Endovascular aortic repair: First twenty years

Endovascular aortic/aneurysm repair (EVAR) was introduced into clinical practice at the beginning of the nineties. Its fast development had a great influence on clinicians, vascular surgeons and interventional radiologists, educational curriculums, patients, industry and medical insurance. The aim of this paper is to present the contribution of clinicians and industry to the development and advancement of endovascular aortic repair over the last 20 years. This review article presents the development of EVAR by focusing on the contribution of physicians, surgeons and interventional radiologists in the creation of the new field of vascular surgery termed hybrid vascular surgery, and also the contribution of technological advancement by a significant help of industrial representatives – engineers and their counselors. This article also analyzes studies conducted in order to compare the successfulness of EVAR with up-to-now applied open surgical repair of aortic aneurysms, and some treatment techniques of other aortic diseases. During the first two decades of its development the EVAR method was rapidly progressing and was adopted concurrently with the expansion of technology. Owing to large randomized studies, early and long-term results indicate specific complications of this method, thus influencing further technological improvement and defining risk patients groups in whom the use of the technique should be avoided. Good results are insured only in centers, specialized in vascular surgery, which have on their disposal adequate conditions for solving all complications associated with this method

Evaluation of indications for the use of protective intraluminal shunt in carotid surgery

Uvod: Karotidna endarterektomija (CEA) se dokazala kao najbolji metod prevencije šloga kod simptomatskih i asimptomatskih pacijenata sa visokostepenom suženjem ekstrakranijalnog segmenta karotidnih arterija i u poslednje dve decenije postala najčešće izvođena procedura u rekonstruktivnoj vaskularnoj hirurgiji. Uprkos tome, više aspekata ove operacije su i dalje predmet debate, a jedan od najkontroverznijih je primena protektivnog intraluminalnog šanta tokom karotidne endarterektomije. Cilj: Radi provere hipoteze da rutinska primena protektivnog intraluminalnog šanta tokom karotidne endarterektomije u regionalnoj anesteziji pruža zaštitu mozga od ishemijskog i reperfuzionog oštećenja, postavljeni su sledeći ciljevi istraživanja: (1) utvrditi ishod i neposredne rezultate lečenja pacijenata podvrgnutih CEA sa i bez rutinske primene šanta; (2) utvrditi promene koncentracija biohemijskih pokazatelja moždanog oštećenja (neuron specifična enolaza, protein S-100B) u perifernoj krvi pacijenata podvrgnutih CEA sa i bez rutinske primene šanta; (3) utvrditi stepen oksidativnog oštećenja lipida i proteina određivanjem biohemijskih pokazatelja lipidne peroksidacije (malondialdehid) i aktivnosti slobodnih radikala (količina karbonilnih grupa, proteinskih tiol grupa i koncentracija nitrotirozina) u krvi ipsilateralne jugularne vene tokom CEA sa i bez rutinske primene šanta i (4) utvrditi promene u aktivnosti ključnih antioksidantnih enzima u perifernoj krvi pacijenata podvrgnutih CEA sa i bez rutinske primene šanta. Metodologija: Prospektivna studija obuhvatila je pacijente podvrgnute karotidnoj endarterektomiji zbog hemodinamski značajne (>70%) stenoze unutrašnje karotidne arterije tokom 2012. godine (01.01. – 31.12.2012.), u Klinici za vaskularnu i endovaskularnu hirurgiju KCS. Od 89 pacijenata operisanih od strane autora tokom perioda istraživanja, 60 je ispunilo kriterijume za uključivanje u studiju, te su metodom slučajnog izbora preoperativno podeljeni u dve grupe od po 30 pacijenata: grupa sa šantom (sCEA) koja je operisana konvencionalnom tehnikom endarterektomije sa rutinskom primenom šanta i grupa bez šanta (eCEA), operisana everzionom tehnikom, bez primene šanta...Introduction: Carotid endarterectomy (CEA) is well recognized as the best method for stroke prevention in symptomatic and asymptomatic patients with significant carotid stenosis, and in the past two decades has become the most frequently performed procedure in reconstructive vascular surgery. However, several aspects of this procedure are still under debate, and the most controversial is probably the use of protective intraluminal shunt during CEA. Objective: To test the hypothesis that routine shunting during CEA in regional anesthesia protects the brain from ischemia and reperfusion injury, this research focused on following objectives: (1) to determine treatment outcome for CEA performed with and without routine shunting; (2) to evaluate the changes in serum concentrations of biochemical markers of cerebral injury (neuron specific enolase, protein S-100B) in patients undergoing CEA with and without routine shunting; (3) to evaluate the extent of lipid and protein oxidative damage by determining jugular concentrations of byproducts of lipid peroxidation (malondialdehyde) and free radical activity (carbonyl groups, protein thiol groups and nitrotyrosine) during CEA with and without routine shunting, and (4) to evaluate the changes in activity of key antioxidant enzymes in patients undergoing CEA with and without the routine use of shunt. Methods: This prospective study was conducted on patients treated by the author for significant (>70%) carotid stenosis, during one-year period (01.01.2012.-31.12.2012.), at the Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia. Of 89 patients operated by the author during the trial period, 60 patients met the inclusion criteria, and were preoperatively randomized in two groups with 30 patients each: shunt group (sCEA) operated with conventional endarterectomy technique and routine shunting, and no shunt group (eCEA) undergoing eversion endarterectomy without shunting. Preoperatively, all patients underwent carotid Duplex ultrasonography, brain multidetector computerized tomography, as well as thorough physical and neurological examination..

