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The success of all vascular interventions depends mainly on the chosen strategy and access, especially in patients with severe co-morbidities, preceding operations or infection. In these cases the combination of retroperitoneal approach and extra-anatomical bypasses makes the revascularization possible. We present a clinical case of a patient after radiotherapy, peritonitis and colostomy with persistent pain in the lower extremities and angiographic finding of bilateral occlusion in the aorto-iliac segment. We did a right retroperitoneal aorto-femoral reconstruction and a crossover femoro-femoral bypass. It is also possible to perform visceral and renal arterial reconstructions with the retroperitoneal approach. In addition, symptomatic and ruptured aneurysms, as well as infected aortic grafts can be operated on with optimal results, without a notable increase in mortality.

Embolotherapy or embolization has rapidly developed in recent years and now represents an integral part of interventional radiology practice. Embolotherapy is defined as the percutaneous endovascular application of one or more of a variety of agents or materials to accomplish vascular occlusion. Embolization has grown dramatically in scope and complexity over the past three decades, and with this growth, there is now a need to define standards for those practicing in this field, including: appropriate training with monitoring of outcomes; provision of pre-, intra-, and postprocedure patient care; and performance of the technical aspects of the procedure. We present 58 patients from clinic of Vascular Surgery and Angiology at "St. Ekaterina" University Hospital. After four abnormal nutrition artery embolization in two consecutive procedure due to recurrences formation of adrenal tumor.

The first lumbar sympathectomy for treatment of arterial occlusive disease of the lower extremity was performed in 1924 by Julio Diez of Buenos Aires. The standart anatomy textbooks indicate, as a rule that the lumbar sympathetic trunk contains four or five ganglia. The overall anatomic denervation is important for achievement of an adequate sympathectomy of a given segment of an extremity. Criteria and indications for complete sympathetic block are still not clear. Exceptionally important for the improvement of the reology of the lower limbs is the option for a direct increase of the collaterals' debit which could be achieved by extensive profundoplasty. As an addition to the arterial reconstructions, the sympathectomy increases the passability of small vessel anastomosis and the recovery of traumatized arteries. Unilateral or bilateral lumbar sympathectomy is performed by retroperitonal access. From 01.01.2008 till 01.11.2008 in our clinic were performed 117 isolated and after arterial reconstruction lumbar sympathectomies.

We present a case of a 56-year-old male patient who was admitted at the clinic with complains of pain and blue-colored index finger of the left hand since a couple of days. He has an anamnesis of claudication of the left arm. After the contrast CT-angiogram, which showed a 80% stenosis of the left subclavian artery, the patient had an allergic reaction. This changed our initial plan for an endovascular intervention and we proceeded to an open surgical procedure. Because of the suitable anatomical characteristics we did a replantation of the subclavian artery to the common carotid artery. The postoperative period went smoothly. Six months after the intervention the patient is feeling fine. He has pulse on the radial and ulnar arteries and no sign of the necrosis of the index linger. Subclavian-carotid transposition is a safe method for the treatment of steno-occlusive lesions of the subclavian artery. Except the ortograde physiological blood flow through the vertebral artery and the construction of only one anastomosis, the main advantage over the bypass surgery is not using autogenous or heterogenous prosthetic material.

Cervix cancer is quite common nowadays. Its progress is followed by painful symptomatology, urosepsis, lymphedem, flebothrombosis and ischemia of the lower limbs. The surgical treatment and the following chemotherapy and radiotherapy causes proliferation of the fibroid tissue, which embraces and presses the vessels of the small pelvis. We are to depict two clinical cases in which the choice of the percutaneous transluminal angioplasty and the implementation of a covered stent - graft is preferable to the open surgery. During the predilatation with a balloon catheter, our first patient suffered of a vessel rupture, visualized on the intraoperative angiogram. The rupture of vessel during angioplasty usually demands open surgical correction, but endovascular procedure can provide a fast, efficient, and less aggressive method. Covered stent-grafts are applicable for both treatment and stabilization of vessel lesions.

