PubMed publikacije

Abstract
Type 2 diabetes mellitus (T2DM) has become a worldwide concern in recent years, primarily in highly developed Western societies. T2DM causes systemic complications, such as atherosclerotic heart disease, ischemic stroke, peripheral artery disease, kidney failure, and diabetes-related maculopathy and retinopathy. The growing number of T2DM patients and the treatment of long-term T2DM-related complications pressurize and exhaust public healthcare systems. As a result, strategies for combating T2DM and developing novel drugs are critical global public health requirements. Aside from preventive measures, which are still the most effective way to prevent T2DM, novel and highly effective therapies are emerging. In the spotlight of next-generation T2DM treatment, sodium-glucose co-transporter 2 (SGLT-2) inhibitors are promoted as the most efficient perspective therapy. SGLT-2 inhibitors (SGLT2i) include phlorizin derivatives, such as canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. SGLT-2, along with SGLT-1, is a member of the SGLT family of proteins that play a role in glucose absorption via active transport mediated by Na+/K+ ATPase. SGLT-2 is only found in the kidney, specifically the proximal tubule, and is responsible for more than 90% glucose absorption. Inhibition of SGLT-2 reduces glucose absorption, and consequently increases urinary glucose excretion, decreasing blood glucose levels. Thus, the inhibition of SGLT-2 activity ultimately alleviates T2DM-related symptoms and prevents or delays systemic T2DM-associated chronic complications. This review aimed to provide a more detailed understanding of the effects of SGLT2i responsible for the acute improvement in blood glucose regulation, a prerequisite for T2DM-associated cardiovascular complications control.

Abstract

Purpose:
Carotid artery stenting (CAS) is an option for carotid restenosis (CR) treatment with favorable outcomes. However, CAS has also emerged as an alternative to carotid endarterectomy (CEA) for the management of patients with primary carotid stenosis. This study aimed to report CR rates after CAS was performed in patients with primary lesions versus restenosis after CEA, to identify predictors of CR, and to report both neurological and overall outcomes. Materials and methods: From January 2000 to September 2018, a total of 782 patients were divided into 2 groups: The CAS (prim) group consisted of 440 patients in whom CAS was performed for primary lesions, and the CAS (res) group consisted of 342 patients with CAS due to restenosis after CEA. Indications for CAS were symptomatic stenosis/restenosis >70% and asymptomatic stenosis/restenosis >85%. A color duplex scan (CDS) of carotid arteries was performed 6 months after CAS, after 1 year, and annually afterward. Follow-up ranged from 12 to 88 months, with a mean follow-up of 34.6±18.0 months.
Results:
There were no differences in terms of CR rate between the patients in the CAS (prim) and CAS (res) groups (8.7% vs 7.2%, χ2=0.691, p=0.406). The overall CR rate was 7.9%, whereas significant CR (>70%) rate needing re-intervention was 5.6%, but there was no difference between patients in the CAS (prim) and CAS (res) groups (6.4% vs 4.7%, p=0.351). Six independent predictors for CR were smoking, associated previous myocardial infarction and angina pectoris, plaque morphology, spasm after CAS, the use of FilterWire or Spider Fx cerebral protection devices, and time after stenting. A carotid restenosis risk index (CRRI) was created based on these predictors and ranged from -7 (minimal risk) to +10 (maximum risk); patients with a score >-4 were at increased risk for CR. There were no differences in terms of neurological and overall morbidity and mortality between the 2 groups.
Conclusions:
There was no difference in CR rate after CAS between the patients with primary stenosis and restenosis after CEA. A CRRI score >-4 is a criterion for identifying high-risk patients for post-CAS CR that should be tested in future randomized trials.
Keywords:
carotid artery; carotid restenosis; carotid stenting; embolic protection device.

Abstract

Background:
Gentiana lutea (GL), commonly known as yellow gentian, bitter root, and bitterwort, belongs to family Gentianaceae. GL belongs to genus Gentiana, which is a rich natural source of iridoids, secoiridoids, xantones, flavonoids, triterpenoids, and carbohydrates. Medicinal plants from Gentiana species have anti-oxidant, anti-inflammatory, anti-mitogenic, anti-proliferative, and lipidlowering effects, as well as a cardioprotective, hypotensive, vasodilator and anti-platelet activities.

Objective:
We reviewed the recent literature related to the effects of Gentiana species, and their active components on vascular diseases.
cMethods:
Data used for this review were obtained by searching the electronic database [PUBMED/ MEDLINE 1973 - February 2020]. The primary data search terms of interest were: Gentiana lutea, Gentienacea family, phytochemistry, vascular diseases, treatment of vascular diseases, antioxidant, anti-inflammatory, anti-atherogenic.
Conclusion:
Gentiana species and their constituents affect many different factors related to vascular disease development and progression. Therefore, Gentiana-based therapeutics represent potentially useful drugs for the management of vascular diseases.
Keywords:
Gentiana lutea; Gentienacea family; anti-atherogenic.; anti-inflammatory; antioxidant; phytochemistry; treatment of vascular diseases; vascular diseases.

Abstract
Hypothyroidism is a common endocrine disorder that predominantly occurs in females. It is associated with an increased risk of cardiovascular diseases (CVD), but the molecular mechanism is not known. Disturbance in lipid metabolism, the regulation of oxidative stress, and inflammation characterize the progression of subclinical hypothyroidism. The initiation and progression of endothelial dysfunction also exhibit these changes, which is the initial step in developing CVD. Animal and human studies highlight the critical role of nitric oxide (NO) as a reliable biomarker for cardiovascular risk in subclinical and clinical hypothyroidism. In this review, we summarize the recent literature findings associated with NO production by the thyroid hormones in both physiological and pathophysiological conditions. We also discuss the levothyroxine treatment effect on serum NO levels in hypothyroid patients.
Keywords:
Cardiovascular diseases; Endothelial dysfunction; Hypothyroidism; Levothyroxine; Nitric oxide.

Abstract

Introduction:
Age-related changes of dental pulp tissue and atherosclerosis of carotid arteries as its feeding arteries could influence the functionality of pulpal circulation. The objective of our study was to evaluate the effect of aging (physiological process) and carotid bifurcation atherosclerosis (pathologic process) on the pulpal microcirculatory system using multifractal analysis of the laser Doppler flowmetry signal.
Methods:
Three groups of 10 subjects were enrolled in the study: the young group (healthy subjects, 20-25 years), the middle-aged group (healthy subjects, 50-60 years), and the clinical group (subjects with carotid bifurcation atherosclerosis, 50-60 years). Pulpal blood flow (PBF) signals recorded by laser Doppler flowmetry were assessed by multifractal analysis that estimates Hölder exponents of the signal. PBF levels, the average mean values, and the range of Hölder exponents were obtained.
Results:
PBF levels were significantly higher in the young group compared with the middle-aged and clinical groups, and the difference between the middle-aged and clinical groups was not statistically significant. The range of the Hölder exponents was narrower in the middle-aged and clinical groups than in the young group and narrower in the clinical group than in the middle-aged group. The average mean value of Hölder exponents was significantly higher in the young group than in the middle-aged and clinical groups, whereas there was no significant difference between the middle-aged and clinical groups.
Conclusions:
Our study investigating the multifractality of the PBF signal showed that the aging process and carotid atherosclerosis could affect the complex structure of PBF oscillations and contribute to a better understanding of pulpal hemodynamics.
Keywords:
Aging; atherosclerosis; dental pulp; laser Doppler flowmetry; multifractal analysis.

Abstract

Background:
The aim of this study was to compare demographic, clinical and biochemical characteristics, including inflammatory markers, according to the nutritional status of patients with verified atherosclerotic disease.
Methods:
This cross-sectional study involved 1045 consecutive patients with verified carotid disease or peripheral arterial disease (PAD). Anthropometric parameters and data on cardiovascular risk factors and therapy for hypertension and hyperlipidemia were collected for all participants.
Results:
Carotid disease was positively and PAD was negatively associated with body mass index (BMI). Negative association between obesity and PAD was significant only in former smokers, not in current smokers or in patients who never smoked. Overweight and general obesity were significantly related to metabolic syndrome (p < 0.001), lower values of high - density lipoprotein cholesterol (p < 0.001), increased triglycerides (p < 0.001), hyperglycemia (p < 0.001), self-reported diabetes (p < 0.001), hypertension (p < 0.001), high serum uric acid (p < 0.001), increased high sensitivity C-reactive protein (p = 0.020) and former smoking (p = 0.005) after adjustment for age, gender and type of disease. Antihypertensive therapy seems to be less effective in patients who are overweight and obese.
Conclusions:
In conclusion, ovhttps://pubmed.ncbi.nlm.nih.gov/33033455/erweight and general obesity were significantly related to several cardiovascular risk factors.
Keywords:
atherosclerosis; carotid disease; obesity; peripheral arterial disease; risk factors.

Abstract
To remedy carotid artery stenosis and prevent stroke surgical intervention is commonly used, and the gold standard being carotid endarterectomy (CEA). During CEA cerebrovascular hemoglobin oxygen saturation decreases and when this decrease reaches critical levels it leads to cerebral hypoxia that causes neuronal damage. One of the proposed mechanism that affects changes during CEA and contribute to acute brain ischemia (ABI) is oxidative stress. The increased production of reactive oxygen species and reactive nitrogen species during ABI may cause an unregulated inflammatory response and further lead to structural and functional injury of neurons. Antioxidant activity are involved in the protection against neuronal damage after cerebral ischemia. We hypothesized that neuronal injury and poor outcomes in patients undergoing CEA may be results of oxidative stress that disturbed function of antioxidant enzymes and contributed to the DNA damage in lymphocytes.
Keywords:
Acute brain ischemia; Catalase; Cerebrovascular hemoglobin oxygen saturation; DNA damage; Superoxide dismutase.

Abstract

Background:
Cardiovascular disease remains the major cause of mortality in the Western World.
Aims:
We aimed to assess the prevalence of polyvascular disease in patients with carotid artery disease and peripheral artery disease (PAD), and to determine the risk profile of patients with polyvascular disease.
Methods:
The study included 1045 consecutive patients presenting to our department with carotid disease or PAD. Demographic characteristics, anthropometric parameters, and data on cardiovascular risk factors were collected in all patients. On the basis of medical history, patients were classified into those who had only symptomatic carotid disease or symptomatic PAD and those who had symptomatic polyvascular disease.
Results:
Carotid disease alone was reported in 366 participants (35%), PAD alone, in 199 (19%), and polyvascular disease, in 480 (46%). Compared with carotid disease, PAD was more often a component of polyvascular disease (P = 0.002) and was combined with a higher number of other atherosclerotic diseases (P = 0.02). Compared with patients with symptomatic atherosclerotic disease in only 1 territory, patients with various types of polyvascular disease more often had hypertension (P from 0.03 to <0.001), dyslipidemia (P <0.001), high sensitivity C reactive protein levels of 3 mg/l or higher (P = 0.005), and more often were current smokers (P <0.001) or former smokers (P from 0.03 to 0.001).
Conclusions:
We showed a high prevalence of symptomatic polyvascular disease in patients with carotid disease or PAD. The risk profile was worse in patients with polyvascular disease than in those with a disease in a single vascular territory.

Abstract

Objective:
The aim of this study was to evaluate the results of endovascular therapy on the treatment of different types of iliac occlusions.
Materials and methods:
A bi-center prospective, non-randomized study was conducted on 100 patients (mean age 59.14 ± 8.53; 64 men) who underwent endovascular treatment of iliac occlusive disease between January 2013 and November 2017. We evaluated baseline data, procedure, and follow-up results for the entire group, and according to Trans-Atlantic Inter-Society Consensus (TASC II) classification. The majority of patients (60%) were treated for severe claudication; 56 (56%) patients had TASC B occlusions, 28 patients TASC C, and 16 patients TASC D.
Results:
The mean length of the occluded segments was 61.41 ± 35.15 mm. Procedural complications developed in 6 patients (6%). Mean ankle-brachial pressure index increased from 0.40 ± 0.12 preoperatively to 0.82 ± 0.16 postoperatively. The mean follow-up was 33.18 ± 15.03 months. After 1 and 5 years, the primary patency rates were 98% and 75.1%, and the secondary patency rate was 97% respectively. Regarding occlusion complexity there were no statistical significant differences in primary patency rates (TASC B vs. C vs. D: p = 0.19). There were no statistically significant differences in primary patency rates between patients in different clinical stages, as well as between the type of stents, and location of the occlusion.
Conclusion:
In our study, endovascular treatment for iliac artery occlusions proved to be a safe and efficient approach with excellent primary and secondary patency rates regardless of the complexity of occlusions defined by TASC II classification. This study is aligned with the notion that in well selected patients, endovascular therapy can be the treatment of choice even in complex iliac lesions if performed by experienced endovascular interventionists in high volume centers.

Abstract

Objective:
Inflammation plays a crucial role in the progression of atherosclerotic plaques. The aim of the study was to investigate serum levels and expression of Interleukin-33 (IL-33) and ST2 receptor in atherosclerotic plaques and to analyze correlation with the type of the carotid plaques in patients with carotid disease.
Methods:
This study included 191 consecutive patients submitted for carotid endarterectomy (CEA). Preoperative serum levels of IL-33 and soluble ST2 (sST2) were measured. Atherosclerotic plaques obtained during surgery were initially histologically classified and immunohistochemical analyzes of IL-33, IL-33R, CD68 and alpha-SMA expression was performed. Ultrasound assessment of the level of carotid stenosis in each patient was performed prior to carotid surgery. Demographic and clinical data such as gender, age, smoking status, blood pressure, glycaemia, hemoglobin and creatinine levels, and comorbidities were collected and the comparisons between variables were statistically evaluated.
Results:
Serum levels of IL-33 (35.86 ± 7.93 pg/ml vs.12.29 ± 1.8 pg/ml, p < 0.05) and sST2 (183 ± 8.03 pg/ml vs. 122.31 ± 15.89 pg/ml, p < 0.05) were significantly higher in the group of CEA patients vs. healthy subjects. We demonstrated abundant tissue expression of IL-33 and ST2 in atherosclerotic carotid artery lesions. The levels of IL-33 and IL-33R expression were significantly higher in vulnerable plaques and significantly correlated with the degree of inflammatory cells infiltration in these plaques (R = 0.579, p = 0.049). Immunohistochemical analysis also revealed that cells responsible for IL-33 expression are not only mononuclear cells confined to inflammatory atherosclerotic lesions, but also smooth muscle cells which gained phenotypic characteristics of foam cells and were loaded with lipid droplets.
Conclusion:
The obtained results confirm the importance of IL-33/ST2 axis in the process of atherosclerosis, and indicate its ambiguous function in immune response, whether as proinflammatory cytokine in advanced atherosclerotic lesions, or as profibrotic, in early lesions.
Keywords:
Carotid atherosclerosis; IL-33; Plaque stability.

Abstract
More people die from cardiovascular diseases (CVD) than from any other cause. Cardiovascular complications are thought to arise from enhanced levels of free radicals causing impaired "redox homeostasis," which represents the interplay between oxidative stress (OS) and reductive stress (RS). In this review, we compile several experimental research findings that show sustained shifts towards OS will alter the homeostatic redox mechanism to cause cardiovascular complications, as well as findings that show a prolonged antioxidant state or RS can similarly lead to such cardiovascular complications. This experimental evidence is specifically focused on the role of glutathione, the most abundant antioxidant in the heart, in a redox homeostatic mechanism that has been shifted towards OS or RS. This may lead to impairment of cellular signaling mechanisms and elevated pools of proteotoxicity associated with cardiac dysfunction.

Abstract
In the past 2 decades, varicose veins surgery went through a great turbulence and various innovations. A number of new techniques have been introduced with a goal to increase the success rate, reduce the periprocedural complications and, overall, to improve patients' quality of life. The latest of them, named cyanoacrylate embolization (CAE) technique, threatens to shake the glory of the currently well-established endovenous methods. We have analyzed all previous studies by searching MEDLINE base using PubMed. Although the idea of using n-butyl cyanoacrylate (NBCA) glue in medical purposes was not new, the very first in vivo and animal experiments using NBCA for vein closure were conducted just at the beginning of this millennium. The results of these studies gave warranty to begin with the first interventions in humans. Early studies reported very high success rates of more than 90%, with the longest follow-up period of 36 months. There were no major adverse events reported, while the minor ones-mostly phlebitic reactions-were defined as mild to moderate. The newest head-to-head studies showed that CAE is a noninferior technique to other endovenous methods, with higher occlusion rates and fewer adverse events. Short procedure time and no need for tumescent anesthesia or compressive stockings reduce patients' discomfort to the minimum and definitely seem to be a step forward answering the modern "walk in-walk out surgery" demands. As an easily handling technique, CAE undoubtedly pierces its path to the top of varicose veins surgery but more head-to-head clinical trials with longer follow-up periods are necessary to obtain a plain picture.

Abstract

Purpose:
To present the feasibility, safety, and efficacy of carotid endarterectomy in patients with type II internal carotid artery occlusions, including the long-term outcomes.
Methods:
From March 2008 to August 2015, 74 consecutive patients (48 men with a mean age of 65.1 ± 8.06 years) underwent carotid endarterectomy because of internal carotid artery (ICA) segmental occlusions. These were verified with preoperative carotid duplex scans (CDS) and CT angiography (CTA). Also, brain CT scanning was performed in all these patients. The indication for treatment was made jointly by a vascular surgeon, neurologist, and an interventional radiologist in a multidisciplinary team (MDT) context. After successful treatment, all the patients were followed-up at 1, 3, 6, and 12 months, then every 6 months thereafter.
Results:
The most common symptom at presentation was transient ischaemic attack (TIA) in 49 patients (66.2%), followed by stroke in the past six months in the 17 remaining patients (23%). Revascularisation of the ICA with endarterectomy techniques was performed successfully in all the patients with an average clamp time of 11.9 min. All the procedures were performed under general anaesthesia in combination with a superficial cervical block. The early complication rate was 8.1% and included two cardiac events (2.7%) (one rhythm disorder and one acute coronary syndrome), three TIAs (4.1%), and one intracerebral hemorrhage (1.3%). Only one patient with the intracerebral hemorrhage died 5 days after surgery giving a postoperative mortality of 1.3% for this series. During the follow-up period (mean 50.4 ± 31.3 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 94.9%, 92.9%, and 82.9%, respectively. Likewise, the survival rates were 98.7%, 96.8%, 89%, and 77.6%, respectively. Ultrasound Doppler controls during follow-up detected 8 ICA restenoses; however, only 3 of these patients required further endovascular treatment.
Conclusions:
Carotid endarterectomy of internal carotid artery (ICA) segmental occlusion is a safe and effective procedure associated with acceptable risk and good long-term results. Therefore, the current guidelines which do not recommend carotid endarterectomy in this patient group should be reassessed, with the requirement for ongoing large-scale randomized controlled trials to compare CEA with best medical therapy in this patient cohort.

