Indication for surgery of asymptomatic carotid lesions.

The incidence of cerebrovascular diseases with transient or persistent neurologic dysfunction has increased significantly. Although patients with symptomatic carotid artery stenosis clearly benefit from operative therapy, the indication to prophylactic surgery of asymptomatic carotid lesions however is still controversial. Based on data from a recently completed prospective randomized study and on analysis of the literature the indication and results of surgical treatment of asymptomatic stenoses of the carotid arteries are discussed. From 1970 to 1990 a total of 744 uni-or bilateral reconstructions of the internal carotid artery were performed in 631 patients. The perioperative morbidity (permanent neurologic deficiency) and mortality was 1.1% (n = 8) resp. 0.8% (n = 6). During the follow up period up to 18 years another 9 patients suffered from stroke (1.2%). The annual stroke incidence amounted to 0.2%. An important prerequisite for surgery is the so called critical internal carotid artery stenosis, implying reduced cerebral vasomotor reactivity or high embolic risk of an ulcerative plaque. Proper selection of patients (exclusion of multiple concomitant diseases) and an experienced team of vascular surgeons with operative morbidity and mortality below 1-2% validates surgical treatment of asymptomatic carotid artery stenoses.

[Paraganglioma of the glomus caroticum--a frequently misdiagnosed disease picture]. / Paragangliome des Glomus caroticum--ein oft verkanntes Krankheitsbild.

24 carotid body tumors in 21 patients (1970-1990) have been analysed retrospectively. These well vascularized tumors are growing slowly in the carotid bifurcation and often cause failures in diagnostic and therapeutical approach. 66% (14) have been operated on partially 2-3 times with wrong diagnosis (cervical gland, lateral cervical cyst a.o.) in other hospitals. It is important to come to an early diagnosis by the typical trias according to Fontaine and Kocher, by CT-scan and arteriography. The best method of operation is the so-called technique of transsection, which is also applicable in advanced tumor stage (type II-III acc. to Linder). In tumors, which are beyond radical operability, good cosmetic and functional results can be achieved by partial resection.

Extraanatomic bypass-prolongation after aorto-respectively ilio-femoral inflow repair.

Redo-operations in patients with a persistent or recurrent vascular insufficiency following a triad procedure (aorto-iliac inflow repair, profundaplasty and lumbar sympathectomy) may bring on problems from re-exposure of the groin with an increased risk of wound healing complications. A new technique for bypass-prolongation, i.e.g., an extraanatomic iliopopliteal bypass (group A: n = 16) is presented as an alternative to the conventional femoro-popliteal bypass prolongation (group B: n = 55). In both groups the effect of revascularisation was sufficient and comparable for definitive healing of distal ischemic lesions in more than 85%. The cumulative patency rate in both collectives after 1 and 5 years did not differ. Group A: 82 respectively 64% versus 75.6 respectively 59.5% in group B. However, the number of redo-operations could be significantly (p less than 0.05) reduced to 12.5% (n = 2) in group A, compared with 21.8% (n = 12) in case of an anatomical bypass-prolongation (group B). There were no wound healing complications in the groin after extranatomical reconstruction, compared with 5 after femoro-popliteal prolongation. The main advantage of this new approach, is 1. avoidance of a difficult femoral redissection in the groin with reduced risk of wound infection, 2. easy extraperitoneal exposure of the prosthetic limb at iliac level and 3. optimal healing in of the graft (ePTFE with external ringsupport). Since a significant reduction of wound healing complications could be achieved, the presented technique therefore is regarded as a superior alternative to the anatomical femoropopliteal bypass prolongation.

[Prevention of postoperative ischemic colitis in aorto-iliac vascular reconstruction]. / Prophylaxe der postoperativen ischämischen Colitis bei aorto-iliacaler Gefässrekonstruktion.

