Low-dose iloprost infusions compared to the standard dose in patients with peripheral arterial occlusive disease Fontaine stage IV. DAWID Study Group.

BACKGROUND: Intravenous iloprost, titrated from 0.5 up to 2.0 ng/kg/min has been shown in patients with PAOD III/IV to significantly improve healing of trophic lesions, relief of rest pain, and reduce the rate of major amputation or death at 6 months as compared to placebo. The effect is considered related to improvement of the microcirculation. The aim of the present trial was to identify an optimum dose regarding treatment response and tolerability, by studying 4 doses of 25, 50, 75 and 100 micrograms iloprost daily. PATIENTS AND METHODS: 302 patients with PAOD IV were randomised via a double-blind fashion to one of the 4 doses. The primary endpoint was the responder rate at end of treatment. Responders were defined as patients with very good or good global efficacy, as judged by lesion healing and pain relief. Side effects were documented and a pre-defined benefit/risk index was calculated. RESULTS: No dose-dependency of iloprost regarding primary or secondary endpoints was observed. The rate of responders ranged between 48.7-53.5%. Side effects, mainly related to vasodilation, increased dose-dependently (p < 0.001, chi 2-test), with a significant decrease of the benefit/risk index from 2.19 +/- 1.19 to 1.64 +/- 0.97 (p = 0.012, ANOVA). Responders had a better outcome at 6 months than non-responders (2.6 fold higher rate of major amputation or death; life table analysis). CONCLUSIONS: It is concluded that iloprost should be titrated to the optimum rather than maximum tolerated dose, since a higher incidence of side effects not associated with an increased treatment response was observed at higher doses.

[Guidelines in vascular surgery: acute mesenteric artery occlusion]. / Leitlinien in der Gefässchirurgie: Der akute Mesenterialarterienverschluss.

Because of the short ischaemic tolerance time of the intestine in case of acute intestinal ischaemia, diagnostic and therapeutic decisions have to be made under extreme time pressure. Because there are still no reliable and quickly available diagnostic criteria for excluding or confirming acute intestinal ischaemia, careful exploration of anamnestic history and the angiography remain the cornerstones of early diagnosis. Depending on the intraoperative findings and the stage of the disease, therapy consists of resection of the diseased bowel, revascularisation of the occluded vessel or the combination of both methods. Additional conservative therapeutic measures are still in an experimental stage.

[Perioperative intra-arterial irrigation perfusion for adjuvant therapy of acute intestinal circulatory disorders]. / Perioperative intraarterielle Spülperfusion zur adjuvanten Therapie akuter intestinaler Durchblutungsstörungen.

The extent of mesenteric infarctions caused by intestinal circulation disorders essentially depends on reactive vasoconstriction and oxygen radical induced lesions of enteric mucosa. Animal experiments indicated protective effects of an intraarterial flushing perfusion of mesenteric arteries with vasodilators and anti-oxidants. We carried out a transaortic perfusion of the superior mesenteric artery with lactated Ringer's-solution and vasodilators (papaverin, tolazolin, PGE1) in acute occlusion of mesenteric arteries in 12 patients (case reports). Three patients were treated successfully without reconstruction by conservative method alone. Only one patient (8.33%) died because of uncontrolled enteric ischemia. Angiological therapy is necessary in modern treatment of acute mesenteric ischemia. Surgical goals are elimination of central vascular occlusions and resection of necrobiotic areas of intestinal organs.

[Vascular reconstruction and/or amputation in severely handicapped patients]. / Gefässrekonstruktion und/oder Amputation bei Schwerbehinderten.

In the course of demographic ageing with a growing number of handicapped and people in need of care the vascular surgeon will be confronted more and more with the question whether to perform a leg-saving vascular reconstruction or a primary amputation, when treating such patients. This question is discussed by analyzing the parameters benefit, risk and costs. On balance the conclusion is made, that considering nursing, medical and psychological aspects also the seriously handicapped will benefit from the leg-saving procedure. Also the risk of a vascular reconstruction is justifiable, when the procedure has a real chance of success. Concerning the costs the question is still unanswered, if in consideration of the dictated economical commulsions it is allowed to perform an expensive reconstructive procedure, when the primary amputation is the substantially "cheaper" solution.

