Endovascular stent treatment for symptomatic benign iliofemoral venous occlusive disease: long-term results 1987-2009.

Venous stenting has been shown to effectively treat iliofemoral venous obstruction with good short- and mid-term results. The aim of this study was to investigate long-term clinical outcome and stent patency. Twenty patients were treated with venous stenting for benign disease at our institution between 1987 and 2005. Fifteen of 20 patients (15 female, mean age at time of stent implantation 38 years [range 18-66]) returned for a clinical visit, a plain X-ray of the stent, and a Duplex ultrasound. Four patients were lost to follow-up, and one patient died 277 months after stent placement although a good clinical result was documented 267 months after stent placement. Mean follow-up after stent placement was 167.8 months (13.9 years) (range 71 (6 years) to 267 months [22 years]). No patient needed an additional venous intervention after stent implantation. No significant difference between the circumference of the thigh on the stented side (mean 55.1 cm [range 47.0-70.0]) compared with the contralateral thigh (mean 54.9 cm [range 47.0-70.0]) (p=0.684) was seen. There was a nonsignificant trend toward higher flow velocities within the stent (mean 30.8 cm/s [range 10.0-48.0]) and the corresponding vein segment on the contralateral side (mean 25.2 cm/s [range 12.0-47.0]) (p=0.065). Stent integrity was confirmed in 14 of 15 cases. Only one stent showed a fracture, as documented on x-ray, without any impairment of flow. Venous stenting using Wallstents showed excellent long-term clinical outcome and primary patency rate.

Superficial vein thrombophlebitis--serious concern or much ado about little?

Superficial vein thrombophlebitis (SVTP) appears in two distinct forms: varicose vein thrombophlebitis (TP) represents the principal cause. It is characterized by a large thrombus in a varicose vein and a modest inflammatory process localized in the vessel surrounding but not in its wall. Rarely, SVTP affects a non-varicose vein. Abundant intima proliferation and media fibrosis with non-important thrombosis are the hallmark of this form which may be associated with a systemic disease. Although SVTP is perceived as trivial and benign coexistence of (mostly distal) deep venous thrombosis (DVT), propagation to popliteal or femoral DVT, and even pulmonary embolism (PE) have been reported. Data for prevalence vary greatly: 6-53% for coexistence, 2.6-15% for propagation, and 0-33% for (asymptomatic) PE. Risk factors for these complications are those known for DVT. SVTP is diagnosed in a clinical setting but ultrasonography is useful to check for concomitant DVT. Anticoagulant treatment is mandatory if DVT is present and thrombectomy should be considered in cases of thrombus propagation into the deep veins. Historical therapy of uncomplicated SVTP consists of compression with bandages or stockings and local or systemic anti-inflammatory agents. Low-molecular-weight heparin (LMWH) has been given in high-prophylactic doses and found equally effective when compared with anti-inflammatory agents and full-therapeutic dose LMWH. Prophylactic saphenous vein ligation alone was found less effective than conservative therapy. Ligation combined with stripping proved the potential of eliminating at once all problems associated with SVTP but was associated with a complication rate of 10% or higher. Careful patient selection and saphenous vein thrombectomy prior to stripping may be the clue for better results.

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.

[Peripheral arterial occlusive diseases: opinion of lay audience]. / Die periphere arterielle Verschlusskrankheit aus der Sicht von Laien.

An audience of about 500 elderly people were interviewed about their knowledge and therapeutic opinion on peripheral vascular disease. After a brief introduction by vascular surgeons 12 questions were presented for vote and answered with the use of a poll system. The audience proved well informed about the risk factors but confounded the symptoms. The participants declined to accept any limitation of their walking ability, overestimated the mid-term results of an eventual revascularisation and underestimated their risks and costs. 80% asked for a stop of smoking as a prerequisite for an intervention and again 80% were willing to pay by them-selves if the insurances would not reimburse them for an operation that would just improve their quality of life status. The honorarium for the surgeon was put up high. The poll shows that an audience can be enabled within a short period of time to deliberate therapeutic decisions and socio-economic problems. The answers reflect an overestimation of the medical possibilities but also a willingness to ask for and make personal contributions to a treatment which is not compelling in many cases.

