Traditional versus endoscopic saphenous vein stripping: a prospective randomized pilot trial.

INTRODUCTION: The aim of this pilot study was to compare two methods of removing the great saphenous vein (GSV) from the groin to the limit of distal venous incompetence. Our aim was to compare endoscopically assisted GSV stripping to conventional stripping. DESIGN: Randomised pilot study. PATIENTS AND METHODS: 60 patients presenting with primary GSV incompetence and symptomatic varicose veins were randomly assigned to sapheno-ligation and either conventional GSV stripping or endoscopically assisted GSV stripping. The primary endpoint was the number of adverse events including haematoma in the thigh, ecchymosis, seroma, wound healing complications and wound infections. The SF-36 health survey was completed before treatment and one and four weeks postoperatively. The study was approved by the local ethics committee (EK 07-041-VK). RESULTS: 60 patients were enrolled in the study and randomized to endoscopic (n=30) and to traditional (n=30) stripping. The patients age ranged from 30 to 75 years (mean 53 years), 18 patients were male, 42 female. The combined rate of postoperative morbidity at week 1 was 32 events (53%), 13 (42%) events in the endoscopic and 19 (63%) in the conventional group (not significant). The SF-36 assessment one week postoperatively showed that patients in the endoscopic group reported significantly less pain (P=0.03, Mann-Whitney). At four weeks, patients in the endoscopic group had significantly less pain (P<0.005) and better physical function (P<0.005) and physical role (P=0.01). For all other parameters no significant difference noted. CONCLUSION: The results of this study suggest that endoscopic GSV excision showed no difference in adverse events between treatments, although our pilot study may have been under-powered to demonstrate this. The SF-36 assessment suggests more rapid return to normal activities post-operatively in the endoscopic group.

Hemodialysis access surgery--is there an increased risk of acquiring hepatitis C virus compared to other elective vascular interventions?

BACKGROUND: To evaluate whether dedicated access surgeons might have a significantly higher risk of acquiring hepatitis C infection compared to other vascular surgeons by assessing the prevalence of hepatitis C patients who are on chronic hemodialysis and to compare the frequency to patients undergoing elective vascular interventions. PATIENTS AND METHODS: A retrospective chart and data analysis of all patients on chronic hemodialysis was conducted. As a comparative group, the prevalence of anti-HCV antibodies and positive HCV RNA PCR among patients admitted for elective vascular surgery was assessed. RESULTS: Of 285 patients on chronic hemodialysis, 202 (71%) were had both tests (antibody test for HCV and specific HCV RNA PCR testing). 5% (n = 11; CI 95 = 3-10%) were antibody positive, and 4% (n = 8; CI 95 = 2-8%) were also PCR positive and therefore infectious. One patient was acutely infected. Of 4963 vascular surgical patients, 1141 (23%) had an anti-HCV antibody ELISA test and specific HCV RNA PCR testing. 0.4% (n = 4; CI 95 = 0.1-1%) were antibody positive and 0.2% (n = 2; CI 95 = 0.03-0.7%) were also PCR positive and hence infectious. No acutely infected patient was detected in this population. The chance of operating on a HCV positive and infectious patient among hemodialysis patients was almost 27 times higher than among elective vascular surgical patients (P < 0.0001; OR = 26.56; CI 95 = 5.42-253.40). CONCLUSIONS: Dedicated hemodialysis access surgeons have a higher risk to acquire hepatitis C infection compared to vascular surgeons performing all other elective vascular surgical interventions. To identify early infected surgeons operating on high risk HCV patient collectives and to start rapid treatment, PCR testing at regular intervals would be advisable.

Homocysteine and early re-stenosis after carotid eversion endarterectomy.