Abstract
The rising pandemic of obesity in modern society should direct attention to a more comprehensive approach to abdominal aortic aneurysm (AAA) treatment in the affected population. Although overweight patients are considered prone to increased surgical risk, studies on the subject did not confirm or specify the risks well enough. Associated comorbidities inevitably lead to a selection bias leaning towards endovascular abdominal aortic repair (EVAR), as a less invasive treatment option, which makes it hard to single out obesity as an independent risk factor. The increased technical difficulty often results in prolonged procedure times and increased blood loss. Several smaller studies and two analyses of national registries, including 7935 patients, highlighted the advantages of EVAR over open repair (OR) of abdominal aortic aneurysm, especially in morbidly obese population (relative risk reduction up to 47%). On the other hand, two other studies with 1374 patients combined, concluded that EVAR might not have an advantage over OR in obese patients (P = 0.52). Obesity is an established risk factor for wound infection after both EVAR and OR, which is associated with longer length of stay, subsequent major operations, and a higher rate of graft failure. Percutaneous EVAR technique could present a promising solution to reducing this complication. EVAR seems like a more feasible treatment option than OR for obese patients with AAA, due to lower overall morbidity and mortality rates, as well as reduced wound-related complication rates. However, there is a clear lack of high-quality evidence on the subject, thus future prospective trials are needed to confirm this advantage.
Keywords:
EVAR; Obesity; abdominal aortic aneurysm; complications; risk; wound.

Abstract
Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies. Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.
Keywords:
Chronic venous disease; hypertension; pain; spinal cord; treatment; venoactive drugs.

Abstract
Biofilm-associated wound infections are a major global health issue, and methicillin-resistant Staphylococcus aureus (MRSA) is among the greatest therapeutic challenges. Vacuum-assisted closure (VAC) therapy is now being revisited as an alternative treatment for both acute and chronic wounds. However, data supporting the concept of its antibiofilm effect remain limited. Using quantitative biofilm-forming assay and a range of genotypic methods (spa, SCCmec, and agr typing), study authors showed that VAC therapy can significantly prevent biofilm formation (P < .01) of a range of MRSA wound isolates differing widely in their biofilm-forming abilities and genetic background. The best effect was presented on CC5-MRSA-SCCmecI-agrII, a dominant MRSA clone among wound isolates worldwide. An assessment of effects of different protocols on dressing changes (1 or 2 times per week) demonstrated significantly greater antibiofilm activity (P < .05) of 3-day dressing changes. These findings support the use of VAC therapy as a topical antibiofilm treatment for the effective management of wound healing.

Abstract
Carotid endarterectomy (CEA) carries a significant risk of procedural stroke and death Guidelines recommend keeping this risk below 6% and below 3% for symptomatic and asymptomatic patients respectively. After analyzing our Institute's CEA results during the past 25 years, we found the rate of postoperative complications was now well below Guideline thresholds. Accordingly, we studied temporal changes in procedural risks in randomized controlled trials (RCTs) and in large observational studies in order to compare these against Guidelines. We found a clear temporal trend towards improving procedural outcomes, which can be explained by improvements in medical therapy, more appropriate timing of CEA, the use of local anesthesia and the use of peroperative cerebral monitoring as well as improving surgical techniques. An update of current guidelines should now be undertaken, since our findings are not unique and are supported by other studies in this review.

Abstract

Objective:
The objective of this study was to report the 1-year follow-up study results of the new Horizon stent graft (Endospan, Herzliya, Israel) from two different prospective consecutive trials. The Horizon abdominal aortic aneurysm stent graft system is a 14F profile system requiring only a single access site. It consists of three modules, introduced separately: base limb (iliac to iliac limb); distal aortic limb; and proximal aortic limb with a bare suprarenal crown and active fixation.
Methods:
Data from the first in man (FIM) clinical study with 10 patients enrolled and the pivotal study with 30 patients were analyzed. Outcomes measured were freedom from major adverse events (MAEs) including all-cause mortality, myocardial infarction, renal failure, respiratory failure, paraplegia, stroke, bowel ischemia, and procedural blood loss ≥1000 mL. Performance end points included successful delivery and deployment of the device, freedom from aneurysm growth ≥5 mm, type I or type III endoleak, stent graft occlusion, conversion to open surgery, rupture, and stent graft migration.
Results:
In the FIM study, one conversion to open surgery with >1000 mL of blood loss was registered perioperatively. In the pivotal study, no perioperative MAE was registered. Overall, at 1-year follow-up, two deaths and one aneurysm growth unrelated to endoleak were registered.
Conclusions:
The results of both the FIM and pivotal studies demonstrated that 39 of 40 procedures were successful for delivery and deployment of the Horizon stent graft. No MAE was registered during the follow-up. The primary safety and performance end points were met in both studies.
Trial registration:
ClinicalTrials.gov NCT02087501.

Abstract

Background:
Inflammation is one of the mechanisms that leads to carotid restenosis (CR). The aim of this study was to examine the influence of increased values of inflammation markers (high-sensitivity C-reactive protein [hs-CRP], C3 complement, and fibrinogen) on CR development after eversion carotid endarterectomy (CEA).
Methods:
A consecutive 300 patients were included in the study, in which eversion CEA was performed between March 1 and August 1, 2010. Demographic data, atherosclerosis risk factors, comorbidities, and ultrasound plaque characteristics were listed in relation to potential risk factors for CR. Serum concentrations of hs-CRP, fibrinogen, and C3 complement were taken just before surgery (6 hours); 48 hours after CEA; and during regular checkups at 1 month, 6 months, 1 year, and 2 years. An "inflammatory score" was also created, which consisted of six predictive values of inflammatory markers (hs-CRP just before and just after CEA, fibrinogen just before and just after CEA, and C3 complement just before and just after CEA) with a maximum score of 6 and a minimum score of 0. At every follow-up visit to the outpatient clinic, ultrasound assessment of the carotid artery for restenosis was done.
Results:
Our results showed an increased risk of early CR within 1 year in patients with increased hs-CRP before CEA (6 hours) and increased fibrinogen 48 hours after surgery and in patients not taking aspirin after CEA. Sex was determined to be an independent predictor of CR, with female patients having a higher risk (P = .002). Male patients taking aspirin with an inflammatory score >2 had an increased risk for restenosis compared with male patients with inflammatory score <2. Not taking aspirin after CEA and fibrinogen (48 hours) were the strongest predictors, and the Fisher equation incorporating these predictors was used to predict CR. A computer program was created to calculate whether the patient was at high or low risk for CR by selecting whether the patient was taking aspirin (yes or no) and whether fibrinogen was increased 48 hours after CEA (yes or no) and to display the recommended therapeutic algorithm consisting of aspirin, clopidogrel, cilostazol, and statins.
Conclusions:
Increased hs-CRP before CEA, increased fibrinogen 48 hours after CEA, and not taking aspirin were the main predictors of early CR. With the clinical implementation of the Fisher equation, it is possible to identify patients at high risk for early CR and to apply an aggressive therapeutic algorithm, finally leading to a decreased CR rate.

Abstract
Coronary artery disease (CAD) and myocardial infarction (MI) are recognized as leading causes of mortality in developed countries. Although typically associated with behavioral risk factors, such as smoking, sedentary lifestyle, and poor dietary habits, such vascular phenotypes have also long been recognized as being related to genetic background. We review the currently available data concerning genetic markers for CAD in English and non-English articles with English abstracts published between 2003 and 2018. As genetic testing is increasingly available, it may be possible to identify adequate genetic markers representing the risk profile and to use them in a clinical setting.
Keywords:
GWAS analysis; coronary artery disease; familial hypercholesterolemia; genetic markers.

Abstract

Background:
To date, all published studies analyzing simultaneous treatment of carotid and proximal atherosclerotic lesions are describing retrograde approach and several technical variations. In the presented study, for the first time, antegrade approach is described for simultaneous carotid endarterectomy (CEA) and associated brachiocephalic trunk (BCT) or common carotid artery (CCA) angioplasty in the hybrid operating room.
Methods:
From January 2012 till January 2016, antegrade hybrid procedures were performed in 18 patients. All patients were admitted to our institute for elective supraaortic arch multidetector computed tomography angiography when significant simultaneous proximal and distal supraaortic arch lesions were revealed. After surgical exposure of carotid arteries, proximal lesions were crossed by antegrade approach. Prior to stent placement, internal carotid artery (ICA) is clamped at its origin with the guidewire placed in the external carotid artery (ECA). After primary stenting and control arteriography, CCA and ECA are clamped and the ICA clamp moved more distally. An arteriotomy is performed in the CCA, with flushing of possible debris and thrombus before performance of the eversion CEA, once again flushing before completion of the anastomosis. Follow-up ranged from 6 to 36 months with average follow-up of 22.15 ± 11.31 months.
Results:
All procedures went uneventfully. Out of 18 patients, 11 were males and 7 females, mean age 66.6 ± 3.82 years. In 10 patients (55.5%), simultaneous CEA and CCA angioplasty was performed, in 7 patients (38.9%) CEA and BCT angioplasty, and in 1 patient (5.5%) tubular graft interposition between the CCA and the ICA and CCA angioplasty. In 6 patients (33.3%), CCA/BCT balloon angioplasty alone was performed simultaneously with CEA. None of the patient had postoperative transient ischemic attack, stroke, hematoma, dissection, myocardial infarction, or ischemia in the early postoperative period and during the follow-up. There were no lethal outcomes, neither in the early postoperative course nor during the follow-up.
Conclusions:
Antegrade approach for simultaneous treatment of proximal CCA/BCT and distal carotid lesions with temporary ICA clamping is safe and feasible procedure that should be thought of in the future in addition to already described retrograde approach.

Abstract

Background:
The aim of this study was to assess the knowledge and attitude of medical students in relation to cardiovascular disease (CVD) risk factors as well as to assess the impact of medical education on their knowledge and recognition of the importance of implementation of preventive measures.
Methods:
This cross-sectional study included 514 students in the second year of studying at the Faculty of Medicine in Belgrade, Serbia (younger students response rate 79.57%) and 511 students in the last year of education (older students response rate 90.21%). For data collection, an anonymous self-administered questionnaire was used, which included two types of questions about CVD risk factors and questions about the student's attitude.
Results:
Older students knew significantly more about CVD risk factors than students who were at the beginning of their medical studies; however, more than half of the older students did not know the correct answers about CVD risk factors. The only exceptions were questions about "bad" and "good" cholesterol, metabolic syndrome (MSy) and lipid lowering therapy in high risk subjects. Physical inactivity, obesity, type 2 diabetes, smoking and hypertension were not ranked highly enough as important CVD risk factors. Compared groups of students did not significantly differ in attitude scores. The majority of them recognized CVD as the leading cause of death, had normal weight and knew their own blood pressure.
Conclusion:
Knowledge of medical students from Belgrade about CVD risk factors should be improved.
Keywords:
Cardiovascular disease; Medical students; Metabolic syndrome; Risk factors.

Abstract

Background:
Vascular age (VA) represents chronological age adjusted for an individual's atherosclerotic burden. Keeping in mind the fact that facial vascularization could influence the success of esthetic interventions, we aimed to investigate the predictive value of VA in development of side effects following facial lipofilling.
Methods:
In the period from October 1, 2014, to October 1, 2015, 106 consecutive subjects who underwent a facial lipofilling were included in the study. The VA was calculated using two approaches: Systematic Coronary Risk Evaluation (SCORE) project equations and means of vascular parameters assessed by color duplex sonographic examinations. The data regarding facial lipofilling-related complications (pain, edema and/or hematoma) have been collected during the regular checkups over 2 weeks after intervention.
Results:
The average chronological age of the participants was 50.9 ± 9.4 years. Estimation of VA using vascular sonographic parameters revealed the value of 45.4 ± 29.1 years, whereas the assessment of VA using SCORE equations showed that the mean age was 53.7 ± 12.7 (p = 0.006). The total frequency of these complications was as follows: 6.6% for hematoma, 15.1% for edema (13.2% mild edema and 1.9% severe edema) and 20.8% for local facial pain (17.0% mild pain and 3.8% severe pain). The multivariate logistic regression models showed that VA had statistically significant (p < 0.01) independent prognostic value for facial lipofilling-related appearance of hematoma and pain.
Conclusions:
The results of our study revealed that advanced VA has an independent predictive role in the appearance of complications following facial plastic surgery.
Level of evidence iii:
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Keywords:
Lipofilling; Side effects; Vascular age.

Abstract
Endovascular surgery represents a minimally invasive procedure for the treatment of occlusive and aneurysmal arterial disease. However, it is followed by inflammatory response, with a rise in specific inflammatory biomarkers, such as C-reactive protein, serum amyloid A and fibrinogen. Shear stress during balloon inflation and vascular injury represents triggering events for the inflammatory process, stimulating the production of proinflammatory molecules and activation of circulating monocytes. The current literature indicates that stent implantation induces more prominent inflammatory reaction. Additionally, it has been shown that muscular arteries of femoropopliteal segment react to a greater extent to stent implantation, compared with elastic carotid or iliac arteries. The endovascular treatment of thoracic and abdominal aortic aneurysm is frequently followed with post-implantation inflammatory syndrome. Most recent findings point out that stent graft material plays a significant role in the inflammatory response, representing a challenge for clinicians. Future studies should consider the pathophysiology of the inflammatory response associated with endovascular procedures as well as predictors and risk factors including preventive strategies and therapeutic algorithms. Although the potential role of anti-inflammatory drugs after endovascular procedures has been observed, it needs to be validated in upcoming trials. The Neutrophil Lymphocyte Ratio, platelet count, Platelet-to-Lymphocyte Ratio and other biomarkers should be considered in future trials to assess the inflammatory response after endovascular procedures. Inflammatory markers may also become therapeutic targets.
Keywords:
Endovascular procedures; endovascular aortic repair; inflammatory response; percutaneous transluminal angioplasty; stent implantation; thoracic endovascular aortic repair.

Abstract
Apoptosis may contribute to a significant proportion of neuron death following acute brain ischemia (ABI), but the underlying mechanisms are still not fully understood. Brain ischemia may lead to stroke, which is one of the main causes of long-term morbidity and mortality in both developed and developing countries. Therefore, stroke prevention and treatment is clinically important. There are two important separate areas of the brain during ABI: the ischemic core and the ischemic penumbra. The ischemic core of the brain experiences a sudden reduction of blood flow, just minutes after ischemic attack with irreversible injury and subsequent cell death. On the other hand, apoptosis within the ischemic penumbra may occur after several hours or days, while necrosis starts in the first hours after the onset of ABI in the ischemic core. ABI is characterized by key molecular events that initiate apoptosis in many cells, such as overproduction of free radicals, Ca2+ overload and excitotoxicity. These changes in cellular homeostasis may trigger either necrosis or apoptosis, which often depends on cell type, cell age, and location in the brain. Apoptosis results in DNA fragmentation, degradation of cytoskeletal and nuclear proteins, cross-linking of proteins, formation of apoptotic bodies, expression of ligands for phagocytic cell receptors and finally uptake by phagocytic cells. This review focuses on recent findings based on animal and human studies regarding the apoptotic mechanisms of neuronal death following ABI and the development of potential neuroprotective agents that reduce morbidity. The effects of statins on stroke prevention and treatment as well as on apoptotic mediators are also considered.
Keywords:
Apoptosis; acute brain ischemia; caspase; death receptor; statins; stroke.

Abstract

Background:
Overexpression of inducible nitric oxide synthase (iNOS) is a key link between high-fat (HF) diet induced obesity and cardiovascular disease. Oestradiol has cardioprotective effects that may be mediated through reduction of iNOS activity/expression.
Methods:
In the present study, female Wistar rats were fed a standard diet or a HF diet (42% fat) for 10 weeks. iNOS gene and protein expressions were measured in heart tissue. HF-fed rats exhibited a significant increase in cardiac iNOS mRNA by 695% (p<.05), iNOS protein level by 248% (p<0.01), without changes in nitrate/nitrite levels. Expression of CD36 protein in plasma membranes was increased by 37% (p<0.05), while the concentration of free fatty acids (FFA) was reduced by 25% (p<0.01) in HF-fed rats. Expression of the p50 subunit of nuclear factor-kB (NFkB-p50) in heart was increased by 77% (p<0.01) in HF-fed rats. Expression of protein kinase B (Akt) and extracellular signalregulated kinases 1/2 (ERK1/2) were unchanged between the groups. There was a significant increase in the ratio of phospho-Akt/total Akt but not for phospho-ERK1/2/total ERK1/2 in HF-fed rats. Estrogen receptor-α levels (by 50%; p<0.05) and serum oestradiol concentrations (by 35%; p<0.05) were shown to be significantly reduced in HF-fed rats.
Results and conclusion:
Our results revealed that a HF diet led to increased iNOS expression, most likely via a mechanism involving Akt and NFκB-p50 proteins. Decreased levels of oestradiol and ERα protein in the HF-fed group, in combination with increased iNOS levels are consistent with the hypothesis that oestradiol has a cardioprotective effect through its ability to regulate iNOS expression.
Keywords:
Cardioprotection; cardiovascular disease; inducible nitric oxide synthase; insulin resistance; obesity; oestradiol.

Abstract
Metabolic syndrome (MetS) is a leading public health and clinical challenge worldwide. MetS represents a group of interrelated risk factors that predict cardiovascular diseases (CVD) and diabetes mellitus (DM). Its prevalence ranges between 10 and 84%, depending on the geographic region, urban or rural environment, individual demographic characteristics of the population studied (sex, age, racial and ethnic origin), as well as the criteria used to define MetS. Persons with MetS have higher mortality rate when compared with people without MetS, primarily caused by progressive atherosclerosis, accelerated by pro-inflammatory and pro-coagulation components of MetS. Considering the high prevalence of metabolic disorders (glucose metabolism disorder, hypertension, dyslipidaemia, obesity etc.), preventive healthcare should focus on changing lifestyle in order to reduce obesity and increase physical activity. This narrative review considers the available evidence from clinical and experimental studies dealing with MetS, and current treatment options for patients with insulin resistance and MetS.

Abstract

Introduction:
Infection of synthetic graft in the groin is a rare but devastating complication. When it occurs, several possibilities of treatment are available. Extra-anatomic reconstruction and in-situ implantation of new, infection resistant grafts are associated with high mortality and morbidity. Therefore, more conservative approach is needed in some cases. Negative-pressure wound therapy is one of the options in treating such patients.
Objective:
The aim of this study was to assess the outcome for deep groin vascular graft infection treated with negative-pressure wound therapy.
Methods:
Seventeen patients (19 wounds), treated for Szilagyi grade III groin infections between October 2011 and June 2014, were enrolled into this observational study.
Results:
Majority of the wounds (11/19) were healed by secondary intention, and the rest of the wounds (8/19) were healed by primary intention after initial negative-pressure wound therapy and graft substitution with silver-coated prostheses or autologous artery/vein implantation. No early mortality was observed. Minor bleeding was observed in one patient. Reinfection was noted in three wounds. Only one graft occlusion was noted. Late mortality was observed in three patients.
Conclusion:
Negative-pressure wound therapy seems to be safe for groin vascular graft infections and comfortable for both patient and surgeon. However, the rate of persistent infection is high. This technique, in our opinion, can be used as a “bridge” from initial wound debridement to definitive wound management, when good local conditions are achieved for graft substitution, either with new synthetic graft with antimicrobial properties or autologous artery/vein. In selected cases of deep groin infections it can be used as the only therapeutic approach in wound treatment.

