Goran Kronja

Popliteal traumatic arteriovenous fistulas.

BACKGROUND The purpose of this report is to analyze the clinical presentation, diagnosis, and outcome of surgical treatment in patients with popliteal arteriovenous fistulas (AVFs) in order to make trauma surgeons aware of the various issues patients with popliteal AVFs might present. METHODS From 1991 to 2000, 49 patients were treated for traumatic AVF. Among these patients, seven suffered from popliteal AVF of various durations. The patients were men and ranged in age from 17 to 27 years, with a mean age of 22.4 years. The time from injury to admission to our institutions varied from 5 days to 2 years. A diagnosis of popliteal AVF was made after clinical examinations revealed thrill and bruit over the injury sites. The diagnosis was confirmed in four of the patients after they underwent angiography. Patients with long-standing popliteal AVF underwent cardiology examinations to check for signs of heart failure. All patients with popliteal AVF received surgical treatment. Five patients had major blood vessels reconstructed, one patient had a minor blood vessel ligated, and another patient had a minor blood vessel reconstructed. RESULTS Five of the seven patients experienced no postoperative difficulties. No serious heart failure occurred; however, there were signs of cardiac overload in three of the five patients. The two remaining patients of the seven underwent leg amputations. However, one of the two patients had a gangrenous foot at admission to our institution, and vascular reconstruction on the other patient was unsuccessful. For all seven patients, the average hospital stay in the vascular surgery department was 16.2 days and the follow-up ranged from 2 to 44 months, with a mean of 21.5 months. CONCLUSION Trauma of the popliteal space requires special attention, since blood vessel injuries in that zone might result in serious complications. Popliteal traumatic AVFs result in a high rate of leg amputation and long-standing fistulas produce cardiac overload. The presence of thrill and bruit over the injury site should alert the examiner to consider the existence of AVF. Angiography is a reliable diagnostic tool, and should be used in all vitally stable patients. Surgical or nonsurgical closure of AVF will prevent local and systemic complications that might be irreversible in long-standing fistulas.

Peripheral nerve lesions associated with missile-induced pseudoaneurysms

OBJECT Reports of traumatic pseudoaneurysms associated with nerve compression are rare, and typically do not focus on the damaged nerves. This prospective study examines the clinical presentation, management, and treatment outcome of such nerve injuries. METHODS Between 1991 and 1995, 22 patients with a missile-induced nerve injury associated with a pseudoaneurysm were treated surgically at the Belgrade Military Medical Academy. The artery and nerves involved with the injury were treated using appropriate surgical procedures, and both the sensorimotor deficit and pain intensity were assessed. RESULTS The occurrence of a pulsatile mass depended on the location of the pseudoaneurysm (p = 0.003) and correlated significantly with the preoperative diagnosis (p < 0.001). In cases in which neurological worsening was due exclusively to the compressive effect of the pseudoaneurysm, the nerves involved were found to be in anatomical continuity intraoperatively, and recovery depended on the actual nerve damage and surgical procedure required (neurolysis or nerve grafting). A symptomatic nerve compression duration of more than 3.5 days was the critical factor that determined if neurapraxia developed into severe nerve damage (p = 0.014). Pain syndromes responded well and rapidly to the surgical treatment (p < 0.001). CONCLUSIONS Whether or not a missile-induced pseudoaneurysm associated with a nerve lesion will be recognized before surgery depends on its location and clinical presentation. The nerves involved almost invariably exhibit a lesion in continuity, but the resulting nerve damage can be severe, particularly if surgery is delayed for more than 3 to 4 days after neurological worsening has begun. A successful outcome may be expected if an appropriate surgical technique (neurolysis or grafting) is chosen on the basis of the intraoperative discovery of nerve action potentials.

Treatment of wounded in the combat zone.

Authors presented their own experiences in treating 735 wounded in high-intensity combat zones in the territories of former Yugoslavia during 1991 to 1992. The mobile field hospital with surgical crews was situated 5 to 10 km from the front line, and its basic task had been continuous triage, immediate resuscitation with vital surgical aid, as well as organization of adequate primary and secondary air evacuation. At the field hospital level, fresh wounds were explored according to principles of war surgery, and major surgical interventions were performed in 3.3% of the wounded. Patients with massive hematothorax were treated with autotransfusion. Mortality at this primary level, field hospital was 0.75% with primary immediate resuscitation and 1.9% with immediate evacuation. We concluded that immediate resuscitation with delayed transport had advantages, compared with fast evacuation of only the wounded.

