I'm fine, doctor, the patient replies, lying on the operating table while the doctor Slobodan Ćulafić, via a "guide wire" and a system of microcatheters and catheters, in a forest of blood vessels, finds its way to the narrowing of the carotid artery that threatened to cause a stroke with unforeseeable consequences in this young man.
In the Angio Hall of the Clinical Hospital Center (KBC) Berane, in addition to the “Vijesti” team that attended this two-hour complicated procedure, at the operating table are two interventional neuroradiologists, an instrument operator, an X-ray technician, an anesthesiologist and an anesthesiologist - a well-coordinated team led by Dr. Ćulafić, an experienced specialist in interventional neuroradiology, who has so far performed around 9.000 of these complex surgical procedures, mostly on blood vessels in the head. What is characteristic of the work of this excellent doctor is that patients are awake and in constant communication with him at all times.
"With me, all patients are awake, regardless of whether it is an aneurysm, arterial malformation or narrowing of the blood vessels in the head and neck, because that way I monitor them neurologically, I monitor what is happening. If I notice that the patient is not responding adequately to my requests, whether he is moving his arm, whether he is moving his leg, opening or closing his eyes, I ask him something, I talk to him, then the patient must be anesthetized in order to continue the intervention. Of course, the other parameters, pressure, frequency, oxygenation are monitored by an anesthesiologist," emphasizes Dr. Ćulafić, noting that the exception is patients who have a brain hemorrhage or stroke, and then the intervention must be performed under general anesthesia.
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In two days, this team will operate on six patients at KBC Berane. Three had narrowing of the blood vessels in the neck, one patient had narrowing of the blood vessels in both the neck and leg, two patients with brain aneurysms, and one younger patient who had an arteriovenous malformation in the brain.
Before entering the operating room, Dr. Ćulafić warns that this patient had previously had a transient cerebral infarction, transient weakness, and it was discovered that the cause was narrowing of the blood vessel in the carotid artery.
"He has over 90% narrowing of the blood vessel. He had a complete diagnostic scan and it was found that, in addition to the narrowing of the carotid artery, he also has a narrowing of the blood vessel in his leg, which is why he had leg cramps. Our goal, the idea, is to do the carotid artery as well, to protect him from developing a stroke, and to resolve the narrowing of the blood vessel in his right leg so that gangrene or ischemia of the foot does not develop," says Dr. Ćulafić, emphasizing that he will perform both interventions at the same time.
The doctors are already at the operating table, the patient is prepared for the operation. He has received blood thinning medication to prevent the formation of thrombi or clots, because these systems that are introduced into the blood vessel can form a clot. That is why patients are prepared well before the intervention, during the intervention they are given certain therapy to prevent the formation of thrombi due to the balloons and stents that remain in the body.
"We clean the surgical field in the groin where the blood vessel is located. At that point, we introduce a needle, through that needle we place a guide wire, over it microcatheter and catheter systems, which have their own length, to reach the place where there is a narrowing or dilation of the blood vessel. When we reach that place, we bring a balloon to the place of the narrowing of the blood vessel, specifically the narrowing of the carotid artery. In the case of carotid artery narrowing, we perform balloon dilation and dilate the blood vessel with a balloon," explains Dr. Ćulafić at the very beginning of the surgical procedure.
During the operation, Dr. Ćulafić is in constant communication with his already well-coordinated team, and occasionally exchanges a few sentences with the patient, mostly asking “how are you?” He is focused on a large screen through which he (and we) follow the path of the “guide wire” through the forest of blood vessels. Of course, all of the patient’s vital parameters are also closely monitored.
As he reaches the target location on the carotid artery, Dr. Ćulafić shows an arteriovenous malformation on the left side.
"That's the dominant hemisphere. He's right-handed and our goal is to close the AVM malformation. That's a bunch of blood vessels, you can see here, that were causing him problems and could have caused epilepsy or bleeding, which would have been fatal for him. Here, you can see the microcatheter that we inserted to get to the center of that AVM malformation. That's the tip of the catheter that you can see here, where we got to the very center of the AVM malformation because the goal is to close the blood vessels and thus prevent bleeding and close the blood vessel that is not functional. Here, I got to the center," says Dr. Ćulafić at one point.
Soon after, the non-functional blood vessel was closed, the patient received functional blood vessels, these smaller ones, Dr. Ćulafić shows on the monitor, these are functional blood vessels that are good, and the one that is not good is disconnected.
"It is believed that sometimes, when these blood vessels that are not good are closed, it happens that the blood flow that is now where it should be, due to the accelerated flow, can cause bleeding. The brain is not used to having this blood flow because until now it has been going through this blood vessel that is not good. And now that you close it like this, and it has received a flow that is good for it, sometimes the increased amount of oxygen and blood can cause a problem for the brain. And that is why we need to be careful here," emphasizes Dr. Ćulafić.
After more than two hours, the operation was successfully completed, and the patient, as well as Dr. Ćulafić, are satisfied.
"We dilated the blood vessel with a balloon, and then we placed a stent through the catheter, which was already in place, thereby ensuring full flow through the blood vessel," Dr. Slobodan Ćulafić states with satisfaction at the very end of the operation.
