (CLI) represents the end stage of peripheral arterial disease (PAD). It is defined as a chronic ischemic rest pain, ulcers or gangrene, attributable to proven arterial occlusive disease. Intra-arterial digital subtraction angiography (IA DSA) still represents the gold standard for the evaluation of steno-occlusive lesions, but it has greatly been replaced with non-invasive multi-detector computed tomography angiography (MDCTA). The purpose of this prospective study was to compare diagnostic performance of MDCTA versus DSA in treatment planning in patients with CLI according to TransAtlantic Inter-Society Consensus Document on Management of Peripheral Arterial disease (TASC II). SUBJECTS AND METHODS: The study was designed as prospective; it was conducted from March 2014 to August 2016, and included 60 patients with symptoms of CLI, Fontaine stage III and IV. MDCTA of the peripheral arteries was performed first, followed by DSA. The lesions of aorto-iliac, femoro-popliteal and infra-popliteal regions were classified according to the TASC II guidelines, and inter-modality agreement between MDCTA and DSA was determined by using Kendall's tau-b statistics. RESULTS: Inter-modality agreement was statistically significant in all three vascular beds, with excellent agreement >0.81 in aortoiliac and femoropopliteal regions, and a very good agreement >0.61 in infrapopliteal region. Treatment recommendations based on MDCTA findings and DSA findings were identical in 54 (90%) patients. In one patient (1.7%), CTA was not interpretable. In five patients (8.3%), CTA findings disagreed with DSA findings in regard to the preferable treatment option. CONCLUSION: 64-row MDCT angiography is highly competitive to DSA in evaluation of steno-occlusive disease and treatment planning in patients with critical limb ischemia.

Cost-Effectiveness Analysis of Treatment Acute Deep Vein Thrombosis in Clinic of Vascular Surgery Sarajevo.

AIM: To compare hospital costs of acute deep vein thrombosis (ADVT) treatment in two periods of time. Evidence of repercussions on reducing costs during successful treatment. Attention was given to the necessity, costs and effectiveness of diagnostic procedures, treatment and complications. METHODS: A retrospective analysis of data obtained from patients medical history in a period from 2000 to 2016. Model management and safe practice of ADVT care consisted of clinical examination, laboratory, colour Doppler and invasive diagnostics. In a treatment was used continuous infusion un-fractionated heparin for 40 patients from 2000th till 2006th and low molecular weight heparin for 40 patients from 2006th till 2016th. All patients were converted to oral anticoagulants. RESULTS: When we look at the overall picture of improving the management model, safe practices and economic rationalization, we conclude that we offer better health service for the patients with ADVT at the moment, which relies on proven medical treatment trends. While we do not forget responsibility towards a society of which depends on treatment funding. CONCLUSION: The implementation of a conceptually new model of management of ADVT did not contribute rise of the desired outcomes, but it justified the positive economic viability of introduced changes at the Clinic of Vascular surgery than the previous concept.

Comparison of Results Classical and Eversion Carotid Endarterectomy.

INTRODUCTION: Atherosclerosis blood vessels, be it on extra-cranial or intra-cranial circulation, the most common cause of incidents such as cerebro-vascular insult (ICV). Carotid endarterectomy (CEA) is a preventive operation to reduce the risk of stroke and it can be performed by eversion carotid endarterectomy (E-CEA) or a classical carotid endarterectomy (C-CEA). The aim of this study was to investigate the influence of the used techniques in basic perioperative results and the incidence of postoperative complications. MATERIALS AND METHODS: It was retrospective-prospective study that involved 173 patients, with carotid stenosis, who underwent CEA, in the period of time December 2013 till December 2016. Subjects were divided into two groups in respect of technique: 90 patients were treated with E-CEA and 83 patients were treated with C-CEA. RESULTS: Between two groups revealed a significant difference in favor of the patients from group E-CEA in the length of the surgery (92.56 ± 29.11 min. vs. 104.04 ± 18.01 min., P = 0.000), the time of clamping the carotid arteries (11.83 ± 1.81 min. vs. 23.69 ± 5:39 min., p = 0.000), the amount of post-operative drainage (25.33 ± 24.67 ml. vs. 36.14 ± 14:32 ml., p = 0.001), time spent in the intensive care unit (± 25.43 vs. 13:51 hours 34.54 ± 35.81 hours, p = 0.000), and the length of stay (4.60 ± 0.90 days vs. 5:42 ± 1.80 days, p = 0.001). In the patients of the group E-CEA, fewer number of individual postoperative complications without statistical significance: ICV (2.2% vs. 4.8%, p = 0.351), cardiac arrhythmia (2.2% vs. 4.8%, p = 0.351), transitory ischaemic attack (TIA) and cognitive disorder (2.2% vs. 7.2%, p = 0.117), mortality (1.1% vs. 1.2%, p = 0.954); and the total number of postoperative complications was significantly less in the same patients (7.77% vs. 18.7%, p = 0.042). CONCLUSION: The results of this study clearly indicate that operating techniques affects the specified monitored outcomes of vascular treatment of carotid arteries in favor of E-CEA technique. It would be ideally that the conclusions of this study contribute to broader use of E-CEA in treatment of carotid stenosis.

