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Background: Carotid endarterectomy (CEA) is a well-established standard therapy for patients with symptomatic or asymptomatic high-grade carotid stenosis. The aim of carotid endarterectomy is to decrease the risk of stroke and avoid relevant functional loss. However, carotid endarterectomy is known to be associated with hemodynamic dysregulation. In this study we compared eversion CEA (E-CEA) and conventional CEA (C-CEA) regarding postoperative blood pressure values as well as preoperative and postoperative baroreceptor sensitivity in the first 7 days after surgery. The aim was to find possible factors influencing changes in baroreceptor sensitivity., Methods: Patients (111 patients were enrolled, of which 50 patients received C-CEA and 61 patients E-CEA) were prospectively enrolled in this study. For the measurement of baroreceptor sensitivity, a noninvasive Finometer measuring device from Finapres Medical System B.V. (Amsterdam, The Netherlands) was used. Measurements were performed 1 day before surgery (PRE), directly after surgery (F1), on day 1 (F2), day 2 (F3), and on day 7 (F4) postoperatively., Results: Postoperative blood pressure values were significantly higher in the E-CEA group on the day of surgery (F1) (P < 0.001) and on day 1 (F2) (P < 0.001). From day 2 (F3, F4) postoperatively, no significant difference was found between the 2 groups. The invasive blood pressure measurement in the postoperative recovery room showed significantly higher systolic blood pressure values in the E-CEA group (P = 0.001). The need of acute antihypertensive therapy was significantly higher in the recovery room in the E-CEA group (P = 0.020). With regard to changes in baroreceptor sensitivity, significantly lower baroreceptor sensitivity (BRS) values were recorded in the E-CEA group at 1 day (F2) postoperatively (P = 0.005). The regression analysis showed that the applied surgical technique and the patient's age were significant factors influencing changes in baroreceptor sensitivity., Conclusions: In this study we could confirm higher blood pressure levels after E-CEA in the first 2 days after surgery. Additionally, we identified 22 factors possibly influencing baroreceptor sensitivity: surgical technique and age. Based on the data obtained in this study, hemodynamic dysregulation after CEA (E-CEA, C-CEA) is temporary and short-term. Already after the second postoperative day, there was no significant difference between the E-CEA and E-CEA groups, this effect remained stable after 7 days., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: This study examines outcome and durability of physician made bovine pericardial tube grafts in aortic infections in all anatomical locations., Methods: This was a retrospective and prospective international multicentre study. Peri-operative and long term outcomes of patients undergoing in situ aortic reconstruction for native or graft infections with physician made bovine pericardial tube grafts between January 2008 and December 2020 in four European tertiary referral centres were analysed. The primary endpoint was recurrent aortic infection. Secondary endpoints were persistent infection, aortic re-operation for infection, graft related complications, and death., Results: One hundred and sixty eight patients (77% male, mean age 67 ± 11 years) were identified: 38 (23%) with native and 130 (77%) with aortic graft infection. The thirty day mortality rate was 15% (n = 26) overall, 11% (n = 4), and 17% (n = 22) for native and aortic graft infections, respectively (p = .45). Median follow up was 26 months (interquartile range [IQR] 10, 51). Estimated survival at one, two, three, and five years was 64%, 60%, 57%, and 50%, and significantly better for native (81%, 77%, 77%, and 69%) than for graft infections (58%, 55%, 51%, and 44%; p = .011). Nine patients (5.3%) had persistent infection and 10 patients (6%) had aortic re-infection after a median of 10 months (IQR 5, 22), resulting in an estimated freedom from re-infection at one, two, three, and five years of 94%, 92%, 90%, and 86%. Estimated freedom from graft complications at one, two, three, and five years was 91%, 89%, 87%, and 87%., Conclusion: This multicentre study demonstrates low re-infection rates when using physician made bovine pericardial tube grafts, comparable to those of other biological grafts. The rate of graft complications, mainly anastomotic aneurysms and stenoses, was low, while graft degeneration was absent. Physician made bovine pericardial tube grafts are an excellent tool for in situ reconstruction in the setting of