Evaluation of indications for the use of protective intraluminal shunt in carotid surgery

Uvod: Karotidna endarterektomija (CEA) se dokazala kao najbolji metod prevencije šloga kod simptomatskih i asimptomatskih pacijenata sa visokostepenom suženjem ekstrakranijalnog segmenta karotidnih arterija i u poslednje dve decenije postala najčešće izvođena procedura u rekonstruktivnoj vaskularnoj hirurgiji. Uprkos tome, više aspekata ove operacije su i dalje predmet debate, a jedan od najkontroverznijih je primena protektivnog intraluminalnog šanta tokom karotidne endarterektomije. Cilj: Radi provere hipoteze da rutinska primena protektivnog intraluminalnog šanta tokom karotidne endarterektomije u regionalnoj anesteziji pruža zaštitu mozga od ishemijskog i reperfuzionog oštećenja, postavljeni su sledeći ciljevi istraživanja: (1) utvrditi ishod i neposredne rezultate lečenja pacijenata podvrgnutih CEA sa i bez rutinske primene šanta; (2) utvrditi promene koncentracija biohemijskih pokazatelja moždanog oštećenja (neuron specifična enolaza, protein S-100B) u perifernoj krvi pacijenata podvrgnutih CEA sa i bez rutinske primene šanta; (3) utvrditi stepen oksidativnog oštećenja lipida i proteina određivanjem biohemijskih pokazatelja lipidne peroksidacije (malondialdehid) i aktivnosti slobodnih radikala (količina karbonilnih grupa, proteinskih tiol grupa i koncentracija nitrotirozina) u krvi ipsilateralne jugularne vene tokom CEA sa i bez rutinske primene šanta i (4) utvrditi promene u aktivnosti ključnih antioksidantnih enzima u perifernoj krvi pacijenata podvrgnutih CEA sa i bez rutinske primene šanta. Metodologija: Prospektivna studija obuhvatila je pacijente podvrgnute karotidnoj endarterektomiji zbog hemodinamski značajne (>70%) stenoze unutrašnje karotidne arterije tokom 2012. godine (01.01. – 31.12.2012.), u Klinici za vaskularnu i endovaskularnu hirurgiju KCS. Od 89 pacijenata operisanih od strane autora tokom perioda istraživanja, 60 je ispunilo kriterijume za uključivanje u studiju, te su metodom slučajnog izbora preoperativno podeljeni u dve grupe od po 30 pacijenata: grupa sa šantom (sCEA) koja je operisana konvencionalnom tehnikom endarterektomije sa rutinskom primenom šanta i grupa bez šanta (eCEA), operisana everzionom tehnikom, bez primene šanta...Introduction: Carotid endarterectomy (CEA) is well recognized as the best method for stroke prevention in symptomatic and asymptomatic patients with significant carotid stenosis, and in the past two decades has become the most frequently performed procedure in reconstructive vascular surgery. However, several aspects of this procedure are still under debate, and the most controversial is probably the use of protective intraluminal shunt during CEA. Objective: To test the hypothesis that routine shunting during CEA in regional anesthesia protects the brain from ischemia and reperfusion injury, this research focused on following objectives: (1) to determine treatment outcome for CEA performed with and without routine shunting; (2) to evaluate the changes in serum concentrations of biochemical markers of cerebral injury (neuron specific enolase, protein S-100B) in patients undergoing CEA with and without routine shunting; (3) to evaluate the extent of lipid and protein oxidative damage by determining jugular concentrations of byproducts of lipid peroxidation (malondialdehyde) and free radical activity (carbonyl groups, protein thiol groups and nitrotyrosine) during CEA with and without routine shunting, and (4) to evaluate the changes in activity of key antioxidant enzymes in patients undergoing CEA with and without the routine use of shunt. Methods: This prospective study was conducted on patients treated by the author for significant (>70%) carotid stenosis, during one-year period (01.01.2012.-31.12.2012.), at the Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia. Of 89 patients operated by the author during the trial period, 60 patients met the inclusion criteria, and were preoperatively randomized in two groups with 30 patients each: shunt group (sCEA) operated with conventional endarterectomy technique and routine shunting, and no shunt group (eCEA) undergoing eversion endarterectomy without shunting. Preoperatively, all patients underwent carotid Duplex ultrasonography, brain multidetector computerized tomography, as well as thorough physical and neurological examination..