The abdominal aneurysm imposes prominent epidemiological impact due to its high incidence and life threatening complications. The first steps in endovascular treatment of abdominal aneurysms in Bulgaria are herein described. Five bifurcated and one straight stent-grafts were implanted in the ,,St.Ekaterina" University Hospital for the period from February till May 2004. Satisfactory therapeutic result was achieved in all cases. The continuing follow-up of the patients proved favorable tolerability. The good therapeutic response, lack of perioperative mortality, and low complication rate provide evidence that endovascular repair can have beneficial implication in patients with abdominal aneurysms and high operative risk.

Although not very often diagnosed, the acute and chronic mesenterial ischemia is advancing and life threatening condition. When associated with multivascular pathology compromising the perfusion and causing multiple organ failure the choice of treatment is a challenge. In such cases the radical surgical treatment is associated with high morbidity and mortality. In recent years endovascular methods of treatment (angioplasty and stenting) are gaining popularity in the treatment of these patients. We report a case of chronic mesenteric ischemia that caused abdominal angina and weight loss in a 63-year-old man with renovasal hypertension, renal insufficiency and peripheral vascular disease. Angiographic study revealed multivascular pathology including total occlusion of the superior mesenteric artery, 90% stenosis of the celiac trunk, bilateral high grade renal stenoses and obstructive pathology of both iliac arteries. One stage successful endovascular treatment was performed in the three vascular territories. In the Celiac trunk, left renal artery and right common iliac artery were implanted stents. A double right renal artery was treated successfully with kissing balloon. A clinical follow-up demonstrated success with no recurrence of abdominal pain, body weight gain, better control of the hypertension and improvement of the renal function. This is the first reported case of one stage endovascular treatment of a visceral artery, bilateral renal arteries and iliac artery. This case report illustrates the value of endovascular treatment in a patient with atherosclerotic narrowing of multiple abdominal visceral arteries.

Percutaneous peripheral and coronary interventions as well as surgical procedures can be complicated by dissections and traumatic lesions of peripheral arteries. Posttraumatic peripheral dissections can be threatening for the extremities and often their management might be a challenge. Open surgery requires wide exposure and dissection of posttraumatic tissues. Endovascular techniques using selfexpandable stents gains popularity because of high efficiency, safety and good results. This technique is associated with decreased trauma, no requirements for anesthesia, short hospital stay. We present two cases of posttraumatic iliac dissections treated with self expandable stents.

Unlabelled: The stroke is one of the major causes for death and invalidization in the modern society. In about 30% of the cases the stroke is attributed to stenosis of a supraaortic vessel. In the last few years the percutaneous angioplasty and stenting is an alternative method of the classical surgical treatment--the carotid thrombendarterectomy. Crucial moment in the evolution of the method is the introduction in the practice of the systems for distal embolic protection of the brain and the routine implantation of stents with new design. One of the main conditions for successful and noncomplicated stenting is the respect of a strict procedural protocol. In the article we present the results of 17 cases with angioplasty and stenting of supraaortic vessels performed in our Clinic in the period 07.02.2001-01.07.2001. The immediate success rate is 100%. No major complications (stroke, myocardial infarction and death) were registered. In the midterm follow-up there were no thrombosis and restenosis of the implanted stents. We present four interesting case reports: 1. One stage stenting of right coronary artery and right internal carotid artery, 2. Stenting of a subocclusive right internal carotid stenosis with balloonexpandable stent and 3. Stenting of a vertebral artery as the unique brain supplying vessel and 4. Stenting of subocclusive aortoostial lesion of the brachiocephalic trunk in a patient with totally occluded contralateral internal carotid artery., Conclusions: Stenting of supraaortic vessels is a safe and reliable method when performed by experienced operator and when are applied the ultimate methods of cerebral protection and the new stent designs. The carotid stenting is a reliable alternative of the surgery and gains more and more popularity.

Posttraumatic false aneUrysms can be life threatening and often their management might be a challenge, because of poor general condition as well as because of specific technical difficulties. Open surgery requires wide exposure and dissection of posttraumatic tissues. Endovascular techniques using stent-grafts gains popularity because of high efficiency, safety and good results. We present a case of posttraumatic false aneurysm of right subclavian artery treated with a stent-graft.

