Virtual ABI: A computationally derived ABI index for noninvasive assessment of femoro-popliteal bypass surgery outcome.

BACKGROUND AND OBJECTIVE: Peripheral arterial disease of the lower limbs, which affects 12-14% of the population, is often treated by bypassing a blocked portion of the vessel. Due to the limited ability of clinicians to predict the outcome of a selected bypass strategy, the five-year graft occlusion ranges from 50% to 90%, with a 20% risk of amputation in the first 5 years after the surgery. The aim of this study was to develop a computational procedure that could enable surgeons to reduce negative effects by assessing patient-specific response to the available surgical strategies. METHODS: The Virtual ABI assumes patient-specific finite element modeling of patients' hemodynamics from routinely acquired medical scans of lower limbs. The key contribution of this study is a novel approach for prescribing boundary conditions, which combines noninvasive preoperative measurements and results of numerical simulations. RESULTS: The validation performed on six follow-up cases indicated high reliability of the Virtual ABI, since the correlation with the experimentally measured values of ankle-brachial index was R² = 0.9485. CONCLUSION: The initial validation showed that the proposed Virtual ABI is a noninvasive procedure that could assist clinicians to find an optimal strategy for treating a particular patient by varying bypass length, choosing adequate diameter, position and shape.

Healthcare associated Clostridioides difficile infection in adult surgical and medical patients hospitalized in tertiary hospital in Belgrade, Serbia: a seven years prospective cohort study.

Introduction: Clostridioides difficile (C. difficile) infection (CDI) is one of the most common healthcare-associated (HA) infections in contemporary medicine. The risk factors (RFs) for HA CDI in medical and surgical patients are poorly investigated in countries with a limited resource healthcare system. Therefore, the aim of the study was to investigate differences in patients' characteristics, factors related to healthcare and outcomes associated with HA CDI in surgical and medical patients in tertiary healthcare centre in Serbia.Materials and Methods: A prospective cohort study was conducted including adult patients diagnosed with initial episode of HA CDI, first recurrence of disease, readmission to hospital, while deaths within 30 days of CDI diagnosis and in-hospital mortality were also recorded. Patients hospitalized for any non-surgical illness, who developed initial HA CDI were assigned to medical group, whereas those who developed initial HA CDI after surgical procedures were in surgical group. The data on patients' characteristics and factors related to healthcare were collected, too.Results: During 7-year period, from 553 patients undergoing in-hospital treatment and diagnosed with CDI, 268 (48.5%) and 285 (51.5%) were surgical and medical patients, respectively. Age ≥ 65 years, use of proton pump inhibitors, chemotherapy and fluoroquinolones were positively associated with being in medical group, whereas admission to intensive care unit and use of second- and third-generation cephalosporins were positively associated with being in surgical group.Conclusions: Based on obtained results, including significant differences in 30-day mortality and in-hospital mortality, it can be concluded that medical patient were more endangered with HA CDI than surgical ones.

Clinical, epidemiological and epizootic features of a Q fever outbreak in the border region between Serbia and Montenegro.

INTRODUCTION: Q fever is a zoonosis which commonly manifests as an acute febrile disease accompanied by pneumonia or hepatitis. The aim of this study was to reveal the reservoirs, sources and routes of infection relevant for the Q fever outbreak that occurred in the border region between Serbia and Montenegro. METHODOLOGY: A prospective study was conducted from 3rd to 23rd March, 2016 in Brodarevo, village near the Serbian-Montenegro border. The EU case definition for Q fever was applied and serological evidence of IgM and/or IgG antibody for phase II antigen Coxiella burnetii used for laboratory confirmation. Animal infection was proven by detection of specific biomarkers for Q fever by ELISA and Real-Time PCR. RESULTS: In total, ten patients were registered with Q fever, giving an attack rate of 0.5% in the village. A severe form of disease with atypical pneumonia ended up with hospitalization of eight patients. Serological surveillance was conducted in 30 herds of the receptive animals in the outbreak area. Overall the anti-Coxiella antibody seroprevalence was 20.6%. Positive molecular findings (68.4%) accompanied with high seroprevalence (63.2%) were identified in a mini-farm of sheep and cattle in the nearby Orasac, these were considered to be active sources of infection. The most probable route of C. burnetii transmission was the inhalation of contaminated aerosols originating from infected animals. CONCLUSION: The main reservoirs for human Q fever at the border region between Serbia and Montenegro are infected cattle and ruminants. Adoption of a comprehensive strategy for disease prevention and control at the intergovernmental level is urgent.

