Prva iskustva u endoluminalnoj rekonstrukciji aneurizme abdominalne aorte uz upotrebu bifurkacijske proteze

The procedure of non-ruptured abdominal aortic aneurysm endoluminal repair is described. The first two procedures in Croatia by use of an AneuRx stent graft were performed in two patients admitted to the Division of Vascular Surgery, Sestre milosrdnice University Hospital in Zagreb. To our knowledge, these were the first self-supporting procedures carried out in Croatia. The principal characteristics of endoluminal material and equipment as well as their use are presented. Preoperative diagnostic procedures and postoperative course in the two patients are also described. Special emphasis is given to the indications and contraindications for this type of procedure as well as to the major possible complications. Endoluminal repair for aortic aneurysm is a new and revolutionary approach to the treatment of this serious and severe illness. Endovascular surgery is expected to mark the first decade of the new millennium.Prikazan je postupak endoluminalne rekonstrukcije nerupturirane aneurizme abdominalne aorte. Operacije je izvedena u dvojice bolesnika na Odjelu za vaskularnu kirurgiju Kliničke bolnice “Sestre milosrdnice” u Zagrebu, upotrebom AneuRx stent grafta. Prema našim spoznajama, operacija je prvi put samostalno učinjena u Hrvatskoj. Prikazana su glavna obilježja materijala i uređaja te njihova primjena. Također se daje prikaz prijeoperacijske dijagnostike i poslijeoperacijskog tijeka u dvojice operiranih bolesnika. Navedene su indikacije i kontraindikacije za primjenu postupka, kao i glavne moguće komplikacije. Endoluminalni način u liječenju aneurizme abdominalne aorte predstavlja nov i revolucionaran pristup, primjena kojega će doći do izražaja u prvom desetljeću novoga tisućljeća

Prva iskustva u endoluminalnoj rekonstrukciji aneurizme abdominalne aorte uz upotrebu bifurkacijske proteze

The procedure of non-ruptured abdominal aortic aneurysm endoluminal repair is described. The first two procedures in Croatia by use of an AneuRx stent graft were performed in two patients admitted to the Division of Vascular Surgery, Sestre milosrdnice University Hospital in Zagreb. To our knowledge, these were the first self-supporting procedures carried out in Croatia. The principal characteristics of endoluminal material and equipment as well as their use are presented. Preoperative diagnostic procedures and postoperative course in the two patients are also described. Special emphasis is given to the indications and contraindications for this type of procedure as well as to the major possible complications. Endoluminal repair for aortic aneurysm is a new and revolutionary approach to the treatment of this serious and severe illness. Endovascular surgery is expected to mark the first decade of the new millennium.Prikazan je postupak endoluminalne rekonstrukcije nerupturirane aneurizme abdominalne aorte. Operacije je izvedena u dvojice bolesnika na Odjelu za vaskularnu kirurgiju Kliničke bolnice “Sestre milosrdnice” u Zagrebu, upotrebom AneuRx stent grafta. Prema našim spoznajama, operacija je prvi put samostalno učinjena u Hrvatskoj. Prikazana su glavna obilježja materijala i uređaja te njihova primjena. Također se daje prikaz prijeoperacijske dijagnostike i poslijeoperacijskog tijeka u dvojice operiranih bolesnika. Navedene su indikacije i kontraindikacije za primjenu postupka, kao i glavne moguće komplikacije. Endoluminalni način u liječenju aneurizme abdominalne aorte predstavlja nov i revolucionaran pristup, primjena kojega će doći do izražaja u prvom desetljeću novoga tisućljeća

Ortostatika i kronična venska insuficijencija u hrvatskih stomatologa

The purpose of the study was to point to occupational exposure of dental medicine doctors in Croatia and to the effect of static performance on developing venous disease. The study included 120 subjects, 60 of them doctors of dental medicine and 60 from other professions. The study was focused on finding a way to upgrade preventive measures against developing chronic venous insufficiency and the quality of life of dental medicine doctors. Study subjects underwent verbal testing (questionnaire), clinical examination and ultrasonography (color Doppler).U radu se ukazuje na utjecaj profesionalne izloženosti doktora dentalne medicine u Hrvatskoj te na statičko opterećenje u odnosu na razvoj bolesti venskog sustava. Istraživanje je obuhvatilo 120 ispitanika, od toga 60 doktora dentalne medicine i 60 ispitanika drugih struka. Cilj istraživanja ponajprije je unaprjeđenje preventivnih mjera kojima bi se spriječio razvoj kronične venske insuficijencije, ali i poboljšanje kvalitete života naših ispitanika. Ispitanici su podvrgnuti usmenom anketiranju (anketni upitnik), kliničkom pregledu te ultrazvučnoj dijagnostici (obojeni Doppler)

