Paradoxical embolism and aortic occlusion: a case report.

This is the case report of a 45-year-old woman who sustained a left popliteal artery embolism. Ten days after popliteal embolectomy, she developed sudden occlusion of the distal aorta. She required a bifemoral embolectomy. Transesophageal echocardiogram demonstrated an atrial septal aneurysm and a septal defect with a right to left shunt. A venogram showed deep venous thrombosis in the right leg as the potential source of the embolism. Paradoxical embolization should be considered when ever an unexplained arterial occlusion occurs, especially in younger patients.

[Infrarenal aortic aneurysm in Behçet's disease. Case report and review of the literature]. / Infrarenales Aortenaneurysma bei Morbus Behçet. Fallbericht und Literaturübersicht.

A 55-year old Turkish male was admitted with a staged aortic rupture requiring emergent surgical resection of the infrarenal aorta. Anamnesis and typical clinical findings (aphthosis, genital ulcers, pustulosis, arthritis) allowed the postoperative diagnosis of Behçet's disease. This etiologically unclear disease rarely occurs in patients from western European countries. Main symptoms are concerning the skin, the mucous membranes, and the eyes. The vascular system may occasionally be involved. In patients presenting with inflammatory arterial aneurysms, arterial or venous occlusions, careful search for the main symptoms will provide adequate diagnosis. Acute arterial affections, especially aneurysms, often urge surgical treatment. Until now, there is no effective medical prophylaxis.

[Lumbar spinal nerve root compression syndrome as an atypical initial manifestation of a rare vascular disease]. / Lumbales Wurzelkompressionssyndrom als atypische Erstmanifestation einer seltenen Gefässerkrankung.

A 55 year old male Turkish patient developed L3/L4 root compression caused by a retroperitoneal hematoma after covered perforation of the infrarenal aorta. The aneurysm was resected and a tube interposition made. For more than 20 years the patient has suffered from oral and scrotal ulcers. These signs led to the diagnosis of Behçet's disease. A review of the literature revealed 200 arterial complications (aneurysms and occlusions) in 105 patients with Behçet's disease, only 19 of them had aneurysms of the infrarenal aorta.

Aneurysma transformation in congenital venous angiodysplasias in lower extremities.

Based on a retrospective evaluation of 107 patients with congenital venous angiodysplasia of the Type Klippel-Trenaunay (n = 76) and Type Servelle-Martorell (n = 31) the frequency and pathogenesis of aneurysma formation in the venous system has been analysed. The vascular patterns include both cylindric ectasia and fusiform aneurysms with an incidence of approximately 40%. Preferred locations are subcutaneous drainage veins, the popliteal, external iliac vein and atypic communicating veins between the superficial and the deep venous system. Complications of the aneurysm such as local thrombosis, recurrent pulmonary embolism or bleeding from ruptur were not observed. The aneurysma formation in venous angiodysplasias results probably from the causative factors: congenital weakness of the venous wall and an abnormal hemodynamical stress situation. The latter is caused by concomitant malformations of the deep venous system. The persistent intermittent venous hypertension associated with a more or less pronounced increase of the venous volume in the affected venous system of the limb results in a deep venous insufficiency respectively venous reflux disease. The therapy of choice is predominantly conservative, i.e., external compression bandages or stockings to reduce the deleterious effects of a chronic deep venous insufficiency respectively venous reflux disease. Surgery is indicated under two conditions: a) in the presence of aneurysm complications or b) for the elimination of a pathological short circuit flow in some drainage veins. Antireflux surgery, i.e., venous valve transfer from the brachial vein, is up to recently still in a stage of experimental-clinical investigation.

[Congenital angiodysplasia of the limbs; diagnosis and therapy]. / Congenitale angiodysplasie van de ledematen; diagnose en therapie.

A complete check-up of vascular morphology and haemodynamics in patients resulted in a differentiation of three clinical entities: (I) type F. P. Weber: multiple active arteriovenous fistulas inducing overgrowth of the skeleton, (2) type Klippel-Trenaunay: venous angiodysplasia with the triad localized gigantism, varicose veins, naevus flammeus, (3) type Servelle-Martorell: systemic haemangiomatosis including the bone and soft tissues resulting in hypoplasia of the skeleton. Early diagnosis and differentiation of these different clinical types are needed for the assessment of the spontaneous course of the disease and choice of an optimal therapeutical approach. In the presence of active arteriovenous fistula (type F. P. Weber) the therapeutic principle should be focused on the normalisation of the shunt volume by surgery (skeletonisation) or catheter embolisation. In patients with venous angiodysplasias (type Klippel-Trenaunay or Servelle-Martorell) the therapy is aimed at prevention or reduction of deep venous insufficiency and is basically conservative by external compression bandages.

[Late vascular damage after unilateral leg amputation]. / Vaskulärer Spätschaden nach unilateraler Beinamputation.