Aortobifemoral reconstruction and renal transplantation in a patient with abdominal aortic aneurysm and occlusion of iliac arteries: A case report.

Introduction: Aortoiliac occlusive disease and abdominal aortic aneurysm in patients with renal insufficiency on hemodialysis can significantly influence the success of renal transplantation. In the recent past, advanced atherosclerosis was considered as contraindication for renal transplantation. Complicated creation of vascular anastomoses and progression of occlusive or aneurysmal disease were the main reasons. Case report: We presented a 52-year-old man with a 5-year history of end-stage renal disease on haemodialysis. The patient was previously excluded from renal transplantation program because of severe aortoiliac atherosclerosis and abdominal aortic aneurysm. Resection of abdominal aortic aneurysm with occlusion of the iliac arteries and reconstruction with aortobifemoral synthetic grafts was performed and followed by cadaveric renal transplantation. Conclusion: Advanced atherosclerotic disease in aortoiliac segment requires elective vascular surgical reconstruction, as part of preparation for renal transplantation in patients with end-stage renal disease.

Influence of open surgical and endovascular abdominal aortic aneurysm repair on clot quality assessed by ROTEM® test.

Introduction/Aim: The disturbances in hemostasis are often in open surgical repair (OR) and endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA). These changes may influence the perioperative and early postoperative period inducing serious complications. The aim of this study was to compare the impact of OR and EVAR of AAA on clot quality assessed by rotational thromboelastometry (ROTEM®) tests. Methods: The study included 40 patients who underwent elective AAA surgery and were devided into two groups (the OR and the EVAR group - 20 patients in each group). The ROTEM ® test was performed in 4 points: point 1 - 10 min before starting anesthesia in both groups; point 2 - 10 min after aortic clapming in the OR group and 10 min after the stent-graft trunk release in the EVAR group; point 3 - 10 min after the releasing of aortic clamp in the OR group and 10 min after stentgraft placement and releasing the femoral clamp in the EVAR group; point 4 - one hour after the procedure in both groups. Three ROTEM® tests were performed as: extrinsically activated assay with tissue factor (EXTEM), intrinsically activated test using kaolin (INTEM), and extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (FIBTEM). All tests included the assessment of the maximum clot firmness (MCF) and the platelet component of clot strength was presented as maximal clot elasticity (MCE). Results: No significant difference in age, gender and diameter of AAA between groups was found. The time required for the procedure was significantly longer and loss of blood was greater in the OR group than in the EVAR group (p < 0.001). The significant deviation of MCF values in EXTEM test was found mainly in the point 3 (p ≤ 0.004) with significant difference between groups (p < 0.001). A significant difference of MCF values in INTEM test between groups was found in the points 3 and 4 (p < 0.001), which were dose-dependent by heparin sulfate. The MCF values in FIBTEM test were more prominent in the OR group than in the EVAR group without significant difference. The significant changes of MCF values in the FIBTEM test were found during time in both groups (p < 0.001). The values of MCE were lower in both groups, but without significant changes and difference between groups (p = 0.105). Conclusion: The disorders of hemostatic parameters assessed by ROTEM® tests are present in both the OR and the EVAR groups being more prominent in OR of AAA. Vigilant monitoring of hemostatic parameters evaluated by ROTEM® tests could help in administration of the adequate and target therapy in patients who underwent EVAR or OR of AAA.

Endovascular treatment of the subclavian artery aneurysm in high-risk patient - a single-center experience.