native aortic infection or aortic graft infection., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: We conducted a prospective evaluation of microperfusion parameters after tibial bypass surgery was performed. Differences between grafts with occlusions during follow-up and patent grafts were analyzed in relation to the pedal arch quality., Methods: Patients receiving tibial bypass grafts for chronic limb-threatening ischemia from 2019 to 2020 were included. Assessment of microcirculation (parameters: hemoglobin oxygen saturation [sO 2 ] and flow) was done by laser Doppler flowmetry and white light spectrometry (oxygen-to-see), supine and in elevation, whereas the macrocirculation was evaluated by the ankle-brachial index and duplex ultrasound examination. The quality of run-off was graded for each patient. Measurements were performed preoperatively, 1 day postoperatively, and after 6 months. Patients with graft occlusions during follow-up (OCCLUDED) and patients without occlusions (OPEN) were compared., Results: We included 42 patients (13 women, 29 men; mean age, 76.1 years; range, 60-89 years) were included. The patency of all grafts 1 day after the operation was confirmed by ultrasound examination. The overall analysis of the microcirculation showed significant changes in both the supine and elevated leg position between measurements taken preoperatively, 1 day after the operation, and after 6 months for the parameters sO 2 and FLOW (sO 2 supine, P = .001; sO 2 elevated, P < .001; FLOW supine, P < .001; FLOW elevated, P < .001). The comparison of the values 1 day after the operation yielded significantly decreased microperfusion parameters (both O 2 and FLOW) in the group that developed bypass occlusion in the later follow-up period (sO 2 supine: OCCLUDED, 35.7% [7.3-65.0] and OPEN, 48.7% [25.0-72.3] P = .011; FLOW supine: OCCLUDED, 27.7 A.U. [12.7-52.7] and OPEN, 57.3 A.U. [16.0-106.7], P = .008). No significant differences in the severity of the arch impairment was found between the OPEN and OCCLUDED groups (P = .651). Absolute values of the parameters sO 2 and flow showed no correlation with the pedal arch classification., Conclusions: Significantly poorer microperfusion was detected postoperatively in patients with later occurrence of graft occlusions despite patent grafts on the first postoperative day. Microperfusion measurements might be a possible tool for the prediction of graft failure., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Post carotid blood pressure fluctuation and hypertension (PEH) are associated with increased risk for adverse outcome; there is limited evidence on the impact of eversion endarterectomy (E-CEA) versus conventional endarterectomy with patch closure (C-CEA) on postoperative blood pressure course., Patients and Methods: In this retrospective observational study, 859 consecutive carotid endarterectomy procedures between 2004 and 2014 (C-CEA n = 585 vs. E-CEA n = 274), were evaluated. Pre- and postoperative blood pressure values were recorded from recovery room until third postoperative day and compared between both techniques; influences on the dichotomous target variable "at least one postoperative blood pressure peak", that is need for postoperative vasodilators, were analyzed by a logistic regression model. Influences on postoperative systolic blood pressure were evaluated by a linear mixed effects regression model., Results: Preoperative baseline blood pressure was not different between both comparison groups. During postoperative course, significantly increased mean systolic blood pressure values in the E-CEA group from recovery room to second postoperative day (recovery room C-CEA: 129.2 mm Hg vs. E-CEA: 136.5 mm Hg; P < 0.001; first postoperative day C-CEA: 132.4 mm Hg vs. E-CEA: 139.3 mm Hg; P = 0.0002; second postoperative day C-CEA: 138.6 mm Hg vs. E-CEA: 143.1 mm Hg; P = 0.023) were observed. No hyperperfusion syndrome was detected as wells as no difference in postoperative complication rate. Frequency of antihypertensive interventions was also elevated in E-CEA group (C-CEA 22.1 % vs. E-CEA 31.8 %; P = 0.003). E-CEA (OR 1.591, 95% CI [1.146; 2.202]; P = 0.005) and presence of preoperatively elevated systolic readings (OR 1.015, 95%CI [1.006;1.024]; P < 0.001) was also associated with increased need for antihypertensive interventions., Conclusion: E-CEA was associated with significantly elevated postoperative blood pressure, compared to C-CEA. C-CEA was associated with postoperative blood pressure decrease; however, no difference as to neurologic and surgical complications was detected between both surgical techniques in clinical practice., (Copyright © 2021. Published by Elsevier Inc.)

