Biomedical subjects

D M Kostić

Publications and source records attributed to D M Kostić.

8 recordsLinked to original sources

PubMedDate not supplied

[Long-term patency of reversed and in situ femoro-popliteal bypasses].

INTRODUCTION: The small choice of graft materials is one of the greatest problems in femoro-popliteal (F-P) bypass reconstructions. Besides all biosynthetics(2-5) and synthetics(6) graft materials, there is no right alternative for autologous saphenous vein graft in F-P reconstructions. There are two main techniques for F-P reconstructions: "reversed" and "in situ". The aim of this study is the comparison of the long-term patency between "reversed" and "in situ" F-P bypasses. PATIENTS AND METHODS: In the study were included 191 patients with "reversed" and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass, and 78 (78.78%) male and 21 (21.22%) female patients in the group with "in situ" bypass. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.43%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and as 80 (80.8%) in the group with "in situ" bypass. In Table 1 the Fontain classification of occlusive diseases in operated patients is presented. The early proximal reconstructions were performed in 49 patients with "reversed" and 16 patients with "in situ" bypasses (Table 2). The associated proximal reconstructions were performed in 21 patients with "reversed" and in 14 patients with "in situ" bypasses (Table 3). All patients were controlled by physical and Doppler ultrasonographic examination immediately after the operation, after 1, 3, 6 months, and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiographic examinations was also performed. The statistical analysis of the results was done using "Life table" analysis. RESULTS: The patients were followed-up from 3 to 10 years. The results of "life-table" analysis are presented in Tables 4-8 and Graph 1. The "in situ" technique showed statistically significant better long-term patency compared to "reversed" technique, after 2 and 10 years (p < 0.05). The immediate patency in cases with "reversed" bypass was 98.96%, while limb salvage was 97.91%. In the same group long-term patency was 72.8% and limb salvage 73.9%. In the group with "in situ" bypasses the immediate patency as well as limb salvage were 96.97%. In the same group long-term patency was 73.8% and limb salvage 77.2%. In Table 5 potential advantages of the "in situ" F-P bypass technique are shown (16-21). However, there are controversial data on clinical results of both bypasses. Some authors described better long-term results of the "in situ" F-P bypass technique (28-30), while according to other data there are no significant differences between these two bypass groups (31-33). Most authors emphasized the two advantages of "in situ" bypasses in F-P reconstructions: a small diameter of the saphenous vein; in cases with pure run off (34-36).

Adult↗

PubMedDate not supplied

[Factors which affect long-term patency in femoro-popliteal bypass].

