Comparative analysis of open and endovascular abdominal aortic aneurysm in high risk patients

Uvod: Premda je endovaskularni tretman aneurizmatske bolesti (EVAR) abdominalne aorte osmišljen upravo za pacijente koji nisu pogodni kandidati za klasičnu otvorenu hirurgiju, njegov inicijalno dobar rezultat ubrzao je implementiranje ove proceduru u kliničku rutinu, a odmah zatim i kod bolesnika sa niskim operativnim rizikom. Ipak, svaki tretman aneurizmatske bolesti infrarenalne abdominalne aorte kod visoko rizičnih bolesnika predstavlja i dalje pravi izazov. Nedavni rezultati pojednih studija doveli su u pitanje apsolutnu korist ovih procedura kod visoko rizičnih bolesnika. Ovo je posebno važno imajući u vidu očekivani životni vek ovih bolesnika kao i značajan komorbiditet. Ciljevi: Cilj srpske multicentrične studije u ukupnoj populaciji tretiranih visoko rizičnih bolesnika sa aneurizmatskom bolešću abdominalne aorte, je poređenje ishoda lečenja dva različita tretmana, endovaskularnog (EVAR) i otvoreno hirurškog (OH). Metodologija: Podaci pacijenata koji su hirurški i endovaskularno lečeni zbog aneurizmatske bolesti abdominalne aorte u periodu januara 2007 do jula 2015, su retrospektivno i prospektivno sakupljani sa četiri Univerzitetske Klinike u Srbiji. Kriterijum visoko rizičnog bolesnika definisan je kao rezultat bodovanja Udruženja američkih anesteziologa klasa 3 ili 4, i jedan od sledećih varijabli komorbiditeta po tipu: bolesti srca, respiratorna insuficijencija, hepatična insuficijencija, revaskularizacija srca, bubrežna insuficijencija, hostilni abdomen i životna dob preko 80 godina. 328 bolesnika od 421 je zadovoljilo ove kriterijume (EVAR, n=180; OH, n=148). Primarni ciljevi istraživanja bili su tridesetodnevni mortalitet i petogodišnje preživljavanje. Sekundarni ciljevi bili su postoperativne komplikacije. Korišćena je Kaplan-Majer-ova analiza preživljavanja i Cox regresiona analiza...Objective: Although, endovascular aneurysm repair (EVAR) was originally designed for patients that are unfit to undergo invasive open repair (OR), the initial positive results, have lead quickly to the implementation of EVAR in clinical routine and also to its frequent use for low-risk patients. However, infrarenal aortic aneurysm repair in high-risk patients still remains a challenge. Recent results after endovascular abdominal aortic aneurysm repair (EVAR) have brought into question its value in patients deemed at high-risk for surgical intervention. In addition, the life span in this category of patients is often limited because of serious comorbidity, so the efficacy of EVAR or open repair in prolonging life expectancy also remains uncertain. Aims: The aim of the Serbian multicentric population-based study was to evaluate the outcome after elective EVAR compared with OR in a high-risk patient cohort. Methodology: Using data from 4 University vascular hospitals in Serbia, we retrospectively and prospectively evaluated patients who underwent elective abdominal aortic aneurysm repair from January 2007 to July 2015. The high-risk cohort was defined as age >60 years, American Anesthesiologists Association (ASA) class 3 or 4, the comorbidity variables of history of cardiac, respiratory, hepatic disease, cardiac revascularization, renal insufficiency and hostile abdomen. These criteria were met by 328 of 421 patients (EVAR, n=180; OR, n=148). Primary end points were 30-day mortality and 5-years survival and the secondary end point was perioperative complications. Kaplan-Meier curves for survival and multivariate Cox regression analyses were performed. Results: Mean age (years) was 69±7.3 (OR 67±6.8; EVAR 70±7.6; p=0.001). Male patients 91.5%, female patients 8.5%. The 30-day mortality rates for EVAR vs OR were 0% vs 4.1%, p=0.008..