Abstract
Copeptin is a sensitive and more stable surrogate marker for arginine vasopressin. In this study, we evaluated copeptin levels in carotid endarterectomy (CEA) patients, perioperatively, to determine whether copeptin levels can be related to carotid artery cross clamping (CC) time and to postoperative neurological outcomes. Copeptin, interleukin 6, C-reactive protein, cortisol, and brain natriuretic peptide were measured preoperatively (T1) and 3 hours postoperatively (T3) as well as intraoperatively (T2). We recruited 77 patients. Values of copeptin rose gradually over the observed times: T1 = 7.9 (6.4-9.6), T2 = 12.6 (9.3-16.8), and T3 = 72.3 (49.1-111.2) pmol/L. There was a significant difference for repeated measurement ( P = .000, P = .000, and P = .000). Duration of carotid artery CC during CEA does not affect postoperative copeptin level (CC ≤ 13 minutes: 106.8 ± 93.6 pmol/L, CC > 13 minutes: 96.7 ± 89.1 pmol/L; P = .634). Preoperative copeptin level was significantly higher in patients with ulcerated plaque morphology. Activation of the stress axis in patients undergoing CEA results in copeptin elevation. Duration of CC during CEA does not affect postoperative copeptin levels.
Keywords:
carotid endarterectomy; copeptin; cross clamping; stress response.

Abstract

Introduction:
The stump wound complications after above-knee amputation lead to other problems, such as prolonged rehabilitation, delayed prosthetic restoration, the increase in total treatment cost and high mortality rates.
Objective:
To evaluate the safety and outcomes of negative-pressure wound therapy (NPWT) using Vacuum-Assisted Closure (VAC®) therapy in patients with stump complication after above-knee amputation (AKA).
Methods:
From January 2011 to July 2014, AKA was performed in 137 patients at the University Cardiovascular Clinic. Nineteen (12.4%) of these patients (mean age 69.3 ± 9.2 years) were treated with NPWT. The following variables were recorded: wound healing and hospitalization time, rate of NPWT treatment failure, and mortality.
Results:
AKA was performed in 17 (89.5%) patients after the vascular or endovascular procedures had been exhausted, while urgent AKA was performed in two (10.5%) patients due to uncontrolled infection. The time before NPWT application was 3.1 ± 1.9 days and the duration of the NPWT use ranged from 15 to 54 days (mean 27.95 ± 12.1 days). During NPWT treatment, operative debridement was performed in 12 patients. All the patients were kept on culture-directed intravenous antibiotics. The average hospital length of stay was 34.7 days (range 21–77 days). There were four (20.9%) failures during the treatment which required secondary amputation. During the treatment, one (5.3%) patient died due to multi-organ failure after 27 days.
Conclusions:
The use of NPWT therapy in the treatment of AKA stump complication is a safe and effective procedure associated with low risk and positive outcome in terms of wound healing time and further complications.

Abstract

Introduction:
Hybrid procedures represent staged or simultaneous endovascular and open surgical techniques in the treatment of complex pathologies of the thoracic and abdominal aorta. We are presenting a patient with previous abdominal aortic surgery in whom hybrid vascular procedure for descending aorta and left subclavian artery aneurysm was performed.
Case outline:
A 63-year-old female patient was admitted for computed tomography angiography. Descending aorta aneurysm (7.6 cm) as well as aneurysm of the left subclavian artery (LSA) was noted. Eight years ago she underwent abdominal aortic aneurysm resection and aortoiliac bypass. Standard TEVAR (thoracic endovascular aortic repair) procedure couldn't be done due to small dimensions of previous "Y" graft (12x6 mm), so first we did LSA transposition and after three days hybrid procedure. After "Y" graft exposure, anastomosis between the corps of "Y" graft and tubular graft 10 mm was created and through this conduit thoracic stent-graft was placed followed by complete "Y"graft replacement. After 6 months angiography showed regular postoperative findings.
Conclusion:
Combined surgical and endovascular procedures in thoracic aorta pathology treatment could be useful solutions with favorable outcome.

Abstract

Introduction:
Necrotizing fasciitis is a rare, progressive bacterial infection of superficial fascia followed by secondary subcutaneous tissue necrosis. We pressented a patient with massive fulminant lifethreatening necrotising fasciitis after bellow-knee femoro-popliteal vein bypass grafting successfully treated by antibiotics, surgical debridement and final skin reconstruction using the Tierch method.
Case report:
A 61-year-old patient was admitted to the Vascular Surgery Clinic for below-knee femoro-popliteal bypass grafting. He complained of intermittent claudication in the left leg after 50 m, ankle brachial indexes were 0.45 on the left and 1.0 on the right side. Femoropopliteal below-knee bypass grafting was done using the autologous great saphenous vein. In the very next day, initial signs of skin infection appeared including local inflammation, erythema, swelling and cellulitis restricted to saphenectomy site. These changes had rapidly spread in the following days on the deep tissue of the whole upper and lower leg, including the groin and with clinical signs of life-threatening systemic infection. Immediate surgical debridement was done followed by extensive wound packing and wide spectrum antibiotics administration for the next 33 days when final skin reconstruction by the Tierch method was performed. Interesting point is that this entire time wound swab was sterile.
Conclusion:
In the presented case immediate surgical debridement, wide spectrum antibiotics administration and consistent wound packing gave satisfactory results in this life-threatening systemic infection. Wound swab is not always a reliable indicator of the infection while clinical findings and surgeons' experience are of great significance in rapid reaction to this rare surgical complication.

Abstract

Introduction:
In this report, we aim to present a rare case of isolated internal iliac artery aneurysm with associated left ureteric obstruction and consequent hydronephrosis.
Case report:
A 66-year-old male patient was admitted for occasional pain in the lower back that appeared one month earlier. CT arteriography revealed isolated internal iliac artery (diameter 99 mm) with ureteral obstruction, hydroureter and left kidney hydronephrosis occurrence. Aneurysm was resected, after six months the patient was doing well. Bearing in mind that 77% of the patients with isolated internal iliac artery have symptoms caused by aneurysmal compression on adjacent organs, we wanted to highlight that despite the amazing expansion of endovascular procedures in the last decades, its therapeutic effect in isolated internal iliac artery's treatment is to a great extent limited since compression symptoms cannot be solved.
Conclusion:
Open surgery remains the gold standard for isolated internal iliac artery's treatment considering significant limitations of endovascular procedures due to the inability to eliminate problems caused by compression.
Keywords:
Internal iliac artery aneurysm; compression; hydronephrosis.

Abstract

Objectives:
The aim of the study was to assess quality of life (QoL) in patients with peripheral arterial disease (PAD) after aortobifemoral bypass.
Methods:
QoL assessments were completed by 78 patients, 61 (78.2 %) men and 17 (21.8 %) women. QoL was measured, using Medical Outcome Survey Short Form 36 (SF-36), before surgery and 1 year later.
Results:
QoL significantly improved after revascularization in about two-third of patients with PAD. Improvement was present in all the SF-36 subscales with the exception of the score for mental health which significantly decreased after operation. Mean SF-36 scores, which were for almost all subscales significantly decreased in patients with PAD in comparison with reference populations, after operation reached or exceeded values of the populations with which they were compared.
Conclusions:
In the present study 1 year after revascularization QoL in patients with PAD was significantly improved in comparison with QoL before operation. Long-term follow-up is needed in order to assess duration of this beneficial effect of bypass surgery.

Abstract

Objective:
To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis.
Background:
The optimal treatment strategy for patients with restenosis after CEA remains unknown.
Methods:
A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA.
Results:
In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications.
Conclusions:
In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.

Abstract

Introduction:
Leiomyosarcomas of the inferior vena cava are rare malignant tumors. A limited number of these cases have been described so far. Only few of them have intracardiac propagation and surgery is rarely undertaken for their treatment.
Case outline:
We present a 52-year-old female patient in whom leiomyosarcoma of the inferior vena cava with intracardiac propagation was diagnosed. The patient underwent successful surgical treatment with complete removal of the tumor and direct suture of the inferior vena cava. No additional modalities of therapy were undertaken.
Conclusion:
Surgery, without radiation therapy can be a successful option for the treatment of inferior vena cava leiomyosarcoma with a good short-term result.

Abstract
Atherosclerosis is a life-long illness that begins with risk factors, which in turn contribute to the development of subclinical disease, followed by the establishment of overt cardiovascular disease (CVD). Thrombotic-occlusive complications of atherosclerosis are among the most widespread and costly health problems. Oxidized low-density lipoprotein (OxLDL) plays an important role in atherogenesis by promoting an inflammatory environment and lipid deposition in the arterial wall. As cardiovascular events occur in individuals without common risk factors, there is a need for additional tools that may help in CVD risk assessment and management. The use of biomarkers has improved diagnostic, therapeutic and prognostic outcome in cardiovascular medicine. This review elaborates on the value of circulating OxLDL as a biomarker of CVD. Three enzyme-linked immunosorbent assays (4E6, DLH3 and E06) using murine monoclonal antibodies for determination of OxLDL blood levels have been developed. However, none of these assays are currently approved for routine clinical practice. We identified studies investigating OxLDL in CVD (measured by 4E6, DLH3 or E06 assay) by searching the PubMed database. Circulating OxLDL was found to be associated with all stages of atherosclerosis, from early atherogenesis to hypertension, coronary and peripheral arterial disease, acute coronary syndromes and ischemic cerebral infarction. The results of studies investigating the usefulness of OxLDL for CVD prediction were also summarized. Furthermore, OxLDL was found to be associated with pathologic conditions linked to CVD, including diabetes mellitus, obesity and metabolic syndrome (MetS). In addition, we have addressed the mechanisms by which OxLDL promotes atherogenesis, and the effects of antiatherogenic treatments on circulating OxLDL. Finally, we highlight the evidence suggesting that lipoprotein (a) [Lp(a)] is the preferential carrier of oxidized phospholipids (OxPL) in human plasma. A strong association between OxPL/apoB level (representing the content of OxPL on apolipoprotein B-100 particles, measured by E06 assay) and Lp(a) has been determined.
Keywords:
Atherogenesis; biomarker; cardiovascular risk assessment; lipoprotein (a); oxidized lipoproteins; statins.

Abstract
Recent studies suggest a protective role of diabetes in the development of aneurysm, but the biological mechanisms behind this are still unknown. This type of association is not present in the case of diabetes and atherosclerosis despite similar risk factors for aneurysm and atherosclerosis. We postulate the existence of genes that disrupt the pathways needed for the onset of aneurysm in the presence of diabetes. Motivated by the significance of genetic interactions in understanding disease-disease associations, we tackle this problem by integrating protein-protein interaction and genetic interaction data, i.e., we examine the biological pathways related to the three diseases that contain genes involved in the following genetic interactions: one gene in a genetic interaction is part of a diabetes pathway, the other gene is part of an aneurysm, or an atherosclerosis pathway. We create a protein-protein interaction sub-network that contains disease pathways described above. We then use a "brokerage" measure - a topological measure that identifies proteins in this sub-network whose removal severely affects the interconnectedness of their neighbourhood, enabling such proteins to disrupt the pathway they are in. We identify a set of proteins with high brokerage values and find this set to be enriched in biological functions, including cell-matrix adhesion, which facilitates mechanisms that have already been suggested as possible causes of diabetes-aneurysm association. We further narrow down our set to 16 proteins that are involved in an aneurysm or an atherosclerosis pathway and are encoded by genes participating in genetic interactions with a gene in a diabetes pathway. This set is enriched in kinases and phosphorylation processes, with two pleiotropic kinases that are involved in both aneurysm and atherosclerosis pathways. Kinases can turn on or off proteins, explaining how functional changes of such proteins could result in the disruption of pathways. So if in an aneurysm-related pathway a gene is turned off, the onset of the disease could be prevented. However, mutations of pleiotropic genes could have effects only on one of the traits, which explains why pleiotropic kinases that are involved in both aneurysm and atherosclerosis pathways could disrupt aneurysm pathways explaining the reduced risk of aneurysm in diabetes patients, but not affect the atherosclerosis pathways.

Abstract
Carotid endarterectomy (CEA) is the gold standard for the treatment of symptomatic patients with atherosclerotic carotid disease. However, benefit of the CEA procedure depends on the rate of peri- and postoperative adverse neurological events. Therefore, brain monitoring is important in detecting cerebral ischemia during and after CEA and also allows to prompt appropriate action. Traditional methods of cerebral monitoring are being replaced by novel, easy-to-use techniques that allow continued monitoring of regional cerebral oxygen saturation. In this review, we present the recent literature data related to the mechanism of cerebral oximetry and its practical use during and after CEA.
Keywords:
carotid endarterectomy; cerebral ischemia; cerebral oximetry; near-infrared spectroscopy.

Abstract
The aim of the study was to determine the factors related to venous ulceration. Patients with venous ulceration (278 patients) were compared with 1401 patients in other categories of clinical classification of venous disease (clinical, etiologic, anatomic, and pathophysiological [CEAP]). Demographic, anthropometric, and clinical data were collected. Univariate and multivariate logistic regression analyses were used. According to multivariate analyses, risk factors for venous ulceration were age, male sex, personal history of superficial and deep venous thrombosis, diabetes, high blood pressure, skeletal or joint disease in the legs and emphysema or chronic obstructive pulmonary disease, higher body mass index and physical inactivity, parental history of ankle ulcer as well as reflux in deep and perforator veins, deep obstruction, and combination of reflux and obstruction. It seems reasonable to pay special attention to patients in whom the postulated risk factors for venous ulceration are present.
Keywords:
chronic venous disease; cross-sectional study; risk factors.

Abstract

Objective:
This study was conducted to determine the efficiency and long-term durability of percutaneous transluminal angioplasty and carotid artery stenting in carotid restenosis (CR) treatment after eversion endarterectomy, with emphasis on variables that could influence the outcome.
Methods:
We analyzed 319 patients (220 asymptomatic and 99 symptomatic) who underwent carotid angioplasty from 2002 until 2012 for CR that occurred after eversion endarterectomy. During this period, 7993 eversion endarterectomies were done for significant carotid artery stenosis. Significant CR was detected by ultrasound examination and confirmed by digital subtraction angiography or multidetector computed tomography angiography. After angioplasty (with or without stenting), color duplex ultrasound imaging was done after 1 month, 6 months, 1 year, and annually thereafter. End points encompassed myocardial infarction, stroke, and cardiovascular death (fatal myocardial infarction, fatal cardiac failure, fatal stroke), and also puncture site hematoma and recurrent restenosis. Primary end points were analyzed as early results (≤30 days after the procedure), and secondary end points were long-term results (>30 days). Variables and risk factors influencing the early-term and long-term results were also analyzed. Median follow-up was 49.8 ± 22.8 months (range, 17-121 months).
Results:
All but one procedure ended with a technical success (99.7%). In the early postoperative period, transient ischemic attack occurred in 2.8% of the patients and stroke in 1.6%, followed by one lethal outcome (0.3%). Stent thrombosis occurred in one patient (0.3%) several hours after the angioplasty, followed by urgent surgery and graft interposition. In the long-term follow-up, there were no transient ischemic attacks or strokes, non-neurologic mortality was 3.13%, and the recurrent restenosis rate was 4.4%. The rate of non-neurologic outcomes during the follow-up was significantly higher in asymptomatic patients than in symptomatic patients (4.54% vs 0%; P = .034). The statically highest rate of transient ischemic attack was verified in patients in whom Precise (Cordis Corporation, New Brunswick, NJ) stents was used (12.2%) and a Spider Fx (Covidien, Dublin, Ireland) cerebral protection device (12.5%) was used. Female gender, coronary artery disease, plaque calcifications, and smoking history were associated with an adverse outcome after angioplasty.
Conclusions:
Carotid artery stenting is safe and reliable procedure for CR after eversion endarterectomy treatment, with low rate of postprocedural complications. Type of stent and cerebral embolic protection device may influence the rate of postprocedural neurologic ischemic events.

Abstract
The pathogenesis of acute brain ischemia (ABI) is highly complex and involves multiple mechanisms including free radical generation. Imbalance between the cellular production of free radicals and the ability of cells to defend against them is referred to as oxidative stress. Oxidative stress is one of the mechanisms contributing to neuronal damage, potentially induced through the ABI. Through interactions with a large number of molecules, reactive oxygen species may irreversibly destroy or alter the function of the cellular lipids, proteins, and nucleic acids and initiate cell signaling pathways after cerebral ischemia. Future investigations should focus on the understanding of oxidative stress mechanisms and neuroprotection in order to discover new treatment targets.
Keywords:
acute brain ischemia; free radicals; oxidative stress; stroke.

Abstract
Acute brain ischemia caused by transient ischemic attack initiates a complex sequence of events in the central nervous system and hypothalamic-pituitary-adrenal (HPA) axis which may ultimately culminate in neuronal and cell damage. The brain is highly susceptible to ischemia and in response to stress shows changes in morphology and chemistry that are largely reversible. These responses are known to modify the function of the HPA axis, but their mechanisms are not yet clear. Duration and size of the HPA axis activation are regulated by corticotropin-releasing hormone, vasopressin (AVP), and glucocorticoids, including cortisol. Numerous studies suggest that activation of these hormones following brain ischemia can result in neurohormonal dysfunction that can exacerbate long-term prognosis following stroke. These studies represent evidence that changes in the HPA axis play an important role in brain ischemia.
Keywords:
acute brain ischemia; hypothalamic–pituitary–adrenal axis; stroke; transient ischemic attack.

Abstract

Background:
To present outcomes following an operative approach of extracranial carotid artery aneurysm (ECAAs) based on anatomic types and associated kinks.
Methods:
This study represents retrospective analysis of anatomic type based approach to operative repair of 84 patients with ECAA from 1994 to 2011, 28 (33.3%) with associated kinking. Patients were followed for neurological ischemic events, hematoma, cranial nerve injury, myocardial infarction, neurological, and overall mortality. The results are presented as early, within 30 days after the surgery, and long term during the follow-up.
Results:
In the early postoperative period, there were no strokes or mortalities, cranial nerve injury rate was 2.4% while 1 patient had myocardial infarction (1.2%). During the follow-up, 4 patients (4.8%) had stroke, out of which 2 patients died (2.3%), while overall mortality was 4.6%. The average 5-year survival rate was 96 ± 3%.
Conclusion:
Excellent outcomes can be obtained with surgical repair of ECAA, which should be tailored to the anatomic types and presence of kinks.
Keywords:
Carotid artery aneurysm; Internal carotid artery kinking; Surgery.

