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Ein arteriovenoser Shunt ist der „golden standard“ fur den Gefaszugang bei Patienten mit dialysepflichtiger Niereninsuffizienz. Nach einer erfolgreichen Nierentransplantation wird der Shunt jedoch nicht mehr benotigt. In diesem Artikel mochten wir die kardiovaskularen Vorteile und potenziellen Probleme einer routinemasigen Shuntligatur nach einer Nierentransplantation erortern. Es erfolgte eine narrative Literaturrecherche in der Literaturdatenbank von MEDLINE, PubMed und Cochrane Database of Systematic Reviews bis inklusive April 2021. Eine Shuntligatur bei stabilen Nierentransplantatempfangern senkt den pulmonal arteriellen Druck und reduziert das Risiko eines Rechtsherzversagens und bringt damit ein geringeres kardiales Risiko mit sich. Die Entscheidung dazu sollte jedoch vorsichtig und patientenbezogen getroffen werden.

Was ist neu? Aktuelle Studien 4 klinische Studien haben die endovaskuläre Versorgung (endovascular aneurysm bzw. aortic repair, EVAR) und die offen chirurgische Therapie (open repair, OR) des Bauchaortenaneurysmas (BAA) randomisiert prospektiv verglichen: Chronologisch sind dies EVAR 1 (UK), DREAM (Niederlande), OVER (USA) und ACE (Frankreich). Alle 4 Studien sind der Frage nachgegangen, ob die frühe postoperative Überlegenheit der endovaskulären Versorgung im Langzeitverlauf aufrechterhalten bleibt 1 2 3 4 5.Aktuelle Untersuchungen zur prophylaktischen Netzanlage nach offener BAA-Versorgung belegen, dass die Narbenhernie als wesentliche Langzeitkomplikation nach transabdomineller Aortenrekonstruktion sicher vermieden werden kann 6. Leitlinienempfehlungen Seit 2018 wurden international 3 große Leitlinien zum abdominellen Aortenaneurysma publiziert 7 8 9, darunter erstmals die deutsche S3-Leitlinie zu Screening, Diagnostik, Therapie und Nachsorge des BAA 9. Langzeitdaten Auf Grundlage der EVAR-1-Studie wurden 2016 die bis dato längsten Follow-up-Daten zum Vergleich von OR und EVAR veröffentlicht, welche die frühe postoperative Überlegenheit von EVAR infrage stellen. Die mittlere Personenjahre-Beobachtung (entweder bis Tod oder Ende der Studie) betrug 8 Jahre 10.Die offene Therapie des BAA bekommt in diesem Kontext einen neuen Stellenwert und die Indikation zur endovaskulären Therapie sollte mit Hinblick auf den Langzeitverlauf kritisch gestellt werden. Die Indikationsstellung zur invasiven Therapie hat sich nicht verändert und sollte bei Männern – von Ausnahmen abgesehen – erst ab einem Durchmesser von 5,5 cm erfolgen.

OBJECTIVES Cerebrospinal fluid (CSF) drainage is routinely utilized to mitigate perioperative and postoperative spinal cord ischaemia in open and endovascular thoraco-abdominal aortic aneurysm repair to prevent permanent paraplegia. Clinical decision-making in the vulnerable perioperative period, however, is still based on limited clinical and experimental data. Our aim was to investigate the isolated effect of CSF pressure elevation on spinal cord perfusion in an established large animal model. METHODS Ten juvenile pigs with normal (native) arterial inflow (patent segmental arteries and collaterals) underwent iatrogenic CSF pressure elevation (×2, ×3, ×4 from their individual baseline pressure). Each pressure level was maintained for 30 min to mimic clinical response time. After the quadrupling of CSF pressure, the dural sac was slowly depressurized against gravity allowing CSF pressure to passively return to baseline values. Measurements were taken 30 and 60 min after normalization, and microspheres for regional blood flow analysis were injected at each time point. RESULTS Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values CONCLUSIONS CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to ‘drainage-related’ iatrogenic reperfusion injury—aggravating the risk of delayed spinal cord injury—and should therefore be avoided.

SPIDER-graft for thoracoabdominal aortic aneurysm repair avoiding thoracotomy and extracorporeal circulation was modified, enabling reimplantation of lumbar arteries to prevent spinal cord ischemia and compared with open aortic repair (control) in a pig model.Graft implantation was performed in 7 pigs per group (75-85 kg). For SPIDER-graft (groups I and II), the infra-diaphragmatic aorta was exposed through retroperitoneal access. The right iliac branch was first temporarily anastomosed end-to-side to the distal aorta maintaining periprocedural retrograde visceral perfusion. SPIDER-graft was deployed in the descending thoracic aorta via the celiac artery ostium. The celiac, superior mesenteric, and renal arteries were successively connected to the corresponding side branches of the graft. In group II, the lumbar arteries were reimplanted into the former access branch. For control, complete thoracoabdominal exposure of the aorta was required. After crossclamping, proximal anastomosis was performed, and the celiac artery, superior mesenteric artery, renal arteries, and iliac arteries were reattached. Technical feasibility, ischemic times, blood flow, and visceral and spinal cord perfusion in the related organs were evaluated before implantation and 3 and 6 hours after implantation using transit-time flow measurement and fluorescent microspheres.Technical success was achieved in all animals in all groups. Total aortic clamping time and selective ischemic times of related organs were significantly longer during open aortic repair compared with groups I and II (P .0001). Fluorescent microspheres confirmed best spinal cord perfusion in group II.SPIDER-graft reduced ischemic time, avoided extracorporeal circulation and thoracotomy, and improved spinal cord perfusion during thoracoabdominal aortic aneurysm repair in a pig model.

