[Incidence, classification and therapy of isolated pelvic artery aneurysm]. / Häufigkeit, Klassifikation und Therapie der isolierten Beckenarterienaneurysmen.

INTRODUCTION: Isolated iliac artery aneurysms (IAA) are rare. The rupture risk, however, is high and the diagnosis can be difficult. The aim of this study was to report the frequency, morphology and outcome of these lesions. METHODS: Retrospective analysis of the medical data of all patients treated for IAA from 1990 to 1999. RESULTS: Fifty-nine consecutive patients, 55 (93%) male and 4 (7%) female, were included in the study. The median age was 68 (48-86) years. During the same time period, 741 consecutive patients with aortoiliac aneurysms were treated; thus the frequency of IAA was 8%. The median diameter of the IAA was 7 (3-12) cm. Most patients had at least one risk factor. IAA were unilateral in 40 (68%) or bilateral in 19 (32%) patients and affected the common iliac artery in 25 (19%), the internal iliac artery in 11 (19%) and simultaneously the common and internal iliac artery in 21 (36%) patients. Additional involvement of the external iliac artery was noted in 2 (3%) patients. Thirty-six (61%) patients with IAA underwent elective treatment while 23 (39%) patients had to be treated on an emergency basis. Endovascular stent grafts were inserted in 2 patients. Overall mortality was 10% (n = 6), 2.8% (n = 1) in asymptomatic and 22% (n = 5) in symptomatic or ruptured IAA. Overall morbidity in this study was 30%. The median follow-up of the patients was 36 (2-120) months. DISCUSSION: Surgical therapy in patients with asymptomatic IAA can be performed with a reasonable mortality. However, mortality and morbidity in patients with symptomatic or ruptured IAA remains high. Postoperative long-term results are excellent. The value of endovascular therapy for IAA has yet to be determined.

[Surgical therapy of acute and chronic arterial occlusions below the inguinal ligament]. / Die chirurgische Therapie akuter und chronischer Arterienverschlüsse unterhalb des Leistenbandes.

The history and physical examination are extremely important in the management of vascular surgical patients because a correct diagnosis can usually be made on the basis of information obtained from these two modalities. The severity of the chronic occlusive process leads to characteristic symptoms in the extremity: claudication, rest pain, skin ulcerations and gangrene. Chronic progressive lesions permit enlargement of collateral blood supply which, for a time, minimizes the severity of symptoms. Milde degrees of arterial insufficiency (claudication) can be treated conservatively. Unreconstructed chronic critical ischemia predicts a poor outcome in terms of survival and limb salvage. The outlook with arterial reconstructive surgery is by far better. Arteriography ist the most reliable diagnostic test for occlusive lesions. It ist essential for the operative planning. Vein-bypass procedures are, if feasible, very effective in most cases. Acute embolic occlusion: Sudden occlusion of a previously patent artery is usually a dramatic event producing severe ischemia of the distal tissue. The characteristic symptoms and signs are the 5 P's: pallor, pain, paresthesia, paralysis, pulselessness. Emergent restoration of blood flow by operation may be essential to prevent limb loss. Milder forms of ischemia (acute thrombosis--acute or chronic disease) can be treated initially with intravenous heparin if the extremity is not threatened (minimal sensory loss, no muscle weakness). Elective surgery at a later date is highly successful.

[Management concept for acute traumatic aortic rupture based on a case report]. / Das Versorgungskonzept der akuten traumatischen Aortenruptur anhand eines Fallbeispieles.

Acute traumatic rupture of the thoracic aorta (ATRRA) is mainly a consequence of high-speed travel or fall from great altitude. Most of the victims die at the accident scene. Only 10-20% reach the hospital alive. Because of the extremely high mortality, emergency repair seems to be indicated. Taking into consideration that the hemorrhage into the mediastinum may remain constained and the patient usually suffers from a wide variety of life-threatening causes of injury the aforementioned option is probably not the best one. We report on a patient whose "stable" aortic rupture was surgically corrected after stablization of the circulation, coagulation and respiratory problems.

[The diabetic foot]. / Der diabetische Fuss.

