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ispartof: INTERNATIONAL ANGIOLOGY vol:41 issue:2 pages:91-104 ispartof: location:Italy status: published

Zusammenfassung Fragestellung Mit dieser Übersichtsarbeit über die aktuellsten Leitlinien zur Shuntchirurgie von Patienten mit chronischer Niereninsuffizienz (NKF-KDOQI, ERBP, GEMAV und ESVS) soll unter anderem geklärt werden, ob es sinnvoll und erforderlich ist, Leitlinien für den deutschsprachigen Raum zu erarbeiten. Material und Methoden Hierfür wurden diese vier Leitlinien hinsichtlich Methodik, Themenspektrum und Evidenzlage verglichen, um Gemeinsamkeiten, Unterschiede und Besonderheiten aufzuzeigen. Sowohl die fachliche Zusammensetzung der Autorenschaft wie auch die Methodik (PICO-/GRADE-System) der einzelnen Leitlinien sind sich ähnlich. Ergebnisse Arbeitsgruppen, die viele Nephrologen im Team hatten (NKF-KDOQI, GEMAV), haben das gesamte Spektrum der Kathetereinlage in ihre Leitlinien aufgenommen. Die Leitlinien der ESVS stellen die chirurgischen Aspekte der Shuntchirurgie in den Vordergrund. In den ERBP-Leitlinien, die bei der Themenwahl auch Patientenbedürfnisse einbeziehen, ist die Fistelreifung und Kanülierung ein wichtiges Thema. Die neuen NKF-KDOQI-Leitlinien zeigen Algorithmen, wie ein individualisiertes Dialysekonzept über die Zeit aussehen könnte. Allen Leitlinien ist gemeinsam, dass viele Empfehlungen aufgrund fehlender Evidenz und fehlender aktueller Studien nur auf Expertenmeinungen beruhen. Schlussfolgerungen Die Evidenzlage muss durch neue randomisierte Studien verbessert werden. Es wäre wünschenswert, wenn mit standardisierten Verfahren und kontinuierlicher Analyse aktualisierte und online abrufbare Empfehlungen zur Verfügung stünden. Um ein solches Projekt zu realisieren, ist eine internationale Kollaboration unabdingbar. Leitlinien für den deutschsprachigen Raum würden sich so erübrigen.

This discussion looks in some depth at the heavily revised second edition, posthumously published in 1802, of Cowper's translation of Homer. For editors and critics it has never displaced the first edition of 1791, yet Cowper's revisions served to correct many of the flaws they diagnosed. It is argued that Cowper's increasing responsiveness to criticism by laymen and scholars alike was neither a symptom of his deteriorating mental state, as Robert Southey claimed, nor a mere expression of his desire to appease hostile reviewers, but rather an extension of the same collaborative modus operandi that helped him produce the translation in the first place. The lack of scholarly attention to the 1802 edition has, until now, prevented proper understanding of Cowper's achievement in translating the Homeric epics.

Retroaurikular fixierte Horhilfen sind in der Regel wenig anfallig fur Infekte im Gegensatz zu Kathetern fur die Hamodialyse (HD), welche transkutan/subkutan eingelegt werden. Diese weisen haufig Infekte als Komplikation mit der dazugehorigen Morbiditat und Mortalitat auf. Ein neu entwickelter retroaurikular am Knochen fixierter Port in Kombination mit einem konventionellen tunnelierten HD-Katheter wird aktuell bezuglich Sicherheit und Funktionalitat fur die HD getestet. Im April 2016 wurde der seit 2010 von Arzten und Industrie entwickelte retroaurikular fixierte Port („bone-anchored port“, BAP) erstmals einem Menschen implantiert. In dieser Phase-I/II-Studie geht es darum, die entworfenen Standards zur Implantation dieses Systems zu uberprufen und ggf. anzupassen, aber auch deren Handhabung und die Dialysequalitat mit prospektiven Daten zu erfassen. Bisher konnten 4 Patienten uber diesen Zugang durchschnittlich ab dem 9. Tag nach Implantation (Range 2–15) problemlos dialysiert werden. Bis dato haben wir 985 (O 246, Range 138–445) Patiententage erreicht. Ein Patient ist unabhangig vom System 14 Monate nach der Implantation verstorben. Probleme mit dem Subventil fuhrten beim ersten Patienten zu einer Anpassung des Systems. Die Implantation eines retroaurikular fixierten Ports braucht ein interdisziplinares Team, kann aber mit der notigen Sicherheit durchgefuhrt werden und wird von den Patienten und Pflegenden wegen der einfachen Handhabung sehr geschatzt. Es braucht eine gute Schulung des chirurgischen Teams und des Pflegefachpersonal, damit sich diese Methode weiter etablieren kann und mehr Daten zur Funktionalitat und Performance dieses Systems erfasst werden konnen.

