Operative technique and morbidity of superficial femoral vein harvest.

BACKGROUND: The use of autologous superficial femoral veins (SFV) as an arterial or venous substitute represents a valuable technique in modern vascular surgery with versatile indications. The SFV autografts exhibit excellent control of infection and durable long-term results in terms of graft patency in prosthetic or arterial infections. In cases of elective use of the SFV, duplex ultrasound evaluation of the deep leg vein system should be implemented to confirm the patency of the profunda femoris vein. MATERIAL AND METHODS: The SFV can be harvested distal to the adductor hiatus with a proximal portion of the popliteal vein but should not exceed the level of the knee joint. Formation of a stump of the proximal SFV must be avoided. Simultaneous harvesting of the ipsilateral greater saphenous vein should be avoided to reduce the risk of significant chronic edema. RESULTS: Early postoperative swelling of the donor leg can be expected but resolves spontaneously in most cases. Chronic mild edema of the leg with a possible indication for compression therapy may occur in up to 20 % of cases but severe complications are very rare if the anatomical borders for vein harvesting are respected. Temporary therapeutic anticoagulation after vein harvest is subject to individual decision making. CONCLUSION: Duplex ultrasound is a reliable tool to assess the residual deep and superficial venous system in the long term. Excellent graft function and the tolerable adverse effects of vein harvest on the donor leg justify the use of the SFV in arterial and venous vascular surgery if indicated.

Long-term patency of open revascularization for visceral artery pathologies.

OBJECTIVE: Aim of the study was to evaluate the long-term patency of bypass grafts used to treat occlusive and aneurysmal disease of the visceral arteries. METHODS: A retrospective analysis of our vascular surgery database identified 30 patients (11 men, mean age 59 ± 14 years) who underwent 32 operations for visceral artery pathology between January 1995 and December 2009. Acute mesenteric ischemia (aMI) was present in 10, chronic mesenteric ischemia (cMI) in 14 and visceral artery aneurysm (VAn) in 7 cases. The primary endpoint of this study was vessel patency, secondary endpoints were survival and freedom from reintervention. RESULTS: A total of 46 vessels were revascularized (26 bypass grafts) and additional revascularization procedures (thromboembolectomy, patch plasty, transposition) were performed in 21 cases. In the perioperative period, 6 deaths (5 aMI, 1 cMI) occurred, resulting in a mortality rate of 50 % for aMI and 7 % for cMI. At long-term follow-up (55 months), 22 patients (100 % follow-up) were interviewed and 21 were scheduled for clinical and imaging examinations. Four vessel (3 grafts) occlusions were found in these patients. CONCLUSION: We were able to show that bypass grafting for a visceral artery pathology, although associated with an increased perioperative mortality, is a successful and durable procedure.

Initial experience with a new method of external polyester scaffolding for infrainguinal vein grafts.

OBJECTIVES: This study aims to evaluate the feasibility of external polyester scaffolding in infrainguinal bypass grafting when available vein material is suboptimal due to varicosity or dilatation. Primary objectives were short-term primary patency, assisted primary patency and secondary patency. Secondary objectives were to assess the rate of graft stenoses, infections and other adverse effects related to the use of external scaffolding. MATERIALS AND METHODS: A total of 50 consecutive patients were included in this prospective, multicentre, feasibility study from six centres. The indication for infrainguinal bypass was critical limb ischaemia (64%), severe claudication (34%) or popliteal aneurysm (2%). Indications for the use of the external scaffolding were varicosity of the vein graft, ectatic vein graft or the use of spliced vein grafts with segments of widely differing diameters. Duplex scanning of the graft was done perioperatively and at follow-up visits at 1, 3, 6 and 12 months after operation. RESULTS: Primary patency, assisted primary patency and secondary patency at 6 months were 82.3% (+/-SE 6.2%), 88.6% (+/-SE 4.8%) and 92.1% (+/-SE 4.4%), respectively. Six graft stenoses were detected in duplex surveillance. There were no infections related to polyester mesh. CONCLUSIONS: External scaffolding of infrainguinal vein grafts may be a promising innovation. Early results from this multicentre study show that polyester mesh is safe and feasible adjunct to peripheral revascularization enabling the use of otherwise non-optimal vein grafts with acceptable short-term patency.