Objectives: This study attempted to determine the possibility for steal phenomenon after coronary surgery using internal mammary artery (IMA) as graft with unligated big side branches. The internal mammary artery (IMA) is considered to be the conduct of choice in coronary artery bypass grafting (CABH). The more IMA grafts are used, the more increases the significance of IMA anomalies and notably the large side branches for the surgical results. The importance of coronary subclavian steal syndrome is well known. We represent two clinical cases with big intercostal branches visualised at the postoperative coronary angiography, performed to evaluate the coronary and graft status cause of recurrent postoperative anginal pain. After cardiac catheterization we performed ECG stress test as follows: 1. A conventional stress test on treadmill (for control) and 2. Modified stress test loading the chest wall muscles in spine position. We expected to provoke and to evaluate steal phenomenon by the main IMA graft to the big lateral branches. At both of the patients on the arteriographic study IMA graft was patent and both had unusual large (> 50% of the IMA lumen) side branches, reducing the blood flow in the IMA graft. The modified stress test loading the chest wall muscles didn't provoke anginal pain at both patients. At the first (50 years old white male, CABG x 3-July 1193) it was evident non significant ST depression (< 2 mm) in V4-V% (suspicion of silent ischemia). At the second (70 years old white male, anterior MI-1990, GABG x 4-1992) the stress test was interrupted because of fatigue at the arm. No evident significant ecg changes. Despite we couldn't prove steal phenomenon through the angiographic study and the modified ECG stress test we suggest several logic.

Objectives: The article reviews the results of PTCA in 164 patients in Hospital "St Ekaterina" in the period January 1994-April 1994., Methods: Patients were divided in four groups: I Stable angina II Unstable angina a) primary stabilized b) refractory to medical treatment III Acute myocardial infarction (AMI) IV Silent ischaemia Patients were followed for: 1.) Acute complications a) mortality b) myocardial infarction (MI) c) emergency CABG 2.) Late complications a) recurrent angina b) MI c) elective CABG d) re-PTCA e) late mortality Follow-up period was 6-12 months, Results: I group 1) acute complications--early mortality--0%; acute MI--0%; emergency CABG--5%; 2) Late complications--recurrent angina--8.4%; MI--1.5%; late mortality--0%; elective CABG--0%; re-PTCA--6.5%. I group 1) acute complications--early mortality--0%; acute MI--6%; emergency CABG--3%; 2) Late complications--late mortality--6%; recurrent angina--10%; MI--6%; elective CABG--1%; re-PTCA--14%. III group 1) acute complications-early mortality--0%; acute MI--17%; emergency CABG--17%; 2) Late complications--recurrent angina--17%; MI--17%; late mortality--17%; elective CABG--0%; re-PTCA--0%. IV group 1) acute complications--early mortality--0%; acute MI--0%; emergency CABG--0%; 2) recurrent angina--18%; late MI--0%; late mortality--0%; elective CABG--0%; re-PTCA--18%., Conclusions: PTCA is a safe and reliable method for revascularization not only in patients with stable angina, but also in patients with acute coronary syndromes.

The arsenic exposure in the main departments and occupational groups of the copper smelter in Pirdop has been estimated in the present study. The contents of arsenic is measured in the air and in biological samples--urine and nails. At most of the workplaces the time-weighted average (TWA) concentrations do not exceed the threshold limit value (0.05 mg/m3). The maximum TWA level is about three times higher. The intake of arsenic is significantly increased in almost all observed occupational groups. However, the excretion of only 8% of the workers is higher than the maximum background level (100 micrograms/l). The estimated degree of exposure corresponds to a low health risk. Some of the most heavily exposed occupational groups may be expected to reach higher levels of intake and health risk.

