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A 52-year-old man, without a medical history, presented with an incidentally detected large, intrathoracic aneurysm of the right subclavian artery. The aneurysm was characterized by the absence of a proximal neck and extended distally close to the origin of the right vertebral artery. We successfully excluded this aneurysm with a combined endovascular and minimally invasive open repair, thereby avoiding a sternotomy or lateral thoracotomy: a stent-graft was placed from the proximal brachiocephalic trunk to the common carotid artery, completely covering the origin of the right subclavian artery. The right subclavian artery was oversewn just distally to the aneurysm and revascularization of the right arm was assured by a carotido-subclavian bypass. Clinical follow-up was uneventful and radiological follow-up by CT-scan showed discrete, but progressive shrinkage of the completely excluded aneurysm.

A 75-year-old woman with a history of coronary artery bypass surgery complicated by mediastinitis presented with hemoptysis and fever. An enlarging pseudoaneurysm of the ascending aorta was found on computed tomography (CT) and magnetic resonance imaging. After a bypass graft procedure for cerebral and cardiac protection, two endoprosthetic cuffs, which are normally used for proximal abdominal aortic stent-graft extension, were positioned over the pseudoaneurysm neck via right carotid artery access. Blood cultures revealed methicillin-sensitive Staphylococcus aureus, and antibiotic therapy was continued for 6 weeks. Follow-up CT images demonstrated exclusion of the pseudoaneurysm with decrease in size over time. Endovascular stent-graft placement combined with antibiotic therapy may offer an alternative to surgery for the management of mycotic ascending aortic pseudoaneurysm.

Current treatment of acute infrainguinal bypass occlusion consists of either surgical revascularization or catheter-guided intra-arterial thrombolysis with adjunctive correction of the underlying flow-limiting lesion. In maintaining long-term patency, improving the number of outflow vessels could be of utmost importance. To compare the efficiency of both thrombolysis and primary surgical revascularization and to study the effect of thrombolysis on the number of patent outflow vessels, a prospective nonrandomized study was performed. Between February 2002 and August 2003, 54 patients with 56 occluded bypasses were included. Thirty bypasses were treated with thrombolysis, 26 primarily with surgery. Thrombolysis was successful in 80% of cases, with restoration of patency of the bypass but also with doubling of the amount of patent outflow vessels; surgery was successful in 85.71% of cases. However, in only 60% of the successfully lysed bypasses no adjunctive major surgery was needed. Amputation-free survival was 87.5% 1 year after surgery and 82.6% 1 year after thrombolysis. One year after thrombolysis without adjunctive major surgery, the amputation-free survival was only 39.7%. Therefore, a strategy could be to start with thrombolysis to improve outflow followed by a new bypass, whatever the underlying causative lesions are.

Objectives To demonstrate that hand-assisted laparoscopy for aortofemoral bypass for severe aorto-iliac occlusive disease reduces morbidity with earlier recovery of bowel function and shorter in-hospital stay. Design Randomised controlled trial. Materials and methods Thirty-six consecutive patients with severe aorto-iliac occlusive disease (TASK C/D) without history of major abdominal surgery necessitating an aortobifemoral bypass were randomised between a hand-assisted laparoscopic (HALS) approach and a conventional medial laparotomy. Operative data, early recovery data, quality of life and vascular outcome were analysed. Results No significant differences in operative data were found. Fluid and solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p = 0.016) (45.6 hrs vs. 105.6 hrs; p = 0.02) and in-hospital stay was shorter (7.5 vs. 8.9 days; p = 0.005) in the HALS group. Six weeks post-operatively social functioning measured by the SF-36survey score was better in patients randomised to HALS ( p = 0.023). Conclusions HALS is a less invasive approach for aortofemoral bypass.

