Correlations between magnetic resonance imaging characteristics of the intraluminal thrombus with its biochemical properties and morphological features of the infrarenal abdominal aortic aneurysm wall

najvećem broju slučajeva sadrži intraluminalni tromb (ILT) u aneurizmatskoj kesi. Uprkos decenijama intenzivnog istraživanja, uticaj ILT-a na progresiju AAA ostao je nedovoljno jasan. Mnoge kliničke studije su potvrdile ulogu matriksmetaloproteinaza (MMP-ova), hemokina i elastaza sekretovanih u ILT-u u razvoju AAA. Mijeloperoksidaze, elastase, MMP-2, 8 i 9 i activator plazminogena tipa urokinaze iz ILT-a mogu imati značajnu ulogu u razgradnji elastina i kolagena tip I i III u aortnom zidu. Definisati adekvatnu dijagnostičku metodu u preoperativnoj evaluaciji efekata ILT-a na zid AAA je izuzetno važno u individualnoj proceni rizika od rupture. Ultrazvučni pregled i kompjuterizovana tomografija nisu dovoljno senzitivne da bi procenile razlike u strukturi ILT-ova. Pregled magnetnom rezonancom (MR) omogućava razlikovanje ILT-ova na osnovu različitih intenziteta signala, te je cilj ovog istraživanja bio da se ispita mogućnost MR pregleda u proceni biološke aktivnosti ILT-a i proteolitičkih procesa u zidu infrarenalne AAA. MATERIJAL I METODE Istraživanje je sprovedeno u vidu studije preseka u Klinici za vaskularnu i endovaskularnu hirurgiju Kliničkog centra Srbije u periodu od aprila 2017. do februara 2018. godine. U navedenom periodu otvorenom hirurškom lečenju podvrgnuto je ukupno 155 bolesnika sa asimptomatskom AAA, od kojih je 50 uključeno u studiju na osnovu uključujućih (prisustvo tromba u aneurizmi, degenerativna i fuziformna infrarenalna AAA planirana za otvoreno hirurško lečenje transperitonealnim pristupom) i isključujućih kriterijuma (asimptomatski bolesnici planirani za endovaskularni tretman, bolesnici sa potkovičastim bubregom, inflamatorne i infektivne AAA, sakularne AAA, kontraindikacije za MR pregled i primenu kontrasta). Pre operativnog zahvata, tokom iste hospitalizacije, pacijenti uključeni u studiju ispitani su MR pregledom. Tokom operacije uzimani su uzorci ILT-a i zida AAA za biohemijsku analizu. Pregled magnetnom rezonancom Pregled je rađen „3 T Siemens Skyra scanner“ aparatom (Skyra Siemens, Berlin, Nemačka) sa 32-kanalnom matricom i 4-kanalnom zavojnicom za abdomen. Analizirani su aksijalni preseci na nivou najvećeg transverzalnog dijametra AAA dobijeni upotrebom T1-weighted (T1W) sekvence nakon intravenske aplikacije paramagnetnog kontrastnog sredstva u arterijskoj fazi pregleda. Podaci dobijeni MR pregledom obrađivani su i analizirani na Syngo (Siemens, Berlin, Nemačka) radnim stanicama uobičajenim alatom...intraluminal thrombus (ILT). Despite decades of intensive research, the implications of ILT on AAA propagation are still unclear. Many clinical studies have confirmed the role of ILT’s locally secreted matrix metalloproteinases (MMPs), chemokines, and elastases in AAA development. ILTs secrete myeloperoxidases, elastases, MMP 2, 8 and 9, and urokinase-type plasminogen activator, all of which are critical for elastin and collagen type I and III degradation in the aortic wall. In the clinical setting, defining the best imaging method for preoperative evaluation of the effects of ILT on the AAA wall is essential for individual assessment of AAA rupture risk. Ultrasonography and computed tomography angiography are not sensitive enough to identify differences in ILT structure. Magnetic resonance imaging (MRI) is a more adequate method of depicting the structural variations of ILT based on differential signal intensity (SI). Therefore, the aim of the present study was to analyze correlation of the SI of ILTs presented on MRI with the biochemical activity of ILTs and their proteolytic effects on the AAA wall. MATERIAL AND METHODS From April 12, 2017 to February 5, 2018, a single center, cross-sectional study was conducted at the Clinic for Vascular and Endovascular Surgery in Belgrade, Serbia. The study included asymptomatic patients with infrarenal AAA who underwent open surgical repair. During the study period, 155 patients with asymptomatic AAA underwent open surgical repair. After application of inclusion (degenerative and fusiform infrarenal AAA with ILT inside the sac underwent open surgical repair through a midline transperitoneal approach) and exclusion criteria (asymptomatic patients scheduled for endovascular treatment, AAA associated with horseshoe kidney, inflammatory or mycotic AAA, saccular AAA, contraindications for MRI and contrast administration), a total of 50 patients were included in the study. Before surgery, all patients selected for the study were evaluated with MRI. ILT and AAA wall samples for biochemical analysis were harvested during the surgery. Measured MRI variables MRI was conducted with a 3-Tesla whole-body MRI scanner (Skyra, Siemens, Berlin, Germany) using a standard 32-channel surface 4-receiver coil. MRI data were processed and analyzed by Syngo workstations (Siemens, Berlin, Germany). AAA diameter was measured at the level of maximum diameter (Dmax) on T1w images after contrast administration in the arterial phase..

