Miroslav Markovic

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.

The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial.

BACKGROUND: Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 &mgr;g) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0–10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. RESULTS: Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0–60] vs 60 [0–160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9–15.6] vs 3.1 [1.0–11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9–18] vs 15 [9–18] minutes, respectively; P = 0.18). CONCLUSIONS: The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

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.

Intraoperative Cell Salvage versus Allogeneic Transfusion during Abdominal Aortic Surgery: Clinical and Financial Outcomes

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS (p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.

Unusual Forms of Ruptured Abdominal Aortic Aneurysms

Over 95% of abdominal aortic aneurysms (AAAs) rupture into the retroperitoneal space. Rare types of AAA ruptures comprise ruptures into the inferior vena cava with aortocaval fistula formation (ACF), ruptures into the duodenum with formation of a primary aortoduodenal fistula (ADF), and chronic contained ruptures (CCRs). This article presents a study of 41 cases with unusual forms of ruptured AAA of a series of 506 patients with AAA rupture treated within a 14-year period. There were 11 cases of CCR, 5 cases with ADF, and 25 cases with ACF. The correct preoperative diagnosis was established in 6 (of 11) cases of CCR, in 2 (of 5) cases of primary ADF, and in 13 (of 25) cases of ACF. AAA replacement was performed in 8 cases using a tube graft, whereas a bifurcated graft was used in 31 patients because of the distant extent of the atherosclerotic/aneurysmatic lesions engaging iliac arteries. Two patients had an axillobifemoral bypass. The overall 30-day mortality rate was 19% (8 of 41), with subgroup mortality rates of 0 (CCR), 60% (ADF), and 20% (ACF). Diagnosis and treatment are simplest in cases of CCR and the most complicated in cases of ADF.

Glacial morphology of Serbia, with comments on the Pleistocene Glaciation of Monte Negro, Macedonia and Albania

Abstract Cvijic was the first to collect evidence on the glacial morphology of the Balkans, at the end of the 19th century. He reported the existence of glacial features on the three highest mountains of Serbia, Prokletije, Sara and Koritnik. The most recent investigations have been carried out using remote sensing techniques supplemented by field observations. This approach has led to the discovery of numerous cirques, glacial troughs, moraines and other characteristic features produced by Pleistocene glaciers in these mountains. Analysis of the positions and mutual relationships between the glacial features of these three mountain areas has enabled determination of the Pleistocene snowline altitude. Results indicate that it occurred at 1900 m elevation on the northern faces and 2200 m on the southern faces. These results indicate that the development of the Pleistocene, more precisely the Wurmian glaciation, was restricted to the highest elevations within the areas investigated. The type of glacier, which was formed, was dependent on the snowline position (i.e. on the topographic surface above it). Most glaciers developed in cirques, as hanging glaciers, and troughs, as valley glaciers. On Sara Mountain, where a vast plain existed at 2200-2400 m altitude, plateau-type glaciers developed.

Role of recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery

BACKGROUND Most recent publications have shown that the recombinant form of activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsværd, Denmark) induces excellent hemostasis in patients with severe intractable bleeding caused by trauma and major surgery. The purpose of this study was to determine the influence of rFVIIa on the treatment of intractable perioperative bleeding in vascular surgery when conventional hemostatic measures are inadequate. MATERIALS AND METHODS There were two groups of patients: the NovoSeven group (group N), 10 patients with ruptured abdominal aortic aneurysms (RAAAs) and 14 patients operated on due to thoracoabdominal aortic aneurysms (TAAAs); the control group (group C), 14 patients with RAAAs and 17 patients with TAAAs. All patients suffered intractable hemorrhage refractory to conventional hemostatic measures, while patients from group N were additionally treated with rFVIIa. RESULTS Postoperative blood loss was significantly lower in group N treated with rFVII (P < .0001). Postoperative administration of packed red blood cells, fresh frozen plasma, and platelets was lower in patients from group N, (P < .0001). Successful hemorrhage arrest was reported in 21 patients (87.5%) treated with rFVIIa, and in 9 patients (29.03%) in group C (P < .001). Thirty-day mortality in these two groups significantly differed. The mortality rate was 12.5% (3 patients) in group N and 80.65% (25 patients) in group C (P < .0001). CONCLUSION Our findings suggest that rFVIIa may play a role in controlling the intractable perioperative and postoperative bleeding in surgical patients undergoing a repair of RAAAs and TAAAs. Certainly, prospective randomized trials are necessary to further confirm the efficacy and cost-effectiveness of rFVIIa in these patients.

The Benefits of Internal Thoracic Artery Catheterization in Patients With Chronic Abdominal Aortic Occlusion

Occlusion of the abdominal aorta may be caused by an embolic lesion, but more commonly by thrombotic disease at the aortoiliac area, progressing retrograde. However, the visualization of the distal run-off via internal thoracic-epigastric inferior artery collateral channel may be a very important diagnostic tool, especially in countries with poor technical equipment. This study was designed to show the benefit of the selective internal thoracic angiography in cases with complete aortic occlusion. We present 30 patients with chronic aortic abdominal occlusion who were submitted to the transaxillary aortography and selective ITA angiography with purpose of distal run off evaluation. Angiographic evaluation was performed by two independent radiologists according to previously defined classification. Good angiographic score via internal thoracic angiography by first observer was achieved in 19 (63.3%) patients and in 18 (60%) by a second observer. Transaxillary aortography showed inferior results: good angiographic score by the first observer in six (20%) patients and by the second observer in three (3%) patients. Low extremity run-off is better visualized during internal thoracic angiography than during transaxillary aortography.