Abstract

Objective:
To examine the incidence and distribution of extravascular compression of the extracranial venous pathway (the jugular and/or azygous veins) in multiple sclerosis patients with chronic cerebrospinal venous insufficiency evaluated by mulitislice computer tomographic angiography.
Methods and results:
Study group consisted of 51 consecutive patients with multiple sclerosis in whom chronic cerebrospinal venous insufficiency was diagnosed by color Doppler sonography (CDS). Mulitislice computer tomographic angiography was performed in all patients, and it revealed significant extravascular compression (>70%) of extracranial venous pathway in 26 patients (51%), while in 25 patients (49%) no significant extravascular compression was seen. Extracranial compression due to transverse processus of cervical vertebrae was seen in 23 patients, carotid bulb compression was seen in two patients, and in one case, compression presented as a thoracic outlet syndrome.
Conclusion:
Our data indicate that extravascular compression of the extracranial venous pathway is frequent in multiple sclerosis patients with chronic cerebrospinal venous insufficiency, and that it is mainly due to compression caused by transverse processus of cervical vertebrae. Further studies are needed to evaluate potential clinical implications of this phenomenon.
Keywords:
Extravascular compression; MSCT angiography; multiple sclerosis.

Abstract

Background:
The purpose of this study was to evaluate the initial and long-term results of endovascular treatment (EVT) in patients with symptomatic high-grade extracranial vertebral artery (VA) origin stenosis.
Methods:
From February 2001 to March 2013, 73 consecutive patients (33 men with a mean age of 61.7 ± 8.8 years) underwent EVT for symptomatic high-grade VA stenosis. Preoperative evaluation included Duplex ultrasonography and arteriography. After successful treatment, all patients were followed up at 1, 3, 6, and 12 months after the procedure and every 6 months thereafter.
Results:
Successful EVT of the VA stenosis was achieved in 68 patients (93.2%). All procedures were performed without use of cerebral protection. The early complication rate was 5.5%, which included one periprocedural transient ischemic attack, two hematomas at the puncture site, and one allergic reaction to the contrast agent. No in-hospital deaths occurred. During follow-up (mean, 44.3 ± 31.2 months; range, 2-144 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 87.3%, 87.3%, and 87.3%, respectively. Ultrasound Doppler controls during follow-up detected seven VA restenoses (10.3%). Univariate analysis failed to identify any variable predictive of long-term patency of successfully treated VA stenosis.
Conclusions:
EVT of symptomatic VA origin stenosis is a safe and effective procedure associated with low risk and good long-term results, even without use of cerebral protection devices.

Abstract
We evaluated health-related quality of life (HRQoL) among patients with peripheral arterial disease (PAD) and compared the results with those of the general population. We also evaluated the possible association between some demographic and clinical characteristics of patients with PAD and HRQoL. A cross-sectional study involved 102 consecutive patients with verified PAD referred to the Dedinje Vascular Surgery Clinic in Belgrade. The HRQoL was measured using Medical Outcome Survey Short Form 36 (SF-36). Patients with PAD had significantly lower mean SF-36 scores for physical functioning, role-physical, bodily pain, social functioning, role-emotional, and mental health in comparison with the general population. The HRQoL was significantly more impaired in patients with severe PAD. Patients with PAD had a reduced HRQoL compared with the general population. The impact of PAD on HRQoL was independent of other factors related to both the disease and the HRQoL.
Keywords:
cross-sectional study; peripheral arterial disease; quality of life.

Abstract

Purpose:
To assess the safety of endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).
Materials and methods:
A total of 72 patients with CCSVI and MS (44 with relapsing remitting--RR, 4 with primary progressive, 20 with secondary progressive and 4 with benign MS) underwent percutaneous angioplasty. Outcome measures were colour Doppler ultrasonography parameters, gradient pressure at the vein abnormality level, postoperative complications, re-stenosis, disease severity scored by means of Expanded Disability Status Scale (EDSS) and patients' assumption of disease status. Controls were done after one month on 72 patients, six months on 69 patients and one year on 61 patients, respectively (the average follow-up was 11 months).
Results:
There were no postoperative complications. Colour Doppler ultrasonography showed significant improvement in cross-sectional area parameters (P < 0.05) and significant decrease in confluence velocity values (P < 0.05). Postoperative gradient pressure decreased, in internal jugular vein (IJV) significantly (P < 0.05). Re-stenosis appeared in 5.3% of patients. EDSS score was significantly improved (P < 0.01) and about half of patients reported significant or mild improvement in disease status and none of them worsening of symptoms.
Conclusion:
Endovascular treatment of the IJV and azygous veins in patients with CCSVI and MS is a safe procedure with no post-procedural complications followed by significant improvement of IJV flow haemodynamic parameters and decrease in the EDSS score. Whether CCSVI percutaneous treatment might affect clinical improvement in patients suffering from MS is yet to be seen after completion of major multicentric clinical trials, still it seems like that this procedure is not negligible.
Keywords:
chronic cerebrospinal venous insufficiency; internal jugular vein; multiple sclerosis; percutaneous angioplasty.

Abstract

Introduction:
Acute lower limb ischemia results from thrombosis or embolization of diseased native artery or previously implanted bypass graft. When this occurs, several options are available to restore blood flow: catheter-directed thrombolysis, mechanical thrombectomy or open surgery. Fundamental reasons to apply percutaneous interventions are avoiding open procedures in high risk patients, and avoiding difficult dissection through scar tissue.
Case outline:
A 67-year-old male was admitted at our Institution for critical limb ischemia. After performed angiography the diagnosis of occluded femoropopliteal graft was established. Occlusion was resolved by catheter-directed thrombolysis with plasmin. Culprit lesions were treated by angioplasty.
Conclusion:
Our patient underwent a successful thrombolysis of occluded femoropopliteal graft with locally-delivered human plasmin.

Abstract

Introduction:
Severe extremity ischemia and the presence of the"blue-toe"syndrome are rarely the first complications of the present abdominal aortic aneurysm.We report two interesting cases of this rare entity.
Outline of cases:
A 61-year-old man presented with the rest pain of his toes accompanied with digital ischemia of both feet. Physical examination confirmed regular arterial pulses at lower extremities accompanied with palpable pulsate mass in the abdomen. Vascular ultrasound and multidetector tomography (MDCT) of blood vessels revealed small abdominal aortic aneurysm (37 mm in diameter), filled with the irregular, ulcerated, heterogeneous thrombotic masses. Aneurysm sac resection was performed with an aorto-bi-iliac bypass reconstruction. A week later, it was mandatory to amputate the fifth toe on the left foot because of the advanced gangrenous process.The second case was a 77-year-old woman with 7-day history of severe feet pain. Abdominal examination revealed pulsatile mass paraumbilical to the left. Performed abdominal ultrasonography and MDCT angiography confirmed coexistence of the infrarenal aortic aneurysm, 40.5 mm in diameter, covered by significant mobile mural thrombus and ulcerations. Surgical reconstruction was mandatory and patient underwent aneurysm sac resection and aortobifemoral reconstruction.
Conclusion:
Embolic phenomenon and peripheral embolic occlusion from the mural thrombus within the abdominal aortic aneurysm are relatively rare events, but associated with tissue loss.Thorough diagnostic examinations and prompt management are required regardless of the aneurysm size once these signs occurred.

Abstract

Background:
Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide.
Objective:
To evaluate the management of CVD provided by general practitioners (GPs).
Methods and materials:
The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews.
Results:
Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist.
Conclusions:
Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.

Abstract
We present the case of a patient with extremely rare associated congenital anomalies: thoracic aorta coarctation and left ectopic kidney with pelvic presentation. A 45-year-old male patient was admitted to our institution for multidetector computed tomography (MDCT) angiography. On admission, he complained of intermittent claudication after 10 meters of walking, frequent chest pain, and hypertension crisis. Femoral pulse was absent in the left leg. At 14 years of age, he underwent insertion of a 10-mm Dacron tubular graft at the descending aorta level for isthmic coarctation. MDCT arteriography revealed significant stenosis (>90%) at the proximal anastomosis site of a previous graft in the form of a floating thrombus (pseudocoarctation‒re-coarctation) as well as an ectopic pelvic left kidney with the left renal and accessory renal artery arising from the left common iliac artery. One year ago we attempted percutaneous angioplasty of the aforementioned in-graft stenosis. At the time, the procedure was partly successful and the patient had been doing well, but all of the aforementioned symptoms reappeared and CT angiography showed no signs of improvement. Therefore, ascending-to-descending aortic bypass was done with an 18-mm Dacron tubular graft with preserved postoperative renal function and palpable peripheral pulses. MDCT angiography showed normal postoperative findings and the patient was doing well. In the case presented, MDCT angiography played a significant role in this rare aortic anomaly detection with incidental discovery of a rare developmental kidney complication.

Abstract
We present a rare case of anterior nutcracker syndrome caused by an abdominal aorta aneurysm (AAA). A 61-year-old woman was admitted to our institution for computed tomography angiography. It revealed an AAA 51 mm in diameter that was lifting off of the left renal vein toward the superior mesenteric artery, causing anterior nutcracker syndrome with consequent left renal vein compression and left ovarian vein congestion. Aneurysm resection was performed, followed by left ovarian vein ligation and left adnexectomy to prevent vein conglomerate rupture. This is the first case that describes anterior nutcracker syndrome caused by AAA, which was successfully treated by aneurysm resection.

Abstract
Before the routine use of computed tomography (CT) angiography, decisions for carotid artery treatment were mostly based on ultrasound findings and conventional angiography. Implementation and increasing use of CT angiography provided better visualization of the carotid and vertebrobasilar arteries system leading to an unexpected more frequent detection of unruptured intracranial aneurysms (UIAs). Concomitant presence of intracranial aneurysms in patients with severe carotid stenosis is a potential cause of significant mortality and morbidity. Due to the possible higher risk of aneurysm rupture after carotid procedures and ischemic events after aneurysm repair, the simultaneous presence of both lesions creates several therapeutic dilemmas. We review the prevalence of UIAs in patients with carotid occlusive disease and management difficulties and the current treatment strategies for handling the concomitant presence of these life-threatening diseases.
Keywords:
carotid diseases; prevalence; treatment.; unruptured intracranial aneurysm.

Abstract

Introduction:
Cardiovascular diseases, especially heart disease and stroke are the cause of more than a half of the total number of deaths in Serbia.
Objectives:
The aim of the present study was to determine sex differences of atherosclerotic risk factors in patients with symptomatic carotid disease.
Methods:
The cross-sectional study, involving 657 consecutive patients with verified carotid atherosclerotic disease, was performed in Belgrade, Serbia. Sex differences of anthropometric parameters and atherosclerotic risk factors were analyzed by means of the univariate logistic regression.
Results:
In comparison with men, lower education and physical inactivity were significantly more frequent in women, and the frequency of metabolic syndrome (MetS), lower high-density cholesterol, abdominal obesity, body mass index > or = 30.0 kg/m2, hypercholesterolemia and depression were also significantly higher in women. Smoking and high serum uric acid level were significantly more frequent in men than in women. Women had significantly higher number of MetS components per person, but there were no significant sex differences in the number of other risk factors. Out of all observed risk factors, including MetS components, physical inactivity and hypertension were most frequent in both sexes followed by ever smoking and low education in men and low education and dyslipidemia in women.
Conclusion:
There were significant sex differences in the distribution of some atherosclerotic risk factors, but not in their number per person. Only the number of MetS components was significantly higher in women.

Abstract

Introduction:
In this report, we aim to present a very rare case of internal carotid artery (ICA) aneurysm secondary to kinking and cystic medial degeneration.
Case report:
A 66-year-old female patient was admitted to our institution for multidetector computed tomography (MDCT) angiography of supra-aortic trunks. On admission, she complained of occasional dizziness; 2 months earlier ascending aorta reconstruction was done for aneurysmal disease. Color Doppler ultrasonography and MDCT arteriography revealed significant right ICA kinking associated with large aneurysm, 24.6 × 24.5 mm(2) in diameter. Aneurysm resection was done followed by ICA reconstruction by end-to-end anastomosis. Pathohistological findings of aneurysmal sac revealed cystical medial degeneration with inflammatory infiltrate mostly consisting of lymphocytes and fibrovascular proliferation.
Conclusion:
This is the first case that describes mutual contribution of cystic medial degeneration and ICA kinking in carotid aneurysm disease etiology successfully treated by aneurysm resection.
Keywords:
aneurysm; cystic medial degeneration; internal carotid artery

Abstract

Objectives:
ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization.
Methods:
Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012.
Results:
A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%.
Conclusions:
Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions.
Clinical trial:
ISRCTN21144362.
Keywords:
Carotid artery stenosis; Carotid artery stenting; Carotid endarterectomy; Randomized controlled trial; Stroke.

Abstract

Background:
This was a psychometric validation of the short Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) as quality of life (QOL) instrument for chronic venous disease (CVD) patients.
Methods:
Patients aged >18 years who had CVD in CEAP C stages C0s to C6 were included in the study. Diagnosis was made by general practitioners according to CVD symptoms and visual examination of the lower extremities. QOL was assessed with the self-administrated CIVIQ-14. The reliability, construct, and convergent validity of the CIVIQ-14 was estimated as well as QOL of CVD patients according to CEAP C stages.
Results:
The study comprised 2260 subjects who fully completed the CIVIQ-14. CIVIQ-14 had a high level of reliability, construct, and convergent validity, but the structure of its three dimensions (pain [P], physical [PHY], and psychological [PSY]) was suboptimal. After adjustment for age, body mass index, and number of CVD symptoms, CIVIQ -14 global, P, PHY, and PSY scores showed significant progressive reduction of QOL from CEAP class C0s to C6. These differences were present in both sexes. The progressive impairment of the QOL involved primarily the pain and the physical items. For all CEAP C classes, the P and PHY scores were lower than the PSY scores. Global scores for men and women were: 76.7 and 73.9 for C0s; 75.5 and 70.6 for C1; 67.8 and 64.5 for C2; 68.3 and 61.6 for C3; 60.7 and 54.6 for C4; 49.5 and 50.2 for C5; and 41.3 and 46.7 for C6.
Conclusions:
CVD in the lower extremities has a substantial effect on both physical and psychologic aspects of QOL, the physical aspects of QOL (P and PHY items) being more important. CIVIQ-14 is valuable in assessing QOL in CVD patients. Further investigations are necessary to confirm the stability of its two dimensions.

Abstract
The structure of protein-protein interaction (PPI) networks has already been successfully used as a source of new biological information. Even though cardiovascular diseases (CVDs) are a major global cause of death, many CVD genes still await discovery. We explore ways to utilize the structure of the human PPI network to find important genes for CVDs that should be targeted by drugs. The hope is to use the properties of such important genes to predict new ones, which would in turn improve a choice of therapy. We propose a methodology that examines the PPI network wiring around genes involved in CVDs. We use the methodology to identify a subset of CVD-related genes that are statistically significantly enriched in drug targets and "driver genes." We seek such genes, since driver genes have been proposed to drive onset and progression of a disease. Our identified subset of CVD genes has a large overlap with the Core Diseasome, which has been postulated to be the key to disease formation and hence should be the primary object of therapeutic intervention. This indicates that our methodology identifies "key" genes responsible for CVDs. Thus, we use it to predict new CVD genes and we validate over 70% of our predictions in the literature. Finally, we show that our predicted genes are functionally similar to currently known CVD drug targets, which confirms a potential utility of our methodology towards improving therapy for CVDs.

Abstract

Introduction:
Obesity, particularly visceral obesity, is considered one of major risk factors for cardiovascular events.
Objectives:
The aim of the present study was to investigate relationship between abdominal obesity and other cardiovascular risk factors.
Methods:
The cross-sectional study involved 657 consecutive patients with verified carotid atherosclerosis. Carotid atherosclerosis was estimated by high resolution B-mode ultrasonography. Abdominal obesity was defined as waist circumference > 102 cm in men and > 88 cm in women.
Results:
Abdominal obesity was present in 324 (49.3%) participants. Multivariate analyses showed that abdominal obesity was significantly positively associated with female sex, increased Baecke's Work Index of physical activity at work, years of school completed < 12, metabolic syndrome, increased triglycerides, hyperglycemia and high serum uric acid. Smoking, alcohol consumption, physical inactivity, hypertension, increased total cholesterol, increased HDL and LDL cholesterols, increased high sensitive C-reactive protein, increased fibrinogen, anti-lipid therapy and anti-diabetic therapy were not significantly related to abdominal obesity.
Conclusion:
Abdominal obesity among patients with symptomatic carotid disease is significantly related to other cardiovascular risk factors, especially metabolic syndrome, metabolic syndrome components and high level of serum uric acid.

Abstract

Introduction:
In this report, we aim to present a very rare case of internal carotid artery (ICA) aneurysm secondary to kinking and cystic medial degeneration.
Case report:
A 66-year-old female patient was admitted to our institution for multidetector computed tomography (MDCT) angiography of supra-aortic trunks. On admission, she complained of occasional dizziness; 2 months earlier ascending aorta reconstruction was done for aneurysmal disease. Color Doppler ultrasonography and MDCT arteriography revealed significant right ICA kinking associated with large aneurysm, 24.6 × 24.5 mm(2) in diameter. Aneurysm resection was done followed by ICA reconstruction by end-to-end anastomosis. Pathohistological findings of aneurysmal sac revealed cystical medial degeneration with inflammatory infiltrate mostly consisting of lymphocytes and fibrovascular proliferation.
Conclusion:
This is the first case that describes mutual contribution of cystic medial degeneration and ICA kinking in carotid aneurysm disease etiology successfully treated by aneurysm resection.
Keywords:
aneurysm; cystic medial degeneration; internal carotid artery.

Abstract
We investigated whether patients with peripheral arterial disease (PAD) with various serum levels of high-sensitivity C-reactive protein (hsCRP) differ in the frequency of atherosclerotic risk factors. Among 388 patients, hsCRP levels were (1) low, <1 mg/L, in 41 (10.6%) participants; (2) medium, from 1 to 3 mg/L, in 152 (39.2%) participants, and (3) high, >3 mg/L, in 195 (50.2%) individuals. According to multivariate logistic regression analysis, in comparison with patients with hsCRP level ≤3.0 mg/L, those with higher hsCRP levels had more frequently a severe form of PAD (gangrene, P ranged from .045 to <.001; ankle-brachial index ≤.40, P = .059) and had more frequently some of atherosclerotic risk factors (metabolic syndrome, P = .007; hypertension, P = .013; abdominal obesity, P = .007; high levels of uric acid, P = .022; high level of fibrinogen, P < .001; and depression, P = .015).