We present our first experience with endovascular treatment of 6 subclavian artery aneurysms (SAA) occurring in five male and one female patient. All patients, in our studies, according to ASA classification were high risk for open repair of SAA. The etiology of the all aneurysms was atherosclerosis degeneration of the artery. Two aneurysms were of intrathoracic location, then the other were extrathoracic. Symptoms related to subclavian artery aneurysms were present in two patients, compression and chest pain in one, and hemorrhage shock in second, while the remaining patients were asymptomatic. We preferred the Viabhan endoprosthesis for endovascular repair in 5 cases. In one patient with ruptured of subclavian artery aneurysm who was high-risk for open repair we made combined endovascular procedure. First at all, we covered the origin of left subclavian artery with thoracic stent graft and after that we put two coils in proximal part of subclavian artery. There was no operative mortality, and the early patency rate was 100%. The follow-up period was from 3 months to 3 years. During this period, one patient died of heart failure and one patient required endovascular reoperation due to endoleak type I. Endovascular treatment is recommended for all patients with subclavian artery aneurysm whenever this is possible due to anatomical reasons especially in high-risk patient with intrathoracic localization of aneurysm, to prevent potential complications.

Different techniques of vessel reconstruction during kidney transplantation.

BACKGROUND/AIM: Multiple renal arteries (MRAs) represent a surgical challenge by the difficulty in performing anastomoses, bleeding and stenosis. MRAs should be preserved and special attention should be paid to accessory polar arteries. All renal arteries (RAs) must be reconstructed and prepared for safe anastomosis. The paper decribed the different techniques of vessel reconstruction during kidney transplantation including important steps within recovery of organs, preparation and implantation. METHODS: In a 16-year period (1996-2012) of kidney transplantation in the Military Medical Academy, Belgrade, a total of 310 living donors and 44 human cadaver kidney transplantations were performed, of which 28 (8%) kidneys had two or more RAs. RESULTS: All the transplanted kidneys had immediate function. We repaired 20 cases of donor kidneys with 2 arteries, 4 cases with three RAs, one case with 4 RAs, one case with 4 RAs and renal vein reconstruction, one case with 3 arteries and additional polytetrafluoroethylene (PTFE) graft reconstruction, one case with transected renal artery and reconstruction with 5 cm long deceased donor external iliac artery. There were no major complications and graft failure. At a minimum of 1-year follow-up, all the patients showed normal renal function. CONCLUSION: Donor kidney transplantation on a contralateral side and "end-to-end" anastomosis of the renal artery to the internal iliac artery (IA) is our standard procedure with satisfactory results. Renal artery reconstruction and anastomosis with IIA is a safe and highly efficient procedure and kidneys with MRAs are not contraindicated for transplantation. A surgical team should be fully competent to remove cadaveric abdominal organs to avoid accidental injuries of organs vessels.

Specificities of transplantation of kidneys procured from donors with situs inversus totalis--a case report and review of the literature.

INTRODUCTION: Situs inversus totalis (SIT) represents a total vertical transposition of the thoracic and abdominal organs which are arranged in a mirror image reversal of the normal positioning. We presented a successful pre-dialysis kidney transplantation from a living sibling donor with SIT and the longest donor follow-up period, along with analysis of the reviewed literature. CASE REPORT: The pair for pre-dialysis kidney transplantation included a 68-year-old mother and 34-year-old daughter at low immunological risk. Comorbid- ities evidenced in kidney donors with previously diagnosed SIT, included moderate arterial hypertension and borderline blood glucose level. Explantation of the left donor kidney and its placement into the right iliac fossa of the recipient were performed in the course of the surgical procedure. A month after nephrectomy, second degree renal failure was noticed in the donor. A 20-month follow-up of the donor's kidney and graft in the recipient proved that their functions were excellent. CONCLUSION: In donors with previously di- agnosed SIT the multidisciplinary approach, preoperative evaluation of the patient and detection of possible vascular anomalies are required to provide maximum safety for the donor.

Renal transplantation promptly restores excretory function but disturbed L-arginine metabolism persists in patients during the early period after surgery.