Hidden Danger of Irrational Abusing Illegal Androgenic-anabolic Steroids in Recreational Athletes Age Under 35 in Bosnia & Herzegovina.

INTRODUCTION: Androgenic-anabolic steroids are rarely used by sportsmen who want to improve physical performance in competition sport. Despite that they are well aware of the side effects of anabolic steroids, many young athletes in Bosnia and Herzegovina without competition motivation come in temptation, trying to achieve better muscle proportion and physical performance unknowing consequence of side effects and what is hiding behind. Risk factors such as increasing of lipid levels and arterial hypertension are major factors which have important role in the Pathogenesis of atherosclerosis and are responsible for occurrence of cardiovascular disease even causing a sudden death in young athletes. OBJECTIVE: The aim of the study was to estimate the frequency of misusing of androgenic anabolic steroid drugs in young recreational sportsmen without competition motivation. This study will try to estimate vascular and lipid status, analyzing the side effects of steroids in young recreational athletes under the age of 35, in Bosnia and Herzegovina. METHODS: The study included 70 individuals in period of 2010 till 2015 on recreational exercising program; 35 individuals misusing androgenic anabolic steroids during the period of 5 years were compared with 35 individuals which do not use androgenic anabolic steroids. Non-invasive methods were used in all individual (clinical examination and vascular ultrasound examination of vein system). The routine of training units in both groups was approximately two hours 4-6 times per week. RESULTS: Final analysis has reveal that in androgenic anabolic steroids group in 18 individuals or 55.7% arterial hypertension with hyperlipidemia was more represented, compared with the group without using anabolic steroids, represented by 2 individuals or 5.7% and it was statistically considered significant by using p value less than 0.05. (p<0.05). Statistically dominant population using anabolic steroids drugs are males (100%) or 35 individuals; we did not find females using anabolic steroids and that is why our research was limited to male population. CONCLUSION: Recreational male sportsmen are dominant androgenic anabolic steroids misusers, trying to achieve better muscle proportion and physical performance, they neglect the anabolic steroids side effects which have devastating consequence on vascular system. Benefits of misusing drugs in recreational exercising program in young sportsmen are mostly connected with development of arterial hypertension and hyperlipidemia and the variety of serious health disorders, progressing the pathogenesis of cardiovascular disease.

Perioperative results eversion carotid endarterectomy in bilateral symptomatic stenosis.

INTRODUCTION: Carotid endarterectomy (CEA) is a standard treatment for the prevention of stroke and death in patients with significant stenosis of the internal carotid artery. Eversion endarterectomy is warranted in patients with symptoms of cerebral ischemia and the degree of stenosis of 70-99%. The same is suitable for treating a symptomatic carotid artery stenosis with contralateral stenosis (50-70%). PURPOSE: The aim of this study was to evaluate perioperative complications (ICV, TIA, MI, mortality) in patients treated with carotid eversion endarterectomy with unilateral and bilateral symptomatic stenosis (with bilateral stenosis treated with ACI stenosis ≥70%). PATIENTS AND METHODS: The study included 139 patients with symptomatic carotid artery stenosis at the Department of Vascular Surgery of the University Clinical Center of Sarajevo in the period from January 2012 to December 2014 year. Given the involvement of ACI stenosis patients were divided into two groups. Group A consisted of 74 patients with bilateral stenosis (surgically treated with ACI stenosis ≥70%, while the degree of stenosis opposite ACI was from 50-70%), and group B of 65 patients with unilateral stenosis ≥70%. RESULTS: Of the 139 patients included in the study, in the group A was 74, of which 46 male (62.2%) and 28 female (37.8%), while in group B were 42 male (64.6%) and 23 female (35.4%) (p = 0.90). The subjects in group A were slightly older 65.9 (± 7.8) compared to group B 64.2 (± 7.7) (p = 0.17). Analysis of risk factors indicating a higher number in Group A compared to group B, but the difference was not statistically significant: 34 smokers (45.9%) versus 36 (55.4%); p = 0:34), patients with hypertension (63 (85.1%) against the 52 (80.0%); p = 0.56), with statin therapy (62 (83.8%) versus 52 (80.0%); p = 0.72), diabetes (18 (24.3%) versus 18 (27.7%); p = 0.79) and with a heart disease (18 (24.3%) versus 7 (10.8%); p = 0.06). Analysis of the frequency of perioperative complications between the groups was not statistically significant: ICV (2/74 versus 3/65; p = 1.00), TIA (2/74 versus 3/65; p = 0.88), one death was recorded in group A, while myocardial infarction (MI) we had in either group. CONCLUSION: In this study, no statistically about significant differences in the number of perioperative complications (from 0 to 30 days) between the two groups. With this risk is acceptable to perform carotid endarterectomy in a patient in the opposite ACI stenosis of 50-70%.