PURPOSE To evaluate whether the presence of type 2 endoleak after internal iliac artery (IIA) coil embolization in patients with residual antegrade flow through the coils is more frequent than in patients who presented with total occlusion of the IIA after embolization. MATERIALS AND METHODS Records were reviewed of 45 patients who underwent unilateral ( n = 37) or bilateral ( n = 8) IIA coil embolization between 1998 and 2004 for endovascular repair of aortoiliac aneurysms ( n = 32), iliac artery aneurysms ( n = 12), pseudoaneurysm ( n = 1), or distal type 1 endoleak after placement of an aortoiliac stent-graft ( n = 8). A total of 53 IIAs were embolized by means of coils and/or microcoils. Computed tomography (CT) was used for follow-up in 40 patients, angiography was used in three, and color Doppler ultrasonography was used in three. RESULTS At the end of the embolization procedure, 23 IIAs were occluded and 30 IIAs demonstrated residual antegrade flow through the coils. Control CT demonstrated two type 2 endoleaks after endovascular stent-graft placement resulting from retrograde blood flow into the left IIA main branch via a patent iliolumbar artery. One of these two patients showed residual antegrade flow through the coils at the end of the IIA embolization procedure, and the other patient underwent complete coil embolization of the ostia of the anterior and posterior division but not of the main trunk of an aneurysmal IIA. CONCLUSION IIA coil embolization with residual antegrade flow through the coils causes no greater incidence of type 2 endoleak after aortoiliac or iliac stent-graft placement. However, care must be taken in case of a proximal postostial origin of the iliolumbar artery on the IIA, which may cause type 2 endoleak if not embolized.

Objectives To evaluate the early and mid-term results of hand-assisted laparoscopic surgery (HALS) for aorto-iliac reconstruction. Design Prospective survey. Materials and methods Between February 2002 and January 2004, 46 patients received an aortobifemoral bypass for advanced occlusive disease by HALS. Result There was one conversion to open surgery. Mortality was 4.5%. The median return to solid oral diet took 36 h (24–182), the median hospital stay was 5 days (3–26). Primary patency rate at 1 year was 97.5%. The incidence of incisional hernia was 19.5%. Conclusions HALS aorto-iliac reconstruction should be considered as a minimal invasive technique with good early and mid-term results.

We report on a patient who presented with perforation of the left main renal artery as a complication of a percutaneous retroperitoneal drainage procedure. Only a small number of cases of iatrogenic main renal artery perforations have been reported, none of them due to a percutaneous drainage attempt. Endovascular treatment by means of a coronary stent-graft was successful.

Objective: to study the short and long term effectiveness of in situ replacement of infected aortic grafts with the lower extremity deep veins. Methods: forty-nine patients operated on for infrarenal aortic graft infection since 1990 were studied. Diagnosis of infection was based on clinical signs, bacteriological tests and typical findings on CT scan and leukocyte scan. The surgical treatment consisted in harvesting the femoral vein, total graft excision, thorough debridement and in situ reconstruction with the femoral veins. After discharge, the patients were followed at 6 monthly intervals with clinical examination, duplex and/or CT scan. Results: there were four in-hospital deaths (8%). One patient required above-knee amputation (2%) and there were two graft limb occlusions (4%). With a mean follow-up 41 months, another 13 patients died, unrelated to the operation (29%). There were no late amputations and only two late graft limb stenoses (4%). We have a 5 year survival rate of 60%, a 5 year limb salvage rate of 98%, and a 5 year primary patency rate of 91%. There were no cases of aneurysmal dilatation of vein grafts and no incidence of reinfection. Conclusion: in situ reconstruction with the lower extremity deep veins is in the long term a safe and attractive alternative in the treatment of infrarenal aortic graft infection. Eur J Vasc Endovasc Surg 25, 240–245 (2003)

From December 1998 through May 2001, seven patients with thoracic aortic isthmus rupture underwent endovascular stent graft repair. Diagnosis was made by chest X-ray, transesophageal echography, CT scan, and aortography. The endoprosthesis was ordered and/or custom made on an urgent basis. During the delay period blood pressure was kept low and the tear closely monitored by means of transesophageal echography and CT scan. The mean delay period was 94 days: three patients were treated within 24 hr, two patients had their treatment postponed because of multiple organ failure, and two patients were diagnosed late. Complete exclusion of the pseudoaneurysmal sac was succesfull in all patients. One patient underwent a preliminary carotidosubclavian bypass because of a short proximal neck, one subclavian artery was unintentionally partially covered, and a second one was deliberately overstented. None of these patients developed arm ischemia or claudication. One patient died 3 weeks after the procedure because of the severity of associated lesions and comorbidity. Our preliminary results prove that endografting for aortic isthmic rupture is technically feasible and that it represents a safe and potentially valuable alternative to the mortality and morbidity of open surgery. Further evaluation is needed to assess the full therapeutic potential and determine the mid and long-term follow-up.