BACKGROUND: Homocysteine (Hcy) appears to be involved in the development of intimal hyperplasia and arterial thrombosis. The purpose of this study was to evaluate the association of plasma Hcy with early re-stenosis following carotid eversion endarterectomy. PATIENTS AND METHODS: Of 398 consecutive patients, 363 were included in this study. 62% of patients had symptomatic internal carotid artery (ICA) stenosis. Patients had preoperative assessment of Hcy and other well established atherosclerosis risk factors. Intraoperatively, completion angiography was performed in 2 planes. Patients had clinical, Hcy and duplex follow up at 1, 3, 18 and 36 months postoperatively. RESULTS: Complete follow up data were available for 312 patients. Five patients suffered from strokes and 2 patients died during the peri-operative period (combined stroke and death rate of 2%). Mean follow up was 26+/-5 months (range 17 to 36 months). Seventeen and six patients (5.5%) developed a 50-69% and >70% re-stenosis, respectively. Serum creatinine was significantly higher in patients with early re-stenosis, occlusion or stroke after CEA (P=0.043). High grade re-stenosis, occlusion and stroke ipsilateral to the operated side (17 patients) was associated with HbA1C and creatinine (P=0.043 and 0.046, respectively) but not Hcy. CONCLUSION: While Hcy is a recognized independent risk factor for atherothrombosis, our study suggests that there is no association of Hcy with early re-stenosis after eversion endarterectomy.

Antiplatelet therapy prior to carotid endarterectomy--still room for improvement.

BACKGROUND: Antiplatelet therapy is one of the most important modalities for secondary prevention of ischemic events. The aim of this prospective study was to evaluate the current practice of antiplatelet therapy in patients with high grade stenosis of the internal carotid artery (ICA), who were referred by neurologists, stroke physicians and cardiologists for carotid endarterectomy. PATIENTS AND METHODS: Patients referred to our department for carotid endarterectomy with ICA stenosis (> 70% according to NASCET criteria) were prospectively evaluated regarding atherosclerosis risk factors and current antiplatelet therapy. During a 7 month period, 235 patients were scheduled for carotid endarterectomy. Their mean age was 70 years (range 42 years to 95 years), 91 patients were female (39%), 144 male (61%). 122 patients (52%) had a symptomatic ICA stenosis, 113 (48%) an asymptomatic ICA stenosis. RESULTS: Of the 235 patients, 29 were either on low molecular weight heparin or vitamin K antagonists for reasons other than ICA stenosis and were therefore excluded from analysis. Therefore, 206 patients (88%) were evaluated for antiplatelet therapy prescribed by their admitting physicians. Of these patients, 77 (37%) (42 (41%) symptomatic and 35 (34%) asymptomatic patients) did not receive any antithrombotic therapy prior to admission for surgery. The majority of patients received aspirin preoperatively (106 patients, 51.5%) 13 (6%) patients were on clopidogrel and 10 (5%) on dual therapy with Aspirin and clopidogrel. CONCLUSIONS: More than one third of patients awaiting carotid endarterectomy did not receive any antiplatelet therapy, despite high grade ICA stenosis. Since this practice does not meet the current guidelines, campaigns to increase the awareness of this problem are urgently needed.

Plasma D-lactate as a potential early marker for colon ischaemia after open aortic reconstruction.

BACKGROUND AND AIM: The breakdown of mucosal barrier function due to intestinal hypo-perfusion is the earliest dysfunction of ischaemic colitis. Severe colon ischaemia after aortic reconstruction is associated with mortality rates up to 90%. Therefore, early detection and treatment of patients with extensive ischaemic colitis is of crucial importance. In experimental studies, both D-lactate and bacterial endotoxin have been reported as markers of intestinal mucosal barrier impairment. However, evidence of their value in clinical practice is lacking. The aim of this pilot prospective cohort study was to assess the association between ischaemia of the colon (assessed histologically) and plasma levels of D-lactate and endotoxin in patients undergoing open aortic reconstruction. PATIENTS AND METHODS: Twelve consecutive patients underwent surgery between February and April 2003. Six patients underwent emergency surgery and six patients elective aortic surgery. D-Lactate and endotoxin levels were measured in blood samples collected according to a standardised protocol. For histological examination biopsies were obtained by sigmoidoscopy on days 4-6 after surgery, or earlier if indicated clinically. RESULTS: As early as 2 h postoperatively, elevated plasma levels of d-lactate were measured in patients with histologically proven ischaemic colitis. The peak of D-lactate elevation was on postoperative days 1 and 2. Concentration of plasma endotoxin was not significantly different in patients with or without ischaemic colitis. CONCLUSION: Our data suggest that plasma D-lactate levels are a useful marker for early detection of ischaemic colitis secondary to aortic surgery.

