Serious complications that require surgical interventions after endoluminal stent-graft placement for the treatment of infrarenal aortic aneurysms.

BACKGROUND: Endoluminal stent-graft placement for the treatment of infrarenal abdominal aortic aneurysms has gained widespread acceptance because it is associated with lower peri-interventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. METHODS AND RESULTS: Between September 1994 and December 1998, 150 patients (age, 69.6 +/- 8.49 years; 142 men, 8 women) with abdominal aortic aneurysms were treated with the placement of an intravascular nitinol stent-graft (Stentor [55] and Vanguard-System [95]); there were eight tubular grafts and 142 bifurcated grafts. Initial placement of the stent-graft was successful in 144 patients. Mean follow-up was 49 +/- 25 months. In 13.3% of stent-graft placements we encountered the following complications: 4 cases of migration or dislocation of the prosthesis (30.5 +/- 7.4 months after placement); 2 ruptures of the aorta (26.7 and 15.0 months after placement); 3 recurrent thromboses of the stent-graft (25.5 +/- 5.3 months after placement); 3 endoleaks (27.5 +/- 15.7 months after placement); and 5 infections of the prosthesis (26.6 +/- 16.5 months after placement). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a Dacron graft. CONCLUSIONS: (1) The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. (2) Explantation of the prosthesis and surgical repair is feasible but bears additional risks. (3) Because the onset of reperfusion of the excluded aneurysm cannot be predicted, all patients with infrarenal aortic stent-grafts require frequent computer tomographic follow-up. (4) Finally, the results call for further improvements in the design of the stent-graft.

[Explantation of aortic stent-grafts]. / Explantation von Bauchaortenstents - Ursachen, OP-Technik, Ergebnisse, Germany.

BACKGROUND: Endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms (AAA) has gained widespread acceptance because it is associated with lower perinterventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. METHODS AND RESULTS: Between 9/94 and 12/98, 150 patients (age = 69.6 +/- 8.5 y; m = 142, f = 8) with AAA were treated by placing an intravascular nitinol stent graft (Stentor, n = 55; Vanguard-System, n = 95; 8 tubular grafts, 142 bifurcated grafts). Initial placement of the stent graft was successful in 144 patients. In 12 % of stent graft placements we encountered one of the following complications (n, days after stent placement): migration or dislocation of the prosthesis (4, 914 +/- 220 d), rupture of the aorta (2, 452 d/802 d), recurrent thrombosis of the stent graft (3, 478 +/- 359 d), endoleak (3, 955 +/- 472 d), infection of the prosthesis (5, 798 +/- 495 d). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a dacron graft. CONCLUSIONS: 1. The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. 2. Explantation of the prosthesis and surgical repair is feasible but bears additional risks. 3. Since the onset of reperfusion of the excluded aneurysm can not be predicted, all patients with infrarenal aortic stent grafts require frequent computer tomographic follow up. 4. Lastly, the results call for further improvements in the design of the stent graft.

Evaluation of transmyocardial laser revascularization by following objective parameters of perfusion and ventricular function.

BACKGROUND: Does transmyocardial laser revascularization (TMLR), a new surgical technique for treating patients with otherwise intractable angina pectoris, improve myocardial perfusion, metabolism, and, consequently, function? METHODS: Patients referred for TMLR, alone or with coronary artery bypass grafting (CABG), were preoperatively evaluated clinically and by treadmill stress testing, echocardiography, ventriculography, radionuclide assessment of perfusion and metabolism, and hemodynamic assessment. Intraoperatively it was decided that some patients only required CABG. Follow-up evaluations were repeated after 6 (n = 40) and 12 months (n = 23) and compared with preoperative values. RESULTS: CABG only was performed in 35 cases, TMLR + CABG in 17, TMLR only in 45. 1-year mortality was 11% in the TMLR, zero in the TMLR + CABG, and 11% in the CABG groups. In all groups a significantly improved CCS angina- and NYHA class was observed immediately after operation and after 6 and 12 months. In all study groups treadmill tolerance (p<0.05) improved, but regional and global function, perfusion at rest, and metabolism were not significantly changed at 6 and 12-months follow-ups. Perfusion studies under stress demonstrated an improvement only in the CABG group after 12 months (p<0.05), whereas in both TMLR groups the lasered ischemic segments remained unchanged. CONCLUSIONS: TMLR significantly improves long-term clinical status and treadmill stress tolerance, but appears to have little if any effect upon regional and global function, perfusion, and metabolism.

