The Comparison of Endovascular and Open Surgical Treatment for Ruptured Abdominal Aortic Aneurysm in Terms of Safety and Efficacy on the Basis of a Single-Center 30-Year Experience.

OBJECTIVE: Ruptured abdominal aortic aneurysm (rAAA) is a critical condition with a high mortality rate. Over the years, endovascular aortic repair (EVAR) has evolved as a viable treatment option in addition to open repair (OR). The primary objective of this study was to compare the safety and efficacy of EVAR and OR for the treatment of rAAA based on a comprehensive analysis of our single-centre 30-year experience. METHODS: Patients treated for rAAA at the Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Germany from 1 January 1993 to 31 December 2022 were included. Relevant information was retrieved from archived medical records. Patient survival and surgery-related complications were analysed. RESULTS: None of the patient-specific markers, emergency department-associated parameters, and co-morbidities were associated with patient survival. The 30-day and in-hospital mortality was higher in the OR group vs. in the EVAR group (50% vs. 8.7% and 57.1% vs. 13%, respectively). OR was associated with more frequent occurrence of more severe complications when compared to EVAR. Overall patient survival was 56 ± 5% at 12 months post-surgery (52 ± 6% for OR vs. 73 ± 11% for EVAR, respectively) (p < 0.05). Patients ≥70 years of age showed poorer survival in the OR group, with a 12-month survival of 42 ± 7% vs. 70 ± 10% for patients <70 years of age (p < 0.05). In the EVAR group, this age-related survival advantage was not found (12-month survival: ≥70 years: 67 ± 14%, <70 years: 86 ± 13%). Gender-specific survival was similar regardless of the applied method of care. CONCLUSION: OR was associated with more severe complications in our study. EVAR initially outperformed OR for rAAA regarding patient survival while re-interventions following EVAR negatively affect survival in the long-term. Elderly patients should be treated with EVAR. Gender does not seem to have a significant impact on survival.

Gene Therapy of Chronic Limb-Threatening Ischemia: Vascular Medical Perspectives.

A decade ago, gene therapy seemed to be a promising approach for the treatment of chronic limb-threatening ischemia, providing new perspectives for patients without conventional, open or endovascular therapeutic options by potentially enabling neo-angiogenesis. Yet, until now, the results have been far from a safe and routine clinical application. In general, there are two approaches for inserting exogenous genes in a host genome: transduction and transfection. In case of transduction, viral vectors are used to introduce genes into cells, and depending on the selected strain of the virus, a transient or stable duration of protein production can be achieved. In contrast, the transfection of DNA is transmitted by chemical or physical processes such as lipofection, electro- or sonoporation. Relevant risks of gene therapy may be an increasing neo-vascularization in undesired tissue. The risks of malignant transformation and inflammation are the potential drawbacks. Additionally, atherosclerotic plaques can be destabilized by the increased angiogenesis, leading to arterial thrombosis. Clinical trials from pilot studies to Phase II and III studies on angiogenic gene therapy show mainly a mixed picture of positive and negative final results; thus, the role of gene therapy in vascular occlusive disease remains unclear.

Reconstruction for Symptomatic Vertebral Artery Lesion Using Vertebral Artery to Carotid Artery Transposition: A Retrospective Study.

BACKGROUND: A posterior circulation infarction is caused by a vertebral artery (VA) lesion (stenosis or occlusion). The purpose of this study is to assess early and long-term outcomes after open surgery for a VA lesion at the origin. METHODS: In a retrospective study conducted from January 1, 2000 through March 31, 2020 in a single center, patients were treated with vertebral artery to carotid artery transposition (VCT). RESULTS: A total of 28 patients, with a mean age of 65.29 ± 9.81 years (range 45-84), were screened, including 22 patients with VA stenosis and 6 patients with VA occlusion. The complication rate was 21.4% (n = 6), including Horner syndrome (n = 2), lymphocele (n = 1), respiratory failure (n = 1), embolism of a subclavian artery stenosis (n = 1), and vocal cord paralysis (n = 1). The 30-day mortality rate was 0%. Primary patency was 100%. Overall, improvement in symptoms was 85.7% (n = 24) after surgery and 96.4% after 30 days. In the long-term results, primary patency was 100%, and the cumulative patency rate after 60 months was 85.7%, with 1 occlusion of the VA. Cumulative survival rates were 94%, 87%, 69%, and 59% after 12, 24, 60, and 72 months (n = 5). One of the 3 patients died after 60 months because of VA occlusion and posterior circulation infarction. CONCLUSIONS: VCT is a safe, effective, and durable procedure. It provides good stroke protection, symptomatic relief, and perioperative risk at acceptable levels, in experienced hands.