William Wordsworth's attempt at translating Virgil's Aeneid reached as far as Book 4, and mostly survives in manuscript drafts. The literary influences behind it can be illuminated through the poet's correspondence, and analysed more fully by tracing verbal echoes and other resonances in his translation. Despite the hostility he expressed towards Dryden and Pope, the foremost translators of the previous age, Wordsworth followed them in using heroic couplets, and, as has previously been argued, his translation draws increasingly on Dryden's Aeneis the further he advanced with his project. But Wordsworth owes an equally large debt, hitherto unrecognized, to the eighteenth-century blank verse renderings by Joseph Trapp and others, who anticipated many of his supposed stylistic innovations.

Kompetenz bezieht sich nicht nur auf Wissen und Fertigkeiten einer Person, sondern auch auf deren Handlungsfahigkeit im klinischen Alltag, insbesondere unter Stress. Deshalb sollten wir die Kompetenzprofile der Mitarbeiter kennen. Die shuntchirurgischen Behandlungskonzepte beruhen heute mehr auf Eminenz als auf Evidenz, weil die Zahl randomisierter Studien beschrankt ist. Es konnen etablierte Simulationskurse belegt werden, um Fertigkeiten in der Shuntchirurgie zu trainieren. In diesem Artikel werden am Beispiel der Shuntchirurgie „entrustable professional activities“ (EPAs) formuliert. Mit diesen „anvertraubaren professionellen Tatigkeiten“ konnen Kernkompetenzen im klinischen Alltag abgebildet werden. Diese EPAs erlauben es dem Vorgesetzten einzuschatzen, wie eigenverantwortlich eine Person arbeiten kann. Wiederholt man diese Beurteilung uber die Zeit, konnen Veranderungen des Kompetenzprofils eines Kandidaten uber eine langere Periode beobachtet werden.

Introduction: In order for Mini-Clinical Evaluation Exercise (Mini-CEX) and Direct Observation of Procedural Skills (DOPS) to actually have a positive effect on trainees’ learning, the way in which the tools are implemented is of key importance. However, there are many factors influencing their implementation. In this study, we aim to develop a comprehensive model of such factors. Methods: Using a constructivist grounded theory approach, we performed eight focus groups. Participants were postgraduate trainees and supervisors from three different specialties; all were experienced with Mini-CEX and/or DOPS. Data were analyzed for recurring themes, underlying concepts and their interactions using constant comparison. Results: We developed a model demonstrating how the implementation of Mini-CEX and DOPS for trainees’ learning is influenced by 13 factors relating to four categories: organizational culture (e.g. value of teaching and feedback), work structure (e.g. time for Mini-CEX and DOPS, faculty development), instruments (e.g. content of assessment), and users (e.g. relationship between trainees and supervisors), and their interaction. Conclusions: We developed a complex model of influencing factors relating to four categories. Consideration of this model might support successful implementation and trainees’ learning with Mini-CEX and DOPS.

INTRODUCTION In Switzerland, the outcome of vascular access creation in the 4500 current dialysis patients is unknown, mainly because there is no prospective registry for patients undergoing vascular access surgery for renal replacement therapy. The aim of the study was to assess the quality of vascular access creation and to compare it with the current literature and guidelines, in order to define strategies to improve clinical outcome. METHODS Retrospective single-centre study in a tertiary referral centre. All consecutive patients over 18 years of age undergoing primary vascular access creation between January 2013 and December 2014 were included. Follow-up data for at least 12 months were collected. RESULTS During the study period, 365 patients had a surgical intervention for renal replacement therapy. A primary vascular access was created in 74 patients (20%), who were further analysed in our study: 63 (85%) had an arteriovenous fistula (AVF) and 11 (15%) an arteriovenous graft (AVG). The intervention-free survival (primary patency rate) of the primary vascular access at 1 year was 46% (95% confidence interval [CI] 33-58%) for AVF and 30% (95% CI 7-58%) for AVG, with a secondary patency rate at 1 year of 75% (95% CI 63-84%) for AVF and 50% (95% CI 18-75%) for AVG. Twenty-seven patients (36%) with primary vascular access underwent central venous catheter (CVC) placement (tunnelled or non-tunnelled) before the access creation. Thirty-seven (50%) patients had their first dialysis through a CVC. Thirty-one patients (42%) never received a CVC. CONCLUSIONS The primary patency of vascular access was unexpectedly low, and the number of CVC requests unexpectedly high. In light of this, we consider it essential that centres creating vascular access should register their activities and compare their outcomes with current guidelines to check and improve clinical management. To facilitate this, there is an initiative starting in 2018 encouraging all Swiss vascular surgeons to provide data on vascular access interventions, including 1-year follow-up, in the national online registry "SwissVasc 2.0".

