[Clinical and functional results after transfemoral thrombectomy for iliofemoral deep venous thrombosis: a 5-year-follow-up]. / Klinische und funktionelle Ergebnisse nach transfemoraler Thrombektomie bei tiefer Bein- und Beckenvenenthrombose: ein 5-Jahres-Follow-up.

PURPOSE: The optimal therapy of deep pelvic and leg venous thrombosis is still a matter of debate. The purpose of our study was to evaluate early and late results of iliofemoral thrombectomy with regard to the prevention of the development of a postthrombotic syndrome. METHODS: Between 1996 and 2000, 57 patients underwent transfemoral venous thrombectomy for acute iliofemoral thrombosis. 30 patients were reexamined after a mean of 60.4 months. At follow-up, the patency of the venous segments as well as the development of reflux was investigated by duplex-ultrasound. Furthermore, clinical signs and symptoms of chronic venous insufficiency as well as the subjective satisfaction of the patients with the operation were recorded. RESULTS: Postoperatively the veins of the lower leg were completely recanalized in 25 % of the cases, those of the thigh in 52.3 %. The patency rate at the level of the groin, the pelvis and the caval vein were 92.5, 86 and 100 %, respectively. At follow-up, the veins of the lower limb, the thigh and the pelvis were patent in 76.7 % each and in 73.3 % at groin-level. The caval vein was completely recanalized in all cases. Reflux occurred in 12 patients. 26.7 % of the patients showed no signs of a postthrombotic syndrome. 63.3 % had mild changes including dilated superficial veins and swelling tendency, and only in 10 % trophic skin changes were apparent. A healed or active ulceration did not occur in any case. Except one, all patients were satisfied with the results of the thrombectomy. CONCLUSIONS: Transfemoral thrombectomy for acute iliofemoral venous thrombosis offers good early and late results in terms of preserving venous function and reducing symptoms of venous insufficiency. In our patient population, the development of a severe postthrombotic syndrome could be reduced effectively.

[Intraoperative and early postoperative results after laparoscopic implantation of aortofemoral bifurcation prostheses]. / Intra- und frühpostoperative Ergebnisse nach laparoskopischer Anlage aortofemoraler Bifurkationsprothesen.

PURPOSE: The evaluation of multiple intra- and early postoperative parameters in patients undergoing laparoscopic aortobifemoral bypass grafting. METHODS: The charts of 22 patients who underwent laparoscopic aortobifemoral grafting between February 2nd, 1996 and April 30th, 1999 were retrospectively reviewed. RESULTS: All patients were men. The mean age was 54 +/- 7.2 years with the mean body weight being 76.3 +/- 10.9 kg and the Body-Mass-Index (BMI) 23 +/- 2.8. Claudication was present in 20 patients; one patient had rest pain and one patient suffered from tissue loss. The mean Ankle-Brachial-Index (ABI) was 0.57 +/- 0.1. In four cases conversion to open technique became necessary. The mean operation time was 316 +/- 73 min and the mean aortic cross-clamp time was 73 +/- 20 min. The mean intraoperative blood-loss reached 689 +/- 461 ml. The mean duration of postoperative ventilator support was 6.0 +/- 5.8 hours and the patients left the ICU after 2.2 +/- 3.2 days. Oral intake was allowed after a mean of 2.6 +/- 2.9 days and the central venous lines were removed after 3.8 +/- 3.9 days. The administration of analgetic drugs was required for 2.9 +/- 3.9 days. The mean length of stay in the hospital was 9.6 +/- 5.5 days. CONCLUSIONS: Laparoscopic aortobifemoral bypass grafting is feasible in a selected group of patients. Despite relatively long operation times and the use of a pneumoperitoneum, we did not encounter significant cardiopulmonary adverse effects.

[Laparoscopic aortic surgery in a swine model using a newly designed intestine retraction system]. / Laparoskopische Aortenchirurgie am Schweinemodell unter Zuhilfenahme neuentwickelter Darm-Retraktionssysteme.

