Treatment of pediatric vascular injuries: the experience of a single non-pediatric referral center.

BACKGROUND: Pediatric peripheral vascular trauma carries significant risk of complications including limb loss and long-term invalidity. Mechanisms and types of morphological lesions are very diverse. The objectives of this study are to present the experience of a single vascular center in the surgical approach to pediatric vascular injuries, and to analyze the main challenges related to this clinical entity. METHODS: Over a period of 25 years, 17 pediatric peripheral vascular injuries were treated in our institution. Patient's age ranged between one day (newborn) and 15 years (mean: 10.7 years). There were five injuries of upper and 12 injuries of the lower extremity. Preoperative diagnosis was established by clinical examination (N.=4), ultrasonography (N.=1) and angiography (N.=12). Blunt trauma mainly caused arterial thrombosis while penetrating trauma caused arterial laceration or complete transection. Five patients had associated orthopedic injuries (29,4%). There were two posttraumatic pseudoaneurysms and two arterio-venous fistulas. RESULTS: There was no perioperative mortality. Vascular reconstructions included arterial suture (N.=4), thrombectomy + patch angioplasty (N.=1), termino-terminal anastomosis (N.=3), venous anatomic bypass (N.=6), PTFE graft reconstruction (N.=2), and venous extra-anatomic reconstruction (N.=1). Two patients had associated venous injury demanding both arterial and venous reconstruction. In the only case of war trauma treatment ended with limb loss. Other reconstructions presented good early and long-term patency. CONCLUSIONS: Pediatric vascular injuries are extremely challenging issues. Treatment includes broad spectrum of different types of vascular reconstructions. It should be performed by vascular surgeon trained in open vascular treatment or pediatric surgeon with significant experience in vascular surgery.

Arterial complications of thoracic outlet syndrome.

Arterial complications of thoracic outlet compression have serious potential implications; however, these complications rarely appear. Between 1990 and 2006, prospectively collected data on 27 patients with arterial complications of thoracic outlet syndrome were analyzed. The causes of arterial compression were cervical rib (20 [74.1%]), abnormalities of the first thoracic rib (three [11.1%]), soft tissue anomalies (two [7.4%]), and hypertrophic callus after clavicle fracture (two [7.4%]). In all cases, a combined supraclavicular and infraclavicular approach was used. Decompression was achieved by cervical rib excision in 13 (48.1%) patients, combined cervical and first rib excision in seven (26%), and first rib excision in six (22.2%). Associated vascular procedures included resection and replacement of the subclavian artery (26 [97.3%]), one subclavian-axillary and one axillary-brachial bypass as well as 17 (63%) brachial embolectomies. The mean follow-up period was 7 years 4 months (range, 1-16 years). Two pleural entries, two transient brachial plexus injuries, and one subclavian artery rethrombosis were found. Complete resolution of symptoms with a return to full activity was noted in all cases. In surgical treatment, a combined anterior supraclavicular and infraclavicular approach is recommended as well as transbrachial embolectomy in all cases with symptoms of distal embolization.

[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.

Unusual forms of ruptured abdominal aortic aneurysms.

Over 95% of abdominal aortic aneurysms (AAAs) rupture into the retroperitoneal space. Rare types of AAA ruptures comprise ruptures into the inferior vena cava with aortocaval fistula formation (ACF), ruptures into the duodenum with formation of a primary aortoduodenal fistula (ADF), and chronic contained ruptures (CCRs). This article presents a study of 41 cases with unusual forms of ruptured AAA of a series of 506 patients with AAA rupture treated within a 14-year period. There were 11 cases of CCR, 5 cases with ADF, and 25 cases with ACF. The correct preoperative diagnosis was established in 6 (of 11) cases of CCR, in 2 (of 5) cases of primary ADF, and in 13 (of 25) cases of ACF. AAA replacement was performed in 8 cases using a tube graft, whereas a bifurcated graft was used in 31 patients because of the distant extent of the atherosclerotic/aneurysmatic lesions engaging iliac arteries. Two patients had an axillobifemoral bypass. The overall 30-day mortality rate was 19% (8 of 41), with subgroup mortality rates of 0 (CCR), 60% (ADF), and 20% (ACF). Diagnosis and treatment are simplest in cases of CCR and the most complicated in cases of ADF.

[Comparative analysis of conventional and eversion carotid endarterectomy--prospective randomized study].