Razvoj poslijeoperacijske okluzije karotidne arterije zbog prisutnosti rizičnih čimbenika

Postoperative internal carotid artery (ICA) occlusion is a rare condition with few data on the risk factors. The aim of the study was to analyze risk factors and ischemic symptomatology in patients with postoperative ICA occlusion. During one year period, 33 patients with postoperative ICA occlusion were examined at Cerebrovascular Laboratory. Medical history, clinical findings and atherosclerosis risk factors were compared with data on 33patients with satisfactory postoperative finding. Student\u27s t-test was used on data comparison (P<0.05). In 31 of 33 patients, ICA occlusion was recorded on the first postoperative examination, 3 months after carotid endarterectomy (18 right and 15 left). In 8 patients, combined occlusion of the common carotid artery and ICA was found (4 right, 4 left). One patient ICA developed occlusion during the first and third postoperative year each. Clinically, three patients presented with ischemic symptoms (one stroke and two transitory ischemic attacks (TIA)). The following risk factors were present in the group with postoperative ICA occlusion: hypertension in 18, smoking in 10, hyperlipidemia in 8, diabetes mellitus in 9, history of stroke in 13, TIA in 3, heart attack in 4 and coronary disease in 3 patients; the respective figures in the control group were as follows: 25, 11, 16, 7, 7, 3, 4 and 3. There was no significant between-group difference in the presence of risk factors. Study results suggested that postoperative ICA occlusion was not caused by atherosclerosis risk factors but by perioperative complications.Poslijeoperacijska okluzija unutarnje karotidne arterije je rijetka komplikacija s nedovoljno poznatim rizičnim čimbenicima. Cilj ove studije bio je analizirati čimbenike rizika ateroskleroze i simptome ishemije kod bolesnika s okluzijom karotidne arterije nakon karotidne endarterektomije. Tijekom godine dana je u Cerebrovaskularnom laboratoriju pregledano 33 bolesnika s poslijeoperacijskom okluzijom unutarnje karotidne arterije. Uzeti su anamnestički podaci, analizirana je klinička slika, te čimbenici rizika ateroskleroze. Podaci su uspoređeni s podacima 33 bolesnika sa zadovoljavajućim poslijeoperacijskim nalazom. Podaci su uspoređeni Studentovim t-testom. U 31 od 33 bolesnika okluzija je ustanovljena tijekom prvog pregleda 3 mjeseca nakon karotidne endarterektomije, u troje bolesnika uz pojavu ishemijske simptomatologije. U 8 bolesnika zabilježena je poslijeoperacijska okluzija cijelog karotidnog stabla. U jednog je bolesnika okluzija nastala tijekom prve godine praćenja. dok je u jednog nastupila nakon tri godine. Čimbenici rizika ateroskleroze u skupini s poslijeoperacijskom okluzijom su bili: hipertenzija u 18, pušenje u 10, hiperlipidemija u 8, dijabetes melitus u 9, preboljeli moždani udar u 13, preboljela TIA u 3, infarkt miokarda u 4, angina pektoris u 3 bolesnika, dok su u skupini sa zadovoljavajućim poslijeoperacijskim nalazom to bili: hipertenzija u 25, pušenje u 11, hiperlipidemija u 16, dijabetes melitus u 7, preboljeli moždani udar u 7, preboljela TIA u 3, infarkt miokarda u 4, angina pektoris u 3 bolesnika. Nije bilo značajne razlike u prisutnim čimbenicima rizika. Dakle, rana poslijeoperacijska okluzija karotidne arterije najvjerojatnije nije uzrokovana uobičajenim čimbenicima rizika ateroskleroze, nego periproceduralnim komplikacijama

