Impact of diabetes mellitus on early outcome of carotid endarterectomy

oznato je da dijabetes melitus povećava rizik za nastanak ishemijskog moždanog udara u opštoj opulaciji, ali je njegov uticaj na rane rezultate karotidne endarterektomije (KEA) kontraverzan sa suprotnim rezultatima. Cilj: primarni cilj ove studije je da ispita da li dijabetes melitus ima uticaj na rani ishod karotidne endarterektomije, a sekundarni da ispita kakav uticaj imaju drugi preoperativni i intraoperativni faktori. Materijal i metode: Ovom prospektivnom, kohortnom studijom, su obuhvaćena 902 bolesnika kojima je učinjena KEA na Klinici za vaskularnu i endovaskularnu hirurgiju KCS u periodu od 1. januara 2015. do 31. decembra 2016. godine. Iz studije su isključeni: pacijenti operisani zbog restenoze karotidne arterije, pacijenti kojima je učinjena karotidna revaskularizacija sa graftom i pacijenti kojima je u ranom postoperativnom periodu učinjena kardiohirurška ili aortna rekonstrukcija. Pacijenti su bili podeljeni u dve grupe. Prvu grupu su činili bolesnici koji nemaju dijabetes melitus (NDM grupa), a drugu grupu bolesnici koji imaju dijabetes melitus (DM grupa). Analizirani su i ispitivani kako na rani ishod (mortalitet i neurološke komplikacije) KEA utiču dijabetes melitus i drugi preoperativni i intraoperativni parametri. U DM grupi ispitivan je i uticaj tipa dijabetes melitusa, načina regulisanja glikemije i vrednosti glikoziliranog hemoglobina (HbAc1) na rani ishod. Rezultati: Bilo je 6 (0.66%) smrtnih ishoda i 33 (3.66%) neurološke (25 moždanih udara i 8 TIA) komplikacije. NDM grupu je činilo 606, a DM grupu 296 bolesnika, od kojih su 83 glikemiju regulisala insulinom, a 213 oralnom terapijom. Ukupna stopa neuroloških komplikacija je bila statistički veća u DM grupi (2.64% vs 5.74%, P=0.02). Moždani udar je bio češći u DM grupi (1.98% vs 4.4%, P=0.04), dok se incidenca TIA nije razlikovala između grupa (0.6% vs 1,35%, P=0.45). Mortalitet je bio statistički češći u DM grupi (0.01% vs 1.68%, P=0.01)...Diabetes mellitus is well known risk factor for ischemic stroke in general population, but its impact on early outcome of carotid endarterectomy (CEA) is controversial with conflicting results. Objective: The primary goal of this study is to examine whether diabetes mellitus has the impact on early outcome of CEA, and the secondary goal is to examine the impact of other prioperative and intraoperative factors on early oucome. Material and Methods: This prospective, cohort study includes 902 consecutive CEA conducted at the Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia during two-years period (01.01.2015.-31.12.2016.). Patients treated due to carotid restenosis and carotid bypass grafting were excluded from the study, as well as patients who underwent cardiac or aortic surgery in the early post-operative course. Patients were divided into non-diabetic (NDM) and diabetic (DM) group. The impact of diabetes mellitus and other prioperative and intraoperative parameters on early outcomes of CEA in terms of neurological complications and mortality were analyzed. In diabetic patients, a type of diabetes mellitus, type of glycaemia management and values of glycosylated haemoglobin (HbAc1) was examined. Results: There were 606 non-diabetic patients. Among 296 diabetic patients, 83 were on insulin therapy. The mortality rate was 0.66%. There were 33 (3.66%) neurological (25 strokes and 8 TIA) complications. The neurological complications were statistically higher in the diabetic group (2.64% vs 5.74%, P=0.02). Stroke was more frequent in the diabetic group (1.98% vs 4.4%, P=0.04) comparing to TIA (0.6% vs 1.35%, P=0.45). Mortality was statistically more frequent in diabetic group (0.01% vs 1.68%, P=0.01)..

