Dusan Kostic

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib (n = 16), soft tissue anomalies (n = 12), and scar tissue after clavicle fracture (n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia (n = 11), transient ischemic attack (TIA) (n = 1), and claudication or vasomotor phenomena during the arm hyperabduction (n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision (n = 12), combined cervical and first rib excision (n = 4), and first rib excision (n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

Aorto-caval fistulas

The surgical repair of 16 aorto-caval (A-C) fistulas (15 male and one female patient; average age of 61.3 years) is reviewed. Fourteen fistulas were caused by aneurysms erosion, one by iatrogenic injury, while one followed abdominal blunt trauma. The interval from presumed occurrence to diagnosis ranged from 6 h to 2 years. The presence of an abdominal bruit (87.5%) was the most reliable physical finding. Congestive heart failure was prominent in three (18.7%) cases, while severe lower extremity edema in five (31.2%). Two patients (12.5%) had hematuria, two (12.5%) renal insufficiency, while four (25%) scrotal edema. The diagnosis was not recognized before the surgery in five (31.2%) cases. In all 16 cases after transaortic suture of the fistula, aortic reconstructions were performed. Four operative deaths (25%) occurred, in patients who were not correctly diagnosed before surgery. In one case the cause of death was massive bleeding, and in three MOFS. All other patients were followed from 1 to 17 years (mean 4 years and 2 months). All grafts are patent, and there is no lower extremity venous insufficiency or pelvic venous hypertension. Surgical repair of A-C fistulas is mandatory to prevent serious complications.

Popliteal artery aneurysms.

Abstract. Altogether 59 patients with 76 popliteal artery aneurysms were treated during the last 36 years. There were 50 (85%) male and 9 (15%) female patients with an average age of 61 years. Nineteen (32%) patients had bilateral aneurysms. The clinical manifestations of the aneurysms included ruptures 4 (5.3%); deep venous thrombosis 4 (5.3%); sciatic nerve compression 1 (1.3%); leg ischemia 52 (68.4%), and asymptomatic pulsatile masses 15 (19.7%). Seventy (92%) aneurysms were atherosclerotic, one (1.3%) mycotic, and four (5.3%) traumatic; one (1.3%) developed owing to fibromuscular displasia. Seven (9.2%) small, asymptomatic aneurysms were not operated on. Reconstructive procedures (end-to-end anastomosis, graft interposition, bypass) after aneurysmal resection or exclusion using a medial or posterior approach were done in 59 cases. An autologous saphenous vein graft was used in 49 cases, polytetrafluoroethylene (PTFE) in 5, and heterograft in 2 cases. The in-hospital mortality rate was 2.9%, the early patency rate 93.3%, and limb salvage 95%. The long-term patency rate after a mean follow-up of 4 years was 78% and long-term limb salvage 89%. The total limb salvage was 73%, and the total amputation rate was 27%. The dangerous complications associated with popliteal artery aneurysms and the good results after elective procedures suggest that operative treatment is appropriate.

Civil and War Peripheral Arterial Trauma: Review of Risk Factors Associated with Limb Loss

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Aortobifemoral Grafting: Factors Influencing Long-Term Results

We present the results and respective determinant factors of 283 consecutive aortobifemoral bypasses. This prospective study included 283 patients with aortoiliac atherosclerotic occlusive disease treated by aortobifemoral reconstructions. Polytetrafluoroethylene (PTFE) grafts were used in 136 patients and Dacron® grafts in 147 patients. The 30-day mortality rate was 11 patients (3.9%). Perioperative (< 30 days) graft failure occurred in 6 patients (2.1%), whereas in 14 (5.25%) patients, it occurred during the follow-up period. There were 3 (1.05%) distal anastomotic pseudoaneurysms and 5 (1.7%) graft infections, with no statistical difference between the two types of grafts. The type of prosthesis did not influence cumulative graft patency. The end-to-end configuration of proximal anastomosis and a simultaneously performed femoropopliteal bypass significantly increased the graft patency (p < .05). The associated occlusion of the superficial femoral and popliteal arteries decreased the cumulative graft patency in comparison with that of the patients without artery disease (p < .05). Our results showed that in the aortobifemoral position, there was no significant difference in the patency, anastomotic pseudoaneurysms, and graft infection between PTFE and Dacron grafts. However, the PTFE grafts had a significantly higher rate (p < .05) of distal anastomotic stenosis, which was mostly caused by neointimal hyperplasia.