Epidemiological aspects of atherosclerosis in patients treated for acute atherothrombosis of extremity arteries.

INTRODUCTION: Risk factors for development of extremity artery atherosclerosis are the same as for coronary and cerebrovascular atherosclerosis namely, diabetes mellitus, hyperlipidemia, arterial hypertension, age and smoking. Atherosclerosis is polyarterial disease that clinically manifests itself most frequently in the form coronary, cerebrovascular or peripheral arterial disease (PAD). All of them have common, ominous and final pathologic step - atherosclerotic plaque rupture that might eventually lead to atherothrombosis and signs of ischemia. There are few studies of risk factor for peripheral artery disease (PAD). AIM OF STUDY: To identify prevalence of known risk factors for atherosclerosis in patients treated for acute atherothrombosis of extremity arteries. PATIENTS AND METHODS: Eighty patient were analyzed with regard to the prevalence of five risk factors for atherosclerosis (diabetes mellitus, smoking, hypertension, hyperlipidemia and age). 80 patients were divided into two groups (Group A and B) depending on country i.e. hospital where they received treatment for acute atherothrombosis of extremity artery. Group A consisted of patients treated at Clinic for vascular surgery in Sarajevo, while patients in Group B were treated in Trollhattan in Sweden at NAL hospital. This study was clinical, comparative, retrospective-prospective. RESULTS: In group A, 20% of patients had diabetes mellitus while in group B prevalence of diabetics was lower (12,5%) but difference was not statistically significant p>0.05. Sixty percent of patients (60%) in group A were smokers. In Sweden, habit of smoking is not as common as in Balkan countries and consequently only 22,5% of patients were smokers in Group l, difference was statistically significant, p<0.05. In patients assigned to group A, 42.5% of them had diagnosis of hypertension while in Group B, 35% of patients were hypertensive. Difference was not statistically significant, p>0.05. 37.5% of patients in group A and 20% of patients in group B had hyperlipidemia. Difference was not statistically significant, p>0.05. In Group A mean age of patients was 67.85 years while mean age in Group B was 73.63. Age difference was statistically significant, p<0.05. CONCLUSION: Prevalence of risk factors of atherosclerosis in peripheral artery disease were evaluated in this study. Significant difference in prevalence of two risk factors were determined namely, smoking and mean age of occurrence of atherothrombosis. Quiting smoking and adopting healthier life habits may lead to reduction of prevalence PAD in younger patients in Bosnia and Herzegovina.

Distal vein patch as a form of autologus modification for infragenicular prosthetic bypass.

INTRODUCTION: Preferred graft for infragenicular bypass is autologus vein. The problem is when there is not available autologus vein. Literature suggest that in these situations, prosthetic graft with some form of modification of distal anastomosis with autogenic tissue is valuable adjunctive. Frequently used modifications are Miller's cuff, Taylor's patch and St. Mary's boot. Recently, there are reports on "Distal vein patch" as a form of autologus modification which, due to its simplicity and patency rate, attracted attention. The aim of this study was to evaluate benefits of this novel modification by comparing its patencies with other autologus modification of distal anastomosis. PATIENTS AND METHODS: Study was performed on 60 patients, diabetics, with critical limb ischemia (CLI). Patients were divided in two groups: Group with distal vein patch modification; and group with some other form modification - control group. Patients were followed at least 22 months. We examined patency of grafts by physical examination or using Color Doppler. For statistical purposes we used KIaplan Meier analysis and curve. Significance was determined by Mann-Whitney, Fisher's exact, Pearsons chi square or Student T test as appropriate. P value less than 0,05 was considered significant. RESULTS: Groups were fairly matched relative to demographics, risk factors, operative intervention and distal anastomosis site. There was not statistical difference in two year primary patency between distal vein patch and control group--50% vs 53% respectivly (X2 = 0,08; p = 0,773). Also, there was not statistically significant difference in extremity survival (77% vs 77%) and patient survival between groups (89% vs 93%; X2 = 2,458; p = 0,117). CONCLUSION: This study proved equivalent patencies of infragenicular prosthetic bypasses performed using distal vein patch technique as with any other modification of distal anastomosis.

