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To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion.All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3-4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality.The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011).Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Objectives To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. Design Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. Materials and methods From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: −1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. Results Technical success rate of AMI endografting was 95.65% ( n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1–Q3: 1.3–9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1–Q3: 17–69 months). Conclusions Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

Thromboembolic events are a known complication in inflammatory bowel disease (IBD). We report on 2 young women with IBD and aortic mural thrombi as a source of arterioarterial embolization to the lower limbs resulting in significant morbidity. The first case was a 36-year-old woman with severe ulcerative colitis who presented with signs of microembolism into two toes of her right foot. A thrombus in the otherwise normal infrarenal aorta with occlusion of the inferior mesenteric artery was revealed by computed tomography (CT) and intrarterial angiography. The digital ischemia resolved without sequelae. The second case was a 41-year-old woman with Crohn's disease complicated by fistulas. She developed acute ischemia of her right leg. Arteriography and CT revealed infrapopliteal embolic occlusions and a thrombus in the distal otherwise normal abdominal aorta and the left iliac artery. A primarily successful thrombectomy had to be repeated 5 times because of reocclusion. Eventually the leg was exarticulated at the knee. In both patients no further thromboembolic event occurred during follow-up of 4 1/2 years and 5 1/2 years, respectively, and aortic thrombi had resolved at follow-up CT scans. Extensive work up for hypercoagulability was negative in both patients. We consider IBD as the most likely trigger for arterioarterial embolization in the absence of thrombophilia in both patients. Finally we give an overview of the literature of similar cases with aortic mural thrombi in IBD patients.

Purpose: To report successful endovascular management of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 40 months after primary stent-grafting. Case Report: A 64-year-old man presented with hypotension, severe back pain, and abdominal distension. Immediate computed tomography revealed a proximal type I endoleak due to distal migration of the stent-graft with subsequent rupture of the aneurysm. The patient was hemodynamically unstable, and open surgery was refused because of severe comorbidities that were the indications for initial endovascular repair. The diameter of the proximal aneurysm neck required the use of a thoracic stent-graft that was overly long, which led to occlusion of the contralateral stent-graft limb supplying not only the left leg but also a left kidney transplant. A crossover bypass was implanted to revascularize both. Conclusions: Minimally invasive strategies, even when challenged by complex vascular reconstructions, offer the possibility of managing ruptured aortic aneurysms in patients unsuitable for open surgery.

Background— Although transfemoral endovascular aneurysm management (TEAM) of infrarenal abdominal aortic aneurysms (AAA) is widely performed, open graft replacement is still considered the standard of care. The aim of this study was to investigate whether clear indications for TEAM can be established in patients with significant comorbidities without investigating differences in relative procedure efficacy or durability. Methods and Results— A propensity score–based analysis of 454 consecutive patients treated electively for AAA from January 1995 through December 2000 was performed. Of those 454 patients, 248 received open surgery and 206 received TEAM. In-hospital mortality rates (MRs) were compared. After adjusting for propensity scores, a Cox proportional hazard model (COX) was employed to test the influence of the respective treatment on postoperative 900-day survival estimates (SEs). Several potential preoperative risk factors were used as covariates. The MR of all patients was 3.7%. Explorative analysis demonstrated that patients treated by TEAM presented with significantly more risk factors. In American Society of Anesthesiologists class IV patients, a significant difference in MR was detected (4.7% for TEAM versus 19.2% for open surgery; P P P P P Conclusions— TEAM represents a less invasive procedure for AAA therapy in patients with significant preoperative risk factors. Especially in geriatric patients with multiple morbidities, TEAM offers a method of therapy with acceptable MRs and SEs, making active treatment possible in otherwise incurable patients.

Background: Ischaemia/reperfusion (I/R) injury is characterized by the production of oxygen free radicals and the loss of high energy phosphates. α-Tocopherol (vitamin E) has been reported to play a protective role against free radical damage. Therefore, its i. v. supplementation prior to onset of ischaemia was investigated in an established I/R injury model. Methods: New Zealand white rabbits were subjected to a bilateral hind limb ischaemia/reperfusion of 2.5 h/2 h without any treatment (IR group), whereas in the VE group the vitamin E emulsion Tocovenos® was given i. v. for 10 min in a dose of 3 mg/kg bw. A SHAM group served as a control. Intramuscular phosphocreatine (PCr) and adenosine triphosphate (ATP), muscle interfibre area (MIFA), and microvessel cross-sectional area (MVCSA) were determined and electron microscopy was performed. Results: In the IR group, PCr decreased by 65 % of the initial level after 2.5 h of ischaemia and a further depletion was noticed after 2 h of reperfusion (20.9±1.1 vs 6.3±3.0 µmol/g wet wt,P