In recent years laparoscopic techniques have been adapted for application in vascular surgery. Since 1993 several authors have published preliminary results of complete or videoscopic-assisted reconstructions of the abdominal aorta. The aim of this retrospective study was to report our initial results with the retroperitoneal videoscopic-assisted technique of aorto-bifemoral grafting (AFG) in ten patients (age 45-71). In one case, conversion into classic reconstruction was necessary because the aorta was to heavily calcified. The duration of the procedures varied between 230 and 390 minutes. The length of the incision ranged between 6 and 9 cm. The hospital stay varied between 5 and 13 days. One patient developed gout, and a left sided, temporary ureteral stent was necessary in another because of hydronephrosis. It is confirmed that video-assisted AFG is feasible. However, whether this technique is truely less invasive, will have to be demonstrated by randomized, prospective studies, once the equipment and instruments have sufficiently been developed and a technique of choice finalized.

Purpose To document a preliminary study to assess the deployment and outcomes of endoluminal stent grafting in the superficial femoral artery (SFA) with use of a prototype device. Materials and Methods Twenty patients with lifestyle-limiting intermittent claudication were selected for treatment with a balloon-mounted expansive polytetrafluoroethylene graft. All patients had angiographically proven SFA disease (median length, 17 cm) with normal arterial inflow and at least two calf vessels patent to the ankle. Follow-up was by means of ankle brachial pressure index (ABPI), duplex ultrasound, and angiography. Results Fourteen patients were successfully treated. Six patients were excluded: five by the study protocol and one because the procedure was a technical failure. ABPI rose from 0.6 before treatment to 1.0. The treated limbs became asymptomatic. Twelvemonth primary, primary assisted, and secondary patency rates of treated patients were 29%, 50%, and 64%. Conclusion Endovascular stent grafting of SFA lesions is technically feasible, but the patency rates obtained with this design are inferior to those obtained with conventional surgical bypass.

This report describes the surgical management of three patients with an extended ilio-femoral deep venous thrombosis. In the first patient a residual occlusion of the common iliac vein was treated conservatively and this patient developed severe chronic venous insufficiency. In the second patient a residual (sub)occlusion of the common iliac vein was treated with a stent and this patient remained asymptomatic with two years follow-up. In the third patient no residual or underlying anatomical abnormality was found with a good result at one year. Venous thrombectomy still has a place in the treatment of deep venous thrombosis and the long term results may be improved by application of endovascular techniques.

This editorial refers to ‘Endovascular stent–graft placement in aortic dissection: a meta-analysis’† by H. Eggebrecht et al ., on page 489 The article of Eggebrecht et al .,1 might provide an important insight into the actual discussion on the preferred treatment for descending thoracic aortic dissection (Stanford type B). Indeed, treatment of descending aortic dissection continues indeed to be a challenge. What we do know for sure is that open surgery, particularly when performed under emergency conditions,2 remains associated with considerable mortality and morbidity rates. On the other hand, the ‘optimal’ medical treatment—the treatment of choice in the overwhelming majority of patients—has also been recognized to result in a far from attractive long-term prognosis.3 Eggebrecht et al . present a meta-analysis on endovascular prosthetic treatment of Stanford type B dissection for the period 1999–2004. Based on 39 studies, including 609 patients, they demonstrate that the technical success of endovascular treatment is over 95% with a 30-day mortality rate of 5.3%. Major complications might be seen in one out of ten patients, but the incidence of neurological complications is quite low: peri-operative stroke occurs is less than 3% of the cases and the incidence of paraplegia is less than 1%. The mean follow-up period was 19.5 months and the authors report a 2-year survival rate of 89%. Apart from this, the authors suggest (1) that the results have improved over the years, (2) … *Corresponding author. Tel: +32 16 344 339; fax: +32 16 344 616. E-mail address : andre.nevelsteen{at}eurheartj.org

Deep infection remains the most problematic complication following prosthetic aortoiliofemoral reconstruction. Prosthetic excision and extra-anatomic revascularization is associated with significant morbidity and mortality. The possibilities of autogenous reconstruction are frequently limited. The authors present a patient with recurrent aortic infection who was successfully treated by prosthetic excision and revascularization in situ with a cryopreserved arterial homograft.