Problems of the diabetic foot are frequent. The magnitude of the clinical picture and morbidity mirrors the severity and complexity of the underlying pathobiology. The three pathogenetic mechanism involved are ischemia, neuropathy and infection. Seldom do these mechanisms work in isolation, rather most foot problems result from a complex interplay among all three. The clinical picture of the diabetic foot reaches from the neuropathic deformity with diminished or absent sensation of pain to limited gangrene or superficial ulcer. The polymicrobial infection leads to extensive tissue destruction (plantarphlegmone) with osteomyelitis. The patients often notes no pain and may become aware of the infection only through the presence of drainage or a foul odor. These infections are usually more extensive than would be predicted by clinical signs and symptoms. These lesions must be debrided and drained promptly and completely. This often requires amputations of one or more toes, combined with an incision along the entire course of the infected track on the plantar or dorsal aspect of the foot. Cultures should be taken from the depth of the wound. Initial treatment should be with broad-spectrum antibiotics, with subsequent adjustment based on culture results. The diabetic foot is a clinical problem that can be solved with a high degree of success when the approached by an interdisciplinary team (specialists in infectious and vascular disease, podiatry and diabetology). Arterial reconstruction should be designed to restore maximum perfusion to the foot. The most effective result can be obtained with infra-inguinal vein bypass with distal anastomosis to the most proximal artery with direct continuity to the ischemic territory. The single most important factor in the achievement of the reduction of amputation is the autologous vein bypass. The overall outcome in the diabetic patient in terms of graft patency and limb salvage is equal to that in the nondiabetic.

[Is infra-inguinal venous bypass less successful in the woman?]. / Ist der infrainguinale Venenbypass bei der Frau weniger erfolgreich?

In the present study the influence of gender in peripheral arterial reconstructions was evaluated. Between 1986 and 1990 we performed 173 infrainguinal vein bypass procedures in 117 men and 56 women. All procedures were carried out for chronic critical leg ischaemia. Bypasses in men were femoral to popliteal in 68%, and femoral to infragenicular in 32% in cases. The corresponding values in women were 52% and 48%. Perioperative 30-day mortality was 2% in men and 2% in women. Long-term survival at 5 years was 50% in men and 44% in women. Life-table primary 5-year patency rates were 81% for men and 74% for women. Limb salvage results at 5 years were 87% for men and 84% for women. The results indicate that in our experience with autogenous vein longterm graft patency and limb salvage results in women are identical to those obtained in men. Infrainguinal arterial reconstruction can be performed in women with mortality rates similar to those of men.

[Superficial femoral vein as vascular graft in surgical therapy of mycotic aneurysm of the common iliac artery]. / Die Vena femoralis superficialis als Gefässersatz bei der chirurgischen Therapie eines mykotischen Aneurysmas der Arteria iliaca communis.

A 38-year-old polytoxicomanic male patient developed an occlusion of both popliteal arteries associated with an aneurysm of the right common iliac artery. A septic cause was suspected and an antimycotic therapy was instituted, but the diameter of the aneurysm increased to 3 cm during 6 months. Moreover, multiple periarterial abscesses occurred. The aneurysm was resected and the iliacal axis reconstructed in situ, using a superficial femoral vein interposition. Six months after operation, patency was confirmed by duplex sonography. Phlebodynamic examinations showed normal flow functions at the donor site.

[Supragenicular bypass: venous in comparison with synthetic prosthesis (PTFE)]. / Der supragenikuläre Bypass: Die Vene im Vergleich mit der Fremdmaterial-Prothese (PTFE).

In the time between 1984 and 1991 we have performed 136 infrainguinal arterial reconstructions to the supragenicular popliteal artery for lower extremity ischemia. We inserted in 98 cases the greater saphenous vein and in 38 cases a PTFE-prosthesis. Life-table primary patency rate at 5 years was 88% for the vein and 60% for the PTFE-grafts. Limb salvage results at 5 years were 92% and 76%. In our experience patency rates with PTFE are inferior compared with vein grafts even with distal anastomosis to the supragenicular popliteal artery. If we have to bypass we preferentially use the greater saphenous vein even in this position. "We do the best operation first".

[Special technics for angioplasty of the brachiocephalic vessels]. / Spezielle Techniken der Angioplastie brachiozephaler Gefässe.

PURPOSE: Description of special techniques for retrograde angioplasty of cerebral arteries with protection of the brain. MATERIAL AND METHOD: During the last 3 years, 51 dilatations of cerebral vessels were carried out in 45 patients; in 8, special techniques were required. In cases with particular operative risks, angioplasty of cerebral vessels can be performed using various techniques (double catheter [8 cases], retrograde PTA [8 cases], kissing balloon technique [3 cases]). RESULTS: All stenoses were successfully dilated, using a local anaesthetic. One patient with a double stenosis of the common carotid artery developed severe headache and visual disturbances in the ipsilateral eye following dilatation of a tight stenosis with total remission of all symptoms within 24 hours. CONCLUSION: Stenoses of cerebral arteries where surgery would be difficult and associated with a high risk can be dilated by retrograde PTA using a double catheter technique with a low complication rate.