Palliative treatment of a secondary aortoduodenal fistula by stent-graft placement.

A 64-year-old male was admitted with suspected aortoduodenal fistula 16 years after transabdominal aortic reconstruction for aortoiliac occlusive disease. Computed tomography (CT) and angiography revealed an aortoduodenal fistula and a suture-line aneurysm at the proximal anastomosis. Due to the patient's poor general condition at the time of diagnosis, endoluminal stent-graft implantation was chosen rather than conventional surgery. Successful placement of the stent graft without leakage of contrast medium and with complete exclusion of the fistula was demonstrated by CT. The patient recovered uneventfully and was discharged 10 days after the intervention. Five months later contrast CT indicated a recurrence of the aortoduodenal fistula. Since the patient was now in good general condition the stent graft was removed surgically and an extra-anatomic axillofemoral bypass was implanted. Endoluminal stent-graft Implantation is effective as palliative therapy for aortoduodenal fistulas and is especially valuable in patients with high risk for conventional surgery.

[Treatment strategies in therapy refractory angina pectoris: transmyocardial laser revascularization]. / Behandlungsstrategien bei therapierefraktärer Angina pectoris: Transmyokardiale Laserrevaskularisation.

BACKGROUND: Does transmyocardial laser revascularization (TMLR) as a new surgical technique for treating patients with otherwise intractable angina pectoris improve myocardial perfusion or contractility? METHODS: Sixty-seven patients transferred for TMLR were evaluated by clinical evaluation, treadmill stress testing, echocardiography, ventriculography, and hybrid positron emission tomography preoperatively and in patients treated with TMLR at 6 and 12 month follow up. Hemodynamic assessment and clinical evaluation were performed perioperatively. RESULTS: In 28/67 cases (42%) CABG, in 9/67 patients (13%) CABG in combination with TMLR (combined group), and in 30/67 patients (45%) only TMLR (sole group) were performed. Perioperative mortality in the sole group was 13%, in the combined group zero, and in the CABG group 11%. In all groups a significantly improved clinical status (p < or = 0.01) 1 week postoperatively and in TMLR groups also at 6 and 12 months was observed. In the TMLR groups treadmill tolerance (p < 0.05) improved, although function, perfusion, and metabolism did not change significantly at the 6 and 12 month follow up. CONCLUSION: TMLR significantly improves clinical status and treadmill stress tolerance, but does not change function, perfusion, and metabolism.

["Myxoma syndrome"--a "benign" disease with "malignant" course]. / "Myxoma-Syndrom"--eine "benigne" Erkrankung mit "malignem" Krankheitsverlauf.

We are reporting on a 36 year-old woman who presented with recurrent cardiac myxomas over a period of nine years. Two of the tumors typically originated in the left atrium and one in the right atrium. Tumor embolization was the presenting symptom twice, leading to reversible cerebral ischemia and minor pulmonary embolism, respectively. The third tumor remained asymptomatic and was detected during routine echocardiographic examination. Based on a positive family history of cardiac tumors, a facially pronounced hyperpigmentation of the skin and the presence of a thyroid adenoma, the diagnosis of a "myxoma syndrome" was established. Patients with "myxoma syndrome" are generally younger than their counterparts with "sporadic myxoma" (mean age at diagnosis 25 vs. 56 years) and have a high frequency of unusual skin freckling (68%). Familial clustering of cardiac myxomas is also frequent (25%). The tumors may be located in any of the cardiac chambers (87% in the atrias, 13% in the ventricles, 50% at multiple sites simultaneously) and have relatively high (18%) 5-year recurrence rate after surgical excision. Since the clinical signs of cardiac tumors are non-specific, diagnosis essentially relies on cardiac imaging by echocardiography, computer tomography, or angiography. The superiority of transesophageal echocardiography is emphasized in this report.

Two-center German experience with aortic endografting.