Purpose: This report evaluates the efficiency of use of the lower extremity deep veins as arterial conduits in the autogenous repair of prosthetic infection after reconstructive aortoiliac surgery. Methods: We reviewed our records for the period 1990 to 1994 of all patients with prosthetic infection after reconstruction for aortoiliac disease, and we selected for this study all those patients who underwent autograft repair with the lower extremity deep veins. Results: Included were 15 patients: 12 had previously undergone direct aorto(ilio)femoral reconstruction, and three had an extraanatomic prosthetic graft. Thirteen patients were admitted with primary graft infection, and two were admitted with secondary graft-enteric erosion. Treatment consisted of prosthetic excision and aorto(ilio)femoral reconstruction with the superficial femoral vein. In situ reconstruction was performed in 12 cases. The operative mortality rate was 7%. There were no early graft occlusions. One patient underwent an above-knee amputation because of concomitant femoropopliteal occlusion in the presence of a patent deep venous aortofemoral graft. Early postoperative limb swelling was common and was controlled with bed rest, elastic stockings, or intermittent pneumatic compression. The mean follow-up of this series was 17 months (range 4 to 33 months). Two patients died of unrelated causes. One graft occluded after 16 months. There were no reinfections, and all but one patient resumed normal daily activities. Disability from removal of the deep veins was minimal: only one patient continues to wear elastic stockings for limb swelling and shows signs of venous hypertension more than 2 years after surgery. Conclusion: Harvesting of the lower extremity deep veins is well tolerated. Autogenous reconstruction with these veins provides good potential for salvage of life and limbs in case of prosthetic infection. A longer period of follow-up is required to study the long-term behavior of these grafts and to allow definite comparison with more conventional approaches. (J VASC SURG 1995;22:129-34.)

The immediate inflammatory response following aortic reconstruction with two types of sealed Dacron grafts was studied in a prospective, randomized manner. C-reactive protein (CRP) levels were measured before surgery and on days 2 and 8 postoperatively. In the collagen-sealed group (n = 10) CRP levels were 10 +/- 9.6, 180.2 +/- 48.3, and 54.3 +/- 34.3 mg/L, respectively. In the gelatin-impregnated group (n = 10) the values were 10.5 +/- 8.7, 200.7 +/- 27.3, and 80.3 +/- 30.2 mg/L, respectively. The slight differences were not significant according to the analysis of variance test for repeated measurements. These findings suggest that implantation of a knitted Dacron graft sealed with collagen does not lead to a higher inflammatory reaction compared with a gelatin-sealed graft.

Although catheter-directed thrombolysis is frequently used in obstructed arteries, experience with this kind of treatment for occluded arterial grafts is limited. Our experience with thrombolysis of 50 recently occluded grafts is reported.

Objective This study assessed the long-term outcome of patients with abdominal aortic and aortoiliac aneurysms treated with the Cook Zenith endovascular graft (Cook Inc, Bloomington, Ind). Methods Between September 1998 and October 2003, 143 patients underwent elective endovascular aneurysm repair (EVAR) using the Cook Zenith endograft. Data from these patients were reviewed from a prospective database in October 2008. Primary outcome measures were overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary outcome measures were early and late postoperative complications, including endoleaks. Results Mean follow-up was 66.4 months (range, 1.9-121.0 months). Overall survival was 72.1% at the 5-year follow-up and 50.9% at the 8-year follow-up. Intervention-free survival was 77.1% at 5 years and 63.8% at 8 years. There were no reintervention-related deaths. Six patients had a late aneurysm rupture, which was fatal in three. Freedom from aneurysm rupture was 98.1% at 5 years and 91.0% at 8 years. Late complications occurred throughout the follow-up period, with a tendency for aneurysm rupture and surgical conversion to occur at a later stage in the follow-up period. Aneurysm sac enlargement during follow-up was associated with late aneurysm rupture and with the need for reintervention. Conclusion Elective EVAR using the Cook Zenith endograft provides excellent results through a mean follow-up of >5 years. There is a low aneurysm-related mortality and an acceptable rate of postoperative complications and reinterventions. The occurrence of late complications throughout the follow-up period stresses the need for continued postoperative surveillance in EVAR patients.

The efficacy and hemodynamic effects of urapidil, an arteriolar vasodilator, and isosorbide dinitrate, a venodilator, were compared, when used for blood pressure control during abdominal aortic surgery. Urapidil is an α-adrenergic receptor antagonist with serotonin-1A receptor-agonist activity in the central nervous system. Hemodynamic profiles were recorded before and after the administration of the study drug (±10 minutes before aortic clamping), 3 and 10 minutes following aortic clamping, and before and 3 and 10 minutes following the removal of the aortic clamp. Arterial and mixed venous oxygen contents were compared. Both groups of 18 patients were similar with respect to demographic profiles, anesthetic technique, and perioperative fluid therapy. Identical heart rate and blood pressure profiles were obtained. In contrast to isosorbide dinitrate, urapidil produced a 17% (P < 0.05) increase in cardiac index as a result of a 30% (P < 0.001) decrease in systemic vascular resistance before placement of the aortic clamp. In patients treated with urapidil, cardiac index was higher (P < 0.05) 10 minutes after aortic clamping, before removal of the clamp, and 10 minutes later. The arterio-venous oxygen content difference decreased from 3.2 ± 0.8 mL O2/dL to 2.4 ± 1.0 mL O2/dL (P < 0.01) following urapidil, but did not change during the administration of isosorbide dinitrate. It is concluded that urapidil is an effective and safe drug for the prevention of the hemodynamic consequences of aortic clamping. Compared to a venodilator (isosorbide dinitrate), urapidil offers the advantage of improving cardiac output and oxygen delivery.

