Surgical treatment for agenesis of the vena cava: a single-centre experience in 15 cases.

OBJECTIVE: Agenesis of the inferior vena cava (IVC) is a rare vascular malformation. Deep vein thrombosis (DVT) and bilateral pelvic thrombosis develop quite frequently, making surgical therapy necessary. PATIENTS AND METHODS: Between 1982 and 2006, 15 patients (nine male, six female, mean age 28 standard deviance 9 years) with agenesis of the IVC (IVCA) were treated surgically because of acute or subacute DVT. These patients underwent bilateral transfemoral ante- and retrograde thrombectomy of the iliofemoral and sometimes popliteal veins and replacement of the IVC with an external ring supported PTFE-graft. Bi- or unilateral arteriovenous fistulae were created in the femoral region. The fistulae were closed, on average, 8 months after trans-arterial venography was performed. These patients were examined clinically and by duplex ultrasound imaging during follow-up to assess graft patency and to allow CEAP classification. Patients were assessed for the development of post-thrombotic syndrome (PTS). RESULTS: No patient died during any part of their treatment or within 60 days. Primary patency of the venous reconstruction was 53%, secondary and long time follow-up patency was 83%. The mean duration of follow-up was 41 SD 12 months. Minor complications were observed in five cases (33%). PTS showed no progression during a follow-up of 41 SD 12 months in all patients. There was no change in the CEAP clinical stage during follow-up nor did any leg ulcer develop. CONCLUSION: A surgical approach to restore venous patency is effective and appears to prevent the deterioration of CVI over time.

[Pulmonary embolism and deep vein thrombosis in the inferior vena cava affected by a rare anomaly]. / Embolisierende Thrombose bei Fehlbildung der V. cava inferior.

Persistent left-sided inferior vena cava (VCI) is a rare venous anomaly, its prevalence being estimated at 0.2-0.5%. Thrombotic occlusion of a VCI has been reported in only a few of these cases. We report the case of a 24-year old woman who suffered an acute thrombosis in a left-sided VCI and recurrent pulmonary embolism. After thrombectomy the course was uneventful. The diagnostic approach and the treatment strategy are discussed with reference to the literature.

[Reconstruction of the inferior vena cava for extended resection of malignant tumors]. / Rekonstruktion der Vena cava inferior zur erweiterten Resektion maligner Tumoren.

OBJECTIVES: Malignant tumor invasion in the inferior vena cava (IVC) has for a long time been the limiting factor in the resection of retroperitoneal tumors. The clinical outcome in these patients depends on vascular surgical techniques, the central role of which is played by IVC reconstruction. METHODS: Within the last 7 years, 9,085 vascular reconstructive procedures were performed in our department. Six patients suffered from retroperitoneal invasion of tumor into the IVC. After tumor resection, the involved IVC segments were replaced by polytetrafluorethylene (PTFE) grafts to restore IVC continuity. In three patients, an adjunctive arteriovenous (AV) fistula was constructed. RESULTS: The graft patency after a mean follow-up of 30.2 months (range 1 to 79) was 83.3%. The only graft occlusion occurred in a patient without AV fistula. There were no perioperative deaths and no major complications demanding reoperation. CONCLUSION: In patients with tumor involvement of the IVC, clinical outcome depends on vascular surgical coprocedure. After resection of the IVC, a PTFE graft should be interposed in combination with an AV fistula. Anticoagulation and CT scan are recommended after 3 months before ligation of the AV fistula.

[Surgical reconstruction of high grade carotid stenosis: a safe procedure?]. / Die operative Rekonstruktion der hochgradigen Karotisstenose: ein sicheres Verfahren? Ergebnisse aus 2.162 Eingriffen.

