Patch angioplasty carotid endarterectomy versus eversion carotid endarterectomy.

OBJECTIVES: To compare carotid endarterectomy patch angioplasty (p-CEA) with eversion carotid endarterectomy (e-CEA) and associated risks of early cardio-cerebrovascular complications. METHODS: The study was a prospective randomized single-blind trial, monocentric, clinically applicable, descriptive analytical and comparative. From June 2021 to June 2023, 62 consecutive patients with symptomatic and asymptomatic stenosis of the internal carotid artery, admitted to our department and randomized into two groups: carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. Follow-up for 30 days after surgery. RESULTS: During surgery e-CEA, 70% patients had an arrhythmia, and 24 hours after 66.7%, seven days after 46.7% and month after 13.3%. During surgery p-CEA, 33.3% patients had an arrhythmia, 24 hours later 33.3%, 7 days after 13.3% and 30 days after 13.3% patients. Statistically significant difference observed during surgery (Fishers p=0.004). One day after the surgery rate of patients with arrhythmia that were treated e-CEA has decreased, but it was still higher than after p-CEA (Fishers p=0.010). CONCLUSION: The frequency and categorization of postoperative cardiac arrhythmias after eversion carotid endarterectomy, the clinical implications of various postoperative heart rhythm disturbances and their long-term effects on patients need to be further investigate through sufficiently powered randomized controlled studies.

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.

Preoperative femoral vein velocity in maximal flexion is a predictor of deep vein thrombosis in patients undergoing total hip arthroplasty.

The aim of the study was to investigate if preoperative blood flow velocity in femoral vein in different positions of the hip during total hip arthroplasty (THA) is a predictor of postoperative deep vein thrombosis (DVT). In patients undergoing THA, blood flow velocity and diameter of proximal femoral vein on THA side were measured preoperatively in four flexion positions of the hip. After THA, patients were followed up for 42 days for DVT occurrence, and clinical features of patients with and without postoperative DVT were compared. The mean blood flow velocity in maximal flexion (90º+) preoperatively was significantly lower in patients with postoperative DVT (19/103) compared to patients without it (8.4±2 cm/s vs. 10.6±2.3 cm/s; p<0.001). Using the receiver operating characteristic curve analysis, the cut-off value for blood flow velocity during maximal flexion was 8.24 cm/s. In addition, anesthesia duration, duration of surgical position of the patient, body mass index, amount of blood transfused after surgery, and clinical signs of DVT were markedly different between patients with and those without postoperative DVT. Blood flow velocity in femoral vein in maximal flexion of the hip (90º+) measured prior to THA is an independent predictor of postoperative DVT.

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.

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.

Critical Carotid Artery Stenosis in Coronary and Non-Coronary Patients - Frequency of Risk Factors.

INTRODUCTION: Stroke is one of the largest socio medical problems of modern times. In addition to the third leading cause of death, it is the first cause of non-trauma disability. Numerous studies show a correlation of risk factors and arteriosclerotic lesions in the coronary arteries and carotid arteries. PATIENTS AND METHODS: Study was conducted at the Clinical Center University of Sarajevo, Clinic for Cardiology surgery, methodologically cross-sectional study and partly manipulative and clinical prevention study, conducted on a representative sample of 100 patients. The subject was divided into 2 groups, coronary and non-coronary patients. Both groups of patients underwent color Doppler of carotid arteries, medical history and laboratory analysis. RESULTS: The results confirm the hypothesis that the critical carotid artery stenosis is more present in patients with coronary disease, while the association of risk factors has been demonstrated for diabetes, hypertension and dyslipidemia. CONCLUSION: Screening of carotid arteries in patients scheduled for coronary revascularization is essential. With the presence of critical stenosis of the carotid artery, surgery of carotid artery should be done before coronary revascularization. The implementation of aggressive education and prevention of risk factors for cardiovascular disease is needed.

Haemodynamic assessment in simulated operative positions before knee arthroplasty can be useful in deep vein thrombosis prediction.

