Aorto-caval fistulas: a review of eighteen years experience.

The operative treatment of 26 aorto-caval fistulas during the last 18 years is reviewed (24 male and two female patients; average of 65.3 year). Out of 1698 cases presenting an abdominal aortic aneurysm, 406 presented with rupture, and 26 had aorto caval fistula. In 24 cases (92.3%) it concerned an atherosclerotic aneurysm. One aneurysm with aorto-caval fistula was secondary to abdominal blunt trauma (3.8%), and one due to iatrogenic injury (3.8%). The time interval between first clinical signs of aorto-caval fistula and diagnosis, ranged from 6 hours to 2 years (average 57,3 days). Clinical presentation included congestive heart failure infive patients (11.5%), extreme leg edema in 13 (50.0%), hematuria in 2 (7.0%), renal insufficiency 2 (7.0%), and scrotal edema in six patients. Diagnosis was made by means of color duplex scan in eight patients (30.7%), CT in seven patients (27%), NMR in three patients (11.5%), and angiography in seven patients (27%). Most reliable physical sign was an abdominal bruit,present in 20 patients (77%). In ten patients (38.4%) correct diagnosis was not made prior to surgery. The operative treatment consisted of transaortic suture of the vena cava (25 pts-96.0%), and aneurysm repair. Five operative deaths occurred (19,2%), and for all of them it concerned a misdiagnosis. Cause of death was myocardial infarction (one patient-3.8%), massive bleeding (one patient-3.8%), MOF (two patients-7, 0%), and colon gangrene (one patient-3.8%). Follow-up period varied from six months to 18 years (mean 4 years and two months). Long term results showed a 96% patency rate. No postoperative lower extremity venous insufficiency nor pelvic venous hypertension was observed post-operatively.

Aorto-caval fistulas.

The surgical repair of 16 aorto-caval (A-C) fistulas (15 male and one female patient; average age of 61.3 years) is reviewed. Fourteen fistulas were caused by aneurysm's erosion, one by iatrogenic injury, while one followed abdominal blunt trauma. The interval from presumed occurrence to diagnosis ranged from 6 h to 2 years. The presence of an abdominal bruit (87.5%) was the most reliable physical finding. Congestive heart failure was prominent in three (18.7%) cases, while severe lower extremity edema in five (31.2%). Two patients (12.5%) had hematuria, two (12.5%) renal insufficiency, while four (25%) scrotal edema. The diagnosis was not recognized before the surgery in five (31.2%) cases. In all 16 cases after transaortic suture of the fistula, aortic reconstructions were performed. Four operative deaths (25%) occurred, in patients who were not correctly diagnosed before surgery. In one case the cause of death was massive bleeding, and in three MOFS. All other patients were followed from 1 to 17 years (mean 4 years and 2 months). All grafts are patent, and there is no lower extremity venous insufficiency or pelvic venous hypertension. Surgical repair of A-C fistulas is mandatory to prevent serious complications.

Femoro-popliteal reconstructions: 'in situ' versus 'reversed' technique.

This study examined 191 patients with 'reversed' and 99 patients with 'in situ' femoro-popliteal bypass technique. There were 85 diabetic patients (44.5%) in the group with 'reversed' bypass, and 43 patients (43.43%) in the 'in situ' group. There were 152 (79.68%) smokers in the 'reversed' bypass group, and 80 (80.8%) in the 'in situ' group. The graft patency was confirmed immediately after operation using CW Doppler and then followed up after 1, 6, l2 months and annually thereafter. The statistical analysis was performed using Pearsons chi-square test, Fischer's test and 'Life table' statistic methods. The patients were followed from 3 to 10 yr after surgery. 'In situ' bypass showed better patency than the 'reversed' bypass technique but only in the second and tenth follow-up year (P < 0.05). Also, 'in situ' bypass proved to be better than 'reversed' only in patients with one patent crural artery (P < 0.01). Diabetes and preoperative smoking did not significantly affect late patency regarding this technique (P > 0.05). However, continuous smoking after the operation significantly decreased late patency rate in both groups of patients (P < 0.01). There was no significant difference in the early thrombectomy rate between groups with 'reversed' and 'in situ' bypasses (P > 0.05). The early thrombectomy, however, significantly reduced late patency rate in both groups (P < 0.01). Therefore we suggest 'in situ' bypass in cases with poor run off, small-calibre vein and 'long' bypass. Also, we consider important more frequent physical and Doppler ultrasonographic control in patients who had early thrombectomy.

