Background: Acute limb ischemia (ALI) is defined as a sudden decrease in limb perfusion that requires urgent treatment 1 .Treatment methods include surgical, endovascular and hybrid revascularization.The aim of this study is to investigate the results of intra-arterial catheter-directed thrombolysis (CDT) in adult patients with acute limb ischemia, treated at University Hospital Centre Zagreb.

Uvod: Kronična ugrožavajuća ishemija ekstremiteta (CLTI – engl. chronic limb-threatening ischemia), kao posljednji stadij periferne arterijske bolesti, predstavlja ozbiljan zdravstveni problem s visokom stopom mortaliteta, morbiditeta i amputacija. Efikasna revaskularizacija ključna je za očuvanje ishemičnog ekstremiteta u bolesnika s CLTI. Odabir najboljeg načina revaskularizacije je izazovan zbog brzog razvoja novih tehnologija i često pridruženih komorbiditeta, stoga zahtijeva multidisciplinarni pristup. Cilj ovog istraživanja bio je ispitati karakteristike i ishode liječenja bolesnika hospitaliziranih zbog CLTI u Kliničkom bolničkom centru (KBC) Zagreb. Materijali i metode: Riječ je o retrospektivnom istraživanju u koje je uključeno 149 konsekutivnih bolesnika s CLTI hospitaliziranih u razdoblju od svibnja 2021. do lipnja 2022. godine u Klinici za kirurgiju i Klinici za bolesti srca i krvnih žila KBC-a Zagreb. Glavni ishod bio je utvrditi preživljenje bez amputacije (AFS – engl. amputation-free survival) i ukupni jednogodišnji mortalitet u bolesnika s CLTI koji su liječeni različitim metodama revaskularizacije (endovaskularna, kirurška, hibridna) ili isključivo medikamentnom terapijom. Dodatno su analizirani rani hospitalni ishodi, uključujući mortalitet i stopu amputacija te trajanje hospitalizacije u odnosu na primijenjene metode liječenja. Rezultati: Najčešće korištena metoda revaskularizacije bila je endovaskularna koja je primijenjena u 62,4% slučajeva, dok je kirurška revaskularizacija učinjena u 17,4% slučajeva. Jednogodišnje preživljenje bez amputacije zabilježeno je u 63,8% bolesnika, dok su mortalitet i velike amputacije zabilježeni u 17,4% i 18,1% bolesnika. Unatoč razlici u trajanju hospitalizacije, nije pronađena značajna razlika u stopama mortaliteta ili amputacija među različitim metodama liječenja. Zaključak: Rezultati ovog istraživanja pokazuju da različite metode revaskularizacije mogu postići slične jednogodišnje stope AFS-a i mortaliteta kada su prilagođene stanju bolesnika. Ovo naglašava važnost individualiziranog i multidisciplinarnog pristupa u optimizaciji ishoda liječenja CLTI.

Iatrogenic injury of the peripheral arteries is becoming more common as the number of endovascular interventions grows. Percutaneous angioplasty of the iliac artery may cause a variety of problems, including arterial rupture, which can be fatal. We report a patient with simultaneous iatrogenic rupture of the right common and external iliac arteries during percutaneous transluminal angioplasty resulting in a life-threatening retroperitoneal haemorrhage that was treated successfully with the use of three balloon expandable stent grafts to seal the rupture.

This case shows the risk of severe cardiovascular complications following lumbar spine surgery, with progressive high output heart failure caused by an iatrogenic iliac arteriovenous fistula. Careful history taking and thorough physical examination are essential in guiding the diagnosis. Endovascular repair can provide excellent short- and long-term outcomes.

Aims We describe a patient that was successfully treated for refractory esophageal stenosis and chronic gastrocutaneous fistula with combined endoscopic-radiology intervention.