Ruptured abdominal aortic aneurysm. Predictors of survival in 229 consecutive surgical patients.

Background and Purpose:A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment.Patients and Methods:This study included 229 subsequent patients (83% males, 17% females, age 67.0 ± 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40–100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%).Results:Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 × 109/l, hematocrit < 0.29%, hemoglobin < 100 g/l, urea > 11 mmol/l, and creatinine > 180 µmol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period.Conclusion:Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.Hintergrund und Ziel:Ein rupturiertes Bauchaortenaneurysma gehört zu den Operationsindikationen mit höchster Dringlichkeit, da es unbehandelt eine hohe Mortalität aufweist. Das Ziel dieser Untersuchung war es, prognostische Faktoren zu identifizieren, die das intra- und postoperative Überleben der Patienten bestimmen.Patienten und Methodik:Zwischen 1991 und 2001 wurden 229 konsekutive Patienten (83% Männer, 17% Frauen, mittleres Alter 67,0 ± 7,5 Jahre) mit der Diagnose eines rupturierten Bauchaortenaneurysmas operiert. Vor der Operation wurden alle Patienten klinisch untersucht und Laborwerte erhoben, bei 78,6% der Patienten wurde eine Ultraschalluntersuchung, bei 16,2% eine Computertomographie (CT), bei 0,9% eine Magnetresonanztomographie (MRT) und bei 12,6% eine Angiographie durchgeführt. Nach den Ultraschallbefunden betrug der mittlere Durchmesser der Aneurysmata 73 mm, der kleinste Durchmesser lag bei 40 mm, der größte bei 100 mm. Bei 74% der Patienten waren die Aneurysmata infrarenal, bei 12,3% juxtarenal, bei 6,8% suprarenal und bei 6,8% thorakoabdominal lokalisiert. Folgende Rupturtypen wurden bei den Patienten nachgewiesen: retroperitoneal (65%), intraperitoneal (26,8%), chronisch (3,8%), in die Vena cava (3,2%) und das Duodenum (0,6%). Das operative Management erforderte folgende Gefäßrekonstruktionen: das Einbringen einer Dacron-Prothese (53%), einen aortobiiliakalen Bypass (32,8%) oder einen aortobifemoralen Bypass (14,2%).Ergebnisse:Die intraoperative Mortalität bei allen Patienten betrug 13,5%, und die Mortalität während des gesamten Krankenhausaufenthalts lag bei 53,7%. Faktoren bei Aufnahme der Patienten, die die Mortalität signifikant erhöhten, waren Bewusstlosigkeit, ein systolischer Blutdruck < 95 mmHg, Herzstillstand, eingeschränkte Diurese, ein Hämatokrit < 0,29%, ein Hämoglobinwert < 100g/l, Kreatinin > 180 µmol/l, Leukozyten > 14 × 109/l und Harnstoff > 11 mmol/l. Intraoperative Faktoren, die die Mortalität erhöhten, beinhalteten eine Aortenischämiezeit > 47 min, eine Operationsdauer > 200 min, einen intraoperativen Blutverlust > 3 500 ml, Nierenversagen mit einer Diurese < 400 ml sowie einen arteriellen systolischen Blutdruck < 97,5 mmHg und die Notwendigkeit einer aortobifemoralen Gefäßrekonstruktion. Beatmungsassoziierte Komplikationen und ein Multiorganversagen waren häufig mit einer hohen postoperativen Letalität verbunden.Schlussfolgerung:Zusammenfassend lässt sich feststellen, dass perioperative Faktoren definiert werden können, die die Prognose der Patienten mit rupturiertem Bauchaortenaneurysma signifikant beeinflussen. Diese intra- und perioperativen Parameter sollten möglichst optimiert werden, um langfristig ein besseres Überleben der Patienten zu erreichen.