INTRODUCTION: Studies completed in the last decade of the 20th century showed benefits of carotid endarterectomy in the prevention of stroke in patients with a high-grade stenosis of the internal carotid artery. OBJECTIVE: The aim of this prospective, randomized study was the comparison of early and long-term results between the conventional and eversion carotid endarterectomy, and literature review. METHOD: By the method of random choice, 103 patients were operated on using the eversion carotid endarterectomy and 98 patients using the conventional technique. Operative treatment was carried out under general anaesthesia. Following the clammping of the carotid artery, retrograde blood pressure was determined by a direct puncture of the internal carotid artery above the stenotic lesions. In patients with retrograde pressure below 20 mm Hg intraluminal shunting was routinely performed. Early results were estimated (during the first seven postoperative days) based on mortality, central neurological complications (stroke, TIA) and cranial or cervical nerve lesions. Long-term results were estimated (after at least two years) based on long-term survival rate, central neurological complications (stroke,TIA) and the incidence of haemodynamically significant restenosis of the carotid artery treated by endarterectomy. RESULTS: The average time of clamming of the internal carotid artery in the eversion carotid anderectomy group was 5.36 minutes shorter than in the group treated by the conventional technique. Student's t-test showed a statistically highly significant difference in the time needed for clamming of the internal carotid artery between the two groups. The average duration of eversion endarterectomy (82 minutes) was most often 19 minutes shorter than the duration of the conventional endarterectomy (101 minutes). Student's t-test showed a statistically highly significant difference in the average length of surgeries. The distal intimal fixation was more often needed during the conventional carotid endarterectomy (34.7%) compared to eversion endarterectomy (3.9%). Chi 2-test showed a statistically highly significant difference. CONCLUSION: Eversion carotid endarectomy represents a statistically significantly shorter procedure. Distal intimal fixation demanded by this procedure is very rare, clammping of the internal carotid artery is significantly shorter, and it also has a lower rate of the early neurological complications. Based on the results of this study, as well as the opinions of other authors, it can be concluded that the eversion carotid endarterectomy has an advantage over the conventional procedure.We recommend conventional procedure only in cases when retrograde pressure indicates the use of the intraluminal shunting.

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.

[Preoperative factors influencing the early results of infrainguinal limb salvage procedures].

INTRODUCTION: The early results of 59 patients treated surgically for critical limb ischemia at the Institute of Cardiovascular Diseases were analyzed. Research was performed in a prospective manner, as an acute study, lasting for three months. OBJECTIVE: Our focus was on primary and secondary patency rate, and graft efficacy (quality accomplished by graft patency, improvement of clinical status of the leg, and quality of life). METHOD: The influence of each variable on the outcome was analyzed (descriptive: sex, comorbidity, risk factors, clinical stage of disease, angiographic verification of pedal arch, previous vascular procedures; and numerical: gender, preoperative Doppler index, angiographic score by Bollinger), as well as their predictive value. Inferential statistics was used for establishing the significance of influence, and univariate regression analysis for predictive values. RESULTS: No influence of variables on the outcome was evident in the first three months, and their predictive value was not important considering the graft patency rates and efficacy (except for preoperative clinical status affecting the graft efficacy, presence of pedal arch, affecting both primary and secondary patency rates and graft efficacy, and finally Doppler index affecting the secondary patency rates). CONCLUSION: When the surgeon needs to give an early prediction of graft destiny, he can rely on preoperative clinical status, earlier vascular operative procedures, presence of pedal arch, and values of Doppler index (in case of reintervention).

[Successful revascularization of the kidney--3 case reports]. / Revaskularizacija bubrega--prikaz tri bolesnika.

Three cases of successful kidney revascularization and recovery of renal function are presented in this study. In all three cases, renal failure and renovascular hypertension were caused by renal artery occlusion associated with aortic aneurysm (two abdominal and one thoracoabdominal). Prior to operation, one patient required dialysis 4 months, one 25 days and one 2 days. After kidney revascularization, renal function recovered immediately in the first case, in the second case after three months, and in the third case after 10 days. In one case, blood pressure restored to normal without medical therapy, while in two other cases blood pressure decreased nearly to normal with minimal medical therapy. In appropriately selected cases, revascularization of the occluded renal artery is recommended for treatment of both renal failure and renovascular hypertension. In such cases, collateral circulation is crucial to enable the preservation of dysfunctional kidney.

[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.

[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.