[Infrarenal aortic aneurysm]. / Infrarenales Aortenaneurysma.

An abdominal aortic aneurysm is defined as the increase of infrarenal aortic diameter of 3.0 cm and more. Infrarenal aortic aneurysm is frequent in the elderly and causes 1-3% of all deaths among men aged between 65 and 85 years. These aneurysms are typically asymptomatic until the life threatening event of rupture. Therefore screening of risk populations like elderly persons and persons with cardiovascular risk factors for aortic aneurysm seems to be most important. An aortic aneurysm is usually detected by sonography. An infrarenal aortic aneurysm with a diameter of 5.0-5.5 cm should be treated either with open surgical or endovascular therapy. If surgical or endovascular therapy is indicated, additional computer tomography (CT) or magnet resonance imaging (MRI) are necessary. The mode of treatment mainly depends on patient co-morbidity and on morphology of the aneurysm according to the CT/MRI-findings and should be determined individually.

Long-term follow-up after endovascular treatment of acute aortic emergencies.

PURPOSE: To investigate the long-term outcome and efficacy of emergency treatment of acute aortic diseases with endovascular stent-grafts. METHODS: From September 1995 to April 2007, 37 patients (21 men, 16 women; age 53.9 +/- 19.2 years, range 18-85 years) with acute complications of diseases of the descending thoracic aorta were treated by endovascular stent-grafts: traumatic aortic ruptures (n = 9), aortobronchial fistulas due to penetrating ulcer or hematothorax (n = 6), acute type B dissections with aortic wall hematoma, penetration, or ischemia (n = 13), and symptomatic aneurysm of the thoracic aorta (n = 9) with pain, penetration, or rupture. Diagnosis was confirmed by contrast-enhanced CT. Multiplanar reformations were used for measurement of the landing zones of the stent-grafts. Stent-grafts were inserted via femoral or iliac cut-down. Two procedures required aortofemoral bypass grafting prior to stent-grafting due to extensive arteriosclerotic stenosis of the iliac arteries. In this case the bypass graft was used for introduction of the stent-graft. RESULTS: A total of 46 stent-grafts were implanted: Vanguard/Stentor (n = 4), Talent (n = 31), and Valiant (n = 11). Stent-graft extension was necessary in 7 cases. In 3 cases primary graft extension was done during the initial procedure (in 1 case due to distal migration of the graft during stent release, in 2 cases due to the total length of the aortic aneurysm). In 4 cases secondary graft extensions were performed--for new aortic ulcers at the proximal stent struts (after 5 days) and distal to the graft (after 8 months) and recurrent aortobronchial fistulas 5 months and 9 years after the initial procedure--resulting in a total of 41 endovascular procedures. The 30-day mortality rate was 8% (3 of 37) and the overall follow-up was 29.9 +/- 36.6 months (range 0-139 months). All patients with traumatic ruptures demonstrated an immediate sealing of bleeding. Patients with aortobronchial fistulas also demonstrated a satisfactory follow-up despite the necessity for reintervention and graft extension in 3 of 6 cases (50%). Two patients with type B dissection died due to mesenteric ischemia despite sufficient mesenteric blood flow being restored (but too late). Two suffered from neurologic complications, 1 from paraplegia and 1 from cerebral ischemia (probably embolic), 1 from penetrating ulcer, and 1 from persistent ischemia of the kidney. Five of 9 (56%) patients with symptomatic thoracic aneurysm demonstrated endoleaks during follow-up and there was an increase in the aneurysm in 1. CONCLUSION: Endovascular treatment is safe and effective for emergency treatment of life-threatening acute thoracic aortic syndromes. Results are encouraging, particularly for traumatic aortic ruptures. However, regular follow-up is mandatory, particularly in the other pathologies, to identify late complications of the stent-graft and to perform appropriate additional corrections as required.

Infrapopliteal composite bypass with autologous vein and second generation glutaraldehyde stabilized human umbilical vein (HUV) for critical lower limb ischaemia.