Carotid Artery Aneurysms

We present the treatment of 17 extracranial carotid artery aneurysms in 16 patients (1 patient had bilateral lesions). There were 15 (93.75%) male patients and 1 (6.25%) female patient, with an average age of 64.8 years. Two (11.8%) aneurysms involved the common carotid artery and 15 (88.2%) the internal carotid artery. Two (11.8%) aneurysms presented with rupture, 3 (17.6%) as an asymptomatic mass, 2 (11.8%) with cranial nerve compression, 6 (35.3%) with transient ischemic attack, and 4 (23.5%) with stroke. The following surgical procedures were performed: extirpation with 8 mm Dacron graft replacement, 5 (29.4%) cases; extirpation with end-to-end anastomosis, 8 (47.1%) cases; extirpation with saphenous vein graft replacement, 3 (17.6%) cases; and ligature of the internal carotid artery, 1 (5.9%) case. One (5.9%) patient died postoperatively owing to stroke. Including this case, 3 (17.6%) patients had a postoperative stroke, whereas 2 (11.8%) patients had transient cranial nerve damage. Sixteen surviving patients were followed from 2 months to 15 years (mean 5 years, 3 months). During this period, 1 patient died 5 years postoperatively owing to a myocardial infarction, whereas all other patients were alive and free of neurologic symptoms. Extracranial carotid artery aneurysms are rare. However, they are of medical importance because of their location, differential diagnosis, natural history, complications, and treatment.

Ruptured Abdominal Aortic Aneurysm

Background and Purpose:A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment.Patients and Methods:This study included 229 subsequent patients (83% males, 17% females, age 67.0 ± 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40–100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%).Results:Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 × 109/l, hematocrit < 0.29%, hemoglobin < 100 g/l, urea > 11 mmol/l, and creatinine > 180 µmol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period.Conclusion:Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.Hintergrund und Ziel:Ein rupturiertes Bauchaortenaneurysma gehört zu den Operationsindikationen mit höchster Dringlichkeit, da es unbehandelt eine hohe Mortalität aufweist. Das Ziel dieser Untersuchung war es, prognostische Faktoren zu identifizieren, die das intra- und postoperative Überleben der Patienten bestimmen.Patienten und Methodik:Zwischen 1991 und 2001 wurden 229 konsekutive Patienten (83% Männer, 17% Frauen, mittleres Alter 67,0 ± 7,5 Jahre) mit der Diagnose eines rupturierten Bauchaortenaneurysmas operiert. Vor der Operation wurden alle Patienten klinisch untersucht und Laborwerte erhoben, bei 78,6% der Patienten wurde eine Ultraschalluntersuchung, bei 16,2% eine Computertomographie (CT), bei 0,9% eine Magnetresonanztomographie (MRT) und bei 12,6% eine Angiographie durchgeführt. Nach den Ultraschallbefunden betrug der mittlere Durchmesser der Aneurysmata 73 mm, der kleinste Durchmesser lag bei 40 mm, der größte bei 100 mm. Bei 74% der Patienten waren die Aneurysmata infrarenal, bei 12,3% juxtarenal, bei 6,8% suprarenal und bei 6,8% thorakoabdominal lokalisiert. Folgende Rupturtypen wurden bei den Patienten nachgewiesen: retroperitoneal (65%), intraperitoneal (26,8%), chronisch (3,8%), in die Vena cava (3,2%) und das Duodenum (0,6%). Das operative Management erforderte folgende Gefäßrekonstruktionen: das Einbringen einer Dacron-Prothese (53%), einen aortobiiliakalen Bypass (32,8%) oder einen aortobifemoralen Bypass (14,2%).Ergebnisse:Die intraoperative Mortalität bei allen Patienten betrug 13,5%, und die Mortalität während des gesamten Krankenhausaufenthalts lag bei 53,7%. Faktoren bei Aufnahme der Patienten, die die Mortalität signifikant erhöhten, waren Bewusstlosigkeit, ein systolischer Blutdruck < 95 mmHg, Herzstillstand, eingeschränkte Diurese, ein Hämatokrit < 0,29%, ein Hämoglobinwert < 100g/l, Kreatinin > 180 µmol/l, Leukozyten > 14 × 109/l und Harnstoff > 11 mmol/l. Intraoperative Faktoren, die die Mortalität erhöhten, beinhalteten eine Aortenischämiezeit > 47 min, eine Operationsdauer > 200 min, einen intraoperativen Blutverlust > 3 500 ml, Nierenversagen mit einer Diurese < 400 ml sowie einen arteriellen systolischen Blutdruck < 97,5 mmHg und die Notwendigkeit einer aortobifemoralen Gefäßrekonstruktion. Beatmungsassoziierte Komplikationen und ein Multiorganversagen waren häufig mit einer hohen postoperativen Letalität verbunden.Schlussfolgerung:Zusammenfassend lässt sich feststellen, dass perioperative Faktoren definiert werden können, die die Prognose der Patienten mit rupturiertem Bauchaortenaneurysma signifikant beeinflussen. Diese intra- und perioperativen Parameter sollten möglichst optimiert werden, um langfristig ein besseres Überleben der Patienten zu erreichen.