Significance of the determination of Doppler sonography haemodynamic indices for the assessment of distal perfusion in patients with critical ischemia of lower limbs

BACKGROUND/AIM The perfusion of tissue, especially the muscles of the lower limbs (LL), implies the blood flow that carries enough nutrition, energy materials and oxygen. The aim of this study was to determine whether the decreased Doppler sonography parameters, resistence index (RI), and pulsatility index (PI) were significant as indicatiors of irreversible ischemia of LL. METHODS In 40 patients (mean age 66 +/- 14.9 years, 21% women and 79% men) with the signs of critical ischemia of LL, Lariche-Fontaine class III and IV, we performed contrast angiography of the LL arteries, and perfusion scintigraphy of LL using, thallium-201, while we performed Doppler sonography to determine resistance index (RI), as well as pulsatility index (PI). After that, all the patients were treated with vasodilatation using Bergmanns solution within a 10-day period. Following that, all the patients underwent the determination of haemodynamic indices RI and PI applying the methods of Doppler sonography. The obtained values of RI and PI indices revealed no clinical recovery which suggested the irreversibility of critical ischemia (unsuccessful therapy in 100% of the patients), and clinical recovery which suggested the reversibility of the disease (unsuccessful therapy in 80% of the patients). RESULTS The obtained values of PI = 0-0.3 and RI = 0-0.25 for the examined LL arteries were the indicators of irreversible ischemia. A significant correlation between the values of RI in the distal parts of a. tibialis anterior and posterior was proved, as well as between the decreased perfusion of LL determined by tallium-201 (p < 0.05, r = 0.43), and a tibialis anterior (p = 0.05, r= 0.38). There was, however, no statistically significant correlation between the angiographic values and perfusion scintigraphy of LL. CONCLUSION The obtained values of haemodynamic RI and PI indices should be a novel approach for introducing a new criteria for the assessment of reversible and irreversible critical ischemia of LL using the method od Doppler.

Acute leg compartment syndrome after exertion

A case of a 22-year old soldier, with a history of pain in the leg during heavy exercise, which desisted at rest, was presented. One day before admission, the patient had felt an extreme exertion-induced pain in his right leg which had not lessenned at rest. At the same time, the patient noticed persistent severe leg edema. On physical examination, the intracompartmental pressure was 62 mmHg (> 30 mmHg). The patient was urgently operated on, and fasciotomy according to Mubarak was used. At second surgery, the debridement of the muscles of the posterior group of the leg, and the evacuation of hemathoma from the anterior and lateral group of the right leg muscles were perfomed. Postoperative recovery was uneventful. Fasciotomy wounds were closed within 14 days of the surgery. The complete physical treatment was done. Follow-up examinations 1, 3, and 6 months afterwards were satisfactory. The soldier completed his compulsory military service without any sequelae. Laboratory results were normal. Overlooked, unrecognized or surgically untreated compartment syndrome can cause severe damage, including even the loss of the extremity.

Predijalizna transplantacija bubrega

Predijalizna transplantacija bubrega je sa medicinskog i socioekonomskog aspekta metoda izbora u lecenju terminalne bubrežne insuficijencije kod bolesnika koji imaju živog davaoca bubrega. Nase pocetno iskustvo sa ovom metodom lecenja vrlo je afirmativno. Predijalizna transplantacija bubrega je posebno prihvatljiva kod dece, dijabeticara i bolesnika sa losim pristupom za dijalizu. U nasoj zemlji postoje dodatni medicinski (los kvalitet dijalize, visok rizik od infekcije virusima hepatitisa, visok rizik od senzibilizacije na tkivne antigene transfuzijama krvi) i paramedicinski razlozi (prepunjenost dijaliznih centara, ograniceni zdravstveni ekonomski resursi) koji namecu potrebu daljeg razvijanja programa predijalizne transplantacije.

Significance of ligature of early detected insufficient perforated lower extremities veins as a cause of the varicous syndrome

BACKGROUND/AIM Perforated veins (PV) connect surface and deep veins net. Insufficient perforated veins (IPV) are considered to be one of the causes of the venous stasis syndrome. Ligating IPV removes increased pressure transmission from the deep veins to the surface veins system and prevents the occurrence of varicosis, as well. The aim of the study was to determine surface veins diameters prior and after the surgical operation on IPV, and to confirm good results of the treatment with this method in removing causes of the surface veins varicosis. METHODS The study included 30 patients of both sexes (25 males and 5 females), mean age 30.10 +/- 10.24 years. The patients were classified in accordance with CEAP (clinical severity, ethiology or cause, anatomy, pathophysiology) classification as those with the initial varicous syndrome based on IPV. Any of the patients were submitted to color Doppler echophlebography. In case of diameter > or = 3.5 mm PV were marked as IPV. All of the IPV were divided into two groups, the group I being with ostium in the stem of Vena Saphena Magna (VSM) or Vena Saphena Parva (VSP), while the group II was with ostium in the venous tributors. VSM and VSP diameters at the level of IPV ostium, bellow and above (1 cm) the ostium were measured prior to IPV ligature, and 30 days after the surgical intervention. RESULTS Comparing the results the highest ligature effects were shown at the level of IPV ostium in the stem of VSM and VSP of both groups (p < 0.0001) with the highest diameter reduction. There was a smaller reduction of diameter in the proximal and distal segment of ostium in the group I, while there was no diameter change in the distal segment of ostium in the group II. CONCLUSION Saphenous stem diameter reduction at the level of ostium, proximally and distally of the confluence, confirms the significance of IPV ligature before pronounced varicosis appears.