Contemporary Surgical Management of Aberrant Right Subclavian Arteries (Arteria Lusoria).

BACKGROUND: An aberrant right subclavian artery (ARSA) is in most cases an asymptomatic aortic arch anomaly. However, dysphagia, aneurysm formation (ARSAA), associated Kommerell diverticulum, or cerebellar/arm malperfusion may require invasive therapy. Large-scale clinical trials do not exist in current literature. We report our patient's outcome of a single-center experience and delineate indications for treatment and surgical techniques. METHODS: A single-center retrospective study was conducted between January 1, 2012 through March 1, 2018. Symptomatic or asymptomatic patients with ARSAA who received invasive treatment at the Department for Vascular and Endovascular Surgery, University Hospital Dusseldorf, Germany were included. RESULTS: Eight patients (4 men, 63 ± 14 (39-78) years) were treated with single-stage (n = 4) or multistage (n = 4) procedures. Treatment for ARSAA (n = 4) included ARSA revascularization (subclavian-carotid transposition (SCT) = 3; carotid-subclavian bypass (CSB) = 1), aortic arch debranching (left SCT = 2, bilateral aorto-carotid bypass + left CSB = 1, right-to-left CSB + left-carotid-to-bypass transposition = 1), and thoracic endovascular aortic repair (TEVAR; n = 4). Other strategies included SCT for dysphagia (n = 2) or subclavian steal syndrome (n = 1) and balloon angioplasty for arm claudication (n = 1). Complications involved vascular access (n = 2) and each one partial common carotid artery overstenting without stroke during TEVAR and Horner syndrome after SCT. Mean follow-up was 23 ± 26 (9-67) months. After 7 months, 1 patient required vertebral artery coiling due to type II endoleak with ARSAA progression. Overall mortality was 0%. Technical and clinical success rates were 100%. CONCLUSIONS: Surgical concepts for ARSA aim on preventing aneurysm rupture and alleviate dysphagia or ischemic symptoms. To generate satisfying patient outcomes, individualized therapy planning in specialized centers is vital.

European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia.

Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.

Clinical outcomes after direct and indirect surgical venous thrombectomy for inferior vena cava thrombosis.

OBJECTIVE: Inferior vena cava thrombosis is rare, but patients are at high risk for development of a post-thrombotic syndrome (PTS) in the long term. Surgical approaches include indirect transfemoral venous thrombectomy (iTFVT) and direct open venous thrombectomy (dOVT). This study reports patient outcomes after iTFVT and dOVT for inferior vena cava thrombosis covering a 25-year follow-up period. METHODS: The study period was from January 1, 1982, to December 31, 2013. Data were retrieved from archived medical records, and patients were invited for a detailed phlebologic follow-up examination (DPFE). Health-related quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. Patient survival, patency rates, and freedom from PTS were calculated using Kaplan-Meier estimation with log-rank testing. The χ2 test with Yates continuity correction and logistic regression analysis were applied to identify associations between risk factors or coagulation disorders, mortality, and PTS. RESULTS: Complete medical records were available for 152 patients. Patients' 5-year survival was 91% ± 3%, and 5-year primary and secondary patency rates were 80% ± 3% and 94% ± 2%. Freedom from PTS after 25 years was 84% ± 6%. No differences for patient survival, patency rates, or freedom from PTS were identified between iTFVT, dOVT, and a combination of both procedures. Antithrombin III deficiency was the most common coagulation disorder, and patients' physical function and social function were impaired compared with those found in German normative data (P < .05). No risk factor or coagulation disorder was associated with survival or PTS. CONCLUSIONS: Open surgical venous thrombectomy is safe and delivers satisfying short- and long-term outcomes compared with endovascular approaches. It remains valuable for patients who are not eligible for other interventional therapies.

