[Does venous thrombectomy still play a role in the treatment of Paget-von-Schroetter-Syndrome?]. / Ist die venöse Thrombektomie beim Paget-von-Schroetter-Syndrom auch heute noch eine therapeutische Option?

In a retrospective study we reviewed 24 patients treated by venous thrombectomy for acute thrombosis of the axillary vein during the past 23 years. We performed 25 venous thrombectomies without any complications. Complete recanalisation could be achieved in all cases of acute thrombosis. Whereas similar clinical results can be achieved by thrombolytic therapy, complete recanalisation by thrombolytic therapy is only achieved in 60% of cases.

Dacron vs. polytetrafluoroethylene grafts for femoropopliteal bypass: a prospective randomised multicentre trial.

OBJECTIVES: To compare the patency of PTFE (Polytetrafluoroethylene) and unsealed knitted Dacron femoro-popliteal bypasses. DESIGN: Multi-centre prospective randomised trial. MATERIALS AND METHODS: Of 203 patients randomised, 194 were included in the final analysis (103 Dacron grafts and 91 PTFE grafts). The median follow-up was 36 months (range: 6-72 months); the distal anastomosis was above-knee in 141 and below-knee in 53 cases. Univariate comparisons of patency were made by the Kaplan-Meier method, multivariate calculations on the effects of covariables by a Cox regression analysis. RESULTS: There was no difference regarding primary and secondary patency or limb salvage between Dacron and PTFE. The primary 3-year patency for Dacron grafts was 64% (95% confidence interval [C.I.] 55-74%) and for PTFE grafts 61% (C.I. 49-72%). The corresponding 3-year secondary patency was 81% (C.I. 73-89%) and 75% (C.I. 65-86%) respectively, the limb salvage rate 90% (C.I. 84-96%) and 91% (C.I. 84-97%). Upon multivariate analysis below-knee anastomosis was the principal independent predictor of primary graft failure (risk ratio 1.7 [C.I. 1.05-2.8]), impaired secondary patency was associated with infragenicular bypass (risk ratio 3.3 [C.I. 1.8-6.3]) and distal gangrene (risk ratio [C.I. 1.01-3.8]p=0.048), major amputation was independently predicted by below-knee bypass, tissue necrosis, and poor run-off index. CONCLUSIONS: PTFE and Dacron are equally suitable for femoro-popliteal bypass.

[Radiotherapy of lymphatic fistula and lymphocele]. / Strahlentherapie von Lymphfisteln und Lymphozelen.

BACKGROUND: The treatment of persistent postoperative lymphatic fistulas or lymphoceles is often a problem. Approximately 2% of patients will develop lymphatic fistula after vascular surgery. This can require a long lasting conservative therapy. If spontaneous cure fails, a second operation with wound revision becomes necessary. We studied low-dose percutaneous radiotherapy to be used as an alternative treatment in addition to conservative or surgical therapy. PATIENTS AND METHODS: Between 1989 and 1998 29 patients (25 with lymphatic fistulas, 4 with lymphoceles) received radiation therapy. Depending on the depth of the fistula 27 patients were treated with electrons (7 to 18 MeV). Two other patients suffering of retroperitoneal lymphoceles received a treatment with photons (15 MV). In all patients the fractionation was 4- to 5 x 1.0 Gy/week and the dose ranged from 3 to 12 Gy depending upon the onset of the radiation therapy effect. RESULTS: In 27 of 28 evaluable patients a complete disappearance of the fistula or lymphocele was achieved by radiation during therapy or shortly afterwards. In 1 case no benefit was observed after a dose of 11 Gy. This patient required further surgery with wound exploration. CONCLUSION: Low dose percutaneous radiotherapy (up to 10 to 12 Gy) is effective to heal lymphatic fistulas and lymphoceles without complications. Individual dosage is required because doses even lower than 10 Gy may be effective. Radiation can be effective even after a failed conservative therapy or instead of surgery.