Objective Fenestrated or branched endovascular aortic repair (FB-EVAR) usually represents the last stage in endovascular treatment of postdissection aneurysm after thoracic endograft coverage of entry tear and false lumen embolization. Methods The study was a retrospective analysis of all patients with postdissection thoracoabdominal aneurysm treated with FB-EVAR in a single center. Short-term outcomes included technical success, operative mortality, and morbidities. Midterm outcomes included secondary intervention, false lumen thrombosis rate, aneurysm size regression, and subsequent survival. Results Twenty patients (95% male with a mean age of 64 ± 9 years) were treated between January 2014 and December 2017. The technical success was 100%. There was one death (5%) within 30 days. Postoperative complications included two patients with spinal cord ischemia (10%; one partial and one full). The median follow-up period was 12 months (range, 0-31 months). A secondary intervention was required in six patients, including thoracic stent graft relining for type III endoleak (n = 2), covered stent relining for junctional leak between main body and renal stent (n = 2), and iliac false lumen embolization (n = 2). Twelve patients completed the 1-year follow-up computed tomography angiogram, and their mean aneurysm diameters were 71 ± 18, 66 ± 19, and 62 ± 19 mm preoperatively, immediate postoperatively, and at 1 year, respectively; the corresponding false lumen thrombosis rates were 0% (0/20), 58% (7/12), and 92% (11/12), respectively. One more patient died during follow-up from a non-aneurysm-related cause. The estimated overall survival rates were 95 ± 5%, 88 ± 8%, and 88 ± 8% at 6, 12, and 18 months, respectively. Conclusions FB-EVAR was feasible for postdissection thoracoabdominal aneurysm. Despite the associated perioperative risk and high probability of planned or unplanned reintervention, the procedure led to favorable aortic remodeling with false lumen thrombosis and aneurysm regression.

In the presence of ischaemia/reperfusion (I/R) induced endothelial injury, volume administration may not correlate with increased microcirculation. The aim of this study was to evaluate intestinal microcirculation after standardised sequential volume loading in an animal model of I/R injury following supracoeliac aortic clamping.This was a prospective exploratory pilot animal study. Intestinal I/R injury was induced in eight pigs during experimental thoraco-abdominal aortic repair. After 6 h of I/R, microcirculatory blood flow (mFlux, measured in the ileum using direct laser speckle contrast imaging) and macrohaemodynamic parameters (using trans-cardiopulmonary thermodilution) were measured and measurements were repeated after each of four sequential volume loading steps (VLS1 - 4). Each load was administered over 5 min followed by another 5 min for equilibration.All animals survived until after VLS4. After 6 h of I/R cardiac output (CO) (p .001) and mFlux (p .001) had both decreased. CO increased again after VLS1 (p .001) and VLS2 (p = .036), whereas mFlux did not change. In contrast, mFlux further decreased after VLS3 (p .01) and VLS4 (p .001), whereas CO did not change anymore. Extravascular lung water continued to increase after VLS2 (p = .046) and VLS4 (p = .049).I/R leads to impaired intestinal microcirculation, which was not restored by volume administration in spite of improved CO. In contrast, further volume administration exceeding preload reserves was associated with additional decreases in the intestinal microcirculation. The potentially negative effect of excessive volume resuscitation after I/R injury should encourage further translational research.

Intraoperative valuation of organ and tissue microperfusion is always a current topic in different surgical situations. Although indocyanine green fluorescent imaging (ICG-FI) has turned to be a more and more common technique to evaluate organ perfusion, only few studies tried to quantitatively validate the technique for microperfusion assessment. The aim of the following manuscript is to present the results of our interdisciplinary research confirming additional quantitative assessment tools in different surgical conditions. Thus, we are implementing the background-subtracted peak fluorescent intensity (BSFI), the slope of fluorescence intensity (SFI), and the time to slope (TTS) using ICG-FI in several regions of interest (ROI).

Abstract. This article analyses if and to what extent gender differences exist in abdominal aortic aneurysm (AAA) therapy. For this purpose Medline (PubMed) was searched from January 1999 to January 2018. Keywords were: “abdominal aortic aneurysm”, “gender”, “prevalence”, “EVAR”, and “open surgery of abdominal aortic aneurysm”. Regardless of open or endovascular treatment of abdominal aortic aneurysms, women have a higher rate of complications and longer hospitalizations compared to men. The majority of studies showed that women have a lower survival rate for surgical and endovascular treatment of abdominal aneurysms after both elective and emergency interventions. Women receive less surgical/interventional and protective medical treatment. Women seem to have a higher risk of rupture, a lower survival rate in AAA, and a higher rate of complications, regardless of endovascular or open treatment. The gender differences may be due to a higher age of women at diagnosis and therapy associated with higher comorbidity, but also because of genetic, hormonal, anatomical, biological, and socio-cultural differences. Strategies for treatment in female patients must be further defined to optimize outcome.

Aufgrund der Verwendung von Schlagwortern wie „Silent Killer“ oder „Zeitbombe im Bauch“ in der Boulevardpresse sehen sich auch Hausarzte immer wieder mit besorgten Patienten oder deren Angehorigen konfrontiert. Dabei muss durchaus nicht jeder Patient invasiv therapiert werden. Sinnvoll sind das effiziente Screening von Risikopopulationen und eine individuelle Stufendiagnostik, die durch eine optimale konservative Therapie und befundadaptierte Uberwachung komplettiert werden sollte. Erfahren Sie hier, was zu tun ist.