Head and neck surgeons hesitate to resect the carotid artery because of the postoperative risk of neurologic sequelae. However, there is no curative therapeutic option for head and neck neoplasms involving the carotid artery, with the exception of complete tumor removal. To evaluate the benefits and risks of carotid revascularization techniques in locally advanced head and neck tumors we performed a retrospective analysis in an institutional, tertiary care medical center. Seven patients (5 males, 2 females) with a median age of 58 years underwent en bloc removal of locally advanced head and neck tumors, including carotid resection and revascularization, in the University of Vienna General Hospital, over a 15-year period. In six patients carotid reconstruction was accomplished by bypass grafting (five autologous grafts, one synthetic graft) and in one patient angiopatchplasty was used. There were no perioperative neurologic complications or deaths. Survival was > 12 months in 5/7 patients; the other 2 patients died within 6 months due to untractable progression of cancer. We conclude that carotid revascularization techniques offer the possibility of better local control for advanced head and neck tumors without additional risks of neuromorbidity or mortality.

To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration.A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion.An average time of 52.2 months (median 46.9, IQR 0.0-92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0-17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero.Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Background. A prospective randomized multicenter trial was performed to compare knitted gelatin-coated Dacron bifurcation grafts, knitted collagen-coated Dacron grafts, and stretch polytetrafluoroethylene (PTFE) grafts. Methods. Between 1991 and 1998, 315 elective patients were randomized by age, gender, diabetes, runoff, indication (aneurysm, aortoiliac occlusive disease), and nicotine consumption at 3 centers of vascular surgery in Austria. The patients received gelatin-coated Dacron (GEL-D) grafts (n = 109), collagen-coated Dacron (COL-D) grafts (n = 100), or stretch PTFE grafts (n = 106). Results. No intraoperative deaths occurred. The 30-day mortality was 3%. No difference was found between the 3 graft materials in long-term patency. The primary 5-year patency rates were 92% for GEL-D, 89% for COL-D, and 91% for stretch PTFE (P =.6001). The secondary 5-year patency rates also differed: 97% for GEL-D, 100% for COL-D, and 97% for stretch PTFE (P =.2062). Early occlusions were observed overall in 3% and late occlusions in 5% of patients. When both Dacron grafts were compared collectively with stretch PTFE, a difference was found in infection rate: Dacron 3% (6/209) versus PTFE 0% (0/106); P

Background: Different therapies in consecutive patients (1987–1992) with chronic critical limb ischemia at a department of medical angiology, their short- and long-term outcome were investigated. Patients and methods: 190 patients (112 males, 78 females; age: 67 ± 12 years); 78 in grade II, 112 in grade III according to Rutherford’s classification. Therapeutic regimen: 1. vascular recanalisation by percutaneous transluminal angioplasty [PTA], local or systemic lysis; 2. surgical vascular reconstruction in case of impossibility or failure of catheter procedures; 3. prostanoids and/or antibiotics; 4. local wound treatment including amputations. Results: Vascular recanalisation was attempted in 156/190 (82.1%): PTA in 116/190, surgical vascular reconstruction in 50/190, local in 24/190 and systemic lysis in 8/190 patients. Prostanoids were applied in 89/190 and antibiotics in 73/190 patients. At the time of dismissal 164/190 (86.3%) patients were clinically improved; 11/190 (5.8%) unchanged, 13/190 (6.8%) had undergone major amputations and 2/190 (1.1%) had died. After 2,6 ± 2,2 years 77 of the 141 patients, who were still alive, were reexamined. Among these 77 patients 84.4% were in grade 0 or I, 15.6% in chronic critical limb ischemia. Furthermore 13.0% had been amputated since dismissal. Forty-nine of 190 (25.8%) patients had died 3,2 ± 1,9 years after dismissal from hospital. Conclusion: Catheter techniques, mostly PTA, is possible in the majority of patients with chronic critical limb ischemia. Cooperation with vascular surgeons in case of technical impossibility or failure of catheter recanalisation is mandatory. Such a regimen yields satisfactory short- and long-term results and a low rate of complications.