[Cystic degeneration of the tunica adventitia of the popliteal artery]. / Cisticna degeneracija tunike adventicije poplitealne arterije.

INTRODUCTION: Adventitial cystic disease of the popliteal artery (PA) is an uncommon and unique entity characterized by a mucinous cyst located in the arterial adventitia. As the cyst enlarges, it provokes vascular compression with stenosis or occlusion, the first only during the knee flexion, and then in all leg position. Atkins and Key (1946) were the first who described this disease in the external iliac artery [1]. Eirup and Hiertonn (1956) described the disease in the PA, which is the place of its most common localization. The aim of the paper is the presentation of our 10 cases of PA adventitial cystic disease. PATIENTS AND METHODS: Ten patients with PA adventitial cyst were treated at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade, over the period between 1978 and 1997. There were 9 males and one female patient, average age 42.7 years (31-62). Two patients were smokers, while all other atherosclerotic risk factors, including heart disease, were absent. The diagnosis was established using Doppler ultrasonography and angiography. The postoperative histological examination revealed PA adventitial cyst in all patients (Figure 1). In Table 1 are presented our patients. The patients 3 and 4 were admitted for acute ischaemia of the leg. In patient 3 Doppler indexes were 0.0, and transfemoral arteriography revealed segmental occlusion of the PA. All other arteries were unchanged. These findings suggested an unusual disease of the PA. During the operation the posterior approach to the PA was used, and intraoperatively the adventitial cyst was found. In patient 4 the tibioperoneal trunk, posterior tibial artery and PA were occluded. Therefore, the medial approach to the PA was used. After thrombectomy of the crural vessels, the popliteo-popliteal bypass procedure was performed. The PA resection by this approach was not possible. The ringed 6 mm PTFE graft was used for reconstruction because of inadequate saphenous vein. The patients 1, 2, 5-10 were admitted with disabling claudication discomforts. In patients 1, 2, 5, 6, 8, 9 popliteal and pedal pulses were absent, and Doppler indexes decreased. In patients 7 and 10 pedal pulses were palpable and decreased during the normal knee position, while absent during the knee flexion. During some maneuvers Doppler indexes significantly decreased. Transfemoral arteriography in patients 1, 2, 5, 6, 8, 9 showed segmental stenosis or occlusion of the PA, and for this reason the posterior approach to the PA was used. The PA adventitial cyst was found in all cases (Figure 2). In patient 7 angiography revealed a "hourglass" deformity of the PA, while in patient 10 "scimitar" sign was found. Both angiographic findings are characteristic of PA adventitial cyst. The posterior approach was carried out in all patients. In patient 2 only cyst aspiration has been performed, while in patients 7, 8, 9 aspiration and resection of the changed PA adventitia (Figure 3a, figure 3b). In patients 1, 3, 5, 6, 10 an occluded arterial segment was resected. The restoration of the flow observed after the end-to-end anastomosis in patient 1, and after interposition of the saphenous graft in other patients. After the operation, the contralateral leg was examined using Doppler ultrasonography in all patients. The Doppler indexes were significantly decreased in patients 1 and 5 during the knee flexion, but the patients refused the angiographic examination. The control examination consisted of physical examination, Doppler ultrasonography and sometimes angiography; it was carried out after 1, 3, 6 and 12 months, and then every year after the operation. RESULTS: There was no mortality among our patients in the early post-operative period. In patients in whom cyst aspiration was performed, claudication discomfort was decreased, and Doppler indexes were significantly increased. In patients with arterial resection and reconstruction (1, 3, 4, 5, 6, 10) the effect of the operation was simi

Popliteal artery aneurysms.