Long-term graft occlusion in aortobifemoral position

Background/Aim. Aortobifemoral (AFF) bypass is still the most common surgical procedure used in treatment of aortoiliac occlusive disease. One of the most common complications of AFF bypass procedure is long-term graft occlusion. The aim of this study was to determine the cause of long-term graft occlusion in AFF position, as well as the results of early treatment of this complication. Methods. This retrospective study, performed at the Clinic of Vascular and Endovascular Surgery, Clinical Center of Serbia in Belgrade, involved 100 patients treated for long-term occlusion of bifurcated Dacron graft which was ensued at least one year after the primary surgical procedure. Results. The most common cause of the longterm graft occlusion was the process at the level of distal anastomosis or below it (Z = 3.8, p = 0.0001). End-to-end type of proximal anastomosis has been associated with a significantly increased rate of long-term graft occlusion (Z = 2.2, p = 0.0278). Five different procedures were used for the treatment of long-term graft occlusion: thrombectomy and distal anastomosis patch plasty (46% of the cases); thrombectomy and elongation (26% of the cases); thrombectomy and femoropopliteal bypass (24% of the cases); crossover bypass (2% of the cases) and a new AFF bypass (2% of the cases). The primary early graft patency was 87%. All 13 early occlusions occurred after the thrombectomy associated with patch plasty of distal anastomosis. Thrombectomy with distal anastomosis patch plasty showed a statistically highest percentage of failures in comparison to thrombectomy with graft elongation, or thrombectomy with femoro-popliteal bypass (Z = 2 984, p = 0.0028). Redo procedures were performed in all the cases of early occlusions. In a 30-day follow-up period after the secondary surgery, 90 (90%) patients had their limbs saved, and above knee amputation was made in 10 (10%) patients. Conclusion. Long-term AFF bypass patency can be obtained by proximal end-to-end anastomosis on the juxtarenal part of aorta and distal anastomosis on the bifurcation of the common femoral, or on the deep femoral artery. [Projekat Ministarstva nauke Republike Srbije, br. 175008

Popliteal artery injury following traumatic knee joint dislocation in a 14-year-old boy: A case report and review of the literature

Introduction. Posterior knee joint dislocation associated with injury of the popliteal artery in children is an extremely rare condition. Rapid diagnosis and treatment are essential for limb salvage and function. Case report. We reported a 14-year-old boy who suffered traumatic displacement of the right knee and contusion of the popliteal artery during motorcycle accident. The diagnosis was confirmed using Doppler and duplex ultrasonography and digital substraction transfemoral arteriography. The urgent surgical procedure was performed using posterior approach to the popliteal artery. During the surgical exploration, rupture of the posterior cruciate ligament associated with thrombosed popliteal artery have been found. The damaged popliteal artery was resected and replaced with autologous saphenous vein graft. The last stage of the procedure was a transosseous femoral fixation of posterior circuate ligament. A 3-year-follow-up after the surgery demonstrated intact arterial perfusion and very good function of the knee with a minimal difference as compared with the contralateral knee. Conclusion. Combined orthopedic and vascular injuries are very rare in children. They require combined treatment. [Projekat Ministarstva nauke Republike Srbije, br. 175008

Correlations between magnetic resonance imaging characteristics of the intraluminal thrombus with its biochemical properties and morphological features of the infrarenal abdominal aortic aneurysm wall