The JOTEC iliac branch device for exclusion of hypogastric artery aneurysms: ABRAHAM study.

OBJECTIVE: Hypogastric artery aneurysms (HAAs) are rare but life-threatening in cases of rupture. Open or endovascular techniques traditionally aimed at occluding the hypogastric artery (HA) have considerable risk of pelvic ischemia. Iliac branch devices (IBDs) are indicated for aortoiliac aneurysms; however, they have also been used lately for HAAs. Currently, there are no reports about patient outcomes focusing on HAA therapy using IBDs. We retrospectively analyzed early and midterm outcomes using IBDs for HAAs. METHODS: Patients who received IBDs for HAAs at our department from January 1, 2012, through March 1, 2018, were included. Exclusion criteria were as follows: no HA involvement, emergency procedures, and HA stent grafting without IBD. Perioperative and follow-up data were collected from medical records. RESULTS: There were 18 IBDs (only IBD, n = 4; IBD + endovascular aneurysm repair [EVAR], n = 7; IBD ± EVAR + side branch occlusion, n = 7) implanted into 14 male patients (76 ± 4 [70-83] years). There were no intraoperative complications, and the technical success rate was 100%. After 19 ± 11 (2-39) months of follow-up, two hybrid (external iliac artery occlusion, n = 1; EVAR graft kinking, n = 1) and four endovascular reinterventions due to two type IB (side branch coiling + stent graft extension) and two type IIIB (stent grafting) endoleaks were required. One IBD-related type II endoleak revealed constant aneurysm diameters during follow-up. One small type IB endoleak was self-limited. Estimated freedom from reintervention was 31% ± 23% at 2.7 years. The clinical success and patency rate was 100%. The IBD-related mortality was 0%. CONCLUSIONS: The IBD for HAA shows good early and midterm results. Adequate sealing of HA landing zones and side branch occlusion are technically challenging but crucial to prevent type IB and type II endoleaks.

Acute Limb Ischemia-Much More Than Just a Lack of Oxygen.

Acute ischemia of an extremity occurs in several stages, a lack of oxygen being the primary contributor of the event. Although underlying patho-mechanisms are similar, it is important to determine whether it is an acute or chronic event. Healthy tissue does not contain enlarged collaterals, which are formed in chronically malperfused tissue and can maintain a minimum supply despite occlusion. The underlying processes for enhanced collateral blood flow are sprouting vessels from pre-existing vessels (via angiogenesis) and a lumen extension of arterioles (via arteriogenesis). While disturbed flow patterns with associated local low shear stress upregulate angiogenesis promoting genes, elevated shear stress may trigger arteriogenesis due to increased blood volume. In case of an acute ischemia, especially during the reperfusion phase, fluid transfer occurs into the tissue while the vascular bed is simultaneously reduced and no longer reacts to vaso-relaxing factors such as nitric oxide. This process results in an exacerbative cycle, in which increased peripheral resistance leads to an additional lack of oxygen. This whole process is accompanied by an inundation of inflammatory cells, which amplify the inflammatory response by cytokine release. However, an extremity is an individual-specific composition of different tissues, so these processes may vary dramatically between patients. The image is more uniform when broken down to the single cell stage. Because each cell is dependent on energy produced from aerobic respiration, an event of acute hypoxia can be a life-threatening situation. Aerobic processes responsible for yielding adenosine triphosphate (ATP), such as the electron transport chain and oxidative phosphorylation in the mitochondria, suffer first, thus disrupting the integrity of cellular respiration. One consequence of this is irreparable damage of the cell membrane due to an imbalance of electrolytes. The eventual increase in net fluid influx associated with a decrease in intracellular pH is considered an end-stage event. Due to the lack of ATP, individual cell organelles can no longer sustain their activity, thus initiating the cascade pathways of apoptosis via the release of cytokines such as the BCL2 associated X protein (BAX). As ischemia may lead to direct necrosis, inflammatory processes are further aggravated. In the case of reperfusion, the flow of nascent oxygen will cause additional damage to the cell, further initiating apoptosis in additional surrounding cells. In particular, free oxygen radicals are formed, causing severe damage to cell membranes and desoxyribonucleic acid (DNA). However, the increased tissue stress caused by this process may be transient, as radical scavengers may attenuate the damage. Taking the above into final consideration, it is clearly elucidated that acute ischemia and subsequent reperfusion is a process that leads to acute tissue damage combined with end-organ loss of function, a condition that is difficult to counteract.