Purpose: To investigate the reasons for endoleaks after transluminal infrarenal abdominal aneurysm management and the potential for transluminal interventions in subsequent management. Methods: Prospective analysis of 50 consecutive patients undergoing endovascular aneurysm repair at a single institution with Stentor® and Vanguard® grafts from March 1995 to March 1997. Setting: Academic teaching hospital Results: Two procedures were converted for other reasons than leak. In the remaining 48 successful procedures endoleaks were detected in 11 (22.9%): proximal aortic leak (2.1%), distal aortic leak (8.3%), iliac leak (12.5%). Leaks were treated at the initial procedure in five patients, resulting in 87.5% excluded aneurysms. Twelve and a half per cent were discharged with a primary leak. Redo was performed on all iliac leaks within 7 weeks. All aortic leaks showed spontaneous thrombosis within 3 months, but reappeared with local aneurysm expansion. Aortic redo-procedures were performed by proximal tubular extension or converting a tube graft into a bifurcation graft. All rescue procedures were successful. Secondary leaks have been observed twice in this series, both treated by endovascular means. Conclusions: Endovascular treatment of primary and secondary endoleaks is possible, and may be a safe alternative to a difficult open procedure.

The purpose of this study was to compare median somatosensory evoked potentials (SEP) in patients undergoing carotid endarterectomy (CEA) with routine shunting and nonshunting (excluding the option of selective shunting) and to evaluate the significance of a decrease in the amplitude of the cortically generated waveforms of the SEP and/or an increase in the central conduction time (CCT) on the one hand, and that of a loss of the cortical SEP, on the other. Somatosensory evoked potentials were recorded in 32 patients before, during, and after CEA with routine shunting or nonshunting. The N13 and N20 latency, the CCT, and the N20/P25 amplitude were evaluated. In addition, a meta-analysis of 15 previous studies was performed comprising a total of 3,136 patients. The intraoperative cortical SEP showed no differences between shunted and nonshunted patients, apart from the preclamping value of the N20/P25 amplitude which was lower in the nonshunted subjects. The number of patients with decreased and/or delayed cortical SEP (findings frequently used as criterion for selective shunting) was similar in the two study groups. A loss of the cortical SEP occurred in one patient operated on without an indwelling shunt. None of these patients had a new neurologic deficit after surgery. In the meta-analysis, the positive predictive value of decreased and/or delayed cortical SEP was extremely poor, that of absent cortical SEP was poor to moderate and the prevalence of new neurologic deficits was similar in patients undergoing CEA with routine shunting-nonshunting and those with selective shunting-nonshunting. Our study suggests that decreased and/or delayed cortical SEP are unreliable predictors of the neurological outcome of CEA patients and consequently an unsuitable criterion for selective shunting. The meta-analysis confirms this finding and shows that the neurologic outcome is not improved by using an indwelling shunt selectively based on SEP monitoring.

Background Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE). Methods A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done. Results Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan–Meier estimates for long-term survival between groups were comparable ( P = .36). Conclusions Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

Intraoperative angioscopic control was performed in an early series of 27 patients undergoing peripheral vascular surgery. The majority were complex or re-do operations; reversed saphenous vein and PTFE-grafts were used as bypass material exclusively. Angioscopic findings were compared to conventional angiography with respect to the detection of technical problems leading to further surgical procedures. Angioscopy was feasable in 92.5%, it failed twice due to irrigation problems, which was before we used a dedicated angioscopy roller-pump. In 6 patients relevant findings requiring further surgical manipulations were only detected angioscopically, in 2 patients such findings were detected by angioscopy as well as by angiography. Such findings included technical problems (graft rotation [n = 1], anastomotic narrowing [n = 2]), balloon catheter injuries after thromboembolectomy (n = 2) and residual thrombi after local thrombectomy (n = 3); 5 of these patients had undergone previous vascular procedures in the same operation field. After local correction (n = 5) or placement of a new bypass (n = 3) there was no early graft failure. This early angioscopic experience confirmed previous reports that satisfactory visualization and specific recognition of angiographically unsuspected problems after peripheral reconstructions can be obtained by intraoperative angioscopic control. This was seen very distinctively in more complex and re-do operations, which we see as the cases most needing routine angioscopic control.