Do workshops improved the technical skill of vascular surgical trainees?

AIMS: Adjuncts to conventional surgical training are needed in order to address the reduction in working hours. This purpose of this study was to objectively assess the efficacy of workshop training on simulators. METHODS: Fifteen consecutive participants of the European Vascular Workshop in 2003 and 2004 were recruited to this study. Participants performed a proximal anastomosis on a commercially available abdominal aortic aneurysm simulator, were then given intensive training on sophisticated models for 3 days and re-assessed. Pre- and post-course procedures were videotaped and independently reviewed by three assessors (tapes were blinded and in random order). The operative end product was similarly assessed. Four measures of technical skill were used: generic skill, procedural skill; a five point technical rating of the anastomosis (assessed using validated rating scales) and procedure time. Non-parametric tests were used in the statistical analysis. RESULTS: The video assessment scores for aneurysm repair increased significantly following completion of the course (p=0.006 and p=0.004 for generic and procedural skill, respectively). End product assessment scores increased significantly post-course (p=0.001) and participants performed aneurysm repair faster following the course (p<0.05). Inter-observer reliability ranged from alpha=0.84-0.98 for the three rating scales pre- and post-course. CONCLUSION: Objective improvements in technical performance follow intensive workshop training. Participants' perform better, faster, and with an improved end product following the course. Such adjuncts to training play an important part in a focused integrated programme that addresses reduced work hours.

Carotid endarterectomy under local anaesthesia does not increase plasma homocysteine concentration.

INTRODUCTION: The purpose of this cohort study was to evaluate the effect of carotid endarterectomy under local anaesthesia on homocysteine (Hcy) concentrations. PATIENTS AND METHODS: Of 100 patients with internal carotid artery (ICA) stenosis >70%, the complete data set was available for 91 patients (39 asymptomatic and 52 symptomatic). All patients underwent eversion endarterectomy of the ICA under regional anaesthesia. RESULTS: Thirty-two percent of the examined patients had a total Hcy above 15 micromol/l. The mean Hcy levels preoperatively were 13.9+/-4.8 micromol/l. The Hcy levels on day 5 were 13.1+/-5.0 micromol/l and after 6 months 14.0+/-5.8 micromol/l. There was no significant change during follow-up. No intraoperative strokes and deaths were observed and during the 6 months follow-up no recurrent strokes, TIAs or deaths occurred. CONCLUSION: Patients undergoing carotid endarterectomy under regional anaesthesia do not have an increase in total Hcy postoperatively. This finding is in contrast to results from cardiac surgery and carotid endarterectomy in a recently published animal study, both performing surgery under general anaesthesia.

Antithrombotic strategies in vascular surgery: evidence and practice.

BACKGROUND: The aim of this study was to evaluate the current practice of peri and postoperative antithrombotic therapy in vascular surgery in Austria and to compare this with the results of randomised prospective clinical trials. METHODS: A questionnaire assessing intra, postoperative and long-term antithrombotic treatment in 13 different surgical procedures (three supra-aortic, three aorto-iliac reconstructions and seven inguinal and infra-inguinal arterial reconstructions) was sent to all 22 institutions training vascular surgical fellows in Austria. RESULTS: Intraoperative antithrombotic therapy was quite consistently performed with unfractionated heparin (UFH) with or without acetylsalicylic acid (ASA). Early and long-term postoperative therapy differed considerably. Most centres used low molecular weight heparin (LMWH) for early postoperative therapy after vascular reconstructions, in > 75% combined with ASA and/or clopidogrel. Long-term therapy consisted of antiplatelet agents in all centres. Vascular grafts were anticoagulated with UFH in 25% of the centres in the early postoperative period, the remaining institutions used LMWH +/- antiplatelet agents. For long-term antithrombotic therapy cumarins were used in 75% of the centres, predominantly for venous grafts. Distal prosthetic grafts were mainly treated with antiplatelet agents. Intraoperative antithrombotic therapy was in accordance to present guidelines, postoperative antithrombotic therapy, however, differed considerably between the participating institutions and the results of available controlled studies. CONCLUSION: Optimal antithrombotic strategies during and after vascular surgery are still under debate, and current practice often differs from available evidence. Vascular surgical societies should be encouraged to define recommendations on antiplatelet therapy and anticoagulation for different vascular interventions.

