Predrag Gajin

Postendarterectomy common carotid artery pseudoaneurysm.

Pseudoaneurysm (PSA) formation is an uncommon complication in carotid surgery. PSA of the carotid artery requires surgical or endovascular treatment to prevent PSA thrombosis, embolization from the thrombotic material within the PSA, hemorrhage after rupture, or compression on the adjacent structures. We present a case of a symptomatic common carotid PSA that occurred 14 months after routinely performed eversion carotid endarterectomy.

Urgent carotid endarterectomy in patients with acute neurological ischemic events within six hours after symptoms onset.

To analyze the outcome of urgent carotid endarterectomy (CEA) performed within less than six hours in patients with crescendo transient ischemic attack (TIA) and stroke in progression. From January 1998 to December 2008, 58 urgent CEAs were done for acute neurological ischemic events – 46 patients with crescendo TIA and 12 patients with stroke in progression. Brain computed tomography (CT) was done prior and after the surgery. Disability level was assessed prior to and after urgent CEA using modified Rankin scale. Median follow-up was 42.1 ± 16.6 months. In the early postoperative period stroke rate was 0% for the patients in crescendo TIA group while in patients with stroke in progression group 3 patients (25%) had positive postoperative brain CT, yet neurological status significantly improved. Mid-term stroke rate was 2.2% in crescendo TIA group and 8.3% in stroke in progression group. In the early postoperative period there were no lethal outcomes, mid-term mortality was 8.3% in stroke in progression while in crescendo TIA group lethal outcomes were not observed. In conclusion, based on our results urgent CEA is a safe and effective treatment option for patients with crescendo TIA and stroke in progression with acceptable rate of postoperative complications.

Missed dissection as a result of the ascending pharyngeal artery arising from the internal carotid artery.

Unlike high-grade stenosis, dissections of craniocervical arteries are a rare cause of cerebrovascular infarction. If the internal carotid artery (ICA) dissection is verified by duplex scanning or computed tomography angiography (CTA), the therapies of choice are antiplatelet and anticoagulation drugs, and surgical treatment is rarely performed. However, despite distinct clinical and radiological manifestation, carotid dissections are still under-recognized. In this study, we demonstrate the case of a 66-year-old man with dissection of ICA verified by duplex scanning and computed tomography angiography. The cause of missed diagnosis was an ascending pharyngeal artery originating from the ICA that runs parallel to it. Other than being a rare variation, this case may be interesting as a cause of misdiagnosis.

Surgical treatment of internal carotid artery restenosis following eversion endarterectomy

INTRODUCTION Carotid angioplasty and internal carotid artery stenting is the therapeutic method of choice in the treatment of carotid restenosis, but when it is not technically feasible (expressed tortuosity of supraaortic branches, calcifications, presence of pathological elongation of very long lesions) a redo surgery is indicated. OBJECTIVE The aim of our study was to examine the benefits and risks of redo surgery in patients with symptomatic and asymptomatic significant internal carotid artery restenosis and its impact on early and late morbidity and mortality. METHODS The study included 45 patients who were surgically treated for a hemodynamically significant internal carotid artery restenosis from January 2000 to December 2009. Surgical techniques included redo endarterectomy with direct suture, redo anderectomy with a patch plastic and resection with Dacron tubular graft interposition. The patients were followed for postoperative neurological ischemic events (transient ischemic attack (TIA), stroke), local surgical complications and lethal outcome after one month, six months, one year and after two years). RESULTS In the early postoperative period (up to 30 days) there were no lethal outcomes. TIA was diagnosed in four patients (8.8%), minor stroke in one patient (2.2%) and one patient (2.2%) also had cranial nerve injury. After two years two patients died (4.4%) due to fatal myocardial infarction, three patients (6.5%) had ipsilateral stroke and one patient developed graft occlusion (2%). CONCLUSION In the case of symptomatic and asymptomatic carotid restenosis that cannot be treated by carotid percutaneous angioplasty, redo surgical treatment is therapeutic option with an acceptable rate of early and late postoperative complications.

Successful intestinal ischemia treatment by percutaneus transluminal angioplasty of visceral arteries in a patient with abdominal angina

INTRODUCTION Abdominal angina, also known as chronic mesenteric ischemia or intestinal angina, is a rare disease caused by intestinal flow reduction due to stenosis or occlusion of mesenteric arteries. A case of successful treatment of a patient with abdominal angina by percutaneous transuliminal angioplasty of high-grade superior mesenteric artery and coeliac trunk stenosis was presented. CASE OUTLINE A 77-year-old male patient was admitted at our Clinic for severe postprandial abdominal pains followed by frequent diarrhoeas. Extensive gastrointestinal investigations were performed and all results were normal. Multislice computerized (MSCT) arteriography was indicated which revealed ostial celiac trunk and superior mesenteric artery subocclusion. Percutaneous transluminal angioplasty of the superior mesenteric artery and coeliac trunk was done with two stents implantation. Just a few hours following the intervention, after food ingestion, there were no abdominal pains. Six months later, the patient described a significant feeling of relief after food ingestion and no arduousness at all. CONCLUSION High-grade visceral arteries stenoses in patients with intestinal ischemia symptoms can be treated by either surgical procedures or percutaneus transluminal angioplasty. In cases when a low operative risk is anticipated, surgical treatment is recommended due to a better anatomical outcome, while percutaneus angioplasty is advised to elderly patients in whom increased operative risks can be expected.