Sinisa Pejkic

Incidence and relevance of groin incisional complications after aortobifemoral bypass grafting.

BACKGROUND Aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AIOD) is traditionally accompanied by substantial groin incisional morbidity, which poses a threat to an underlying prosthetic graft. We performed a study to investigate the frequency and define the clinical course and significance of such problems. METHODS One hundred twenty consecutive patients undergoing primary elective ABFB for AIOD were enrolled in a prospective study. The healing of groin wounds was systematically assessed, the occurrence of incisional complications of any type noted, and their clinical course and economic consequences documented and analyzed. RESULTS Early postoperative complications (30 days) affected 35 (15%) groin wounds in 29 (24.8%) patients. Lymph fistulas/lymphoceles were observed in 15 (6.4%), infection in 11 (4.7%), and noninfectious wound dehiscence in 9 (3.8%) of groin incisions. The only significant predictor of groin healing impairment was preoperative length of stay. Groin incision-related morbidity significantly increased the duration and cost of hospitalization. Sixty percent of groin healing problems were diagnosed after discharge and they represented the most common cause for early readmissions. CONCLUSIONS The incidence of groin wound complications after ABFB is considerable, their financial impact significant, and delayed onset frequent. Femoral incisional morbidity after ABFB still represents an unremitting nuisance, necessitating further improvements in preventive strategies and techniques and strict adherence to conventional ones, including the minimization of preoperative length of stay.

Aorto-left renal vein fistula is a rare complication of abdominal aortic aneurysm with unique clinical presentation

Spontaneous aorto-left renal vein fistulas (ALRVF) are extremely rare, with only 30 cases presented in the literature. In the majority of the reported cases, the fistula involved an anomalous retroaortic left renal vein. In some aspects, the clinical findings differ from those of aortocaval fistulas, often making the correct diagnosis difficult and contributing to the delay in treatment. In this article, we present 2 such cases, review previously reported data, and discuss clinical features and treatment options of this rare condition.

Technical considerations for transabdominal aortic reconstruction with renal fusion and ectopia: case series.

Aortic diseases associated with renal anomalies can present special challenges during surgery of the abdominal aorta. The aim of this paper is evaluation of morbidity and definition of optimal management according to the clinical histories of 30 patients with horseshoe and ectopic kidneys who underwent surgical procedures on the abdominal aorta over a 20-year period. Twenty-two of them had horsheshoe kidney and eight had ectopic kidney. Indications for surgery included aortic aneurysms in 25 patients and aortoiliac occlusive disease in 5. Preoperative diagnostics were performed in all cases by means of computed tomography and angiography (except in the cases with ruptures) associated with duplex ultrasonography. In patients with ectopic kidney a Carrel patch technique was used for the reimplantation of the renal arteries into the body of the bifurcated (four cases) or tubular (four cases) Dacron graft in five (62.5%) cases whereas aortorenal bypass with Dacron graft was obtained in three cases (37.5%). Sixteen patients from the horseshoe kidney group required renal revascularization (reimplantation using Carrel patch in 10 patients and aortorenal bypass using Dacron graft in 6 patients). Two patients, both with ruptured abdominal aortic aneurysms died after the operation. In other cases the average follow up period was 6.2 years (6 months to 17 years). In one case control, angiography after 6 months revealed an occluded left renal artery that was reimplanteted by Carrel patch but without repercusions on the renal function. Aortic surgery in patients with renal anomalies can be safely performed without increased mortality.

Posterior approach for sciatic aneurysm repair - technical note.

Aneurysm of the persistent sciatic artery is a rare cause of limb ischemia, which is a challenge for both diagnosis and treatment. After successful diagnosis adequate treatment may require skills in open and endovascular surgery. We present a patient with the aneurysm of the persistent sciatic artery treated by bypass procedure with PTFE graft using posterior approach. We named this procedure “dorsal bypass”. Detailed explanation of clinical presentation, diagnosis and the surgical procedure is given in this paper.

Open Treatment of Blunt Injuries of Supra-Aortic Branches: Case Series

BACKGROUND Blunt injuries of the supra-aortic branches are rare entity, and majority of patients die before arrival at the hospital. Those who arrive alive require complex and fast procedure that requires sternotomy. We report 3 successfully managed cases. CASE REPORTS We report 3 patients with injury of supra-aortic branches. One was treated urgently due to longitudinal rupture on the posterior wall of innominate artery after car accident, and another 2 had chronic false aneurysm located at the very orifice of the right subclavian and left common carotid artery. In first and second patient bypass grafting with a hand-made, Y-shaped, 8-mm Dacron graft from the ascending aorta to the right common carotid and proximal right subclavian artery were performed, whereas in last 1 bypass grafting from the ascending aorta to the cervical part of the left common carotid artery was performed. In our facility, there were no possibilities for any endovascular treatment. CONCLUSIONS When endovascular technology is not available, open surgical repair of blunt injuries of supra-aortic vessels can be performed without complications. No matter to that, endovascular and hybrid procedures should be considered whenever possible.