PURPOSE: To report the results of a two-center study of endovascular abdominal aortic aneurysm (AAA) exclusion using a polyester-covered nitinol stent-graft. METHODS: Candidates were evaluated with arteriography and computed tomography. Criteria for endovascular therapy were a proximal aortic neck > 10 mm in length and < 25 mm in diameter, no bilateral internal iliac artery involvement in the aneurysm, no markedly tortuous common iliac arteries (CIAs) or CIAs < 7 mm in diameter, and no superior mesenteric artery occlusive disease. Patients were treated with the Mialhe Stentor and Vanguard stent-grafts in either tube or bifurcated versions. RESULTS: Between August 1994 and November 1996, 149 patients (mean age 67 years, range 49 to 90) were admitted to the study. Overall primary technical success (aneurysm exclusion without endoleak) was 87% (130 patients): 78% (7 patients) for tube grafts and 88% (123 patients) for bifurcated endografts. The rate of local, remote, or systemic complications was 10.8%, with a 30-day mortality rate of 0.7%. During an average 13.5-month follow-up, there were no late deaths. Four of 20 endoleaks sealed spontaneously, 14 were treated with endoluminal techniques, and 2 remain untreated by patient request. Three graft limb thromboses occurred; one was treated surgically, one with lytic therapy, and one was untreated. Secondary patency was 96%. CONCLUSIONS: Endoluminal repair of infrarenal AAAs using straight or bifurcated grafts is a feasible alternative to conventional surgical repair. Longer follow-up and more experience with refined endograft models will elucidate the durability of this endovascular approach to treating AAAs.

Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.

BACKGROUND: The treatment of aortic aneurysms with endovascular stents or stent-graft prostheses is receiving increasing attention as an alternative to major abdominal surgery. To define the clinical value of this technique, we prospectively studied the use of stent-graft endoprostheses made of nitinol and covered with polyester fabric for the treatment of infrarenal abdominal aortic aneurysms. METHODS: We treated a total of 154 patients at three academic hospitals. Twenty-one patients with aortic aneurysms not involving the aortic bifurcation received straight stent-grafts, and 133 patients with aortic aneurysms involving the bifurcation and the common iliac arteries received bifurcated stent-grafts. After a unilateral surgical arteriotomy, the endoprostheses were advanced through the femoral arteries and placed under fluoroscopic guidance. Computed tomography and intraarterial angiography were performed during an average follow-up of 12.5 months. RESULTS: The primary success rate, defined as complete exclusion of the abdominal aortic aneurysm from the circulation, was 86 percent in the group receiving straight grafts and 87 percent in the group receiving bifurcated grafts. In three patients the procedure had to be converted to an open surgical operation. Minor (n=13) or major (n=3) complications associated with the procedure (including 1 death) occurred in 10 percent of the patients. All patients had a postimplantation syndrome, with leukocytosis and elevated C-reactive protein levels. CONCLUSIONS: Our results suggest that endovascular treatment of infrarenal abdominal aortic aneurysms is technically feasible and can effectively exclude abdominal aortic aneurysms from the circulation. With further refinement, endoluminal repair may emerge as an interventional strategy to treat infrarenal aortic aneurysms, especially in patients at high surgical risk.

Abdominal aortic aneurysms: preliminary technical and clinical results with transfemoral placement of endovascular self-expanding stent-grafts.

PURPOSE: To evaluate treatment of infrarenal abdominal aortic aneurysm (AAA) with a new endoluminal stent-graft. MATERIALS AND METHODS: In 26 male patients, straight or bifurcated nitinol stents covered with woven Dacron graft material were implanted to treat eccentric saccular AAA (n = 3) or AAA involving the bifurcation and common iliac arteries (n = 23), with follow-up from 8 days to 8 1/2 months. RESULTS: Implantation was technically successful in all but one of the 26 (96%) patients (leak of the stent-graft for more than 3 months necessitated implantation of an additional covered stent). In seven of the 26 patients, minor residual perfusion persisted immediately after implantation, but complete thrombosis occurred within 7 days. Five procedure-related complications occurred: distal embolization (n = 2); local hematoma, which necessitated surgery (n = 1); acute hepatic failure due to gastric bleeding, in a patient with liver cirrhosis (n = 1); and stent-graft occlusion due to emboli originating from the left atrium (n = 1). CONCLUSION: Exclusion of AAA from circulation was feasible, safe, and clinically effective with the new stent-graft.