OBJECTIVE: To audit a single center consecutive series of infrapopliteal composite bypasses with second generation glutaraldehyde stabilized human umbilical vein. DESIGN: Retrospective study. PATIENTS: From January 1996 to July 2006 89 femoro-distal bypasses were constructed in 85 patients with HUV and residual vein segments as composite grafts in the absence of sufficient length of autologous vein. METHODS: All patients with infrainguinal bypass operations were registered prospectively. Bypasses to infrapopliteal arteries performed with HUV-composite grafts were reviewed for graft patency, limb salvage, patient survival and possible biodegeneration of the HUV. RESULTS: Early graft thrombosis was noted in 21.3%, necessitating revision surgery. Primary, primary assisted and secondary patency rates were 35%, 40% and 42% respectively, with a limb salvage rate of 87% after 5 years. Graft infection occurred in 7 limbs. Aneurysmal HUV graft degeneration was not detected by duplex scanning. CONCLUSION: HUV-composite bypasses provide acceptable patency and favorable limb salvage rates. Patency was similar to previous series using PTFE-composite bypasses but was significantly inferior to vein bypass. Possible biodegradation of the HUV grafts seems to be of minor clinical relevance.

Sequential femorodistal composite bypass with second generation glutaraldehyde stabilized human umbilical vein (HUV).

OBJECTIVE: To evaluate the performance of sequential composite bypasses with second generation glutaraldehyde stabilized human umbilical vein (HUV) and autologous vein. DESIGN: Retrospective study of consecutive patients, in a single centre. PATIENTS: From January 1998 to December 2003, 54 femoro-distal HUV-autologous vein sequential composite bypasses were constructed in 52 patients with critical leg ischemia and absence of sufficient length of autologous vein. METHODS: All infra-inguinal bypass operations were registered in a computerized database and prospectively followed. Bypasses using sequential HUV-composite technique were reviewed for graft patency, limb salvage and patient survival. RESULTS: Primary patency and secondary patency rates at 1, 2, 3 and 4 years were 71, 61, 53 and 53% and 89, 80, 73 and 67%, respectively. Corresponding limb salvage rates were 96, 92, 88 and 88%. Patient survival was 56% at 4 years. After 30 days additional procedures to maintain graft patency were necessary in six bypasses. Asymptomatic occlusion of one sequential anastomosis was found in five patients. CONCLUSION: Graft patency and limb salvage rate support the use of the sequential composite technique with second generation HUV in femorodistal bypass surgery, when autologous vein of sufficient length is not available.

[Classification and treatment of endoleaks after endovascular treatment of abdominal aortic aneurysms]. / Klassifikation und Therapie von Endolecks nach endovaskulärer Behandlung von abdominellen Aortenaneurysmen.

This article describes the classification of endoleaks after endovascular treatment of abdominal aortic aneurysms, thereby summarizing the most important problems of this endovascular technique. The correct classification of endoleaks is a prerequisite for interdisciplinary discussion. It is indispensable for professional reporting of the pathological findings and for the decision making as to the adequate treatment of endoleaks. Irrespective of the types of stent graft and property of the material, five endoleak types are defined in the literature: leakage at the anchor sites (type I); leakage due to collateral arteries (type II); defective stent grafts (type III); leakage due to porosity of the graft material (type IV); and endotension (type V). The causes of endoleaks are discussed and treatment options are reviewed for the diverse pathologic findings.

[Comparison of contrast-enhanced MR angiography of the aortoiliac vessels using a 1.0 molar contrast agent at 1.0 T with intra-arterial digital subtraction angiography]. / Ergebnisse der kontrastverstärkten MR-Angiographie der aortoiliakalen Gefässe mit einem 1-molaren Kontrastmittel bei 1,0 T: Vergleich zur i. a. DSA.

PURPOSE: To evaluate the diagnostic accuracy of contrast-enhanced MR angiography (CE-MRA) using a 1.0 molar contrast agent at 1.0 T for the diagnosis of abdominal aortic aneurysms and stenoses of renal or iliac arteries in comparison to intraarterial digital subtraction angiography (DSA). MATERIALS AND METHODS: A total of 19 patients with the suspicion of abdominal aortic aneurysm or stenosis of renal or iliac arteries were examined with CE-MRA at 1.0 T. Intra-arterial DSA served as reference in all cases. After test bolus tracking, 10 or 8 ml of the 1.0 molar contrast agent Gadobutrol corresponding to a dose of 0.1 - 0.15 mmol/kg bw were injected and imaging performed using a FLASH-3D sequence. To evaluate the interobserver-variability, the blinded images were analyzed by two radiologists. Besides the rating of overall image quality on a 4-point-scale, the images were evaluated for aneurysms and arteriosclerotic lesions with a stenosis of < 50 % or > 50 % or occlusion. RESULTS: A total of 144 segments were analyzed. The mean value of the CE-MRA image quality was 3.4 on a 4-point-scale. The sensitivity of CE-MRA in depicting relevant pathological findings was 96 % and the specificity 99 %. The positive predictive value was 96 % and the negative predictive value 99 %. Inter-observer variability was low with a kappa value of 0.82. CONCLUSION: CE-MRA using a 1.0 molar contrast agent at 1.0 T enables an excellent diagnosis or exclusion of pathologies of the aortoiliac vessels.