INTRODUCTION: The aim of this study was to investigate how "run off", diabetes, cigarette smoking and early reinterventions influence long-term patency of the "reversed" and "in situ" femoro-popliteal (F-P) bypass grafts. PATIENTS AND METHODS: The study included 1991 patients with "reversed" F-P and 99 patients with "in situ" F-P bypass grafts operated on between 1988 and 1994. There were 153 (80.10%) male and 38 (19.90%) female patients in the group with "reversed" bypass and in the group with "in situ" bypass there were 78 (78.8%) male and 21 (21.2%) female patients. The average age of all patients was 59.04 (27-80) years. Eighty five (44.5%) patients in the group with "reversed" F-P bypass had diabetes mellitus and 43 (43.4%) in the group with "in situ" bypass. One hundred and fifty two (79.68%) patients in the group with "reversed" bypass were cigarette smokers and 80 (80.8%) in the group with "in situ" bypass. In Table 1 patients according to Fontain's classification of occlusive arterial disease are presented. On the basis of angiographic examination all patients were divided into four groups (with patent all 3 crural arteries, with patent 2 crural arteries, with patent one crural artery and without patent crural arteries) (Table 2). All patients were controlled using physical and Doppler ultrasonographic examinations immediately after the operation; after 1, 3, 6 months and then every year postoperativelly. In cases with suspected graft occlusion or any other complication, control angiography has also been carried out. Statistical analysis of the results was performed using chi 2 and Fisher's test. RESULTS: The patients were followed-up from 3 to 10 years. In cases with patent all 3 crural arteries there was no significant difference in long-term patency between "reversed" and "in situ" bypasses (Fisher's test, P = 0.66; p > 0.05) (Graph 1). In cases with patent two crural arteries, there was no significant difference between groups with "reversed" and "in situ" bypasses chi 2 = 0.25, p > 0.05) (Graph 2). The long-term patency was significantly better in the group with "in situ" bypass if only one crural artery was patent (chi 2 = 4.96, p < 0.05) (Graph 3). In cases with occluded all three crural arteries there was no significant difference in long-term patency between the two examined groups (Fisher's test, P = 0.29; p > 0.05) (Graph 4). There was no significant difference between groups with "reversed" and "in situ" bypasses in patients with diabetes mellitus (chi 2 = 0.01; p > 0.05) (Graph 5). There was also no statistically significant difference between the two examined groups regarding the preoperative cigarette smoking (chi 2 = 0.94; p > 0.05) (Graph 6). However, in both groups postoperative cigarette smoking showed a statistically significant decrease in long-term patency (chi 2 = 66.71; p < 0.01) (Graph 7). The early REDO operations statistically significantly decreased long-term patency in both groups (chi 2 = 34.89; p < 0.01) (Graph 8). The late graft occlusions were found in 60 patients with "reversed" and 23 patients with "in situ" F-P bypasses. Table 3 shows causes of late graft occlusions. CONCLUSION: In some cases with pure "run off" "in situ" bypass technique showed better long-term patency. We preferred this technique when "run off" was pure, when diameter of the saphenous vein was small, and when bypass was "long". Diabetes mellitus had no significant influence on long-term graft patency in both groups, as well as regarding preoperative cigarette smoking. However, postoperative cigarette smoking and early REDO operations, statistically significant by decreased long-term graft patency in both groups. The reason was that cigarette smoking was not permitted postoperatively, while in cases with early reinterventions physical screening and ultrasonographic examinations were necessary.

Adult↗

PubMedDate not supplied

[Ruptured abdominal aortic aneurysms].

Eighty two aortic replacements of ruptured abdominal aortic aneurysms have been performed during the last 6 years. There were 72 male and 10 female patients, and the average age was 71.33 years. Hemorrhagic shock on the admission was observed in 45 patients, and 13 have been operated urgently without any diagnostic procedures. The transperitoneal approach have been used for the operation. Two aorto duodenal and one aorto caval fistulas, have been found. Only exploration (three patients died immediately after laparotomy and 6 after cross clamping) has been done in 9 cases, and the aortic replacement in 70 cases (27 with tubular, and 43 with bifurcated graft). In 3 cases and axillobifemoral bypass had to be done. During the operation eleven patients died, and 30 in postoperative period, during the period between one and 40 days. Total intrahospital mortality rate was 50%, compared with 3.5% for 250 electively operated patients with abdominal aortic aneurysms in same period. In postoperative period the most important cause of death was multiple organs failures. Statistically significant greater mortality rate (p > 0.01%) was found in cases of late operative treatment, hemorrhagic shock, intra-operational bleeding, ruptured front wall, suprarenal cross clamping and in patients older than 75 year. In complicated cases such as juxtarenal aneurysm, 3 sutures parachute technique for proximal anastomosis, a temporary transection of the left renal vein, and intraaortal balloon occlusive catheter for proximal bleeding control are recommended.

Aged↗

PubMedDate not supplied

[Pseudo-occlusion of the femoro-popliteal bypass].