Carotid surgery is still controversial. Some large randomized trials have demonstrated the benefit of surgery in correlation to conservative treatment alone, but these positive results depend on how specific the diagnosis is and a low complication rate. This study presents the results of 2162 patients (male n = 1596 (74%), female n = 566 (26%), mean age 65 +/- 9 years), who underwent carotid surgery between 1990 and 1999. Forth-three percent of these patients had no ipsilateral neurological symptoms with high-grade carotid artery stenosis (Stage I). Thirty-eight percent appeared with prior ipsilateral TIA or PRIND--symptomatology (Stage II) and 19% suffered from stroke with persisting deficits (Stage IV). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure in 1967 patients (91%). In 1324 patients segmental resection of the internal carotid artery was performed. Carotid endarterectomies and other reconstructions for coronary artery disease including abdominal aortic aneurysm were combined during the same operation in 11% of the patients. The rate of postoperative ipsilateral neurological events was 4.1%. On the ontralateral side neurological symptoms appeared among 0.8%, and 0.4% of the patients had bilateral symptoms. Twenty patients (0.9%) died as a result of postoperative stroke. In relation to preoperative staging of the cerebrovascular occlusive disease in stage I, postoperative neurological symptoms appeared in 2.8% (mortality 0.6%), stage II in 5.7% (mortality 1.0%) and stage IV in 7.8% (mortality 1.2%) of the patients. These results confirm the importance of carotid reconstruction as a measure in the prevention of cerebral infarction in patients with asymptomatic or symptomatic high-grade carotid artery stenosis. The complication rate was lower than the data reported in the literature and the results were clearly better than under conservative treatment alone. In our opinion, the indication for carotid artery reconstruction should be made by a team of vascular surgeons, neurologists and neuroradiologists taking all patient-specific factors into consideration. Only by optimal patient selection and minimal complication rates will a significant benefit for the patient be achieved.

[Survey of therapy of deep venous thrombosis among members of the German Society of Vascular Surgery]. / Umfrage zur Therapie der tiefen Beinvenenthrombose unter den Mitgliedern der Deutschen Gesellschaft für Gefässchirurgie.

INTRODUCTION: In the literature of the past 15 years, deep venous thrombectomy has been rarely described. The only indications reported for thrombectomy seem to be recurrent pulmonary embolisation and phlegmasia coerulea dolens. Many contraindications and severe complications are making decisions concerning thrombolysis very difficult. At present, anticoagulation therapy is preferred over fibrinolysis. There is no conclusive concept for the standardization of treatment for deep venous thrombosis. As a first step towards achieving this, it was necessary to know what therapy is performed in hospitals throughout Germany. METHODS: In 1999, we sent letters of enquiry to the members of the "Deutsche Gesellschaft für Gefässchirurgie". We wrote to 341 members (hospitals), and the information gained by means of a questionnaire was analysed and evaluated. RESULTS: We received answers from 39.9% (n = 136) of the members. In all, 69% of the hospitals had an independent vascular department. In 1999, 6,718 patients underwent treatment for deep venous thrombosis, on average, 51 patients per hospital. Overall, 7,665 therapies were performed in one year (15.9% thrombectomy, 18.6% fibrinolysis, and 65.5% only anticoagulation). Only 23.5% of the hospitals had their own data about the outcome of their patients. The patency rate was 71.8% for thrombectomy and 48.9% for fibrinolysis. A severe postthrombotic syndrome was seen in 6.2% after thrombectomy, in 8.1% after fibrinolysis, and in 10.4% after singular anticoagulation. CONCLUSION: At present, there is still no standardized concept for the treatment of patients with deep venous thrombosis. It seems that there are better results for some indications with thrombectomy than with other methods. For the establishment of a concept of treatment, a prospective randomised study is necessary.

[Long-term results after carotid reconstruction in patients with completed stroke caused by cerebrovascular occlusive disease]. / Langzeitergebnisse nach Karotisrekonstruktion im Defektstadium der zerebrovaskulären Verschlusskrankheit.

UNLABELLED: Long-term results after carotid reconstruction in patients with completed stroke caused by cerebrovascular occlusive disease. BACKGROUND AND OBJECTIVE: In patients with completed stroke caused by cerebrovascular occlusive disease the reconstruction of high grade carotid artery stenosis is discussed as prophylaxis for prevention of recurrent stroke. The operative complications of all patients who underwent surgery for carotid occlusive disease in the Heinrich Heine University between 1990 and 1999 were evaluated in this study. PATIENTS AND METHODS: We present the results of 596 reconstructions in 537 patients (404 men, 133 women; mean age 64,5 plus minus 9,4 years). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure. RESULTS: A postoperative ipsilateral neurological deficit was observed in 41 patients (6,9 %): 4,7 % permanent, 2,2 % transitory. Thirtyeight percent of the permanent deficits appeared after reconstructions performed within six weeks after stroke and only 9 % after surgery between six and twelve weeks. The in-hospital mortality was 0,7 % for neurological and 1,0 % for cardiopulmonary complications. During long-term follow-up (mean follow-up time 50 plus minus 34 months) only 17 (3,7 %) of 462 patients, which could be evaluated, presented with a new neurological event for the reconstructed side. Fifty-eight percent had none or minimal neurological deficits. 115 Patients (24,0 %) died during follow-up. CONCLUSION: Even after completed stroke carotid reconstruction can be carried out successfully in selected patients with an acceptable complication rate in prophylaxis of recurrent stroke. In our retrospective study the optimal time for surgery seems to be between six and twelve weeks after stroke, but new imaging techniques may alter in the future the time window for operation in patients with an unstable neurological situation early after stroke. The reduction of social mobility and the high mortality in follow-up in correlation to patients without stroke are mostly related to accompanying severe cardiopulmonal risk factors.