[Influence of endoleaks on aneurysm volume and hemodynamics after endovascular aneurysm repair]. / Einfluss von Typ-II-Endoleaks auf die Grössenänderung und Hämodynamik experimenteller Aortenaneurysmen nach endovaskulärer Therapie.

PURPOSE: To evaluate the aneurysm volume and the intra-aneurysmatic pressure and maximal pressure pulse (dp/dtmax) in completely excluded aneurysms and cases with endoleaks. MATERIALS AND METHODS: In 36 mongrel dogs, experimental autologous aneurysms were treated with stent-grafts. All aortic side branches were ligated in 18 cases (group I) but were preserved in group II (n = 18). Aneurysm volumes were calculated from CT scans before and after intervention, and from follow-up CT scans at 1 week, 6 weeks and 6 months. Finally, for hemodynamic measurements, manometer-tipped catheters were introduced into the excluded aneurysm sac (group I and II), selectively in endoleaks (group II), and intraluminally for aortic reference measurement. Systemic hypertension was induced by volume load and pharmacologic stress. Pressure curves and dp/dt were simultaneously recorded and the ratios of aneurysm pressure to systemic reference pressure calculated. RESULTS: At follow-up, type-II. endoleaks were excluded in all cases of group I by selective angiography. In contrast, endoleaks were evident in all cases of group II. Volumetric analysis of the aneurysms showed a benefit for group I with an improved aneurysm shrinkage: DeltaVolume + 0.08 %, - 1.62 % and -9.76 % at 1 week, 6 weeks and 6 months follow-up (median, group I), compared to + 1.43 %, + 0.67 %, and - 4.04 % (group II), p < 0.05. In case of complete aneurysm exclusion the ratio of systolic aneurysm pressure to systemic reference pressure was 0.662, 0.575 and 0.385 (median) at 1 week, 6 weeks and 6 months. The corresponding dp/dtmax ratios were 0.12, 0.07 and 0.04, respectively. However, within endoleaks selective measurements showed significantly increased pressure load: the ratios of systolic endoleak pressure to systemic reference pressure and the corresponding ratios for dp/dtmax were 0.882 and 0.913 (median), respectively. These hemodynamic findings were linear from hypotension, physiologic blood pressure to hypertension. CONCLUSION: Occlusion of all aortic side branches of an aneurysm prior to stent-grafting reduces endoleaks and promotes aneurysm shrinkage. Complete aneurysm exclusion significantly reduces systolic pressure and dp/dt max. In contrast, endoleaks showed nearly systemic pressure load and undamped pulsatility.

[Endovascular therapy of abdominal aortic aneurysm: results of a mid-term follow-up]. / Endovaskuläre Therapie von abdominellen Aortenaneurysmen: Klinisch-radiologische Ergebnisse im mittelfristigen Verlauf.