In consecutive series with 1740 aorto-iliac reconstructions (1970-1989) 32 patients (1.8%) with postoperative ischemic colitis have been registered. In a retrospective follow-up (1970-1983, group I, n = 1121) the incidence of this postoperative complication (ischemic colitis grade C) reached to 0.7%. In a further prospective follow-up (group II, 1984-1989, n = 619) the operative procedure was influenced by: 1) intraoperative stump pressure in the inferior mesenteric artery, 2) by the penile brachial index (PBI), 3) pre- and postoperative rectoscopy, and 4) measurement of perfusion in branches in the inferior mesenteric artery. The frequency of ischemic colitis could not be reduced. Grade C colitis reached to 1.3%. Rectosigmoidoscopy as a routine method before and after operation caused an remarkable decrease of the time interval between operation and diagnosis of ischemic colitis in group II (from 11 days to 24/48 h). As a result the mortality rate of transmural colon necrosis (grade C) could be reduced from 50% (group I) to 13.6% (group II). The IMA stump pressure alone (limit of 40 mm Hg) doesn't help to decide if reimplantation of the IMA necessary. The stump pressure with Doppler ultrasound flow registration in the branches of the IMA gains a greater sensitivity by a "two vessel clamping" (infrarenal aorta and digital compression of the SMA) (sensitivity 100%). During the last 230 surgical interventions the incidence of ischemic colitis ranged 0.9%.

[Infrarenal aortic aneurysm in Behçet's disease. Case report and review of the literature]. / Infrarenales Aortenaneurysma bei Morbus Behçet. Fallbericht und Literaturübersicht.

A 55-year old Turkish male was admitted with a staged aortic rupture requiring emergent surgical resection of the infrarenal aorta. Anamnesis and typical clinical findings (aphthosis, genital ulcers, pustulosis, arthritis) allowed the postoperative diagnosis of Behçet's disease. This etiologically unclear disease rarely occurs in patients from western European countries. Main symptoms are concerning the skin, the mucous membranes, and the eyes. The vascular system may occasionally be involved. In patients presenting with inflammatory arterial aneurysms, arterial or venous occlusions, careful search for the main symptoms will provide adequate diagnosis. Acute arterial affections, especially aneurysms, often urge surgical treatment. Until now, there is no effective medical prophylaxis.

New prostheses for venous substitution.

In 81 Beagle dogs, 6 cm long segments of the inferior vena cava were replaced end-to-end by artificial vascular grafts (10 mm in diameter) without an av-fistula and anticoagulant drugs. Different graft materials have been used, such as various e-PTFE (30-90 microns fiber length) and polyurethane with low and increased microporosity. e-PTFE with 75 microns fiber length and polyurethane with increased porosity showed the best tissue incorporation, complete endothelialization of the whole length and a high patency rate of 80-85% after a follow-up of 12 months. In contrast to other commercially available vascular grafts (textile woven or knitted, e-PTFE 30 microns) tested in previous series, polyurethane and e-PTFE with increased microporosity had already achieved complete endothelialization after 6-12 weeks. Therefore, these optimized prostheses should be introduced into clinical practice for large venous substitution. Thereafter, an adjunctive av-fistula as protection is probably no longer necessary.

[Changes in the form of perigraft reaction]. / Formenwandel der Perigraft-Reaktion.

Perigraft-reaction is characterized by a late fluid accumulation around a graft. As a rule bacterial contamination is missed. The fluid has the same characteristics as blood serum. An aggressive surgical approach is necessary. The cyst wall must be excized and the prosthesis has to be replaced by a different synthetic material. In these cases a healing can be expected in more than 90%. By using the same material after resection of the cyst wall is followed by a recurrence rate of 79%.

[Reoperations of the abdominal aorta and pelvic arteries]. / Rezidiveingriffe an der Aorta abdominalis und den Beckenarterien.

In 2654 aorto-iliac vascular reconstructions (1970-1990) it was necessary to perform 413 repeat operations (15.6%). A total of 231 reinterventions were done for late complications, i.e., after the end of the first postoperative year. The most frequent indications for repeat operation were recurrent stenoses or occlusions (4.5%), followed by anastomotic aneurysms (2.1%), aorto-enteric fistulas (0.7%), perigraft reactions (0.3%) and late infections (0.3%). Operative techniques and postoperative results are presented.

[Paragangliomas of the carotid body--clinical problems and therapy]. / Paragangliome des Glomus caroticum--Klinische Problematik und Therapie.