INTRODUCTION: Pseudo-occlusion of femoro-popliteal/crural (F-P/Cr) bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow [1]. The aim of this paper is the presentation of 24 new cases which, as far as we know, have not been published in Yugoslav medical literature. CASE REPORT: The group consisted of 20 men and 3 women (aged 28 to 71 years, mean 61.95) with 24 cases of "pseudo-occlusion" of the F-P/Cr bypass. More details are presented in Tables 1 and 2. Saphenous vein graft was used for the reconstruction in 19 patients, and Dacron in 5 subjects. "Pseudo-occlusion" was symptomatic in all 24 patients. Fifteen patients had pain at rest, seven presented disabling claudication, and 2 foot gangrene. The mean time interval between primary operation and occurrence of new symptoms was 25.41 (4-84) months (Table 2). In 15 patients control angiography showed hemodynamically significant lesions in inflow tract, and in 9 subjects in outflow tract. Of the total number of inflow tract lesions, there were 3 late occlusions of previously implanted aorto-femoral graft (1, 3 and 17, Table 1), and in other 21 patients lesions of the native aorto-iliac segment. In 8 patients with changes in outflow tract, a distal progression of atherosclerotic disease was found, while one patient (number 8) had intraoperative lesion of the popliteal artery with vascular clamp. All 24 patients were treated operatively. The early postoperative result was favourable in all 24 (100%) patients. Patients were followed-up from 3 months to 5 years (mean 29.625 months). In this period one (4.1%) late graft occlusion was followed by major limb amputation. Four (16.6%) patients died with patent graft. CONCLUSION: 1. Pseudo-occlusion of the F-P/Cr bypass occurs when a patent graft is clinically indistinguishable from a thrombosed graft because of reduced flow. 2. Pseudo-occlusion may be provoked by changes in inflow and outflow tract. 3. Pseudo-occlusion is not associated only with saphenous vein graft. 5. Recurrence of symptoms, loss of previously palpable distal pulses and reduction of Doppler indices in a previously patent F-P/Cr bypass graft, can indicate pseudo-occlusion. Early diagnosis provides a simple and safe treatment.

Adult↗

PubMedDate not supplied

[Dacron and polytetrafluoroethylene aorto-bifemoral grafts].

INTRODUCTION: In reconstructive procedures of the abdominal aorta synthetic grafts are today mostly used. There are two types of bifurcated synthetic grafts: Dacron and polytetrafluorethilene (PTFE). In many papers these grafts are compared in aortobifemoral position. Karner 1988, and Lord 1988, found no significant difference between them after aortobifemoral reconstructions. In 1955. Paaske wrote about a new "stretch" bifurcated PTFE graft in aortobifemoral position. Comparing this material with standard Dacron graft, he only found a shorter operating time. The aim of this paper is to compare Dacron and PTFE bifurcated grafts in aortobifemoral position in patients with aortoiliac occlusive diseases. MATERIAL AND METHODS: This prospective study included 283 aortobifemoral reconstructions due to aortoiliac occlusive diseases operated between January 1st, 1984 and December 31st, 1992 at the Institute for Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade. Bifurcated PTFE grafts were used in 136 patients, and nonimpregnated knitted Dacron grafts in 147 subjects. There were 25 (8.8%) female and 258 (91.2%) male patients, average age 56.88 years. Ninety one (32.2%) patients had a claudication discomfort (Fonten stadium II), 91 (32.2%) disabling claudication discomfort (Fonten stadium IIB), 45 (15.9%) rest pain (Fonten stadium III), and 56 (19.8%) gangrene (Fonten stadium IV). In 45 (15.9%) patients previous vascular procedures were performed. Prior to operation, Doppler ultrasonography and translumbar aortography were carried out (Figure 1). Transperitoneal approach to abdominal aorta, and standard inguinal approach to femoral arteries were used. In 154 (54.4%) patients proximal anastomosis had an end to side (TL), and in 129 (45.6%) end to end (TT) form. In 152 (26.88%) cases distal anastomosis was done in the common femoral (AFC) artery, and in 414 (73.2%) cases in the deep femoral (APF) artery. In 7 patients the aorto-femoro-popliteal "jumping" bypass was done, and in 29 patients simultaneous sequential femoro-popliteal bypass graft. The patients were following-up over the period from one, six and twelve months after operation, and later once a year, using physical examination and Doppler ultrasonography. In patients with suspected graft occlusion, anastomotic stenosis, pseudoaneurysms, progression of distal arterial diseases, Duplex ultrasonography and angiography were also used, and leukoscintigraphy in patients with suspected infection. Statistical analysis was performed using Long Rank and Student t-test. RESULTS: Inhospital mortality rate was 11 (7%). Distal reconstructions significantly increased the mortality rate when simultaneously performed with aortobifemoral bypass graft (p < 0.01). The follow-up period was from 2 months to 9.5 years (mean 3.6 years). The early patency rate was 97% from PTFE and 99.4% for Dacron grafts, while the late patency rate was 94.9% for PTFE and 96.6% for Dacron grafts. The type of the graft had no statistical influence on the early and late graft patency (p > 0.05) (Graphs 1, 2, 3). Six (2.1%) early unilateral limb occlusions were observed. Five patients had the PTFE and one the Dacron graft, without statistically significant difference (p > 0.05). The reasons for early graft occlusion were: stenosis of distal anastomosis in 3 patients, and pure run off in 3 patients. In 5 patients urgent reoperation (limb thrombectomy with profundoplasty or femoro-popliteal bypass graft above the knee) were done with complete recovery of legs. However, in one patient the above knee amputation was done. During the follow-up period, 14 (5.2%) late graft occlusions were recorded. There were 11 unilateral limb occlusions and 3 bilateral. All patients with bilateral occlusions had PTFE grafts but this was not statistically significant (p > 0.05) comparing two types of grafts. Taking into account all late occlusions, there were 7 PTFE and 7 Dacron grafts. There was no statistical difference betwe