Abstract

Background/aim:
Endovascular treatment of thoracic aortic diseases is an adequate alternative to open surgery. This method was firstly performed in Serbia in 2004, while routine usage started in 2007. Aim of this study was to analyse initial experience in endovacular treatment of thoracic aortic diseses of three main vascular hospitals in Belgrade - Clinic for Vascular and Endovascular Surgery of the Clinical Center of Serbia, Clinic for Vascular Surgery of the Military Medical Academy, and Clinic for Vascular Surgery of the Institute for Cardiovascular Diseases "Dedinje".
Methods:
Between March 2004. and November 2010. 41 patients were treated in these three hospitals due to different diseases of the thoracic aorta. A total of 21 patients had degenerative atherosclerotic aneurysm, 6 patients had penetrating aortic ulcer, 6 had posttraumatic aneurysm, 4 patients had ruptured thoracic aortic aneurysm, 1 had false anastomotic aneurysm after open repair, and 3 patients had dissected thoracic aneurysm of the thoracoabdominal aorta. In 15 cases the endovascular procedure was performed as a part of the hybrid procedure, after carotid-subclavian bypass in 4 patients and subclavian artery transposition in 1 patient due to the short aneurysmatic neck; in 2 patients iliac conduit was used due to hypoplastic or stenotic iliac artery; in 5 patients previous reconstruction of abdominal aorta was performed; in 1 patient complete debranching of the aortic arch, and in 2 patients visceral abdominal debranching were performed.
Results:
The intrahospital mortality rate (30 days) was 7.26% (3 patients with ruptured thoracic aneurysms died). Endoleak type II in the first control exam was revealed in 3 patients (7.26%). The patients were followed up in a period of 1-72 months, on average 29 months. The most devastating complication during a followup period was aortoesofageal fistula in 1 patient a year after the treatment of posttraumatic aneurysm. Conversion was performed with explantation of stent-graft and open aortic in situ recontruction, followed by esophagectomy and the creation of cervical and gastrical stoma.
Conclusion:
Having in mind initial results of the 3 main vascular clinics in Belgrade, Serbia, economical situation in our country, as well as the published international results, endovascular treatment of thoracic aortic diseases is indicated in hemodinamicaly unstable patients with acute traumatic aneurysm, or in stabile patients older than 65, as well as in case of chronic diseases of the thoracic aorta in patients with significant comorbid conditions or in patients older than 65 years. Endovascular procedures on the thoracic aorta could be performed, hower, only in high-volume centers with experience in routine open surgery of thoracic aorta.

Abstract

Objectives:
To evaluate health-related quality of life (HRQoL) in patients with symptomatic carotid disease (amaurosis fugax, transient ischaemic attack, stroke); to compare it with that of the general population; to explore whether HRQoL depends on the severity of the disease and to investigate the possible association between some demographic and clinical characteristics of patients and HRQoL.
Methods:
This cross-sectional study involved 175 patients with symptomatic carotid atherosclerotic disease who were referred for endarterectomy between January 2011 and December 2011. HRQoL was measured using Medical Outcome Survey Short Form 36 (SF-36).
Results:
In comparison to both referent populations, patients with carotid disease had significantly lower mean SF-36 scores for role-physical (41.6 vs. 61.5 and 67.8), social functioning (65.4 vs. 73.8 and 80.0), role-emotional (48.2 vs. 68.6 and 80.5) and mental health (51.5 vs. 61.9 and 66.0). The SF-36 scores were significantly lower in female patients with carotid disease than in men (for role-physical 32.3 vs. 46.5; for bodily pain 57.0 vs. 73.0; for general health 55.6 vs. 61.5; for vitality 55.4 vs. 60.1; for social functioning 57.1 vs. 69.8 and for role-emotional 37.2 vs. 54.1). Significantly lower SF-36 scores were also found in patient with comorbidity (for physical functioning 68.1 vs. 77.7; for role-physical 35.1 vs. 52.3; for bodily pain 62.6 vs. 75.4; for general health 56.8 vs. 63.8; for social functioning 61.9 vs. 71.0, for role-emotional 41.6 vs. 59.1and for mental health 52.5 vs 49.8). In a multivariable analysis, education, occupation, body mass index, metabolic syndrome and severity of the disease had a weak influence on patients' HRQoL, while age, marital status, smoking, alcohol consumption, physical activity and the degree of carotid stenosis had no effect on patients' HRQoL. The SF-36 scores did not substantially change after adjustment for confounding variables.
Conclusions:
Patients with symptomatic carotid disease had poorer HRQoL, especially its mental components, than the general population. The severity of the disease was significantly associated only with the SF-36 role-physical subscale. HRQoL in patients with symptomatic carotid disease was poorer in women than in men, and was not affected by age and other demographic and clinical characteristics of patients.

Abstract
Thoracic endovascular aortic repair (TEVAR) is a safe and reliable technique utilized in the treatment for aortic aneurysms. However, in up to 40% of patients, devices are typically placed over the left subclavian artery (LSA) origin. In this report, we present a case of a successful TEVAR procedure following the transposition of the LSA with protective carotico-axillary/carotid bypass in a patient with a patent left internal thoracic artery (LITA)-left anterior descending (LAD) coronary artery bypass graft and right internal carotid artery (ICA) occlusion.

Abstract

Introduction:
Severe extremity ischemia and the presence of the"blue-toe"syndrome are rarely the first complications of the present abdominal aortic aneurysm.We report two interesting cases of this rare entity.
Outline of cases:
A 61-year-old man presented with the rest pain of his toes accompanied with digital ischemia of both feet. Physical examination confirmed regular arterial pulses at lower extremities accompanied with palpable pulsate mass in the abdomen. Vascular ultrasound and multidetector tomography (MDCT) of blood vessels revealed small abdominal aortic aneurysm (37 mm in diameter), filled with the irregular, ulcerated, heterogeneous thrombotic masses. Aneurysm sac resection was performed with an aorto-bi-iliac bypass reconstruction. A week later, it was mandatory to amputate the fifth toe on the left foot because of the advanced gangrenous process.The second case was a 77-year-old woman with 7-day history of severe feet pain. Abdominal examination revealed pulsatile mass paraumbilical to the left. Performed abdominal ultrasonography and MDCT angiography confirmed coexistence of the infrarenal aortic aneurysm, 40.5 mm in diameter, covered by significant mobile mural thrombus and ulcerations. Surgical reconstruction was mandatory and patient underwent aneurysm sac resection and aortobifemoral reconstruction.
Conclusion:
Embolic phenomenon and peripheral embolic occlusion from the mural thrombus within the abdominal aortic aneurysm are relatively rare events, but associated with tissue loss.Thorough diagnostic examinations and prompt management are required regardless of the aneurysm size once these signs occurred.

Abstract

Background:
Abdominal aortic aneurysm is considered an atherosclerosis-related disease, but the mechanisms underlying abdominal aortic aneurysm remain poorly defined. Despite the large number of cytokines identified in an aneurysm sample, the relative importance of particular cytokines in aneurysm formation is unknown. We have studied the production of interleukin-6 and interleukin-10 cytokines in plasma and cultures of abdominal aortic aneurysm explant samples obtained from patients subjected to elective surgery and their correlation with cellular composition.
Materials and methods:
Inflammatory cells from the abdominal aortic aneurysm samples were phenotypically characterized using specific monoclonal antibodies (anti-CD3, -CD4, -CD8, -CD19, -CD38, -CD68, -HLA-DR) by means of immunocytochemistry staining. Production of interleukin-6 and interleukin-10 in culture supernatants of abdominal aortic aneurysm explant samples expanded in vitro for 24 h was measured by enzyme-linked immunosorbent assay.
Results:
We showed that the levels of interleukin-6 and interleukin-10 in supernatants of abdominal aortic aneurysm sample cultures were higher by 73 and 86 times compared to their levels in plasma, respectively. In individual abdominal aortic aneurysm explant cultures, a negative correlation between interleukin-6 and interleukin-10 production was observed. Such inverse correlation was not detected in plasma. Based on these results, we divided abdominal aortic aneurysm into two cytokine-producing groups and showed that the interleukin-6(hi)/interleukin-10(lo) group contained higher percentages of granulocytes, HLA-DR(+), and CD68(+) cells but lower percentages of lymphocytes and plasma cells compared to the interleukin-6(lo)/interleukin-10(hi) group. Exogenously added interleukin-10 suppresses the production of interleukin-6 by abdominal aortic aneurysm explants.
Conclusion:
These results suggest that interleukin-6 and interleukin-10 may have a different role in the pathogenesis of abdominal aortic aneurysm.

Abstract

Background:
To study the initial and long-term results of endovascular treatment in patients aged <50 years with trans-Atlantic inter-society consensus-II type B unilateral iliac lesions and chronic limb ischemia.
Methods:
From January 2000 to February 2010, 60 consecutive endovascular interventions were performed on 23 women and 37 men aged ≤50 years. After successful treatment, all patients were followed up at 1, 3, 6, and 12 months after the procedure and every 6 months thereafter.
Results:
Successful percutaneous revascularization of the iliac artery was achieved in 56 patients (93.3%). The early vascular-related complication rate was 6.7%. The primary patency rates at 1, 3, and 5 years were 88%, 59%, and 49%, respectively. Cox univariate analysis revealed that an age range of 45 to 50 years (hazard ratio [HR]: 0.290; 95% confidence interval [CI]: 0.152-0.553; P = 0.0001), lower preprocedural ankle-brachial index (HR: 2.438; 95% CI: 1.04-5.715; P = 0.047), lesion length >5 cm (HR: 0.838; 95% CI: 0.746-0.943; P = 0.003), and diabetes (HR: 2.005; 95% CI: 1.010-3.980; P = 0.047) had significant influence on decreasing primary patency.
Conclusions:
Endovascular treatment of TASC-II type B iliac lesions in patients aged <50 years is a safe procedure with low procedural risk. Primary patency rates at 1, 3, and 5 years were 88%, 59%, and 49%, respectively.

Abstract

Introduction:
The natural course of abdominal aneurysms is progressive expansion, rupture, embolisation, thrombosis and compression of the visceral organs. The majority of papers report that inflammatory aortic and iliac aneurysms are associated with perianeurysmal and retroperitoneal fibrosis that ultimately results in the structural compromise of the urinary tract. Ureteral obstruction occurs in 20% to 71% of cases and approximately one half of these patients will present with obstructive uropathy. Most patients with inflammatory aneurysm are symptomatic, with elevated serum inflammatory markers, and characteristic multislice CT findings including a thickened aortic wall and a mass of periaortic inflammatory tissue.
Case outline:
A 70-year-old man was admitted at the Vascular Surgery Clinic "Dedinje", Belgrade, because of ultrasonically verified asymptomatic aortoiliac aneurysm. Multisclice CT findings showed left urethral dilatation and hydronephrosis secondary to extrinsic ureteral obstruction due to aortoiliac aneurysm. CT findings, laboratory tests and finally, histopathologic examination showed atherosclerotic aneurysm without inflammation and retroperitoneal fibrosis. The patient was successfully treated with surgical resection of the aneurysm and aortobiliac reconstruction with "Y" prosthesis.
Conclusion:
We present a rare case of ureteral obstruction secondary to atherosclerotic aneurysm which, to our knowledge, has not been previously described in the domestic literature. A successful operative repair was performed. Postoperative course was uneventful and the patient was discharged on the seventh day after the surgery with normal vascular status and renal function.

Abstract

Introduction:
Telangiectasias represent an esthetic problem. Sclerotherapy, laser and radiowave coagulation are established methods of treatment. The aim of the treatment is a cosmetic improvement in the leg appearance.
Aim:
To define which method provides best results in lower extremity telangiectasias treatment and also to determine which method is most comfortable for the patient.
Materials and methods:
Thirty female volunteers, ages 30-66 years (mean 49 years), were included in the research, with telangiectasias in the thigh measuring 0,1 to 2 mm in diameter, and skin phototype according to Fitzpatrick I-IV. Three rectangular areas 3 × 5 cm, were marked on the thigh, with nearly same pattern and appearance of telangiectasias in each field. In each rectangle, only one session of sclerotherapy, laser, and radiowave coagulation were performed, respectively. It is completely documented with the digital camera prior to the therapy and 3 months after the treatment. At the end of the study, three blinded experts graded leg telangiectasias for clearance using obtained digital images. Patients were also required to describe the sense of pain during each procedure as minimal, mild, or strong. Chi-square test was used for statistical data processing.
Results:
After 3 months period, there was a high statistical significant difference among methods of treatment (χ(2) = 45.492, p < 0.01). The most efficient was sclerotherapy. Also there was a high statistical significant difference (χ(2) test = 30.549, p < 0.01) among levels of pain experienced by patients in the study. Minimal sense of pain was associated with sclerotherapy.
Conclusion:
Our study revealed that the most efficient method in terms of telangiectasias clearance is sclerotherapy. It also showed that most comfortable method for the patient is sclerotherapy, since it produces minimal pain during the procedure. It can be concluded that sclerotherapy is a successful method in treating lower extremity telangiectasias leaving both, patient and physician content.

Abstract

Background:
The aim of this article is to review our experience in surgical treatment of carotid atherosclerosis using eversion carotid endarterectomy (eCEA) in 9,897 patients performed in the last 20 years, with particular attention to diagnostic approach, surgical technique, medical therapy, and final outcome.
Methods:
From January 1991 to December 2010, 9,897 primary eCEAs were performed for high-grade carotid stenosis. Patients treated for restenosis after previous carotid surgery were excluded from the analysis. Follow-up included routine clinical evaluation and noninvasive surveillance, with duplex scanning, 1 and 6 months after surgery, and annually afterward.
Results:
The majority of the patients were symptomatic (stroke, 42.8%; transient ischemic attack, 55.1% [focal cerebral and retinal ischemia]), whereas only 2.1% of the patients were asymptomatic. For the final diagnosis, duplex scanning was performed in 83.4% of patients and angiography in only 16.3% (P < 0.001). Average carotid artery clamping time was 11.9 ± 3.2 minutes, and the majority of the patients were operated under general anesthesia (99.4%). Intraoperative shunting and local anesthesia were rarely performed; 0.6% of the patients were operated under local anesthesia, and in 0.5% of the patients, intraluminal shunt was used. Neurological and total morbidity showed a steady decline over time, with rate of neurological morbidity of 1.1% and total morbidity of 3.9% at the end of 2010. Neurological mortality and total mortality also showed a steady decline over time, with rate of neurological mortality of 0.3% and total mortality of 0.8% at the end of 2010. There was a low rate of both, nonsignificant restenosis (<50%), which was verified in 2.1% of the patients, and significant restenosis (>50%), which was observed in 4.3% of the patients.
Conclusion:
Our data show that eCEA is a reliable surgical technique for the treatment of atherosclerotic carotid disease, with low morbidity and mortality. The specificity of our experience is the significant number of patients with preoperative stroke, but despite this fact, results are comparable with previously published series. It also highlights the importance of comprehensive surgical training in reducing complications.

Abstract

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.

Abstract

Background:
We and others have shown previously that left ventricular (LV) contractile reserve assessed quantitatively by high-dose dobutamine stress-echocardiography (DSE) has prognostic implications in patients with dilated cardiomyopathy.
Purpose:
To assess the feasibility of semi-quantitative assessment of LV contractile reserve by differently skilled operators in patients with dilated cardiomyopathy.
Methods:
High-dose DSE was performed in 63 consecutive patients, mean age 50 ± 10 years and ejection fraction (EF) 19 ± 8%. LVEF was calculated 1) using Simpson's biplane formula, and 2) semi-quantitatively (5% increments) by novice and experienced echocardiographers, and by a DSE expert. Patients were considered to have preserved LV contractile reserve if LVEF dobutamine-induced change was ≥5%.
Results:
Twenty-seven (45.8%) patients died during the 5-year follow-up. The feasibility of the assessment was 89%, 94%, and 98% for novice and experienced readers and DSE expert, respectively. Kaplan-Meier analysis showed that LV contractile reserve assessed semi-quantitatively by DSE expert and experienced reader achieved the best prognostic separation (log rank 19.63 and 18.99, respectively, p < 0.001 for both), followed by quantitative assessment (log rank 9.76, p = 0.0018) and assessment by novice reader (log rank 8.76, p = 0.012). Areas under the curves were similar for quantitative and semi-quantitative assessment of LV contractile reserve.
Conclusions:
Our data indicate that semi-quantitative assessment of LV contractile reserve is feasible by differently skilled operators.

Abstract

Background:
The increased number of carotid endarterectomies performed worldwide in recent years is associated with a greater need for carotid restenosis evaluation. Carotid restenosis rate ranges from 0.6% to 3.6% in symptomatic patients and from 8.8% to 19% in asymptomatic patients. Carotid angioplasty and stenting is a preferable therapeutic choice for carotid restenosis treatment, but whenever it is not technically feasible (tortuosities of supra-aortic branches, calcifications, pathological elongation, or very extensive lesions), redo surgical treatment is indicated. The aim of our study was to examine outcome of redo surgical treatment in patients with symptomatic and asymptomatic carotid restenosis, in whom carotid angioplasty could not be done, and its impact on early and late morbidity and mortality.
Methods:
The study included 52 patients who were surgically treated for significant carotid restenosis from January 2000 to December 2008 in two high-volume vascular surgery university clinics. Surgical techniques included redo eversion endarterectomy, standard endarterectomy with Dacron patch closure, and Dacron tubular graft interposition. The patients were followed for significant events (transient ischemic attack, stroke, cranial nerve injuries, surgical site hematoma, the occurrence of carotid re-restenosis, or occlusion), and mortality after 1 month, 6 months, 1 year, and annually afterward.
Results:
In the early postoperative period (within 30 days), there were no lethal outcomes. Transient ischemic attack was diagnosed in four patients (7.6%), minor stroke in two patients (3.8%), and cranial nerve injury in four patients (7.6%). After 4 years, three patients died (5.7%), two due to a fatal myocardial infarction (3.8%) and one after a major stroke (1.9%); four patients (7.6%) had ipsilateral stroke; and graft occlusion was verified in one patient (1.9%).
Conclusion:
Carotid angioplasty might be a primary option for carotid restenosis treatment, but whenever it cannot be performed, redo surgical treatment is indicated, owing to its acceptable rate of early and late postoperative complications.

Abstract
Carotid endarterectomy has been established as the preferred treatment for symptomatic and asymptomatic high-grade carotid stenosis. Internal carotid artery restenosis is defined as a specific entity with a great clinical significance in carotid surgery due to accompanied increased future cerebral ischemic events risk. Carotid restenosis is the result of neointimal hyperplasia in the early postoperative period (within 36 months) or recurrent atherosclerotic lesions at a later date. While the restenotic lesions caused by neointimal hyperplasia are determined by ultrasound as smooth lesions, atherosclerotic carotid stenosis has almost the same ultrasound and angiographic characteristics as primary atherosclerotic lesions. Some authors believe that patients with internal carotid artery restenosis have insignificant risk of stroke or progression to total occlusion, and suggest conservative treatment only. On the other hand, many surgeons have more aggressive attitude towards the treatment of asymptomatic carotid stenosis and indicate surgical treatment in asymptomatic patients with carotid restenosis above 80%. The aim of our paper was to present a review of literature available data concerning etiology, pathophysiology, clinical significance and treatment of carotid restenosis following endarterectomy. Numerous studies have reported satisfactory results of redo endarterectomy and carotid angioplasty as treatment options of carotid restenosis. Carotid angioplasty for primary atherosclerotic lesions treatment is accompanied by a high carotid restenosis rate and therefore its role in primary carotid symptomatic and asymptomatic stenosis treatment is still the issue of numerous debates and the subject of extensive ongoing clinical studies worldwide.