BACKGROUND: Recently, the feasibility of laparoscopic surgery for aortic occlusive and aneurysmal disease has been demonstrated in clinical studies. However, aortic access is compromised by poor exposure of the operative field from uncontrolled bowel. Currently available retractors are inadequate. The development of new retracting instruments therefore may facilitate laparoscopic aortic surgery. METHODS: Two paddles inserted in a polyester bilayer (mobile device, group A) or a mesh net fixed to the abdominal wall (fixed device, group B) were used to retain the bowel. Six female piglets (28-30 kg) in each group underwent laparoscopic aortic surgery. RESULTS: Mean time to deploy the device was 22 +/- 12 min in group A and 36 +/- 34 min in group B (n.s.). Vascular surgery time averaged 60 +/- 24 min in group A and 68 +/- 16 min in group B (n.s.), the time to withdraw the nets was respectively 3.6 +/- 1.2 min and 13.5 +/- 8.2 min (p < 0.05). Total surgery time was 155 +/- 41 min vs. 174 +/- 49 min (n.s.). Two retraction failures have been registered (1 in group A and 1 in group B). No major complications were documented. CONCLUSIONS: Both nets provided adequate exposure of the infrarenal aorta. Vascular surgery time and blood loss were similar in both groups. Nevertheless, the handling of the mobile device (group A) seemed to be more comfortable in direct comparison. The newly developed retraction devices might facilitate the performance of laparoscopic aortic surgery.

Pharmacokinetics of tissue plasminogen activator in an isolated extracorporeal circuit.

PURPOSE: The aim of this study was to investigate the pharmacokinetics of tissue plasminogen activator (tPA) under the conditions of an isolated extracorporeal circuit. METHODS: Plasma levels of tPA were measured in the perfusion solution and in central venous blood before, during, and after the perfusion in seven patients undergoing regional hyperthermic fibrinolytic perfusion with tPA in addition to surgical thrombectomy for extended deep venous thrombosis. RESULTS: After 15 minutes of fibrinolytic perfusion, the level of tPA in the perfusion solution was 10,427 +/- 4432 ng/mL, and after 30 minutes the maximum level of 19,726 +/- 5630 ng/mL was reached. After 60 minutes when the perfusion was discontinued, tPA concentrations dropped to 15,931 +/- 4818 ng/mL. In central venous blood, tPA levels increased to a maximum of 230.7 +/- 89.6 ng/mL after 60 minutes of perfusion, which represented 1.4% of the concentration measured in the perfusion solution at the same time. With disconnection of the extracorporeal circuit, the tPA levels in central venous blood decreased rapidly and reached a level of 24.1 +/- 8.7 ng/mL after 120 minutes. CONCLUSION: The use of regional hyperthermic fibrinolytic perfusion in the treatment of extended deep venous thrombosis makes it possible to achieve extremely high concentrations of tPA in the perfusion solution. At the same time, the entry of the fibrinolytic agent into the systemic circulation is minimized.

Newly designed retraction devices for intestine control during laparoscopic aortic surgery: a comparative study in an animal model.

BACKGROUND: Recent clinical studies have demonstrated the feasibility of laparoscopic surgery for aortic occlusive and aneurysmal disease. However, transperitoneal aortic access is compromised by poor exposure in the operative field from uncontrolled bowel. The retractors that are currently available are inadequate for this task. The development of new retractors would help to facilitate laparoscopic aortic surgery. METHODS: Six female piglets (28-30 kg) in each group underwent laparoscopy with pneumoperitoneum (12 mmHg). Exposure of the infrarenal aorta and cross-clamping were undertaken through a transperitoneal approach. Two paddles inserted in a polyester bilayer (mobile device, group A) or a mesh net fixed to the abdominal wall (fixed device, group B) were used to retain the bowel. Aortotomy and suturing were performed to mimic a vascular procedure. After bleeding was controlled, the intraabdominal pressure (IAP) was lowered to 6 mmHg, and retraction was assessed for 30 min. The main outcome measures were time to deploy the retractors, time to perform the vascular procedure, time to withdraw the devices, and total procedural time. Blood loss and frequency of retraction failure were also recorded. RESULTS: Mean time to deploy the device was 22 +/- 12 min in group A and 36 +/- 34 min in group B (n.s.). Vascular surgery time averaged 60 +/- 24 min in group A and 68 +/- 16 min in group B (n.s.). The times to withdraw the nets were 3.6 +/- 1.2 min and 13.5 +/- 8.2 min, respectively (p < 0.05). Total surgery time was 155 +/- 41 min vs 174 +/- 49 min (n.s.). There were six retraction failures, five in group A and one in group B. When lower IAP was used, there was only one failure in each study group. Mean blood loss was <150 ml in both groups. There were no major complications. CONCLUSIONS: Both methods provided adequate exposure of the infrarenal aorta. Vascular surgery time and blood loss were similar for both groups. The movable device proved more usable and, at lower IAP, more effective. The results of this study demonstrate effective bowel retraction for laparoscopic aortic surgery.