Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center.

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

[Surgical treatment of abdominal tumours closely related to major blood vessels].

INTRODUCTION: Radical operative treatment of abdominal tumours closely related to major blood vessels often demands complex vascular procedures. OBJECTIVE: The aim of this paper was to present elementary principles and results of the complex procedures, based on 46 patients operated on at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, from January 1999 to July 2006. METHOD: Primary localisation of the tumour was the kidney in 14 patients, the suprarenal gland in 2, the retroperitoneum in 23 and the testis in 7 patients. Histologically, the most frequent were the following: renal carcinoma in 14 patients, teratoma in 7, liposarcoma in 5, fibrosarcoma and lymphoma in 3 patients. The tumour compressed abdominal aorta occurred in 3 cases, vena cava inferior in 5 and both the abdominal aorta and vena cava inferior in 11 cases. In 4 cases the tumour infiltrated the abdominal aorta, in 11 the vena cava inferior and in 8 both of them. In two patients, the tumour compressed the vena cava inferior and infiltrated the aorta; in two patients the aorta was compressed and the vena cava was infiltrated. In three cases only the exploration was performed due to multiple abdominal organ infiltration. The ex tempore biopsy showed the type of tumour in which the radical surgical treatment did not improve the prognosis. In 20 cases of tumour compression, subadventitional excision was performed. In 23 cases of infiltration, the tumour excision and vascular reconstruction had to be performed. Intraoperative blood cell saving and autotransfusion were applied in 27 patients. RESULTS: The lethal outcome happened in 3 (6.5%) patients during hospitalization. In other patients all reconstructed blood vessels were patent during the postoperative hospitalization period. CONCLUSION: Treatment of the abdominal tumours closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. Tumour reduction cannot improve long term prognosis, and has no major impact on life quality. There have been not many papers that analyse the long term results after such complex operations proving their appropriateness.

False anastomotic aneurysms.

This retrospective study covers the period from 1991 to 2002, during which 3,623 patients were operated on because of aneurysmal or occlusive disease of aortoiliac and femoropopliteal segments. Among them, 87 patients (2.4%) developed a false anastomotic aneurysm in the 12-year follow-up period and were treated operatively. Most frequently, in 53 patients (6.9%), a false anastomotic aneurysm developed after aortobifemoral bypass performed owing to aortoiliac occlusive disease. The cause of false anastomotic aneurysm was infection in 21 cases (24.7%); resection and revascularization were performed with a Dacron graft in 46 cases (52.9%), with a polytetrafluoroethylene graft in 10 cases (11.5%), and with the great saphenous vein in 16 cases (18.4%). Homograft implantation in 4 patients (4.6%) or extra-anatomic bypasses in 11 cases (12.6%) were performed when graft infection was suspected. Of 87 patients who underwent surgery, 74 (85.5%) had good early results without infection, reintervention, limb loss, and mortality. The presence of infection as a cause of false anastomotic aneurysm and comorbidity increased the mortality rate significantly after the reoperation, whereas the type of graft used in treatment had no influence on early results.

[Anastomotic pseudoaneurysms].

Anastomotic pseudoaneurysm is a form of false aneurysm, whose wall does not consist of all normal layers of arterial wall. Given the rising number of reconstructive vascular procedures, the increase of anastomotic pseudoaneurysm cases is expected. Therefore, identification of causes, clinical manifestations as well as factors which affect the outcome of operative treatment of anastomotic pseudoaneurysms is of great practical value. This retrospectively-prospective study included 87 surgically treated cases of anastomotic pseudoaneurysms in the period from 1991 to 2002. The most often localization of anastomotic pseudoaneurysms was the inguinal region (68-86.2%). In the majority of cases, they were caused by arterial degeneration in the anastomotic region--56 cases (65.9%) and infection--21 cases (24.7%). The most frequent manifestations of anastomotic pseudoaneurysms were bleeding due to rupture in 26 cases (29.9%) and chronic limb ischaemia in 22 cases (25.3%). An acute limb ischaemia was present in 17 cases (19.5%), the symptoms caused by local compression to the surrounding structures--in 9 cases (10.3%), and in 12 cases (13.8%), the only manifestation of anastomotic pseudoaneurysm was asymptomatic pulsatile mass. In 32 cases (36.8%), surgical treatment involved the resection of anastomotic pseudoaneurysm and graft interposition, whereas in 39 cases (44.8%), bypass procedure had to be performed after the resection. Comorbidity significantly increased mortality in the first 30 days. The use of Dacron graft in primary operation significantly improved early results of operative treatment. Absence of infection as the cause of anastomotic pseudoaneurysm is a statistically important prognostic factor of operative treatment, considering the graft patency, limb salvage, infection, need for reintervention and mortality.