Background: Popliteal artery aneurysms (PAAs) are the most common peripheral aneurysms. Although rare and often asymptomatic, there is a significant risk of thrombosis, embolism, and limb loss. The aim of this study was to evaluate the eligibility for endovascular repair of patients treated for symptomatic and asymptomatic PAAs in accordance with the instructions for use (IFU)., Methods: All patients treated for PAA with open surgical repair between the years 2010 and 2017 were analyzed if suitable for endovascular treatment. Preoperative imaging was reviewed for applicability with an interventional radiologist and 2 vascular surgeons. Evaluation was performed in accordance with the following criteria adopted from the IFU of the Gore ® Viabahn stent graft: at least a single-vessel tibial runoff, proximal and distal landing zone more than 2 cm, no large difference in vessel diameter proximal and distal to the aneurysm, no overstenting of significant collaterals necessary, and no inadequate kinking of the artery. The patients were classified in 3 categories: the patient was eligible, endovascular treatment was feasible, and endovascular treatment was not appropriate., Results: 51 patients with 61 symptomatic and asymptomatic PAAs were identified. Forty-five cases were asymptomatic, 11 cases showed clinical symptoms such as claudication, and in 5 cases, the patients presented with acute ischemia. Twenty-four patients were eligible for endovascular intervention, 14 cases were feasible, and in 23 cases, it was not appropriate in accordance with the IFU., Conclusions: In this study, more than one-third of the patients with PAA were not eligible for endovascular treatment in accordance with the IFU and another 23 % showed substantial reasons against endovascular treatment. These data suggest that endovascular repair remains a treatment option for selected patients only. Cross-sectional imaging is mandatory for procedure selection., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Graft infections are rare but serious complications of vascular operations. The aim of this study was to evaluate the results of in situ reconstruction with bovine pericardium in infected aortic and peripheral vessel fields., Methods: A retrospective cohort study was conducted with a focus on the treatment of infected grafts with bovine pericardium. We retrospectively reviewed 19 consecutive patients with prosthetic graft infections and in situ repair with bovine pericardium. All operations were done between March 2015 and January 2018. No other materials were used. Excision of the infected graft, radical débridement of the infected tissue, and in situ reconstruction with bovine pericardium were applied in all patients. Short-term outcomes including primary patency, freedom of reinfection, mortality, and complication rates were analyzed., Results: Bovine pericardium was used in 19 patients (84% male) with a median age of 70 years (range, 56-84 years) to reconstruct the descending aorta (n = 1), abdominal aorta (n = 5), iliac artery (n = 4), and femoral artery (n = 9). Graft infections were observed in all patients (one thoracic endovascular aneurysm repair, three infrarenal endovascular aneurysm repairs, two open aortic repairs, four iliac-femoral reconstructions, and nine femoral reconstructions including two closure device infections after coronary angiography). Ten patients (53%) had a complication perioperatively and postoperatively. The 30-day mortality was 10.5%; the total mortality rate after 1 year was 32%. There was no reinfection after bovine reconstruction observed in our cohort. Graft occlusions were detected in two cases during follow-up (median, 6 months; range, 1-47 months)., Conclusions: Bovine pericardium reconstruction shows a good short-term outcome after aortic or peripheral graft infections. It is associated with good patency, low reinfection rate, and acceptably low early mortality rate. It can be a good therapeutic option in prosthetic graft infections when in situ repair with a prosthetic (even soaked) or autologous vein or homograft is not recommended or is not possible., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: An analysis was conducted of intermediate outcomes and possible influencing factors in patients with end-stage renal disease (ESRD) and critical limb ischemia after lower limb revascularization compared with patients with regular renal function (non-ESRD)., Methods: Data collection was performed by inquiry of the German multicenter registry of First-Line Treatments in