[Ambulatory therapy in varicose veins]. / Die ambulante Therapie der Varikose.

The treatment of varicose veins comprises conservative and active options. Every patient with varices has to be informed on the conservative modalities and should apply them in daily life. Compression therapy, as the most important part of the conservative treatment, should be considered individually for any patient according to the varicose-type, the grade of chronic venous insufficiency and the compliance of the patient. Active treatment modalities are clearly indicated in varices with complications such as trophic skin changes, varicophlebitis or when varices cause pain. But the cosmetic problem should not be underestimated. Morphologic and hemodynamic information obtained by noninvasive duplex technique allows the individualization of the surgical strategy for each patient. Besides surgical techniques used being less and less traumatic (invagination stripping, stab evulsion phlebectomy), more and more interventions are realized under ambulatory conditions in local anesthesia, even crossectomy with partial stripping of truncal varices. More important and complex operations, interventions involving more than one saphenous vein or reinterventions in recurrent varices are still performed under hospital conditions. They require only a short hospitalization time (2 to 4 days). Considering this very favourable evolution in surgery with a net trend to ambulatory, thus more economic treatment, the indications for sclerotherapy--a traditionally ambulatory modality with high recurrence-rate--are limited to reticular varices and telangiectasies.

A case of acute mesenteric ischemia that responded to a combined treatment concept.

Acute mesenteric ischemia (AMI) is still associated with a high mortality rate. Early diagnosis and treatment are mandatory since irreversible bowel damage occurs within a few hours of total ischemia. Reactive vasoconstriction, high postoperative vascular reocclusion rate and the release of toxic substances from the damaged bowel followed by bacterial translocation are all part of the disease process. A combined treatment plan for AMI devides to combat the unrelenting disease process on different levels involving early operation, perioperative intraarterial fibrinolytic and vasodilative treatment and anticoagulation, selective small bowel decontamination and mandatory second look operation is presented. The rationale of this concept and its successful outcome in a highly complex case are discussed.

[Chronic critical leg ischemia: revascularization of the isolated popliteal segment in comparison with femoro-distal bypass]. / Chronisch kritische Beinischämie: Die Revaskularisation des isolierten Poplitealsegmentes im Vergleich zum femoro-distalen Bypass.

Several patients with chronic critical limb ischemia show angiographically an isolated popliteal segment (IPS) and a single calf vessel (SCV) with no direct communication to the former. In this situation a bypass can be inserted from the common femoral artery to the IPS or to the SCV. The results of 73 bypass procedures--40 to an isolated popliteal segment and 33 to a single calf vessel for limb salvage--were prospectively evaluated. Eighty percent of the grafts were performed with an autogenous saphenous vein (ASV), the rest with a thin wall polytetrafluoroethylene (PTFE) prosthesis. The mean age of our patients was 75 years and many suffered from cardiovascular disease. The operative mortality rate was 3% and the mean postoperative survival 32 months. Three year patency and limb salvage rates for ASV grafts was 83% and 87% (IPS) respectively 77% and 76% (MCV); for PTFE grafts 58% and 88% (IPS) respectively 17% and 50% (MCV). There was no significant difference found in patency and limb salvage rates of the two procedures if the graft was an autogenous saphenous vein (p > 0.05). The PTFE prosthesis was only suitable for grafts inserted to the isolated popliteal segment.

[Transgenicular amputation with special reference to partial secondary femoral condyle resection]. / Die transgenikuläre Amputation mit spezieller Berücksichtigung der partiellen Femurkondylennachresektion.

During the last five years 54 patients (mean age 69 years) have undergone a unilateral, transgenicular (through-knee) amputation, instead of an impending amputation through the thigh. The indication for surgery was a chronic, or an acute critical ischemia of the leg. In 32 and 22 cases respectively, amputations have been preceded by a multitude of reconstructive measures. Uncomplicated stump healing was observed in 25 of 51 survivors (49%). Disturbances in the wound healing process necessitated further amputation in 26 cases (51%). In 13 of these cases the advantage of the transgenicular amputation could be retained by a partial femoral condylectomy, whereas in the other 13 cases a thigh amputation was inavoidable. Thus, in three out of four of the survivors, a long, strong stump with a good terminal load-carrying capacity could be retained which, when supplied by a prosthesis, led to the recovery of the original walking ability in 90% of these cases.

Intraoperative flow measurement of distal runoff: a valid predictor of outcome of infrainguinal bypass surgery.