[Initial clinical experiences with endovascular stent-grafts for treatment of infrarenal abdominal aortic aneurysm]. / Erste klinische Erfahrungen mit endovaskulären Stent-Grafts zur Behandlung des infrarenalen Bauchaortenaneurysmas.

With a series of 34 transluminal stent-graft procedures, we assessed the feasibility and clinical effectiveness of a new stent-graft for the treatment of infrarenal abdominal aortic aneurysms (AAAs). We treated 34 male patients (mean age 71 years) with straight of bifurcated nitinol stents covered with woven Dacron graft material for infrarenal excentric saccular AAA (n = 3) or AAA involving the bifurcation and the common iliac arteries (n = 31). The 18-F delivery system was advanced via a surgical arteriotomy and the stent-graft was placed under fluoroscopic control. Follow-up period ranged from 8 days to 13 months. The implantation of the stent-grafts was technically successful with exclusion of AAA in 31/34 cases (91%). In 2 patients, there was a persisting leak at the distal end of the endoprosthesis after treatment; in another, marked coiling of the external iliac artery impeded the delivery system to be advanced and consecutive rupture resulted in conversion to surgical repair. Other procedure-related complications were acute hepatic failure due to gastric bleeding in a patient with liver cirrhosis, graft occlusion due to emboli originating from the left atrium (n = 1), local hematoma (n = 1), and AV-fistula (n = 1) requiring surgery. A post-implantation syndrome with leucocytosis and elevated C-reactive protein was observed in all patients. Endoluminal repair of infrarenal AAA with use of Dacron covered nitinol stent-grafts is feasible, safe and clinically effective. However, careful long-term evaluation is necessary before it will become clinical practice.

[Surgical therapy of chronic traumatic aortic aneurysm]. / Chirurgische Therapie des chronischen traumatischen Aortenaneurysmas.

Rupture of the aorta that usually occurs with major blunt trauma of the chest is associated with a high mortality, and only 2% of the patients survive long enough to develop a false aneurysm. Although symptom-free latent period is not rare, there is evidence of progression. Since 1970 we operated on 28 patients (24 male and 4 female, mean age 41.2 years) for chronic traumatic aneurysm of the descending aorta. A previous blunt trauma of the chest had certainly occurred in 23 cases (3 months to 20 years before) and was likely in 4 patients; in one young woman the aneurysm developed after percutaneous angioplasty of a coarctation. In 26 patients surgical repair consisted in a Dacron tube interposition, and in 2 cases patch repair was adequate. In 11 cases the "clamp and repair" technique was applied, while in 17 patients extracorporeal circulation was established to perform the reconstruction, two of these cases were operated with hypothermic circulatory arrest. Although there was no correlation between the occurrence of complications and the applied procedure, we lately turned to establish cardiopulmonary bypass in all cases with regard to a better control of the hemodynamics during clamping, the possibility of direct retransfusion of blood, and the option to extend the procedure, if necessary. In view of the facts, that traumatic thoracic aneurysms develop late complications in about 75% of the cases, and the morbidity in elective surgery is of a low figure, we conclude, that surgery of such lesions is mandatory, once the diagnosis has been established, and that an expectant attitude in the treatment is justified only in exceptional cases.

[Endoluminal therapy of infrarenal abdominal aortic aneurysms: a new interventional technique]. / Die endoluminale Therapie des infrarenalen Bauchaorten-aneurysmas--ein neues interventionelles Verfahren.