Objective: Last trials clearly documented and confirmed the efficacy of renal denervation (RDN) on decrease of blood pressure (BP). Our aim was to analyze the effects of RDN beyond BP lowering in truly resistant hypertensive patients in real-life conditions. Design and method: Out of 31 truly resistant patients whose secondary forms of hypertension were ruled out and were enrolled into the Croatian Spyral RDN registry, 18(10 m, 8 w, average age 49.3) were eligible for analysis. Office BP, ABPM, central BP and PWV were measured with Omron M6, Mobilograph and Sphygmocor devices, respectively. Albuminuria and salt intake were determined from 24-h urine samples, eGFR using the CKD Epi equation. Sympathetic/parasympathetic activity was measured with an ANX-3.0 ANSAR device. All RDN procedures(Spyral Medtronic) were done by one physician (average number of ablation spots was 41/procedure). Patients were examined day before and that day, 1,3,6, and 12 months after the RDN. Reponse was drop of office systolic BP by 10 mmHg or more 6 months after RDN. There were no differences in the RDN procedure between responders and non-responders. Results: Office and ABPM values dropped the day after RDN and remained significantly lower at the end of the follow-up (6.5/-5.5 and -16.2/9 mmHg, respectively). The effect of RDN on BP was not abolished with high salt intake(15.5 g/day at the end of follow up). eGFR remained stable, and even slight improvement was observed at the end of follow-up(+8.4 ml/min/1.72m 2 ); albuminuria significantly decreased (-115 mg/day). All metabolic parameters (lipids, uric acid) improved at the end of follow-up. LFa/RFa decreased the day after RDN and remained lower during the follow-up period. After RND central systolic BP and Aix decreased more in responders than in non-responders (-12.8 vs. -7.3; -7 vs. -2.6) while PP amplification was improved in responders (1.22 to 1.33) but decreased in non-responders (1.33 to 1.25). Conclusions: In real-life circumstances, BP significantly decreased after RDN despite large salt ingestion. eGFR and albuminuria improved as well as metabolic parameters at the end of follow-up and all of the beneficial changes run in parallel with observed decrease in sympathetic activity.

Objective: Heterogeneity in response to renal denervation (RDN) is acknowledged phenomena and one of most important tasks in this field is to find reliable predictive biomarker for positive response. Our aim was to analyse characteristics of resistant hypertensive patients who were responders 6 months after RDN. Design and method: Out of 31 truly resistant patients whom secondary forms of hypertension were ruled out and were enrolled into the Croatian Spyral RDN registry, 18 (10 m, 8 w, average age 49.3) were eligible for analyses. Office BP, ABPM, central BP and PWV were measured with Omron M6, Molbilograph and Sphygmocor devices, respectively. Sympathetic/parasympathetic activity was measured with ANX-3.0 ANSAR device. Results: Responders were 6.7 years older, less obese with at basal slightly higher eGFR (88.6 vs. 79.8), uric acid (406.5 vs. 376.4), salt intake (12.6 g/day vs.9.8 g/day) and had significantly higher basal office BP (169.5/99.7 vs. 153.3/96.5) as well as ABPM values. Central aortic systolic BP and Aix were higher in responders (154.5 vs, 147.1; 31.5 vs 27.3) without difference in PWV (10.1 vs. 9.6). Responders had lower values of PP amplification (1.22 vs. 1.33). Significantly higher basal sympathetic activity (LFa/RFa) was determined in responders than in non-responders (6.68 vs. 1.25). Conclusions: Responders were older with higher basal office BP, ABPM but also higher central BP and Aix with lower pulse pressure amplification. They ingested more salt, had higher values of uric acid and importantly had more exaggerated sympathetic activity. Whether some of identified parameters could be considered as a biomarker for positive response in resistant hypertensive patients should be determined in larger cohort of patients.

Renal denervation (RDN) as a method of treating arterial hypertension (AH) was introduced in Croatia in 2012. A multidisciplinary team and a network of hospitals that diagnose and treat patients with severe forms of AH were established, and a very strict diagnostic-treatment algorithm was prepared. At monthly meetings patients with truly resistant hypertension who were candidates for RDN were discussed. According to the 2021 ESH position statement and 2023 ESH guidelines, RDN is considered an alternative and additional, not a competitive method of treating patients with various forms of AH which must be performed by following a structured procedure and the patient's preference should be considered. In view of the changes in the global scientific community, the Croatian Hypertension League brings this consensus document on RDN conducted with radiofrequency-based catheter, the only currently available method in Croatia. In this document, exclusion and inclusion criteria are shown, as well as three groups of patients in whom RDN could be considered. The new diagnostic-treatment algorithm is prepared and follow-up procedure is explained. In Croatia, RDN is reimbursed by the national insurance company, thus pharmacoeconomic analyses is also shown. Criteria required by an individual centre to be approved of RDN are listed, and plans for prospective research on RDN in Croatia, including the Croatian registry for RDN, are discussed.