Between 1980 and 1990, 354 aortoiliac repair procedures were performed with polytetrafluorethylene (PTFE), which had become available in 1980. This retrospective analysis was designed to show whether anticoagulation or antiaggregant treatment had beneficial effects on patient survival and graft function. In patients with unilateral aortoiliac grafts, antithrombotic therapy with phenprocoumone or acetylsalicylic acid (ASA) improved graft function (Breslow, p=0.038; Mantel, p=0.013) and long-term survival (Breslow, p=0.013; Mantel, p = 0.009). However, the results concerning survival are devaluated, because the members of the control group were older (65.9 years vs 61.1 years, Chi square test p=0.01). In patients with PTFE bifurcation grafts, in whom risk factors and age were well balanced, survival was also significantly prolonged by postoperative drug treatment in the early years of the follow-up (Breslow, p=0.038; Mantel, p=0.298), but graft function was unaffected. These results suggest that postoperative anticoagulant therapy with ASA or phenprocoumone may be of some benefit in patients undergoing iliac PTFE grafting procedures. Based on these retrospective data, a randomized prospective trial was initiated to study the effects of different drugs suppressing coagulation, ie, anticoagulants and antiaggregants, on allogenous grafts.

Zwischen 1980 und 1990 wurden 471 Thrombendarteriektomien der A. carotis interna an 437 Patienten durchgefuhrt. Kriterien zur Indikationsstellung waren: 1. hamodynamisch relevante Karotisstenose oder embolisierende Plaques in kausaler Beziehung mit der Klinik, 2. Ausschlus von schweren Begleiterkrankungen, intrazerebralen Blutungen und frischen Apoplexien. Es wurde in Allgemeinanasthesie ohne Shuntapplikation operiert.

Occlusion of an infrainguinal saphenous vein bypass presents an unresolved problem of further treatment in patients with threatened limbs. The implantation of alloplastic grafts is an attempt to possibly avoid amputation. The authors report 56 patients who were treated by secondary alloplastic grafts after occlusion of their vein bypass. All secondary procedures were performed for limb salvage. The median time of patency of sequential combined saphenous vein plus an additional alloplastic bypass was sixteen months. Following a reocclusion of the secondary grafts, 45 % required major amputation. Nevertheless, the median period of limb salvage was fifty-four months. Therefore, secondary alloplastic grafts seem to be a reasonable procedure in the treatment of threatened limbs after occlusion of an infraginguinal saphenous vein bypass, if one takes the limited life expectancy of sixty-four months into account for these patients.

Objectives The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. Design Retrospective analysis of database. Material and Methods Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5 cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. Results Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p Conclusions Patients with small aneurysms (≤5.5 cm) have an improved long-term survival than patients with larger aneurysms.

Two treatment options are available for abdominal aortic aneurysms (AAAs): open surgical technique with graft replacement and endovascular aortic aneurysm repair (EVAR) as a minimally invasive procedure. The intention of this review is to highlight the advantages of both procedures and to demonstrate that offering both procedures is beneficial for the patient when he or she makes the important decision regarding which treatment to select. A comparative evaluation of both treatment options is offered as well as a short description of the risk of rupture and its consequences. The authors discuss the latest literature as well as their own experiences. An innovative statistical approach-the propensity score-based Cox model-is presented to evaluate the 2 treatment options. The benefits of offering both EVAR and open surgery permit optimal management of AAA for the individual patient and tailor the treatment to his or her organ dysfunctions and impaired physical status. In addition, EVAR offers a treatment option for otherwise incurable high-risk patients.

Background: Arterial intimal hyperplasia and following restenosis may be inhibited by estrogens. We investigated the effect of a synthetic steroid hormone, Tibolon: (a) on intima hyperplasia and restenosis in vivo, and (b) on production of endothelial nitric oxide synthase (eNOS), vascular endothelial growth factor (VEGF), endothelial cell proliferation and apoptosis in vitro. Methods: Influence of Tibolon treatment (0.1 mg/kg body weight, during 3 days before and 3 weeks after the operation as a drinking solution once daily) on neointimal formation (measured by morphometry) and arterial wall damage (by qualitative histology) were investigated in vivo using an animal model of balloon injury of carotid artery. In human umbilical vein endothelial cells (HUVEC) and human microvascular endothelial cells (HMEC-1), the effect of Tibolon (0.1 µg/ml) on eNOS and VEGF was assessed by ELISA. Cell proliferation was induced by VEGF165 and measured by BrdU incorporation assay, cell apoptosis was detected colorimetrically measuring DNA fragmentation. Results: Balloon injury resulted in neointima formation and prominent damage of the carotid artery wall. Treatment with Tibolon increased luminal area, decreased intimal area and intima to media ratio, and promoted better reparation of damaged vessel wall. In vitro, Tibolon treatment did not influence the expression of eNOS protein in HUVEC as well as cell proliferation rate but reduced apoptosis of endothelial cells by about 40%. Additionally, this treatment suppressed basal and IL-1β-stimulated synthesis of VEGF in HMEC-1. Conclusions: Tibolon treatment suppressed neointimal formation and promoted better reparation of damaged vessel wall in carotid artery after balloon injury. This positive effect seems to be associated with improved endothelial cell survival resulting possibly in increased NO production. It might be also related to the decrease of VEGF generation.