Patients with Critical Limb Ischemia (CRITISCH); 102 ESRD patients and 674 non-ESRD patients were included. Four different therapy modalities were analysed: bypass surgery, endovascular therapy (EVT), femoral artery endarterectomy, and no vascular intervention (conservative treatment or primary major amputation). Predefined end points were amputation-free survival (AFS), death, major amputation, and reintervention. Cox regression models were built to analyze independent risk factors for outcome parameters., Results: ESRD patients showed inferior results at 2 years in the rate of AFS (ESRD, 35.4%; non-ESRD, 67.2%; P < .001). Similarly, death rate (ESRD, 55.0%; non-ESRD, 20.7%; P < .001) and major amputation rate (ESRD, 24.5%; non-ESRD, 15.8%; P = .029) were significantly elevated for ESRD patients. The choice of therapeutic approach in ESRD did not influence the incidence of the investigated end points (death or major amputation: EVT, 56.9% vs bypass, 76.9% [P = .225]; death: EVT, 46.2% vs bypass, 61.5% [P = .372]; amputation: EVT, 15.4% vs bypass, 15.4% [P = 1.000]; reintervention: EVT, 32.3% vs bypass, 15.4% [P = .324]). Cox regression analysis indicated that dialysis patients carry a twofold increased hazard of death or major amputation (hazard ratio, 2.27; 95% confidence interval, 1.67-3.10; P < .001), and open surgical treatment (all patients combined) was associated with reduced risk of death compared with EVT (hazard ratio, 0.58; 95% confidence interval, 0.37-0.91; P = .017). Comorbidities were not found to have a noticeable impact on AFS, survival, reintervention, or major amputation., Conclusions: Two-year AFS, overall survival, and freedom from major amputation were decreased in ESRD patients compared with non-ESRD patients with critical limb ischemia. Cardiovascular comorbidities were without significant impact on outcome parameters, whereas choice of treatment modality within the ESRD group did not influence AFS. Decision-making in ESRD as to choice of therapeutic approach in dialysis patients should notably account for the individual's lesion characteristics and vascular disease; surgical revascularization and EVT may be used as complementary options., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Defect reconstruction of the trunk can be performed using microsurgical free flap transplantation. In cases of missing or inappropriate recipient vessels, microsurgical defect reconstruction of the trunk can be achieved by combining free flaps with arteriovenous loops. Here we present our 5-year experience of trunk reconstruction using AV loops and free flaps in a retrospective evaluation. We analyzed 32 cases of trunk reconstruction using a combined approach of free flap transplantation and arteriovenous loops between 2011 and 2016 regarding postoperative complications and perioperative course. Twenty-one patients suffered from sternal defects, 4 from presacral defects, 3 patients presented with lateral chest wall defects, 2 patients suffered from lumbosacral defects, 1 patient had a gluteal defect and 1 patient a defect at the clavicle. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure. There were 8 thromboses of the arteriovenous loops with 4 flap failures. Only 1 flap loss was located in the sternal region, whereas one presacral flap and both lumbosacral flaps were lost. Reconstruction of large soft tissue defects of the trunk by a combined approach with an arteriovenous loop creation and consecutive free flap transplantation represents a reliable procedure in ventral and posterior cranial localization, whereas in the caudal posterior region, AV loop thrombosis can occur. Therefore, to minimize flap loss, a two-stage procedure should be performed., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: The "angiosome" concept as a model for decision making in revascularisation of patients with critical limb ischaemia (CLI) has been subject to lively discussion in recent years. The aim of this prospective pilot study was to use intra-operative fluorescence angiography to provide further data on the angiosome concept on the level of microcirculation after tibial bypass surgery., Design, Materials, and Methods: This was a prospective analysis of 40 patients presenting with CLI Rutherford stage IV to VI before and after tibial bypass surgery. The macrocirculation was measured by the ankle brachial index. Skin microcirculation was assessed by intra-operative fluorescence angiography. The alteration of microcirculation was compared in direct and indirect revascularised angiosomes. Clinical follow-up investigations were performed and the wound healing rate