Comparative analysis of open and endovascular abdominal aortic aneurysm in high risk patients

Uvod: Premda je endovaskularni tretman aneurizmatske bolesti (EVAR) abdominalne aorte osmišljen upravo za pacijente koji nisu pogodni kandidati za klasičnu otvorenu hirurgiju, njegov inicijalno dobar rezultat ubrzao je implementiranje ove proceduru u kliničku rutinu, a odmah zatim i kod bolesnika sa niskim operativnim rizikom. Ipak, svaki tretman aneurizmatske bolesti infrarenalne abdominalne aorte kod visoko rizičnih bolesnika predstavlja i dalje pravi izazov. Nedavni rezultati pojednih studija doveli su u pitanje apsolutnu korist ovih procedura kod visoko rizičnih bolesnika. Ovo je posebno važno imajući u vidu očekivani životni vek ovih bolesnika kao i značajan komorbiditet. Ciljevi: Cilj srpske multicentrične studije u ukupnoj populaciji tretiranih visoko rizičnih bolesnika sa aneurizmatskom bolešću abdominalne aorte, je poređenje ishoda lečenja dva različita tretmana, endovaskularnog (EVAR) i otvoreno hirurškog (OH). Metodologija: Podaci pacijenata koji su hirurški i endovaskularno lečeni zbog aneurizmatske bolesti abdominalne aorte u periodu januara 2007 do jula 2015, su retrospektivno i prospektivno sakupljani sa četiri Univerzitetske Klinike u Srbiji. Kriterijum visoko rizičnog bolesnika definisan je kao rezultat bodovanja Udruženja američkih anesteziologa klasa 3 ili 4, i jedan od sledećih varijabli komorbiditeta po tipu: bolesti srca, respiratorna insuficijencija, hepatična insuficijencija, revaskularizacija srca, bubrežna insuficijencija, hostilni abdomen i životna dob preko 80 godina. 328 bolesnika od 421 je zadovoljilo ove kriterijume (EVAR, n=180; OH, n=148). Primarni ciljevi istraživanja bili su tridesetodnevni mortalitet i petogodišnje preživljavanje. Sekundarni ciljevi bili su postoperativne komplikacije. Korišćena je Kaplan-Majer-ova analiza preživljavanja i Cox regresiona analiza...Objective: Although, endovascular aneurysm repair (EVAR) was originally designed for patients that are unfit to undergo invasive open repair (OR), the initial positive results, have lead quickly to the implementation of EVAR in clinical routine and also to its frequent use for low-risk patients. However, infrarenal aortic aneurysm repair in high-risk patients still remains a challenge. Recent results after endovascular abdominal aortic aneurysm repair (EVAR) have brought into question its value in patients deemed at high-risk for surgical intervention. In addition, the life span in this category of patients is often limited because of serious comorbidity, so the efficacy of EVAR or open repair in prolonging life expectancy also remains uncertain. Aims: The aim of the Serbian multicentric population-based study was to evaluate the outcome after elective EVAR compared with OR in a high-risk patient cohort. Methodology: Using data from 4 University vascular hospitals in Serbia, we retrospectively and prospectively evaluated patients who underwent elective abdominal aortic aneurysm repair from January 2007 to July 2015. The high-risk cohort was defined as age >60 years, American Anesthesiologists Association (ASA) class 3 or 4, the comorbidity variables of history of cardiac, respiratory, hepatic disease, cardiac revascularization, renal insufficiency and hostile abdomen. These criteria were met by 328 of 421 patients (EVAR, n=180; OR, n=148). Primary end points were 30-day mortality and 5-years survival and the secondary end point was perioperative complications. Kaplan-Meier curves for survival and multivariate Cox regression analyses were performed. Results: Mean age (years) was 69±7.3 (OR 67±6.8; EVAR 70±7.6; p=0.001). Male patients 91.5%, female patients 8.5%. The 30-day mortality rates for EVAR vs OR were 0% vs 4.1%, p=0.008..