Zusammenfassung: Hintergrund: Aneurysmen und Pseudoaneurysmen von Hämodialysezugängen treten mit einer Häufigkeit von bis zu 6% auf. Es besteht ein enger Zusammenhang mit der jeweiligen Punktionstechnik. Wegen der zunehmenden Anzahl an Dialysepatienten, wird die Zahl der Fisteloperationen auch in Zukunft steigen. Ziel: Anhand einer Literaturübersicht und gestützt auf eigene Erfahrungen soll die Behandlung von echten und falschen Aneurysmen von Hämodialyseshunts dargestellt werden. Material und Methode: Es erfolgte eine systematische Literaturrecherche in Pubmed/Medline. Folgende Suchbegriffe wurden teils in Kombination verwendet:"arteriovenous fistula”,"arteriovenous aneurysm”,"arteriovenous graft”,"haemodialysis access” und"vascular access surgery”. Ergebnisse: Eine einheitliche Definition und klare Empfehlungen zur Therapie finden wir in der Literatur nicht. Je nach Art, Größe und Lokalisation des Aneurysmas kann die Shuntfunktion gefährdet sein und es besteht Interventionsbedarf. Rupturen können sogar lebensbedrohlich werden. Schlussfolgerung: Bedingt durch stetes Punktieren, neigen AVF zur Dilatation bis hin zur Aneurysmabildung. Solche Veränderungen müssen nur dann korrigiert werden, wenn die Haut über dem Shunt gefährdet ist, wenn eine Massenblutung droht oder aufgrund einer Wandthrombosierung eine nur ungenügende Punktionsstrecke vorhanden ist. Die Implantation eines ePTFE-Interponats war bisher ein gängiges Verfahren, doch hat die Aneurysmorrhaphie vermehrt Anhänger gefunden, weil damit ohne Fremdmaterial ein Shunt funktionstüchtig gehalten werden kann. Bei Pseudoaneurysmen, meist verursacht durch punktionsbedingte, lokale Zerstörung eines PTFE-Grafts, kann ein lokaler Graftersatz erfolgen oder eine partielle Neuanlage mit Umfahrung, wenn zusätzlich ein lokaler Infekt vermutet wird. Alternativtherapien zur Chirurgie wie Stentgrafts sind aktuell noch nicht etabliert und müssen ihren Stellenwert erst noch beweisen

The partial shift from patient to model is a reasonable and necessary paradigm shift in surgery in order to increase patient safety and to adapt to the reduced training time periods in hospitals and increased quality demands. Since 1991 the Vascular International Foundation and School has carried out many training courses with more than 2,500 participants. The modular build training system allows to teach many open vascular and endovascular surgical techniques on lifelike models with a pulsatile circulation. The simulation courses cannot replace training in operating rooms but are suitable for supporting the cognitive and associative stages for achieving motor skills. Scientific evaluation of the courses has continually shown that the training principle established since 1991 can lead to significant learning success. They are extremely useful not only for beginners but also for experienced vascular surgeons. They can help to shorten the learning curve, to learn new techniques or to refine previously used techniques in all stages of professional development. Keywords Advanced training · Advanced training regulations · Training model · Vascular International · Certification, Der zumindest partielle „shift“ vom Patienten zum Modell ist für die Chirurgie ein sinnvoller und notwendigen Paradigmenwechsel, um die Patientensicherheit zu erhöhen und den verkürzten Weiterbildungszeiten in den Kliniken und den gestiegenen Qualitätsansprüchen gerecht zu werden. Seit 1991 wurden von der Vascular International Foundation & School zahlreiche Trainingskurse mit mehr als 2500 Kursteilnehmern durchgeführt. Das modular aufgebaute Trainingssystem ermöglicht das Erlernen einer Vielzahl offen-gefäßchirurgischer und endovaskulärer Operationstechniken an lebensechten, pulsatil durchströmten Modellen. Die Simulationskurse können das Training im OP zwar nicht ersetzen, sie sind aber geeignet, die kognitive und die assoziative Stufe des Erreichens motorischer Fähigkeiten zu unterstützen. Die wissenschaftliche Evaluation der Kurse zeigt durchgehend, dass das seit 1991 etablierte Trainingsprinzip zu signifikanten Lernerfolgen führen kann. Sie sind nicht nur für Anfänger sinnvoll, sondern auch für erfahrene Gefäßchirurgen. Sie können in allen Stadien der professionellen Entwicklung helfen, die Lernkurve abzukürzen, neue Techniken zu erlernen oder bereits angewandte Operationstechniken zu verfeinern. Schlüsselwörter Weiterbildung · Weiterbildungsordnung · Trainingsmodelle · Vascular International · ZertifikatModular training