The higher incidence of infrarenal aortic aneurysms in war-veterans with above knee amputations indicates that leg amputation besides arteriosclerotic risk factors constitutes a relevant pathogenetic factor for the late development of an abdominal aortic aneurysm. A retrospective study of 25 mainly young patients with above knee amputation showed that already one year after leg-loss a typical adaptive narrowing of the pelvic and leg arteries with significant reduction of the flow volume of 37% on the amputated side could be registered. Unilateral flow reduction resp. interruption causes an asymmetric flow pattern at the aortic bifurcation. The changed hemodynamics are probably the main cause for late damage to the aorto-iliac vessels. The clinical importance of these results is that patients with unilateral leg amputation should have regular follow up investigation in order to detect late sequelae on the aorto-iliac vessels and to perform elective surgery for abdominal aortic aneurysm. Ipsilateral occlusive arterial disease as well as abdominal aortic aneurysms must be regarded as secondary late damage after leg amputation justifying obligatory indemnification.

[Profound revascularization: a forgotten alternative for multiple vessel reconstruction. A case study]. / Die Profundarevaskularisation: Eine vergessene Alternative zur Mehretagenrekonstruktion. Ein Fallbericht.

The profundaplasty represents with the lengthy conical widening of the deep femoral artery in combination with a lumbar sympathectomy L3-L5 a time-saving and effective alternative to multiple and extensive arterial reconstructions in the above and below knee level. An important prerequisite for this method is the exclusion of arteriosclerotic lesions at the aorto-iliac level. Critical selection of the patients and optimal operative technique of the profundaplasty offers results better or at least similar to that of time consuming femoropopliteal resp. cruro-pedal reconstruction. A below the knee reconstruction can always added in case of failure of the profundaplasty. The concentration on the revascularization of the deep femoral artery and reconstruction of the aorto-iliac segment offers a reduction of the operative risk and represents a time saving procedure.

[Aneurysm of the abdominal aorta and leg amputation. A chance coincidence or a pathogenetic correlation?]. / Aneurysma aortae abdominalis und Beinamputation. Zufällige Koinzidenzoder pathogenetische Korrelation?

A retrospective analysis of 545 patients, operated on between 1970 and 1987 for a closed or ruptured infrarenal aneurysm of the abdominal aorta (AAA), revealed an incidence of 5.1% of unilateral leg amputations among them (20 above, 8 below the knee) during the Second World War. Patients in both groups (with or without amputation) had one or more arteriosclerotic risk factors, their frequency rising with increasing age. There were differences between the two groups in the frequency of certain morphological characteristics in the area of the bifurcation and the terminal aorta affecting the haemodynamics of these regions. Stenosis or occlusion of the ipsilateral iliac arteries may be a possible pathogenetic factor. A prospective study will be required to decide whether the coincidence between leg amputation and AAA is pathogenetic or accidental.

[Atypical initial manifestation of abdominal aortic aneurysm. The causes of diagnostic and therapeutic errors]. / Atypische Erstmanifestation des abdominellen Aortenaneurysmas. Ursache diagnostischer und therapeutischer Fehlentscheidungen.

Initial manifestations of an abdominal aortic aneurysm may, depending on its site, morphology and direction of expansion, imitate numerous other intraabdominal diseases, but also lesions of peripheral vessels, vertebral column and spine. In this way they may give rise to errors of diagnosis and treatment. An abdominal aortic aneurysm should be considered especially in case of unclear gastrointestinal bleeding or abnormal intestinal passage (ischaemic colitis; mechanical displacement or compression of the duodenal-jejunal flexure and of the small-intestinal mesentery). In case of massive or recurrent gastrointestinal bleeding, especially in combination with a septicaemia, an aorto-intestinal fistula should be considered in the differential diagnosis. Radicular compression syndrome may be caused by an aortic aneurysm which is usually contained and predominantly suprarenal (to be considered especially once a herniated disk has been excluded by computed tomography). The same is true for unclear bone defects of the lumbar vertebrae (erosion by a penetrating aneurysm). Noninvasive methods, such as upper abdominal sonography, computed tomography and relatively minor invasive transvenous digital subtraction angiography now predominate in the definitive diagnosis of abdominal aortic aneurysm.

Temporary Witzel enterostomy in decompensated small-bowel obstruction or paralytic ileus.

The technique of temporary Witzel enterostomy and its indications are reported and results in 81 patients (99 enterostomies) retrospectively reviewed. The procedure is recommended as an adjunct to primary surgery in cases of small-bowel obstruction with severe distention, extensive peritoneal defects and compromised vascularity, in paralytic ileus due to generalized peritonitis and in peritoneal carinomatosis. With the Witzel tunnel, postoperative bowel paralysis can be prevented, endangered anastomosis protected, bowel function directly monitored and long-term intestinal decompression achieved in patients with obstruction due to peritoneal carcinomatosis. The tube is easily removed when bowel function has normalized. The overall mortality in the series was 25% and the rate of enterostomyrelated complications 10%. There were no enterocutaneous fistulas requiring surgical correction. Possible long-term complications due to narrowing at the enterostomy site could not be assessed. Carefully constructed Witzel enterostomy, used on suitable indications, is an effective procedure in the management of small-bowel obstruction and peritonitis.