The synthesis and whole body metabolism of L-arginine (Arg) are disturbed in renal diseases. Renal transplantation represents the best therapy in the end-stage of these diseases. In the present we compared alterations of plasma Arg and related compounds with renal excretory function in patients with end-stage renal disease, before and after kidney transplantation. Arg, asymmetric dimethylarginine (ADMA), citrulline (Cit), glutamine (Gln), ornithine (Orn), phenylalanine (Phe), tyrosine (Tyr), urea, creatinine, albumin, and nitrate were analyzed in patients before, immediately after (0-time) and 1, 2, 3, 7 and 14 days following living donors kidney transplantation. Healthy subjects were controls. Glomerular filtration rate (GFR) and amino acid molar ratios were calculated. Before transplantation creatinine, urea, Cit, Gln, ADMA, and nitrate were above, while GFR and Arg were below controls, confirming disturbed excretory and metabolic renal functions in patients with renal disease. Renal transplantation promptly normalized creatinine, urea, GFR, Cit, and nitrate. However, regardless of increased molar Phe/Tyr ratios, indicating increased net protein catabolism in peripheral tissues, low Arg and elevated ADMA concentrations persisted throughout the examined period. Alterations of other amino acids also suggest similarly disturbed Arg metabolism in patients after kidney transplantation. In conclusion, renal transplant promptly restored its excretory function, but increased net protein catabolism, disturbed Arg metabolism and endothelial dysfunction in entire body of these patients were not improved throughout the early period after the operation. That has to be considered in their therapy.

Visceral hybrid reconstruction of thoracoabdominal aortic aneurysm after open repair of type A aortic dissection by the Bentall procedure with the elephant trunk technique--a case report.

INTRODUCTION: Reconstruction of chronic type B dissection and thoracoabdominal aortic aneurysm (TAAA) remaining after the emergency reconstruction of the ascending thoracic aorta and aortic arch for acute type A dissection represents one of the major surgical challenges. Complications of chronic type B dissection are aneurysmal formation and rupture of an aortic aneurysm with a high mortality rate. We presented a case of visceral hybrid reconstruction of TAAA secondary to chronic dissection type B after the Bentall procedure with the 'elephant trunk' technique due to acute type A aortic dissection in a high-risk patient. CASE REPORT: A 62 year-old woman was admitted to our institution for reconstruction of Crawford type I TAAA secondary to chronic dissection. The patient had had an acute type A aortic dissection 3 years before and undergone reconstruction by the Bentall procedure with the 'elephant trunk' technique with valve replacement. On admission the patient had coronary artery disease (myocardial infarction, two times in the past 3 years), congestive heart disease with ejection fraction of 25% and chronic obstructive pulmonary disease. On computed tomography (CT) of the aorta TAAA was revealed with a maximum diameter of 93 mm in the descending thoracic aorta secondary to chronic dissection. All the visceral arteries originated from the true lumen with exception of the celiac artery (CA), and the end of chronic dissection was below the origin of the superior mesenteric artery (SMA). The patient was operated on using surgical visceral reconstruction of the SMA, CA and the right renal artery (RRA) as the first procedure. Postoperative course was without complications. Endovascular TAAA reconstruction was performed as the second procedure one month later, when the 'elephant trunk' was used as the proximal landing zone for the endograft, and distal landing zone was the level of origin of the RRA. Postoperatively, the patient had no neurological deficit and renal, liver function and functions of the other abdominal organs were normal. Control CT after 6 months showed full exclusion of the aneurysm from the systemic circulation without endoleak and good flow through visceral anastomosis. CONCLUSION: In patients with comorbidities, like in the presented case, visceral hybrid reconstruction of chronic dissection type B with TAAA could be the treatment of choice.

Endovascular repair of ruptured abdominal aortic aneurysm.