was compared between the different revascularisation methods., Results: Cumulated microcirculation parameters showed a significant improvement after surgery (ingress, ingress rate p<.001). Likewise, general microcirculatory improvement was observed in each foot angiosome after revascularisation, regardless of the tibial artery revascularised. Furthermore, a comparison of the direct (DR) and the indirect revascularised (IR) angiosomes did not show a significant difference concerning the improvement of microcirculation (difference DR-IR, ingress: 1.69, 95% CI 71.73-75.11; ingress rate: 0.08, 95% CI -12.91 to 13.07). The wound healing rate was similar in both groups, although the time to wound healing was faster by on average 2.5 months in the DR group (p=.083)., Conclusion: Microcirculatory improvement was seen over the whole foot after tibial bypass. Therefore, fluorescence angiography is a promising tool to evaluate the angiosome concept in future larger studies. Clinicaltrials.gov: NCT03012750., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Intact microperfusion of the foot in the critical ischemic limb remains a crucial condition for ulcer healing. Aim of this clinical study was to evaluate the immediate effect of tibial bypass surgery on the microcirculation by usage of fluorescence angiography., Methods: Prospective analysis of 33 patients presenting with critical limb ischemia (Rutherford IV-VI) undergoing tibial bypass surgery was performed. Macroperfusion was investigated by measurement of ankle-brachial index. For assessment of microperfusion, intraoperative fluorescence angiography (SPY Elite, NOVADAQ) was undertaken during general anesthesia immediately before and after operation. For each investigation, a fluorescence dye (Indocyanine green) with an amount of 0.1 mg/kg was administered intravenously. Follow-up investigations were performed to assess the clinical outcome., Results: The mean follow-up time was 8.28 (±4.46) months. The parameters Ingress (IN) and Ingress rate (InR) of the fluorescence dye representing the microcirculation showed a significant improvement to preoperative values and correlated with the ankle-brachial index significantly. Furthermore, a significant difference between the individual improvement of the microcirculation parameters (preoperative-postoperative) between patients with postoperative clinical improvement (wound healing, absence of rest pain) and those without could be demonstrated (InR: P = 0.039, IN: P = 0.036)., Conclusions: The parameters IN and InR significantly reproduced the postoperative improvement of the microcirculation. An increased ankle-brachial index significantly correlated with increased microcirculation parameters. A better clinical outcome was found in those patients who had a higher relative improvement of microcirculation postoperatively., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: In recent years, a controversial discussion about the clinical relevance of the angiosome concept during tibial angioplasty has developed. Therefore, we conducted a prospective study to evaluate the angiosome concept on the level of microcirculation during tibial vascular interventions., Methods: Thirty patients with isolated tibial angioplasty were examined prospectively. Macrocirculation was evaluated by measurement of the ankle-brachial index (ABI). For the assessment of microcirculation, a combined method of laser Doppler flowmetry and tissue spectrometry (O2C; LEA Medizintechnik GmbH, Giessen, Germany) was applied. Microcirculatory parameters were measured continuously during the procedures. Measuring points were located over different angiosomes of the index foot; a control probe was placed on the contralateral leg., Results: Cumulated microcirculation parameters (sO 2 , flow) as well as the ABI showed a significant improvement postinterventionally (ABI, P < .001; sO 2 , P < .001; flow, P < .001). Assessment of the separate angiosomes of the index leg and the comparison of the directly revascularized (DR) and indirectly revascularized (IR) angiosomes showed no significant difference concerning the microperfusion postinterventionally (DR - IR: sO 2 , P = .399; flow, P = .909) as well as during angioplasty. Even a further subdivision of the collective into patients with diabetes (sO 2 , P = .445; flow, P =.758) and renal insufficiency (sO 2 , P = .246; flow, P = .691) could not demonstrate a superiority of the direct revascularization at the level of microcirculation in these patients (comparison DR - IR)., Conclusions: There is a significant overall improvement in tissue perfusion of the foot immediately