Objective: To determine the outcome and management of iatrogenic neck-vessel complications after central venous line placement (CVLP). Design: Retrospective study. Setting: Department of Cardiovascular Surgery and the Intensive Care Unit of a 1000-bed university hospital. Patients: Eleven patients with acute central venous line placement complications were identified between 1998 and 2002. Of them, eight were inadvertent arterial punctures (one cannulation of the vertebral artery, one resulting in late pseudoaneurysm formation). There were eight lacerations of carotid, subclavian, or vertebral arteries, two perforations of the superior vena cava, and one uncontrollable jugular venous bleeding. Intervention: Eight arterial cannulations were treated operatively: suture of the artery was performed in five; litigation in one; one pseudoaneurysm was reconstructed; one pleural empyema was evacuated after initial conservative management. One uncontrollable jugular vein bleeding was treated operatively, one perforation of the superior vena cava conservatively, one surgically. Results: Two patients died: one intraoperatively due to uncontrollable bleeding after inadvertent cannulation of the subclavian artery; one arterial laceration resulted in a large subpleural hematoma, which led to an empyema. The patient died from sepsis two weeks after the initial complication. Both high-risk patients suffered from pulmonary hypertension. The other surgically treated patients made an uneventful recovery. Conclusion: Arterial complications of CVLP are very rare, but may be life-threatening. Venous perforations may seal spontaneously, but bleeding can be uncontrollable. In highly selected cases, vascular surgical consultation may be advantageous, when 24-hour service is available. Open exploration or radiological intervention may be considered.

Problems of wound healing following vascular surgery through inguinal incisions include hematoma formation, infection, lymphocele and lymph fistula, and occur in up to 20% of the cases. Closure of chronic wounds is sometimes obtained only after plastic reconstructions such as muscle flaps. We have examined if the use of the less invasive method of vacuum-assisted closure (VAC) may be beneficial. Between January 1999 and May 2002, 36 (2.6%) inguinal wound healing problems were retrospectively identified among 1410 operations originally involving inguinal dissection. There were 15 (42%) females and 21 (58%) males, with a median age of 72 years (range 46–98 years). The indication for the initial operation was arterial surgery in 31 (86%), including aortofemoral reconstruction, arterial reconstruction or endarterectomy with a patch plasty of the femoral artery. Three patients (8%) were operated on for pseudoaneurysm after radiological intervention, two (6%) because of a lymph fistula. Of the 36 patients, 13 (36%) had a frank infection, 12 (33%) were deemed clinically contaminated, and 11 (31%) were non-infected. Operative strategy included vacuum-assisted closure of the wound. Change of the vacuum system was performed a median of 1.8 times (range 1–9) in the operating room. The median length of therapy was 9.2 days (range 3–29). Direct delayed secondary suture was possible in 25 (69%) cases. In 9 (25%) the defect was covered with a split-skin graft. Two patients (6%) required a secondary plastic reconstruction. One leg (2.8%), originally treated for phlegmasia coerulea dolens was amputated. One patient (2.8%) with an infected aortofemoral Dacron graft died from intractable bleeding after homograft reconstruction. No grafts were lost. Vacuum-assisted wound management led to healing of 34 (94%) wounds during initial hospitalisation. Initial strategy was changed twice (6%). Vacuum-assisted closure system is one of the most efficient tools in the treatment of problematic groin wounds in vascular surgery as well as endovascular interventions.