Vaskularna hibridna dvorana – operacijaska dvorana budućnosti

The last two decades have seen a paradigm shift in the treatment of vascular related diseases from once traditional open surgical repairs to the entire vascular tree being amenable to percutaneous interventions. Neither the classic operating room nor the conventional angiography suite is optimal for both open surgery and endovascular procedures. Important issues for the vascular hybrid operating room include quality of the imaging equipment, radiation burden, ease of use of the equipment, need for specially trained personnel, ergonomics, ability to perform both open and percutaneous procedures, sterile environments, as well as quality and efficiency of patient care. The most important feature of working in a dedicated hybrid vascular suite should be the ability to attain best treatment of vascular patients. Whether the interventional radiologist or the vascular surgeon uses the facilities is of less importance. Establishment of an endovascular operating room suite has the benefit of a sterile environment, and the possibility of performing hybrid procedures and conversions when necessary. Moreover, angiography immediately before treatment gives contemporary anatomical information, and after treatment provides quality control. Consequently, better quality and service can be provided to the individual patient. These changes in the treatment of vascular disease require that a new type of vascular specialist, named ‘vascular hybrid surgeon’, trained to perform both endovascular and open surgical procedures in this highly complex patient group.U posljednja dva desetljeća primjećuje se pomak u liječenju vaskularnih bolesti od tradicionalno otvorenih kirurških zahvata prema perkutanoj intervenciji cijelog vaskularnog stabla. Niti klasične operativne dvorane, a niti konvencionalne angio dvorane nisu optimalne za izvođenje otvorene operacije ili za endovaskularne zahvate. Glavne značajke vaskularne hibridne operativne dvorane obuhvaćaju kvalitetnu opremu za snimanje, radijacijski štit, opremu za jednostavnu upotrebu, potrebu za dobro izučenim kadrom, ergonomičnost, mogućnost odvijanja otvorenih i perkutanih zahvata, sterilnu okolinu, kao i kvalitetu i učinkovitost bolesničke skrbi. Najznačajnija značajka rada u hibridnoj vaskularnoj operacijskoj dvorani trebala bi biti mogućnost pružanja najbolje operacije bolesniku s krvožilnom bolešću. Manje je važno tko će opremu upotrebljavati, intervencijski radiolog ili vaskularni kirurg. Uspostava jedne endovaskularne operativne dvorane ima prednost sterilne okoline, mogućnost izvođenja hibridnih zahvata, te ako je potrebno i konverzije. Također, angiografija učinjena neposredno prije operativnog zahvata pruža točnije anatomske informacije, a nakon zahvata pruža bolju kontrolu kvalitete. Posljedično, bolja kvaliteta i usluga može se ponuditi svakom pojedinačnom bolesniku. Takve promjene u liječenju bolesnika s bolešću krvnih žila zahtijevaju i novi profil vaskularnog kirurga nazvan “vaskularni hibridni kirurg” koji mora biti osposobljen u izvođenju endovaskularnih, ali i otvorenih operativnih zahvata kod iznimno složene skupine bolesnika

Subfascijalna endoskopska kirurgija perforantnih vena (SEPS): tehnika i naša stajališta

Chronic venous insufficiency is a major health and socioeconomic issue throughout the world. Some 2%-5% of the adult population suffers from chronic venous insufficiency, while about 1% of the European population has chronic leg ulceration. The role of retrograde blood flow through incompetent perforating veins has an important role in the development of chronic venous insufficiency. Duplex ultrasound imaging is the preferred diagnostic tool, which is used to confirm the presence of bidirectional flow through the perforators adjacent to the areas of lipodermatosclerosis, healed ulcers and open ulcerations, i.e. in patients with chronic venous insufficiency CEAP class 4, 5 and 6. Subfascial endoscopic perforating vein surgery (SEPS) is a minimally invasive surgical procedure, which is the treatment of choice in these patients. The endoscope and surgical instruments are introduced through skin incisions that are distant from the areas of skin changes. The perforating veins are excellently visualized, while clipping and dividing the perforators interrupt retrograde blood flow. In patients with insufficiency of the superficial venous system, ligation and stripping of the superficial veins are usually performed at the same time. The lesser saphenous vein can be occluded with SEPS itself. The healing time with SEPS is substantially decreased when compared with conventional treatment and carries low complication and recurrence rates. However, SEPS should be offered to selected patients, i.e. to those with chronic venous insufficiency CEAP class 4, 5 and 6.Kronična venska insuficijencija predstavlja značajan zdravstveni i socioekonomski problem u cijelom svijetu. Oko 2% do 5% odrasle populacije ima kroničnu vensku insuficijenciju, a oko 1% europske populacije ima kronične venske ulceracije. Za razvoj kronične venske insuficijencije važna je uloga retrogradnog protoka krvi kroz nekompetentne perforantne vene. Dupleks ultrazvučni prikaz je dijagnostičko sredstvo izbora kojim se potvrđuje prisutnost dvosmjernog protoka kroz perforatore koji se nalaze uz mjesta lipodermatoskleroze, zacijeljenih ili otvorenih ulceracija, tj. kod bolesnika s kroničnom venskom insuficijencijom 4., 5. i 6. CEAP razreda. Subfascijalna endoskopska kirurgija perforantnih vena (SEPS) je minimalno invazivni kirurški postupak koji predstavlja metodu izbora kod ovih bolesnika. Endoskop i kirurški instrument se uvode kroz rezove na koži, koji su udaljeni u odnosu na kožne promjene. Perforantne vene se odlično prikazuju, te se njihovim "klipsanjem" i presijecanjem uklanja retrogradni protok krvi. Kod bolesnika s insuficijentnim površinskim venskim sustavom se u istom aktu učini i podvezivanje, kao i odstranjivanje površinskih vena. Vena saphena parva se može okludirati i samim SEPS-om. Vrijeme cijeljenja kod SEPS-a znatno je kraće u odnosu na klasično liječenje i praćeno je niskim stopama komplikacija i recidiva. Ipak, SEPS bi se trebao indicirati samo u određenih bolesnika, tj. onih s kroničnom venskom insuficijencijom 4., 5. i 6. CEAP razreda