Impact of diabetes mellitus on early outcome of carotid endarterectomy

oznato je da dijabetes melitus povećava rizik za nastanak ishemijskog moždanog udara u opštoj opulaciji, ali je njegov uticaj na rane rezultate karotidne endarterektomije (KEA) kontraverzan sa suprotnim rezultatima. Cilj: primarni cilj ove studije je da ispita da li dijabetes melitus ima uticaj na rani ishod karotidne endarterektomije, a sekundarni da ispita kakav uticaj imaju drugi preoperativni i intraoperativni faktori. Materijal i metode: Ovom prospektivnom, kohortnom studijom, su obuhvaćena 902 bolesnika kojima je učinjena KEA na Klinici za vaskularnu i endovaskularnu hirurgiju KCS u periodu od 1. januara 2015. do 31. decembra 2016. godine. Iz studije su isključeni: pacijenti operisani zbog restenoze karotidne arterije, pacijenti kojima je učinjena karotidna revaskularizacija sa graftom i pacijenti kojima je u ranom postoperativnom periodu učinjena kardiohirurška ili aortna rekonstrukcija. Pacijenti su bili podeljeni u dve grupe. Prvu grupu su činili bolesnici koji nemaju dijabetes melitus (NDM grupa), a drugu grupu bolesnici koji imaju dijabetes melitus (DM grupa). Analizirani su i ispitivani kako na rani ishod (mortalitet i neurološke komplikacije) KEA utiču dijabetes melitus i drugi preoperativni i intraoperativni parametri. U DM grupi ispitivan je i uticaj tipa dijabetes melitusa, načina regulisanja glikemije i vrednosti glikoziliranog hemoglobina (HbAc1) na rani ishod. Rezultati: Bilo je 6 (0.66%) smrtnih ishoda i 33 (3.66%) neurološke (25 moždanih udara i 8 TIA) komplikacije. NDM grupu je činilo 606, a DM grupu 296 bolesnika, od kojih su 83 glikemiju regulisala insulinom, a 213 oralnom terapijom. Ukupna stopa neuroloških komplikacija je bila statistički veća u DM grupi (2.64% vs 5.74%, P=0.02). Moždani udar je bio češći u DM grupi (1.98% vs 4.4%, P=0.04), dok se incidenca TIA nije razlikovala između grupa (0.6% vs 1,35%, P=0.45). Mortalitet je bio statistički češći u DM grupi (0.01% vs 1.68%, P=0.01)...Diabetes mellitus is well known risk factor for ischemic stroke in general population, but its impact on early outcome of carotid endarterectomy (CEA) is controversial with conflicting results. Objective: The primary goal of this study is to examine whether diabetes mellitus has the impact on early outcome of CEA, and the secondary goal is to examine the impact of other prioperative and intraoperative factors on early oucome. Material and Methods: This prospective, cohort study includes 902 consecutive CEA conducted at the Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia during two-years period (01.01.2015.-31.12.2016.). Patients treated due to carotid restenosis and carotid bypass grafting were excluded from the study, as well as patients who underwent cardiac or aortic surgery in the early post-operative course. Patients were divided into non-diabetic (NDM) and diabetic (DM) group. The impact of diabetes mellitus and other prioperative and intraoperative parameters on early outcomes of CEA in terms of neurological complications and mortality were analyzed. In diabetic patients, a type of diabetes mellitus, type of glycaemia management and values of glycosylated haemoglobin (HbAc1) was examined. Results: There were 606 non-diabetic patients. Among 296 diabetic patients, 83 were on insulin therapy. The mortality rate was 0.66%. There were 33 (3.66%) neurological (25 strokes and 8 TIA) complications. The neurological complications were statistically higher in the diabetic group (2.64% vs 5.74%, P=0.02). Stroke was more frequent in the diabetic group (1.98% vs 4.4%, P=0.04) comparing to TIA (0.6% vs 1.35%, P=0.45). Mortality was statistically more frequent in diabetic group (0.01% vs 1.68%, P=0.01)..

Hybrid procedure in the treatment of thoracoabdominal aortic aneurysms: Case report

Introduction. Treatment of thoracoabdominal aortic aneurysms is a major problem in vascular surgery. Conventional open repair is associated with significant rates of mortality and morbidity and therefore, there is a need for better solutions. One of them is a hybrid procedure that includes visceral debranching. This paper presents the first such case performed in Serbia, with a brief overview on all published procedures worldwide. Case Outline. A 57-year-old woman was admitted to the hospital because of thoracoabdominal aneurysms type V by Crawford-Safi classifications. Because of the significant comorbidities it was concluded that conventional treatment would bear unacceptably high perioperative risk, and that the possible alternative could be the hybrid procedure in two stages. In the first stage aortobiliacal reconstruction with bifurcated Dacron graft (16×8 mm) and visceral debranching with hand made tailored branched graft was done. In the second act, the thoracoabdominal aneurysm was excluded with implantation of the endovascular Valiant stent graft, 34×150 mm (Medtronic, Santa Rosa, CA). Control MSCT angiography showed a proper visceral branch patency and positioning of the stent graft without endoleaks. Nine months after the procedure the patient was symptom-free, with no aneurysm, diameter change and no graft-related complication. All visceral branches were patent. Conclusion. So far about 500 cases of visceral debranching have been published with the aim of treating thoracoabdominal aneurysms, and still we have no valid guidelines concerning this method. However, in carefully selected high-risk patients this is an excellent alternative to open surgery of thoracoabdominal aneurysms

Axillobifemoral bypass grafting

INTRODUCTION Axillo-femoral bypass (AxF) means connecting the axillar and femoral artery with the graft that is placed subcutaneously [1]. Usually, this graft is connected with contralateral femoral artery via one accessory subcutaneous graft, and this connection is known as axillobifemoral bypass (AxFF). This extra-anatomic procedure is an alternative method to the standard reconstruction of aortoiliac region when there are contraindications for general or local reasons. OBJECTIVE The objective of this paper is to show early and late results of AxFF bypass grafting as well as to show the indications for AxFF bypass. METHODS The sample consisted of 37 patients. The procedure was performed in 28 patients who suffered from aortoiliac occlusive disease and who were at high risk due to the comorbidity- in one patient with the rupture of juxtarenal aneurysm of abdominal aorta; in five patients with aortoenteric fistula, in two patients with iatrogenic lesion of abdominal aorta and in one female patient with anus preternaturalis definitivus who was treated for rectovaginal fistula. Donor's right axillary artery was used in 26 cases (70.3%), and donor's left axillary artery was used in 9 cases (29.7%). Dacron graft was used in 34 patients and Polytetrafluo-roethlylene graft was used in three patients. Simultaneously, profundo-plastic was done in four patients and femoro-popliteal bypass was performed in three patients. In five patients who suffered from aortoenteric fistula, simultaneous intervention of gastrointerstinal system has been done, x2 test was used for statistical evaluation and life table method was used for verification of late graft patency. RESULTS The rate of early postoperative mortality was 13.5%. The causes of death were: sepsis -1, MOFS - 3, and infarct myocardium -1. The mean follow up period was 40.1 months, ranging from six months to 17 years. During the follow up period, an early graft thrombosis was identified in two and late graft occlusion was reported in four patients. As the cause of occlusion, the progression of occlusive disease of receptive artery was identified in three patients, while anastomotic neointimae hyperplasia of recipient artery was identified in one patient. Three patients died during the follow up period. As the cause of death, CVI was reported in two patients and malignancy of the urinary tract was fpund in one patient. The other complications were - artery angulation on the level of proximal anastomosis in one patient (Figure 1), false aneurysm in one patient, perigraft seroma in one patient and graft infection in three patients. Life table method has shown that cumulative rate of late graft patency is 80.39% after five years (Graph 1). DISCUSSION Our results were analyzed and compared with the results of the study on 283 patients who had undergone aortobifemoral bypass (AFF) operation due to the aortoiliac occlusive disease. This study was completed in 1995 (18). The results showed that there was no statistically significant differences between AxFF and AFF group (p>0.05), considering early mortality rate and late graft patency (Graph 2). The review of mortality and late patency rate after AxFF bypass grafting in a world well known studies has shown the similar results (Table 1). CONCLUSION The authors suggest that axilobifemoral bypass is indicated when there are contraindications or difficulties to perform anatomic reconstruction due to the abdomen condition (infection, adhesion, comorbidity) as well as in high risk patients with low life expectancy

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