Background. In this prospective randomized multicenter trial, knitted gelatine-coated Dacron, knitted collagen-coated Dacron, and stretch polytetrafluoroethylene (PTFE) aortic bifurcation grafts were compared for their long-term results. Methods. Between 1991 and 1998, 149 patients undergoing elective revascularization for aortoiliac occlusive disease were prospectively randomized at 3 tertiary referral centers of vascular surgery. The patients received either gelatine-coated Dacron (GEL-D) grafts (n = 52), collagen-coated Dacron (COL-D) grafts (n = 49), or stretch PTFE grafts (n = 48). Results. No intraoperative deaths were recorded. The 30-day mortality was 4%. The mean follow-up time was 97 months. Primary patency rates were 77% for GEL-D, 78% for COL-D, and 79% for PTFE at 8 years. The differences were not different (P >.8). Secondary corrected 8-year patency rates were also not significantly different (P >.5): 91% for GEL-D, 96% for COL-Dm and 90% for PTFE. Five Dacron and 1 PTFE grafts were affected by infections. Conclusions. Bifurcation grafts for revascularization of aortoiliac occlusive disease using these 3 materials were comparable in terms of primary and secondary patency and long-term complication rates. (Surgery 2003;134:80-5.)

It is well established that high expression of the antiapoptotic Bcl-2 family proteins Bcl-2 and Bcl-xL can significantly contribute to chemoresistance in a number of human malignancies. Much less is known about the role the more recently described Bcl-2 family member Mcl-1 might play in tumor biology and resistance to chemotherapy. Using an antisense strategy, we here address this issue in melanoma, a paradigm of a treatment-resistant malignancy. After in vitro proof of principle supporting an antisense mechanism of action with specific reduction of Mcl-1 protein as a consequence of nuclear uptake of the Mcl-1 antisense oligonucleotides employed, antisense and universal control oligonucleotides were administered systemically in combination with dacarbazine in a human melanoma SCID mouse xenotransplantation model. Dacarbazine, available now for more than three decades, still remains the most active single agent for treatment of advanced melanoma. Mcl-1 antisense oligonucleotides specifically reduced target protein expression as well as the apoptotic threshold of melanoma xenotransplants. Combined Mcl-1 antisense oligonucleotide plus dacarbazine treatment resulted in enhanced tumor cell apoptosis and led to a significantly reduced mean tumor weight (mean 0.16 g, 95% confidence interval 0.08–0.26) compared to the tumor weight in universal control oligonucleotide plus dacarbazine treated animals (mean 0.35 g, 95% confidence interval 0.2–0.44) or saline plus dacarbazine treated animals (mean 0.39 g, 95% confidence interval 0.25–0.53). We thus show that Mcl-1 is an important factor contributing to the chemoresistance of human melanoma in vivo . Antisense therapy against the Mcl-1 gene product, possibly in combination with antisense strategies targeting other antiapoptotic Bcl-2 family members, appears to be a rational and promising approach to help overcome treatment resistance of malignant melanoma.

Purpose Our goal was to evaluate the value of maximum intensity projections (MIPs) rendered from spiral CT in the assessment of abdominal aortic aneurysms after stent graft implantation. Method Spiral CT of the aorta was performed in 28 patients 1 week after implantation of covered aortic stent grafts. MIPs were evaluated in a blinded fashion. Transaxial scans and intravenous angiographs were considered the reference standard. Results Stent deformity was evident on the MIPs in 5 cases and stent angulation was seen in 24 cases. The excluded aneurysmal sac was visualized in 14 (50%) cases. MIPs depicted the patent inferior mesenteric artery in 20 of 23 cases (87%). Renal artery occlusion (n = 3), leaks (n = 8), and parietal thrombi, (n = 3) were detected on the MIPs in all cases. Conclusion MIPs are a valuable tool in the assessment of aortic stent grafts.