PURPOSE: Prospective study to evaluate clinical results and complications of endovascular abdominal aortic aneurysm treatment in a mid-term follow-up. MATERIALS AND METHODS: A total of 122 patients (9 females, 113 males, average age 70.9 +/- 7.9 years) with abdominal aortic aneurysms were treated with stent grafts (53 Vanguard or Stentor endografts, 69 Talent endografts). Group I consisted of 40 patients who had all aortic tributaries of the aneurysm sac occluded prior to endovascular grafting, either spontaneously by parietal thrombosis or by selective coil embolization of the respective ostia preserving collateral circulation distal to the vessel occlusion. Group II consisted of 82 patients and included all cases without or with incomplete coil embolization with at least one patent vessel. Stent grafting was performed in general anesthesia in the first 21 patients, followed by peridural anesthesia in 15 cases, and local anesthesia with conscious sedation in 86 cases. The results were evaluated with Spiral-CT, MRI and radiographs of the endovascular graft, with follow-up examinations obtained at 3, 6, 12 months, and every year. RESULTS: Implantation was successfully completed in all cases without primary conversion surgery, laparotomy, or any significant complication. Mean follow-up was 29 +/- 21 months (maximum 84 months). The 30-day mortality was 0.8 % due to a myocardial infarction 3 days after discharge from the hospital. A total of 47 re-interventions were performed in 29 patients (23.8 %), with 35 re-interventions in 18 cases with Vanguard or Stentor endografts and 12 re-interventions in 11 patients with Talent endografts. 23 percutaneous re-interventions included distal graft extension (n = 11), Wallstents for kinking and limb stenosis (n = 3), and secondary coil embolization of collateral vessels (n = 9). 24 surgical re-interventions included proximal graft extension (n = 6), new endovascular grafts (n = 3), surgical clipping of lumbar and mesenteric artery branches for type-II endoleaks following ineffective secondary coil embolization (n = 1), and femorofemoral crossover bypasses (n = 4). A total of 10 secondary conversion operations were performed because of damage to the membrane (n = 4; 3 Vanguard endografts, 1 Talent endograft), significant caudal migrations (n = 5; 4 Vanguard endografts, 1 Talent endograft) associated with type-I endoleaks (n = 2), limb occlusion (n = 1), disconnection of graft components (n = 1), and significant endoluminal thrombus deposits (n = 1). One patient, who was followed for 82 months, suffered from a significant endoleak for 10 months with increasing aneurysm diameter but he refused surgery. He was admitted with aneurysm perforation and was successfully operated with aortic graft replacement. Compared to group II, the incidence and size of endoleaks was reduced in group I (incidence 19.2 % versus 29.9 %, p < 0.05). Group I demonstrated significantly better aneurysm shrinkage at 36 months follow-up (Delta sagittal diameter - 11.1 +/- 8.4 mm versus - 4.9 +/- 6.2 mm, p < 0.05). CONCLUSION: In selected patients, endovascular aneurysm treatment is an effective alternative to open surgery. It is safely performed in local anesthesia with low mortality rate and a low number of acute complications. Intermediate follow-up revealed re-interventions in around one quarer of all patients, especially when Vanguard or Stentor endografts were implanted. Primary coil embolization of all aortic branches prior to endovascular grafting improves clinical outcome. Insufficient proximal fixation and its consecutive complications remains a major problem of this method.

[Limb salvage in diabetic foot syndrome with pedal bypass using the in-situ technique]. / Extremitätenerhalt durch pedalen In-situ-Bypass beim diabetischen Fusssyndrom.

INTRODUCTION: Treatment of the ischemic diabetic foot syndrome still represents a medical and economic challenge. Contrary to the aims of the Saint Vincent declaration a dramatic reduction of major amputations in Germany was not noted, although in the diabetic patients the predominant type of tibial artery occlusion allows construction of pedal bypasses for limb salvage. METHOD: In patients with ischemic diabetic foot syndrome following angiographic evaluation of the ischemic limb, the indication for surgical revascularisation of patent pedal arteries was established. The in-situ technique was preferred in the presence of a suitable ipsilateral greater saphenous vein whenever possible. Revascularisation was followed by treatment of foot ulcerations or, if necessary, minor amputations. Patients were followed by clinical examination and duplex scan investigation of the bypass in regular intervals. RESULTS: From 01/89 to 12/01 in 79 patients (59 men and 20 women) with non healing ulcerations or established gangrene from a total of 175 pedal bypasses 84 pedal bypass operations in 84 limbs were performed using the in-situ technique. All patients were diabetic and in addition 13.9% were dependent on hemodialysis for end stage renal disease. 59.5% of the bypasses originated from the popliteal artery (distal origin bypass). The dorsalis pedis artery was chosen for the distal anastomosis in 83% and the posterior tibial artery in 17%. Two patients (2.4%) died postoperatively from cardiac events. Early bypass occlusion occurred in 8.4% resulting in a major amputation rate of 6%. After 60 months primary, primary assisted and secondary patency was 67.7%, 71.5% and 75.3% respectively with a limb salvage rate of 78%. CONCLUSION: Pedal bypass using the in-situ technique provides excellent long term limb salvage rates in a disease with a generally unjustified bad prognosis with respect to limb salvage.