24 carotid body tumors in 21 patients (1970-1990) have been analysed retrospectively. These well vascularized tumors are growing slowly in the carotid bifurcation and often cause failures in diagnostic and therapeutical approach. 66% (14) have been operated on partially 2-3 times with wrong diagnosis (cervical gland, lateral cervical cyst and others) in other hospitals. It is important to come to an early diagnosis by the typical trias according to Fontaine and Kocher by CT-scan and arteriography. The best method of operation is the so-called technique of transsection, which is also applicable in advanced tumor state (type II-III according to Linder). In tumors, which are beyond radical operability, good cosmetic and functional results can be achieved by partial resection.

[Neoangiogenesis in aneurysmatic autologous venous transplants]. / Neoangiogenese in aneurysmatischen autologen Venentransplantaten.

In two patients with femoro-popliteal bypass using autogenous saphenous vein, aneurysmatic dilatation of the transplants occurred after a follow-up of 4 and 20 years. In the inner thrombus layer of the aneurysms side-branches could be shown by transfemoral angiography. A special microcorrosion cast technique for SEM-analysis was able to make a vascular network visible, which spread within the inner thrombus layer of the aneurysms. Venules were found predominantly. According to clinical and experimental results the potential of the phylogenetic older venous system is greater than the ability of the arterial system.

[Arterial lesions following radiotherapy]. / Arterielle Gefässschäden nach Strahlentherapie.

From 1980 to 1990 twelve patients with vascular lesions attributable to irradiation were treated. The time interval between radiotherapy because of malignancy and onset of symptoms due to radiation-induced atherosclerosis was on an average 7 years (1 month-29 years). A typical morphological finding at angiography was the well-localised vascular lesion in the previous radiation area, its localisation clearly distinguishable from typical atherosclerotic lesions. 10 patients had other radiation damage with involvement of the skin and perivascular tissue frequently necessitating an extra-anatomic reconstruction (n = 6). 4 patients had an anatomical reconstruction, one had a PTA, one was treated conservatively. Due to absence of multifocal arteriosclerotic lesions, long-term results of vascular reconstruction are good and will certainly contribute to further improvement of life quality after curative therapy for malignant disease.

Aneurysma transformation in congenital venous angiodysplasias in lower extremities.

Based on a retrospective evaluation of 107 patients with congenital venous angiodysplasia of the Type Klippel-Trenaunay (n = 76) and Type Servelle-Martorell (n = 31) the frequency and pathogenesis of aneurysma formation in the venous system has been analysed. The vascular patterns include both cylindric ectasia and fusiform aneurysms with an incidence of approximately 40%. Preferred locations are subcutaneous drainage veins, the popliteal, external iliac vein and atypic communicating veins between the superficial and the deep venous system. Complications of the aneurysm such as local thrombosis, recurrent pulmonary embolism or bleeding from ruptur were not observed. The aneurysma formation in venous angiodysplasias results probably from the causative factors: congenital weakness of the venous wall and an abnormal hemodynamical stress situation. The latter is caused by concomitant malformations of the deep venous system. The persistent intermittent venous hypertension associated with a more or less pronounced increase of the venous volume in the affected venous system of the limb results in a deep venous insufficiency respectively venous reflux disease. The therapy of choice is predominantly conservative, i.e., external compression bandages or stockings to reduce the deleterious effects of a chronic deep venous insufficiency respectively venous reflux disease. Surgery is indicated under two conditions: a) in the presence of aneurysm complications or b) for the elimination of a pathological short circuit flow in some drainage veins. Antireflux surgery, i.e., venous valve transfer from the brachial vein, is up to recently still in a stage of experimental-clinical investigation.

[Congenital angiodysplasia of the limbs; diagnosis and therapy]. / Congenitale angiodysplasie van de ledematen; diagnose en therapie.