PURPOSE: With a series of 31 transluminal stent-graft procedures, we assessed the feasibility and clinical effectiveness of a new stent-graft for the treatment of infrarenal abdominal aortic aneurysms (AAAs). METHODS: We treated the patients (male; mean age 71 years) with straight or bifurcated nitinol stents covered with woven dacron graft material for infrarenal eccentric saccular AAA (n = 4) or AAA involving the bifurcation and the common iliac arteries (n = 27). The 18-F delivery system was advanced via a surgical arteriotomy and the stent-graft was placed under fluoroscopic control. Follow-up period ranged from 8 days to 9 months. RESULTS: The implantation of the stent-grafts was technically successful in 30/31 cases. Procedure-related complications were acute hepatic failure due to gastric bleeding in a patient with liver cirrhosis, graft occlusion due to emboli originating from the left atrium (n = 1), macro-embolisation (n = 3), local haematoma (n = 1) and av-fistula (n = 1) requiring surgery. A post-implantation syndrome with leukocytosis and elevated C-reactive protein was observed in all patients. CONCLUSIONS: Endoluminal repair of infrarenal AAA with use of dacron covered nitinol stent-grafts is feasible, safe and clinically effective. However, careful long-term evaluation is necessary.

Dopaminergic and alpha-adrenergic control of neurotransmission in human right atrium.

The aim of the present study was to investigate dopamine receptor- and alpha-adrenergic receptor-mediated modulation of norepinephrine release in human atria. Right atrial appendages were incubated with 3H-norepinephrine, placed in superfusion chambers, and field-stimulated by platinum electrodes at a frequency of 5 Hz. The stimulation-induced (S-I) outflow of radioactivity was taken as an index of norepinephrine release. The dopamine D2-receptor agonist quinpirole (0.03-3 microM) concentration dependently inhibited the S-I outflow of radioactivity with an EC50 of 0.03 microM. The concentration-response curve of quinpirole was potently shifted to the right by the D2-receptor antagonists domperidone (0.003 microM, pKB approximately 9.2) and S(-)-sulpiride (0.1 microM, pKB approximately 8.6). The D1-receptor antagonist SCH 23390 (1 microM) slightly (pKB approximately 6.9) shifted the concentration-response curve of quinpirole, whereas the alpha 2-adrenergic antagonist rauwolscine (0.01 microM) and the alpha 1-adrenergic antagonist prazosin (1 microM) had no effect. The D1-receptor agonist did not affect fenoldopam (0.03 and 0.3 microM), but fenoldopam (3 microM) enhanced the S-I outflow of radioactivity. The facilitatory effect of fenoldopam (3 microM) was unaltered by SCH 23390 (0.1 microM) but prevented by rauwolscine (0.01 microM). The alpha 2-adrenergic agonist UK 14304 (0.01-1 microM) (EC50: 0.06 microM), but not the alpha 1-adrenergic agonist methoxamine (0.3-30 microM), inhibited S-I outflow of radioactivity. The concentration-response curve of UK 14304 was shifted to the right by rauwolscine (0.01 microM, pKB approximately 8.6).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of surgical and medical therapy for atrial septal defect in adults.

BACKGROUND: The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study. METHODS: In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26). RESULTS: Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different. CONCLUSIONS: The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.

[Acute and chronic aortic rupture. Management without and with a protective bypass procedure]. / Die frische und veraltete Aortenruptur. Versorgung ohne und mit dem Schutz eines Bypassverfahrens.

The use of partial cardiopulmonary bypass in the surgery of thoracic aortic ruptures is still a matter of controversey. Since 1970, 38 patients with thoracic aortic rupture have been treated at our institution, 13 in a acute or subacute stage and 25 with traumatic aneurysm. Partial cardiopulmonary bypass was installed in 13 cases, and in 23 patients the "clamp and repair" technique was performed. Although there was no coherence between the occurrence of complications and the applied procedure, we prefer the use of partial cardiopulmonary bypass in view of the advantages in safe distal perfusion, direct retransfusion of blood, controlled decompression of the left heart, and the possibility to extend surgery to the aortic arch.

[Histologic examinations of internal mammary artery, saphenous vein and aorta specimens collected during heart surgery]. / Badania histologiczne wycinków tetnicy piersiowej wewnetrznej, zly odpiszczelowej wielkiej i aorty pobranych w czasie operacji kardiochirurgicznych.

133 patients with coronary heart disease were treated surgically. 60 patients had Internal Mammary Artery (IMA) grafting performed together with saphenous vein grafts (IMA group), another 70 patients had saphenous vein grafts only (SVG group). Material for histological examination was intraoperatively taken from saphenous vein and ascending aorta and in IMA group also from the distal part of internal mammary artery. The intensity of atherosclerosis was estimated with 5-grade scale from 0 to 4 (0-no atherosclerosis, 1-minimal, 2-insignificant, 3-moderate, 4-pronounced). To visualize and to assess the blood flow through the internal mammary artery Digital Subtraction Angiography (DSA) was performed between day 6 and day 8 postoperatively in the IMA group. Results obtained were correlated with the intensity of atherosclerosis estimated histologically and the numeric data were statistically analysed. In the IMA grafts mean atherosclerosis intensity was 0.94 which is the evidence of minimal atherosclerotic changes. In saphenous vein the corresponding value was in the IMA group 2.14 and in the SVG group 2.17, in aortic scraps 2.64 in the IMA group and 2.73 in the SVG group. Patients in the SVG group were average 8.4 years older than in the IMA group. The difference is statistically significant. Despite the age difference, the intensity of atherosclerosis was not statistically different in aortic and saphenous vein scraps. Among 63 patients in the IMA group in 31 patients (49.2%) no atherosclerosis was found during histological examination and in 32 patients (50.8%) changes ranged from minimal to moderate. There were no IMA grafts with the pronounced atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transfemoral, transatrial double-balloon valvuloplasty of rheumatic mitral stenosis]. / Transfemorale, transatriale Doppelballon-Valvuloplastie der rheumatischen Mitralstenose.

A percutaneous transfemoral, transatrial double-balloon valvuloplasty was performed on 21 patients (53 +/- 14 years) with rheumatic mitral stenosis. An open commissurotomy was performed in six patients, 20 +/- 9 years previously; in three patients an arterial embolism had occurred previously. Balloon valvuloplasty resulted in a reduction of the mean diastolic gradient from 16 +/- 7 to 8 +/- 3 mm Hg (p less than 0.001), and the mitral valve orifice area increased from 1.1 +/- 0.3 to 2.2 +/- 0.8 cm2 (p less than 0.001). Mitral insufficiency increased in three patients and was first observed after valvuloplasty in four patients. Complications were seen in three patients: a left ventricular perforation resulting in pericardial tamponade occurred in two patients, which required cardiothoracic intervention. In one patient a pulmonary embolism occurred five days after the invasive procedure. The study shows that percutaneous transfemoral balloon valvuloplasty can successfully be performed in patients with severe or even calcified mitral valve stenosis. The risk of severe complications is, however, not negligible.

[Fractures accompanied by injuries of the great vessels in sport and leisure accidents. Diagnosis and management concept]. / Frakturen mit begleitenden Verletzungen grosser Gefässe bei Sport- und Freizeitunfällen. Diagnostik und Behandlunskonzept.

Extremity fractures with concomitant vascular injuries are surgical emergencies. Especially injuries of the upper extremities require a preoperative angiographic examination for the localization of the vascular lesion. In vascular lesions of the lower extremities a primary angiography is not necessary, if there is an opportunity for an intraoperative radiologic evaluation. In our traumatological department 104 patients were treated over the last 15 years with that combined injury. The concept of immediate stabilization of the fracture with simultaneous or postponed arterial repair has been proved to be appropriate. The fasciotomy as prophylactic procedure of a postischemic compartment syndrome is also a part of our concept during the last years. The late results in our mostly young patients depended on the degree of soft tissue damage and the time of ischemia. The often untreatable nerve lesions contributed to a loss of use of about 30% in the late courses.

Atrioventricular septal defect with double-outlet right atrium.

A rare type of primum atrial septal defect is described in which the atrial septum deviated to the left, resulting in a double-outlet right atrium. The obstruction at the site of the small atrial septum defect led to an elevation of the left atrial mean pressure and to pulmonary arterial hypertension. The presence of mixed blood in the right atrium caused systemic arterial desaturation. A cleft in the septal leaflet of the left atrioventricular (AV) valve caused a left ventricular-right atrial shunt, which-added to the left-to-right atrial shunt--totaled 60% of the pulmonary circulating volume. Preoperative knowledge of the anatomic features facilitated surgical repair, which consisted in resection of the abnormal septum, construction of a new septum with a Dacron patch, and closure of the septal commissure of the left-sided AV valve.