The mortality rate for elective infrarenal aortic surgery is on the order of 5%–7%. Most deaths are related to coronary heart disease (CAD). Significant coronary heart disease is present in some 60% of patients who need elective aortic operations. Risk-stratification scales are not particularly helpful in finding CAD. It is generally assumed that since the more straightforward cases are managed by endoprosthesis, the mortality rate related to open repair may be on the rise. We report 218 consecutive elective infrarenal aortic operations performed at the Swiss Cardiovascular Center (University Hospital, Berne) between 1998 and 2001. There were 36 (17%) females and 182 (83%) males, mean age 66.7 years (range 42–86 years). Of the patients, 87 (40%) were older than 70, 35 (16%) older than 75 years of age. A prior myocardial infarction was diagnosed in 42 (19%), 141 (65%) were hypertensive, 20 (9%) had diabetes mellitus (IDDM), 24 (11%) renal insufficiency (creatinin >13 mg/dL) and 79 (36%) chronic obstructive pulmonary disease (COPD). The initial screening was done by an in-house internist. As a result, 179 patients (82%) underwent cardiological evaluation, which in turn led to 71 (33%) stress echocardiographies, and subsequently 47 (22%) coronary angiographies. This in turn led to coronary revascularization in 24 (11%). Five carotid endarterectomies (2.3%) were performed prior to planned aortic surgery. There was no mortality related to these operations. Aneurysm repair was performed in 165 (76%) patients, surgery for atherosclerotic lesions in 53 (24%). In-hospital mortality was 1 (0.5%). There was no further 30-day mortality. We conclude that the results of open infrarenal aortic surgery can be improved by active screening by an in-house internist and treatment of underlying vascular and lung disease. This should be reflected in reimbursement policies.

Background and Aims: Two thirds of patients with an abdominal aortic aneurysm (AAA) have relevant coronary artery disease (CAD). AAAs are prevalent in up to 16% of smokers with CAD. General screening of AAA is controversial. Aim was to assess the potential of finding AAA prior to rupture among patients with known CAD. Main endpoint was whether AAA could have been found during follow-up by sonography or at other time of cardiovascular evaluation. Material and Methods: Retrospective study. 213 consecutive, formerly unknown emergently operated AAAs, treated emergently for symptoms (n = 91) or rupture (n = 122) (rAAA) between January 1998 and June 2005. Patient charts were analysed and primary care physicians contacted. Results: At presentation, mean age was 71 (+/–9) years, twenty (9%) were female. AAA had a mean diameter of 7.6 cm. Two thirds (143) were clinically obese (BMI 27 +/–5). 137 (64%) were active smokers, 32 (15%) had diabetes, 151 (71%) were hypertensive, and 80 (38%) received statin treatment. CAD had been diagnosed in 95 (45%) 9 years earlier and followed up. Thirty-five (16%) had had myocardial infarction. Echocardiography had been performed in 52 (24%). Thirty day mortality after open surgery was 25 (21%). Conclusion: All patients with rAAA had been seen by a GP or cardiologist within a year prior to presentation. The cost effectiveness of selective AAA screening should be evaluated in a larger study.

Erratum zu: Gefasschirurgie 2018 https://doi.org/10.1007/s00772-018-0418-4 In der Abbildungslegende der Abb. 2c des Beitrags wurde die rechte mit der linken Hand verwechselt. Wir bitten Sie die korrigierte Abbildungslegende zu beachten und den Fehler zu …

Bei einem 30-jährigen Mann wurde klinisch ein Aneurysma in der A. temporalis superficialis sinistra diagnostiziert. Nach problemloser chirurgischer Sanierung wurde histopathologisch ein posttraumatisch entstandenes Pseudoaneurysma nachgewiesen. Zudem fand man eine assoziierte fibromuskuläre Dysplasie in der Tunica media. Nach unserem Wissensstand wurde diese spezielle Befundkonstellation bislang noch nie beschrieben.

Objective: The study was conducted to determine activation of coagulation in patients undergoing open and endovascular infrarenal abdominal aortic aneurysm repair (EVAR).Methods: In a prospective, comparative study, 30 consecutive patients undergoing open repair (n = 15) or EVAR (n = 15) were investigated. Blood samples to determine fibrinopeptide A, fibrin monomer, thrombin-antithrombin complex, and D-dimer were taken up to 5 days postoperatively. Routine hematologic and hematochemical parameters as well as clinical data were collected.Results: Both groups showed comparable demographic variables. Operating time was longer in open repair (249 +/- 77 minutes vs 186 +/- 69 minutes, P < .05). Perioperatively elevated markers of coagulation were measured in both groups. Fibrinopeptide A levels did not differ significantly between the groups (P = .55). The levels of fibrin monomer and thrombin-antithrombin complex were significantly higher in patients undergoing EVAR (P < .0001), reflecting increased thrombin activity and thrombin formation compared with open surgery. The D-dimer level did not differ significantly between the groups. These results were also valid after correction for hemodilution.Conclusion: These data suggest increased procoagulant activity in EVAR compared with open surgery. A procoagulant state may favor possible morbidity derived from micro- and macrovascular thrombosis, such as in myocardial infarction, multiple organ dysfunction, venous thrombosis and thromboembolism, or disseminated intravascular coagulation.