Examination is performed on 87 miners from mine for copper production subject to intensive local vibrations with average rate of increase (K) of the norms for the individual octave frequencies 2.4 times for 3 h exposure of the working shift, as well as to intensive noise--113-115 dB/A equivalent level, general dust--23 mg/m3, fine dust--3.5 mg/m3 and fine quartz--0.43 mg/m3. There are data for vibration effect--changes in the cold test, vibration sensoriness, ultra sound sonometry, in all miners. In a significant part of them are established dyslipoproteinemia--increase of triglycerides, total and LDL cholesterol, values beyond reference (mainly above the norm) of 10 electrolytes and microelements in blood serum (blood). An extremely high prevalence of the cases and the days of total morbidity with temporary disability (respectively 189.7 and 2935 per 100), with predominance in its structure of diseases of the central and peripheral nervous systems, hypertension disease, etc. The importance of vibrations for disorder in the metabolic processes in the organism and development of temporary diseases are underlined.

An economic evaluation is made on temporary disability because of disease of trauma, for a three-year period in one shop of technological plant for nonferrous metallurgy. The established, by means of economics-mathematical method, not produced production sums up to approximately 18 million leva.

A study was carried out on soils for heavy metals content in the region of one of the largest scale enterprises in the country - Copper Extraction Plant "G. Damjanov", Srednogorie town. A sensitive method was used with atom absorption spectrophotometer Perkin Elmer, Model 272, for the determination of the heavy metals investigated: manganese, nickel, zinc, copper, lead and cadmium. The authors investigated soil samples from two horizones: from 0.30 and from 30-60, comparing the results obtained with those in control "pure" soils and with the existing maximum allowable concentration (MAC). Elevation of the quantity of heavy metals in the soils was established, being best manifested with copper and lead, 90% of the samples containing copper over MAC, and with lead-over 33%.

The study of morbidity rate with temporary disability according to subjects, based on the Soviet experience has an approximately thirty year history in our country. Even though, numerous scientific, methodical and organizational problems with a view to the application of the method-according-to-subjects are still unsolved. The object of our study is a plant of the Union of the Blind in Bulgaria, producing cork stoppers, electrical materials and haircloth. The information derived from the patients' chart by an individual index-card, allowed a more detailed and more comprehensive analysis of the indices of the morbidity rate with temporary disability according to subjects, cases and the days lost because of temporary disability, depending on age-sex structure, occupational group, workshop, length of service and place of residence. The results obtained were compared with those supplied by the official statistics of the TIITs-Gabrovo. The groups of often and continuous sick subjects (6.96%) and (8.56%) have been established for 1983, covering about 40% of the cases with temporary disability and over 60% from the labour losses for that year. Well grounded hygienic and medical-prophylactic measures are recommended on the base of the conclusions drawn.

Studied were the bones of the limbs of 20 male rats of the Wistar line divided into 2 groups--one immobilized and one control. The latter was raised under the normal conditions of a vivarium, and the test group of 60-day-old rats was kept in individual cells for physiologic immobilization. The experiment lasted for a total of 390 day, i.e., at the time of killing and sampling the animals were at the age of 450 days. Each part of the limbs was measured severalfold at several sites by means of a slide-gauge and the data were processed statistically and via dispersion analyses. Besides, the structure of the bone tissue was investigated in histologic preparations, determining the density of the osteocytes. Measured was also the microhardness after Wikers of the bones of the two groups of animals, using a metallographic microhardmeter. It was established that all bones of the fore- and the hindlimb were shorter and in general smaller under the effect of hypokinesia. Immobilization was shown to affect chiefly the proximal bones of the limb skeleton. The growth of the bones decreased in hypokinesia to the detriment not so much of the cell elements than of the intercellular matter of the bone tissue. The microhardness of the bones of the immobilized rats was lower than that of the control ones.

Extremely important for the character of the health status of the medical staff of the Bulgarian Medical Academy is tracing the level and dynamics of their morbidity (general, expressed by means of integral parameters of morbidity with temporary incapacity for work and of the professional, including the industrial traumatism). On the basis of a two-year study performed at the Medical Academy, with the assistance of the confidential medical staff was gathered the necessary information for the extent and noslogical structure of the morbidity with temporary work incapacity and the number and nosology of the professional diseases, poisonings and occupational accidents. By making use of the basic statistical analyses, the prepared information served to establish the status of morbidity (low for the cases and high for work loss), in order to arrange the Institutes and Departments according to the incidence of temporary work incapacity for work (in days), and give recommendations for undertakings directed on the one side to more profound study of the morbidity and on the other to its practical decrease.