Die Inzidenz von Narbenhernien nach offenem abdominellem Aortenersatz variiert zwischen 10 und 38 %. Neue Optionen zur Reduktion dieses hohen Risikos beinhalten die prophylaktische Mesh-Augmentation. Das vorliegende Manuskript gibt einen allgemeinen Uberblick uber aktuelle Ergebnisse unter Verwendung unterschiedlicher Techniken der Mesh-Implantation im Vergleich zum direkten Abdominalverschluss nach medianer Laparotomie. Es wurde eine systematische Literaturanalyse unter Verwendung der Datenbanken PubMed und Medline zwischen 2007 und 2017 durchgefuhrt (Suchdatum: 30. Dezember 2017). Es wurde ausschlieslich in der englischsprachigen Literatur nach folgenden Begriffen gesucht: „prophylactic – mesh – abdominal aortic aneurysm repair – incisional hernia“. Von insgesamt 304 Studien wurden ausschlieslich randomisierte prospektive klinische Studien sowie Kohortenstudien und Metaanalysen in diese Ubersicht eingeschlossen. Patienten entwickeln nach offenem Aortenersatz signifikant seltener eine Narbenhernie, wenn eine prophylaktische Netzaugmentation durchgefuhrt wird. Onlay- und Sublay-Techniken unterscheiden sich in Details, jedoch sind beide Techniken effektiv. Die prophylaktische Netzanlage sollte daher grundsatzlich durchgefuhrt werden und auch Eingang in die aktuellen Leitlinien finden.

Background Mesenteric ischemia is a severe and potentially lethal event. Assessment of intestine perfusion is eminently depending on the skills, and the experience of the surgeon. Thus, the therapy is biased by the right evaluation. Aim of this study is to determine the applicability, and the usefulness of fluorescent-imaging (FI) with indocyanine green (ICG) in a porcine model of mesenteric ischemia. Second end-point is the verification of a visual and quantitative assessment tool of the intestinal perfusion. Methods In 18 pigs (54,2 ±2,9kg) an occlusion of a side-branch of the mesenteric artery was performed for 3 (group I, n = 7), 6 (group II, n = 7), and 10 hours (group III, n = 4). After reperfusion a 60 minutes observation period was carried out. 3 regions of interest were defined: ischemic bowel (D1), transitional zone (D2), and non-ischemic bowel (D3). ICG-FI was performed during baseline (T0), occlusion (T1), reperfusion (T2) and after an observation period of 60 minutes (T4). Results All experiments could be finished successfully. ICG-FI was assessed using assessment of background-subtracted peak fluorescence intensity (BSFI), slope of fluorescence intensity (SFI), and a baseline adjusted ratio of both parameters. ICG-FI confirmed loss of perfusion in D1, decreased perfusion in D2, and increased perfusion in D3. After reperfusion ICG-FI increased in group 2 due to a severe tissue damage resulting in a capillary leakage. In group I ICG-FI was equal to baseline values indicating the totally reversible loss of perfusion. Conclusion Using ICG-FI to estimate intestine perfusion after different durations of ischemia is viable using a porcine model of mesenteric ischemia. Even small differences in perfusion can be reliably determined by ICG-FI. Thus, ICG-FI is an encouraging method to evaluate intestine perfusion intraoperatively.

Abstract. The incidence of primary aorto-enteric fistula (PAEF) is low with only few case reports and case series published. Depending on the location of the PAEF, the perforation leads to upper or lower gastrointestinal haemorrhages. We conducted a MEDLINE search according to the PRISMA statement. Articles with publication dates from 2000 to 2016 were included and present an own case report. We considered all case reports and series reporting on PAEF and identified 85 individual patients from 32 case reports and five case series. The majority of PAEF is associated with atherosclerotic or aneurysmatic findings of the aorta and in particular with inflammatory aortic diseases. Most commonly, the duodenum (64 %) was mentioned as location of the perforation. Other cases involved the jejunum (< 10 %) and the colon (5 %). Almost all patients were diagnosed either with gastrointestinal haemorrhage, abdominal or back pain, or anaemia due to bleeding. The immediate and correct diagnosis of this entity remains difficult. Therefore, treatment is delayed leading to an extraordinary high mortality of almost 100 % in untreated cases. Duplex ultrasound and contrast-enhanced CT angiography have high diagnostic sensitivity and specificity to rule out acute abdominal aortic pathologies. New endovascular approaches can help to lower mortality.

To analyze the outcome of surgeon-modified fenestrated and branched stent-grafts (sm-FBSG) in high-risk patients with symptomatic complex aortic pathology or contained rupture.A single-center retrospective analysis was conducted of 21 consecutive patients (mean age 70 years, range 58-87; 16 men) treated with a sm-FBSG from April 2014 to September 2016. The indications included 11 thoracoabdominal and 10 pararenal aortic pathologies, which presented as symptomatic in 8 and as contained rupture in 13 patients. The mean aneurysm diameter was 7.4±2.3 cm.Technical success was 100%. From 1 to 4 (mean 3) renovisceral branch vessels were targeted with fenestrations. The mean length of in-hospital stay was 19 days (range 1-78). There was 1 death within 30 days and 2 further in-hospital deaths. Two patients suffered permanent spinal cord injury, 2 developed respiratory failure, and 2 had renal failure requiring temporary or permanent dialysis. No myocardial infarction, stroke, or bowel ischemia occurred. Six early endoleaks (3 type II and 3 minor type III) were detected. Mean follow-up was 11.2 months (range 2-33) in 17 patients. One late aneurysm-related death occurred. All 13 follow-up imaging studies showed patent target renovisceral vessels, with 1 type I and 2 type II endoleaks.Sm-FBSG can be utilized for urgent treatment of complex abdominal and thoracoabdominal aortic pathologies in high-risk patients with anatomy unsuitable for commercially available stent-grafts.