Comparison of transperitoneal and retroperitoneal approach in aorto iliac occlusive disease.

INTRODUCTION: Despite the fact that the transperitoneal approach (TP) is most widely accepted approach to the aortic surgery because it is simple, fast, and provides good exposure of the abdominal cavity and vascular structures, lately have been increasingly advocated as an alternative retroperitoneal (RP) approach in order to avoid entering peritoneal sac, achieving lower physiological trauma and faster establishment of gastrointestinal function. OBJECTIVE: The aim of this study was to compare the basic peri and postoperative results of TP and RP approaches in the surgical treatment of AIOD. PATIENTS AND METHODS: The study included 114 patients with aortoiliac occlusive disease (AIOD) that underwent surgical treatment at the Department of Vascular Surgery, Clinical Center University of Sarajevo from January 2010 until December 2012 year. In view of the surgical technique used subjects were divided into two groups. Group A consisted of 57 patients on who had been used RP approach, and group B 57 subjects with TP used approach. RESULTS: In patients from group A were observed significantly lower values: the length of operation (201.66 +/- 43.9 minute vs. 267.36 +/- 47.57 min, p < 0.001), amount of postoperative drainage (56.14 +/- 55.5 ml versus 130.71 +/- 92.34 ml, p < 0.001), length of stay in the intensive care unit (ICU) (1.10 +/- 0.36 days versus 2.46 +/- 1.25 days, p < 0.001), time required for the restoration of gastrointestinal motility (4.38 +/- 5.59 versus 1.05 days +/- 1.19 days, p < 0.001), length of hospitalization (9.26 +/- 1, 95 +/- 11 days versus 1.96 days, p < 0.001), costs of hospitalization (2394.98 +/- BAM 346.67 versus 2933.72 +/- 428.10 BAM, p < 0.001). Analysis of the incidence of postoperative complications (8 vs. 7 complication complications, p > 0.05) and mortality (3 versus 3, p > 0.05) showed no statistically significant difference between the analyzed groups. CONCLUSION: RP approach in vascular reconstructive surgery in AIOD offers better postoperative results when compared to TP approach.

Comparative study of operative treatment [corrected] of varicose veins according to the Klapp and Smetana method versus Myers method.

Venous abnormalities in lower extremities are among the most frequent disorders that affects general population with significant morbidity and mortality. Usually, the problem consists of a mild form of varicose veins and teleangiectasis. Treatment in this stage of disease is highly recommended since progression can lead to chronic venous insufficiency and chronic disability with very few effective treatment options. The most effective and popular treatment of varicose veins is operative treatment; specifically two different operative procedures: method according to Myers and method according to Klapp and Smetana. We designed this study in order to determine which method is superior based on clinical parameters and patients satisfaction. Our evidence strongly support clinical superiority, as well as patient satisfaction, of Klapp and Smetana method.

Femoro-popliteal bypass above knee with saphenous vein vs synthetic graft.

There is still debate whether sintethic graft (polytetrafluoroethylene or Dacron) is equivalent to vein as bypass graft material for the above-knee femoropopliteal bypass. Therefore, we performed prospective randomized trial to compare vein with polytetrafluoroethylene/dacron for femoropopliteal bypasses with the distal anastomosis above the knee. Between January 2000 and June 2003, 121 femoropopliteal bypasses were performed. The indications for operation were severe claudication in 96 cases, rest pain in 16 cases, and ulceration in 9 cases. After randomization, 60 reversed saphenous venous bypasses and 61 polytetrafluoroethylene/dacron bypasses were performed. No perioperative mortality was seen, and 5% of the patients had minor infections of the wound, not resulting in loss of the bypass, the limb, or life. After 5 years, 37% of the patients had died and 7% were lost to follow-up. Only once saphenous vein was necessary for coronary artery bypass grafting. Primary patency rates after 5 years were 76,6% for venous bypass grafts and 59,1% for polytetrafluoroethylene/dacron grafts (p=0,035). Secondary patency rates were 83,3% for vein and 69,2% for polytetrafluoroethylene/dacron bypasses (p = 0,036). In the venous group, 10 bypasses failed, leading to four new bypasses. In the polytetrafluoroethylene group, 22 bypasses failed, leading to 12 reinterventions. After 5 years of follow-up, we conclude that a bypass with saphenous vein has better patency rates at all intervals and needs fewer reoperations. Saphenous vein should be the graft material of choice for above-knee femoropopliteal bypasses and should not be preserved for reinterventions. Polytetrafluoroethylene/dacron is an acceptable alternative if the saphenous vein is not available.