after tibial angioplasty. The effect shown in this study, however, was found to be global and was not restricted to certain borders, such as defined by angiosomes., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Management of dialysis patients with critical limb ischemia (CLI) still represents a challenge to vascular medicine, whereas the effects of the pedal arch quality in these patients with predominant affection of the infrapopliteal vessels have rarely been evaluated. Therefore, our aim was to analyze the outcomes of infrapopliteal angioplasty in the setting of chronic renal failure (end-stage renal disease) and evaluate the influence of the pedal arch involvement on clinical success., Methods: Prospective follow-up of 32 ERSD patients on hemodialysis (mean age, 72 years) with CLI and consecutive infrapopliteal angioplasty over a 5-year period 2010-2014 was performed. Mean follow-up was 10 months (range, 0-51 months). Statistical end points were defined for amputation-free survival, overall survival, and wound healing. Each patient's pedal arch was classified in 4 categories according to patency on completion angiography and the influence of the pedal arch quality on end points was assessed., Results: A total of 44 vessels in 32 ischemic legs were treated. Technical success was achieved in 96% of patients, no major complications were observed. A 30-day mortality rate amounted 6% with no procedure-related deaths. The 1-year amputation-free survival rate was 56% and 34% at 2 years. Two major amputations were required. Subsequent revascularization procedures were necessary in 11 patients (10 redo angioplasty, 1 pedal bypass graft). The pedal arch was classified as category I in 1 patient (3%), category IIa in 12 (38%), IIb in 3 (9%), and III in 16 patients (50%). No statistical significant differences in terms of survival or wound-healing rate were observed between those groups, and the pedal arch quality had no impact on predefined end points., Conclusions: End-stage renal disease patients represent a subgroup with poor prognosis of limb salvage in CLI. Amputation-free survival remains poor and based on these data, an endovascular therapy is feasible and safe in these highly multimorbid patients. The quality of the pedal arch was not found to have any impact on wound healing or survival in the present study., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Free flap transplantation to vascular reconstructions as arteriovenous (AV) loops has been established in centers as a feasible therapeutic option for defect reconstruction in the absence of proper recipient vessels, caused by oncologic resections, radiation, or trauma. We report our 10-year experience in free flap transplantation after vascular reconstruction with special emphasis on complication rate and postoperative mobility., Patients and Methods: Forty-seven patients (mean age: 60 years, range: 19-86) were included. Defect etiology was posttraumatic in 19 patients; 14 defects were due to oncological resections and seven sternal osteomyelitis; three patients presented with radiation ulcers, two with aseptic femoral head necrosis, and one with defects caused by acne inversa and hip joint prosthesis infection. Long-term follow-up was 45 months (range: 0-126). We performed arterial revascularization with 36 AV loops, eight bypass grafts, and three venous interposition grafts. Subsequent tissue transfer comprised 24 latissimus dorsi, two vastus lateralis, one gracilis, one anterior lateral thigh (ALT), 16 rectus abdominis, one radialis forearm, and two osteocutaneous vascularized fibula flaps., Results: Complications occurred in 25/47 patients (53%). Early complications included five acute occlusions of arterial reconstructions and six major bleedings. There were six flap losses and three major amputations. Two in-hospital deaths were observed (4%). Overall survival accounted for 89.0 and 74.7% after 1 and 5 years, respectively., Conclusion: The 5-year survival rate in long-term follow-up is favorable, despite an initially elevated complication rate. Successful defect coverage can be achieved by this method in a high percentage of patients., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Analysis of in-hospital outcomes in patients treated for critical limb ischemia (CLI) and end-stage renal disease (ESRD) compared to CLI patients with normal renal function., Methods: A subgroup analysis of the German CRITISCH registry, a prospective multicenter registry, assessing the first-line treatment strategies in CLI patients in 27 vascular centers in Germany was performed. The study cohort was divided into