OBJECTIVE: To assess the power of operative flow measurements in the prediction of outcome after infrainguinal bypass operations for critical ischaemia DESIGN: Open study SETTING: University department of vascular surgery SUBJECTS: 197 patients operated on for critical ischaemia between 1 January 1982 and 31 December 1989 under the care of one surgeon. INTERVENTIONS: Standard operative angiography and measurement of flow of distal runoff MAIN OUTCOME MEASURES: Patency and limb salvage RESULTS: All patients were followed up prospectively until 31 March 1991 or death. The estimated 5 year rates of primary patency and limb salvage were 0.75 and 0.86, respectively. Multivariate analysis showed that flow measurement was the most powerful predictor of graft patency (p = 0.0003) and limb salvage (p = 0.004) of all factors studied, including angiography. Irrespective of the site of distal anastomosis no polytetrafluoroethylene (PTFE) graft remained patent if the flow was less than 50 m/minute, whereas vein grafts remained patent if the flow was as little as 10 ml/minute. CONCLUSIONS: Flow is easy to measure and is a better predictor of outcome than angiography. Decisions about grafting should rely on flow measurements if there is any doubt about patency or limb salvage, particularly if a PTFE graft is going to be used.

Video-assisted thoracoscopic treatment of pleural empyema. A new therapeutic approach.

Pleural empyema is a disease which is not always recognized. Despite consecutive treatment and antibiotics its mortality rate is still high, especially in older patients with concomitant disease or in the case of delayed treatment. We report our experience with early video-assisted thoracoscopic surgery of pleural empyema in 13 patients, where chest tube drainage had failed. The clinical symptoms of empyema did not exceed 14 days, bacteriologic cultures were positive in 62%. In all patients the fever disappeared within 1 to 5 days (mean 3.5) post-operatively and they remained in hospital for an average of 11.5 days after video-assisted thoracoscopic surgery. Pulmonary function tests 6 months later revealed normal values without a substantial loss of lung volumes. No relapse of empyema occurred.

[Second look laparoscopy after mesenteric infarct]. / Die Second-look-Laparoskopie nach Mesenterialinfarkt.

Second-look laparotomy is not always routinely performed after mesenteric infarction. Such operations are often not performed because of the high operative risk in aged patients and those with cardiovascular disease. We developed a minimally invasive technique for second-look laparoscopy with the aim of decreasing the operative morbidity. With the patient under general anaesthesia, the old incision is opened at the umbilicus. The running suture in the abdominal wall is lifted with a clamp and the incision line is gently reopened. A trocar with a blunt tip designed for open laparoscopy is then inserted and fixed. Following insufflation of CO2 through the trocar it is possible to explore the entire small bowel and colon. We operated on five patients after bowel resection performed for mesenteric infarction. Second-look laparoscopy was diagnostic in all but one, in whom laparoscopy failed due to massive small bowel dilatation. The technique described here is very promising and deserves further evaluation.

[Popliteal aneurysm]. / Das Poplitealaneurysma.

At our institution operative repair was undertaken for 67 popliteal aneurysms in 45 patients between 1986 and 1991. In 24 cases emergency surgery was necessary: acute critical ischemia due to thrombosis or embolism in 22 cases, and rupture of the aneurysm in 2 cases. Two patients died within the first 30 postoperative days. Four major amputations could not be avoided. On the other hand, elective surgical intervention was possible in 43 cases without operative morbidity and mortality. Given the high incidence of serious complications such as thrombosis or embolism in popliteal aneurysms, and the reduced success rate of surgery in acute critical ischemia, surgical correction upon diagnosis is especially recommended in aneurysms with intraluminal thrombus.

Intraoperative catheter thrombolysis as an adjunct to surgical revascularisation for infrainguinal limb-threatening ischaemia.

The objective of this study was to assess the benefits of intraoperative thrombolysis (IOL) on patients with acute leg ischaemia. This study was conducted in the Department of Cardiovascular Surgery, Inselspital, Berne, Switzerland. IOL was prospectively assessed in 25 patients with infrainguinal limb-threatening ischaemia due to acute thrombosis of atherosclerotic lesions and aneurysms (44%), occluded grafts (32%), arterial injuries (12%), delayed embolism (8%) and trash foot (8%). Three hundred and seventy-five thousand units of urokinase were delivered over 30 min with inflow occlusion to the profunda femoral artery in 8%, to the calf arteries via exposed trifurcation in 88% and to the pedal arch via exposed posterior tibial artery at the ankle in 8% of the patients. This was followed by graft thrombectomy in 24%, femoropopliteal bypass in 60%, intraoperative percutaneous transluminal angioplasty in 12% and vein patch angioplasty in 16%. Chief outcome measures were: postoperative morbidity; mortality; patency and limb salvage up to a maximum of 2 years. Postoperative bleeding complications occurred in two patients (8%) and consisted of two wound haematomas. Four patients died within 30 days after IOL, but no death could be attributed to IOL. All remaining patients were followed with a mean follow-up time of 10.9 months. The patency and limb salvage rate remained stable at 71 and 86% after 6 and 2 months, respectively. Conclusions were that IOL followed by surgical inflow restoration is a straightforward procedure for limb-threatening ischaemia with rewarding results regarding side effects, patency and limb salvage.