The treatment of aortic aneurysms with endovascular stents or stent-graft prostheses is receiving increasing attention as an alternative to major abdominal surgery. To define the clinical value of this technique, we prospectively studied the use of stent-graft endoprostheses made of nitinol and covered with polyester fabric for the treatment of infrarenal abdominal aortic aneurysms.We treated a total of 154 patients at three academic hospitals. Twenty-one patients with aortic aneurysms not involving the aortic bifurcation received straight stent-grafts, and 133 patients with aortic aneurysms involving the bifurcation and the common iliac arteries received bifurcated stent-grafts. After a unilateral surgical arteriotomy, the endoprostheses were advanced through the femoral arteries and placed under fluoroscopic guidance. Computed tomography and intraarterial angiography were performed during an average follow-up of 12.5 months.The primary success rate, defined as complete exclusion of the abdominal aortic aneurysm from the circulation, was 86 percent in the group receiving straight grafts and 87 percent in the group receiving bifurcated grafts. In three patients the procedure had to be converted to an open surgical operation. Minor (n=13) or major (n=3) complications associated with the procedure (including 1 death) occurred in 10 percent of the patients. All patients had a postimplantation syndrome, with leukocytosis and elevated C-reactive protein levels.Our results suggest that endovascular treatment of infrarenal abdominal aortic aneurysms is technically feasible and can effectively exclude abdominal aortic aneurysms from the circulation. With further refinement, endoluminal repair may emerge as an interventional strategy to treat infrarenal aortic aneurysms, especially in patients at high surgical risk.

Carotid endarterectomy (TEA) has proven to be beneficial for symptomatic patients. Anticoagulation (AC) and antiplatelet therapy (ASA) have been shown to prolong life following vascular surgery in patients with occlusive arterial disease (PAOD). To determine whether ASA or AC prolong life after TEA, retrospective analysis was undertaken, since cerebral haemorrhage is associated with the use of both drugs, especially AC. Between 1979-1986, 328 patients with stenotic lesions of the carotid bifurcation were operated upon electively. Patient survival and causes of death were the primary end points of the analysis. Recent data were obtained from the Austrian Central Bureau of Statistics. Cumulative survival rates were calculated by Kaplan-Meier estimation and differences determined by Breslow and Mantel tests. 36 patients were on AC, 157 on ASA and 135 remained without medication (0-group). Since the common risk factors in PAOD were unevenly distributed between groups, a stepwise Cox regression model was applied which revealed age (p0.01), cardiac pathology (p0.01) and diabetes (p0.05) as relevant for survival. Therefore, ASA patients and 0-group patients were selected and matched, employing the aforementioned prognostic criteria, and compared to the patients on long-term AC for various indications (vein bypass surgery, myocardial infarction, pulmonary embolism; i.e. data-matching). The median postoperative survival was 7.72 years for ASA and 8.48 years for AC, compared to 6.07 years for the 0-group (p = 0.0095 Breslow, p = 0.477 Mantel). There was no significant difference between AC and ASA treated patients. Irrespective of medication, the causes of death were well balanced, and no higher incidence of intracerebral haemorrhage was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine whether antiplatelet therapy following carotid bifurcation endarterectomy influences postoperative survival and whether signs of progression in the plaques harvested at the time of surgery might be a prognostic indicator, a controlled clinical trial was undertaken. During 1982 to 1985, 66 patients were recruited, operated on (carotid endarterectomy) and assigned, using the method of adaptive randomisation to the therapy group (n = 32) receiving 1.0 g acetylsalicylic acid (ASA) per day, starting day two prior to surgery, or to the control group (n = 34), which remained without antiplatelet medication. The plaques harvested at the time of surgery were processed using standard histopathological methods and examined "blindly" by light microscopy for signs of arterio-sclerotic progression. The final endpoint was patient survival. The last assessment of the participants survival status was done by June 1989. During follow-up, 20 patients died, six in the treatment group and 14 in the untreated group, the difference being statistically significant (P less than 0.013 Breslow, P less than 0.029 Mantel). In 27 instances the histo-pathological examination showed signs of progression. In this subgroup ASA yielded a significant prolongation of patient survival (P less than 0.017 Breslow, P less than 0.048 Mantel). In the remaining patients no signs of cellular infiltration were evident and no influence of ASA on patient survival was demonstrable (P less than 0.503 Breslow, P less than 0.390 Mantel).