Reconstructive surgery for carotid artery occlusive disease in the elderly--a high risk operation?

Patients over 80 yr of age may require carotid surgery for symptomatic or critical asymptomatic carotid artery occlusive disease.A total of 2262 operations were performed between 1990 and 1999; 76 (3.4%) were carotid reconstructions in 70 patients over 80 yr of age. Twenty patients (26%) presented with asymptomatic critical stenosis. Transient ischemic symptoms were the reason for presentation in 35 patients (46%). Progressive stroke was documented in two patients (3%) and a stroke with persisting neurological deficit was demonstrated in 19 cases (25%). Coronary artery disease was present in 47 patients (38%) and arterial hypertension in 55 (72%). Fifty-nine patients (84%) were classified as ASA group 3. Seventy-one thromboendarterectomies of the carotid bifurcation with vein-patch closure were performed. Five patients had other types of reconstruction. Simultaneous operations (aorto-coronary vein-bypass, aortic interposition graft etc.) were performed in nine patients. Postoperative complications occurred in three patients. One had a transient neurological deficit and another a lethal stroke; the third patient died from myocardial infarction. The in-hospital mortality was 2.9%, which was not significantly higher than the results of the other 2186 reconstructions (1.5%). Surgery for carotid artery occlusive disease can be safely performed in selected patients of more than 80 yr of age.

Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases.

OBJECTIVE: A mycotic aneurysm of the aorta and adjacent arteries is a dreadful condition, threatening life, organs, and limbs. With regard to the aortic segment involved, repair by either in situ replacement or extra-anatomic reconstruction can be quite challenging. Even when surgery has been successful, the prognosis is described as very poor because of the weakened health status of the patient who has developed this type of aneurysm. The aim of our study was to find out whether any progress could be achieved in a single center over a long time period (18 years) through use of surgical techniques and antiseptic adjuncts. MATERIAL AND METHODS: From January 1983 to December 1999, a total of 2520 patients with aneurysms of the thoracic and abdominal aorta and iliac arteries underwent surgery for aortic or iliac replacement at our institution. During that period, 33 (1.31%) of these patients (mean age, 64.3 years) were treated for mycotic aneurysms of the lower descending and thoracoabdominal (n = 13), suprarenal (n = 4), and infrarenal (n = 10) aorta and iliac arteries (n = 6). Twenty (61%) of these 33 patients had histories of various septic diseases; in the other 13 (39%), the etiology remained uncertain. Preoperative signs of infection, such as leukocytosis and elevated C-reactive protein, were found in 79% of the patients, and fever was apparent in 48%; 76% of the patients complained of pain. At the time of surgery, eight (24%) mycotic aneurysms were already ruptured, and 20 (61%) had penetrated into the periaortic tissues, forming a contained rupture. Five (15%) aneurysms were completely intact. The predominant microorganisms found in the aneurysm sac were Staphylococcus aureus and Salmonella species. Careful debridement of all infected tissue was essential. In the infrarenal aortic and iliac vascular bed, in situ reconstruction was performed only in cases of anticipated "low-grade" infection. Alternative revascularization with extra-anatomic procedures (axillobifemoral or femorofemoral crossover bypass graft) was carried out in eight of 16 cases. All four suprarenal and all 13 mycotic aneurysms of the thoracoabdominal aortic segment were repaired in situ. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics. RESULTS: In-hospital mortality was 36% (n = 12). Because of the smallness and heterogeneity of the sample, we could not demonstrate significant evidence for any influence of aneurysm location or type of reconstruction on patients' outcome. However, survival was clearly influenced by the status of rupture. During long-term follow-up (mean, 30 months; range, 1-139 months), 10 patients (48%) died-one (4.8%) probably as a consequence of the mycotic aneurysm, the others for unrelated reasons. Eleven patients (52%) are alive and well today, with no signs of persistent or recurrent infection. CONCLUSIONS: A mycotic aneurysm of the aortic iliac region remains a life-threatening condition, especially if the aneurysm has already ruptured by the time of surgery. Although the content of the aneurysm sac is considered septic, as was proved by positive cultures in 85% of our patients, in situ reconstruction is feasible and, surprisingly, was not more closely related to higher morbidity and mortality in our series than ligation and extra-anatomic reconstruction, although most of the aneurysms repaired in situ were located at the suprarenal and thoracoabdominal aorta. We assume that our operative mortality rate of 36%, which relates to a rupture rate of 85%, could be substantially lowered if the diagnosis of mycotic aneurysm were established before rupture.