Civil and war peripheral arterial trauma: review of risk factors associated with limb loss.

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Abdominal aortic surgery and horseshoe kidney.

Horseshoe kidney presents a special challenge during surgery of the abdominal aorta. The aim of this study was to evaluate the morbidity and define optimal management based on clinical histories of 15 patients with horseshoe kidney who underwent surgical procedures on the abdominal aorta over a 20-year period. There were 2 female and 13 male patients with an average age of 62.66 (50-75) years. The indications for surgery included aortic aneurysms in 10 patients and aortoiliac occlusive disease in 5. The horseshoe kidney was detected before surgery in 12 patients (80%) by ultrasonography, angiography, computed tomography (CT) or excretory urography. Angiography revealed multiple or anomalous renal arteries in 8 of 12 patients studied preoperatively. At surgery, 10 patients (66.6%) were found to have multiple or anomalous renal arteries. Five patients (33.41%) were without multiple or anomalous renal arteries. Ten required renal revascularization (reimplantation with a Carrel patch in 7 patients and aortorenal bypass in 3). Two patients, both with ruptured abdominal aortic aneurysms, died postoperatively. In the other 10 cases the average follow-up period was 5.3 years (6 months to 17 years). During this period there were no signs of graft occlusion, renovascular hypertension, or renal failure. From these results we conclude that aortic surgery can be performed safely in patients with horseshoe kidney without increased mortality. These patients require exact preoperative diagnosis (ultrasonography, CT scan, angiography), reimplantation of anomalous renal arteries, and preservation of the renal isthmus.

[Axillobifemoral bypass grafting]. / Aksilobifemoralni bajpas.

INTRODUCTION: Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons. OBJECTIVE: The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass. METHODS: The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity--in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with latrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluoroethlylene graft was used in three patients. Simultaneously, profundoplastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done. Chi2 test was used for statistical evaluation and life table method was used for verification of late graft patency. RESULTS: The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis--1, MOFS--3, and infarct myocardium--1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was found in one patient. The other complications were--artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in three patients. Life table method has shown that cumulative rate of late graft patency is 80.39% after five years (Graph 1). DISCUSSION: Our results were analyzed and compared with the results of the study on 283 patients who had undergone aortobifemoral bypass (AFF) operation due to the aortoiliac occlusive disease. This study was completed in 1995 (18). The results showed that there was no statistically significant differences between AxFF and AFF group (p > 0.05), considering early mortality rate and late graft patency (Graph 2). The review of mortality and late patency rate after AxFF bypass grafting in a world well known studies has shown the similar results (Table 1). CONCLUSION The authors suggest that axilobifemoral bypass is indicated when there are contraindications or difficulties to perform anatomic reconstruction due to the abdomen condition (infection, adhesion, comorbidity) as well as in high risk patients with low life expectancy.

[Long-term results after elective and emergency surgery of abdominal aortic aneurysm]. / Udaljeni rezultati elektivnih i urgentnih operacija aneurizme abdomenske aorte.