Objectif Etudier la physiopathologie de la necrose œsophagienne apres endoprothese pour anevrysme rompu et definir des mesures preventives et des options possibles de traitement. Methode Un homme de 72 ans avec un anevrysme thoracoabdominal de type I et une dysphagie a eu un pontage carotido-carotidien en urgence associe a la reparation endovasculaire thoracique d’un anevrysme de l’aorte commencant en aval du tronc brachiocephalique et se terminant en amont de l’artere mesenterique superieure. A J12, une decortication etait faite pour traiter une infection dans l’hematome residuel. Cependant, une deterioration s’est produite en raison d’une mediastinite secondaire a la necrose transmurale du tiers moyen de l’œsophage associee a la mediastinite. La famille du patient a refuse de donner un consentement pour un traitement par œsophagectomie. Il est mort pendant 24 jours apres la premiere intervention. Conclusion Une dysphagie aortique, des anomalies muqueuses a l’œsophago-gastroscopie et une compression mediastinale par l’hematome au moment de la rupture attire l’attention vers une ischemie de l’œsophage apres reparation endovasculaire d’anevrysme de l’aorte thoracique. L’œsophagoscopie repetee peut nous fournir l’occasion d’agir avant qu’une necrose transmurale avec mediastinite ne se produise.

Objectifs Nous avons examine les raisons pour ne pas avoir retrouve une endofuite de type III sur l’imagerie conventionnelle et la pathophysiologie d’une paraparesie apres le realignement d’une endoprothese. Methodes et resultats Un homme de 46 ans a ete traite par une endoprothese thoracique pour la rupture thoracique d’une dissection chronique thoraco-abdominale de type B avec degenerescence anevrysmale. Au cours d’une deuxieme intervention, la revascularisation retrograde des arteres viscerales et renales a ete realisee en association avec l’insertion d’une endoprothese abdominale. Apres un retrecissement initial du sac anevrismal, le diametre de l’aorte thoracique a commence a croitre de nouveau. Les angioscanners consecutifs ne montraient aucune endofuite. En raison d’une douleur dorsale insupportable, une exploration chirurgicale ouverte a ete effectuee. Celle-ci montrait une endofuite de type III. Le realignement de l’endoprothese thoracique a ete fait, mais une paraparesie s’est developpee. Conclusion Chez les patients presentant une augmentation non expliquee du sac anevrysmal, l’angio-IRM avec injection de produit de contraste paut permettre de documenter une endofuite. Le concept de reseau de collaterales peut expliquer les lesions de la moelle epiniere par des modifications hemodynamiques meme mineures.

The authors present a consecutive series of 869 patients, who received an aorto(bi)femoral Dacron graft for occlusive disease between 1963 and 1988. The operative indications were grade 1 disease ( n = 371), grade 2 disease ( n = 408) or grade 3 disease ( n = 90). The operative mortality was 4.5% and remained stable over the years of the study. The median survival was 8.2 years and 25% of the patients survived for more than 15 years. Late patency decreased to 74% and 70% after 10 and 15 years, respectively. Fifty-six patients underwent a major amputation in the long run. The amputation rate increased to 3, 8.6 and 12.1%, respectively for grade 1, grade 2 and grade 3 disease. Satisfactory functional results were obtained by 51% and 40% of the patients after 10 and 15 years, respectively. By means of secondary and tertiary operations this increased to 70% and 61%. Long term functional results were primarily dependent on smoking habits postoperatively, the date of operation and the presence of concomitant femoropopliteal occlusive disease.

Laser-assisted balloon angioplasty is expected to meet the well-documented shortcomings of conventional angioplasty. By vaporizing rather than redistributing the atheromatous plaque, reduction of the recurrence rate and of the risk of peripheral embolization is expected (Isner and Clarke 1986; Grundfest et al. 1985; Ginsburg et al. 1985; Geschwind et al. 1984).

(2003). In Memoriam Professor Dr. Hendrik Lacroix. Acta Chirurgica Belgica: Vol. 103, No. 5, pp. 433-433.