[Short distal origin vein graft in diabetic foot syndrome]. / Der kurze popliteodistale Venenbypass beim diabetischen Fusssyndrom DFS.

PURPOSE: World wide increase of diabetes compound with diabetic foot syndrome becomes a challenge in vascular surgery to avoid limb loss. In diabetics a special pattern of atherosclerosis is prevalent with disease limited to the infrageniculate arteries but sparing inflow vessels and distal tibial and pedal arteries. This provides short bypass grafting from popliteal to tibial and pedal arteries, a concept first described by F. Veith in 1981. METHODS: Diabetics with severe atherosclerotic disease and limb-threatening ischemia got general evaluation and vascular imaging. Falling in this special category the patients underwent short vein bypass grafting originating at the first or third popliteal segment extending to the tibial or pedal arteries. Follow up of patency and limb salvage was nearly complete. RESULTS: From 1988 to 2001 124 diabetics received 140 vein bypass grafts for limb salvage, 95.7% already preoperatively with foot necrosis. Operative mortality rate was 1.4%, major morbidity rate was 9.3%, early graft failure rate 8.5% and early amputation rate was 3.8%. 2 year primary patency, primary assisted patency, secondary patency rates and limb salvage were 73.3%, 75.7%, 76.4% and 87.2%. 5 years results were 63.6%, 69.2%, 70.0% and 81.9% respectively. DISCUSSION: This series revealed exceptionally good results in patients with diabetes mellitus after short vein bypass grafting in concert with earlier studies since 1981. Compared to long femorodistal grafts there was no difference in longterm patency. Bypass grafting in diabetic foot syndrome is still regarded to have a poor prognosis. Just the contrary is the case. This study in concert with former studies revealed distal origin bypass grafting a durable and effective procedure to fight limb loss in diabetic foot syndrome. CONCLUSION: Distal origin vein bypass grafting is an excellent method just for patients with diabetes. Looking at limb salvage rates over 80 % in 5 years, this procedure should be offered more often suitable patients with diabetic foot syndrome.

External reinforcement of varicose veins with PTFE prosthesis in infrainguinal bypass surgery -- clinical results.

OBJECTIVE: Segmental varicose degeneration of the autogenous greater saphenous vein may limit its use in infrainguinal bypass surgery. Wrapping a PTFE prosthesis around dilated veins has emerged as an option to create externally reinforced vein bypasses. Results regarding graft patency and limb salvage were analyzed. METHODS: Between September 1995 and January 2001, 35 infrainguinal bypass operations in 33 patients were performed with greater saphenous veins exhibiting segmental varicose dilatation. Grafts were followed by duplex scan and retrospective analysis of graft patency and limb salvage was performed. RESULTS: One bypass prompted successful revision for early occlusion. Four bypasses required additional reintervention during follow-up. 48 months primary, primary assisted and secondary patency rates were 66%, 82% and 82%, respectively, with a limb salvage rate of 97%. Duplex scan failed to demonstrate stenosis of the reinforced vein segments or aneurysmal degeneration of the residual vein. CONCLUSION: External reinforcement with a PTFE prosthesis allows the use of autogenous greater saphenous veins with varicose dilatation and enables the construction of all autogenous bypasses with promising graft patency and limb salvage.

Limb trauma with arterial injury: long-term performance of venous interposition grafts.

BACKGROUND: In contrast to arterial occlusive disease, data on long-term outcomes after vein grafts in limb trauma with arterial injury are sparse. PATIENTS: From 1991 through 2001, 22 trauma victims received 23 interposition vein grafts performed by an interdisciplinary team of trauma and vascular surgeons. Indications included both blunt and penetrating injuries with critical limb ischemia in the majority of cases. RESULTS: Operative treatment of the injured vessels (brachial n = 5, radial/ulnar n = 7, popliteal n = 6, tibial n = 3, pedal n = 2) encompassed venous interposition graft of either saphenous (n = 15) or cephalic vein (n = 8). All patients survived the operative procedure. 4 graft occlusions were noted and 3 major amputations had to be performed (one despite patent graft). 13 patients (76%) were available for duplex ultrasound examination after a mean follow-up of 59 months where patent grafts could be detected in all cases. CONCLUSION: A multidisciplinary approach ensures optimal treatment strategy of arterial injury in extremity trauma. Interposition vein grafts provide durable long-term results and should be attempted even in single-vessel injuries of forearm and lower leg.