[Thoracic outlet syndrome--an interdisciplinary topic. Experience with diagnosis and therapy in a 15-year patient cohort (80 trans-axillary resections of the 1st rib in 67 patients) and a literature review]. / Das "Thoracic outlet Syndrome"--ein interdisziplinäres Thema. Erfahrungen mit Diagnostik und Therapie an einem Patientenkollektiv aus 15 Jahren (80 transaxilläre Resektionen der 1. Rippe bei 67 Patienten) und eine Literaturübersicht.

Because of its wide variety of symptoms, the neurovascular compression syndrome of the upper thoracic aperture or thoracic outlet syndrome (TOS) has to be distinguished from several differential diagnoses, especially orthopedic ones. It is mainly characterized by pressure lesion of the brachial plexus and secondly, by accompanying vascular damages. An indication for surgery exists in cases of persisting or increasing complaints or function loss of shoulder, arm or hand muscles as well as in cases with occurrence of vascular damage. The treatment of choice consists of transaxillary resection of the first rib. This report presents a record of our results after transaxillary surgery and compares them to the results given in current international literature. During the last few years 3031 cases of transaxillary resections (13-473 cases) were described in international literature. The average follow-up period was 7.8 years (2-22 years). The results were good in 81.4% (50-93%) of the cases. From 02/80 to 03/94, we treated 67 patients with altogether 80 thoracic outlet syndromes (TOS). Each of them was treated similarly with extensive transaxillary resection of the first rib, excision of fibrous bands and, if necessary, of cervical ribs. Our results after surgery (84.5% of complete resolution or improvement of symptoms) compare favorably to those given by other authors. The average follow-up period was 6.6 years (0.5-14 years). Our results confirm, that transaxillary resection of the first rib is the method of choice in the treatment of thoracic outlet syndromes.

[Aortitis and development of an aneurysm after PTA of distal aortic stenosis]. / Aortitis und Entstehung eines Aneurysmas nach PTA einer distalen Aortenstenose.

A 43-year-old woman was admitted with peripheral arterial occlusive disease (PAD), pelvis-type. The angiography showed a high-grade stenosis of the aortal bifurcation. A percutaneous transluminal angioplasty (PTA) in "kissing-balloon-technique" was performed. After 7 days the patient developed a sepsis with distinct back-pain. The ultrasound-B-scan and CT-scan of the abdomen showed the development of an infrarenal aortic aneurysm during a period of 29 days. Bacterial infection of the aorta was considered to be the reason of development of the aneurysm occurred. Immediate antibiotic therapy got the patient afebrile after 14 days. We implanted an aortobiiliacal Dacron graft 2 weeks later. The follow-up time was without complications except for two thrombotic occlusions of the graft after 4 and 19 months. Thrombectomy was carried out in both cases without complications.

Malignant duodenal stenosis: palliation with peroral implantation of a self-expanding nitinol stent.

The authors implanted a duodenal stent in a woman with a high-grade duodenal stenosis due to inoperable tumor compression. A flexible self-expanding knitted nitinol stent that conformed to the shape of the duodenum was introduced orally to keep the duodenal passage patent. After stent implantation, repeated vomiting stopped and the patient was able to eat and drink. This technique resolved the patient's duodenal stenosis.

Whole blood intra-operative salvage and reinfusion in patients undergoing venous thrombectomy.

Concern regarding the risk of disease transmission via blood transfusion together with periodic shortages of homologous blood has stimulated an interest in and the usage of autologous blood. Forty-nine patients had shed blood salvaged during venous thrombectomy. Between 200-3800 ml of blood were salvaged and reinfused using Solcotrans. No patient in this study required an homologous blood transfusion. The haematological parameters studied showed figures within the normal, acceptable range post-reinfusion. No patient experienced a clinical coagulopathy or showed evidence of renal dysfunction. The device is simple to use, safe and effective.

[Evaluation of the prevention of perioperative thromboembolism with low molecular weight heparin and dihydroergotamine. A study of the incidence of lethal pulmonary embolisms and undesired symptoms, especially the risk of vasospasm and myocardial infarction]. / Bewertung der perioperativen Thromboembolie-Prophylaxe mit niedermolekularem Heparin und Dihydroergotamin. Eine Untersuchung zur Frage der Inzidenz tödlicher Lungenembolien sowie unerwünschter Begleiterscheinungen, insbesondere des Vasospasmusund Herzinfarktrisikos.