INTRODUCTION: Rupture of an abdominal aortic aneurysm (AAA) is a potentially lethal state. Only half of patients with ruptured AAA reach the hospital alive. The alternative for open reconstruction of this condition is endovascular repair (EVAR). We presented a successful endovascular reapir of ruptured AAA in a patient with a number of comorbidities. CASE REPORT: A 60-year-old man was admitted to our institution due to diffuse abdominal pain with flatulence and belching. Initial abdominal ultrasonography showed an AAA that was confirmed on multislice computed tomography scan angiography which revealed a large retroperitoneal haematoma. Because of patient's comorbidites (previous surgery of laryngeal carcinoma and one-third laryngeal stenosis, arterial hypertension and cardiomyopathy with left ventricle ejection fraction of 30%, stenosis of the right internal carotid artery of 80%) it was decided that endovascular repair of ruptured AAA in local anaesthesia and analgosedation would be treatment of choice. Endovascular grafting was achieved with aorto-bi-iliac bifurcated excluder endoprosthesis with complete exclusion of the aneurysmal sac, without further enlargment of haemathoma and no contrast leakage. The postoperative course of the patient was eventless, without complications. On recall examination 3 months after, the state of the patient was well. CONCLUSION: The alternative for open reconstruction of ruptured AAA in haemodynamically stable patients with suitable anatomy and comorbidities could be emergency EVAR in local anesthesia. This technique could provide greater chances for survival with lower intraoperative and postoperative morbidity and mortality, as shown in the presented patient.

Conversion from calcineurin inhibitors to sirolimus of recipients with chronic kidney graft disease grade III for a period 2003-2011.

BACKGROUND/AIM: Tremendous breakthrough in solid organ transplantation was made with the introduction of calcineurin inhibitors (CNI). At the same time, they are potentially nephrotoxic drugs with influence on onset and progression of renal graft failure. The aim of this study was to evaluate the outcome of a conversion from CNI-based immunosuppressive protocol to sirolimus (SRL) in recipients with graft in chronic kidney disease (CKD) grade III and proteinuria below 500 mg/day. METHODS: In the period 2003-2011 24 patients (6 famale and 18 male), mean age 41 +/- 12.2 years, on triple immunosuppressive therapy: steroids, antiproliferative drug [mycophenolate mofetil (MMF) or azathiopirine (AZA)] and CNI were switched from CNI to SRL and followe-up for 76 +/- 13 months. Nine patients (the group I) had early postransplant conversion after 4 +/- 3 months and 15 patients (the group II) late conversion after 46 +/- 29 months. During the regular outpatient controls we followed graft function through the serum creatinine and glomerular filtration rate (GFR), proteinuria, lipidemia and side effects. RESULTS: Thirty days after conversion, in all the patients GFR, proteinuria and lipidemia were insignificantly increased. In the first two post-conversion months all the patients had at least one urinary or respiratory infection, and 10 patients reactivated cytomegalovirus (CMV) infection or disease, and they were successfully treated with standard therapy. After 21 +/- 11 months 15 patients from both groups discontinued SRL therapy due to reconversion to CNI (10 patients) and double immunosuppressive therapy (3 patients), return to hemodialysis (1 patient) and death (1 patient). Nine patients were still on SRL therapy. By the end of the follow-up they significantly improved GFR (from 53.2 +/- 12.7 to 69 +/- 15 mL/min), while the increase in proteinuria (from 265 +/- 239 to 530.6 +/- 416.7 mg/day) and lipidemia (cholesterol from 4.71 +/- 0.98 to 5.61 +/- 1.6 mmol/L and triglycerides from 2.04 +/- 1.18 to 2.1 +/- 0.72 mmol/L) were not significant. They were stable during the whole follow-up period. Ten patients were reconverted from SRL to CNI due to the abrupt increase of proteinuria (from 298 +/- 232 to 1639 +/- 1641/mg day in 7 patients), rapid growth of multiple ovarian cysts (2 patients) and operative treatment of persisted hematoma (1 patient). Thirty days after reconversion they were stable with an insignificant decrease in GFR (from 56.10 +/- 28.09 to 47 +/- 21 mL/min) and significantly improved proteinuria (from 1639 +/- 1641 to 529 +/- 688 mg/day). By the end of the follow-up these patients showed nonsignificant increase in the serum creatinine (from 172 +/- 88 to 202 +/- 91 mmol/L), decrease in GFR (from 56.10 +/- 28.09 to 47 +/- 21 mL/day) and increased proteinuria (from 528.9 +/- 688 to 850 +/- 1083 mg/min). CONCLUSION: In this small descriptive study, conversion from CNI to SRL was followed by an increased incidence of infections and consecutive 25-50% dose reduction in the second antiproliferative agent (AZA, MMF), with a possible influence on the development of glomerulopathy in some patients, which was the major reason for discontinuation of SRL therapy in the 7 (29%) patients. Nine (37.5%) of the patients experienced the greatest benefit of CIN to SRL conversion without serious post-conversion complications.