Case report of gross hematuria in the nutcracker syndrome resolved by renocaval reimplantation

Introduction. Nutcracker syndrome is defined as a set of signs and symptoms secondary to compression of the left renal vein (LRV) in the acute anatomic angle between the aorta and its superior mesenteric branch. Case report. A 38-year old woman with asymptomatic and “idiopathic” gross hematuria came to the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade. Hematuria was documented by cystoscopy and was found to be unilateral, located to the left urethral orifice. The contrast-enhanced multidetector computed tomography (MDCT) scan showed a stenotic LRV due to the extrinsic compression in the angle formed by the ventral aorta and superior mesenteric artery (MSA), with a jet of contrast through the lumen. Considering the negative investigations for more common causes of hematuria, its incapacitating nature, and above mentioned imaging findings suggestive of the nutcracker syndrome, an indication for the open surgical correction of the LRV entrapment was established. The patient underwent reimplantation of the LRV into the more distal inferior vena cava (IVC), to relocate it out of the constrictive aortomesenteric space. Intraoperative findings were notable for blood flow turbulence in the LRV and hypertrophy of its tributaries, which were ligated. We presented the first published case in the Serbian literature on nutcracker syndrome with hematuria resolved by renocaval reimplantation. Conclusion. This case report demonstrates that renocaval reimplantation, as the open surgery technique, could be the adequate method for resolving gross hematuria in patients with nutcracker syndrome

Subclavian steal syndrome - surgical or endovascular treatment

Background/Aim. A phenomenon of subclavian steal is caused by occlusion or stenosis of the proximal subclavian artery with subsequent retrograde filling of the subclavian artery via the ipsilateral vertebral artery. The aim of this research was to compare surgical method [carotid-subclavian bypass grafts (CSBG)] and endovascular methods [percutaneous transluminal angioplasty (PTA) and stenting of subclavian artery] from the aspect of immediate and long-term results. Methods. Thirty patients [16 (53.33%) males], of average age between 60.1 ± 8.25 years were treated with CSBG and compared with a group of forty patients [18 (45%) males], of the average age between 57.75 ± 6.15 years treated by PTA and stenting of subclavian artery. Immediate and long-term results were determined clinically and confirmed by Doppler pressures and duplex ultrasound/angiography. All patients were followed-up after 1, 6 and 12 months post-procedure, and annually thereafter. Results. The average follow-up for both groups was 22.37 ± 11.95 months. There were 2 (6.67%) procedural complications in the CSBG group (transient ischemic attack in 2 patients) and 3 (7.5%) ones in the PTA/stent group (dissection and distal embolization in one patient and puncture site hematoma in one patient). Systolic blood pressure difference between the two brachial arteries in CSBG group was: 42.6 ± 14.5 mmHg vs 4.75 ± 12.94 mmHg (p 0.05). Conclusions. Both, the CSBG and PTA/stenting of subclavian artery are safe, efficacious and durable procedures. They have similar immediate and long-term results. PTA and stenting are the methods of choice for high grade stenosis, near total occlusions and segment occlusions of subclavian artery. CSBG is indicated in case of diffuse occlusive lesions and when the PTA and stenting do not succeed or cause complications

Abdominal aortic surgery and renal anomalies

Introduction. Kidney anomalies present a challenge even for the most experienced vascular surgeon in the reconstruction of the aortoilliac segment. The most significant anomalies described in the surgery of the aortoilliac segment are a horse-shoe and ectopic kidney. Objective. The aim of this retrospective study was to analyze experience on 40 patients with renal anomalies, who underwent surgery of the aortoilliac segment and to determine attitudes on conventional surgical treatment. Methods. In the period from 1992 to 2009, at the Clinic for Vascular Surgery of the Clinical Centre of Belgrade we operated on 40 patients with renal anomalies and aortic disease (aneurysmatic and obstructive). The retrospective analysis involved standard epidemiological data of each patient (gender, age, risk factors for atherosclerosis, type of anomaly, type of aortic disease, presurgical parameter values of renal function), type of surgical approach (laparatomy or retroperitoneal approach), classification of the renal isthmus, reimplantation of renal arteries and perioperative morbidity and mortality. Results. Twenty patients were males In 30 (70%) patients we diagnosed a horse-shoe kidney and in 10 (30%) ectopic kidney. In the cases of ruptured aneurysm of the abdominal aorta the diagnosis was made by ultrasound findings. Pre-surgically, renal anomalies were confirmed in all patients, except in those with a ruptured aneurysm who underwent urgent surgery. In all patients we applied medial laparatomy, except in those with a thoracoabdominal aneurysm type IV, when the retroperitonal approach was necessary. On average the patients were under follow-up for 6.2 years (from 6 months to 17 years). Conclusion. Under our conditions, the so-called double clamp technique with the preservation of the kidney gave best results in the patients with renal anomalies and aortic disease