Surgical Treatment of Carotid Restenosis After Eversion Endarterectomy—Serbian Bicentric Prospective Study

BACKGROUND The increased number of carotid endarterectomies performed worldwide in recent years is associated with a greater need for carotid restenosis evaluation. Carotid restenosis rate ranges from 0.6% to 3.6% in symptomatic patients and from 8.8% to 19% in asymptomatic patients. Carotid angioplasty and stenting is a preferable therapeutic choice for carotid restenosis treatment, but whenever it is not technically feasible (tortuosities of supra-aortic branches, calcifications, pathological elongation, or very extensive lesions), redo surgical treatment is indicated. The aim of our study was to examine outcome of redo surgical treatment in patients with symptomatic and asymptomatic carotid restenosis, in whom carotid angioplasty could not be done, and its impact on early and late morbidity and mortality. METHODS The study included 52 patients who were surgically treated for significant carotid restenosis from January 2000 to December 2008 in two high-volume vascular surgery university clinics. Surgical techniques included redo eversion endarterectomy, standard endarterectomy with Dacron patch closure, and Dacron tubular graft interposition. The patients were followed for significant events (transient ischemic attack, stroke, cranial nerve injuries, surgical site hematoma, the occurrence of carotid re-restenosis, or occlusion), and mortality after 1 month, 6 months, 1 year, and annually afterward. RESULTS In the early postoperative period (within 30 days), there were no lethal outcomes. Transient ischemic attack was diagnosed in four patients (7.6%), minor stroke in two patients (3.8%), and cranial nerve injury in four patients (7.6%). After 4 years, three patients died (5.7%), two due to a fatal myocardial infarction (3.8%) and one after a major stroke (1.9%); four patients (7.6%) had ipsilateral stroke; and graft occlusion was verified in one patient (1.9%). CONCLUSION Carotid angioplasty might be a primary option for carotid restenosis treatment, but whenever it cannot be performed, redo surgical treatment is indicated, owing to its acceptable rate of early and late postoperative complications.

False Anastomotic Aneurysms

This retrospective study covers the period from 1991 to 2002, during which 3,623 patients were operated on because of aneurysmal or occlusive disease of aortoiliac and femoropopliteal segments. Among them, 87 patients (2.4%) developed a false anastomotic aneurysm in the 12-year follow-up period and were treated operatively. Most frequently, in 53 patients (6.9%), a false anastomotic aneurysm developed after aortobifemoral bypass performed owing to aortoiliac occlusive disease. The cause of false anastomotic aneurysm was infection in 21 cases (24.7%); resection and revascularization were performed with a Dacron graft in 46 cases (52.9%), with a polytetrafluoroethylene graft in 10 cases (11.5%), and with the great saphenous vein in 16 cases (18.4%). Homograft implantation in 4 patients (4.6%) or extra-anatomic bypasses in 11 cases (12.6%) were performed when graft infection was suspected. Of 87 patients who underwent surgery, 74 (85.5%) had good early results without infection, reintervention, limb loss, and mortality. The presence of infection as a cause of false anastomotic aneurysm and comorbidity increased the mortality rate significantly after the reoperation, whereas the type of graft used in treatment had no influence on early results.