Objective: Recent trials confirmed the lowering effect of renal denervation (RDN) on blood pressure (BP). We aimed to analyze the impact of RDN on BP variability and circadian rhythm. Design and method: Out of 31 truly resistant patients whose secondary forms of hypertension were ruled out and were enrolled into the Croatian Spyral RDN registry, 18 (10 m, 8 w, average age 49.3) were eligible for analyses. Office BP, ABPM, central BP, and PWV were measured with Omron M6, Mobilograph, and Sphygmocor devices. Sympathetic/parasympathetic activity was measured with ANX-3.0 ANSAR device. All RDN procedures (Spyral Medtronic) were done by one physician (average number of ablation spots was 41/procedure). Patients were examined the day before and that day, 1,3,6, and 12 months after the RDN. The response was a drop of office systolic BP by 10 mmHg or more 6 months after RDN. There were no differences in the RDN procedure between responders and non-responders. Results: Office and ABPM values dropped the day after RDN and remained significantly lower at the end of the follow-up (6.5/-5.5 and -16.2/9 mmHg, respectively). We failed to find changes in BP variability (SD) after RDN. However, a significant decrease in morning BP surge was observed immediately the day after RDN (-12.4) and was even lower at the end of the follow-up (-18.8 mmHg). Substantial number of patients who had an abnormal nocturnal BP pattern became dippers. Central systolic BP and PWV decreased (-6.3 mmHg and -0.72 m/s, respectively). LFa/RFa decreased the day after RDN and reminded lower during the follow-up period. After RDN morning BP surge remained stable and normal in responders; however, in non-responders, it decreased immediately after RDN (-21.2) and remained lower during the follow-up till the last visit (-33.3). Conclusions: Significant improvements in circadian rhythm and several parameters of central hemodynamics were observed after RDN indicating that RDN might be considered as a pathway to the complete, so-called perfect 24-hour BP control. Observed beneficial effects run in parallel with the observed decrease in sympathetic activity. Importantly, even in non-responders, RDN had a beneficial effect on morning BP surge.

Background:Endovascular aneurysm repair (EVAR) has become a well-established approach in the elective treatment of abdominal aortic aneurysms (AAA).It represents a treatment of choice for high-risk patients ineligible for open surgery due to the increased risk of perioperative morbidity and mortality.However, it requires lifelong surveillance with CT aortography (CTA) or contrast-enhanced ultrasound due to more long-term complications compared to open surgery.Endoleak is the most common graftrelated complication with type II endoleak being the most common type.Type I and III endoleaks (T1E, T3E) are the most dangerous type of endoleaks, both leading to pressurization of the aneurysm sac and rupture.We report the case of a 72-year-old male patient with various types of endoleaks after EVAR. Case presentation:In 2015 ASA IV patient with known asymptomatic infrarenal 6.6x6cm AAA underwent elective EVAR with main device and bilateral iliac limbs (Medtronic, Endurant II).His past medical history revealed myocardial infarction, ischemic cardiomyopathy, hypertension, pancreatitis, and cholecystectomy.He was on regular stent-graft surveillance.Until 2021 he had been free of any EVAR-related complications when he presented to the emergency department with cramping abdominal pain.CTA demonstrated the presence of T1aE and T1bE.ChEVAR with Aortic Extension 32mm (Medtronic, Endurant II) and BeGraft Peripheral 5x59mm for T1Ea, stent grafting with two additional main device extensions, 28x28mm and 13x13mm, for T1Eb followed by ballooning, was successfully performed.Follow-up CTA in 2022 revealed the presence of a T3E that was immediately managed with an additional 16x10x199 mm endograft extension and by repeat ballooning at areas of component overlap. Conclusions:Endoleak is an important complication for EVAR which is often asymptomatic hence regular follow-up is needed and immediate management is crucial to prevent future aneurysm rupture.Nevertheless, this case demonstrates the importance of lifelong attentive surveillance to promptly diagnose and treat complications.

A 44-year-old female patient with chemotherapy-induced cardiomyopathy presented with acute cardiogenic shock requiring ECMO support. Multiple failed weaning trials from temporary mechanical circulatory assistance prompted a transition to staged durable biventricular support. Her course was complicated with recurrent RVAD stoppages. The initial event was treated with pump exchange, while for the subsequent RVAD standstill, we employed a device wash-out and reimplantation strategy. A brief period of circulatory arrest was employed to explore the right-sided cardiac chambers using a single-use bronchoscope.

Aim: Brachial artery access is an alternative approach to endovascular interventions when access to the femoral, radial, or ulnar arteries is not feasible, but it carries higher risk of periprocedural complications than other approaches, including median nerve injury. Nerve injuries can occur by direct puncture or by compression, with hematoma being the most common cause. Sometimes the compartment syndrome can accompany the direct nerve injury, masking the signs of a nerve dysfunction. Case report: We present a patient with a false aneurysm of brachial artery, surrounding soft tissue hematoma with volar arm and forearm compartment syndrome and a simultaneous median nerve intraneural hematoma caused by a direct punction. The combination of injuries occurred after brachial artery access for endovascular treatment of bilateral iliac artery steno-occlusive disease. The patient was successfully treated by fasciotomy, arterial sutures, and nerve decompression via paraneuriotomy. Conclusions: Intraneural hematoma caused by direct puncture can be masked by concomitant compartment syndrome. Emphasis should be put on prevention, early recognition, and timely surgical treatment of intraneural hematomas, especially those accompanied by fascial compartment syndrome after endovascular interventions.