5, 10-Methylenetetrahydrofolate Reductase (MTHFR) 677 C->T Genetic Polymorphism in 228 Croatian Volunteers

5, 10-Methylenetetrahydrofolate Reductase (MTHFR) is one of the key enzymes in the metabolism of homocysteine, where it catalyses its remethylation. The autosomal recessive bp 677 C->T mutation in the MTHFR gene leads to the substitution of valine for alanine. Individuals who are homozygous for this C677T mutation exhibit a decreased specific activity and increased thermolability of this enzyme. This leads to increased plasma levels of homocysteine, which is a known risk factor for atherosclerosis and various manifestations of the atherosclerotic disease. The aim of this study was to find out the distribution and frequency of this mutation in the general Croatian population. A group of 228 volunteers (175 males and 53 females) has been analyzed for the MTHFR polymorphism, which revealed the following distribution: 105 (46.05%) individuals were without mutation (C/C), 102 (44.74%) were heterozygous (C/T) and 21 (9.21%) homozygous (T/T). These findings are within the results of studies on other European populations

Assessment of apoptosis in the native vein used for hemodialysis access

Aim To determine whether apoptosis is more common in previously punctured native veins than in non-punctured native veins among patients who undergo surgical creation of arteriovenous fistula (AVF) for dialysis access. Methods Cephalic vein specimens were obtained from January 1, 2013 to December 31, 2014 from 60 patients, 30 with previously punctured native veins and 30 with nonpunctured native veins. Before AVF placement, a 1-cm vein segment was excised from distal part of the vein for histological, histochemical, and immunohistochemical analysis. Vein specimens were divided into two portions along the longitudinal axis and stained with hematoxylin and eosin for routine histological evaluation. Immunohistochemical analysis was used to localize Bax, p53, caspase 3, and Bcl-2 expression. Results The group with previously punctured veins showed significantly increased caspase 3 (P < 0.001, twosided Fisher`s Exact Test) and Bax expression (P = 0.002, two-sided Fisher`s Exact Test) and significantly decreased Bcl-2 expression (P < 0.001, two-sided Fisher`s Exact Test) compared with the control group. There were no significant differences between the groups in p53 expression (χ2 = 0.071, df = 1, P = 0.791). Fistula failure was significantly more common in the study group (26.7% vs 6.7%, χ2 = 4.32, df = 1, P = 0.038). Conclusion Our study indicates a possible role of venipuncture in apoptosis development and a possible role of apoptosis in fistula failure, but we do not have sufficient evidence to conclude that it represents its main cause

Carotid Bifurcation Position and Branching Angle in Patients with Atherosclerotic Carotid Disease

Carotid artery bifurcation (CB) is the preferred site for development of atherosclerosis (AS) in extracranial cerebral arteries; internal carotid artery stenosis is the most common cause of ischemic stroke. The frequent atherosclerotic disease of CB may best be explained by the hemodynamic influence of complex blood flow that results from the unique geometry of the bifurcation. Few papers analyze all possible geometric structural characteristics of this bifurcation. While performing many carotid endarterectomies, we noticed that a certain correlation between CB height in the neck and its angle existed, that a larger angle is accompanied with increased frequency of elongation and kinking and that CB shape influences distribution of atherosclerosis. The purpose of this paper is to quantify and evaluate these clinical observations. Radiogrametric analysis of 154 bi-plane orthogonal aortic arch arteriograms of patients with symptomatic atherosclerotic carotid artery disease was performed and a total of 289 CBs were analyzed. The CB height in relation to cervical spine segments was measured and real angles of each bifurcation were calculated. A positive linear correlation between CB height and angle exists: the CB angle increases/decreases 3,34o for each third of the cervical vertebral body height or intervertebral space height. The CB is positioned a little higher on the left side. The proximal border of the atherosclerotic process is found at the level of intersection of the axes of the common carotid artery branches in 92.6% of examined CBs. In lower CBs (with smaller angles) the proximal border was located in the last segment of the common carotid artery, while in high bifurcations (wider angles) the proximal border of the AS process is more distally in the blood flow, in the beginning of the internal carotid artery, and the process was more extensive. High CBs are more suitable for eversion endarterectomy while normal and low CBs are more suitable for open (classic) carotid endarterectomy. The influence of the geometric risk factor demands further investigation