INTRODUCTION: Abdominal aortic aneurysm can be repaired by elective procedure while asymptomatic, or immediately when it is complicated--mostly due to rupture. Treating abdominal aneurysm electively, before it becomes urgent, has medical and economical reason. Today, the first month mortality after elective operations of the abdominal aorta aneurysm is less than 3%; on the other hand, significant mortality (25%-70%) has been recorded in patients operated immediately because of rupture of the abdominal aneurysm. In addition, the costs of elective surgical treatment are significantly lower. OBJECTIVE: The objective of this study is to compare long-term survival of patients that underwent elective or immediate repair of abdominal aortic aneurysm (due to rupture), and to find out the factors influencing the long-term survival of these patients. MATERIAL AND METHODS: Through retrospective review of prospectively collected data of the Institute for Cardiovascular Diseases of Clinical Center of Serbia, Belgrade, 56 patients that had elective surgery and 35 patients that underwent urgent operation due to rupture of abdominal aneurysm were followed up. Only the patients that survived 30 postoperative days were included in this review, and-were followed up (ranging from 2 to 126 months). Electively operated patients were followed during 58.82 months on the average (range 7 to 122), and urgently operated were followed over 52.26 months (range 2 to 126). There was no significant difference of the length of postoperative follow-up between these two groups. RESULTS: During this period, out of electively operated and immediately operated patients, 27 and 22 cases died, respectively. There was no significant difference (p>0.05a) of long-term survival between these two groups. Obesity and early postoperative complications significantly decreased long-term survival of both electively and immediately operated patients. Graft infection, ventral hernia, aneurysm of peripheral arteries and other vascular reconstructive procedures were the factors that significantly reduced long-term survival of patients operated immediately due to rupture. DISCUSSION: This comprehensive study has searched for more factors than others had done before. The applied discriminative analysis numerically evaluated the influence of any risk factor of mortality. These factors were divided in three groups as follows: preoperative, operative and postoperative ones. Preoperative factors were sex, age, diabetes mellitus, arterial hypertension, obesity, COPD, and naturally, the indication for operative treatment of ruptured or non-ruptured abdominal aneurysm. Among all these factors, only obesity significantly reduced long-term survival of electively operated patients. It may be said that immediately operated patients who survived the first 30 postoperative days had quite good long-term survival. Operative factors such as type of operative procedure and vascular graft had no influence on long-term survival of patients in both groups. Postoperative risk factors were early postoperative complications, graft infection, symptomatic cerebrovascular disease, carotid endarterectomy, myocardial revascularization, ventral hernias, "other" non vascular operations, malignancy, mental disorders, peripheral aneurysms and occlusive vascular disease, and other vascular operations either due to aneurysm or peripheral occlusive disease. Early postoperative complications (even graft infection) had no significant effect on long-term survival. Ventral hernias and peripheral aneurysms were factors that significantly decreased long-term survival of patients operated for rupture of the abdominal aneurysm. CONCLUSION: It is interesting that endarterectomy, myocardial revascularization or malignancy after repair of the abdominal aneurysm (ruptured or non-ruptured) had no effect on long-term survival.

[Reconstruction of the supra-aortic branches]. / Rekonstrukcije supraaortnih grana.