Prothrombin and factor V mutations in women with a history of thrombosis during pregnancy and the puerperium.

BACKGROUND: Venous thromboembolism is a leading cause of morbidity and mortality during pregnancy and the puerperium. However, the role of mutations in the prothrombin and factor V genes and other thrombophilic abnormalities as risk factors for thromboembolism in women during pregnancy and the pueperium is not known. METHODS: In a study of 119 women with a history of venous thromboembolism during pregnancy and the puerperium and 233 age-matched normal women, we measured the activity of antithrombin, protein C, protein S, and lupus anticoagulant. We also performed genetic analyses to detect the G1691A mutation in the factor V gene (factor V Leiden), the G20210A mutation in the prothrombin gene, and the C677T mutation in the methylenetetrahydrofolate reductase gene. Blood samples were obtained at least three months post partum or after the cessation of lactation. RESULTS: Among the women with a history of venous thromboembolism, the prevalence of factor V Leiden was 43.7 percent, as compared with 7.7 percent among the normal women (relative risk of venous thromboembolism, 9.3; 95 percent confidence interval, 5.1 to 16.9); that of the G20210A prothrombin-gene mutation, 16.9 percent as compared with 1.3 percent (relative risk, 15.2; 95 percent confidence interval, 4.2 to 52.6); and that of both factor V Leiden and the G20210A prothrombin-gene mutation 9.3 percent as compared with 0 (estimated odds ratio, 107). Assuming an overall risk of 1 in 1500 pregnancies, the risk of thrombosis among carriers of factor V Leiden was 0.2 percent, among carriers of the G20210A prothrombin-gene mutation, 0.5 percent, and among carriers of both defects, 4.6 percent, as calculated in a multivariate analysis. CONCLUSIONS: The G20210A prothrombin-gene mutation and factor V Leiden individually are associated with an increased risk of venous thromboembolism during pregnancy and the puerperium, and the risk among women with both mutations is disproportionately higher than that among women with only one mutation.

[Vena cava umbrella filter: complications and treatment]. / Cava-Schirmfilter: Komplikationen und Therapie.

BACKGROUND AND OBJECTIVE: Increasing numbers of vena canal filters are being implanted to prevent pulmonary embolism, which are mainly the consequence of deep vein and pelvic vein thrombosis. Can a filter be removed again in case of complications arising from it? What is the risk of such operative explantation? What is the subsequent risk of pulmonary embolism? PATIENTS AND METHODS: In nine patients (5 males, 4 females; mean age 45 (30-39 years) who had vena caval filters implanted because of thromboembolism despite anticoagulation, complications due to the filter required its operative removal and thrombectomy of the large veins 3 days to 48 months after implantation in the inferior vena cava (IVC). One inguinal arteriovenous fistula (due to perforation of rods of a displaced filter) were closed. The patients' case note were retrospectively analysed and eight of the nine patients' were reexamined according to a standardized procedure a mean of 20 months after removal of the filter. RESULTS: Explantation of the filter had been successful in all patients. But there were two nonfatal postoperative complications: a pulmonary embolus and a paradoxical cerebral embolus. In one patient a segmental stenosis of the IVC with retroperitoneal collateral circulation was found at operation. All but one of 16 pelvic veins that had thrombectomies performed at the time of filter explanation were patent, as were the IVCs in seven of the eight re-examined patients. None of the patients had evidence of postoperative pulmonary embolism. CONCLUSIONS: Vena caval filters can be explanted with a low operative risk. After removal and venous thrombectomy, implantation of another caval filter is unnecessary. As anticoagulation properly monitored is almost always an effective measure in the prevention of pulmonary thromboembolism, filter implantation should be performed only on the strictest indication, as an ultimate step.