Abstract
Atherosclerosis is known as an inflammatory disease in which a recruitment of leukocytes to the endothelium wall represents a preliminary step of the initiation and the development of disease. The P-selectin glycoprotein ligand (PSGL-1) seems to be the major molecule mediating leukocyte-endothelium interactions and leukocyte rolling on stimulated endothelium. There are limited number of studies reporting on association of Met62Ile SNP in PSGL-1 gene and the risk for atherosclerosis. The aim of this study was to analyze possible association of this polymorphism with an advanced carotid atherosclerosis and biochemical markers of inflammation and haemostasis. The 275 patients consecutively admitted for carotid endarterectomy with stenosis >70% and 256 controls of the same ethnic origin were included in the study. The Met62Ile genotypes were determined by PCR RFLP. The Ile/Ile homozygotes had significantly higher CRP compared to the other genotypes in patients. Female patients had Ile allele dose-dependent association with the carotid plaque presence (Met/Met vs. Met/Ile vs. Ile/Ile; OR 1, OR 2.02, CI 1.0-4.08, OR 4.08, CI 1.0-16.81, respectively, p = 0.04). Our results suggest the impact of PSGL-1 Met62Ile polymorphism on inflammation in advanced atherosclerosis. We observed the sex-differential association of Met62Ile with advanced carotid atherosclerosis. Studies in larger and different populations should validate and further examine the suggested role of genetic variations in PSGL-1 with atherosclerosis and thrombosis.

Abstract

Introduction:
Congenital interruption of the inferior vena cava is a rare entity. It can be associated with other organ and system malformations, especially the cardiovascular system. Usually, patients are asymptomatic and the anomaly is therefore diagnosed incidentally. In some cases it can be of clinical importance.
Case outline:
A 22-year-old female was diagnosed during evaluation of cardiac symptoms. Clinical examination showed normal findings. CT angiography and cavography were used to establish the diagnosis of inferior vena cava interruption. Since there was no need for surgical intervention the patient was discharged in good condition. During a five year follow-up no significant health problems were noted with patient leading normal life.
Conclusion:
Diagnostic tools used to establish the diagnosis of inferior vena cava interruption are ultrasonography, as well as CT and MR angiography and phlebography. Mediastinal masses found on chest roentgenogram must raise suspicion of inferior vena cava interruption. Although the anomaly is rare, physicians should be aware of the infrahepatic interruption of the IVC, especially because it can present at any age.

Abstract

Background/aim:
Doppler ultrasonography is now a reliable diagnostic tool for noninvasive examination of the morphology and hemodynamic parameters of extracranial segments of blood vessels that participate in the brain vascularisation. This diagnostic modality in recent years become the only diagnostic tool prior to surgery. The aim of the study was to determine hemodynamic status in symptomatic and asymtomatic patients with severe carotid stenosis prior to and after carotid endarterectomy (CEA).
Methods:
A total of 124 symptomatic and 94 asymptomatic patients who had underwent CEA at the Clinic for Cardiovasculare Disease "Dedinje" in Belgrade were included in this study. Doppler ultrasonography examinations were performed one day before CEA and seven days after it. The peak systolic velocity (PSV), end-dyastolic velocity (EDV), time-averaged maximum blood flow velocity (MV), resistance index (RI) and the blood flow volume (BFV) of the ipsilateral and the contralateral internal carotid artery (ICA) were measured.
Results:
Diabetes was the only risk factor found significantly more frequent in symptomatic patients. There were significantly more occluded contralateral ICAs in the group of symptomatic patients. There was a significant increase in PSV, EDV, MV and BFV of the ipsilateral ICA after CEA and a significant decrease in PSV, EDV, MV and BFV of the contralateral ICA after CEA. RI is the only hemodynamic parameter without significant changes after CEA in both groups of patients. Comparing the values of hemodynamic parameters after CEA between the group of symptomatic and the group of asymptomatic patients no significant differences were found.
Conclusion:
The occlusion of the contralateral ICA is an important factor differentiating between symptomatic and asymptomatic patients with severe carotid stenosis. Successful surgery provides good recovery of cerebral hemodynamics in both symtomatic and asymptomatic patients.

Abstract
We aim to present a very rare case of chronic cerebrospinal venous insufficiency due to both brachiocephalic vein obstruction by aberrant right subclavian artery and internal jugular vein distal compression by first cervical vertebra transverse process, demonstrated by multislice computerized tomography in a patient with multiple sclerosis.

Abstract

Purpose:
To study the initial and long-term results of angioplasty and primary stenting for the treatment of chronic total occlusion (CTO) of the subclavian artery (SA).
Materials and methods:
From January 1999 to February 2010, 56 patients (25 men with a mean age of 58 ± 8 years) underwent endovascular treatment for CTO of the SA. Duplex scans and arteriograms confirmed occlusion in all cases. Indications for recanalization were subclavian steal syndrome in 33 patients (58.1%), arm claudication in 13 patients (23.2%), and coronary ischemia in 7 patients (12.5%) who had a history of previous coronary artery bypass grafting that included left internal thoracic artery graft. Three patients (5.4%) were treated before the scheduled coronary artery bypass surgery, which included left internal thoracic artery graft. After successful recanalization, all arteries were stented, and all of the patients were followed-up at 1, 3, 6, and 12 months after surgery and annually thereafter.
Results:
Successful recanalization of the SA was achieved in 46 patients (82.1%), and the complication rate was 7.1%. During follow-up (mean 40 ± 26 months; range 2 to 125), the primary patency rates after 1 and 3 years were 97.9% and 82.7%, respectively. At the end of follow-up, 76% of the arteries showed no evidence of restenosis. Univariate analysis failed to identify any variable predictive of long-term patency of successfully recanalized SA.
Conclusion:
Percutaneous transluminal angioplasty with stenting of the complete total occlusion of the SA is a safe and effective procedure associated with low risks and good long-term results.

Abstract

Introduction:
The ACE I/D polymorphism was mostly investigated in association with intima-media thickness, rarely with severe atherosclerotic phenotype.
Materials and methods:
We investigated the association of I/D polymorphism with severe carotid atherosclerosis (CA) (stenosis > 70%) in asymptomatic and symptomatic patients undergoing carotid endarterectomy. The 504 patients subjected to endarterectomy and 492 healthy controls from a population in Serbia were investigated as a case-control study.
Results:
The univariate logistic regression analysis revealed ACE DD as a significant risk factor for severe CA (odds ratio [OR] = 1.3, 95% confidence interval [CI] 1.0-1.7, p = 0.04). After adjustment for the common risk factors (age, hypertension, smoking, and HDL) ACE was no longer significant. However, we found a significant independent influence of DD genotype on plaque presence in a normotensive subgroup of patients (OR 1.8, CI 1.2-3.0, p = 0.01, corrected for multiple testing). In symptomatic patients D allele carriers were significantly more frequent compared with asymptomatic patients (OR 1.6 CI 1.0-2.6, p = 0.05).
Conclusions:
Our data suggests that ACE I/D is not an independent risk factor for severe CA. On the other hand, a significant independent genetic influence of ACE I/D appeared in normotensive and symptomatic patients with severe CA. This should be considered in further research toward resolving the complex genetic background of severe CA phenotype.

Abstract

Background:
Metabolic syndrome (MetS) has been related to type 2 diabetes and cardiovascular diseases. Different criteria for diagnosis of MetS have been recommended, but there is no agreement about which criteria are best to use. The aim of the present study was to investigate agreement between the National Heart, Lung, and Blood Institute, American Heart Association (NHLBI/AHA) and the International Diabetes Federation (IDF) definitions of MetS in patients with symptomatic carotid disease and to compare the frequency of cardiovascular risk factor in patients with MetS diagnosed by these two sets of criteria.
Methods:
The study was a cross-sectional one involving 644 consecutive patients with verified carotid disease who referred to the Vascular Surgery Clinic Dedinje in Belgrade during the period April 2006 - November 2007. Anthropometric parameters blood pressure, fasting plasma glucose and lipoproteins were measured using standard procedures.
Results:
MetS was present in 67.9% of participants, according to IDF criteria, and in 64.9% of participants, according to the NHLBI/AHA criteria. A total of 119 patients were categorized differently by the two definitions. Out of all participants 10.7% had MetS by IDF criteria only and 7.8% of patients had MetS by NHLBI/AHA criteria only. The overall agreement of IDF and NHLBI/AHA criteria was 81.5% (Kappa 0.59, p < 0.001). In comparison with patients who met only IDF criteria, patients who met only NHLBI/AHA criteria had significantly more frequently cardiovascular risk factors with the exception of obesity which was significantly more frequent in patients with MetS diagnosed by IDF criteria.
Conclusion:
The MetS prevalence in patients with symptomatic carotid disease was high regardless of criteria used for its diagnosis. Since some patients with known cardiovascular risk factors were lost by the use of IDF criteria it seems that NHLBI/AHA definition is more suitable for diagnosis of MetS. Large follow-up studies are needed to test prognostic value of these definitions.

Abstract

Objectives:
There is still a dilemma about best treatment option for patients with severe carotid and coronary artery disease. Reviving of beating heart revascularization technique and using of carotid stenting makes things even more difficult. Discussion about this subject is getting more and more profound. This is analysis of our initial experience with simultaneous carotid and off pump coronary procedures.
Materials and methods:
This is retrospective analysis of 18 patients operated using this technique in a period from 2001-2003 yrs. Follow up was done by telephone interview. For survivors specially designed questionaire was fulfilled.
Results:
We operated total number of 18 patients with average age 60,6+/-9.32 years. Carotid recontruction was performed by eversion technique in all patients. Average number of coronary grafts was 2,67+/-0.88. During postoperative period 1 patient (5.55%) had verified perioperative infarction and 1 patient (5.55%) suffered from stroke. Average number of days in hospital was 9.95+/-4.74. During follow up period of 21 months two more patients died from cardiovascular causes. There was no need for repeat coronary angiogram or reintervention on carotid or coronary arteries.
Conclusion:
Simultaneous carotid and coronary operation performed on beating heart is safe and efficent method of treatment for patients with severe concomitant carotid and coronary artery disease.

Abstract
Like other invasive procedures, percutaneous coronary interventions are associated with complications. Most common access site for these procedures is common femoral artery. Complications such as groin and retroperitoneal hematoma can be encountered as well as pseudoaneurysms, arteriovenous fistulas, acute arterial occlusion, and infection. When infected pseudoaneurysm occurs, surgical treatment can be extremely difficult. We present a case of the patient in whom infected pseudoaneurysm of common femoral artery developed after percutaneous coronary intervention and was successfully treated by surgical excision and autoarterial graft insertion.

Abstract

Introduction:
The natural course of abdominal aneurysms is progressive expansion, rupture, embolisation, thrombosis and compression of the visceral organs. The majority of papers report that inflammatory aortic and iliac aneurysms are associated with perianeurysmal and retroperitoneal fibrosis that ultimately results in the structural compromise of the urinary tract. Ureteral obstruction occurs in 20% to 71% of cases and approximately one half of these patients will present with obstructive uropathy. Most patients with inflammatory aneurysm are symptomatic, with elevated serum inflammatory markers, and characteristic multislice CT findings including a thickened aortic wall and a mass of periaortic inflammatory tissue.
Case outline:
A 70-year-old man was admitted at the Vascular Surgery Clinic "Dedinje", Belgrade, because of ultrasonically verified asymptomatic aortoiliac aneurysm. Multisclice CT findings showed left urethral dilatation and hydronephrosis secondary to extrinsic ureteral obstruction due to aortoiliac aneurysm. CT findings, laboratory tests and finally, histopathologic examination showed atherosclerotic aneurysm without inflammation and retroperitoneal fibrosis. The patient was successfully treated with surgical resection of the aneurysm and aortobiliac reconstruction with "Y" prosthesis.
Conclusion:
We present a rare case of ureteral obstruction secondary to atherosclerotic aneurysm which, to our knowledge, has not been previously described in the domestic literature. A successful operative repair was performed. Postoperative course was uneventful and the patient was discharged on the seventh day after the surgery with normal vascular status and renal function.

Abstract

Objective:
The aim of this study was to determine the distribution of major risk factors among patients with atherosclerotic disease aged ≤50 years.
Subjects and methods:
The study population comprised 944 patients aged ≤50 years with clinically significant manifestations of atherosclerotic disease compared with 350 consecutive (control) older patients (age >50 years).
Results:
The most significant risk factors for atherosclerotic disease of the supra-aortic branches were: smoking (87.5%, p < 0.001), family history of atherosclerosis (52.3%, p < 0.001), diabetes mellitus (28.5%) and being male (56.9%) (p < 0.05 for both). In patients with coronary artery disease, there was considerable disparity in the prevalence of smoking (85.4%), hyperlipoproteinemia (67.4%), and family history of atherosclerosis (68%) (p < 0.001). For peripheral artery disease, the most significant risk factors were smoking (97%, p < 0.001), hyperlipidemia (p < 0.01), and family history of atherosclerotic disease (p < 0.01). When compared to controls, patients with premature atherosclerosis smoked more frequently, had hyperlipidemia, had a family history of atherosclerosis, and were more frequently of male sex.
Conclusion:
Premature atherosclerosis was most frequently associated with smoking, hyperlipidemia, family history of atherosclerotic disease, and male sex.

Abstract

Objectives:
Internal carotid artery restenosis after carotid endarterectomy is a major postoperative event, but the clinically best suited means for diagnosis of restenosis are still debated. The objective of this study was to evaluate the sensitivity and specificity of color duplex sonography for detection of substantial internal carotid artery restenosis, verified by computed tomographic (CT) angiography.
Methods:
The study group consisted of 210 consecutive patients with internal carotid artery restenosis, defined as restenosis of 50% or greater, verified by color duplex sonography. The degree of restenosis was calculated according to the European Carotid Surgery Trial guidelines. All patients underwent CT angiography. The specificity, sensitivity, positive predictive value, and negative predictive value of color duplex sonography were calculated.
Results:
In 85 patients, internal carotid artery restenosis on color duplex sonography was 50% to 69%, whereas in 125 patients it was 70% or greater. When color duplex sonography was compared with CT angiography, only 2 patients in the group with restenosis of 50% to 69% were misclassified by color duplex sonography, in whom CT angiography showed stenosis of 70% or greater. No patient with stenosis of 70% or greater on color duplex sonography was shown to have a lesser degree of restenosis on CT angiography. When compared with CT angiography, color duplex sonography had specificity of 97.7%, sensitivity of 100%, a positive predictive value of 98.4%, and a negative predictive value of 100% for the detection of internal carotid artery restenosis.
Conclusions:
Color duplex sonography can be effectively used as a primary diagnostic tool for evaluation of patients with suspected internal carotid artery restenosis after carotid endarterectomy.

Abstract

Objective:
Matrix metalloproteinases (MMPs) are involved in the remodeling of the extracellular matrix in the arterial wall. Collagen I is associated with vascular smooth muscle cell (VSMC) migration and monocyte differentiation. MMP-8 is expressed in atherosclerotic plaque and preferentially cleaves collagen type I. The aim of this study was to investigate the associations of two MMP-8 promoter polymorphisms, rs11225395 (-799C/T) and rs1320632 (-381 A/G), with carotid plaque occurrence, and the influence of these polymorphisms on MMP-8 mRNA expression in plaque tissue.
Methods:
The study included a total of 766 participants: 277 controls and 489 patients with carotid atherosclerosis undergoing endarterectomy. The two investigated polymorphisms were genotyped by PCR-RFLP. The gene expression analysis was performed by real-time PCR.
Results:
In females only, a significantly higher frequency of the -381G allele was found in patients with carotid atherosclerosis compared to controls (OR, 1.7; 95% CI 1.1-2.9; p = 0.001). Significant up-regulation of MMP-8 gene expression was observed in patients carrying the -381G allele compared to those with the AA genotype (mean factor, 3.54; S.E. range, 0.643-19.551; p = 0.007). Carotid plaque tissue of the haplotype G(-381)T(-799) showed a significantly higher mRNA level compared with the reference A(-381)C(-799) haplotype (p = 0.003).
Conclusion:
Our preliminary results indicate that MMP-8 -381A/G and -799C/T gene polymorphisms could be risk factors for carotid atherosclerosis. Further validation and functional studies are needed to establish the potential regulatory role of these polymorphisms and their impact on susceptibility to carotid atherosclerosis.

Abstract

Objective:
To evaluate early and long-term results of radical surgical removal of renal cell cancer (RCC) with tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA).
Methods:
The study included five patients with RCC with TT in IVC and right atrium, operated from January 2004 to September 2009 in the Institute for Cardiovascular disease "Dedinje", Belgrade, Serbia. All patients underwent atrial and caval thrombectomy with the use of normothermic cardiopulmonary bypass (CPB) and the radical nephrectomy, by a joint cardiovascular and urological team. After the surgery, patients were evaluated every 3 months for the first year, every 6 months for the next 2 years, and yearly thereafter. The mean follow-up was 32.6 months (range: 7-67 months).
Results:
There were no per-operative embolism and no in-hospital deaths. Two patients developed tumor recurrence during a mean time of 5 months and died within 1 year after the surgery. The three remaining patients are alive (mean follow-up: 48 months) and without the evidence of tumor recurrence or metastases. No patients received adjuvant therapy.
Conclusions:
Patients with RCC and the extension of TT in IVC and right atrium need a multidisciplinary surgical strategy. Atrial and caval tumor thrombectomy can be performed safely and effectively, with a low complication rate, using normothermic CPB. Long-term results are promising; however, larger prospective multicentre studies are necessary.

Abstract
The role of inflammation is well established in the pathogenesis of atherosclerosis and an increased level of circulating inflammatory markers may predict the future risk of atherosclerosis progression and plaque rupture. C-reactive protein (CRP) identification by hypersensitive methods (high-sensitivity CRP [hsCRP]) has become a clinical and laboratory inflammation marker. Carotid endarterectomy (CEA) is a well-established procedure for carotid stenosis treatment which can reduce stroke rate. Internal carotid artery (ICA) restenosis reduction may be prevented by the anti-inflammatory effect of statins. This review considers the recent findings on the presence of hsCRP and C3 complement concentration and inflammatory plaque composition as well as their effects on ICA restenosis rate, following eversion CEA with emphasis on human studies.