Perioperative morbidity and mortality of carotid artery surgery under loco-regional anaesthesia.

BACKGROUND: Loco-regional anaesthesia for carotid artery surgery has many advantages over general anaesthesia. It may be associated with a reduction in neurological, and equally important, non-neurological morbidity and mortality. However, sufficiently powered randomised controlled trials comparing general anaesthesia with local anaesthesia for carotid artery surgery are not yet published. Herein, we present our single centre experience of carotid endarterectomy under local anaesthesia and their respective procedure-related morbidity and mortality rates. PATIENTS AND METHODS: From January 1996 to December 2002, 1271 patients were operated on their carotid arteries. Of these, 1210 (95%) patients and 1355 carotid arteries were operated on in loco-regional anaesthesia and included in a prospective recording. The patients age ranged from 47 to 100 years (mean 70.5 years), 711 patients were male, 499 female. 496 patients (41%) were asymptomatic (Fontaine stage I), 460 have had a transient neurological deficit (TIA) prior to admission (Fontaine stage II) and 254 patients have had a stroke (Fontaine stage IV). RESULTS: The combined stroke rate was 2.2% (n = 30). The overall 30 day mortality was 0.2% (n = 3). The rate of haematoma indicating revision was 3% (n = 40). The revision in all cases was within 12 hours of surgery. No patient developed respiratory insufficiency after surgery. However, of the 40 patients with revision for haematoma, 4 (10%) needed prolonged respiratory assistance and one patient ultimately died of respiratory insufficiency and stroke. No cardiac mortality was observed. The over all rate of myocardial infarction observed postoperatively was 1.4% (n = 19), of which 1.1% (n = 15) were non q-wave infarcts. The combined shunting-rate for all stages was 18.6% (n = 252). CONCLUSION: Morbidity and mortality of carotid endarterectomy in loco-regional anaesthesia is comparable to recently published single-centre results. Patients with severe COPD, usually unsuitable candidates for general anaesthesia, can also be treated safely.

Combined open and endovascular stent grafting of internal carotid artery fibromuscular dysplasia: long term results.

BACKGROUND: Symptomatic fibromuscular dysplasia (FMD) of the internal carotid artery (ICA) can present as thrombo-embolic ischemic events, spontaneous or post-traumatic dissection, aneurysmal degeneration or intracranial haemorrhage and needs definitive surgical treatment. PATIENTS AND METHODS: Six patients and nine ICA with FMD were revascularised using a carotid approach with minimal exposure of the common, external and internal carotid arteries for covered stent repair. All patients were female, the age ranged from 30 to 65 years (mean 44). RESULTS: One patient suffered from a perioperative transient neurological deficit. Duplex revealed a patent stent. The patient fully recovered after 5h, not showing any changes on repeat CT scans. One patient developed a recurrent laryngeal nerve palsy. The symptoms gradually resolved within 1 month. No perioperative strokes or deaths occurred. During a mean follow up of 48 months (range 13-63) no thromboembolic neurological events, graft occlusions or haemodynamically significant stenoses occurred. CONCLUSION: ICA FMD stent grafting is an alternative to open surgery or percutaneous endovascular intervention with excellent long-term results.

Renal artery surgery in the era of endovascular intervention.