PURPOSE: During knee arthroplasty, the leg is placed in several forced positions, which are mainly uncomfortable for all tissue structures in the region, including the vascular structures. Veins have a weaker quality of the wall structure than arteries, so during the forced position morphological and haemodynamic consequences are expected mainly in the venous system. Conditions of safe aseptic environment for the arthroplasty are in collision with routine intra-operative analysis of local haemodynamics in real time. This is the reason why we have no insight into the haemodynamic and morphological changes at the time in which the initiation of deep vein thrombosis (DVT) occurs. For this reason we created the hypothesis that the monitoring of the occurrence and detection of potential DVT risks can be achieved pre-operatively using echosonograms in simulated operative positions, and then compare them with the cases of postoperative DVT. METHODS: This research was conducted as a prospective, analytical, minimally manipulative and observational clinical study in the period January 2011 to October 2013. In the preoperative period we made ultrasound and colour-Doppler examinations of deep veins in simulated operative position (full extension 0°, semiflexion 30-60°, flexion 90° and maximal flexion 90°+). The target vein was the posterior tibial vein in the distal third of calf. During the operation we took a note of anaesthesia duration and forced positions duration. After the operation we were looking for ultrasound signs of DVT in a follow-up period of six weeks. The sample was made from 91 patients selected for knee arthroplasty: 56 women and 35 men patients of average age 67.46 years. The oldest patient was 81, and the youngest 48. Average body mass index was 26.98 (±2.20) kg/m(2). After initial ultrasound, the sample was divided into two groups according to vein flow velocity. Patients who had a flow velocity lower than 10 cm/s in any of the forced positions were in the investigated group (N-b, n = 38), and patients who had more favourable haemodynamics in forced positions were in the control group (N-a, n = 53). Patients underwent arthroplasty without tourniquet, and the operative, postoperative and anaesthesiological protocol was the same for all the patients. RESULTS: Friedman's test results point out significant differences of posterior tibial vein flow velocity in four simulated positions (0°, 30-60°, 90°, 90°+). Overview of the median value of the posterior tibial vein flow velocity points out reduction of the posterior tibial vein flow velocity in the third and fourth simulated positions. Average range values were lowest in simulated position 90°+. Relative risk for the DVT occurrence was 21.6% higher in the group of patients with flow velocity lower than 10 cm/s with statistical significance. The incidence of DVT was higher in women (22.85%) than in men (14.28%). There was one (1.09%) case of pulmonary embolism (PE) presented as segmental PE. CONCLUSIONS: We believe that preoperative ultrasound analysis performed during the simulation of operative positions is a useful pre-operative test that can identify patients at risk of developing postoperative DVT. We would recommend that during surgery procedure to minimise forced position of knee flexion.

Extensive Operation as One of the Solution for Patients with the Insufficient Proximal Landing Zone for TEVAR in Aortic Dissection - short term results.

OBJECTIVE: In our study we wanted to showed the safety, feasibility, efficacy and way how to solve the problems of endovascular repair for aortic dissection with insufficient proximal Landing Zone. METHODS: The clinical data of all the patients with insufficient proximal Landing Zone (PLZ) for endovascular repair for aortic aneurism and dissection Stanford type B for the period from October 2013 to June 2014 was prospectively reviewed. According to the classification proposed by Mitchell et al, aortic Zone 0 was involved in 3 cases, Zone 1 in 1 case, Zone 2 in 9 cases and Zone 3 in 6 cases (19 patients in total). A hybrid surgical procedure of supraortic debranching and revascularization, with direct anastomosed truncus brachiocephalicus and left common carotid artery, were performed to obtain an adequate aortic PLZ. Revascularization of the left subclavian artery was carried out on the patient with dissection Stanford type B and short PLZ 2. RESULTS: There was no significant difference of risk factors between Zone 0, Zone 1, and Zone 2 (Table 1.), but the length of the PLZ significantly differed between groups (p<0.01) and there is no significant difference in technical and clinical success rate among the groups. CONCLUSION: The procedure of extending insufficient PLZ for endovascular repair for aortic arch pathology is feasible and relatively safe. The TEVAR applicability in such aortic disorders could be extended.