Low cardiac output impairs the hepatic arterial buffer response (HABR). Whether this is due to low abdominal blood flow per se is not known. Dobutamine is commonly used to increase cardiac output, and it may further modify hepatosplanchnic and renal vasoregulation. We assessed the effects of isolated abdominal aortic blood flow changes and dobutamine on hepatosplanchnic and renal blood flow. Twenty-five anesthetized pigs with an abdominal aorto-aortic shunt were randomized to 2 control groups [zero (n = 6) and minimal (n = 6) shunt flow], and 2 groups with 50% reduction of abdominal blood flow and either subsequent increased abdominal blood flow by shunt reduction (n = 6) or dobutamine infusion at 5 and 10 microg kg(-1) min(-1) with constant shunt flow (n = 7). Regional (ultrasound) and local (laser Doppler) intra-abdominal blood flows were measured. The HABR was assessed during acute portal vein occlusion. Sustained low abdominal blood flow, by means of shunt activation, decreased liver, gut, and kidney blood flow similarly and reduced local microcirculatory blood flow in the jejunum. Shunt flow reduction partially restored regional blood flows but not jejunal microcirculatory blood flow. Low-but not high-dose dobutamine increased gut and celiac trunk flow whereas hepatic artery and renal blood flows remained unchanged. Neither intervention altered local blood flows. The HABR was not abolished during sustained low abdominal blood flow despite substantially reduced hepatic arterial blood flow and was not modified by dobutamine. Low-but not high-dose dobutamine redistributes blood flow toward the gut and celiac trunk. The jejunal microcirculatory flow, once impaired, is difficult to restore.

Objectives. This observational study was set up to prospectively follow all bovine heterograft (ProCol ® ) fistulas implanted for hemodialysis access between 1998 and 2002. Methods. ProCol ® was implanted if autogenous vein was not available or if patients presented with a history of failed, infected or otherwise complicated ePTFE grafts and/or on immunosuppressive therapy. Fistula patency was the primary outcome; secondary outcomes were clinical events and the rate of access revisions. Results. Sixty-two ProCol ® grafts were implanted in 56 patients. The mean primary (PP) and secondary patency (SP) was 334 (SEM 57) and 528 (SEM 59) days, respectively. Coronary heart disease was associated with a significantly better SP (OR 0.2, 95% CI 0.1–0.9) whilst diabetes mellitus was associated with a significantly worse SP (OR 0.2, 95% CI 0.1–0.9). Reinterventions were performed at a mean rate of 1.23 (SEM 0.17) per fistula. The relative risk of access revision was significantly higher in patients with diabetes mellitus (OR 9.2, 95% CI 2.3–37.2). Conclusions. ProCol ® grafts, used for AV-fistulas, demonstrate acceptable patency rates in high-risk haemodialysis patients. Diabetes mellitus jeopardizes the patency of these fistulas and is associated with a high revision rate.

Zusammenfassung: Hintergrund: Neben der Hämodialyse und der Nierentransplantation ist die Peritonealdialyse ein weiteres Nierenersatzverfahren, das aktuell in unseren Breitengraden zu selten angewandt wird. Ziel der Arbeit: Die Gefäßchirurgen sollen mit den Modalitäten dieser Methode als mögliche Alternative zu einem Hämodialyseshunt vertraut werden. Methode: Der Artikel gibt einen Überblick über die verfügbaren Techniken zur Peritonealdialyse. Resultate: Der durch Diffusion, Konvektion und Ultrafiltration bewerkstelligte Austausch von harnpflichtigen Substanzen unter Verwendung von heute meist glukosehaltigem Dialysat in verschiedenen Konzentrationen kann manuell oder automatisch, kontinuierlich oder intermittierend, am Tag oder während der Nacht erfolgen. Es gibt die offene, die laparoskopische oder kombinierte Katheterimplantation neben interventionellen Verfahren mit ihren jeweiligen Vor- und Nachteilen. Es stehen auch eine breite Palette von Kathetermodellen zur Verfügung, angefangen vom klassischen Tenckhoff®-Katheter bis hin zu sich selbst lokalisierenden Wolfram-Kathetern. Katheterdislokationen und -infekte sind die häufigsten Komplikationen bei diesem Verfahren. Schlussfolgerungen: Die Peritonealdialyse ist bezüglich Mortalität und Morbidität einer Hämodialyse ebenbürtig, bietet aber für den Patienten dank kontinuierlicher Dialyse einen großen Komfort und erlaubt eine ortsungebundenere Bewegungsfreiheit.