Seventy-nine intra-operative balloon angioplasties were performed in 72 patients undergoing a vascular reconstructive procedure over a 7-year-period (1981 through December 1987). The primary purpose of balloon angioplasty was either to increase inflow (26 procedures) or outflow (53 procedures) in association with a planned vascular operation and to avoid more extensive operative procedures in high risk patients. Peroperative balloon angioplasty involved atherosclerotic stenotic lesions in 26 iliac, 37 femoro-popliteal and 10 crural arteries. In 6 cases distal graft anastomotic stenoses were dilated. Follow-up ranged from 2 to 78 months (mean 32.4 months). The overall initial success rate was 84.8% and five procedure related complications were seen. One iliac restenosis with distal thrombosis, two superficial femoral artery dissections, one tibial artery thrombosis necessitating below knee amputation and one distal popliteal embolus after superficial femoral artery dilatation. There were no postoperative deaths. Fifty-one patients remained asymptomatic during follow-up. One iliac, eight femoro-popliteal and two tibial arteries restenosed with or without occlusion and thrombosis. The 3-year cumulative patency rate for the iliac and femoro-popliteal angioplasties is 80.2%. Intra-operative balloon angioplasty broadens the surgical therapeutic armamentarium available to correct multiple symptomatic arterial lesions. In addition this technique offers several advantages over a two stage procedure.

Platelets, activated to release vasoactive mediators on a stasis thrombus in the inferior aorta of the cat proximally from a mechanical ligation, induced a loss of collateral tissue perfusion in the hindlegs. Blood platelet number, platelet-bound 5-hydroxytryptamine, and plasma levels of 5-hydroxy-indoles, thromboxane B2 and 6K-PGF1α did not differ significantly when measured in systemic arterial blood and in venous blood sampled distally from the stasis thrombus. The platelet-mediated defect in the function of the collateral circulation in the periphery was corrected by ketanserin. This correction was evidenced by objective parameters such as blood pressure ratios and blood flow rates determined both by plethysmography and by radioactive microsphere measurements of regional tissue perfusion of skeletal muscles. This study demonstrated a predominant role for 5-hydroxytrytamine in the platelet-mediated inhibition of peripheral collateral circulation.

The authors present a series of 175 femoropopliteal (below-knee) and 65 femorotibial reconstructions with the human umbilical vein (HUV) graft performed over an eight year period. With a mean follow-up of 36.7 months (range one month to 84 months) the early patency rate of 89% decreased to 54% after five years. Long-term patency was found to be primarily related to the location of the distal anastomosis and the quality of the outflow, showing a statistically significant decrease after repeat revascularization. Early thrombosis, even in the absence of a technical failure and late aneurysmal degeneration remain the major problems associated with the use of the HUV graft. It is therefore recommended that these reconstructions be preserved for patients with advanced ischemia or a limited life-expectancy.

Between November, 1970, and December, 1977, 932 consecutive patients received the standard Björk-Shiley prosthesis. Operative mortality was 4.6% for aortic valve replacement (AVR; N = 364), 5.1% for mitral valve replacement (MVR; N = 313); 11.3% for multiple valve replacement (N = 194), and 13.7% for valve replacement combined with coronary artery bypass grafting (CABG; N = 51). Factors influencing hospital mortality included type of valve replacement, age at operation, whether the valve replacement was done as an emergency, and year of implantation. Complete follow-up (mean, 3.7 years) was achieved in 95% of the survivors. Actuarial survival was 82% for AVR patients at 8 years, 83% for MVR patients at 7 years, 72% for multiple valve replacement patients at 7 years, and 76% for those who had valve replacement with CABG at 3 years. No significant difference in late survival was found between patients with mitral insufficiency alone (p greater than 0.2) or aortic insufficiency alone (p greater than 0.9) and those with stenotic lesions only. Thromboembolic complications occurred at an incidence of 1.17% per patient-year, and Dicumarol-induced hemorrhages occurred at an incidence of 2.11% per patient-year. Twelve out of 13 patients survived operation for prosthetic valve thrombosis, indicating that this complication is not as catastrophic as many believe. The incidence of reoperation in anticoagulated patients was 0.63% per patient-year. All of these results are compared with data from the recent literature.