Vacuum-assisted wound closure in vascular surgery - clinical and cost benefits in a developing country

Background/Aim. Surgical and chronic wounds in vascular patients might contribute to limb loss and death. Vacuum-assisted closure (VAC) - Kinetic Concepts, Inc. (KCI), has been increasingly used in Western Europe and the USA clinical practice for 15 years. Advantages of this method are faster wound healing, wound approximation, lower wound related treatment costs and improved quality of life during treatment. Evidence related to the usage of VAC therapy in vascular patients and cost effectiveness of VAC therapy in a developing country are lacking. The aim of this study was to explore results of VAC therapy in vascular surgery comparing to conventional methods and to test cost effects in a developing country like Serbia. Methods. All patients with wound infection or dehiscence operated at the tertiary vascular university clinic in the period from January 2011 - January 2012, were treated with VAC therapy. The primary endpoint was wound closure, while secondary endpoints were hospital stay, the number of weekly dressings, costs of wound care, working time of medical personnel. The patients were divided into groups according to the wound type and location: wound with exposed synthetic vascular implant (25%), laparotomy (13%), foot amputation (29%), major limb amputation (21%), fasciotomy (13%). The results of primary and secondary endpoint were compared with the results of conventional treatment during the previous year. Results. There was one death (1/42, 2.38%) and one limb loss (1/12, 2.38%) in the VAC group, and 8 deaths (8/38, 21.05%) and 5 (5/38, 13.15%) limb losses in the patients treated with conventional therapy. In the VAC group there was one groin bleeding (1/12, 2.38%), one groin reinfection (1/12, 2.38%) and one resistance to therapy with a consequent limb loss. Costs of hospital stay (p < 0.001) and nursing time (p < 0.001) were reduced with VAC therapy in the group with exposed graft. Conclusion. VAC therapy is the effective method for care of complicated wounds in vascular surgery. Patients with infection of wound with the exposed synthetic graft significantly benefit form this therapy. Cost effectiveness of VAC therapy is applicable to a developing country scenario, however cautious selection of patients contributes to the effectiveness

High rate of native arteriovenous fistulas: How to reach this goal?

The types of vascular accesses for hemodialysis (HD) include the native arteriovenous fistula (AVF), arteriovenous graft (AVG) and central venous catheter (CVC). Adequately matured native AVF is the best choice for HD patients and a high percentage of its presence is the goal of every nephrologist and vascular surgeon. This paper analyses the number and type of vascular accesses for HD performed over a 10-year period at the Clinical Center of Serbia, and presents the factors of importance for the creation of such a high number of successful native AVF (over 80%). Such a result is, inter alia, the consequence of the appointment of the Vascular Access Coordinator, whose task was to improve the quality of care of blood vessels in the predialysis period as well as of functional vascular accesses, and to promote the cooperation among different specialists within the field. Vascular access is the “lifeline” for HD patients. Thus, its successful planning, creation and monitoring of vascular access is a continuous process that requires the collaboration and cooperation of the patient, nephrologist, vascular surgeon, radiologist and medical personnel

Portal hypertension caused by postoperative superior mesenteric arteriovenous fistula

Introduction. Arteriovenous fistula of the superior mesenteric blood vessels is a rare complicaton in abdominal surgery. Case report. We presented a 49-year-old man with cramplike abdominal pain, abdominal distension and weight loss symptoms, with a history of previous small bowel resection and right colectomy, due to Crohn disease, 16 years ago. Clinical examination revealed a paraumbilical pulsation with systolic murmur and thrill. Ultrasonography and computed tomography revealed cystic dilatation of the superior mesenteric vein, hepatomegaly and ascites. Upper endoscopy revealed grade I esophageal varices with portal hypertensive gastropathy. The diagnosis of arteriovenous fistula between superior mesenteric artery and vein was confirmed by angiogram of the superior mesenteric vessels and resection of the fistula was performed. Control examination after nine months showed no signs of portal hypertension. Conclusion. Early diagnosis and treatment of mesenteric blood vessel arteriovenous fistula prevents portal hypertension development and its complications