Open surgery for iliofemoral deep vein thrombosis with temporary arteriovenous fistula remains valuable.

Objective We assessed outcomes of open surgical venous thrombectomy with temporary arteriovenous fistula, and the procedure's effect on health-related quality of life. Method We retrospectively analyzed 48 (26 at long-term) patient medical records. Mortality rates, patency, and risk of post-thrombotic syndrome were analyzed using Kaplan-Meier estimation. The association between risk factors/coagulation disorders and patency/post-thrombotic syndrome along with patient health-related quality of life at long-term was analyzed employing various statistical methods. Results Patient one-year survival rate was 93 ± 4% and primary one-year patency rate was 89 ± 5% (secondary one-year patency rate 97 ± 3%). Freedom from post-thrombotic syndrome after eight years was 80 ± 12% (post-thrombotic syndrome rate 20 ± 12%). Health-related quality of life was impaired vs. normative data in the physical and social subscales, and in the mental component score ( p < .05). Conclusions Open surgical venous thrombectomy appears safe compared with literature-reported outcomes in similar patients using alternative approaches. Iliofemoral deep vein thrombosis impairs physical, social, and mental health-related quality of life.

Open vascular treatment of median arcuate ligament syndrome.

BACKGROUND: Median arcuate ligament syndrome is a rare condition with abdominal symptoms. Accepted treatment options are open release of median arcuate ligament, laparoscopic release of edian arcuate ligament, robot-assisted release of median arcuate ligament and open vascular treatment. Here we aimed to evaluate the central priority of open vascular therapy in the treatment of median arcuate ligament syndrome. METHODS: We conducted a monocentric retrospective study between January 1996 and June 2016. Thirty-one patients with median arcuate ligament syndrome underwent open vascular surgery, including division of median arcuate ligament in 17 cases, and vascular reconstruction of the celiac artery in 14 cases. RESULTS: In a 20-year period, 31 patients (n = 26 women, n = 5 men) were treated with division of median arcuate ligament (n = 17) or vascular reconstruction in combination with division of median arcuate ligament (n = 14). The mean age of patients was 44.8 ± 15.13 years. The complication rate was 16.1% (n = 5). Revisions were performed in 4 cases. The 30-day mortality rate was 0%. The mean in-hospital stay was 10.7 days. Follow-up data were obtained for 30 patients. The mean follow-up period was 52.2 months (range 2-149 months). Patients were grouped into a decompression group (n = 17) and revascularisation group (n = 13). The estimated Freedom From Symptoms rates were 93.3, 77.8, and 69.1% for the decompression group and 100, 83.3, and 83.3% for the revascularisation group after 12, 24 and 60 months respectively. We found no significant difference in the Freedom From Re-Intervention CA rates of the decompression (100% at 12, 24 and 60 months post-surgery) and revascularisation (100% at 12 months, and 91.7% at 24 and 60 months post-surgery) groups during follow-up (p = 0.26). CONCLUSIONS: Open vascular treatment of median arcuate ligament syndrome is a safe, low mortality-risk procedure, with low morbidity rate. Treatment choice depends on the clinical and morphological situation of each patient.

Outcomes after Open Surgery for Inflammatory Abdominal Aortic Aneurysm: A 10-Year Single-Center Experience.