ESRD patients (n = 102) and patients with normal renal function (n = 674; glomerular filtration rate >60/mL/min/1.73 m(2)). The following first-line treatment strategies were assessed: endovascular therapy (EVT), bypass surgery, patch plasty, and no vascular intervention (conservative treatment, primary amputation). Uni- and multivariate analyses were performed to identify differences between groups as to six end points: amputation or death (composite end point), amputation, death, hemodynamic failure, major adverse cardiac and cerebrovascular events, and reintervention., Results: Differences between the ESRD and non-ESRD group were found regarding the applied first-line therapy (P = .016): The first-line treatment strategies in ESRD patients were EVT in 64% (n = 65), bypass surgery in 13% (n = 13), patch plasty in 11% (n = 11), and no vascular intervention in 13% (n = 13). In non-ESRD patients, EVT was applied in 48% (n = 326), bypass surgery in 27% (n = 185), patch plasty in 13% (n = 86), and no vascular intervention in 11% (n = 77). For ESRD patients, a noticeably increased risk of the composite end point (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.19-5.79; P = .017), amputation (OR, 3.14; 95% CI, 1.35-7.31; P = .008), and hemodynamic failure (OR, 2.19; 95% CI, 1.19-4.04; P = .012) was observed., Conclusions: CLI patients on dialysis represent a challenging cohort prone to in-hospital death, amputation, and hemodynamic failure. Two-thirds of these high-risk patients are treated with EVT. Present data suggest that this modality is generally considered as the most favorable treatment option in this patient subgroup., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Combined vascular reconstruction and free flap transfer has been established in centers as a feasible therapeutic option in cases with critical limb ischemia (CLI) and large tissue defects otherwise destined for major amputation. However, the number of patients treated with this combined approach is limited, and data regarding long-term follow-up and functional outcome are scarce. We therefore report our 10-year experience in free flap transplantation after vascular reconstruction as a last attempt for limb salvage, with special emphasis of complication rate, limb salvage, and postoperative mobility., Methods: CLI patients undergoing combined vascular reconstruction and consequent free flap transfer from 2003 to 2013 were retrospectively observed. Of 80 cases in total, patients with traumatic and oncologic indications were excluded; 33 (mean age, 66 years; range, 51-82 years) of these cases were performed for limb salvage and were included in this study. Long-term follow-up was possible in 32 of 33 patients (mean, 58 months; range, 2-126 months)., Results: Thirty-three patients were analyzed. We performed arterial revascularization with 9 arteriovenous loops, 23 bypass grafts (10 popliteal-pedal, 9 femoral-crural, and 4 femoral-popliteal), and 1 venous interposition graft. For defect coverage, tissue transfer was comprised of six different flap entities (10 latissimus dorsi, 2 gracilis, 1 anterior lateral thigh, 7 rectus abdominis, 11 radialis, and 2 greater omentum flaps). Complications occurred in 16 of 33 patients (49%). Early complications included eight acute occlusions of arterial reconstructions; major bleedings were seen in eight patients as well. There were two flap losses and one major amputation in the early postoperative period. No in-hospital deaths were observed. Late results revealed a limb salvage rate of 87% after 1 year and 83% after 5 years. Amputation-free survival was 87% after 1 year and 75% after 5 years. Overall survival was 100% and 87% after 1 year and 5 years, respectively. Follow-up showed 42% of patients with no limitations in ambulation, 54% with maintained preoperative ambulatory status, and one bedridden patient., Conclusions: The combined approach for limb salvage in CLI patients is associated with excellent results in limb salvage and functional outcome in patients who would otherwise be candidates for major amputation, despite an initially elevated complication rate. The option of combined revascularization with free tissue transfer should be evaluated in all mobile patients with CLI, large tissue defects, and exposed tendon or bone structures before major amputation. However, further studies are required to support these results., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Middle aortic syndrome (MAS), defined as localized abdominal or thoracic aortic hypoplasia, represents an extraordinary rare condition, often diagnosed in younger patients with