Aortoesophageal and aortobronchial fistula caused by Candida albicans after thoracic endovascular aortic repair

Introduction. Endovascular stent-graft placement has emerged as a minimally invasive alternative to open surgery for the treatment of aortic aneurysms and dissections. There are few reports of stent graft infections and aortoenteric fistula after endovascular thoracic aortic aneurysm repair, and the first multicentric study (Italian survey) showed the incidence of about 2%. Case report. We presented a 69-year-old male patient admitted to our hospital 9 months after thoracic endovascular aortic repair, due to severe chest pain in the left hemithorax and arm refractory to analgesic therapy. Multislice computed tomography (MSCT) showed a collection between the stent graft and the esophagus with thin layers of gas while gastroendoscopy showed visible blood jet 28 cm from incisive teeth. Surgical treatment was performed in collaboration of two teams (esophageal and vascular surgical team). After explantation of the stent graft and in situ reconstruction by using Dacron graft subsequent esophagectomy and graft omentoplasty were made. After almost four weeks patient developed hemoptisia as a sign of aorto bronchial fistula. Treatment with implantation of another aortic cuff of 26 mm was performed. The patient was discharged to the regional center with negative blood culture, normal inflammatory parameters and respiratory function. Three months later the patient suffered deterioration with the severe weight loss and pneumonia caused by Candida albicans and unfortunately died. The survival time from the surgical treatment of aortoesophageal fistula was 4 months. Conclusion. Even if endovascular repair of thoracic aortic diseases improves early results, risk of infection should not be forgotten. Postoperative respiratory deterioration and finally hemoptisia could be the symptoms of another fistula

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

Anastomotic pseudoaneurysms

Anastomotic pseudoaneurysm is a form of false aneurysm, whose wall, does not consist of all normal layers of arterial wall. Given the rising number of reconstructive vascular procedures, the increase of anastomotic pseudoaneurysm cases is expected. Therefore, identification of causes, clinical manifestations as well as factors which affect the outcome of operative treatment of anastomotic pseudoaneurysms is of great practical value. This retrospectively-prospective study included 87 surgically treated cases of anastomotic pseudoaneurysms in the period from 1991 to 2002. The most often localization of anastomotic pseudoaneurysms. was the inguinal region (68-86.2%), In the majority of cases, they were caused by arterial degeneration in the anastomotic region - 56 cases (65.9%) and infection - 21 cases (24.7%). The most frequent manifestations of anastomotic pseudoaneurysms were bleeding due to rupture in 26 cases (29.9%) and chronic limb ischemia in 22 cases (25.3%). An acute limb ischemia was present in 17 cases (19.5%)., the symptoms caused by local compression to the surrounding structures - in 9 cases (10.3%), and in 12 cases (13.8%), the only manifestation of anastomotic pseudoaneurysm was asymptomatic pulsatile mass, In 32: cases (36.8%), surgical treatment involved the resection of anastomotic pseudoaneurysm and, graft interposition, whereas in 39 cases (44.8%), bypass procedure had to be performed after the resection. Comorbidity significantly increased mortality in the first 30 days. The use of Dacron graft in primary operation significantly improved early results of operative treatment. Absence of infection as the cause of anastomotic pseudoaneurysm is a statistically important prognostic factor of operative treatment, considering the graft patency, limb salvage, infection, need for reintervencion and mortality

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

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement