Uros Zoranovic

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.

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.

Fournier's gangrene.

BACKGROUND Fourniers gangrene (FG) represents a necrotizing infection of the skin and subcutaneous soft tissue of the external genitalia and perineum. It arises as a result of propagation of anorectal, urogenital and skin infections. The principles of treatment include improving general condition of a patient, debridement of wound, excision of necrotic tissue, combined antibiotic therapy, hyperbaric oxygen therapy and reconstructive procedures. It is a rare but very serious condition which regardless to aggressive treatment can lead to a lethal outcome in up to 20-30% of patients. CASE REPORT Since the year 2000 we have treated six patients with FG. We presented the course and positive treatment outcome in a 65-year-old male patient with numerous comorbid conditions, nonregulated insulin-dependent diabetes, hypertension, previous myocardial infarction, chronic viral hepatitis and thrombocytopenia, rehabilitation was complicated with heart failure, atrial fibrillation and pulmonary thromboembolism. The treatment consisted of two extensive debridement of the wound with removing necrotic tissue, drainage, consolidation of state of health, correction of his blood sugar levels and thrombocytopenia, antimycotic and combination of three antibiotics and hyperbaric oxygen therapy. In two delayed surgical procedures reconstruction of a large defect of the urethra was performed. CONCLUSION A patient with numerous and serious comorbid conditions with FG could recover as a result of teamwork of urologists, infective medicine specialists, cardiologists, endocrinologist, vascular and plastic surgeons.