A complete check-up of vascular morphology and haemodynamics in patients resulted in a differentiation of three clinical entities: (I) type F. P. Weber: multiple active arteriovenous fistulas inducing overgrowth of the skeleton, (2) type Klippel-Trenaunay: venous angiodysplasia with the triad localized gigantism, varicose veins, naevus flammeus, (3) type Servelle-Martorell: systemic haemangiomatosis including the bone and soft tissues resulting in hypoplasia of the skeleton. Early diagnosis and differentiation of these different clinical types are needed for the assessment of the spontaneous course of the disease and choice of an optimal therapeutical approach. In the presence of active arteriovenous fistula (type F. P. Weber) the therapeutic principle should be focused on the normalisation of the shunt volume by surgery (skeletonisation) or catheter embolisation. In patients with venous angiodysplasias (type Klippel-Trenaunay or Servelle-Martorell) the therapy is aimed at prevention or reduction of deep venous insufficiency and is basically conservative by external compression bandages.

[A new variant of the popliteal artery compression syndrome]. / Neue Variante eines Kompressionssyndroms der A. poplitea.

The authors describe a new variant of the popliteal artery across the lateral head of the gastrocnemius muscle. Therefore a new more simple classification is proposed: type I-III. A further differentiation in subgroups as Ia, IIa according to Insua has no clinical value. A posterior approach to the popliteal artery gives a detailed view of the anatomic structures such as muscle and band origin. A medial incision should be chosen if crural reconstruction is expected.

[What does asymptomatic stenosis mean? Topics in clinical terminology and documentation]. / Was bedeutet asymptomatische Stenose? Fragen der klinischen Terminologie und Dokumentation.

A generally accepted classification and documentation for cerebrovascular insufficiency are needed to eliminate controversies and misinterpretation in clinical studies on the spontaneous course of the disease and the outcome of patients receiving surgical or conservative treatment. The author proposes a clinical classification (stages I to IV) based on the affected vascular territory (A, B, C). The following findings should be included: 1. the number of diseased extracranial arteries (I to IV vessel disease), 2. the presence of ischemic brain lesions (CT, SPECT, RMI), 3. concomitant diseases or risk factors (hypertension, coronary heart disease etc.). Such morphological and functional staging makes possible the selection of comparable groups of patients for investigation.

[Postoperative results of treatment in comparison with results of the German prospective randomized CASANOVA Study]. / Postoperative Behandlungsergebnisse im Vergleich zu den Resultaten der prospektiven randomisierten CASANOVA-Studie der BRD.

Independent of the results pending from the postoperative randomized German multicenter trial (CASANOVA Study), in which the course of operative versus non-operative treatment of asymptomatic carotid artery stenoses is being compared, there is still a clear justification for operative desobliteration if the following criteria are fulfilled: 1. Severe carotid stenosis with hemodynamic significance is proved by an extremely reduced or abolished autoregulatory reserve in the transcranial Doppler CO2-test. 2. Lesions with high embolic risk are confirmed by arteriography or B-Scan sonography. In 744 patients who underwent surgery according to these prerequisites there was a mere annual stroke rate of 0.2% during a followup of up to 18 years. This means that in comparison with the results of non-surgical therapy (annual stroke rate 1-3%) the risk of stroke was reduced by tenfold.

[Late vascular damage after unilateral leg amputation]. / Vaskulärer Spätschaden nach unilateraler Beinamputation.

The higher incidence of infrarenal aortic aneurysms in war-veterans with above knee amputations indicates that leg amputation besides arteriosclerotic risk factors constitutes a relevant pathogenetic factor for the late development of an abdominal aortic aneurysm. A retrospective study of 25 mainly young patients with above knee amputation showed that already one year after leg-loss a typical adaptive narrowing of the pelvic and leg arteries with significant reduction of the flow volume of 37% on the amputated side could be registered. Unilateral flow reduction resp. interruption causes an asymmetric flow pattern at the aortic bifurcation. The changed hemodynamics are probably the main cause for late damage to the aorto-iliac vessels. The clinical importance of these results is that patients with unilateral leg amputation should have regular follow up investigation in order to detect late sequelae on the aorto-iliac vessels and to perform elective surgery for abdominal aortic aneurysm. Ipsilateral occlusive arterial disease as well as abdominal aortic aneurysms must be regarded as secondary late damage after leg amputation justifying obligatory indemnification.