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

OBJECTIVE: in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients. MATERIAL AND METHODS: two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading. RESULTS: diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004). CONCLUSIONS: our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.

Therapeutic concept for acute leg and pelvic venous thrombosis.

Combination treatment in acute deep venous thrombosis essentially consists of a highly dosed locoregional thrombolysis of the valve-carrying crurofemoral axis and a mechanical thrombectomy of the valveless pelvic axis by Fogarty catheter. The success of this method is due to the fact that it largely eliminates the disadvantages of systemic thrombolysis, as well as those at conventional surgical thrombectomy, whilst retaining the advantages. Using combination treatment in acute leg and pelvic venous thrombosis within the first 7 days can result in restitutio ad integrum, i.e. complete desobliteration with maintained valve function in more than 80% of the cases.

[Combination therapy of venous thrombosis with local thrombolysis and surgical thrombectomy]. / Kombinationstherapie der Venenthrombose mit lokaler Thrombolyse und chirurgischer Thrombektomie.

Combination therapy in acute deep venous thrombosis essentially consists of a highly dosed locoregional thrombolysis of the valve carrying crurofemoral axis and a mechanical thrombectomy of the valveless pelvic axis by Fogarty catheter. The success of this method is due to the fact that it largely eliminates the disadvantages of systemic thrombolysis as well as conventional surgical thrombectomy whilst retaining the advantages. Using combination therapy within the first 7 days in acute leg and pelvic venous thrombosis can result in restutio ad integrum, i.e. complete desobliteration with maintained valve function (more than 80% of cases).

Treatment of pelvic venous spur (May-Thurner syndrome) with self-expanding metallic endoprostheses.

PURPOSE: The application of self-expanding metallic endoprostheses (stents) to treat symptomatic pelvic venous spurs as an alternative to surgery. METHODS: Wallstents with a diameter from 14 to 16 mm and one Cragg stent were placed in the left common iliac vein of eight patients (seven women, one man; mean age 42 years) with a symptomatic pelvic venous spur (left deep venous thrombosis or post-thrombotic leg swelling). Four patients had surgical thrombectomy prior to stent placement. RESULTS: Technical success with immediate reduction of left leg circumference was achieved in all eight patients. A primary patency rate of 100% was observed during an average follow-up of 3 years (range 10-121 months). There were no procedural or stent-related complications. CONCLUSION: The percutaneous transfemoral placement of self-expanding metallic stents is an effective minimally invasive alternative to surgery in the treatment of symptomatic pelvic venous spur.

[Long-term outcome of distal bypass]. / Langzeitergebnisse nach distalem Bypass.

Although 30 years age reconstructive surgery on crural arteries was technically not feasible, primary successful revascularization is now possible in 95% of arterial occlusive diseases in the lower leg. If untreated, reocclusion of the graft occurs in 40 to 60% during the first postoperative year. With a close, morphologically oriented follow-up routine, an assisted primary patency of up to 80% and an even higher secondary patency can be achieved. Myointimal proliferation is mostly responsible for bypass failure in the early postoperative period especially at the site of the distal anastomosis.

[Acute abdominal pain. Surgeon's viewpoint]. / Der akute Abdominalschmerz. Chirurgische Sicht.

From the surgical point of view acute abdominal pain is the cardinal symptom of acute abdomen. Additional leading symptoms of acute abdomen are tension of the abdominal wall, peristaltic disorders and, in rare cases, shock symptoms. Acute abdomen is an operational diagnosis for painful, in part life threatening diseases of various etiologies. The most frequent cause is acute appendicitis, followed by cholecystitis and by diverse forms of ileus. These three diseases together are the cause of acute abdomen in more than 80% of cases. Over 90% of cases with acute abdomen are treated surgically. The decision in favour of a surgical intervention must be determined within minutes to hours depending on the etiology. A delay may lead to further, partly most serious sequelae.