Hintergrund Die spinale Ischamie mit klinischer Manifestation eines kompletten Querschnittsyndroms ist eine der relevantesten Komplikationen der thorakoabdominellen Aortenchirurgie und wird perioperativ v. a. durch die Unterbindung oder Uberstentung ruckenmarkversorgender Segmentarterien verursacht. Zur Pravention dieser schwerwiegenden Komplikation haben sich spezielle Staging-Verfahren in der endovaskularen Aortentherapie entwickelt, die das Ziel haben, die operative Versorgung des thorakoabdominellen Aortenaneurysmas (TAAA) in mehrere Eingriffe zu unterteilen, um die Entwicklung von Kollateralkreislaufen zur Sicherung der spinalen Perfusion zu starken.

Purpose: To describe the combined use of a tubular stent-graft for the ascending aorta and an inner-branched arch stent-graft for patients with acute type A aortic dissection. Technique: The technique to deploy these modular, custom-made stent-grafts is demonstrated in 2 patients with acute DeBakey type I aortic dissections and significant comorbidities precluding open surgery. Both emergent procedures were made possible by the availability of suitable devices manufactured for elective repair in other patients. After preliminary carotid-subclavian bypass, a long Lunderquist guidewire was introduced from the right femoral artery to the left ventricle for delivery of the Zenith Ascend and Zenith Branched Arch Endovascular Grafts under inflow occlusion. Bridging stent-grafts were delivered to the innominate and left common carotid arteries to connect to the 2 inner branches; the left subclavian artery was occluded. Both cases were technically successful and resulted in exclusion of the false lumen in the ascending aorta. The operating and fluoroscopy times did not exceed those of comparable elective procedures. The patients were rapidly extubated shortly after the procedure and without serious immediate complications. One patient survived 11 months with a satisfactory repair; the other succumbed to complications of recurrent pneumonia after 23 days. Conclusion: Endovascular treatment of patients with acute type A aortic dissection using a combination of tubular and branched stent-grafts in the ascending aorta is feasible and offers an alternative strategy to open surgery.

Objectives Evaluation of intestinal perfusion remains subjective and depends on the surgeon´s individual experience. Intraoperative quality assessment of tissue perfusion with indocyanine green (ICG) fluorescence using a near-infrared camera system has been described in different ways and for different indications. The aim of the present study was to evaluate fluorescent imaging (FI) in the quantitative assessment of intestinal perfusion in a gastric tube model in pigs and to compare the results to results obtained with florescent microspheres (FM), the gold standard for tissue perfusion. Methods Seven pigs (56.0±3.0 kg), both males and females, underwent gastric tube formation after transection and ligation of the gastric arteries, except the right gastroepiploic artery, to avoid collateral blood flow. After baseline assessment (T0), hypotension (T1) was induced by propofol (Karampinis et al 2017) (< 60 mmHg). Then, propofol was paused to obtain normotension (T2, Mean arterial pressure (MAP) 60–90 mmHg). Finally, hypertension (T3, MAP>90 mmHg) was induced by norepinephrine. Measurements were performed in three regions of interest (ROIs) under standardized conditions: the fundus (D1), corpus (D2), and prepyloric area (D3). Hemodynamic parameters and transit-time flow measurement (TTFM) in the right gastroepiploic artery were continuously assessed. FI, FM and the partial pressure of tissue oxygen (TpO2) were quantified in each ROI. Results The study protocol could successfully be performed during stable hemodynamics. Flow in the gastroepiploic artery measured by transit time flow measurement (TTFM) was related to hemodynamic changes between the measurements, indicating improved blood flow with increasing MAP. The distal part of the gastric tube (D1) showed significantly (p Conclusion Visual and quantitative assessment of gastric tube perfusion is feasible in an experimental setting using ICG-FI. This might be a promising tool for intraoperative assessment during visceral surgery in the future.

Proximal displacement of thoracic aortic endografts is a catastrophic adverse event, which rarely occurs but is associated with extremely high morbidity and mortality. We describe herein the case of a patient with accidental proximal displacement of a thoracic endograft with occlusion of all supra-aortic branches, successfully rescued by the combination of three advanced endovascular techniques: (1) aggressive pull-back maneuver with a compliant balloon; (2) establishment of an arterio-arterial temporary shunt to the occluded carotid artery over sheaths; and (3) in-situ fenestration of the occluded carotid artery.

Abstract. This overview analyses gender differences in prevalence, epidemiology, risk factors and therapy in patients with carotid stenosis in a systematic review. Ischemic stroke is a leading cause of death in Western society, where about 20% of cases are triggered by a carotid stenosis or occlusion, which occurs more frequently in men than in women. The stroke-protective effect of carotid endarterectomy is greater in men. Men have lower peri-procedural stroke and death rates. Particularly men with carotid stenosis and a life expectancy of at least 5 years benefit from surgical treatment. Also, the recurrence rate of ipsilateral stroke 5 years after initial surgery is lower in men than in women. It is not yet fully clarified whether there are significant gender differences regarding the outcome after endovascular versus surgical treatment. Gender differences in the outcome of carotid artery repair may be caused by biological, anatomical (smaller vessel diameter in women) or hormonal differences as well as a protracted development of atherosclerotic changes in women and different plaque morphology. Moreover, women are on average older at the time of surgery and their surgical treatment is often delayed. To reduce the risk of stroke and to improve treatment outcome especially for women, further research on gender differences and their causes is mandatory and promising.