[Intraoperative aspiration and reinfusion of autologous blood in resection of abdominal aortic aneurysms with Solcotrans plus]. / Intraoperative Aspiration und Reinfusion von autologem Blut bei Resektion von Bauchaortenaneurysmen mittels Solcotrans plus.

Quantitative and qualitative assessment of intraoperative aspiration and reinfusion of autologous blood with the Solcotrans was carried out in 11 males (52-79 years) undergoing elective resection of abdominal aortic aneurysms. Hematology, blood chemistry, coagulation parameters and complement activation were studied in the patient's blood at the following time points: preoperatively, before and after heparinisation, after retransfusion of the first and last Solcotrans, 6 and 20 hours postoperatively. In addition the same quality control was performed in the first and last Solcotrans blood. Results (mean values of 11 patients +/- 1 SD): Intraoperatively 2-3 Solcotrans units were salvaged (total 1039 +/- 565 ml) of which 805 +/- 487 ml were retransfused to the patients. As a mean patients required only 1 unit of homologous RBC's (395 +/- 781 ml) intraoperatively. Patient's intraoperative hemoglobin concentration amounted to 10 g/dl or more. Whereas the hemoglobin level in the Solcotrans attained only 8.2 g/dl. Thrombocyte counts (48 +/- 18 x 10(9)/l) and ionized calcium (0.2 +/- 0.4 mmol/l) were significantly depressed when compared to the preoperative patient values (p < 0.05). The protein concentration remained within normal limits in the patient's and in the Solcotrans blood. Complement activation (C4a, C5a [des Arg]) showed a significant increase after initiation of surgery and there was no significant difference between the solco- or patient blood. Whereas plasma free hemoglobin, coagulation and fibrinolysis parameters showed a significant elevation in the Solcotrans blood. In conclusion the solcotrans system offers a fast, efficient and simple method for salvage and retransfusion of intraoperative autologous blood.

[Morphological changes of the lower leg arteries and the plantar arch in diabetic and nondiabetic patients with chronic critical ischemia of the leg]. / Morphologische Veränderungen der Unterschenkel-arterien und des Arcus plantaris beim Diabetiker und Nichtdiabetiker mit chronisch kritischer Beinischämie.

In this prospective study we evaluated if atherosclerosis of crural and pedal arteries differs in diabetic and non-diabetic patients suffering from chronic ischemia. We performed intraoperative angiography after completion of a femoro-popliteal or femoro-distal bypass. No statistically significant difference was found between the two groups (25 diabetic and 44 non-diabetic patients) concerning the severity and localisation of the arteriosclerosis in the three crural arteries and the pedal arch. The prerequisite for a successful arterial reconstruction were identical in our patients with or without diabetes and a similar number of potential recipient arteries were found at below knee and foot level in both groups.

[Spinal lesions in surgery of the aorta]. / Schäden des Rückenmarks bei Eingriffen an der Aorta.

Aortic diseases in particular aneurysms may be accompanied by spinal ischemia occurring either spontaneously or as complications of surgical interventions. Surgery of the abdominal or thoraco-abdominal aorta is followed in 5 to 15% by ischemia of the spinal cord, in exclusively abdominal interventions in 1.5%. Clinical manifestation depends largely on anatomy of the spinal vessels. If complete transverse myelopathy does not occur, presentation as anterior or posterior arterial ischemic syndrome is common. Other forms of myelopathy are rare. Perfusion deficits through intercostal and lumbar arteries are important in pathogenesis. The great radicular artery is particularly important. Ischemia occurs after hypotensive episodes (ruptured aneurysm) intraoperative clamping of the suprarenal aorta or by occlusion (thrombotic, arterio-arterial embolism). Careful surgical techniques are important for prevention of these neurologic complications. Possibilities for treatment and chances for spontaneous recovery of established spinal-cord lesions are poor.