Altogether 59 patients with 76 popliteal artery aneurysms were treated during the last 36 years. There were 50 (85%) male and 9 (15%) female patients with an average age of 61 years. Nineteen (32%) patients had bilateral aneurysms. The clinical manifestations of the aneurysms included ruptures 4 (5.3%); deep venous thrombosis 4 (5.3%); sciatic nerve compression 1 (1.3%); leg ischemia 52 (68.4%), and asymptomatic pulsatile masses 15 (19.7%). Seventy (92%) aneurysms were atherosclerotic, one (1.3%) mycotic, and four (5.3%) traumatic; one (1.3%) developed owing to fibromuscular displasia. Seven (9.2%) small, asymptomatic aneurysms were not operated on. Reconstructive procedures end-to-end anastomosis, graft interposition, bypass) after aneurysmal resection or exclusion using a medial or posterior approach were done in 59 cases. An autologous saphenous vein graft was used in 49 cases, polytetrafluoroethylene (PTFE) in 5, and heterograft in 2 cases. The in-hospital mortality rate was 2.9%, the early patency rate 93.3%, and limb salvage 95%. The long-term patency rate after a mean follow-up of 4 years was 78% and long-term limb salvage 89%. The total limb salvage was 73%, and the total amputation rate was 27%. The dangerous complications associated with popliteal artery aneurysms and the good results after elective procedures suggest that operative treatment is appropriate.

[Dacron and polytetrafluoroethylene aorto-bifemoral grafts]. / Dakronski i politetrafluoretilenski aorto-bifemoralni graftovi.

INTRODUCTION: In reconstructive procedures of the abdominal aorta synthetic grafts are today mostly used. There are two types of bifurcated synthetic grafts: Dacron and polytetrafluorethilene (PTFE). In many papers these grafts are compared in aortobifemoral position. Karner 1988, and Lord 1988, found no significant difference between them after aortobifemoral reconstructions. In 1955. Paaske wrote about a new "stretch" bifurcated PTFE graft in aortobifemoral position. Comparing this material with standard Dacron graft, he only found a shorter operating time. The aim of this paper is to compare Dacron and PTFE bifurcated grafts in aortobifemoral position in patients with aortoiliac occlusive diseases. MATERIAL AND METHODS: This prospective study included 283 aortobifemoral reconstructions due to aortoiliac occlusive diseases operated between January 1st, 1984 and December 31st, 1992 at the Institute for Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade. Bifurcated PTFE grafts were used in 136 patients, and nonimpregnated knitted Dacron grafts in 147 subjects. There were 25 (8.8%) female and 258 (91.2%) male patients, average age 56.88 years. Ninety one (32.2%) patients had a claudication discomfort (Fonten stadium II), 91 (32.2%) disabling claudication discomfort (Fonten stadium IIB), 45 (15.9%) rest pain (Fonten stadium III), and 56 (19.8%) gangrene (Fonten stadium IV). In 45 (15.9%) patients previous vascular procedures were performed. Prior to operation, Doppler ultrasonography and translumbar aortography were carried out (Figure 1). Transperitoneal approach to abdominal aorta, and standard inguinal approach to femoral arteries were used. In 154 (54.4%) patients proximal anastomosis had an end to side (TL), and in 129 (45.6%) end to end (TT) form. In 152 (26.88%) cases distal anastomosis was done in the common femoral (AFC) artery, and in 414 (73.2%) cases in the deep femoral (APF) artery. In 7 patients the aorto-femoro-popliteal "jumping" bypass was done, and in 29 patients simultaneous sequential femoro-popliteal bypass graft. The patients were following-up over the period from one, six and twelve months after operation, and later once a year, using physical examination and Doppler ultrasonography. In patients with suspected graft occlusion, anastomotic stenosis, pseudoaneurysms, progression of distal arterial diseases, Duplex ultrasonography and angiography were also used, and leukoscintigraphy in patients with suspected infection. Statistical analysis was performed using Long Rank and Student t-test. RESULTS: Inhospital mortality rate was 11 (7%). Distal reconstructions significantly increased the mortality rate when simultaneously performed with aortobifemoral bypass graft (p < 0.01). The follow-up period was from 2 months to 9.5 years (mean 3.6 years). The early patency rate was 97% from PTFE and 99.4% for Dacron grafts, while the late patency rate was 94.9% for PTFE and 96.6% for Dacron grafts. The type of the graft had no statistical influence on the early and late graft patency (p > 0.05) (Graphs 1, 2, 3). Six (2.1%) early unilateral limb occlusions were observed. Five patients had the PTFE and one the Dacron graft, without statistically significant difference (p > 0.05). The reasons for early graft occlusion were: stenosis of distal anastomosis in 3 patients, and pure run off in 3 patients. In 5 patients urgent reoperation (limb thrombectomy with profundoplasty or femoro-popliteal bypass graft above the knee) were done with complete recovery of legs. However, in one patient the above knee amputation was done. During the follow-up period, 14 (5.2%) late graft occlusions were recorded. There were 11 unilateral limb occlusions and 3 bilateral. All patients with bilateral occlusions had PTFE grafts but this was not statistically significant (p > 0.05) comparing two types of grafts. Taking into account all late occlusions, there were 7 PTFE and 7 Dacron grafts. There was no statistical difference betwe