To examine the role of antiplatelet drugs in the secondary prevention of arteriosclerotic arterial disease following carotid endarterectomy, a clinical series (n = 252) was analyzed. Based on these results a prospective randomized trial was initiated, comparing the effect of antiplatelet drugs (acetyl-salicylic acid [ASA] 1000 mg/day) versus untreated controls. In both investigations patient survival was the primary end point. A cardiac risk (n = 91) implied a significant reduction in patient survival (p less than 0.019 Breslow, p less than 0.052 Mantel). Antiaggregating drugs prolonged survival in the collective series (p less than 0.0001 Breslow, p less than 0.0002 Mantel) and in the subgroup of patients with cardiac risk (p less than 0.014 Breslow, p less than 0.020 Mantel) as well. In the prospective trial 66 patients were recruited, receiving ASA (n = 32) versus no therapy (n = 34). During follow-up 15 patients died, 4 in the treatment, and 11 in the control group. Between both groups there was a significant difference in the probability of survival (p less than 0.021 Breslow, p less than 0.048 Mantel).

Hypothesis To investigate whether staged or synchronous treatment of infrarenal abdominal aortic aneurysms (AAAs) and concomitant diseases (CDs) requiring surgical repair plays a clinical role. We considered endovascular aneurysm repair (EVAR) in particular. Design Review of a prospectively gathered database. Setting Tertiary care university teaching hospital. Patients We reviewed a total of 946 patients receiving elective AAA exclusion from 1980 through 2002. We divided the period into 2 observation intervals: 1980-1994, when only open graft replacement was available (n = 331), and 1995-2002, with 615 patients (326 who had open graft replacement and 289 who had EVAR). With regard to the physical status, expressed by the score from the American Society of Anesthesiologists (Park Ridge, Ill), we recorded in-hospital mortality rates and checked possible differences. Main Outcome Measures Indications for therapy and mortality rates before and after the availability of EVAR. Results During the first interval, 14 simultaneous operations were carried out. During the second period, 19 patients received simultaneous operations while 49 underwent staged treatment using EVAR. The overall mortality rate was 3.7%. Irrespective of the American Society of Anesthesiologists classification, the mortality rate for patients who had EVAR was 0% in comparison with 13.6% for patients in American Society of Anesthesiologists class 3 or 4 after open graft replacement ( P Conclusions The coincidence of a patient having both an AAA and a CD is rare but should not be neglected. Staged treatment of AAAs using EVAR followed by surgical therapy for CDs can be an effective causal therapy with an acceptable mortality rate provided that suitable aneurysm anatomy exists.

Objective: To determine the clinical characteristics of carotid body tumors to define better a standardized proceeding in the management of carotid body tumors. Design: Retrospective survey. Duration of postoperative follow-up was 4 months to 16 years (median, 57 months). Setting: Institutional, tertiary care medical center. Patients: Consecutive sample of 24 patients (10 men and 14 women) with 28 carotid body tumors treated in the University of Vienna (Austria) General Hospital in 35 years. Interventions: Surgical resection, preoperative embolization. Main Outcome Measures: Initial signs, duration of symptoms, extension of the tumors, methods of investigations, and treatment modality, with special respect to the operative technique. Results: Doppler color flow imaging and angiography provided essential mainstays for definite diagnosis. Computed tomography and magnetic resonance imaging contributed additional information about tumor extension. Nineteen patients (79%) underwent surgical resection of 22 tumors, 8 (42%) after preoperative embolization. There were no perioperative deaths. Hemiplegia occurred in 1 patient, and cranial nerve palsy occurred in 5 patients. Tumor recurrence was observed in 3 patients. Five patients refused surgery or tumors were unresectable. Conclusions: Our standard diagnostic procedure consists of establishing diagnosis by Doppler color flow sonography, angiography for detailing the vascularization of the tumor, and selective embolization to enable safer surgery with less bleeding. Early surgery is recommended to minimize major risks. Arch Surg. 1997;132:279-284