The patient will go home after two days and continue with his daily life without the previous health risks, and Dr. Ćulafić's team will continue with the surgical plan for that day after a short break.
In stroke, time is of the essence
Dr. Slobodan Ćulafić warns that these are preventive interventions.
"When a stroke occurs, intervention must be performed within the first six hours, when it comes to the carotid arteries, and when it comes to the posterior circulation, it can be up to ten hours. In such situations, catheter and microcatheter systems and a special stent or aspiration are used to extract the thrombus from the blood vessel that led to the development of symptoms, right-sided paralysis or speech disorders or disorders of consciousness," emphasizes Dr. Ćulafić.
When this is done on time, he adds, in most cases the patient is left without a serious neurological deficit.
"When it comes to aneurysms, and bleeding occurs, half of the patients die. If the intervention is performed immediately, it prevents death," emphasizes Dr. Slobodan Ćulafić.
The great importance of the angio hall
A little less than three years ago, the Berane General Hospital was transformed into the Berane Clinical Hospital Center. At that time, the decision was made to begin implementing certain tertiary-level healthcare procedures in order to bring services closer to patients, especially those from the north who would no longer have to travel to Podgorica and other places.
According to dr Milorad Magdelinić, director of KBC Berane, the angio room began operating in 2024.
"During that period, in just under two years, 2.334 patients from the cardiology program and 57 patients from the neurology program were treated. The angio room is open daily. A year and a half ago, we also launched the neurology program in agreement with Dr. Slobodan Ćulafić, who started working here and treating the most complex interventions, so we are treating patients who previously had to travel abroad, to Belgrade, Turkey or other destinations," explains Dr. Magdelinić.
According to him, Berane treats patients mainly from the north, but also from other parts of Montenegro.
"We are involved together with the Clinical Center of Montenegro to resolve waiting lists. In Montenegro, people no longer have to wait longer than a month for the cardio program, but everything is taken care of within that period, which is something that few countries can boast of," emphasizes the director of KBC Berane, adding that, as for the neuro program, these patients were not taken care of in Montenegro.
"With the arrival of Dr. Ćulafić, opportunities have been created for these patients to be cared for in a quality manner in Montenegro. This is a great benefit for patients, as they do not have to expose themselves to additional costs and harassment of the entire family by traveling to Turkey or somewhere else. In addition, the costs of the Health Insurance Fund are significantly reduced when patients are cared for in Berane. So there are benefits for patients, for institutions, and in general for the entire community, for Montenegro," said Dr. Magdelinić.
He emphasizes that the procedures for the neuro program are very expensive, as are the consumables used.
"Since the opening of the angio room in April 2024, the Ministry of Health and Minister Vojislav Šimun have given maximum support to this program and, thanks to their support, we have expanded this program to include a neuro program. So far, it is working great, to everyone's satisfaction, because this has proven to be one of the best moves in Montenegrin healthcare that has been made," emphasizes Dr. Milorad Magdelinić.
Specialization in America
Dr. Slobodan Ćulafić was born in Berane, where he completed elementary and high school.
He graduated from the Faculty of Medicine in Belgrade. After that, in 1988, he started working at the DZ in Podgorica. After three years, he went to Peć and specialized in urology there. He returned to Podgorica in 1993, and after completing a course in aviation medicine in Batajnica, he began working at the Military Airport in Golubovci as a doctor for military pilots. After two years, he received a specialization in radiology at the Military Medical Academy, where he worked until 2012. He was a radiologist at the Institute of Radiology of the Military Medical Academy at the beginning, then the Head of the Department of Neuroradiology and for three years the Head of Radiology of the Institute of Radiology of the Military Medical Academy, as the youngest head in the history of the Institute and a lieutenant colonel at that time.
He left the Military Medical Academy in 2012 and moved to the "Sveti Sava" hospital, where he established the department for interventional neuroradiology, where he was also the head until 2021, when he established the Center for Vascular Diseases of the Brain at the IKVB "Dedinje", of which he was the director.
Professional training in the field of interventional neuroradiology or, as they say in the USA, endovascular surgery began in 2003 in Chicago, at Rush University, then in 2006 in Paris, at Hospital Lariboisere (Department of Neuroradiology), and then in Houston and New York.
As a consultant, he worked at the University of Tuzla, the Clinical Center Niš, the Clinical Center Kragujevac, the Clinical Center in Novi Sad, the University of Sofia and the University of Skopje, as well as at Adži Badem, where he is still a consultant.
He has educated numerous doctors from the country and abroad, including colleagues from Kragujevac, three neurosurgeons from Sofia, two neurosurgeons and an interventional radiologist from Skopje, and doctors from Sarajevo, Tuzla, and Pristina.
As a pioneer, Dr. Ćulafić introduced all these procedures to Serbia and the region.
He had his first aneurysm treated in 2004, arteriovenous malformation in 2007, basilar artery stenosis in 2006, and stroke treatment in 2008 while working at the Military Medical Academy.
Acute stroke treatment was introduced in 2014 at the Sveti Sava Hospital with new stents and aspiration catheters, a year before the procedure was officially introduced into the protocol worldwide.
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