[Factors determining late patency of aortobifemoral bypass graft]. / Cinoici koji odredjuju dugotrajniju protocnost aorto-bifemoralnog bajpasa.

INTRODUCTION: Most of the patients with aortoiliac occlusive diseases have a multilevel localization of atherosclerotic diseases. In patients with aortoiliac occlusive diseases, the femoro-popliteal segment is involved in 28 to 66% of cases. These patients are usually old persons with many risk factors. Therefore, simultaneous proximal and distal reconstruction is often associated with a higher morbidity and mortality rates. In contrast, can proximal reconstruction help only patients with multilevel occlusive diseases? The aim of this paper is: definition of factors determining late patency rate of aortobifemoral bypass graft in patients with multilevel occlusive diseases; definition of factors determining clinical effects after aortobifemoral bypass procedures. MATERIAL AND METHODS: This prospective study included 283 aortobifemoral reconstructions due to aortoiliac occlusive diseases operated between January 1st, 1984 and December 31st, 1992 at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade. Bifurcated polytetrafluorethylene (PTFE) grafts were used in 136 patients, and standard nonimpregnated knitted Dacron grafts in 147 paetients. There were 25 (8.8%) female and 258 (91.2%) male patients, average age 56.88 years. Ninety one (32.2%) patients had claudication discomfort (Fonten stadium II), 91 (32.2%) disabling claudication discomfort (Fonten stadium IIb), 45 (15.9%) rest pain (Fonten stadium III), and 56 (19.8%) gangrene (Fonten stadium IV). In 45 (15.9%) patients previous vascular procedures were performed. Prior to operation Doppler ultrasonography and translumbar aortography were done. Isolated aortoiliac occlusive diseases with intact femoro-popliteal segment (Type I) were found in 83 (29.3%) patients; combined aorto-iliac and diseases of superficial femoral artery (Type II) in 170 (60%) patients; and combined aorto-iliac and femoro-popliteal diseases (Type III) in 30 (10.7%) individuals. Transperitoneal approach to abdominal aorta and standard inguinal approach to femoral arteries, were used. In 154 (54.4%) patients proximal anastomosis had an end to side (TL), while in 129 (45.6%) end to end (TT) form. In 152 (26.88%) patients distal anastomosis was found on the common femoral artery (AFC), while in 414 (73.2%) on the deep femoral artery (APF). In 7 patients the aorto-femoro-popliteal "jumping" bypass was performed, and in 29 subjects the simultaneous sequential femoro-popliteal bypass graft (Figures 1, 2, 3, 4a and 4b). The patients were followed-up over a period from one, six and twelve months after reconstruction, and later once a year, using physical examination and Doppler ultrasonography. In patients with suspected graft occlusion, anastomotic stenosis, pseudoaneurysms, progression of distal diseases, Duplex ultrasonography and angiography were also used, and leukoscintigraphy in patients with suspected graft infection. Statistical analysis was performed by Long Rank and Student's t-test. RESULTS: Inhospital mortality rate was 11 (7%). Simultaneous distal reconstructions significantly increased the mortality rate (p< 0.01). The follow-up period was from 2 months to 9.5 years (mean 3.6 years). Configuration of proximal anastomosis showed no significant influence on graft patency (p>0.05) (Graphs 1, 2, 3). Location of distal anastomosis at the deep femoral artery contributed to statistically significant increase in graft patency (p < 0.01) (Graphs 4, 5, 6). Simultaneous distal bypass showed statistically significant increase in graft patency (p < 0.01), but also significant increase in inhopsital mortality rate (p < 0.01) (Graphs 7, 8, 9). The type of occlusive diseases had no statistically significant influence on graft patency (p > 0.05) (Graphs 10, 11, 12). Six (2.1%) early unilateral limb occlusions were observed. The reasons for early graft occlusions were: stenosis of distal anastomosis in 3 patients and pure run off in 3 subjects. In 5 patients urgent reoperations (limb thrombectomy and