21 patients had aortoiliac reconstructions for aortic aneurysms or occlusive disease with the new PTFE Y-graft during the past 12 months. 2 patients in the aneurysm group with additional renal artery reconstruction suffered postoperative myocardial infarction and subsequently died. 2 patients older than 80 years died after aneurysm repair in cause of graft infection, respectively respiratory insufficiency. All grafts (n = 17) are functioning well or did so until death of the patient (n=4). The obvious advantage of the PTFE Y-graft is the fact, that there is no need of preclotting. Suture line — even using 4-0 material at the proximal anastomosis — and graft body is absolutely tight and no blood loss has to be expected from this site. However positioning of the left limb of the y-graft can be difficult in patients with right sided extraperitoneal approach and proximal side end anastomosis. Performing an end-end anastomosis can overcome this problem. For occlusion of the prosthesis limbs two vascular clamps on each side are needed to control blood flow within the rather stiff graft. Immediate and short term function is excellent. There was no material specific complication noted until now. Further longterm experience is necessary to evaluate the definitive quality of this new prosthetic material after some years.

For patients with advanced malignant melanoma, the 5 y survival rate with current treatment modalities is low. There is an urgent need for more effective therapeutic concepts. One approach with great potential is to stimulate the body's own immune defense to reject cancer cells using CpG oligonucleotides. Distinct oligonucleotides containing nonmethylated cytidine residues in cytidine-guanosine dinucleotides with particular flanking bases (CpG motifs) are capable of eliciting powerful immune stimulation by mimicking infectious disease. We evaluated the in vivo antitumoral effects of CpG oligonucleotides against human malignant melanoma xenografts in NOD/SCID mice. CpG oligonucleotides administered in single peritumoral subcutaneous injections three times per week resulted in elevated plasma levels of interleukin-12 and significant inhibition of the growth of established tumor xenografts by 60% (p

To examine whether anticoagulants given after autologous saphenous bypass surgery influenced patient survival 119 patients who received such a graft for obliterative arterial disease were recruited for a controlled clinical trial. Patients were randomly assigned to start, in the second postoperative week, phenprocoumon (60 patients) or no treatment (59 patients). The median duration of survival for all patients was greater than 60 months, and the 75%-quartile was 39.0 (SE of the median 3.9) months. 10 patients died in the treated group and 20 in the control group. The treated group had a greater probability of survival (p less than 0.023, Breslow; p less than 0.043, Mantel). Graft occlusions occurred in 11 patients in the treatment group and in 17 controls. When these patients were excluded from the analysis, the difference in probability of survival between the two groups remained significant (p less than 0.009, Breslow; p less than 0.013, Mantel).

One-hundred and sixty-three patients in whom an isolated profundaplasty was performed as treatment for superficial femoral artery occlusion were evaluated for postoperative improvement, taking into consideration the degree of stenosis of the profunda origin and the patency of peripheral vessels. One-hundred and eleven (68.1%) patients achieved clinical improvement. Fifty-two patients had to undergo amputation (27 below the knee and 19 above the knee) or distal reconstruction (6 patients) because of unrelieved ischaemia. In patients with Fontaine stage II and III disease (89% and 70% respectively) improvement was observed more often than in those with stage IV disease (53%). Half of the patients had an increase of the resting systolic ankle-brachial arterial pressure index, but the rise was only slight (0.12 ± 0.1). While radiological information of the presence and degree of a stenosis had little influence on the operative outcome, stenosis at the origin of the profunda, when seen and described at operation, resulted in a more frequent improvement in the clinical state and systolic ankle-brachial arterial pressure index. A patent popliteal artery was not necessary for a favourable outcome but the number of patent tibial arteries was important. Whenever two tibial vessels were patent, relief was achieved in 75% of the cases; the existence of one patent tibial artery produced improvement in 64% but if all were occluded only 31% showed improvement. In cases of severe ischaemia, success following profundaplasty is limited and the results are often inadequate. If at least one tibial artery is patent, the alternative is a femoro-crural reconstruction. In stage II with two patent tibial vessels, adequate results may be expected.

Twenty-two years after an obvious radical mastectomy with axillary lymph node dissection and postoperative conventional radiotherapy for carcinoma of the right breast, an 80-year-old lady was admitted because of the third bleeding episode within one year originating from the axilla. An aneurysm from the axillary artery was identified as the source of hemorrhage. Since the sites of irradiation had to be avoided, an extra-anatomic reversed saphenous vein graft was run from the right common carotid to the brachial artery. In the same session the bleeding was finally controlled by therapeutic embolization of the aneurysm using Gianturco-Anderson-Wallace coils. The postoperative angiogram showed the patent graft. Bleeding did not reoccur during the follow-up period of 17 months.