najvećem broju slučajeva sadrži intraluminalni tromb (ILT) u aneurizmatskoj kesi. Uprkos decenijama intenzivnog istraživanja, uticaj ILT-a na progresiju AAA ostao je nedovoljno jasan. Mnoge kliničke studije su potvrdile ulogu matriksmetaloproteinaza (MMP-ova), hemokina i elastaza sekretovanih u ILT-u u razvoju AAA. Mijeloperoksidaze, elastase, MMP-2, 8 i 9 i activator plazminogena tipa urokinaze iz ILT-a mogu imati značajnu ulogu u razgradnji elastina i kolagena tip I i III u aortnom zidu. Definisati adekvatnu dijagnostičku metodu u preoperativnoj evaluaciji efekata ILT-a na zid AAA je izuzetno važno u individualnoj proceni rizika od rupture. Ultrazvučni pregled i kompjuterizovana tomografija nisu dovoljno senzitivne da bi procenile razlike u strukturi ILT-ova. Pregled magnetnom rezonancom (MR) omogućava razlikovanje ILT-ova na osnovu različitih intenziteta signala, te je cilj ovog istraživanja bio da se ispita mogućnost MR pregleda u proceni biološke aktivnosti ILT-a i proteolitičkih procesa u zidu infrarenalne AAA. MATERIJAL I METODE Istraživanje je sprovedeno u vidu studije preseka u Klinici za vaskularnu i endovaskularnu hirurgiju Kliničkog centra Srbije u periodu od aprila 2017. do februara 2018. godine. U navedenom periodu otvorenom hirurškom lečenju podvrgnuto je ukupno 155 bolesnika sa asimptomatskom AAA, od kojih je 50 uključeno u studiju na osnovu uključujućih (prisustvo tromba u aneurizmi, degenerativna i fuziformna infrarenalna AAA planirana za otvoreno hirurško lečenje transperitonealnim pristupom) i isključujućih kriterijuma (asimptomatski bolesnici planirani za endovaskularni tretman, bolesnici sa potkovičastim bubregom, inflamatorne i infektivne AAA, sakularne AAA, kontraindikacije za MR pregled i primenu kontrasta). Pre operativnog zahvata, tokom iste hospitalizacije, pacijenti uključeni u studiju ispitani su MR pregledom. Tokom operacije uzimani su uzorci ILT-a i zida AAA za biohemijsku analizu. Pregled magnetnom rezonancom Pregled je rađen „3 T Siemens Skyra scanner“ aparatom (Skyra Siemens, Berlin, Nemačka) sa 32-kanalnom matricom i 4-kanalnom zavojnicom za abdomen. Analizirani su aksijalni preseci na nivou najvećeg transverzalnog dijametra AAA dobijeni upotrebom T1-weighted (T1W) sekvence nakon intravenske aplikacije paramagnetnog kontrastnog sredstva u arterijskoj fazi pregleda. Podaci dobijeni MR pregledom obrađivani su i analizirani na Syngo (Siemens, Berlin, Nemačka) radnim stanicama uobičajenim alatom...intraluminal thrombus (ILT). Despite decades of intensive research, the implications of ILT on AAA propagation are still unclear. Many clinical studies have confirmed the role of ILT’s locally secreted matrix metalloproteinases (MMPs), chemokines, and elastases in AAA development. ILTs secrete myeloperoxidases, elastases, MMP 2, 8 and 9, and urokinase-type plasminogen activator, all of which are critical for elastin and collagen type I and III degradation in the aortic wall. In the clinical setting, defining the best imaging method for preoperative evaluation of the effects of ILT on the AAA wall is essential for individual assessment of AAA rupture risk. Ultrasonography and computed tomography angiography are not sensitive enough to identify differences in ILT structure. Magnetic resonance imaging (MRI) is a more adequate method of depicting the structural variations of ILT based on differential signal intensity (SI). Therefore, the aim of the present study was to analyze correlation of the SI of ILTs presented on MRI with the biochemical activity of ILTs and their proteolytic effects on the AAA wall. MATERIAL AND METHODS From April 12, 2017 to February 5, 2018, a single center, cross-sectional study was conducted at the Clinic for Vascular and Endovascular Surgery in Belgrade, Serbia. The study included asymptomatic patients with infrarenal AAA who underwent open surgical repair. During the study period, 155 patients with asymptomatic AAA underwent open surgical repair. After application of inclusion (degenerative and fusiform infrarenal AAA with ILT inside the sac underwent open surgical repair through a midline transperitoneal approach) and exclusion criteria (asymptomatic patients scheduled for endovascular treatment, AAA associated with horseshoe kidney, inflammatory or mycotic AAA, saccular AAA, contraindications for MRI and contrast administration), a total of 50 patients were included in the study. Before surgery, all patients selected for the study were evaluated with MRI. ILT and AAA wall samples for biochemical analysis were harvested during the surgery. Measured MRI variables MRI was conducted with a 3-Tesla whole-body MRI scanner (Skyra, Siemens, Berlin, Germany) using a standard 32-channel surface 4-receiver coil. MRI data were processed and analyzed by Syngo workstations (Siemens, Berlin, Germany). AAA diameter was measured at the level of maximum diameter (Dmax) on T1w images after contrast administration in the arterial phase..

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