Injection of fluorescence-labelled microspheres (FMs) in pigs allows only the postmortem determination of organ perfusion. Colour duplex ultrasound (CDU) and contrast-enhanced ultrasound were established as techniques for real-time imaging of tissue perfusion in a porcine haemorrhagic shock model. Haemorrhagic shock was provoked in nine domestic pigs by taking at least 15% of the calculated blood volume. Ultrasound examinations were performed with a Hitachi HI VISION Ascendus. SonoVue was injected for contrast-enhanced ultrasound. Monitoring of the resistive index and time-to-peak ratio enabled quantification of tissue perfusion in vivo during the entire study, allowing real-time differentiation of animals with systemic shock versus failing shock effect. Postmortem analyses of injected FMs confirmed the sonographic in vivo results. Determination of the resistive index and time-to-peak ratio by CDU and contrast-enhanced ultrasound allowed real-time monitoring of tissue perfusion. Effects of haemorrhagic shock and therapeutic approaches related to organ perfusion can be observed live and in vivo.

Introduction This study evaluates the current experience on endovascular repair of the aortic arch pathologies, the feasibility and safety of the procedure. Evidence acquisition A systematic review was performed. MEDLINE, CENTRAL, and Cochrane databases were searched with PRISMA methodology for published studies reporting on endovascular repair of aortic arch pathologies from 2000 to 2018. Evidence synthesis Thirteen non-randomized retrospective studies (either single or multicenter), two multicenter Registries and one multicenter non-randomized interventional study were included in the systematic review. The total number of patients who underwent total endovascular repair of the aortic arch pathology with either fenestrated, branched, or a combination of those devices or chimney technique was 952 patients (73%; 634/872 males, mean age ranging from 51 to 78 years). The technical success rate was 96.7% (921/952), while the 30-day mortality rate was 3.3% (32/952). The most common adverse events were endoleak type I (13.5%; 35/259), stroke (5.1%; 49/952), spinal cord ischemia (1.4%; 14/952) and retrograde dissection (1%; 8/952). During the follow-up period (mean ranging: 16.9 to 41.4 months; median ranging: 9 to 44.8 months) the total number of deaths was 31 (4.4%; 31/693). The total loss of supra-aortic vessel patency rate was 1.7% (14/803) and a re-intervention was needed in 50 patients (9%; 50/559; 11 open conversion). Conclusions Endovascular repair of aortic arch pathologies is a feasible treatment option with good early and reasonable mid-term outcomes. This treatment modality approaches a level of maturity and may be considered as a solid alternative method of treatment.

Purpose: To describe a novel modification technique to lower the distal radial force of a thoracic stent-graft so as to avert stent-graft–induced new entry tears (SINE) in the fragile aorta of patients with genetic aortic disease and aortic dissection. Technique: A commercially available thoracic stent-graft is partially deployed on a back table. The most distal Z-stent is removed, the distal fabric is marked by vascular clips, and the modified stent-graft is reloaded and deployed in the true lumen of an aortic dissection. The technique is demonstrated in 3 patients with aortic dissection related to genetic aortic diseases. Conclusion: Creating a low distal radial force stent-graft is easy and can be done in a short time. Endovascular implantation appears feasible and safe.

Early survivors of acute type A aortic dissection (AAAD) remain at risk for late death and late aortic events. However, the frequency and long-term effects of warfarin anticoagulation on long-term outcome in post-surgical AAAD survivors have not been elucidated.Two tertiary care centers performed a retrospective observational cohort study of warfarin anticoagulation in AAAD in 243 persons with early survival of surgical repair (WATAS). Serial postoperative tomographic imaging was available in 106 persons.A total of 88 postoperative AAAD survivors (36%) were on long-term warfarin anticoagulation. The indication for anticoagulation was a mechanical aortic prosthesis in 46 (52%), atrial fibrillation in 33 (38%), stroke in 7 (8%), and pulmonary embolism in 1 (1%). The indication for anticoagulation remained unclear in 1 person (1%). Survival and aortic event free survival were 98.3±0.01 and 98.7±0.01 at 1 year, and 76.4±0.03 and 91.8±0.02 at 5 years, respectively, with no differences irrespective of warfarin anticoagulation. Multivariate Cox regression analysis established higher age (P0.001), and operation extending into the descending aorta (P=0.030) as independent predictors of late death. Follow-up without tomographic imaging independently predicted increased long-term mortality (P0.001) and lower rates of documented aortic events (P=0.003). Kaplan-Meyer analysis showed a relationship of aortic diameter growth ≥0.5 cm per year with late death (P=0.041) and with late aortic events (P0.001). However, rapid aortic growth did not relate to warfarin anticoagulation.Warfarin anticoagulation is frequent in postsurgical AAAD and it is administered for vital indications. Warfarin anticoagulation does not relate to late mortality or to late aortic events. Rapid aortic growth predicts late mortality and late aortic events, but warfarin anticoagulation is not associated with aortic growth. Follow-up tomographic imaging is mandatory for long-term survival after surgical repair of AAAD.