BACKGROUND: In the last decade the therapeutic concept of renovascular disease has changed. The numbers of primary surgical revascularisations have fallen substantially due to the invention of percutaneous transluminal angioplasty (PTA). PATIENTS AND METHODS: Retrospective data analysis. From September 1992 to December 2001, 42 patients were operated on 49 renal arteries at our institution. During the same period, 166 PTA of renal arteries alone and 92 PTA with stent were performed. Twenty-five patients and 27 renal arteries were operated encompassing an aortic reconstruction due to atherosclerosis (aortic occlusion 14, aortic aneurysm 11). The median age at operation was 61 years (range 47 years to 76 years). Four patients were operated on because of renal artery aneurysms with a diameter of more than 2.5 cm. The median age of these patients was 68.5 years (range 60 years to 77 years). Seven patients presented with atherosclerotic changes of the renal artery without aorto-iliac involvement. Their median age was 62.8 years at operation (range 39 years to 77 years). Of these, one suffered from rupture of the renal artery during PTA and needed emergency surgery: Six patients and 11 renal arteries with FMD were surgically reconstructed. RESULTS: The primary patency rate of all reconstructed renal arteries of surviving patients after 5 years was 92%, the secondary patency rate after 5 years was 98%. Two patients died perioperatively (4.7%). One patient had presented with a symptomatic thoraco-abdominal aneurysm and died ultimately because of a stroke. The second patient had an infrarenal AAA and died after a myocardial infarction. Twenty (47.7%) of all surgically treated patients had had at least one PTA preoperatively. CONCLUSION: During the last decade, primary surgical renal artery reconstruction was performed in about half of the cases. The decrease of primary open surgery of the renal arteries was most striking in patients with aorto-iliac occlusive disease. From 1996 on no patient of this group underwent open surgery without having had prior PTA of the renal arteries.

Incidence of cranial nerve injuries after carotid eversion endarterectomy with a transverse skin incision under regional anaesthesia.

OBJECTIVES: The objective of this prospective study was to evaluate the incidence and distribution of cranial nerve injuries after carotid eversion endarterectomy (EEA) performed under regional anaesthesia using a transverse skin incision. PATIENTS AND METHODS: The study included 165 patients and 180 carotid arteries. All patients had a standard pre-operative assessment performed by a neurologist and ENT specialist. All carotid endarterectomies were performed by the eversion technique under regional anaesthesia. RESULTS: Ten cranial nerve injuries were observed. Seven patients had injuries of the marginal mandibular branch of the facial nerve, two patients had lesions of the hypoglossal nerve, and one patient had an injury of the recurrent laryngeal nerve. Eleven patients developed hoarseness without cranial nerve injury. Injuries of the marginal mandibular branch recovered after 3-8 months (mean 5.2 months). Both hypoglossal nerve injuries recovered after 4 months. The patient with the recurrent laryngeal palsy had no improvement after 19 months. Patients with hoarseness secondary to laryngeal haematoma recovered within 1 month. CONCLUSION: The incidence of cranial nerves injury after carotid EEA under regional anaesthesia is comparable to that reported for conventional carotid surgery. Postoperative hoarseness is most frequently due to laryngeal haematoma.

Long-term results of covered stent repair of internal carotid artery dissections.

BACKGROUND: Traumatic and spontaneous dissections of internal carotid arteries (ICA) are rare conditions. So far, these pathologies are primarily treated conservatively, surgical revascularization being an option only after recurrent thromboembolic neurologic episodes or continuous aneurysm growth. Successful endovascular treatment strategies with covered stents have been reported in patients with ICA dissections. However, no long-term results are published so far. Herein, we report our experience of a combined conventional and endovascular repair of ICA dissections under reversed flow and their respective long-term results. METHODS: In a prospective evaluation of clinical and morphologic outcome of 6 patients with carotid artery dissections, 2 patients were treated for continuous aneurysm growth and 4 patients for high-grade ICA stenoses with recurrent thromboembolic episodes during a 6-month follow-up period. A 6-mm polytetrafluoroethylene Hemobahn endoprosthesis was inserted under reversed flow of the internal carotid artery. RESULTS: No perioperative strokes were observed; one TIA occurred, lasting less than 3 hours; no peripheral cranial nerve injuries or deaths were observed. No occlusions, hemodynamically significant stenosis, or recurrent neurologic symptoms were seen during follow-up, which ranged from 6 to 54 months (mean, 38.3 months). CONCLUSION: Open endovascular repair of the ICA of symptomatic patients with dissections with a 6-mm covered endoprosthesis is a safe alternative to conventional surgery, with excellent long-term patency.