In a prospective trial 33,421 patients receiving a combination of low molecular weight heparin and dihydroergotamine (LMWH/DHE; Embolex NM) as a routine antithrombotic agent were observed. The patients were recruited from surgical, traumatological, orthopedic, gynecological and urological departments. During the observation period 17 patients suffered from myocardial infarction leading to death in 7 cases. In 63 patients pulmonary embolism occurred, causing death in 12 cases. No irreversible vasospastic reaction due to DHE was seen. In one case a reversible ischaemic reaction in a lower limb was described which might have possibly been due to DHE. The low rate of complications suggests that LMWH/DHE is a safe and highly effective combination with a low risk of vasospastic reactions.

[Surgical therapy of chronic arterial obstructions of the lower extremities in elderly patients]. / Die chirurgische Therapie des chronischen arteriellen Verschlusses der unteren Extremitäten bei Patienten im hohen Lebensalter.

The aim of this study was to determine whether arterial reconstructions in old age carry an acceptable risk and are reasonable as far as long term results are concerned. The operative mortality was 3,4% for reconstructions distal to the inguinal ligament and 20.5% for reconstructions in the aorto-iliac region. Limb amputations were fraught with a very high mortality of 38.9%.

[Results of operative thrombectomy]. / Ergebnisse nach operativer Thrombektomie.

144 iliofemoral thromboses were treated operatively between 1973 and 1978. The method according to Brunner was preferably applied, but under general anaesthesia and using an autotransfusion-system. The postoperative mortality rate came up to 2,1%. 85% of the patients are free of complaints. Phlebographic check-ups show a normal, patent vascular bed in 50%. The best results could be achieved within 3 days from the onset of symptoms.

[Surgical therapy of arterial occlusions. Indication and results of revascularization in 5370 peripheral arteriosclerotic occlusions]. / Chirurgische Therapie arterieller Durchblutungsstörungen. Indikation und Ergebnisse der Revaskularisation bei 5370 peripheren arteriosklerotischen Durchblutungsstörungen.

The results of 5370 revascularizations in peripheral arteriosclerotic occlusive diseases are reported. The operative mortality in 532 carotis interna desobliterations with ischaemia stage II was 2.3%. In stage I of 98 prophylactic operations we lost no patient. Instead of the transthoracic reconstruction we now prefer the extrathoracic bypass because of the lower risk involved. The abdominal aortic aneurysm always is an indication for resection because of the danger of rupture. In cases of 100 operated patients with aneurysm we had a mortality rate in the elective stage of 5.3%, in stage of covered rupture of 47.1% and in ruptured aneurysm 85.7%. The complications in vascular reconstruction of the lower extremity are low. The mortality rate after implantation of aortic bifemoral prosthesis is 3.7%, after an unilateral aortic-femoral prosthesis 2.8% and after all operations below the inguinal ligament 1.0%. Also the femoro-tibial occlusions could be revascularized in bypass-technique with a risk of 1.5% and good early results of 90.3%.

[Peripheral arterial injuries due to fractures and dislocations]. / Periphere arterielle Verletzungen durch Frakturen und Luxationen.

Using 12 typical cases, which are tabulated, the diagnosis and therapy of combined bone and vascular injuries are demonstrated. Particular emphasis is put on a detailed presurgery diagnosis, if possible angiographic diagnosis. Early surgery, subject to a generous indication, with resection of the injured vascular segments and subsegment interposition of an autologous vein transplant is preferred. The correctness of this procedure is confirmed by the corresponding good postsurgery results.

[Vein substitution using PTFE prosthesis--results of animal experiments and initial clinical experiences]. / Venenersatz durch PTFE-Prothese--tierexperimentelle Ergebnisse und erste klinische Erfahrungen.