The authors followed-up five patients with primary myelofibrosis in the course of 4 years. The diagnosis, in all cases, was confirmed via histologic investigation of trepenation biopsy material of bone marrow and bone. The clinical and hematologic variety, observed by the authors, provided grounds for the formation of the following variants of the primary myelofibrosis: myelemic-anemic form, form with leucosis transformation, form with sarcomatization, myelofibrosis with immune hemolytic anemia and myelofibrosis in aplastic state. The establishment of transitory forms between the myeloproliferation and dysanaplastic blast processes allows the presumption that the pathogenesis essence of primary myelofibrosis is manifested in clonal lesion of the stem bone-marrow cells.

The economic aspects of morbidity with temporary incapacity for work are in close connection with the setbacks of the industrial unit, as a result of illness of their workers. On the basis of data taken from the Planning and Economic Department of the Success Plant and using the corresponding method for defining the waste of production, connected with temporary incapacity for work because of illness, which comes up to more than 2 million leva and at the same time payed compensations for 73,000 leva. This allows to establish the true balance between the expenditures of the plant for preventive measures, directed towards a decrease of the setback because of temporary invalidity and take decisions on behalf of the managers of the plant.

Morphologic studies were carried out on the skeletal musculature of two groups (test and control) of male rats of the Wistar line. The animals of the test group were kept when at the age of 60 days in individual cells for physiologic immobilization. Those of the control group were kept under normal conditions of raising. All animals were killed for sampling at the age of 450 days. Twenty-four hours after killing the following muscles were prepared and weighed for study: musculus longissimus dorsi, m. semitendinosus, m. semimembranosus, and m. triceps brachii. Micromorphologic and histometric investigations were conducted with the first three muscles, determining the quantitative ratio between the tissue components with the use of an 'integrational table' ISA. It was found that the skeletal muscles of rats kept for 390 days in the conditions of immobilization had a lower weight. The intramuscle fatty tissue of m. longissimus dorsi and m. semitendinosus as well as the connective tissue of m. longissimus dorsi showed higher weight, resp., amount in the immobilized animals, while the muscular tissue (the primary muscle bundles) was better developed in the control animals. The diameter of the muscle fibers of m. semitendinosus only was smaller in the immobilized rats. The variability in the thickness of the muscle fibers in the test group animals proved higher. Degenerative processes involved both the light and the dark fibers.

Plasma aluminium concentration was followed up in 28 patients with chronic renal insufficiency, treated with hemodialysis in the course of four years. Increased value of plasma aluminium was established as compared with a control group of healthy subjects, not observing any clinical signs of dialysis dementia. Slight increase of plasma aluminium at the end of the dialysis, was observed when the dialysis solution was prepared with non-purified potable water. When purified water, by reverse osmosis, was used the plasma aluminium concentration of the patients was not changed during the dialysis (the differences observed were not statistically significant). That fact provided grounds the authors to admit that the reason for the plasma aluminium increase during dialysis was the aluminium found in the dialysis solution, which necessitates water meeting the standard requirements for the allowable aluminium content, to be used for the needs of hemodialysis.

A survey is carried out among the population of a district with nonferrous metallurgy in view of studying the mutual relation between the exposure to heavy metals and some basic risk factors for the development of ischemic disease of the heart. The study pertains to the content of lead, cadmium, copper and zinc in blood and its relation to the serum lipids, glutathione in blood, arterial pressure and age. A higher level of triglycerides and free butyric acids were established in the serum with absence of clinical manifestations as a result of exposure to heavy metals. A significant correlation of cadmium, copper and zinc with serum lipids was found. On the basis of regressive analysis equations for the changes in the biochemical indices are derived under the effect of exposure to heavy metals, as well as for the connection of the arterial pressure with age and serum cholesterol. It is reckon that in clinical healthy young people under the effect of nonoccupational exposure to heavy metals a prerequisite is created for development of atherosclerotic diseases in mature and advanced age. It is recommended that the environmental pollution by nonferrous metallurgy to be accepted as risk factor for development of ischemic disease of the heart and to be taken under consideration in the complex preventive measure for this disease.