Chronic complete thrombosis of abdominal aortic aneurysm: An unusual presentation of an unusual complication

Although mural thrombosis frequently accompanies aneurysmal disease, complete thrombosis is distinctly unusual complication of abdominal aortic aneurysm (AAA). A case study of a patient with chronic, asymptomatic complete thrombosis of a large juxtarenal AAA is presented along with a literature review and discussion of the potential secondary complications, mandating aggressive management of this condition. A 67-year-old man with multiple atherogenic risk factors and unattended complaints consistent with a recent episode of a transient right hemispheric ischemic attack was referred to our clinic with a diagnosis of a thrombosed AAA established by computed tomography. Duplex ultrasonography and aortography confirmed the referral diagnosis and also revealed near occlusion of the left internal carotid artery. The patient underwent a two-stage surgery, with preliminary left-sided carotid endarterectomy followed three days later by an aneurysmectomy and aortobifemoral reconstruction. He had an uncomplicated recovery and was discharged home on postoperative day 7, remaining asymptomatic at the 42-month follow-up. Complete thrombosis is an uncommon presentation of AAA and may be clinically silent. It is frequently associated with other manifestations of generalized atherosclerosis. Radical open repair yields durable result and is the preferred treatment modality.

Vascular graft thrombosis secondary to activated protein C resistance: a case report and literature review:

Hypercoagulability is a well-documented and prominent risk factor for venous thromboembolism. The role of thrombophilia in arterial thrombotic events is less well defined. A 52-year-old male patient with multiple atherogenic risk factors was admitted for non-healing pedal ulcer and absent distal pulses. Based on the clinical presentation, Doppler ultrasound and angiography findings, the patient underwent elective in situ bypass arterial reconstruction. The saphenous vein graft was of satisfactory quality and the procedure went routinely. Acute graft thrombosis on postoperative day 0 was recognized immediately and prompted an emergent surgical revision. No technical errors or anatomical/mechanical causes for failed reconstruction were found and the graft was successfully thrombectomized using a Fogarty balloon-catheter. Graft rethrombosis, however, ensued after several hours. Considering the absence of threatening limb ischemia and the idiopathic recurrent thrombosis, raising suspicion of prothrombotic state, conservative treatment was pursued. Postoperative thrombophilia testing proved positive for activated protein C resistance, mandating introduction of chronic oral anticoagulation. Six months later, the operated extremity is viable. Inexplicable vascular graft thrombosis, particularly if early and recurrent, should raise suspicion of underlying thrombophilia. If confirmed by laboratory testing, long-term secondary antithrombotic prophylaxis may be required.

Steal phenomena in TEVAR, a reality after all.

Steal is a well-established phenomenon in open thoracoabdominal aortic surgery recognized by Wadouh et al. and was accused as one of potential factors related to spinal cord ischemia (SCI) development. By proximal clamping of the aorta blood from the spinal cord tends to flow towards the zones of lower resistance (depressurized aorta) aggravating spinal ischemia. Ongoing theory of SCI development in TEVAR supports endoleak type II as a protective factor. Nevertheless, it is hard to believe that endoleak type II which should be considered as a pathological state, could play a protective role. The last study by Schurink et al. revealed an interesting thing which could make us change our opinion. During performing branched procedure in patients with TAAA type III they noticed that when the last branch (celiac trunk) was cannulated and occluded by a balloon for a maximal period of 15min motor evoked potentials (MEP) decreased by more than 50%. At that time all other visceral arteries were connected to the stent graft by covered stents. When the balloon was deflated, MEP returned immediately to normal values. We think that this particular finding was a typical example of the steal phenomenon. Before the last branch was temporarily occluded the pressure in the aneurysm sac was equal or at least close to the pressure in the spinal cord network, keeping anterograde flow through intercostals. By occluding the celiac trunk the sac was deprived of retrograde flow which caused the pressure in the sac to decrease. At this moment, gradient pressure between the sac and the spinal collateral network emerged, allowing the steal phenomenon to evolve, emphasizing the importance of anterograde flow through intercostals. Having in mind that majority of paraplegia cases during endovascular treatment occurs postoperatively, it seems logical that only alterations of blood flow (steal) aggravated by hemodynamical instabilities and flow pattern changes, lead to this dreadful complication. It would be of great importance to keep the pressures between the sac and the spinal collateral network approximately in the same range during this particular period. Perhaps, by continually measuring intra-sac pressure postoperatively we could be able to predict the possible steal phenomenon development.

Syndactylization as a technique in treatment of infectious limb following aortobifemoral reconstruction.

The infection in vascular surgery is a nightmare of every vascular surgeon. There are numerous ways of treatment but neither one is definitive. We present the case of the patient with infectious limb following aortobifemoral reconstruction treated by partial graft extirpation and with re-implantation of the superficial femoral artery into deep femoral artery.

A proposal for a predictive model of paraplegia prevention during thoracic endovascular aortic repair

A PROPOSAL FOR A PREDICTIVE MODEL OF PARAPLEGIA PREVENTION DURING THORACIC ENDOVASCULAR AORTIC REPAIR To the Editor: Thoracic endovascular aortic repair (TEVAR) has been promoted as a promising alternative to open surgical graft replacement, but despite initial promising results in spinal cord ischemia prevention, a paraplegia rate still varies between 0% and 10% depending on the surgical center. During the early 1990s, Wadouh and colleagues published interesting experiments on animals regarding hemodynamic alterations and steal phenomena after aortic crossclamping (T4) as a consequence of blood originating from the area of lower blood resistance accompanied by a severe decrease in intrathecal O2 pressure (PO2). 1 By applying a second clamp (T13), they restored PO2 to approximately half of the initiate values and reduced steal phenomenon. By performing pressure measurements, they concluded that the increase in the PO2 of the spinal cord occurs only when the arterial pressure between T-4 and T-13 reaches a minimum pressure of 40 mm Hg. Similar results were presented by Christiansson and colleagues, who also performed histopathologic investigations and showed that reduction of PO2 to 50% was accompanied with neuronal ischemic changes, which were