The frequency of complications of pseudoaneurysms after cardiac interventional diagnostic and therapeutic interventions.

Pseudo aneurysms as complications are a major source of morbidity after cardiac catheterization. Their incidence varies in the literature due to different definitions, methods of interrogation and presence of certain complications. We found in the literature that post-catheterization lesions occur in approximately 0.05% of treated patients after diagnostic catheterization and up to 1.2% after more complex procedures. The aim of this retrospective study was to determine the incidence of pseudo aneurysm after cardiac catheterization using the physical findings and color Doppler ultrasound. In the study, which encompasses the period of 2009-2010, there were 400 coronary angiography with trans femoral catheterization. After compression hemostasis was carried out, each patient was checked after 24 hours and again after 48 hours. Diagnostic coronary angiography was made in 400 patients (100%), out of which, 110 patients (27,5%) had a percutaneous coronary intervention with stent placement (PCI), Color Doppler ultrasound of femoral artery was normal in 384 (96.3%), local hematoma was found in 360 (90%), pseudo aneurysm in 14 (3.7%), AV fistula in 1 (0.25%) and dissection of the femoral artery in 1 (0.25%) patient. Complications in 16 patients were treated surgically, in 7 patients they were treated conservatively and in 1 case thrombin was applied within pseudo aneurism. Patients with complications were more often present with concomitant use of anticoagulant and anti platelet tablets than patients without complications (P = 0.003). Prevention of post catheterization pseudo aneurysm can be achieved by proper puncture technique, choosing the right place and right post interventional hemostatic compression with or without external devices. Special attention should be paid to the use of anti platelet drugs and anticoagulant and combinations thereof.

Treatment of ankle fractures--our results.

INTRODUCTION: Break ankle today is becoming more frequent. There is a dilemma to operate immediately upon receipt or delayed surgical treatment for a day or two. THE AIM OF THE WORK: This work aims at showing the importance of the anatomy, mechanism of injury, injury classification, diagnostic and therapeutic methods in treatment of brake ankle from our experience. MATERIAL AND METHODS: In the past year in our clinic there were 30 patients treated for all types of ankle fractures, and these patients were divided in two groups. Patients of the first group are those immediately operated, and the second group were with delayed surgery. The results showed that the patients of the first group had better healing, fewer complications, better and faster rehabilitation. Second groups of patients were with complications in terms dehiscence of wounds, bad healing fracture and DVT. CONCLUSION: Our results showed that better result in the treatment of ankle fractures is achieved by aggressive treatment immediately after trauma, with reconstruction of articular surface and tibiofibular syndesmosis with early rehabilitation.

Treatment of rare posttraumatic false aneurism and A-V fistula of the deep femoral artery and vein.

UNLABELLED: Article presents a rare case of posttraumatic pseudoaneurysm and A-V fistula between deep femoral artery and vein in 16 year old patient with stab wound in middle third of the lateral side of left femoral region. There were no signs of arterial injury on initial angiogram. During the observation we noticed subcutaneous bruise on the posterior side of the femoral region, and strong systolic murmur by ordinary auscultation over the involved region as a significant sign of the A-V fistula. At day 3, CT angiogram and Doppler analysis showed 4 cm sized false aneurysm combined with A-V fistula between distal portion of the deep femoral artery and vein. We made ipsilateral transfemoral catheterization and coiling of the feeding arterial branch with good immediate result, but at next Doppler checking, appearance of the same picture was disappointing. After we recognized retrograde filling through distal collateral artery, technically unsuitable for endovascular procedure, conventional surgery with posterolateral approach was indicated. An excision of the pseudoaneurysm, and ligation of the A-V fistula was done with good postoperative result. CONCLUSION: Obliterative endovascular procedure is a method of choice, but sometimes can not guarantee satisfactory result. In those cases conventional surgery is recommended.

Cerebrovascular events: correlation with plaque type, velocity parameters and multiple risk factors.