Comparison of analgesic effect of intrathecal morphine alone or in combination with bupivacaine and fentanyl in patients undergoing total gastrectomy: a prospective randomized, double blind clinical trial.

BACKGROUND/AIM: Combined spinal-epidural-general anesthesia has several advantages over general anesthesia alone. This study was designed to compare the efficacy of intrathecal (IT) morphine alone, or in combination with bupivacaine and fentanyl, as part of a combined spinal-epidural (CSE) analgesia, in patients undergoing elective total gastrectomy. METHODS: This prospective, randomized double-blind study included 60 patients undergoing total gastrectomy under general anesthesia and CSE. We compared the analgesic effect of lumbar IT morphine 300 microg (the group M, n = 20) vs morphine 300 .g + bupivacaine 2 mg (the group MB, n = 20) vs morphine 300 microg + bupivacaine 2 mg + fentanyl 25 pg (the group MBF, n = 20) given after thoracic epidural catheter placement (T6-7) but before general anesthesia induction. Pain visual analogue scale (VAS) at rest (R), with movement (M) and with cough (C), and the number of analgesia requests were assessed for 72 h and after epidural catheter removal. RESULTS: Compared to other groups, the MBF group required significantly fewer additional intra-operative epidural bupivacaine doses (p < 0.001), whereas the M group required significantly more supplemental intraoperative intravenous fentanyl, compared with the MBF (p = 0.022) and MB groups (p = 0.005). Postoperative pain relief was satisfactory in all the groups at all the time. VAS-R and VAS-M did not differ significantly among the groups. Compared to the M group, VAS-C scores 30 min postoperatively were significantly lower in the MBF (p = 0.029) and MB groups (p = 0.002). Duration of analgesia was longer in the MBF and MB groups, but the difference reached no significance. The number of supplemental analgesia requests was similar in all the groups in the first 12 h and during 72 h. Additional analgesia requests after epidural catheter removal were similar in all the groups, and side effects were infrequent. CONCLUSION: Compared to IT morphine alone, triple IT combination administered as part of CSE provided better intraoperative analgesia, but conferred no benefit with regards to postoperative analgesia.

Unilateral nephrectomy causes an early abrupt decrease in plasma arginine and simultaneous reduction in glomerular filtration rate in living kidney donors.

OBJECTIVES: Living donor kidney transplantation is regarded as beneficial to allograft recipients and not particularly detrimental to the donors. Recently we have documented a reduced glomerular filtration rate (GFR) in living kidney donors (LKDs). Considering kidneys as essential for l-arginine (Arg) metabolism, in the present study we analyzed plasma Arg and related compounds comparing them with the function of remaining kidney in LKDs after donation. DESIGN AND METHODS: We analyzed GFR, plasma Arg, asymmetric dimethylarginine (ADMA), citrulline (Cit), glutamine (Gln), ornithine (Orn), phenylalanine (Phe), tyrosine (Tyr), thiobarbituric acid reactive substances (TBARS), urea, creatinine, nitrite, nitrate and their sum (NOx) in blood samples taken from LKDs before, immediately after (0-time) and 1, 2, 3, 7 and 14 days following surgery. RESULTS: Gradual and moderate creatinine increase and albumin decrease were associated with decreased GFR. An abrupt decrease in Arg occurred, staying below baseline level throughout the 14 days. Also decreases in Gln, Cit, Orn, increase in Phe and TBARS, and unaltered ADMA, nitrite and NOx concentrations were obtained. Despite increased net protein catabolism (indicated by elevated Phe/Tyr ratios) lack of Arg, suggested by decreased molar Arg/Phe ratios, occurred. Decreased molar Arg/Gln suggests an early but transient decrease in Arg synthesis. CONCLUSION: Unilateral nephrectomy causes an early abrupt decrease in plasma arginine and reduction in glomerular filtration rate in LKDs that was associated with increased net protein breakdown in the peripheral tissues and elevated oxidative damage, which has to be considered in their therapy.