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PubMedDate not supplied

[Acute superficial thrombophlebitis--modern diagnosis and therapy].

Acute superficial thrombophlebitis of the lower extremities is one of the most common vascular diseases affecting the population. Although it is generally considered as a benign disease, it can be extended to the deep venous system and pulmonary embolism. We examined 50 patients (22 males and 28 females), mean age 52.5 years. These patients were surgically treated due to acute superficial thrombophlebitis of the lower limbs that affected great saphenous vein above the knee. The diagnosis was made by palpable subcutaneous cords in the course of great saphenous vein or its tributaries in association with tenderness, erythema and oedema. Of these 50 patients, 26 were examined by duplex ultrasonography before the operation. In 20 patients duplex scanning confirmed that the process was greater than we supposed after clinical examination (77%) and in 6 patients there were no differences (23%) (Figures 1 and 2). The operation included crossectomy, ligation and resection of the proximal part of the great saphenous vein. Intraoperative findings in 38 patients showed that the level of the phlebitic process was higher than the clinical level (76%). There was no difference in 12 patients (24%). Deep vein thrombosis and pulmonary embolism were noted in 14 patients (28%) (Tables 1 and 2). Both complications were found in two patients, and 12 had one of these complications. Generally, there were 12 patients with deep venous thrombosis and 4 patients with pulmonary embolism. Only in one patient deep venous thrombosis appeared postoperatively, while all other complications occurred before surgical intervention (Scheme 1 and Table 3). The most common risk factor was the presence of varicose veins (86%). Obesity, age over 60 years, cigarette smoking are listed in decreasing order of frequency. Patients under 60 years were more likely to have complications while older patients usually followed a benign clinical course (Tables 4 and 5). There was no intrahospital mortality. Average hospitalization was 5.7 days. It was 4 days in patients without complications. After thes urgent operation that practically removed the risk of potentially fatal consequences, the patients were dismissed from hospital. New hospitalization was recommended after two weeks when the second act of surgical treatment was performed. It included stripping of the great saphenous vein and extirpation of varicose veins in the area without acute inflammation. The findings of this study confirm the general opinion that acute superficial thrombophlebitis is a very common vascular disease with usually "benign" clinical course. In its ascending form that affects the great saphenous vein above the knee it can be associated with deep venous thrombosis and pulmonary embolism. The level of phlebitic process is usually much higher than can be palpated clinically. Duplex scanning was a highly reliable, precise, fast non-invasive diagnostic method that is necessary in examining, following and making decision for operative treatment of acute superficial thrombophlebitis. If suspected complications an urgent surgical intervention should be performed. It is short and efficient, contributing to the fast recovery of the patients and their return to normal activities.