PURPOSE: Cerebrovascular events (CVE) are the third most common cause of death in Western countries and about 65-70% of CVE are due to atherosclerotic disease of carotid arteries. Color Doppler scanning is used to evaluate the presence, severity and type of atheromatous plaques as well as velocity parameters of carotid arteries. We performed this study to correlate data of morphological and velocity parameters with clinical variables in patients following CVE. METHODS: We included total of 211 pts who had CVE, 118 females, 93 males, mean age 71.1 +/- SD 12.5 years. Out of total number of pts (n = 211) 93 pts had transient ischemic attacks (TIAs), 49 had recurrent TIAs (rTIAs), 44 had ischemic stroke (IS), and 25 had recurrent IS (rIS). As a control group we took 50 pts without CVE but with at least three multiple risk factor (MRF). Morphological parameters were; plaque composition and echogenecity. Velocity parameters were: peak-systolic velocity (PSV) and end-diastolic velocity (EDV). The following MRF were evaluated: age, gender, hypertension, tobacco smoking, hyperlipidemia (total cholesterol and LDL-cholesterol), obesity, and diabetes mellitus. Examination was performed on CCA/ICA segment. RESULTS: We found significant presence of heterogeneous plaques in TIAs and rIS subgroup, p < 0.014, and borderline significance for the rTIAs and IS subgroups, p < 0.04. We found significant difference in PSV in TIAs and rTIAs subgroups vs. controls (PSV 103 cm/s vs. PSV in controls 87 cm/s, p < 0.01). Decreased EDV, below 20 cm/s, was found in all subgroups, p < 0.01, while EDV, below 16 cm/s, was found in IS and rIS subgroups. MRF score of CVE group was 4.34 vs. 3.65 in controls, p < 0.012, while MRF score in TIAs and rTIAs vs. IS and rIS subgroups was 4.34 vs. 4.51, NS, p = 0.14. We found a significant correlation (95% CI) of tobacco smoking, obesity and arterial hypertension with presence of heterogeneous plaques, p = 0.0069. Interestingly, hyperlipidemia showed no correlation with heterogeneous plaques, p = 0.027. CONCLUSIONS: (i) in CVE group we found significant presence of heterogeneous plaques in TIAs and rIS subgroups, (ii) in the pts with TIAs and rTIAs events we found significant increase in PSV, (iii) EDV below 16 cm/sec was a significant single predictor of IS and rIS events, (iv) MRF score was significantly increase in the pts with CVE compared to controls, but between CVE subgroups there was no significant difference.

[Post-reconstructive anastomosis of a pseudoaneurysm of a. femoralis comunis and its surgical solution]. / Postrekonstruktivna anastomotska pseudoaneurizma arterije femoralis komunis i njeno hirursko rjesavanje.

Case of post reconstructive aneurism of right a. femoralis has been solved with excision, resection of part of grapht and bifurcation of a. femoralis comunis, and then we made revascularization with interposes of tubular grapht with reinsertion of a. profunda femoris. Post operative complication is dehiscence of wound and exposition of front wall of interpenetrated grapht. Complication is solved by covering defect with rotate muscle-skin part. Final result of surgical treatment is completely successful.

[Treatment of rupture of the infrarenal aneurysm of the abdominal aorta]. / Zbrinjavanje rupturirane infrarenalne aneurizme aorte abdominalis.

One of the 15 most common cause of death in USA is rupture of the aneurism of the abdominal aorta. In 8-10% cases patients have no previous symptoms of aneurysm of the abdominal aorta, and they are coming to thr hospital with clinical picture of rupture This paperwork presents one such case. After assuming the data of basic lab. findings, clinical finding, and diagnostic procedures, an urgent operation was indicated. A resection of aneurismaticly changed infrarenal portion of abdominal aorta and its reconstruction with synthetic graft was done. In postoperative course we noticed cardiac decompensation followed by acute ischaemic attac of the left lower limb. It was solved by urgent disobliterative procedure--embolectomy in local anestesion. Patient was discharged after 21 day in good general condition.