BACKGROUND: Inflammatory abdominal aortic aneurysms (IAAAs) are rare clinical entities with an exaggerated inflammatory component. The aim of this study is to report outcomes of a single-center 10-year experience in open surgical management of IAAA and to compare the results with noninflammatory, atherosclerotic abdominal aortic aneurysms (non-IAAAs). METHODS: We retrospectively reviewed the medical records of 18 patients with IAAA selected out of patients with AAA who underwent open surgery in the Department of Vascular and Endovascular Surgery at the University Hospital Dusseldorf from January 2006 to December 2015. These patients were matched with controls, selected from a prospectively retained database of patients with AAA undergoing open surgery during the study period. A 1:2 case-control match regarding age, gender, and year of treatment was performed. We analyzed both groups for preoperative parameters, intraoperative findings, and early postoperative outcomes. RESULTS: The 2 groups showed considerable similarities with no significant differences in the clinical features. Both groups outlined comparable aneurysm size (62 vs. 56 mm); however, the mean preoperative C-reactive protein was found to be significantly elevated in the study group (mean value: 2.6 vs. 0.9 mg/dL, P < 0.05). Most patients were operated using a standard transperitoneal median laparotomy approach; only 1 patient of each group was operated using a left retroperitoneal approach. There was no significant difference in operation time (190 vs. 194 min) and 30-day mortality 0%. The in-hospital mortality was 11% in the study group and 0% in the control group. We found a significant higher complication rate in the study group 10 (56%) vs. 12 (33%). The major complications were also more frequent in the study group 4 (22%) vs. 6 (16.7%). IAAA showed a statistically significant longer length of intensive care unit and hospital stay when compared with non-IAAA (7 and 20 days vs. 2 and 14 days, P < 0.05). IAAAs outlined a significantly greater transfusion requirement for erythrocytes and fresh frozen plasma than non-IAAA. CONCLUSIONS: Open surgical treatment of IAAA guarantees a regression of the inflammatory process in most patients, which was detected through ultrasound in follow-up examination, although the approach to the surgical site is highly demanding. IAAA exhibits clear gender predominance and is associated with significantly higher transfusion requirement, early morbidity, and length of stay.

Retrograde Aortomesenteric Bypass with Left Retrorenal Route-"French Bypass" in 16 Cases of Chronic Mesenteric Ischemia.

BACKGROUND: There are several options for treating patients suffering from chronic mesenteric ischemia (CMI). One possibility contains bypass grafting following a left renal route to avoid inter alia kinking of the bypass. This study reviews the results of 16 patients suffering from CMI treated with this bypass technique, called "French Bypass" (FB). METHODS: A retrospective study conducted between June 1, 2002, and December 31, 2015. Sixteen patients were included with an average age of 54.6 years (10 women) who were treated with FB. Risk factors, surgical course, and follow-up were evaluated. RESULTS: Average stay in hospital took 28.4 days, with mostly minor complications occurring. Overall, 4 cases of FB occlusion were diagnosed in between 30 days after surgery, of which 3 made interventions necessary. Primary patency rates were 75%/56%/56% after 12/24/60 months. Overall survival rate after 60 month was 78%. CONCLUSIONS: The FB is a sufficient option for treatment of CMI combining advantages of anterograde and retrograde bypass grafting, with comparable outcome to established techniques in visceral vessel reconstruction.

Chronic Mesenteric Ischemia: Patient Outcomes Using Open Surgical Revascularization.

BACKGROUND: Chronic mesenteric ischemia (CMI) is a rare disease. Open treatment (OT) remains a valuable treatment option. We analyzed patient outcomes after OT and investigated health-related quality of life (HRQoL). METHODS: Data were analyzed retrospectively. The investigation period was from January 1, 2001, to December 31, 2014. We investigated mortality and patency rates using Kaplan-Meier analysis. HRQoL was measured using a 36-item health survey. Various statistical methods were employed. RESULTS: A total of 100 patients (celiac trunk [TC: n = 23], superior mesenteric artery [SMA: n = 26], or both [n = 51]) were included. Median follow-up was 5 ± 35 months. One-year survival rate for TC was 75 ± 11%, for SMA: 79 ± 10%, and for both: 96 ± 3%. TC 5-year survival was 75 ± 11% (SMA: 57 ± 16%: both: 80 ± 8%). Obesity and the length of hospital stay were independently associated with patient survival (p < 0.05). Primary 1-year patency rate was 60 ± 13% for TC (SMA: 86 ± 10%; both: 71 ± 8%) and secondary 1-year patency rate was 84 ± 9% for TC (SMA: 100%; both: 79 ± 7%). HRQoL was inferior compared to the German normative data (p < 0.05). CONCLUSION: CMI overlaps between gastrointestinal and vascular surgery. OT is safe, and simultaneous revascularization of the TC and the SMA does not affect mortality. Patients would not necessarily benefit from OT in terms of HRQoL.

