Sidor Misovic

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.

Early inflammatory response following elective abdominal aortic aneurysm repair: A comparison between endovascular procedure and conventional, open surgery

BACKGROUND/AIM Abdominal aorta aneurysm (AAA) represents a pathological enlargment of infrarenal portion of aorta for over 50% of its lumen. The only treatment of AAA is a surgical reconstruction of the affected segment. Until the late XX century, surgical reconstruction implied explicit, open repair (OR) of AAA, which was accompanied by a significant morbidity and mortality of the treated patients. Development of endovascular repair of (EVAR) AAA, especially in the last decade, offered another possibility of surgical reconstruction of AAA. The preliminary results of world studies show that complications of such a procedure, as well as morbidity and mortality of patients, are significantly lower than with OR of AAA. The aim of this paper was to present results of comparative clinical prospective study of early inflammatory response after reconstruction of AAA be tween endovascular and open, conventional surgical technique. METHODS A comparative clinical prospective study included 39 patients, electively operated on for AAA within the period of December 2008 - February 2010, divided into two groups. The group I counted 21 (54%) of the patients, 58-87 years old (mean 74.3 years), who had been submited to EVAR by the use of excluder stent graft. The group II consisted of 18 (46%) of the patients, 49-82 (mean 66.8) years, operated on using OR technique. All of the treated patients in both groups had AAA larger than 50 mm. The study did not include patients who have been treated as urgent cases, due to the rupture or with simptomatic AAA. Clinical, biochemical and inflamatory parameters in early postoperative period were analyzed, in direct postoperative course (number of leucocytes, thrombocytes, serum circulating levels of cytokine--interleukine (IL)-2, IL-4, IL-6 and IL-10). Parameters were monitored on the zero, first, second, third and seventh postoperative days. The study was approved by the Ethics Commitee of the Military Medical Academy. RESULTS The study showed a statistically significantly shorter time of treatment in the EVAR group (average 90 min) compared to the OR group (average 136 min). Also, there was a statistically significantly less blood loss in the patients operated on by the use of EVAR surgery (average 60 mL) as compared to the patients treated with OR techinique (average 495 mL), as well as a shorter postoperative hospitalization of patients in the EVAR group (average 4 days) compared to the OR group (average 8 days). The OR group was detected with a statistically significant increase of leucocytes and statistically significant fall of the number of thrombocytes in comparison with the EVAR group in all the investigated terms. A significant concentration rise of IL-2 in the OR group and concentration rise of IL-6 in the EVAR group was shown 24 hours after the procedure, whereas on the second postoperative day there was detected a significant fall of IL-6 in the EVAR group. IL-4 concentration in the OR group was significantly higher as of the third postoperative day in comparison to the EVAR group. There was no significant difference in IL-10 concentration between the groups. CONCLUSION The EVAR techinique is a safer and less invasive and less traumatic procedure for patients than the OR of AAA. Following the EVAR, there are less inflammatory reactions in the early postoperative period as compared to the OR and therefore less possibility of the development of systemic inflammatory respons syndrome in patients treated.

[Intra-abdominal hypertension and abdominal compartment syndrome].

Abdominalni kompartment sindrom je stanje udruženo sa visokim morbiditetom i mortalitetom. Identifikacija i brižljivo pracenje bolesnika sa rizikom, ukljucujuci i merenje IAP treba da bude rutina, kako bi se izbegle neželjene posledice ovoga stanja. Posto ne postoje detaljni protokoli koji govore o tacnim vrednostima IAP pri kojima treba pravovremeno reagovati adekvatnom terapijom i terapijskim procedurama, neophodno je svakog bolesnika sa ovim stanjem individualno posmatrati i ukljuciti u naucnoistraživacke studije. Shodno utvrđenim vrednostima i znacima za ACS, formiranje protokola za lecenje AP i njegova primena omogucice poboljsanje u smanjivanju morbiditeta i mortaliteta kod AP.

Endovascular Reconstruction of Giant Gastroduodenal Artery Aneurysm With Stent Graft: Case Report

Introduction: Gastroduodenal artery (GDA) aneurysms are rare and mainly asymptomatic vascular diseases. Endovascular intervention can provide an alternative method of treatment for GDA aneurysms. Report: We present a case of endovascular repair of giant GDA aneurysm, with stent graft. A 56-year-old man, smoker, presented with nausea, acute worsening of chronic abdominal pain, and a large, tender, pulsating mass in his right upper abdomen with no previous medical history. Computed tomographic (CT) angiography was performed, and there was GDA aneurysm. Through the left brachial approach, we did the endovascular repair of GDA with Viabahn stent graft. Discussion: Endovascular gastroduodenal aneurysm artery reconstruction with stent graft is a reasonable alternative to open surgical repair and it is safety option in carefully selected patients.

Abdominal aortic aneurysm: Rupture of the anterior wall

INTRODUCTION An aneurysm is a focal dilatation of an artery (aorta), involving an increase in diameter of at least 50% as compared to the expected normal diameter (over 3 cm). Abdominal aortic aneurysms (AAA) cause thousands of deaths every year, many of which can be prevented with timely diagnosis and treatment. AAA can be asymptomatic for many years, but in one third of patients whose aneurysm ruptured, the mortality rate is 90%. In the past, palpation of the abdomen was the preferred method for identifyng AAA. However, diagnostic imaging techniques, such as ultrasonography and computed tomography are more accurate and offer opportunities for early detection of AAA. CASE REPORT This paper is a case report of an 83-year-old female patient. She was admitted due to severe pain in the abdomen. We already knew about the AAA (from her medical history). After using all available diagnostic procedures, rupture or disection of the AAA were not comfirmed. The patient underwent emergency surgery. During the operation, rupture of the anterior wall of the aneurysm was found. The anterior wall was filled with parietal thrombus, which hermetically closed the perforation. The patient was successfully operated and recovered. CONCLUSION The aim of this case report was to point out that our diagnostic procedures failed to confirm the rupture of AAA. We decided to apply surgical treatment, based on medical experience, clinical findings, ultrasonography and computed tomography and during operation rupture of AAA was confirmed Patients with an already diagnosed AAA, or patients with clinical picture of rupture or dissection, are in urgent need for surgery, no matter what diagnostic tools are being used.

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.

Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm

INTRODUCTION According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. CASE REPORT We presented a 75-years-old man, with elective visceral hybrid reconstruc tion of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patients vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. CONCLUSION Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemic-reperfusion injury of the body is reduced to a minimum.