Acute Disease↗

PubMedDate not supplied

[Treatment of the thoracic outlet vascular syndrome].

INTRODUCTION: The title "Thoracic Outlet Syndrome" (TOS) was introduced by Peet in 1956 [1]. In 1958 Charles Rob defined TOS as a "set of symptoms that may exist due to compression on the brachial plexus and on subclavian vessels in the region of the thoracic outlet" [2]. Compression due to cervical rib was first described by Galenus and Veaslius in the 2nd century A.D. The first unsuccessful resection of the cervical rib in patients with TOS was performed by Coote in 1861 [4]. In 1905 Murphy first made a successful resection of the cervical rib in patients with TOS and subclavian artery aneurysm [5]. He also removed the normal first rib in patients with TOS using the supraclavicular approach for the first time [6]. In 1920 Law described ligaments and other structures originating in soft tissue associated with TOS [8], while Adson and Coffey in 1927 emphasized the role of the scalene anticus muscle in TOS [3]. Ochsner, Gage and DeBakey in 1935 named it the "scalenus anticus syndrome", and made the first successful resection of the anterior scalene muscle [9]. In 1966 David Ross introduced the transaxillary resection of the first rib to relieve TOS [11]. The aim of the paper is to describe the treatment of patients with vascular TOS. MATERIAL AND METHODS: Over a six-year-period (1990-1997) 12 patients with vascular TOS were evaluated at our Centre. Seven (58%) were female and 5 (42%) male patients, average age 33.1 years. Eleven of them had congenital TOS, and one acquired TOS after trauma at neck-shoulder region. Seven patients had arterial and 5 venous TOS. Two patients with arterial TOS had ischaemia of the upper extremity due to embolism of the brachial artery. In one of them axillary artery was completely thrombosed, and in the other postenotic dilatation of the subclavian artery was present. The other 5 patients with arterial TOS demonstrated only hand pain and radial puls during hyperabduction of the arm. One of our patients with venous TOS had also symptoms and signs of hand oedema during hyperabduction, while four patients had axillary-subclavian deep venous thrombosis (DVT). All patients underwent CW-Doppler and Duplex-ultrasonographic examination. The results were positive in all patients with arterial TOS. The angiographic (selective arteriography of the subclavian artery) examination showed the same results. Diagnostic procedures were performed in normal position of the arm and during hyperabduction. The angiography also revealed: one aneurysm of the subclavian artery, one poststenotic dilatation of the subclavian artery with brachial artery embolization, and one thrombosed axillary artery with brachial artery embolization (Figure 1). In five patients the angiogram was normal in normal position of the arm, but showed arterial flow obstruction at the thoracic outlet during hyperabduction (Figures 2a and 2b). In patients with venous TOS Duplex ultrasonographic examination was performed. The cervical rib caused TOS in four of our patients and clavicle fracture calus in one case. In 7 patients bone anomalies were not found (Figure 3). The operative treatment was carried out in 3 patients with venous and 7 patients with arterial TOS. In two patients with DVT of the axillary-subclavian segment, 6 months after standard anticoagulant therapy, decompressive procedures were performed (one resection of the cervical rib, and one transauxillary resection of the first rib). In the case of venous TOS without DVT, a supraclavicular resection of the first rib was performed immediately after diagnosis. In 5 patients with arterial TOS without morphologic changes on the arterial system, a decompressive procedure was done. The following procedures were carried out: one scalenotomy, one supraclavicular and three transaxillary resections of the first rib. (ABSTRACT TRUNCATED)

Adult↗

PubMedDate not supplied

[Cystic degeneration of the tunica adventitia of the popliteal artery].