Ambulatory phlebectomy under tumescent local anesthesia in a kidney-transplant patient.

INTRODUCTION: Tumescent local anesthesia (TLA) is widely used for ambulatory surgery. Patients with transplanted or gans are on immunosuppressive therapy and with risk for organ rejection or severe infection. CASE REPORT: Saphe nectomy with phlebectomy on the left leg under TLA was performed in a patient with kidney transplantation per formed four years ago. A combination of 35 mg of 1% prilocaine-hydrochloride, 5 mL of 8.4% sodium bicarbonate and 500 microg of epinephrine in 460 mL of normal saline was used for TLA. Overall 750 mL of the solution was used. The patient had satisfactory postoperative analgesia and was discharged home on the same day. Blood levels of urea, cre atinine, estimated glomerular filtration rate (eGFR) and ta crolimus concentration, measured preoperatively and on the second postoperative day, were in a regular range. Prilocaine blood concentrations determined on the 4th, 10th and 16th postoperative hours, were below toxic levels. CONCLUSION: TLA in a kidney-transplanted patient performed for saphe nectomy with phlebectomy proved to be a safe and reliable anesthesia method.

Endovascular repair of mycotic aneurysm of the descending thoracic aorta: diagnostic and therapeutic dilemmas-two case reports with 1-year follow-up.

A mycotic aneurysm of the thoracic aorta is a rare diagnosis with high mortality. We present two cases of endovascular reconstruction of mycotic descending thoracic aorta. Specific or nonspecific bacterial or other infectious agent in serial samples of blood, urine, cerebrospinal fluid, and pleural puncture was not detected in the first case, but we found in sputum sample Mycobacterium tuberculosis in the second patient. We empirically began by administering broad-spectrum intravenous antibiotics in the first case, with preoperative antibiotic prophylaxis and antituberculotic drugs therapy in the second case, and continued with the same medication for 4 months after endovascular repair. Control computed tomographic scans 6 months after reconstruction showed no endoleak in both patients. Repair of mycotic descending thoracic aortic aneurysms by endoluminal stent graft is reasonable alternative to open surgical intervention. A broad-spectrum antibiotic therapy has a high significance in the treatment of patients with mycotic aneurysm.

[Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm].

INTRODUCTION: According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. CASE REPORT: We presented a 75-years-old man, with elective visceral hybrid reconstruc tion of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patient's vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. CONCLUSION: Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemic-reperfusion injury of the body is reduced to a minimum.

[Subcutaneous paratibial fasciotomy in the treatment of chronic venous ulcer].

BACKGROUND/AIM: Chronic venous ulcer (CVU), a disease of high incidence, is one of the most serious chronic venous insufficiency complications. It has been estimated that there are 1%-2% of adults with CVU deriving a high social significance. The aim of this study was to, using the clinical experience, determine the influence of subcutaneous paratibial fasciotomy (SPF) on the course and the treatment outcome of CVU. METHODS: From February 2006 to September 2009 SPF was applied in a group of 43 patients treated for CVU along with other standard methods of treatment, and its influence on the course of ulcus cruris was followed up regarding the control group of another 43 patients treated with standard methods with no paratibial fasciotomy. RESULTS: In the group of patients treated with SPF there was a significantly better clinical course of ulcus cruris closing as compared with the group of patients in which this method was not applied. In the group with paratibial fasaciotomy there was no Thiersch skin transplant rejection recorded nor ulcus recurrence within a 6-month after-surgery period, while in the control group there was Thiersch skeen transplant rejection in 11 patients, and ulcus recurrence in 9 patients within the same period. CONCLUSION: SPF is a useful method with a favorable influence on better clinical course of ulcus cruris closing, reducing recurrence rate and improving local microcirculation in the affected region. Operation act itself is safe, requires no specific equipment nor special training of the team of surgeons, thus being applicable to the majority of patients with ulcus cruris indicated for surgery.