[Surgical treatment of infrarenal abdominal aortic aneurysm]. / Die chirurgische Behandlung des infrarenalen Bauchaortenaneurysmas.

Results of surgical treatment of infrarenal abdominal aortic aneurysms (AAA) have improved in recent years. Through worldwide experience associated risk factors could be determined and reduced significantly. Therapy of associated diseases and profound morphologic knowledge about AAA are the most important factors to influence survival after surgery. Nowadays average mortality after elective surgery is 5%, 5-year survival rate 70%. By recognition of asymptomatic AAA on time the rupture rate with a mortality of more then 50% must be reduced in the near future. The purpose of this article is to represent, beyond the standard surgical technique, the possibilities to prevent ischemic complications from the myocardium, kidneys, colon and gluteal region during abdominal aortic surgery.

[Complications in surgery of varicose veins]. / Komplikationen bei der Chirurgie der Varikose.

Complications after varicose vein operations are rare. Minor complications such as lesions of cutaneous nerves, e.g. saphenus or sural nerve, hematomas, lymphogenic fistulas or postoperative edemas are reported and can be treated conservatively. Major complications like injuries to the femoral vein must be considered in about 1% and injuries to the femoral arteries in 0.02%. This means, for example, for the FRG 50 serious venous and 10 serious arterial injuries with the possibility of limb loss/year. Deep vein thrombosis and pulmonal infarction occurred in 3300 of our varicose vein operations, in 0.15% and 0.06% respectively. Knowledge of vascular surgery and anatomy with all variations of the venous systems are mandatory for varicose vein surgery.

[Acute mesenteric vascular occlusion: pathophysiology, clinical stages, diagnosis]. / Der akute Mesenterialgefässverschluss: Pathophysiologie, klinische Stadien, Diagnostik.

Advanced age and cardiovascular diseases cause of SMA occlusion. Shock is triggered and maintained by bowel ischemia. Since lactate is the end product of anaerobic glycolysis, lactacidosis is a valuable clinical parameter. Lactate values above 4-5 mmol/l are conclusive evidence in the presence of symptoms of acute SMA occlusion. Chance of survival are poor in stages II and III with advanced shock and non reversible gangrene. Revascularisation of the SMA combined with adequate bowel resection reduces the production of toxic and lethal substances in the intestinal mucosa, thus increasing the chance of survival. Determination of serum lactate should be an integral part of the diagnostic procedure and the close followup for it is both an adequate index of the grade of intestinal ischemia and a means of assessing whether a second-look is warranted.

[Lactate in the diagnosis of acute intestinal vascular occlusions]. / Lactat zur Diagnose akuter intestinaler Gefässverschlüsse.

The diagnostic value of lactate in acute occlusion of intestinal vessels was investigated in two groups of patients: Group 1 included 86 patients with reconstructions of aorta and intestinal arteries: The lactate-concentrations measured during uncomplicated postoperative course over 24 hours remained within the normal range of 4.31 +/- 1.06 mmol/l. Only in 3 patients with acute postoperative occlusion of intestinal arteries, lactate rose to high pathologic levels up to 59.94 mmol/l. In 10 patients after reconstruction of acute mesenteric artery occlusion the postoperative lactate levels enforced the decision in 9 cases against and in one patient to second look operation. Group 2 included 36 patients with acute abdomen: In 18 patients with intestinal vascular occlusions the mean value of lactate was 7.45 +/- 2.86 mmol/l, in 18 patients without intestinal ischemia lactate was only 1.94 +/- 1.02 mmol/l. The statistical difference is significant. In summary, the results of this study document the reliable value of lactate for the diagnosis of acute occlusions of intestinal vessels during pre- and postoperative course.