The authors present surgical techniques and distant results of the operative treatment in patients with occlusive lesions of the supraaortic branches. The study included 29 men (55.8%) and 23 women (44.2%), with the average age of 54 years. The majority of patients--44 (84.6%) had symptoms and signs of the upper extremities ischemia while 25 (48.1%) had symptoms and signs of cerebral ischemia (the posterior circulation mainly). Among seven patients with isolated cerebral ischemia of the anterior circulation, four of them developed transient ischemic attack (TIA) and three had cerebrovascular insult (CVI). All patients were examined ultrasonographically and angiographically. Operative treatment was performed under general anesthesia. In eight cases the anatomic, and in 44 extraanatomic procedure was applied. Following reconstructive procedures were used: endarterectomy and patch of the brachiocephalic trunk--2, bypass from ascending aorta--7, carotid to subclavian bypass--31, subclavian to carotid bypass--7, subclavian artery transposition--3, axillo-axillary bypass--2. During the follow-up period (10-228 months), eight out of 52 patients exhibited the occlusion of the graft. Six occlusions developed after carotid-subclavian bypass: in two patients reconstructions were performed using Dacron grafts, in three using PTFE grafts and in one patient using autologous vein graft. Two occlusions developed after subclavio-carotid bypass. In both cases the vein graft was used: one was coming from the ipsilateral and the other one from the contralateral subclavian artery. The mean period from the operation to the occlusion of the graft (the mean lasting of the primary flow) was 14.72 years (SE = 1.41; 95% CI = 11.96-17.48). There was no statistically significant difference in primary patency and survival without symptoms between patients treated with the anatomic and those treated with the extraanatomic approach. Practically, this means that both approaches were equally good, so that the decision about the approach should be made individually, according to the loading factors of each patient. In the case of the carotid-subclavian bypass, according to our results, we recomend the use of the PTFE graft.

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

[An obturator or "lateral" bypass in infected vascular prostheses in the groin?]. / Opturacioni ili "lateralni" bajpas zbog infekcije vaskularne proteze u preponi?

The infection of the previously implanted vascular graft at the groin, is associated with great mortality and morbidity rate [1]. The authors present a retrospective study in which they analyzed management of infected vascular prostheses at the groin, using obturator bypass in 26 cases, and "lateral" bypass in 15 cases. The indications for obturator bypass reconstructions included: 20 infections of aorto-femoral grafts, two infected pseudoaneurysms in the groin after PTA of the superficial femoral artery, and 4 infections of iliac-femoral grafts. The indications for lateral bypass reconstructions were: infections after aorto-femoral reconstructions--8 cases; infection after femoro-popliteal reconstructions--4 cases; infection after iliac-femoral reconstruction--2 patients, and one infected pseudoaneurysm in the groin after PTA of the superficial femoral artery. In 3 subjects obturator bypass was performed using extraperitoneal approach, while in other 23 patients transperitoneal approach was done by donor's artery. The obturator bypass was performed using a PTFE graft in 3 cases, and Dacron graft in 23. The donor's artery used for obturator bypass was a noninfected proximal part of aortofemoral graft in 20 cases, and iliac artery in 6 patients. The superficial femoral artery was recipient artery for obturator bypass in 3 cases, deep femoral artery in one case, and above the knee popliteal artery in 22 cases (Figure 1). In two patients transperitoneal approach to donors artery for "lateral" bypass has been used, and in 13 cases extraperitoneal. The proximal noninfected part of aorto femoral graft was used as a donor's artery for lateral bypass in 8 patients, while common iliac artery in 7 subjects. In 5 cases reconstructions were performed using PTFE grafts, in 3 using autologous saphenous vein grafts, and in 7 using Dacron grafts. The recipient artery for "lateral" bypass was deep femoral in 8 cases, superficial femoral in three patients and above the knee popliteal artery in 4 subjects. After both types of reconstruction, extirpation of infected grafts from the groin was performed (Figure 2). The control examination was performed using physical and Doppler ultrasonographic examinations, one, 3, 6, 12 months, and then every year after the operation. In cases with suspected graft infection or thrombosis, control angiography was also performed. One intraoperative perforation of the urinary bladder has been done accidentally during obturator bypass reconstruction. The mean follow-up period for patients with obturator bypasses was 2.3 years, while 2.1 years for patients with "lateral" bypasses. Comparing with "lateral" bypass, obturator bypass showed statistically significant lower (p < 0.05) 30-day mortality and early graft infection rate, as well as statistically significant better early and total limb salvage rate. There were no statistically significant differences (p > 0.05) between obturator and "lateral" bypass procedures, having in mind, late graft infection rate, as well as early and late graft patency (Figures 3 and 4). In cases with infected vascular prostheses in the groin, the authors recommend obturator bypass comparing with "lateral" bypass.