Background: Comparison of intrathoracic latissimus dorsi (LD) versus serratus anterior (SA) muscle transposition for treatment of infected spaces, broncho-pleural fistulae, and for prophylactic reinforcement of the mediastinum after extended resections following induction therapy. Patients and methods: Twenty LD and 17 SA transfers were performed for prophylactic reinforcement (11 LD; nine SA), and treatment of infections (nine LD; eight SA) from 1995 to 1998. Results: The 30-day mortality was 0% following prophylactic reinforcement and 29% following treatment of infections (three LD; two SA). Prophylactic mediastinal reinforcement was successful in 11 of 11 patients with LD and nine of nine with SA transpositions, and treatment of infected spaces in eight of nine patients with LD and two of three with SA transfers. Morbidity requiring re-intervention consisted of flap necrosis (one LD), bleeding (one SA), and skin necrosis over a winged scapula (one SA). Subcutaneous seromas and chest wall complaints were more frequent following LD (45 and 36%, respectively) compared with SA transfers (29 and 27%, respectively), whereas impaired shoulder girdle function was more frequent after SA than after LD transfer (27 vs. 21%). Conclusion: Intrathoracic LD and SA muscle transpositions are both efficient for the prevention or control of infections following complex thoracic surgery, and are both associated with similar and acceptable morbidity and long-term sequelae. q 2000 Elsevier Science B.V. All rights reserved.

Objectives: in a retrospective study, attempts have been made to identify individual organ-dysfunction risk profiles influencing the outcome after surgery for ruptured abdominal aortic aneurysms. Methods: out of 235 patients undergoing graft replacement for abdominal aortic aneurysms, 57 (53 men, four women, mean age 72 years [s.d. 8.8]) were treated for ruptured aneurysms in a 3-year period. Forty-eight preoperative, 13 intraoperative and 34 postoperative variables were evaluated statistically. A simple multi-organ dysfunction (MOD) score was adopted.Results: the perioperative mortality was 32%. Three patients died intraoperatively, four within 48 h and 11 died later. A significant influence for pre-existing risk factors was identified only for cardiovascular diseases. Multiple linear-regression analysis indicated that a haemoglobin

Background The aim of this study was to evaluate a new surgical concept for the treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases. Methods Between 2004 and 2011, 15 patients (mean age 72 ± 10 years, 87% men) with prosthetic graft or endovascular graft infection were treated with complete removal of the infected prosthetic material, extensive debridement of the surrounding tissues, and orthotopic vascular reconstruction with self-made xenopericardial tube grafts constructed from a patch. Perioperative and long-term outcomes were evaluated. Results Perioperative mortality was 27% (n = 4). All deaths were due to multiorgan failure resulting from uncontrolled septicemia from the local infectious process. Mean observational follow-up was 24 months (5 to 83 months). Control computed tomographic scans showed normal findings at the operative site in all patients. Antibiotic treatment was continued for a mean of 6 months. Freedom from reinfection was 100%. Freedom from reoperation was also 100%. Conclusions Treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases by complete removal of the infected prosthetic material and extensive debridement as well as orthotopic vascular reconstruction using self-made xenopericardial tube grafts as neoaortic segments provides excellent results with regard to durability and freedom from reinfection and reoperation. This new concept is an additional alternative to cryopreserved homografts that extends the armamentarium for treating patients with these highly complex conditions.

Treatment of dialysis access-related hand ischaemia with preservation of the access remains an issue. We report the case of a patient presenting critical hand ischaemia 2 years after proximalisation of a distal radio-cephalic fistula with preservation of the original access. After valvulotomy, the distal cephalic vein was used as in situ bypass and directly anastomosed to the distal brachial artery, providing a direct flow to the hand. This procedure relieved the hand ischaemia without sacrificing the functioning fistula. Six months later, the fistula and bypass were still patent, showing that flow reversal of a previous fistula can be an efficient strategy to correct dialysis access-related hand ischaemia in selected cases.