Objective The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. Methods A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. Results Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate Conclusions The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF

Intraoperative fluorescent cardiac imaging (FCI) can quantitatively assess myocardial perfusion abnormalities produced by graded flow-limiting coronary stenosis (FLS), but there are no data to distinguish FLS from non flow-limiting stenosis (NFLS) to determine their functional significance. The aim of the study was to evaluate whether non-ischemia inducing NFLS can be quantified and differentiated from FLS by FCI technology. Data are compared to gold standard fluorescent microspheres (FM). 11 domestic pigs of either sex underwent sternotomy. Left anterior descending coronary artery blood-flow was recorded by transit-time flow measurements. After baseline and Adenosine-induced hyperemia, two stenosis of low severity (50 and 90 % NFLS) were produced, followed by FLS (50 %) and total vessel occlusion. Time-dependent fluorescence intensity curves were recorded by FCI. Slope of fluorescence intensity (SFI) and background-subtracted peak fluorescence (BSFI) intensity were calculated and data compared to myocardial blood flow measurements using FM. All NFLS and FLS reduced myocardial perfusion as quantified by FCI showing decreased normalized BSFI and SFI (P < 0.001). Box-plot analysis showed significant difference between NFLS (50 and 90 %) and FLS (50 %) assessed by BSFI (P < 0.001) and SFI (P < 0.001). In each animal, a linear correlation between FM-derived myocardial blood flow and FCI-derived BSFI (r = 0.936, P < 0.001) or SFI (r = 0.942, P < 0.001) was observed during baseline, hyperemia, graded NFLS, and FLS. Both, BSFI (r = 0.789, P < 0.001) and SFI (r = 0.802, P < 0.001) significantly correlated with transit-time flow measurements. FCI quantitative technology is capable of distinguishing between non-ischemia inducing NFLS and ischemia inducing FLS showing a good correlation compared to fluorescent microspheres.

Purpose: To compare the technical feasibility and hemodynamic alterations during antegrade transcardiac access routes vs conventional transfemoral access (TFA) for endovascular treatment of the ascending aorta in a porcine model. Methods: Antegrade transseptal access (TSA), transapical access (TAA), and TFA were used for implantation of custom-made endografts into the ascending aorta under fluoroscopy (6 pigs each). Hemodynamic parameters, myocardial and cerebral blood flow, and carotid artery blood flow were evaluated during baseline (T1), sheath advancement (T2), after sheath retraction (T3), and after endograft deployment (T4). Results: Endograft deployment was feasible in all animals; all coronary arteries remained patent. Hemodynamic parameters were comparable in all 3 study groups during all measurements. During T2, transient hemodynamic alteration occurred in all groups, with transient severe valve insufficiency in TSA and TAA reflected by the higher pulmonary to mean arterial pressure ratio (pConclusions: TSA, TFA, and TAA to the ascending aorta are feasible for endograft delivery to the ascending aorta in a porcine model. Transient hemodynamic instability in TSA and TAA recovered to near preoperative values. TAA appeared technically easier.

Goldstandard der Behandlung von Pathologien der Aorta ascendens ist nach wie vor die offene herzchirurgische Operation mit extrakorporaler Zirkulation in milder bis tiefer Hypothermie, ggf. mit selektiver Kopfperfusion. Allerdings ist dieser Eingriff, insbesondere bei alteren Patienten oder nach bereits stattgehabter Herzoperation, mit einer erheblichen Komplikationsrate vergesellschaftet. Die endovaskulare Versorgung von Pathologien der thorakalen Aorta (Thoracic endovascular aortic repair/TEVAR) hat sich mittlerweile im Bereich der Aorta descendens zu dem favorisierten Standardverfahren etabliert und zeigt im Vergleich zur offenen operativen Versorgung eine geringere Morbiditat und Mortalitat. Trotz einer raschen Entwicklung im Bereich der endovaskularen Technik kann der Zugangsweg, insbesondere fur die Versorgung der herznahen Aortensegmente, eine Herausforderung darstellen. Der konventionelle, retrograde transfemorale Zugangsweg kann durch starke Knickbildung oder atherosklerotische Plaques der iliakalen und femoralen Zugangsgefase sowie der Aorta erschwert sein. Ferner ist die grose Distanz zum Zielgefas problematisch fur die exakte Graftpositionierung. Um eine praktizierbare Alternative bei der endovaskularen Versorgung herznaher Aortenpathologien zu ermoglichen, sind antegrade transkardiale Zugangswege zur Aorta ascendens und zum Aortenbogen zunehmend bedeutsam.

We present the case of a 50-year-old gravida with a chronic Stanford type B aortic dissection with false lumen aneurysm and discuss a literature-based treatment strategy. She underwent oocyte donation in the United States and was seen in week 15 of gestation. We chose a strategy of “watchful waiting” at a constant aortic diameter of 52 mm on magnetic resonance imaging. In week 32 + 6 days, cesarean delivery was induced in a hybrid operating room with subsequent thoracic endovascular aortic repair to reduce the risk of early dilation and rupture during the nursing period. One year later, she cared for her healthy baby with stable aortic diameters.

Purpose: To describe the technique of carbon dioxide (CO2) flushing of thoracic stent-grafts to reduce the risk of cerebral air embolism. Technique: To remove room air, thoracic stent-grafts were preoperatively flushed 2 minutes with carbon dioxide from a cylinder connected to the flushing chamber of the captor valves of Zenith custom-made endografts; this was followed by the standard saline flush. Thirty-six patients undergoing thoracic endovascular aortic repairs (TEVAR) involving the ascending aorta and the aortic arch received CO2-flushed Zenith endografts. One patient with a highly calcified arch experienced a minor stroke. Conclusion: Arterial air embolism is a potentially underappreciated problem of aortic endografting, especially in the proximal segments of the aorta. CO2 flushing may have the potential to reduce air embolization during TEVAR.