severe renal hypertension. Etiology is divided into congenital and acquired causes (e.g., Takayasu disease). Because of its extremely unfavorable course, treatment of symptomatic patients is mandatory, whereas open surgery with aorto-aortic bypass or patch aortoplasty is considered the standard therapy. This report describes a case of a 19-year-old Macedonian woman presenting with MAS and renal hypertension who was successfully treated with aorto-aortic bypass, including reconstruction of both renal and the hepatic and superior mesenteric arteries, and reviews the current literature., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Inferior vena cava filters are considered a valuable therapeutic option in patients with deep vein thrombosis, subsequent pulmonary emboli, and contraindication for anticoagulation. However, these filters bear the risk of rare but serious complications (e.g., symptomatic caval perforation). We report our experiences with retrievable vena cava filters by means of an actual case and review the recent literature with special regard to filter-dependent delayed symptomatic vena cava perforations. Here, an inferior vena cava filter could be identified as the source of a patient's abdominal pain; after an interventional retrieval approach had failed, open surgical removal became necessary and led to the instant relief of this patient's symptoms. Retrievable vena cava filter removal should be performed in all cases as soon as no longer needed to avoid fatal complications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Mycotic aneurysms represent a diagnostic and therapeutic challenge still lacking general recommendations for optimal therapy. So far, Listeria monocytogenes (L. monocytogenes) is very rarely reported to be the causative organism of mycotic aortic aneurysms. We report 2 cases of mycotic abdominal aortic aneurysms due to L. monocytogenes infection being treated by radical debridement, open in situ reconstruction with aorto-bi-iliac Dacron grafts, and long-term antibiotic therapy. Both patients recovered well from surgery. Interestingly, the long-time follow-up for the first patient 9 years after surgery was entirely uneventful. Open debridement in an in situ reconstruction with Dacron grafts followed by antibiotic therapy seems to be a suitable therapeutic regime for mycotic aneurysms due to L. monocytogenes., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Microvascular transfer of the omentum provides well-vascularized and pliable tissue but has not widely been used in vascular extremity reconstruction because of the potentially high donor site morbidity caused by the necessary laparotomy. Laparoscopic minimally invasive harvest of a free greater omentum flap and microsurgical transfer of this tissue with split skin grafts on top and connected to sequential vein bypasses may be a an interesting new modality when other reconstructive options are absent or scarce. We report this novel technique in a patient with arterial occlusive disease and an extensive and circular ulcer of the lower extremity.

This report highlights the importance of accurate interpretation of even small intraoperative capnography changes. In this case, an otherwise unexplained sudden small decrease in end-expiratory carbon dioxide tension (P(ET)CO2) led to the detection of a deep venous thrombus. During the surgery of a 34-year-old woman with a known carcinoma of the corpus uteri, who was scheduled for paraaortal lymphadenectomy, a sudden decrease in carbon dioxide tension occurred. In careful exploration of the surgical field to rule out a thromboembolic event, the surgeons noticed an induration of the right iliac vein. A consulting vascular surgeon exposed a right-sided, irregular, double-lumen, common iliac vein with a thrombus the tip of which floated in the inferior vena cava. Following complete thrombectomy, the procedure was accomplished without further adverse events.

We report a 84-year-old man with an aneurysm of the superficial femory artery (SFA). Primarily, after B-mode sonography soft tissue neoplasm was suspected and sectional MR imaging was performed for further diagnostics. Because of blood flow related ghost artifacts, sectional MR led to the diagnosis of an partially thrombosed aneurysm without angiography. Initially, the differential diagnosis of an SFA aneurysm, which is extremely rare, has not been considered. Soft tissue neoplasms may have a similar appearance to partially thrombosed aneurysms. This case demonstrate the importance to notice also artifacts in sectional MRI which can give important informations for correct diagnosis.