GUIDELINES FOR TREATMENT OF CAROTID ARTERY STENOSIS

Stenoza unutarnje karotidne arterije povećava rizik od moždanog udara. Velike randomizirane studije pokazale su da karotidna endarterektomija (engl. carotid endarterectomy – CEA) ima važnu ulogu u prevenciji moždanog udara te da se kod operiranih bolesnika smanjuje rizik i dugoročno poboljšava kvaliteta života. Tijekom posljednjeg desetljeća metoda postavljanja stenta u karotidnu arteriju (engl. carotid artery stenting – CAS) razvila se kao način liječenja ekstrakranijalne stenoze karotide. Ideja je da se karotidna endarterektomija zamijeni manje invazivnim postupkom koji je poštedniji za bolesnika, a s jednakim rezultatima liječenja (što tek treba potvrditi randomiziranim studijama). Zahvat izvode liječnici različitih specijalnosti poput vaskularnih kirurga, općih kirurga, neurokirurga, kardiologa, radiologa i sl.1 Stoga su smjernice namijenjene potonjima radi zauzimanja jedinstvenog stajališta o liječenju bolesnika sa znatnim suženjem unutarnje karotidne arterije. Dodatak smjernicama jest dio koji se odnosi na CEA-u do 2 tjedna nakon moždanog udara te indikacija za liječenje restenoze nakon CEA-e ili CAS-a. Članovi Hrvatskog društva za vaskularnu kirurgiju (HDVK) prihvatili su izložene smjernice na stručnom sastanku HDVK u Vodicama u svibnju 2016. god. Njihova izrada nije bila financijski potpomognuta. Smjernice su namijenjene ponajprije vaskularnim kirurzima i interventnim radiolozima koji provode invazivno liječenje bolesnika sa znatnim suženjem unutarnje karotidne arterije radi zauzimanja jedinstvenog stajališta.Carotid artery stenosis is a risk factor for developing a stroke. Large randomized studies have shown that carotid endarterectomy (CEA) plays a significant role in preventing a stroke. Carotid endarterectomy decreases the risk of stroke and increases the quality of life after surgery. During the past decades carotid artery stenting (CAS) has evolved as a less invasive way of treating extracranial artery stenosis. Carotid artery stenting is supposed to be less invasive but equally successful and durable (randomized studies are expected to support this statement). Carotid artery stenting is being performed by vascular surgeons, general surgeons, neurosurgeons, cardiologists, radiologists etc1. In addition to these guidelines we provide indications for CEA (especially within 2 weeks after the onset of symptoms) and indications for the treatment of restenosis after CEA or CAS. Indications were presented and accepted by the members of the Croatian Society for Vascular Surgery (CSVS) during the meeting in Vodice in May, 2016. Making of these guidelines is not financially supported. The guidelines are primarily intended for vascular surgeons and interventional radiologists to provide a unified stance in the treatment of patients with a significant narrowing of the internal carotid artery

Smjernice za liječenje stenoze karotidne arterije [Guidelines for treatment of carotid artery stenosis]

Carotid artery stenosis is a risk factor for developing a stroke. Large randomized studies have shown that carotid endarterectomy (CEA) plays a significant role in preventing a stroke. Carotid endarterectomy decreases the risk of stroke and increases the quality of life after surgery. During the past decades carotid artery stenting (CAS) has evolved as a less invasive way of treating extracranial artery stenosis. Carotid artery stenting is supposed to be less invasive but equally successful and durable (randomized studies are expected to support this statement). Carotid artery stenting is being performed by vascular surgeons, general surgeons, neurosurgeons, cardiologists, radiologists etc1. In addition to these guidelines we provide indications for CEA (especially within 2 weeks after the onset of symptoms) and indications for the treatment of restenosis after CEA or CAS. Indications were presented and accepted by the members of the Croatian Society for Vascular Surgery (CSVS) during the meeting in Vodice in May, 2016. Making of these guidelines is not financially supported. The guidelines are primarily intended for vascular surgeons and interventional radiologists to provide a unified stance in the treatment of patients with a significant narrowing of the internal carotid artery

Low-dose Computed Tomography in a Pregnant Woman with a Ruptured Pseudoaneurysm of the Abdominal Aorta

Imaging the pregnant patient presents a unique challenge to radiologist due to the risk of radiation to the conceptus (embryo/fetus). A rare case of a successfully recognized and treated pseudoaneurysm (PA) of the abdominal aorta is to be presented. The pseudoaneurysm occurred in the third trimester and had a favorable outcome for the mother and the baby. Emergent abdominal ultrasound (US) is the first modality in diagnostic algorithm for the rupture of aortic aneurysm in a pregnant woman. It provides the most rapid diagnostic information, although intestinal gas and abdominal tenderness may limit its accuracy. To confirm the findings, magnetic resonance angiography (MRA) or CT angiography (CTA) can be used. In our case, the diagnosis was established using a color Doppler ultrasonography of the abdomen and was later confirmed by a low dose CT scan of the abdominal aorta. MRA in such cases have some disadvantages. At many health centers, the monitoring of patients with acute ruptures is more difficult in the MR suite than at the CT scanner. MRA angiographic images are also subject to degradation by multiple artifacts, and the visualization of the distal vasculature is suboptimal and inferior to the one done by CTA. Due to fetal movements, a small quantity of fresh blood can be overlooked by MR. MRA is often not available on a 24-hours basis, and the time required for making a diagnosis can preclude the use of MRA in an unstable patient. For this reason, we used a low dose CTA protocol to confirm the diagnosis. Low dose scanning protocols in CT can obtain sufficient diagnostic information while reducing the risk of radiation. A particular focus is put on the outline of new concepts for dose management and optimization. We used new approaches based on tube current modulation. The birth was induced by an urgent Caesarean section followed by a resection of a pseudoaneurysm and a reconstruction of the aorta with an end-to- end vascular prosthesi