profundoplasty or femoro-popliteal bypass graft above the knee) were performed with complete recovery of patients. However, in one patient an above the knee amputation had to be done. During the follow-up period 14 (5.2%) late graft occlusions were recorded: 11 unilateral limb and 3 bilateral graft occlusions. The reasons for late graft occlusion were: distal progression of atherosclerotic diseases, distal anastomotic stenosis, proximal progression of atherosclerotic diseases and anastomotic neointimal hyperplasy. All patients with late graft occlusion underwent successful redo-operations. Next late redo-procedures had to be done: three new aorto-bifemoral bypass grafts (patients with bilateral occlusion), two limb thrombectomies, 6 limb thrombectomies with profundoplasty and 3 femoro-femoral "cross-over" bypass grafts. Configuration of proximal anastomosis and type of occlusive disease showed no statistically significant influence on the number of early and late graft occlusions (p > 0.05). Location of distal anastomosis at the deep femoral artery and simultaneous distal bypass, statistically significantly decreased the number of early and late graft occlusions (p < 0.05). "Small aorta syndrome" statistically significantly increased the number of late graft occlusions. Eleven distal anastomotic pseudoaneurysms were noted. In 8 patients pseudoaneurysms were infected and in 3 noninfected. In all patients new redo-operations were carried out. Graft infection was recorded in 5 (1.7%) patients. One (0.3%) secondary aortoduodenal fistula was found. During the follow-up period new disabling claudication discomforts were found in 46 patients. The causes were distal anastomotic stenosis in 30 patients and progression of distal arterial diseases in 16 subjects. Of the total number of 30 patients with distal anastomotic stenosis 14 were reoperated (profundoplasty) and 16 patients refused a new operation. Also, 16 patients with progression of distal atherosclerotic diseases were reoperated. The operation was a kind of femoropopliteal or crural bypass grafts. During the follow-up period 97 patients were asymptomatic, 128 showed significant improvement, 29 had disabling claudications, and 111 had amputations. Distal anastomosis at the deep femoral artery and patent superficial femoral artery, statistically significantly influenced the clinical course after operation (p 0.01), while configuration of proximal anastomosis and simultaneous distal bypass had no significant effects (p < 0.05). CONCLUSIONS: (1) Only location of distal anastomosis has a statistically significant influence on the patency of aorto-bifemoral bypass graft. (2) The location of distal anastomosis and type of occlusive disease have a statistically significant influence on the clinical effect of the operation. (3) The simultaneous distal bypass had no influence on the late patency of aortobifemoral bypass graft and on the number of asymptomatic patients. Also, it increased inhospital mortality rate.

Titrimetric determination of fluoride in some pharmaceutical products used for fluoridation.

Two titrimetric methods were developed for the determination of fluoride contents in some pharmaceutical preparations used for fluoridation. One of the methods is catalytic controlled-current potentiometry involving two identical platinum indicator electrodes and thorium nitrate as titrant. The reaction between hydrogen peroxide and potassium iodide in the presence of acetate buffer (pH 3.6), which is catalysed by the excess of thorium nitrate, served for the end-point indication. The other method is the automatic potentiometric titration involving a fluoride-selective electrode and lanthanum nitrate as titrating agent. In both procedures, special attention was paid to sample pretreatment and to determination of optimal experimental conditions. Fluoride contents in the range 16-32 microg/ml are determined with a relative standard deviation less than 1.34%. The results are compared to those obtained by standard methods described in the United States Pharmacopeia XXI and recommended by the manufacturer of the preparations.