Abstract

Introduction:
A right-sided aortic arch is a rare congenital defect of the aorta with incidence of 0.05% to 0.1% reported in published series. Usually it is associated with congenital heart anomalies and esophageal and tracheal compression symptoms. We present a case of a right-sided aortic arch of anomalous left subclavian artery origin, accidentally revealed during multislice CT (MSCT) supraaortic branches angiography.
Case outline:
A 53-year-old female patient was examined at the Outpatients' Unit of the Vascular Surgery University Clinic for vertigo, occasional dizziness and difficulty with swallowing. Physical examination revealed a murmur of the left supraclavicular space, with 15 mmHg lower rate of arterial tension on the left arm. Ultrasound of carotid arteries revealed 60% stenosis of the left subclavian artery and bilateral internal carotid artery elongation. MSCT angiography revealed a right-sided aortic arch with aberrant separation of the left subclavian artery that was narrowed 50%, while internal carotid arteries were marginally elongated. There was no need for surgical treatment or percutaneous interventions, so that conservative treatment was indicated.
Conclusion:
A right-sided aortic arch is a very rare anomaly of the location and branching of the aorta. Multislice CT angiography is of great importance in the diagnostics of this rare disease.

Abstract

Introduction:
Combined endovascular interventions on carotid and coronary arteries are rare. Stenting of the unprotected coronary left main stem is a high risk procedure. We presented hemodynamically unstable patient with combined carotid artery and left main stem coronary artery stenting.
Case report:
A 78-year-old female patient was admitted to our institution for right carotid endaterectomy. The patient had 80% stenosis of the right carotid artery and occlusion of the left carotid artery. Coronary angiography revealed 70% ostial left main stenosis, occlusion of the right coronary artery and the left circumflex artery, and 80% stenosis of the left anterior descending artery. Simultaneous carotid artery endaterectomy and coronary artery by-pass grafting were considered. Due to high perioperative risk, surgery was rejected, and the patient was treated endovascularly with stenting of arteries occluded. The procedure was completed without complications and the patient was hemodynamically stabilised.
Conclusion:
This report illustrates simultaneous coronary and carotid stenting as a successfull lifesaving procedure.

Abstract
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.

Abstract
Nitric oxide synthases (NOS) are the enzymes responsible for nitric oxide (NO) generation. NO is a reactive oxygen species as well as a reactive nitrogen species. It is a free radical which mediates several biological effects. It is clear that the generation and actions of NO under physiological and pathophysiological conditions are regulated and extend to almost every cell type and function within the circulation. In mammals 3 distinct isoforms of NOS have been identified: neuronal NOS (nNOS), inducible NOS (iNOS) and endothelial NOS (eNOS). The important isoform in the regulation of insulin resistance (IR) is iNOS. Understanding the molecular mechanisms regulating the iNOS pathway in normal and hyperglycemic conditions would help to explain some of vascular abnormalities observed in type 2 diabetes mellitus (T2DM). Previous studies have reported increased myocardial iNOS activity and expression in heart failure (HF). This review considers the recent animal studies which focus on the understanding of regulation of iNOS activity/expression and the role of iNOS agonists as potential therapeutic agents in treatment of IR, T2DM and HF.
Keywords:
Inducible nitric oxide synthase; diabetes; heart failure.; insulin resistance.

Abstract

INTRODUCTION
Internal carotid artery (ICA) kinking is a pathological malformation with angulation of the vessel's axis of 90 degrees or less. It is known that kinking causes the reduction of flow within the vessel that may be exacerbated by progressive head rotation up to the point that causes complete cessation of flow. In this article, we report on the case of acute reversible ischaemic deficit induced by internal carotid artery kinking and immediate neurological recovery following surgical reconstruction. CASE OUTLINE A 64-year-old woman was admitted to Vascular Surgery Clinic due to severe dizziness, fainting and walking instability, suddenly arising a few days prior to admission. Two years before, the left ICA reconstruction was done for kinking, after which there was no cerebral ischaemia symptoms. Symptoms have been present perpetually, enhanced when resting and with head movement. CT angiography (MSCT) showed haemodynamic significant right ICA kinking. The left ICA postoperative finding was regular. Computerized tomography (CT) of the endocranium was done and no novel lessions were verified than those seen two years earlier. Resection, shortening and reimplantation of the right ICA were performed. A few hours following surgical reconstruction, there was no cerebral ischaemia symptoms, neither when resting nor with head movement. On the third postoperative day, the patient was discharged for home treatment.
Conclusion:
Surgical repair for symptomatic ICA kinking contributes to cerebral ischaemia symptoms reduction, improves cerebral perfusion and significantly prevents carotid thrombosis and stroke. In this paper, we have seen that in case of acute cerebral ischaemia symptoms and ICA kinking, surgical ICA treatment appears to be justified.

Abstract
The purpose of this report is to describe our experience of infected false aneurysm treatment following internal carotid artery (ICA) reconstruction. Five and 6 years before admission, bilateral reconstruction was done because of ICA kinking at a local health center. The patient was symptomless for 5 years but later became partially symptomatic (dizziness, vertigo, and visibly bilateral neck pulsatile masses). On routinely performed ultrasonography and multislice scanner examinations, the bilateral ICA pseudoaneurysms were revealed. The final treatment was surgery and aneurysmal sac resection followed by end-to-end arterial reconstruction. A right-sided wound swab was positive; Staphylococcus aureus was cultured. Antibiotics were administered: teicoplanin (Targocid) 800 mg as an initial dose followed by 400 mg maintenance doses over the following 4 days. After 1 month, left ICA reconstruction was done and a wound swab showed staphylococcal infection as well. At the 12-month follow-up, the patient was doing well; cerebral vascularization was well preserved. Infected false aneurysms are rare complications following carotid artery reconstruction. Aneurysmal sac resection and arterial reconstruction with end-to-end anastomosis or autologous saphenous vein are recommended. A wound swab is mandatory.

Abstract

Introduction:
Peripheral arterial disease (PAD) is a severe atherosclerotic condition. The relationship between various risk factors and severity of PAD, measured by Ankle Brachial Index (ABI), has been the subject of a relatively small number of studies.
Objective:
The aim of the present study was to investigate whether there was any relationship between severity of PAD, expressed as ABI, and anthropometric, clinical and biochemical characteristics of patients, including inflammatory markers.
Methods:
The cross-sectional study, involving 388 consecutive patients with verified PAD, was performed at the Dedinje Vascular Surgery Clinic in Belgrade. The diagnosis of PAD was defined by Doppler sonography as ABI < 0.9, and by symptoms. Data on cardiovascular risk factors, anthropometric parameters, clinical and biochemical characteristics were collected for all participants. In the analysis, chi2 test, t-test and multivariate logistic regressions were used.
Results:
According to the results of multivariate analysis (the model of which included age, percentage of body fat, average value of uric acid, high sensitivity C-reactive protein--hsCRP > or = 3 mg/L, fibrinogen > or = 4 g/L, Baecke index of physical activity at work and Baecke index of leisure-time physical activity), the patients with more severe form of peripheral arterial disease (ABI < or = 0.40) had more frequently increased high sensitivity C-reactive protein (p = 0.002), lower Baecke index of physical activity at work (p = 0.050) and lower Baecke index of leisure-time physical activity (p = 0.024). Average value of body fat was significantly higher in the patients with a less severe form of disease (p = 0.006).
Conclusion:
According to the results obtained, the increased values of hsCRP and physical inactivity are associated with a more severe form of PAD (ABI < or = 0.40).

Abstract

Background:
Angiofollicular lymphoid hyperplasia (Castleman's disease) is a rare inflammatory condition. Its cause is unknown and it can be both localized and general. Eighty-six percent of lesions are found in the mediastinum or hilum, and 91% are of the hyaline vascular type. Although Castleman's disease is primarily involving the chest and retroperitoneum, it may also involve neck and axilla in 2-4% of cases. In this article, we present a very rare case of Castleman's disease causing axillary artery pseudoaneurysm.
Methods and results:
A 30-year-old woman patient presented with pulsating tumefaction of the left arm which was 3.5 x 10 cm in size, and became evident 15 days before admission. History revealed that she suffered trauma of the left upper arm in childhood; therefore, it was suspected that tumefaction may be due to a post-traumatic aneurysm. Duplex scan and multislice computed tomography examinations were performed and an axillary artery pseudoaneurysm was diagnosed. Since intraoperatively the tumefaction resembled the tumorous formation but not the aneurysmal wall, specimens were sent for pathohistological analysis. Arterial reconstruction was performed using autologous vein graft. Pathohistological findings showed vascular type of angiofollicular lymphoid hyperplasia.
Conclusion:
Although angiofollicular lymphoid hyperplasia is rarely localized in the axillary area, this disease should also be considered when axillary artery pseudoaneurysm is diagnosed.

Abstract

Introduction:
Congenital coarctation of the thoracic aorta at the ligamentum arteriosum or the aortic arch is well recognized. But a much less common variety (0.5-2.0%) of aortic coarctation is located in the distal thoracic aorta or abdominal aorta or both and is often called "middle aortic syndrome" or "mid-aortic dysplastic syndrome". This represents serious pathological condition and indicates multidisciplinary therapy approach.
Outline of cases:
From 1996 to 2007, at the Vascular Surgery Clinic of the Institute for Cardiovascular Diseases "Dedinje", Belgrade, three patients were treated due to abdominal aorta coarctation, two females aged 55 and 50 and a 4-year-old child. The patients were treated surgically (by-pass with a prosthetic graft and patch angioplasty) and endovascular- percutaneous transluminal angioplasty (PTA) with and without a stent. The follow-up period was 3-70 months. In the 50-year-old patient, angiography showed severe narrowing of the suprarenal segment of the abdominal aorta. Thoraco-abdominal bypass with a 16 mm dacronic tubular graft was performed. In the 4-year-old patient angiography also showed a suprarenal aorta narrowing. In the first act patch angioplasty was performed and after PTA of the visceral arteries was done on several occasions. In the 55-year-old patient, after diagnostic angiography, infrarenal aorta coarctation was registered. PTA was performed with stent placement. All patients were asymptomatic on control check-ups.
Conclusion:
Abdominal coarctation is a pathological disease which is seldom found in vascular surgery. Angiography is of major importance for setting the diagnosis and for the control of the results of surgical and nonsurgical treatment. The combination of surgical and endovascular treatment in our patients showed very good results in the studied period.

Abstract

Background:
To measure by Doppler sonography the blood flow volume (BFV) of the ipsilateral and contralateral extracranial internal carotid arteries (ICAs) and both vertebral arteries (VAs) before and after a carotid endarterectomy (CEA) of the ICA. We correlated the result with the degree of stenosis of the ICA.
Method:
One hundred seven patients who had a CEA were divided into 2 groups. Group I consisted of subjects with stenosis of ipsilateral ICA of >or=70% to near occlusion and Group II included subjects with near occlusion. The Doppler sonographic examinations were performed 1 day before the CEA, 7 days after the CEA, and 1 month after the CEA. The peak systolic velocity, end-diastolic velocity, time-averaged maximum blood flow velocity, resistance index of the ipsilateral ICA, and the BFV of both ICAs and both VAs were calculated.
Result:
There was a significant increase in the peak systolic velocity, maximum blood flow velocity, and the BFV of the ipsilateral ICA after the CEA. The BFV of the contralateral ICA and both VAs were not significantly altered after the CEA in both groups.
Conclusion:
The main CEA hemodynamic effect was an increase in the BFV of the ipsilateral ICA regardless of the degree of stenosis.

Abstract

Introduction:
Though surgical approach is common in arteriovenous (AV) fistula treatment, endovascular procedures such as stent-graft placement has become more popular in recent years. We aim to present a case of thrombosed femoral artery stent-graft which was placed one year earlier due to multiple AV fistulas following gunshot wounds.
Case outline:
A 43-year-old patient was admitted to the Institute for Cardiovascular Diseases "Dedinje", Belgrade, Serbia, for arteriography. Five years before, he had suffered from six gunshot wounds in his right leg and one year before, in the health centre in Vienna, stent-graft had been placed in the right superficial femoral artery due to multiple AV fistulas. Because of artery dilation proximal to AV fistula location, a large dimensional stent-graft had to be placed (24 mm). After admission, arteriography and Multislice CT (MSCT) angiography revealed thrombotic masses in the stent-graft with intraluminal stenosis of 50%. Extirpation of thrombosed stent-graft was performed followed by Dacron tubular graft 10 mm interposition. On the fifth postoperative day, the patient was discharged from the clinic, and after 3 months, the right leg vascularisation was well preserved.
Conclusion:
Large dimensional stent-graft placement in patients with mutiple AV fistulas and blood vessel dilation proximal to AV site of communication carries an increased risk of thrombotic events due to turbulent blood flow and parietal thrombosis occurrence. Though stent-graft placement can be a very useful solution in acute AV fistula treatment, the very same thrombosis should be thought of when surgical management is the only treatment choice.

Abstract

Background:
We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion.
Methods:
From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months.
Results:
There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B.
Conclusion:
Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Abstract
The role of hepatitis C virus (HCV) infection in the development of vascular disease is controversial. Insulin resistance (IR) is a recognized risk factor for cardiovascular disease (CVD) and is associated with chronic hepatitis C (CHC) infection. Thus, IR may promote atherosclerosis and vascular disease in CHC patients. HCV-associated IR may also cause hepatic steatosis and resistance to antiviral treatment. In addition, HCV may impose direct, proatherogenetic action in the vascular wall. This review will elaborate the impact of IR on interferon-α based therapy of HCV infection and the role of insulin-sensitizing agents on the response to antiviral treatment and prevention of IR complications, including vascular disease.

Abstract
The aim of the study was to estimate the prevalence of metabolic syndrome among 388 patients with peripheral arterial disease, to determine the relationship between the number of metabolic syndrome components (metabolic syndrome score) and the degree of established and some of the emerging vascular risk factors, and to estimate whether there was any relationship of metabolic syndrome score and other vascular risk factors with the severity of peripheral arterial disease clinical manifestations. Metabolic syndrome was present in 59.8% of the patients with peripheral arterial disease. All metabolic syndrome components were significantly related to metabolic syndrome score. The same was true for the body weight, body mass index, percentage of body fat, total cholesterol/high-density lipoprotein cholesterol ratio, uric acid, and percentage of patients with high-sensitivity C-reactive protein. The metabolic syndrome score was also significantly, but inversely, related to high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and smoking. The degree of peripheral arterial disease clinical manifestations was not related to metabolic syndrome score, but gangrene was significantly positively associated with increased fasting glucose, high-sensitivity C-reactive protein, and lower education.

Abstract
Recanalization of an occluded extracranial internal carotid artery is a rare event. The mechanism remains unclear. We report a case of recanalized internal carotid artery in its extracranial portion. The patient underwent successful carotid endarterectomy.

Abstract

Background:
Metabolic syndrome (MetS) is associated with increased risk of carotid atherosclerosis.
Aim:
To estimate the frequency of MetS in patients with symptomatic carotid atherosclerotic disease, and to compare clinical, biochemical and ultrasonographic characteristics of patients with and without MetS.
Material and methods:
Cross-sectional study of 657 consecutive patients (412 males) with symptomatic carotid atherosclerotic disease. Carotid atherosclerosis was estimated by high resolution B-mode ultrasonography. National Cholesterol Education Program (NCEP) M criteria were used for estimation of MetS.
Results:
Metabolic syndrome was present in 55.6% of studied patients. Among patients with metabolic syndrome there was a significantly higher proportion of women, and mean values of body weight, body mass index, waist circumference, percentage of body fat, systolic and diastolic blood pressure, serum triglycerides, total cholesterol and glucose were significantly higher. Mean values of high density lipoprotein cholesterol and alcohol consumption were significantly lower in patients with MetS. No differences between patients with or without MetS, were observed for age, smoking, mean values of low density lipoprotein cholesterol, high sensitive C-reactive protein and fibrinogen, and for degree of carotidstenosis or severity of clinical manifestations.
Conclusion:
Half of these patients with carotid stenosis have features of the metabolic syndrome.

Abstract
The American otolaryngologist Eagle was the first to describe styloid syndrome in 1937. Stylohyoid complex is composed of styloid process, stylohyoid ligament and a lesser horn of the hyoid bone. Embriologicaly, these anatomical structures originate from Reichert's cartilage of the second brachial arch. In the general population, the frequency of the elongated styloid process is estimated to be 4%, of which only 4% show clinical manifestations suggesting that the incidence of styloid syndrome is 0.16% (about 16,000 persons in Serbia). The styloid process deviation causes external or internal carotid impingement and pains which radiate along the arterial trunk. Classical stylohyoid syndrome is found after tonsillectomy and is characterised by pharyngeal, cervical, facial pain and headache. Stylo-carotid syndrome is the consequence of the pericarotid sympathetic fibres irritation and compression on the carotid artery. Clinical manifestations are found most frequently after head turning and neck compression. The diagnostic golden standard for styloid syndrome is 3D CT reconstruction. Sagital CT angiography has a leading role in the radiological diagnosis of the stylo-carotid syndrome. Differential diagnosis requires the differentiation of the styloid syndrome from numerous cranio-facio-cervical painful syndromes. If conservative treatment (analgesics, anticonvulsants, antidepressants, and local infiltration with steroids or anaesthetic agents) has no effect, surgical treatment is applied. Styloid syndrome is underrepresented in neurological literature. The syndrome is considered important, because it is clinically similar to many other painful cranio-facial syndromes; it is difficult to be recognized, and the patient should be treated adequately.
Keywords:

Abstract

Introduction:
The sciatic artery represents the earliest embryological blood supplyto the lower extremity. It regresses after the 3rd month of embryologic development. The proximal part of the sciatic artery eventually persists as the inferior gluteal artery. Rarely, however, it persists into adulthood when it is frequently associated with numerous possible complications (aneurysm formation, embolism, nerve compression, rupture, thrombosis).
Case outline:
In March 1996, a 48-year-old male was admitted for angiography of the blood vessels of the right inferior extremity, before an elective orthopaedic procedure. Arteriography of the right leg was done in a usual manner through the right common femoral artery in order to get an angiogram of the popliteal trifurcation and crural arteries. However, on the first field we noticed a hypoplastic superficial femoral artery, as well as a huge persistent sciatic artery (PSA) originating from the internal iliac artery running distally and overlapping the deep femoral artery. There were no aneurysm and stenotic changes of PSA.
Conclusion:
If clinical condition is stable, follow-ups at 12 months intervals should be done by means of ultrasound. The therapeutic decisions also depend on complete or incomplete PSA.