Postoperative brachial artery entrapment associated with pediatric supracondylar fracture of the humerus: a case report.

BACKGROUND: Severely displaced supracondylar fractures of the humerus in children are frequently associated with complications including neurovascular injuries, non-union, or compartment syndrome. In the current literature, no report exists about postoperative brachial artery entrapment in combination with an inconspicuous preoperative neurovascular examination. CASE PRESENTATION: We present a case of a 6-year-old white boy with a pulseless radial and ulnar artery after open reduction and internal fixation of a severely displaced supracondylar fracture of his right humerus (Gartland type III) using four K-wires. Remarkably, the preoperative neurovascular examination was inconspicuous. Doppler ultrasound of his brachial artery revealed no pulse when his elbow was in flexion and a faint pulse when it was in full extension 10 hours postoperatively. Revision surgery was performed immediately. On intraoperative examination, a kinking of his brachial artery caused by an entrapment of the tunica externa in the reduced fracture was seen and the artery was released by microsurgical arteriolysis immediately. At the final follow-up examination, positive palpable pulse with good capillary filling and, according to Flynn's criteria, an excellent recovery of elbow function was observed 3 months postoperatively. CONCLUSIONS: This case demonstrates a rare complication of postoperative artery entrapment with inconspicuous preoperative neurovascular examination. It strongly emphasizes the need for a standardized postoperative neurovascular assessment with fully flexed as well as fully extended elbow.

Open Repair for Abdominal Aortic Aneurysm in a Young Boy with Tuberous Sclerosis and Review of the Literature.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are very rare in pediatric patients and can rarely be associated with tuberous sclerosis (TS). Open surgery is the first-line therapy. We report our experience added by a review on current literature. CASE REPORT: A 9-year-old boy with TS and history of 2 earlier open repairs for AAA presented to our department with a recurrent juxtarenal aortic aneurysm. We performed a polytetraflourethylene patch plasty. Postoperative course was uneventful. After 8 months, reconstruction was stable, and no recurrent aneurysm developed. CONCLUSIONS: Recurrent aneurysms may develop after open surgery for TS-associated AAA. However, open surgery is the recommended therapy but requires special techniques and experience in pediatric patients.

Reconstruction for renal artery aneurysms using the tailoring technique.

OBJECTIVE: Renal artery (RA) aneurysm (RAA) is a rare and complex disease. Treatment options for a RAA include endovascular surgery and open surgery with ex vivo repair or in situ reconstruction. This study evaluated the long-term outcome after vascular reconstruction of RAAs using the tailoring technique. Tailoring or aneurysmorrhaphy means a partial resection of the aneurysm with direct suture of the remaining arterial wall. METHODS: A single-center retrospective study was conducted between January 1990 and December 2015. The tailoring technique was used to surgically repair 88 RAAs in 80 patients (52 women) with a mean age of 52.9 years. Patients' demographic data, vascular therapy, and renal function during follow-up were retrospectively evaluated. RESULTS: The localization of the RAA was at the right kidney in 58 patients. The mean size of the aneurysm was 21.4 ± 9.7 mm (range, 8-67 mm). Hypertension was diagnosed in 56 patients, and 23 were asymptomatic. One RAA was ruptured. The overall morbidity rate was 16.3%, including bleeding (n = 4), RA stenosis (n = 3), RA occlusion (n = 4), RA dissection (n = 1), and myocardial infarction (n = 1). One patient died of myocardial infarction for a 30-day mortality rate of 1.3%. The 30-day primary patency rate was 90.0%. The 30-day secondary patency rate was 95.0%. Follow-up data were obtained from 71 patients who underwent tailoring in 78 RAAs. The mean follow-up period was 60.7 months (range 2-229 months). In 76.4% of patients with RAA and hypertension, RAA reconstruction contributed to the cure or improvement of hypertension. The long-term patency after RAA reconstruction was demonstrated in a Kaplan-Meier curve, with cumulative patency rates of 98.7%, 97.4%, 94.8%, and 92.3% after 18, 24, 36, and 48 months, respectively. Estimated survival rates were 98.8%, 97.5%, and 96.3% after 12, 48, and 60 months, with an estimated mean time of 216.5 ± 7.2 months. CONCLUSIONS: The tailoring technique is a safe and effective procedure with good long-term outcomes. RAA reconstruction contributed to the cure or improvement of renovascular hypertension.