[Treatment concept in deep pelvic-leg venous thrombosis]. / Behandlungskonzept bei tiefer Becken-Beinvenen-Thrombose.

The treatment of choice in acute deep vein thrombosis continues to be controversial. Conservative treatment with heparin and anticoagulation, systemic thrombolysis, thrombectomy and the combination of local thrombolysis and surgical unblocking are possible therapies. Regarding long term results; both after non operative treatment or after venous thrombectomy, many authors describe a majority of patients who suffer from chronic venous insufficiency in varying clinical severity. Requirements for normal venous function are complete phlebographic patency and valvular competence without venous reflux. Our proposed treatment for thromboses not older than 7 days combines local thrombolysis with venous thrombectomy to achieve these requirements and contains the following operative proceeding: An incision is made in the groin or - for more distal thromboses - on the proximal end of the clot. For the removal of the clot in the iliac vein a Fogarty-catheter is used. Urokinase is administered through a vein puncture in the instep while the blood flow is blocked by a pneumatic cuff around the thigh. After at least 20-30 minutes the clots can be removed through the proximal incision after removal of the cuff and manual massage of the leg. During this procedure the vein proximal of the venotomy is occluded by a soft clamp. An analysis of the results of 34 patients on average 3 1/2 years after combined therapy confirms normal valvular function of the popliteal vein in 27 (79%) cases. This improved long term outcome is going to be checked in an prospective study evaluating anticoagulation versus our treatment concept.

[Small-caliber polyurethane arterial prosthesis: clinical and angiomorphological follow-up of 20 patients in a prospective study]. / Prothèses artérielles de petit calibre en polyuréthane: Suivi clinique at angio-morphologique de 20 patients d'une étude prospective.

The five year patency rate for femoropopliteal vein bypass grafts is around 70% according to the literature. Patency rates for synthetic grafts (eg PTFE, Dacron) range between 43 and 57%. If a vein is not available there is a new polyurethane 6 mm artery substitute on the market, that has shown in vitro promising physical characteristics and good long term results after implantation in dogs. In a prospective, randomized trial the results of the new polyurethane graft (PUR) were compared with those of a Dacron graft of the same diameter. Included in the study were 20 patients with lower limb ischemia stage Fontaine II B, III and IV, 10 in each group. Patency rates, handling of the graft and complications were analysed. During the one year follow up 7 PUR grafts had to be changed due to recurrent bypass occlusion within the first 3 months. At the end of the year there were only one PUR-bypass but 8 Dacron grafts open. 5 PUR grafts were examined histologically and no morphological reason for the occlusion, especially no myointimal hyperplasia, was found. A special regard was brought to the arterial run-off in both groups. It was confirmed to be comparable with only slightly better data for the PUR group. The exact reasons for the astonishing bad results of the PUR graft for femoropopliteal above knee bypass cannot be explained in our study. Due to the unexpected high occlusion rate the study was stopped earlier then planned.

A new therapeutic approach to popliteal artery entrapment syndrome (PAES).

OBJECTIVES: An alternative therapeutic approach to popliteal artery entrapment syndrome (PAES) with vascular complications. MATERIALS: Three male patients (16, 42 and 68 years) with thrombotic and/or embolic obstructions of popliteal or crural vessels as a consequence of popliteal entrapment syndrome. METHODS: Combined catheter treatment consisting of percutaneous transluminal thrombembolectomy (PTEE), local thrombolysis (LTL) and percutaneous transluminal dilatation (PTA) was performed for thrombotic and embolic obstructions of popliteal or crural vessels. The aberrant tendomuscular structures were surgically corrected at a later date. RESULTS: After the procedure systolic ankle/arm pressure ratios in the three patients improved from 0.66 to 1.13, 0.57 to 1.07 and 0.46 to 1.10. Twelve, 8 and 4 months later the patients were asymptomatic. None of the patients showed popliteal artery compression during plantar flexion on Duplex scanning. CONCLUSIONS: This new therapeutic approach avoids direct vascular surgery with bypass or patch implantation in patients with PAES who are often young. The long term results remain to be evaluated.