[Successful embolectomy of the main branches of the celiac trunk and the superior mesenteric artery]. / Erfolgreiche Embolektomie der Hauptäste von Truncus coeliacus und Arteria mesenterica superior.

This is a case report of a female patient, 81 years old, with embolic occlusions of the celiac trunk and superior mesenteric artery. The surgical therapy was embolectomy of both vessels through a transversal arteriotomy. The peripheral mesenteric vascular bed was flushed with a special conservation solution in continuity. It is given a plentiful discussion about the details of this successful treated course of disease.

[Physiology and pathophysiology of intestinal circulation]. / Physiologie und Pathophysiologie der intestinalen Zirkulation.

Splanchnic blood flow is regulated by cardiovascular factors, the autonomic nervous system, circulating vasoactive agents and local mechanical factors. Typical physiologic phenomena such as "autoregulation", "autoregulatory escape" and "countercurrent exchange" are discussed. Aspects of therapy especially for acute mesenteric infarction, are elucidated with reference to the circulating vasoactive agents, the effects of bowel distension on intestinal blood flow and reperfusion injuries.

[Secondary circulatory disorders following rectosigmoid resection]. / Sekundäre Durchblutungsstörungen nach Recto-Sigmoid-Resektionen.

The radicular ligation of the inferior mesenteric artery close to the aorta, usual in surgery for rectosigmoid carcinoma, generally has no clinical consequences if the vascular anatomy is normal. However, owing to advanced age of the carcinoma patient, there may be coexistent stenosing arterio-sclerotic vessel wall lesions which are sometimes compensated through a collateral circulation originating from the inferior mesenteric artery. In that case, routine ligation of the inferior mesenteric artery may lead to a regression of the perfusion of the visceral organs or of the lower extremity, with the corresponding clinical consequences. The possibilities of preoperative determination of the contingent risks of the mesenteric artery ligation and their prevention and treatment are described.

[Reconstructive procedure in aortoiliofemoral occlusive disease (author's transl)]. / Zur operativen Taktik beim Zwei-Etagen-Verschluss.

Based on experience with about 1,000 patients with operable aortoiliofemoral occlusive disease, the factors influencing the operative procedure are discussed. These include the angiographic picture, the severity of ischemia, general risks, accessibility of the operating field, and availability of reconstructive material. It is concluded that, in discussing the operative procedure in aortoiliofemoral occlusive disease, the central question must be, which procedure is best for this patient, in view of his special circumstances, and not, which procedure is technically possible.

[Aortic aneurysm and anomalies of the kidney (author's transl)]. / Aortenaneurysma und Nierenanomalien.

Because of the embryological position of the kidney in the small pelvis anomalies of the kidney are mostly localized in the area of the distal aorta. Therefore they can make the resection of an aortic aneurysm more difficult. While anomalies of the renal veins and the urinary tract hardly impair the resection of an aortic aneurysm, an abnormal arterial vascularization of the kidney can be an essential problem during operation. According to criteria concerning localization the arterial anomalies are divided into 4 types. For every type techniques of resection and reconstruction guaranteeing the viability of the abnormal arteries and the kidney are demonstrated.

[Aortic aneurysm and horseshoe kidney--case report and collective review (author's transl)]. / Aortenaneurysma und Hufeisenniere--Kasuistik und Literaturübersicht.

Based on the own experience and on an intesive study of the literature with a total of 52 patients with an aortic aneurysm and a horseshoe kidney the problems of operative treatment are discussed. The conclusion is made, that the treatment of this rare combination has its special difficulties in nearly 2/3 of all cases, but the same results as conventional surgery of aortic aneurysms, when the renal artery abnormalities are respected and treated with adequate vascular surgical skill.

[Intestinal angina]. / Angina intestinalis.

Based on the experience with 243 patients with chronic occlusive disease of the visceral arteries, the different symptoms of intestinal angina are described. Problems concerning diagnostic procedures, especially angiography, and indication for reconstructive arterial surgery are discussed.