Purpose We have analyzed markers of accelerated atherosclerosis like large artery stiffness, ankle-brachial index, carotid and vertebral duplex ultrasonography and their possible associations with the incidence of intracranial calcifications, clinical course of hemodialyzed patients, and cardiovascular mortality. Methods A computed tomographic scan of the head was performed for any neurological indication on 100 hemodialyzed patients. Eleven intracranial arteries were analyzed for calcification score, while internal carotid arteries and vertebral arteries were excluded in cerebral artery calcification score. As a control group for assessing intracranial calcifications, we have analyzed computed tomographic scans from diabetic patients who had an acute stroke. Results Deceased patients had significantly higher values of augmentation index and pulse wave velocity, lower ankle-brachial index, and higher internal carotid arteries peak systolic value than survived patients. Deceased patients had significantly higher number of calcified middle cerebral arteries as well as significantly higher intracranial artery calcification score and cerebral artery calcification score. Hemodialyzed patients had significantly higher both intracranial and cerebral artery calcification scores than diabetic control group. Age and calcified middle cerebral arteries had increased HR of 1.08 and 1.36 for cardiovascular mortality. Conclusion This study showed that large artery stiffness and not the presence of peripheral arterial disease or carotid artery stenosis have the prognostic role of middle cerebral arteries' calcifications and cardiovascular mortality in hemodialyzed patients. The presence of middle cerebral arteries' calcifications diagnosed by a non-invasive method should be considered a marker of middle-sized conduit arteries atherosclerosis, subclinical brain damage, and future fatal cardiovascular events.

Most renal injuries in pediatric patients are treated conservatively, but prolonged hematuria and major blood vessel injuries often require active bleeding control. Traumatic pseudoaneurysms of segmental branches of the renal artery occur in 2.5% of renal injuries. They usually manifest as prolonged or intermittent secondary hematuria, but may be asymptomatic as well. Watchful waiting is the initial treatment, and around one third of patients eventually require active surgical or endovascular treatment. The two main endovascular coil embolisation methods are the “sandwich” and the “coil packing” technique, but occlusion using a stent is also possible. Traumatic prolonged hematuria caused by pseudoaneurysm of the renal segmental arterial branch, and the methods of treatment are rarely reported, especially in children. This report presents a boy in whom a blunt kidney injury lead to the formation of a pseudoaneurysm of the renal segmental arterial branch, causing prolonged hematuria. The patient was treated by endovascular embolisation through the right femoral artery, in local anesthesia and conscious sedation. A 2.7 Fr microcatheter was used to selectively enter the dominant cranial renal artery and show the pseudoaneurysm of a segmental interlobar arterial branch. A 2×4 mm coil was used to occlude the segmental interlobar arterial branch and pseudoaneurysm, with no post-procedural bleeding or significant renal segmental ischemia. Endovascular treatment offers advantages over open surgery, but has certain drawbacks as well, such as high radiation and contrast exposure. In the last few years, a minimally invasive robotic surgical procedure has been described for the treatment of intra-renal pseudoanurysm. The current worldwide trend in pediatric renal injuries treatment is the reduction in the number of nephrectomies, and a shift to non-operative and minimally invasive treatment, including endovascular procedures. University Hospital Centre Zagreb has all the specialities and capacities required for surgical and endovascular procedures in children, making it the national referral centre for pediatric renal injuries treatment.

AccePteD: December 18, 2020 Introduction: Klippel-Trenaunay Syndrome (KTS) is rare syndrome characterized by a presence of capillary and venous malformation, limb overgrowth, with or without lymphatic anomalies1. KTS is related to mutations in the PIK3CA gene. Complications of KTS include clotting disorder, bleeding, lymphedema, soft tissue infection and pain. Treatment is individualized; it may include endovascular or surgical procedures and supportive care (management of coagulopathy, infection, pain). The use of mammalian target of rapamycin (mTOR) inhibitor sirolimus shows promising results in complex vascular malformations2,3. Case report: We present a 45 years old patient, currently living out of Croatia. Vascular malformation of the left arm was noticed a few months after his birth. During his childhood an angiography of the left arm lead to confirmation of KTS without further specific treatment. During the last 15 years he was undergoing regular hematology controls and treatment of consumptive coagulopathy as complication of KTS. In 2010 at age 35, he suffered a fracture on the left arm, but he was declared inoperable on basis of vascular malformation which extended the healing process. From 2018 further proliferation of vascular malformation was noticed on his left hemithorax. In 2020 he was presented to multidisciplinary vascular team, MR angiography was performed Unfortunately, due to extreme extension of vascular malformation with soft tissue hypertrophy and osseous deformation the patient is not suitable for any surgical or endovascular procedure. We suggested a treatment with sirolimus which is delayed due to patient’s temporary relocation. Genetic panel testing covering PIK3CA gene is in progress.