INTRODUCTION: Adventitial cystic disease of the popliteal artery (PA) is an uncommon and unique entity characterized by a mucinous cyst located in the arterial adventitia. As the cyst enlarges, it provokes vascular compression with stenosis or occlusion, the first only during the knee flexion, and then in all leg position. Atkins and Key (1946) were the first who described this disease in the external iliac artery [1]. Eirup and Hiertonn (1956) described the disease in the PA, which is the place of its most common localization. The aim of the paper is the presentation of our 10 cases of PA adventitial cystic disease. PATIENTS AND METHODS: Ten patients with PA adventitial cyst were treated at the Institute of Cardiovascular Diseases of the Serbian Clinical Centre in Belgrade, over the period between 1978 and 1997. There were 9 males and one female patient, average age 42.7 years (31-62). Two patients were smokers, while all other atherosclerotic risk factors, including heart disease, were absent. The diagnosis was established using Doppler ultrasonography and angiography. The postoperative histological examination revealed PA adventitial cyst in all patients (Figure 1). In Table 1 are presented our patients. The patients 3 and 4 were admitted for acute ischaemia of the leg. In patient 3 Doppler indexes were 0.0, and transfemoral arteriography revealed segmental occlusion of the PA. All other arteries were unchanged. These findings suggested an unusual disease of the PA. During the operation the posterior approach to the PA was used, and intraoperatively the adventitial cyst was found. In patient 4 the tibioperoneal trunk, posterior tibial artery and PA were occluded. Therefore, the medial approach to the PA was used. After thrombectomy of the crural vessels, the popliteo-popliteal bypass procedure was performed. The PA resection by this approach was not possible. The ringed 6 mm PTFE graft was used for reconstruction because of inadequate saphenous vein. The patients 1, 2, 5-10 were admitted with disabling claudication discomforts. In patients 1, 2, 5, 6, 8, 9 popliteal and pedal pulses were absent, and Doppler indexes decreased. In patients 7 and 10 pedal pulses were palpable and decreased during the normal knee position, while absent during the knee flexion. During some maneuvers Doppler indexes significantly decreased. Transfemoral arteriography in patients 1, 2, 5, 6, 8, 9 showed segmental stenosis or occlusion of the PA, and for this reason the posterior approach to the PA was used. The PA adventitial cyst was found in all cases (Figure 2). In patient 7 angiography revealed a "hourglass" deformity of the PA, while in patient 10 "scimitar" sign was found. Both angiographic findings are characteristic of PA adventitial cyst. The posterior approach was carried out in all patients. In patient 2 only cyst aspiration has been performed, while in patients 7, 8, 9 aspiration and resection of the changed PA adventitia (Figure 3a, figure 3b). In patients 1, 3, 5, 6, 10 an occluded arterial segment was resected. The restoration of the flow observed after the end-to-end anastomosis in patient 1, and after interposition of the saphenous graft in other patients. After the operation, the contralateral leg was examined using Doppler ultrasonography in all patients. The Doppler indexes were significantly decreased in patients 1 and 5 during the knee flexion, but the patients refused the angiographic examination. The control examination consisted of physical examination, Doppler ultrasonography and sometimes angiography; it was carried out after 1, 3, 6 and 12 months, and then every year after the operation. RESULTS: There was no mortality among our patients in the early post-operative period. In patients in whom cyst aspiration was performed, claudication discomfort was decreased, and Doppler indexes were significantly increased. In patients with arterial resection and reconstruction (1, 3, 4, 5, 6, 10) the effect of the operation was simi

Adult↗