Abstract. Background: Perioperative evaluation in peripheral artery disease (PAD) by common vascular diagnostic tools is limited by open wounds, medial calcinosis or an altered collateral supply of the foot. Indocyanine green fluorescent imaging (ICG-FI) has recently been introduced as an alternative tool, but so far a standardized quantitative assessment of tissue perfusion in vascular surgery has not been performed for this purpose. The aim of this feasibility study was to investigate a new software for quantitative assessment of tissue perfusion in patients with PAD using indocyanine green fluorescent imaging (ICG-FI) before and after peripheral bypass grafting. Patients and methods: Indocyanine green fluorescent imaging was performed in seven patients using the SPY Elite system before and after peripheral bypass grafting for PAD (Rutherford III-VI). Visual and quantitative evaluation of tissue perfusion was assessed in an area of low perfusion (ALP) and high perfusion (AHP), each by three independent investigators. Data assessment was performed offline using a specially customized software package (Institute for Laser Technology, University Ulm, GmbH). Slope of fluorescent intensity (SFI) was measured as time-intensity curves. Values were compared to ankle-brachial index (ABI), slope of oscillation (SOO), and time to peak (TTP) obtained from photoplethysmography (PPG). Results: All measurements before and after surgery were successfully performed, showing that ABI, TTP, and SOO increased significantly compared to preoperative values, all being statistically significant (P < 0.05), except for TTP (p = 0.061). Further, SFI increased significantly in both ALP and AHP (P < 0.05) and correlated considerably with ABI, TTP, and SOO (P < 0.05). Conclusions: In addition to ABI and slope of oscillation (SOO), the ICG-FI technique allows visual assessment in combination with quantitative assessment of tissue perfusion in patients with PAD. Ratios related to different perfusion patterns and SFI seem to be useful tools to reduce factors disturbing ICG-FI measurements.

Objective The aim of this study was to assess the immediate postoperative and midterm outcome of complex aortic aneurysm treatment necessitating four-vessel revascularization with either a total endovascular approach (fenestrated-branched stent graft [FBSG]) or a hybrid technique of visceral debranching plus stenting. Methods The clinical data of consecutively treated patients presenting with a complex aortic aneurysm that necessitated four-vessel revascularization between 2010 and 2015 were retrospectively analyzed. Results There were 98 patients (65 men [68%]) with a mean age of 70.65 ± 4 years who presented with aortic aneurysm (Crawford type I, 12; type II, 18; type III, 12; type IV, 24; type V, 6; and juxtarenal and suprarenal, 26) and were treated with either FBSG (76/98 [77.5%]) or hybrid repair (22/98 [22.4%]). Twenty-six patients were symptomatic (16, pain; 10, contained rupture). The mean maximum aneurysm diameter was 65 ± 15 mm, and 53% of the patients had a prior aortic intervention. In FBSG-treated patients, 15 off-the-shelf multibranched stent grafts, 3 surgeon-modified fenestrated stent grafts, and 58 custom-made devices tailored to the patient's anatomy were used. Four fenestrations, four branches, and their combination were used in 38 cases, 30 cases, and 8 cases, respectively. A total of 304 target vessels were addressed, with technical success rate of 96% (292/304). In most hybrid cases (18/22 [82%]), a two-stage procedure was undertaken. All target vessels were successfully revascularized with 88 bypasses. The 30-day mortality was 15.3% (15/98), and the early target vessel occlusion was 9.1% (2 in FBSG, 7 in hybrid). After multivariate analysis, type of procedure (hybrid) was independently associated with higher early mortality (odds ratio, 6.3; P = .01). The morbidity was mainly attributed to pulmonary complications (16.3%), lower extremity weakness (16.3%), mesenteric ischemia (6.1%), dialysis on discharge (6.1%), and complete paraplegia (4.3%). Acute renal failure (2.6% vs 18%; P = .03) and mesenteric ischemia (3% vs 23%; P = .001) presented more commonly in the hybrid group. The mean follow-up was 16.4 ± 5 months, and the mortality rate was 19.4% (12% in the FBSG group vs 45% in the hybrid group; P = .05). The graft and stent graft patency rate was 87.8% (three branches and nine bypasses were occluded). Conclusions FBSG and hybrid technique seem to be feasible treatment options for complex aortic aneurysms that necessitate four-vessel revascularization. FBSG may be associated with lower mortality and morbidity rates in comparison to the hybrid procedure. FBSG should be the treatment of choice for complex aneurysms in patients with comorbidities, whereas hybrid repair should be considered for acute cases unsuitable for endovascular repair.

Intraoperative graft assessment in coronary artery bypass (CAB) grafting is important to avoid early graft failure. This study aimed to evaluate the accuracy of fluorescent cardiac imaging (FCI) for intraoperative qualitative angiographic and quantitative myocardial perfusion assessment during graded CAB stenosis compared to coronary angiography (CA). After CAB grafting to the left anterior descending coronary artery, graded distal bypass stenoses were created in ten pigs by 25, 50, 75, and 100% flow reduction assessed by transit-time flow measurement (TTFM). Visual angiographic assessment was performed by FCI and CA during baseline and graded bypass stenoses. Altered myocardial perfusion was assessed by quantitative intraoperative fluorescence intensity (QIFI) derived from FCI and correlated to TTFM. Patent bypass grafts and graft occlusion were visualized successfully by FCI and CA, while discrimination between various graded bypass stenosis was possible in 73.3%. The degree of CAB stenosis was overestimated in 16.7% and underestimated in 10.0% by FCI compared to CA. Graded CAB stenosis reduced regional myocardial perfusion quantified by decreased QIFI value (p