[Interdisciplinary treatment of diabetic foot syndrome]. / Die interdisziplinäre Therapie des diabetischen Fusssyndroms.

The amputation rate in patients with diabetic foot syndrome (DFS) in Germany is still as high as 28,000 per year. Ischemia and osteomyelitis often complicate the DFS. Impaired wound healing frequently requires further surgery with a higher amputation level. The results of treating patients with DFS in our specialized foot care center were evaluated in order to assess our interdisciplinary strategy. Advanced diabetic foot wounds in patients with ischemia and osteomyelitis first require diagnostics concerning polyneuropathy, osteomyelitis, and blood supply. If peripheral arterial vessel disease is present, surgical revascularization by distal bypass grafting is the first and crucially important element of the interdisciplinary approach. Minor amputation or elective resection of the infected bone improves wound healing. Post-interventional care for wounds with secondary healing and prevention of new ulcers are provided in a foot care clinic specialized in diabetes. The clinical and radiological results of 77 patients who underwent this treatment algorithm including bypass surgery and bone resection within 1 year were collected using a standardized questionnaire. Those results were subjected to a historical comparison. Only three patients needed further intervention because of persisting ulcers and osteomyelitis. The frequency of major amputations in all patients with DFS and ischemia combined with osteomyelitis was low (10.3%). This interdisciplinary concept of treatment guarantees a high healing rate in patients even with osteomyelitis and ischemia and allows the reduction of the rate of major amputations. The data obtained allow a fact-based design for future studies.

Arterial embolism to the upper extremity in a patient with factor V Leiden mutation (APC resistance)--a case report and review of the literature.

Factor V Leiden mutation has emerged as one of the leading abnormalities in inherited blood coagulation disorders, resulting in a markedly increased risk for deep leg vein thrombosis. A 24-year-old woman presented with acute onset of critical ischemia of her left thumb and index finger. Intraarterial angiography revealed an embolus in the distal radial artery and a thrombotic occlusion of the digital artery of the thumb and index finger. Immediate therapy encompassed a selective surgical embolectomy of the distal radial artery followed by a local intraarterial lysis that was continued for 3 days. Additionally, therapeutic anticoagulation and vasodilating drugs (prostaglandin E) were administered. Within 2 days, capillary refill reappeared and the initial loss of sensory function at the tip of the thumb and index finger diminished. A screening test for thrombophilic disorders led to the diagnosis of a heterozygous mutation of factor V (Leiden mutation). Arterial thromboembolic events of factor V Leiden mutation are rare and have to date been described only in the supraaortic and coronary circulation. Therefore, the arterial embolism to the left hand presented in this report constitutes a rarity that could be successfully salvaged by the combined use of a vascular surgical procedure and intensified medical management.

Pedal arterial bypass for limb salvage in patients with diabetes mellitus.

OBJECTIVE: to evaluate pedal bypass grafting in patients with diabetes mellitus with critical limb ischaemia. PATIENTS AND METHOD: from 1994 to 1999, 49 consecutive pedal bypass grafts were performed in 46 patients with a median age of 69 years (range 37-85 years). The incidence of insulin-dependent diabetes mellitus was 87%. The distal anastomosis was located at the dorsalis pedis artery in 36, at the inframalleolar posterior tibial artery in 9 and at the plantar artery in 4 cases, respectively. RESULTS: one patient died perioperatively. Two bypass occlusions and one major amputation accounted for a primary patency rate of 96% and a limb salvage rate of 98% at 30 days, respectively. During a median follow-up of 28 months (range 1-70 months), 21 patients died of nonrelated causes. Three additional graft occlusions and 4 major amputations were noted resulting in a primary patency rate of 89% and a limb salvage rate of 87% at 48 months, respectively. CONCLUSION: Pedal bypass grafting utilising the greater saphenous vein with in-situ technique is a reliable and effective procedure to achieve durable limb salvage in patients with diabetes mellitus.

[Endovascular aneurysm treatment: Radiological and macropathological findings of the endoluminal surface of modular stent grafts]. / Endovaskuläre Aneurysmatherapie: Radiologisch-makropathologische Befundkorrelation der endoluminalen Oberfläche einer modularen Stentprothese.