Percutaneous transluminal angioplasty of 23 subclavian arteries was attempted in 22 patients. Dilatation was successful in 3 of 4 right subclavian artery stenoses and 18 of 19 left subclavian artery stenoses. The primary clinical indication was posterior fossa ischemia in 11 patients, upper limb ischemia in 14 and both symptoms in 6. In 2 patients, dilatation of an asymptomatic high-degree left subclavian artery stenosis was performed before coronary artery bypass surgery using the internal mammary artery. Eighteen patients on follow-up over 6-60 months (mean 25 months) are free of symptoms with equivalent systolic blood pressures in both arms. Three patients showed relapse of the stenosis after 8, 12, and 15 months; one was successfully treated with a second dilatation. Complications consisted of an occlusion at the left axillary artery puncture site and a distal embolus to a finger artery. Percutaneous transluminal angioplasty appears safe and efficient therapy for subclavian artery stenoses with excellent short- and long-term results.

In 1978 Leveen et al. described an original technique for extended aortobifemoral disobliteration using a retroperitoneal approach. This technique was introduced to Europe by Widdershoven and Willekens in 1977 and was adopted in Belgium by Suy and Nevelsteen in 1982 and in Spain by Cuesta and Bengoechea in 1984. A group of 228 patients treated by the Leveen's method from 1982 to 1987 were followed-up for a mean of 21 months (1–54). Disabling claudication (66%) or more advanced ischaemia (34%) was the indication for treatment. An aorto-bifemoral endarterectomy was performed in 124 patients. Aorto-biiliac endarterectomy in 39, unilateral aortofemoral endarterectomy with a contralateral aorto-iliac endarterectomy in 17 and unilateral iliofemoral endarterectomy in 48 cases. There were seven postoperative deaths (3%) and an early thrombectomy had to be performed in 8 patients. There were 14 late deaths. Occlusion occurred in 11 patients giving a 3-year-patency rate of 97%. There were no late complications related to the technique. It is concluded that disobliteration using the Leveen technique compares well with prosthetic grafting. Since this method does not require the use of foreign material the patient is protected from the complications sometimes seen after the insertion of prosthetic grafts.

Fibromuscular dysplasia (syn. arterial dysplasia, fibromuscular hyperplasia, medial fibroplasia) is an arteriopathy of unknown etiology, most frequently involving the renal arteries. The string-of-beads appearance of these lesions seems to be a characteristic angiographic finding. We report atypical angiographic findings at an unusual site, which proved to correspond to fibromuscular dysplasia at histological examination.

An unselected consecutive series of 30 males, receiving an aorto-bifemoral Dacron graft for occlusive arterial disease, were randomised preoperatively to a transperitoneal or extraperitoneal approach. Pulmonary function tests (Forced Vital Capacity--Forced Expiratory Volume at 1 s) were performed once preoperatively and repeated four times postoperatively. As far as pulmonary function tests are concerned the results clearly demonstrated the superiority of the retroperitoneal to the transperitoneal approach. It is therefore recommended that the extraperitoneal approach should be used more frequently in reconstructive aorto-ilio-femoral surgery.

Infection of a vascular prosthesis or an arterial receptor site is one of the most challenging situations for the vascular surgeon. In some instances the standard extraanatomic routes to bypass infected areas cannot be used. Two cases of arterial infection following renal transplantation are presented. An infrascrotal perineal approach for a femorofemoral bypass was used to achieve revascularization of a threatened limb.

We report a case of aneurysm of the abdominal aorta with spontaneous rupture in a 64-year-old man with emphysema and chronic alcoholism. Campylobacter fetus subspecies fetus was repeatedly recovered from the blood and from specimens of the excised aneurysm. The patient died in spite of early diagnosis, intravenous erythromycin and surgical intervention. The bacteriology and epidemiology of campylobacteriosis in man is briefly discussed and eight other published cases of aneurysm, infected with the same organism, are tabulated. C. fetus ssp. fetus should be added to the list of bacteria having a tropism for vascular endothelium.

Purpose To review our experience of endovascular treatment of aorto-enteric fistula (AEF). Methods Between March 1999 and March 2005, 15 patients in five university and teaching hospitals in Belgium and The Netherlands were treated for AEF by endovascular repair. Twelve (80%) were male. The mean age was 67 years. Thirteen (87%) had had previous aortic or iliac surgery, 1.7–307 months before. All patients showed clinical or biochemical signs of bleeding. Eight (53%) were in shock, five (33%) had systemic signs of infection. Eight (53%) patients were treated in an emergency setting. Ten (67%) were treated with an aortouniiliac device, three (20%) with an aortobiiliac device, one with a tube graft and one with occluders only. All patients received antibiotics postoperatively for a prolonged period of time. Results All AEF were successfully sealed, the 30-days mortality was nil. Mean hospital stay was 20 (2–81) days. One patient died 2.7 months later of postoperative complications, one died of lung cancer. Until now, there are no signs of reinfection in four (27%) patients (mean follow-up 15.7 (1–44) months). However, reinfection or recurrent AEF occurred in nine (60%) patients after 9.5 (0.61–31) months. Seven patients were reoperated successfully, two patients died after reintervention. Conclusion Endovascular sealing of AEF is a promising technique, which provides time to treat shock, local and systemic infection, and co-morbidity. This creates a better situation to perform open repair in the future with possibly better outcome. Danger of reinfection remains high. Endovascular sealing of AEF should, therefore, be seen as a bridge to open surgery when possible.