Background The hybrid SPIDER-graft consists of a proximal descending aortic stent graft and a conventional six branched Dacron graft for open abdominal aortic repair. Technical feasibility with regard to avoiding thoracotomy and extracorporeal circulation (ECC) during thoraco-abdominal aortic hybrid repair and peri-procedural safety of this novel device are unknown. Material and methods This was a feasibility and safety study in domestic pigs (75–85 kg). The abdominal aorta including iliac bifurcation, left renal artery, and visceral arteries were exposed via retroperitoneal access. The right iliac branch was first temporarily anastomosed end to side to the distal aorta via partial clamping. During inflow reduction and infra-coeliac cross-clamping, the coeliac trunk (CT) was divided and the proximal stent graft portion of the SPIDER-graft was deployed into the descending aorta via the CT ostium. Retrograde visceral and antegrade aorto-iliac blood flow was maintained via the iliac side branch. The visceral, renal, and iliac arteries were sequentially anastomosed, finally replacing the first iliac end to side anastomosis. Technical success, blood flow, periods of ischaemia, and peri-procedural complications were evaluated after intra-operative completion angiography and post-operative computed tomography angiography. Results Six animals underwent successful thoracic stent graft deployment and distal open reconstruction without peri-operative death. The median thoracic graft implantation time was 4.5 min, and the median ischaemia times before reperfusion were 10 min for the CT, 8 min for the superior mesenteric artery, 13 min for the right renal artery, and 22 min for the left renal artery. Angiography demonstrated appropriate graft implantation and blood flow measurements confirmed sufficient blood flow through all side branches. Conclusion In this translational pig model, thoraco-abdominal hybrid repair using the novel SPIDER-graft was successful in avoiding thoracotomy and ECC. Technical feasibility and safety appear promising, but need to be reassessed in humans.

Acute aortic thrombosis (AAT) is a rare life threatening event that leads to a sudden occlusion of the aorta. The mortality and morbidity of AAT is still high despite modern surgical techniques. Usually it is the result of a large saddle embolus to the aortic bifurcation, in situ thrombosis of an atherosclerotic aorta or acute occlusion of an abdominal aortic aneurysm. Clinical symptoms depend on the level of the aortic occlusion and can be mistaken for a stroke or similar neurological disease. The combination of age and advanced cardiac disease seems to be significant risks factors for AAT. In patients who have no cardiac or vascular disease this catastrophic event is very rare and is mostly due to hypercoagulable disorders. Revascularization of the ischemic organ/limb as soon as possible is the major aim in the therapy of AAT to avoid further ischemic damage. Surgical reperfusion is the first line approach. If the accepting clinic has no facilities for an immediate surgical intervention it is of primary importance that these patients should be referred to an appropriate center for further management. Paradox seems the fact that most of the patients die as a consequence of reperfusion injury/postperfusion syndrome that occurs after revascularization of acute ischemic limbs.

Purpose: To describe a hybrid technique of reversed frozen elephant trunk to treat thoracoabdominal aortic aneurysms (TAAA) through an abdominal only approach. Technique: The technique is demonstrated in a 29-year-old Marfan patient with a chronic type B aortic dissection previously treated with a thoracic stent-graft who presented with a thoracoabdominal false lumen aneurysm. Through an open distal retroperitoneal approach to the abdominal aorta, a frozen elephant trunk graft was implanted over a super-stiff wire upside down with the stent-graft component in the thoracic aorta. Following deployment of the stent-graft proximally and preservation of renovisceral perfusion in a retrograde manner, the renovisceral vessels were sequentially anastomosed to the elephant trunk graft branches, thus reducing the ischemia time of the end organs. The aortic sac was then opened, and the distal part of the hybrid graft was anastomosed with a further bifurcated graft to the iliac vessels. Conclusion: The reversed frozen elephant trunk technique is feasible for hybrid treatment of TAAAs via an abdominal approach only. This has the benefit of substantially reducing the trauma of thoracic exposure, thus preserving major benefits of open thoracoabdominal surgery, such as the presence of short bypasses to the renovisceral vessels and reimplantation of lumbar arteries to reduce spinal cord ischemia.

Die offene Operation stellt aktuell den „Goldstandard“ fur die Versorgung der Aorta ascendens und des Aortenbogens dar. Die konventionellen Operationstechniken erfordern allerdings einen hypothermen Kreislaufstillstand, der mit relevanten Komplikationen assoziiert ist. Die minimalinvasive Therapie von pathologischen Veranderungen des Aortenbogens bedeutet aufgrund der komplexen Probleme dieser vaskularen Region eine technische Herausforderung. Die aus dem Aortenbogen abgehenden Abzweigungen versorgen u. a. das Gehirn, das eine minimale Ischamietoleranz hat. Weiterhin ist der Aortenbogen weit, gebogen, starker pulsatil und weiter von den Femoralarterien entfernt. Die endovaskularen Therapieoptionen zur Behandlung von pathologischen Veranderungen der Aorta ascendens und des Aortenbogens sind Hybridtechniken im Aortenbogen, Chimney-Prozeduren fur die supraaortalen Aste, In-situ-Fenestration von thorakalen Stent-Prothesen sowie individuell angefertigte fenestrierte und gebranchte Stent-Prothesen. Individuell angefertigte fenestrierte und gebranchte Stent-Prothesen sind eine sehr gute Option fur Patienten, die fur offene Operation nicht geeignet sind, und konnten in der Zukunft die endovaskuare Therapie der Wahl werden. Eine gute praoperative Planung, die exakte Kenntnis der individuellen anatomischen Verhaltnisse sowie das Verstandnis der Besonderheiten der Aorta ascendens und des Aortenbogens sind fur die erfolgreiche endovaskulare Versorgung entscheidend.

Fragestellung Die folgende Ubersicht nimmt zu geschlechtsspezifischen Unterschieden hinsichtlich Pravalenz, Epidemiologie, Risikofaktoren und Therapie bei Patienten mit peripherer arterieller Verschlusskrankheit (PAVK) Stellung.