Abstract

Introduction:
The American otolaryngologist Eagle was the first to describe styloid syndrome in 1937 and the syndrome was named after him (Eagle's syndrome). The original description of two separate syndromes is connected with his name: classical syndrome, which almost constantly occurs after tonsillectomy and carotid artery syndrome, which occurs without tonsillectomy and also in cases when stylohyoid complex compresses the carotid segments and perivascular sympathetic fibers. In the following years, two more syndromes were defined: stylohyoid and pseudostylohyoid, which according to their manifestations, correspond to the genuine classical form.
Case outline:
A 40-year-old male is presented, with a history of 3-year duration of pains in the upper part of the left side of the neck, in the left eye and its surroundings. Pain occurrences were not regular. Throbbing pains were most often provoked by sudden head movements and neck compression. He was healthy until the onset of these problems. The findings of all examinations were normal. The applied prophylactic therapy, typical for cluster headache, was without any effect. On 64-MSCT (multislice computed tomography), the neck arteries did not show any intraluminal pathology. The styloid processes were of normal length. On the left side, the styloid process tip pressed the internal carotid artery disturbing its longitudinal axis.
Conclusion:
In our presentation, the defined lengths of the styloid processes were normal. The medial angulation of the left styloid process was more expressed reaching 63.5 degrees (the right side angulation was normal). Persistent and throbbing pain in the region of the left eye with backward projection suggested compression on the internal carotid artery. Pains were most frequently provoked by head turning and neck compression. 64-MSCT diagnostics enabled us to determine the characteristics of styloid processes and their relation to the internal carotid artery. Improvement was achieved by administration of antiepileptic (gabapentin) and antidepressant (amitriptyline) drugs.

Abstract

Objectives:
Stromelysin-1 (MMP-3) as a key member of metalloproteinase family could have an important role in atherogenesis. The 5A/6A polymorphism in the promoter of MMP-3 gene affects the level of MMP-3 gene expression. We assessed whether the MMP-3 promoter low- and high-activity genotypes are related to susceptibility for carotid atherosclerosis (CA) in Serbian population.
Design and methods:
The study group of case-control design consisted of 515 participants. The 265 patients with ultrasonographic evidence of carotid plaque presence were recruited for the study. The 5A/6A polymorphism was typed by RFLP-PCR.
Results:
There was significantly higher prevalence of genotypes containing 6A allele in the patients with CA compared to controls (p<0.05). The model of inheritance with the dominant effect of 6A allele gave elevated and significant OR for carotid atherosclerosis (adjusted OR 2.35, CI=1.0-5.5, p=0.048).
Conclusions:
Subjects carrying genotypes with 6A allele had significantly higher susceptibility to carotid atherosclerosis.

Abstract

Introduction:
Although the incidence is low, infection of prosthetic vascular graft bears a high incidence of serious complications including 25-75% mortality rate and 40-75% limb loss. The standard treatment of vascular graft infection consists of excision of the prosthesis, wound debridement and extraanatomic revascularization. Conservative treatment might be an option in a limited number of patients. We present three cases of surgical and conservative treatment of vascular graft infection.
Case outline:
Case 1: A patient developed silver-coated graft infection after femorodistal arterial reconstruction performed because of critical limb ischemia. In the early postoperative period, massive skin and subcutaneous tissue necrosis developed, with the graft being exposed. After two months of persistent debridement and wound toilette, the defect was covered with aThiersch skin graft. Case 2: PTFE graft infection in the right groin followed reconstruction of the isolated common femoral artery aneurysm. This graft was replaced with a silver-coated graft in situ. Reinfection of the proximal end of the implanted silver-coated graft occurred and the graft was exposed. After repeated debridement and wound toilette, the exposed prosthesis was covered with granulomatous tissue, and the wound healed. Case 3: A year after anastomotic pseudoaneurysm resection in the left groin, prosthesis was exposed following wound infection. This graft was substituted with a silver-coated graft in situ. The wound healed primarily.
Conclusion:
These three cases demonstrate that under some circumstances vascular prosthesis infection can be successfully treated conservatively without graft removal, and also by in situ replacement using silver-coated graft.

Abstract
Since antiquity, there has been a mystery about the cerebral circulation function. Scientific methods were introduced in research at the end of the nineteenth century. During the first half of the last century, the problem of occlusive carotid disease was defined and the basis for the surgical treatment of carotid disease was established. The first contemporary reconstructive surgical procedures were performed in the middle of the last century, the time when successful surgical treatment of carotid disease began. Today, carotid endarterectomy is one the most frequently performed vascular surgical procedures of all, followed by very low morbidity and mortality rates.

Abstract

Introduction:
Aneurysms of digital arteries are considered to be rarity. They could be true or false. False aneurysms are usually the result of penetrating trauma, while the causes of development of true aneurysms are various, such as blunt trauma, and rarely atherosclerosis, vasculitis and infection. Also, they can be idiopathic. Reviewing the literature we found 13 cases of previously described true aneurysms of digital arteries. None of them referred to the common digital artery aneurysm.
Case outline:
We report a case of an idiopathic true aneurysm of the common digital artery, with its clinical presentation and a corresponding multislice CT arteriogram. Surgical treatment by ligation and excision of the aneurysm was performed.
Conclusion:
As mentioned above, true aneurysms of digital arteries are very rare, so they are of little clinical importance. The most common symptom of digital artery aneurysms is pain, with a tender pulsatile mass on examination. Since natural healing cannot be expected, surgical treatment of true digital artery aneurysms is recomended for pain relief and avoidance of complications which may occur and are related to the aneurysm presence. Aneurysm resection and ligation of a blood vessel can be performed. Also, artery reconstruction can be performed by primary end-to-end anastomosis or the placement of a reversed interposition vein graft.

Abstract
Procedures used in treatment of carotid stenosis are endarterectomy, PTA with stent implantation, resection with graft interposition and by-pass procedure. Segmental lesions are found more often and treated by the first two mentioned procedures. In case of longer lesions and extension to the greater part of the common carotid artery, the other two procedures are performed. For the past few years, the main dilemma has been whether to perform carotid endarterectomy or PTA with stent implantation. Both early and long-term results speak in favour of carotid endarterectomy, regardless of an increased number of PTA and carotid stenting. At the same time, PTA and carotid stenting are more expensive procedures. Both methods have their defined and important roles in treatment of segmental occlusive carotid lesions. Severe cardiac, pulmonary and renal conditions, which increase the risk of general anaesthesia, are not an absolute indication for PTA and stenting, since endarterectomy can be done in regional anaesthesia. Main indications for PTA with stent implantation are: surgically inaccessible lesions (at or above C2; or subclavian); radiation-induced carotid stenosis; prior ipsilateral radical neck dissection; prior carotid endarterectomy (restenosis).

Abstract
We report a case of successful transcatheter arterial embolization of a pancreaticoduodenal artery pseudoaneurysm (PSA) caused by erosion of the pancreatic pseudocyst content near pancreaticoduodenal arteries. A 55-year-old man was admitted to a local hospital for investigation of severe, stabbing epigastric pain confined to the upper abdomen. He had a history of previous alcohol abuse, chronic pancreatitis, and a duodenal ulcer. Upper gastrointestinal endoscopy revealed narrowing in the pyloric channel along with an ulcer located at the first and second portions of the duodenum with oozing beneath an adherent cloth and duodenal distortion. Computed tomography additionally revealed an enlarged head of the pancreas with numerous spot calcifications and round cystic formation inside, with a diameter of 30 x 25 mm. Following two surgical procedures for duodenal ulcers, selective angiography revealed a PSA located inside the pancreas head and high-grade stenosis > 90% of the celiac trunk and hepatic artery that rose separately from the aorta. Fiber coil embolization was used to occlude the PSA sac successfully. There was no complication after completion of the last embolic procedure. The patient was doing well after 26 months.

Abstract

Introduction:
Transplantation is the method of choice in the treatment of terminal liver diseases with acute and structural damage of liver tissue and congenital liver diseases.
Objective:
The aim of our study was to determine specificity and significance of vascular anastomosis in liver transplantation by postoperative evaluation of vascular anastomosis function.
Method:
The study included 16 patients with 16 liver transplantations and one re-do liver transplantation. In all patients, preoperative angiography and postoperative duplex sonographic and angiographic evaluation of vascular anastomosis were performed.
Results:
Preoperative angiographic evaluation did not reveal anomalies in liver blood vessels of transplant candidates. In one patient, we identified and angiographically confirmed stenosis on anastomosis of the hepatic artery on the 7th postoperative day. In another patient, we had artificial thrombosis of the hepatic artery branch due to the liver biopsy.
Conclusion:
The successful performance of vascular anastomosis in liver transplantation is significant for adequate liver graft perfusion, good postoperative graft function and overall outcome of the liver transplantation.

Abstract
The aim of this article is to review our experience in surgical treatment of carotid atherosclerosis using eversion carotid endarterectomy (ECEA) in 5,034 patients, with particular attention to temporal changes in patients' characteristics, diagnostic approach, surgical technique, medical therapy, and outcome in the early (group A, 1991-1997) versus late (group B 1998-2004) period of ECEA. From January 1991 to December 2004, 5,034 primary ECEAs were performed for high-grade carotid stenosis. Patients treated for restenosis after previous carotid surgery were excluded from the analysis. Group A consisted of 1,714 patients who underwent surgery between 1991 and 1997, and group B consisted of 3,320 patients who underwent surgery between 1998 and 2004. Follow-up included routine clinical evaluation and noninvasive surveillance, with duplex scanning at 1 month after surgery, after 6 months, and annually afterward. Only 3% of patients in group A and 0.6% in group B were asymptomatic, with 23% and 47% of them having preoperative stroke, respectively. In group A, angiography was used for the final diagnosis in 78% of patients. In group B, duplex scanning was performed in 82% of patients and angiography in only 18% (p < .001). Clamping time was shorter in the latter group (12.4 +/- 3.1 vs 14.5 +/- 4.1 min, p < .01). Introperative shunting and regional anesthesia were rarely performed in both groups (1.4% vs. 0.4%, p < .01, and 2% vs 0.3%, p < .001). Total and neurologic morbidity was significantly higher in group A than in group B (6.41% +/- 0.47% vs 4.81% +/- 0.53%, p < .001, and 2.14% +/- 0.31% vs 1.23% +/- 0.29%, p < .001, respectively). Total mortality was also higher in group A than in group B (1.92% +/- 0.24% vs 1.36% +/- 0.50%, p < .05), but although there was a trend toward lower neurologic mortality, it did not reach statistical significance (1.04% +/- 0.5% vs 0.57% +/- 0.25%, p = .074). There was a lower rate of nonsignificant restenosis (< 50%) in group B (2% vs 5%, p < .01), but the incidence of restenosis > or = 50% was identical between the groups (5.5% for both). Our data show that ECEA is a reliable surgical technique for the treatment of atherosclerotic carotid disease. Temporal trends in our patients demonstrated a decline in periopertive mortality and morbidity, despite a higher incidence of preoperative stroke.

Abstract

Introduction:
Hypersplenism is a common complication of portal hypertension. Cytopenia in hypersplenism is predominantly caused by splenomegaly. Distal splenorenal shunt (Warren) with partial spleen resection is an original surgical technique that regulates cytopenia by reduction of the enlarged spleen.
Objective:
The aim of our study was to present the advantages of distal splenorenal shunt (Warren) with partial spleen resection comparing morbidity and mortality in a group of patients treated by distal splenorenal shunt with partial spleen resection with a group of patients treated only by a distal splenorenal shunt.
Method:
From 1995 to 2003, 41 patients with portal hypertension were surgically treated due to hypersplenism and oesophageal varices. The first group consisted of 20 patients (11 male, mean age 42.3 years) who were treated by distal splenorenal shunt with partial spleen resection. The second group consisted of 21 patients (13 male, mean age 49.4 years) that were treated by distal splenorenal shunt only. All patients underwent endoscopy and assessment of oesophageal varices. The size of the spleen was evaluated by ultrasound, CT or by scintigraphy. Angiography was performed in all patients. The platelet and white blood cell count and haemoglobin level were registered. Postoperatively, we noted blood transfusion, complications and total hospital stay. Follow-up period was 12 months, with first checkup after one month.
Results:
In the first group, only one patient had splenomegaly postoperatively (5%), while in the second group there were 13 patients with splenomegaly (68%). Before surgery, the mean platelet count in the first group was 51.6 +/- 18.3 x 10(9)/l, to 118.6 +/- 25.4 x 10(9)/l postoperatively. The mean platelet count in the second group was 67.6 +/- 22.8 x 10(9)/l, to 87.8 +/- 32.1 x 10(9)/l postoperatively. Concerning postoperative splenomegaly, statistically significant difference was noted between the first and the second group (p < 0.05). Comparing the postoperative platelet count between the first and second group, we found that there was a very significant statistical difference, too (p < 0.01).
Conclusion:
Distal splenorenal shunt (Warren) with partial spleen resection is a very reliable surgical technique in treatment of hypersplenism and decompression of oesophageal varices caused by portal hypertension and has advantage in treatment of hypersplenism over the distal splenorenal shunt method.

Abstract
Patient was admitted for endarterectomy of the left internal carotid artery. Echocardiography showed mitral stenosis with mitral valve area of 1.4 cm2. Since the patient's functional capacity could not be determined due to left-sided hemiplegia, it was decided to perform high-dose dobutamine stress-echocardiography in order to assess the patient's hemodynamics during stress. Gradients over mitral valve increased from 32/10 mmHg at baseline to 43/16 mmHg at 40 mcg/kg/min dobutamine infusion. Preoperative and 24 hour perioperative hemodynamic variables were monitored by Swan-Ganz catheter, and their values did not change significantly as compared to baseline. Postoperative course was uneventful, and the patient was discharged on the fifth postoperative day.

Abstract
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.

Abstract

Introduction:
The goal of modern carotid surgery is relief of symptoms, stroke prevention, improvement in quality of life, prevention of vascular dementia, and prolongation of lifetime.
Objective:
The objective of this paper was to compare the outcome of carotid endarterectomy in cervical block vs. general anesthesia in patients with occluded contralateral internal carotid artery (ICA).
Method:
One hundred patients (76 male, 24 female, mean age 60.81 years) with occluded contralateral ICA were operated from 1997-2000. Neurological symptomatology, deficiency and stroke incidence were preoperatively analyzed in two groups. Duplex-scanning, angiograms and CT-scan confirmed the diagnosis. Risk factors analysis included hypertension, diabetes, lipid metabolism disorders, smoking and history of CAD, CABG and PAOD. Morbidity and mortality were used to compare the outcome of surgery in two groups.
Results:
There was no difference of age, gender and symptomatology between the groups. Paresis, TIA and dysphasia were most frequent. 70%-90% of ICA stenosis was seen in the majority of patients. Hypertension and smoking were dominant risk factors in these two groups. Eversion carotid endarterectomy was the most frequent technique used. In three cases out of nine that were operated under cervical block, the neurological symptoms developed just after clamping, so the intraluminal shunt was placed. Postoperative morbidity was 12% and mortality was 8%.
Conclusion:
There was no difference of preoperative parameters, surgical technique and outcome in these two groups. Without other intraoperative monitoring, cervical block anesthesia might be an option in patients with the occlusion of the contralateral ICA. However, prospective studies involving more patients are needed.

Abstract
Coiling (or looping) of the artery is a rare morphologic entity, most frequently described in the internal carotid artery. In other arteries, coiling is rarely reported because it remains asymptomatic and without clinical relevance unless inadvertently injured, as for diagnostic or monitoring purposes. We present a case of an unusually difficult thrombectomy of the brachial artery after occlusion following withdrawal of the arterial cannula placed for monitoring during cardiac surgery owing to coiling of the distal part of the artery, which produced the "spring-squeeze phenomenon" during balloon catheter thrombectomy.

Abstract

Introduction:
Copper and zinc have significant antiatherogenic effect influencing activity of antioxidant enzymes (glutathione-peroxidase and superoxide-dismutase), mechanism of apoptosis and other mechanisms. Few studies showed increased copper and zinc concentration in atherosclerotic plaque in comparison to normal vascular tissue.
Aim:
The aim of the study was to compare copper and zinc concentrations in carotid artery tissue without significant atherosclerotic changes and human ulcered atherosclerotic plaque.
Material and methods:
Study was conducted on 66 patients. Carotid endarterectomy due to the significant carotid atherosclerotic changes with cerebrovascular disorders was performed in 54 patients (81.8%). Control group consisted of 12 patients (18.2%) without carotid atherosclerotic changes operated due to the symptomatic kinking and coiling of carotid artery. Operated group consisted of 38 men (62.96%) and 16 women (37.04%). Control group had the same number of patients: six men (50%) and six women (50%). Preoperatively, all patients were examined by vascular surgeon, neurologist and cardiologist. Duplex sonography of carotid and vertebral arteries was performed by Aloca DSD 630 ultrasound with mechanical and linear transducer 7.7 MHz. Indication for surgical treatment was obtained according to non-invasive diagnostic protocol and neurological symptoms. Copper and zinc concentration in human ulcered atherosclerotic plaque and carotid artery segment were estimated by spectrophotometry (Varian AA-5).
Results:
Average age of our patients was 59.8+/-8.1 years. For males average age was 76.1+/-9.8 years. And for females 42.4+/-5.8 years. In group with carotid endarterectomy female patients were significantly younger than male patients (p<0.01). In group with carotid endarterectomy clinically determined neurological disorders were found in 47 patients (87.03%)--35 male (74.47%) and 12 female patients (25.53%). Regarding risk factors for cardiovascular diseases, no significant difference among groups was found for blood pressure and smoking. However, patients with carotid endarterectomy had significantly more diabetes mellitus (p<0.05), obesity (p<0.01) and hypercholesterolemia (p<0.01).
Discussion:
Our study showed significantly lower total copper value in the group with human ulcered atherosclerotic plaque in comparison with the control group (p<0.05). We also found significantly lower total zinc value in the group with human ulcered atherosclerotic plaque in comparison with the control group (p<0.05).
Conclusion:
Our study revealed significant difference in copper and zinc content between human ulcered atherosclerotic plaque and normal carotid tissue. Closer correlation of these oligoelements and endothelial dysfunction will be established in future investigations.

Abstract

Introduction:
Arterial occlusive disease is a systemic phenomenon frequently coexisting in more than one arterial system. Often in one arterial bed disease is manifested with symptoms, in another is asymptomatic. There are only several reports indicating the prevalence of carotid stenosis in patients with peripheral vascular disease. Asymptomatic carotid stenosis is defined as the presence of internal carotid/carotid bifurcation stenotic or occlusive lesions in patients with no signs or symptoms of cerebrovascular disease. Lesions are important causative factors in unheralded stroke. Two factors are particularly important: severity of stenosis and morphologic characteristics of the stenotic plaque. The recent largest completed clinical trial concerning asymptomatic carotid artery stenosis (completed 1995) ACAS (Asymptomatic Carotid Artery Study) established the benefit of surgical treatment vs. best medical treatment. The reduction in relative risk of stroke was 55% in favor of surgery. Population screening for carotid stenosis is inefficient and expensive. The current interest is focused on the efficacy of screening population at risk.
Aim of the study:
The aim of the study was to establish prevalence of asymptomatic carotid artery stenosis in patients with symptomatic lower extremities atherosclerosis. Furthermore, possibility for limiting screening to subgroups of patients concerning risk factors, carotid bruit and severity of lower extremities atherosclerosis, was examined.

Abstract

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.