Objectives: to study the technical feasibility and results of endovascular treatment of inflammatory abdominal aortic aneurysms (AAA). Design: prospective study. Material and methods: seven patients underwent endovascular repair of an inflammatory AAA. Five patients (8 ureters) were treated with ureteric stents CT scans were obtained one year. Results: the early technical success rate was 100%. Four ureters remained entrapped at one year. Partial regression of periaortic fibrosis was documented in three patients, while four patients showed no regression. Conclusion: endovascular reconstruction of inflammatory abdominal aneurysms is technically feasible. Further study is warranted with regard to the evolution of the periaortic fibrosis and the possible benefits for patients with concomitant hydronephrosis.

Objectives: Percutaneous treatment of iliac artery occlusive disease has replaced open vascular reconstruction for several indications. A balloon angioplasty with or without stent is not an option in the presence of infrainguinal extension of the disease. The authors describe a technique that allows the construction of an aorto- or iliofemoral graft through a single groin incision, using a 4 mm PTFE graft, anchoring it proximally with a Palmaz stent and dilating both to the desired diameter. Design: Retrospective non-randomised study. Materials and Methods: Nineteen procedures were performed in 16 patients mainly because of ischaemic rest pain, often with trophic skin changes or minor gangrene. Three patients had a bilateral procedure. Twelve patients had one or more associated procedures: 10 distal bypasses, one thrombectomy, one reimplantation of a distal bypass on the iliofemoral graft, one contralateral profundaplasty and two stents of the contralateral common iliac artery. Results: Two patients died, one of small bowel ischaemia and the other of a myocardial infarction. During the mean follow-up of 8.8 months, two graft thromboses occurred. In another patient bilateral stenting of a residual stenosis was necessary. Conclusions: Our experience shows that the reported technique is feasible. Whether the procedure is truly “less invasive” and the long-term results acceptable remains to be shown.

In patients with low degree stenoses of the iliofemoral arteries, a discrepancy can occur between the clinical complaints and the severity of the angiographic lesions. Intra-arterial injection of 20 mg of papaverine by mimicking the need for augmented blood supply during exercise will help to objectify the clinical importance of a stenosis. Therefore, it will be of help in the decision of balloon dilatation of low-degree lesions.

Fifty-five obturator bypasses were performed over a 16 year period for limb salvage. The indications for the choice of this technique included arterial infection, aneurysm formation or soft tissue skin loss at the groin (26 patients), and extensive atherosclerotic disease of the iliofemoral vessels, precluding their use for inflow or outflow (27 patients). There were five perioperative deaths and the five-year patency rate was 37%. Long-term results after above-knee reconstruction substantially exceeded those for below-knee anastomoses (three year patency rates of 71% and 45% respectively). Due to its morbidity and mortality the decision to perform an obturator bypass should be based upon sound indications such as deep infection at the groin, or extensive multilevel arterial disease. Its usefulness in extensive multilevel arterial disease is not demontrasted.

To define the exact incidence of late degeneration, 32 patients underwent intravenous digital subtraction angiography (IVDSA) and/or a Duplex scan more than 3 years after human umbilical vein (HUV) grafting. IVDSA (n = 26) showed a 23 per cent aneurysmal degeneration rate which increased to 40 per cent with Duplex scanning (n = 25). Although the differences obtained in those patients receiving both examinations (n = 19) were statistically not significant, Duplex scanning appeared to be more sensitive, demonstrating two additional cases of aneurysmal degeneration not detected by IVDSA. Since, moreover, Duplex scanning proved able to detect anastomotic stenosis, it appears to be the examination of choice in long-term follow-up of the HUV graft. Despite this relatively high degeneration rate, the authors consider continued use of the HUV graft in selected patients to be justified, especially when the long-term patency rates, the available alternatives, and the less favourable long-term survival after femoropopliteal reconstruction are taken into consideration.