POSTOPERATIVE HEALTH RELATED QUALITY OF LIFE AFTER CARDIAC SURGERY

Unazad četiri desetljeća opaža se smanjenje mortaliteta i morbiditeta u bolesnika nakon otvorenih i minimalno invazivnih kardijalnih zahvata. Međutim, danas glavni pokazatelj ishoda kardijalnih zahvata postaje preoperacijska kvaliteta života bolesnika. Cilj današnjih istraživanja je napraviti prediktivni model bodovanja preoperacijske kvalitete života koji bi pružio pouzdanu informaciju bolesniku i liječniku o utjecaju zahvata na funkcionalni status bolesnika i razdoblju u kojem će bolesnik postići sposobnost da istim ili boljim kapacitetom obavlja svakodnevne životne aktivnosti. Stoga uvođenje prediktivnih upitnika o preoperacijskoj kvaliteti života u svakodnevnu kliničku praksu, osobito kod starijih bolesnika, ima važnu ulogu u ranom i pravovremenom identifi ciranju bolesnika s mogućim lošijim postoperacijskim ishodom te omogućuje pravovremenu primjenu perioperacijskih mjera i postupaka radi poboljšanja kliničkog stanja bolesnika. Također, uvođenje prediktivnog modela procjene kvalitete života omogućit će bolesnicima i njihovim obiteljima bolje razumijevanje operacijskog tijeka kardiokirurškog liječenja i oporavka bolesnika, dok će liječnicima olakšati donošenje odluka o vrsti invazivnosti liječenja kod bolesnika koji se nalaze u tzv. sivoj zoni liječenja.Over the past four decades, decreasing morbidity and mortality rates of cardiac surgery patients have been noticed. However, the postoperative health-related quality of life (HRQoL) is becoming the key indicator of cardiac surgical outcome. Postoperative HRQoL is described as the impact of invasive medical procedures on functional status of patients and the ability and required time patients can proceed with their ordinary life. QoL is measured by self-report questionnaires, which according to accessible studies, are a subjective, valid, consistent and reliable way of patient QoL rating. Implementing preoperative QoL assessment in everyday practice can help in early identifying the patients with worse surgical outcome. Also, timely perioperative clinical optimization can be applied. Moreover, patients and their families are more properly informed about the consequences of cardiac procedure and its impact on the patient postoperative functional status

POSTOPERATIVE HEALTH RELATED QUALITY OF LIFE AFTER CARDIAC SURGERY

Unazad četiri desetljeća opaža se smanjenje mortaliteta i morbiditeta u bolesnika nakon otvorenih i minimalno invazivnih kardijalnih zahvata. Međutim, danas glavni pokazatelj ishoda kardijalnih zahvata postaje preoperacijska kvaliteta života bolesnika. Cilj današnjih istraživanja je napraviti prediktivni model bodovanja preoperacijske kvalitete života koji bi pružio pouzdanu informaciju bolesniku i liječniku o utjecaju zahvata na funkcionalni status bolesnika i razdoblju u kojem će bolesnik postići sposobnost da istim ili boljim kapacitetom obavlja svakodnevne životne aktivnosti. Stoga uvođenje prediktivnih upitnika o preoperacijskoj kvaliteti života u svakodnevnu kliničku praksu, osobito kod starijih bolesnika, ima važnu ulogu u ranom i pravovremenom identifi ciranju bolesnika s mogućim lošijim postoperacijskim ishodom te omogućuje pravovremenu primjenu perioperacijskih mjera i postupaka radi poboljšanja kliničkog stanja bolesnika. Također, uvođenje prediktivnog modela procjene kvalitete života omogućit će bolesnicima i njihovim obiteljima bolje razumijevanje operacijskog tijeka kardiokirurškog liječenja i oporavka bolesnika, dok će liječnicima olakšati donošenje odluka o vrsti invazivnosti liječenja kod bolesnika koji se nalaze u tzv. sivoj zoni liječenja.Over the past four decades, decreasing morbidity and mortality rates of cardiac surgery patients have been noticed. However, the postoperative health-related quality of life (HRQoL) is becoming the key indicator of cardiac surgical outcome. Postoperative HRQoL is described as the impact of invasive medical procedures on functional status of patients and the ability and required time patients can proceed with their ordinary life. QoL is measured by self-report questionnaires, which according to accessible studies, are a subjective, valid, consistent and reliable way of patient QoL rating. Implementing preoperative QoL assessment in everyday practice can help in early identifying the patients with worse surgical outcome. Also, timely perioperative clinical optimization can be applied. Moreover, patients and their families are more properly informed about the consequences of cardiac procedure and its impact on the patient postoperative functional status

Radical surgery of a recurrent low grade endometrial stromal sarcoma with a comprehensive intravenous growth from ovarian vein to the right ventricle – a case report

Radical surgery of a recurrent low grade endometrial stromal sarcoma with a comprehensive intravenous growth from ovarian vein to the right ventricle – a case repor