The expanded PTFE prosthesis (Gore Tex), which has been used for 4 years as an artery substitute, was examined in the "low-pressure system" in dogs. In 23 dogs an infrarenal segment of the vena cava was resected and substituted by a Gore Tex prosthesis. In nine dogs an arteriovenous shunt between the right iliac artery and the corresponding vein was also performed. Phlebographic examinations were made 8 days after the operation and at monthly intervals thereafter. After a mean period of 233 days the dogs were killed and histopathologic and electron microscopic analyses performed. Patency was found in 89% of transplants with, and 86% of transplants without, the arteriovenous shunt. Aafter these experiments the Gore Tex prosthesis was implanted successfully in patients suffering from postthrombotic syndrome to serve as a substitute for the superior vena cava and iliac vein. It also acted as a substitute for the jugular vein after neck dissection.

[Operative treatment of arterial occlusive disease: the risk of operation in high age patients (author's transl)]. / Operative Behandlung der arteriellen Verschlusskrankheit im holen Lebensalter unter Berücksichtigung des Risikos.

Comparative study of 2,168 revascularizations and 221 limb amputations at the surgical hospital of Fürth/Bavaria (1970--1977). The lethality rate after arterial reconstructions in older patients, depending on the type of revascularization, was 3.3 per cent up to 21.1 per cent, being considerably lower than after amputation after which 42.5 per cent of the patients died. Therefore vascular surgery should be considered at an early stage of the disease in older patients with problems of circulation, particularly before any limb amputation.

[The venous thrombectomy (author's transl)]. / Die venöse Thrombektomie.

Between 1973 and 1977 we performed 106 venous thrombectomies. 100 of these cases showed occlusion in the ilio-femoral area and 6 in the axillary area. The postoperative mortality was 2 per cent in pelvic thrombosis and 0 per cent in the Paget-von-Schroetter-Syndrome. Fatal pulmonary embolism did not occur. Seventy per cent of patients were free of complaints 6 months postoperatively. Best results were achieved by early operation. The Paget-von-Schroetter-Syndrome is frequently caused by a thoracic outlet syndrome. Therefore, the first rib has to be removed during the second operation in order to prevent recurrence.

[Surgical treatment of acute deep leg and pelvic vein trombosis]. / Chirurgische Behandlung der akuten tiefen Bein-und Beckenvenen-Thrombose.

In the last 3 years 93 cases of iliofermoral trombosis were treated by surgery. We prefer the method used by Brunner, but under general anaesthesia and using a Bentley-Autotransfusion-System (ATS). The average age of our patients was 55 years (age ranged between 17 and 87 years). No lethal pulmonary embolism was observed. 2, 1 percent of the patients died following apoplex or acute heart failure. Of 67 patients who were operated on 6 months ago or more 70 percent have no further complaints, 28 percent still have some residual edema and only 2 patients have a severe postthrombotic syndrome. 50 percent of 40 control-phlebograms demonstrated patency of all veins. 20 percent had short segmentary occlusions with definite signs of recanalisation, while in 27 percent of the cases occlusions of the lower leg and thigh were found, the iliac veins being free. Only 2 postoperative phlebograms showed a complete iliofemoral venous occlusion. Our results prove, that the operative thrombectomy is a successful method, with which the main complications of the iliofemoral thrombosis-pulmonary embolisation and postthrombotic syndrome-can difinitely be reduced. Also because of better long term results, the operative therapy of acute ilofemoral thrombosis should be generally prefered instead of conservative treatment.

[Serologic breast cancer follow-up monitoring using pregnancy-associated alpha-2-glycoproteins]. / Serologische Mammacarcinomverlaufskontrolle mit Hilfe des schwangerschaftsassoziierten alpha-2-Glykoproteins.

The variations in serum level of the alpha 2-PAG (pregnancy associated glycoprotein) were studied during the treatment of 25 patients with breast cancer. A good correlation was found between alpha 2-PAG concentration and the course of the disease. Serum alpha 2-Pag levels rose prior to the clinical recognition of metastatic disease and decreased significantly on successful treatment. alpha 2-PAG appears to have potential as an indicator of the growth of micrometastases.