Surgical management of iliofemoral vein thrombosis during pregnancy and the puerperium.

BACKGROUND: The risk of deep venous thrombosis is elevated during pregnancy and the puerperium. Therapy is usually limited to conservative measures as invasive thrombus removal is feared because of possible complications. However, leg- or life-threatening situations require fast thrombus removal, and the long-term rate of post-thrombotic syndrome (PTS) may be reduced by venous recanalization. Our center's experience may give support to surgical venous thrombectomy (VT). METHODS: Between 1996 and 2016, all women who received VT for pregnancy-related deep venous thrombosis in our department were included. Retrospective data were combined with a current follow-up. RESULTS: The study included 82 women with a mean age of 29 years (17-38 years). An additional arteriovenous fistula was performed in 79 and planned simultaneous cesarean section in 13 patients. Neither pulmonary emboli nor fetal complications occurred during surgery, and perioperative and postoperative mortality was 0%. Operative revision was required in 38% mainly for rethrombosis (24%) and bleeding (12%). One fetus died 2 months after VT of unrelated causes. After a mean of 83 months, complete venous recanalization was seen in 88%, venous valve sufficiency in 90%, and PTS in 31% without any ulcers. At 10 years, PTS incidence rose to reach 50% with limited statistical significance because of the number of patients reaching long-term follow-up. CONCLUSIONS: Iliofemoral venous recanalization during pregnancy can be performed safely in a specialized center, with lower PTS rates than in historical controls.

The importance of open emergency surgery in the treatment of acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) is a complex disease with a high mortality rate. A patient's chance of survival depends on early diagnosis and rapid revascularization to prevent progression of intestinal gangrene. We reviewed our experience with open surgery treatment in 54 cases of AMI. METHODS: A monocentric retrospective study was conducted between 01/01/2001 and 04/30/2014; 54 AMI patients with a mean age of 56.6 years underwent surgery (26 women and 28 men). Retrospectively, the risk factors, management until diagnosis, vascular therapy and follow-up were evaluated. RESULTS: The symptom upon admission was an acute abdominal pain event. The delay time from admission to surgery was, on average, 13.9 h (n = 34). The therapeutic procedures were open surgical operations. The complication rate was (53.7 %) (n = 29). The 30-day mortality was 29.6 % (n = 16). The late mortality rate was 24.1 % (n = 13), and the cumulative survival risk was 44.6 %. Survival was, on average, 60.54 months; however, in the over 70-year-old patient subgroup, the survival rate was 9.5 months (p = 0.035). The mortality rate was 27 % (n = 22) in the <12 h delay group, 20 % (n = 5) in the 12-24 h delay group, and 50 % (n = 7) in the > 24 h delay group. CONCLUSIONS: The form of therapy depends on the intraoperative findings and the type of occlusion. Although the mortality rate has decreased in the last decade, in patients over 70 years of age, a significantly worse prognosis was seen.

Implantation of an Iliac Branch Device After EVAR via a Femoral Approach Using a Steerable Sheath.

PURPOSE: To describe a contralateral femoral approach for iliac branch device implantation using a steerable sheath in the setting of an existing bifurcated stent-graft. TECHNIQUE: The method is demonstrated in an 80-year-old man who developed a 4-cm iliac aneurysm 3 years after implantation of an Endurant bifurcated stent-graft. Both femoral arteries were cannulated after surgical cutdown. The steerable sheath was advanced from the contralateral side over the neobifurcation of the bifurcated stent-graft. A 0.014-inch Roadrunner wire was used as a through-and-through wire to stabilize the curve of the sheath and to get proper push. The bridging stent-graft for the iliac branch was advanced over this sheath to seal the iliac aneurysm. During the entire procedure, the sheath was stable over the neobifurcation without pulling it down. CONCLUSION: The contralateral femoral approach for iliac branch graft implantation is feasible in cases with an extant bifurcated stent-graft using a steerable sheath and a through-and-through wire.