[Gallstone surgery today]. / Gallensteinchirurgie heute.

The gold standard in treatment of cholelithiasis is and remains cholecystectomy. The gallbladder must be removed not because it contains stones but because it produces them. Only cholecystectomy prevents late complications. Laparoscopic cholecystectomy offers more comfort to the patient. By improved technique and refined instruments its indication can be continuously enlarged. Complicated forms of cholelithiasis such as the Mirizzi syndrome, chronic fibrosing cholecystitis, necrotizing infections and tumors as well as high operative risks are treated better by open cholecystectomy. Open and laparoscopic operations have both advantages and disadvantages. They are not competing procedures. On one hand, they have to be used individually according to their corresponding pathomorphology; on the other hand, their respective use has to be met by appropriate surgical skill. By no means the indication may orient itself on questions of prestige.

[Amebic appendicitis with subsequent perforated pancolitis]. / Amöben-Appendicitis mit konsekutiver perforierter Pancolitis.

Amoebic appendicitis is very rare, occurring in about 0.5 to 1% of acute appendicitis in tropical countries. The most severe complication is transmural amoebic colitis with perforation, described in 1.6 to 3.2% of cases. The mortality of such cases can be very high (up to 80%). We present a Swiss patient with amoebic appendicitis followed by severe perforated colitis; a total colectomy was necessary and the patient survived. Because of the good results of amoebicidal therapy and because of the severity of the complication after colitis we suggest that patients with signs of acute appendicitis after travel in tropical areas should be screened.

[Endovascular and open reconstructive treatment of arterial occlusive disease of the lower extremity in the critical ischemia stage]. / Endovasculäre und offene rekonstruktive Behandlung der arteriellen Verschlusskrankheit der unteren Extremität im Stadium der kritischen Ischämie.

Arterial revascularization is mandatory in the vast majority of patients with critical ischemia in the leg. Open surgical and percutaneous catheter procedures (angioplasty, local thrombolysis, clot extraction) can each be applied alone or in combination to avoid major amputation. Given the low invasiveness and morbidity of percutaneous techniques, they should be the method of first choice, provided suitable occlusion morphology is available. If catheter therapy is not successful, surgery can be performed. Five-year patency after surgery for femoropopliteal obstructions is approximately 60% and 40% after catheter therapy. Iliac revascularization shows higher patency rates for both procedures. Percutaneous catheter techniques can be an alterative to vascular surgery, but more importantly both can be used as complementary procedures in the same patient, provided there ist good cooperation between the vascular surgeon and the person during the interventional angiology.

[Damage to the vessel wall by the Fogarty balloon catheter]. / Gefässwandschädigung durch Fogarty-Ballon-Katheter.

Thromboembolectomy with the Fogarty balloon-catheter is a well-established surgical therapy for the treatment of acute ischemia with generally good results. However, arterial injuries caused by balloon embolectomy occur in up to 6%. The different types of injury are mentioned, the role of myointimal hyperplasia as a result of endothelial denudation is discussed. We conclude that after balloon-catheter thromboembolectomy an early angiographic control should be performed and repeated 3 months postoperatively.

[Treatment of venous stenoses and occlusions of benign etiology with vascular endoprostheses: a new, non-operative therapeutic concept]. / Behandlung von Venenstenosen und -verschlüssen benigner Atiologie mit vaskulären Endoprothesen: Ein neues, nichtoperatives Therapiekonzept.

8 patients (7 women and 1 man, age between 35 and 66 years, mean 46.3) suffering from a stenosis or occlusion of the pelvic or superficial femoral vein after surgical or percutaneous intervention were successfully treated with endovascular stents of the wallstent type. Clinical and Doppler sonographic as well as phlebographic controls showed patency of all stented lesions at followup times between 3 and 82 months (average 27 months). The use of percutaneous transluminal angioplasty (PTA) in the venous system in combination with implantation of self-expanding vascular endoprostheses offer a new therapeutic modality to treat veins with stenosis or occlusion of benign etiology without surgical intervention.