PURPOSE: Characterization of the endoluminal surface of a modular stent graft and correlation of macropathological findings with results of radiological methods. METHODS: Aneurysms of the infrarenal aorta were created in 36 mongrel FBI dogs using autologous material. Endovascular treatment was performed with modular stent grafts using two polyester-covered nitinol stents connected with overlap within the aneurysm. Follow-up was 1 and 6 weeks, and 6 months for 12 animals, respectively. Results were documented using sonography, intravascular ultrasound (IVUS), spiral CT, MRI, and digital subtraction angiography (DSA). After fixation, the aorta was prepared and incised lengthwise. Before histopathological work-up, the different segments were macropathologically characterized and correlated with the respective findings of the radiological methods. RESULTS: 4 cases showed high grade stenosis within the stent grafts and graft occlusion occurred in two cases. The connection sites of these modular stent grafts showed steps and partial separation of the graft components was causative in 5 of these cases. Migration of graft components occurred in three cases, one of them with complete disconnection of the modular device. Irregulartities and deposits on the endoluminal surface were systematically underestimated with all radiological techniques used. IVUS showed moderate concordance concerning deployment and unfolding of the stent graft, however, irregularities of the endoluminal surface were systematically underestimated. Concordance of MRI, sonography, and CT was worse. Contrast-enhanced T1-w MRI detected endoluminal deposits with moderate concordance. However, the thickness of deposits was underestimated. DSA, IVUS, and CT showed only poor concordance with macropathological findings. CONCLUSIONS: The connection site of modular stent grafts predisposes to stenosis, occlusion, and disconnection of the modular device. Stent deployment and unfolding of the membrane might be examined with IVUS. MRI is useful for detecting endoluminal deposits and stenosis. However, radiological methods will underrate irregularities and deposits of the endoluminal surface.

[Emergency endovascular treatment of acute aortic diseases]. / Endovaskuläre Behandlung akuter Erkrankungender thorakalen Aorta.

PURPOSE: To investigate the safety and efficacy of emergency treatment of acute aortic diseases with endovascular stent grafts. METHODS: In 11 patients (median age 55 years, range 18 - 85) with acute complications of descending aortic diseases endovascular emergency treatment was performed: traumatic aortic rupture (n = 4), penetrating ulcer with aortobronchial fistula or hematothorax (n = 4), acute type B dissection (n = 2, one with penetration, one with subacute mesenteric ischemia), and symptomatic aneurysm of the thoracic aorta (n = 1) with pain and diameter progression. 15 stent grafts were implanted (Talent n = 11, Vanguard/Stentor n = 4). Stent extension was necessary in 4 cases. In 2 cases graft extension was done during the first procedure (due to distal migration and due to the total length of the aortic aneurysm). In 2 cases graft extension was performed 5 days (due to a new aortic ulcer at the proximal stent struts) and 5 months after the initial procedure (recurrent aortobronchial fistula due to aneurysm progression). 14 of 15 implantations required general anesthesia, one symptomatic thoracic aneurysm was performed in local anesthesia and sedation. RESULTS: 14 of 15 graft procedures were performed using the femoral or iliac approach. One procedure required aortofemoral bypass grafting due to extensive arteriosclerotic stenosis and the stent graft was inserted via the bypass graft. The orifice of the subclavian artery was crossed with bare stent struts in 4 cases without neurological complications. Median follow-up is 27 months (range 6 to 72 months). In traumatic aortic ruptures, immediate sealing of bleeding was achieved and follow-up is inconspicuous at a maximum of 72 months. In cases of aortobronchial fistulas, follow-up is satisfactory (maximum 72 months) despite the necessity for reintervention and graft extension. In one acute type B dissection retrograde dissection of the aortic arch occurred during stent release with stable disease during follow-up without neurological complications. In one type B dissection with mesenteric ischemia the mesenteric blood flow was restored. A second look operation confirmed pulsatile flow in the mesenteric trunk but a total necrosis of the small intestine and the patient consequently died. CONCLUSION: Endovascular treatment is safe and effective for emergency treatment of life-threatening complications in selected acute aortic syndromes. Mid-term results are encouraging, however, regular follow-up is mandatory to recognize late complications of the stent graft.