Zusammenfassung: Die moderne Behandlung von Gefäßpatienten stellt eine reizvolle und anspruchsvolle Aufgabe dar, welche aufgrund der Komplexität und der Breite des Spektrums heute in interdisziplinären Gefäßzentren durchgeführt werden sollte. Die enge Zusammenarbeit zwischen Gefäßchirurgen und Angiologen hat an der Universität Bern eine lange Tradition. Der vorliegende Artikel legt die grundlegende Philosophie unserer gefäßchirurgisch-angiologischen Freundschaft und Zusammenarbeit dar und schildert deren Umsetzung im klinischen Alltag

Zusammenfassung: Aufgrund der demografischen Entwicklung und der ansteigenden Prävalenz des Diabetes mellitus steigt die Zahl dialysepflichtiger Patienten stetig an. Bei vielen dieser Erkrankten stellt die Anlage einer autologen arterio-venösen Fistel eine echte Herausforderung dar. Im ersten Teil wurde die Thematik der Neuanlage von Hämodialysezugängen besprochen. Früh- und Spätkomplikationen von Shunts wie Stenosen, Verschlüsse, Aneurysmen, Infekte und Steal-Syndrom sind bei dieser chirurgischen Technik häufig und müssen nach heute gültigen Richtlinien behandelt werden, was in diesem 2. Teil abgehandelt wird

Zusammenfassung: Aufgrund der demografischen Entwicklung und der ansteigenden Prävalenz des Diabetes mellitus nimmt die Zahl dialysepflichtiger Patienten stetig zu. Bei vielen dieser Erkrankten stellt die Anlage einer autologen arterio-venösen Fistel eine echte Herausforderung dar. Erweist sie sich als unmöglich, muss der Gefäßchirurg mit alternativen Zugängen sowie den Vor- und Nachteilen von alloplastischen und heterologen Prothesen vertraut sein (Teil 1). Früh- und Spätkomplikationen wie Aneurysmen, Stenosen, Verschlüsse, Infekte und Steal-Syndrom sind in der Shuntchirurgie häufig und sollten nach heute gültigen Richtlinien behandelt werden (Teil 2)

Eine 43jahrige Patientin stellt sich bei ihrem Hausarzt mit linksseitigen, belastungsabhangigen Knieschmerzen vor. Sie hat keine weiteren Beschwerden. Der Status ist bis auf leichte Unterschenkelodeme und eine leichte Varikosis beidseits unauffallig. Der Hausarzt veranlasst wegen des Verdachtes einer beginnenden Gonarthrose eine MRI-Untersuchung ohne Kontrastmittel. Die Verdachtsdiagnose wird bestatigt, doch findet sich als Zufallsbefund eine popliteal gelegene Raumforderung mit einem Maximaldurchmesser von 2 cm, die strukturell mit der Vena poplitea in Verbindung steht (Abb. 1 x). Als Differentialdiagnose zu einer Gefasserkrankung ist an eine Baker-Zyste zu denken. Der Hausarzt uberweist die Patientin zur Beurteilung und Therapie an unsere Klinik, wo zur endgultigen Diagnosestellung eine Phlebographie des linken Beines durchgefuhrt wird, welche eine aneurysmatische Erweiterung der Vena poplitea zeigt (Abb. 2 x). Die Indikation zu einer operativen Raffung des venosen Aneurysmas wird gestellt. In einer zweistundigen Operation wird der asymmetrische Teil des venosen Aneurysmas uber einen dorsalen Zugang von der Fossa poplitea her freiprapariert (Abb. 3 x) und mit fortlaufenden Nahten gerafft (Abb. 4 x). Postoperativ wird das linke Bein der Patientin mit einer automatischen pneumatischen «Muskelpumpe» versehen, die den venosen Blutfluss fordern soll. Die Patientin wird am 4. postoperativen Tag mit p.p. heilenden Wunden nach Hause entlassen. Eine Kontroll-Duplex-Untersuchung 6 Monate postoperativ zeigt eine offene Vena poplitea. Aneurysma der Vena poplitea

Objectives. Poor results have been reported following infrainguinal reconstructions using heterogenous grafts. The objective of this study was to assess the use of bovine mesenteric vein (ProCol) graft in patients with critical limb ischaemia (CLI), tissue loss/infection and no autologous vein available for reconstruction.Methods. Prospective analysis of 32 patients with CLI and tissue loss/infection, in whom reconstruction with ProCol was undertaken between October 1999 and May 2002.Results. The primary patency rate was 16% at 1 month. After thrombectomy, the secondary patency rate was 50% at 1 month and 26% at 14 months. No graft infections were seen. Aneurysmal dilatation of the graft occurred in 2 (6%). Limb salvage at 14 months was 47%.Conclusion. In patients with critical limb ischaemia, tissue loss/infection and no available vein, the ProCol graft may be an alternative. However, primary patency is a problem. In situations without tissue loss/infection, where the risk of graft infection is less, prosthetic material may be a better alternative.