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p = 0.32, NS). Arterial and mixed venous partial oxygen pressure and shunt also showed no significant differences 15 minutes before and after examination, nor did the blood pressure or pulse. The use of four of the bronchoscopes resulted in preinterventional contamination with Pseudomonas . Bronchoscopically controlled lavage shows no advantages over blind endotracheal lavage for diagnosing pneumonia. Blind suctioning with single-use sterile catheters can be done more quickly and inexpensively with fewer personnel and a lower complication rate. [ABSTRACT FROM AUTHOR]

Copyright of Der Chirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Urologe A is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Pleural effusions are a severe complication of advanced malignant disease. Palliative treatment strategies should be simple and effective. We investigated iodized talc pleurodesis through tube thoracostomy for this purpose. A total of 43 patients received a suspension of 5 g talc with 3 g thymol iodine via chest tube. The procedure was well tolerated without major complications in all cases. Unfortunately, 4 patients died of disease within the 1st month after treatment, so that only 39 patients were evaluable for treatment outcome. Follow-up ranged from 1 to 14 months. The success rate after 3 months was 92.5%. In conclusion, iodized talc pleurodesis is an excellent tool in the palliative management of malignant pleural effusions. Administration via chest tube is sufficient for treatment success. [ABSTRACT FROM AUTHOR]

In the case presented an intravenous line for large volume infusion rates was to be placed in a patient with an aortic aneurysm during clinical preoperative care. After a high-flow catheter had been placed without any problems retraction of the guide wire was found to be impossible. Computer tomography revealed that the reason was a kink in the catheter resulting in the guide wire being nipped off. Fortunately both catheter and guide wire could be removed completely without any further complications. [ABSTRACT FROM AUTHOR]

This narrative review summarizes the situation of research concerning exercise therapy in patients suffering from intermittent claudication. In depth we present the evidence-based guidelines and their underlying studies. Aspects as angiomorphology, adherence, long-term effect, quality of studies and their comparability are discussed. We focus on the gap between guidelines and therapy of healthcare providers. Therefore, we discuss the relevance of exercise therapy in healthcare policy. Reasons for the missing congruence between guidelines and the implementation in the healthcare system in Germany are analysed. According to this we express recommendations corresponding to international experiences (Netherlands, Denmark)., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

This review article summarizes the epidemiology of vascular injuries during urologic surgery and discusses intraoperative strategies to control bleedings. Techniques of vascular approaches (arteries and veins) are discussed and tricks for vascular repair are explained. Generally, vascular injuries during urologic surgery are rare. However, hemorrhage due to vascular injury is a common cause of critical morbidity and mortality in the perioperative period. Susceptibility to vascular complications such as oncological debulking and revision surgery increase risk for damage. As vascular injuries range from arrosion to avulsion, treatment is also broad, ranging from vascular suture to open or endovascular repair. Prevention of exsanguination requires visual control to stop the bleeding. The surgeon must act quickly to initiate appropriate repair, aiming for damage control and stabilization of the patient. Planning the surgery and consulting an experienced surgeon are decisive for successful management. Catastrophic bleeding has to be controlled and in the case of arterial injury it is often necessary to reconstitute perfusion. Reconstructions such as vascular anastomoses, patch angioplasty or interposition grafts are the preferred surgical techniques which are influenced by the nature of the injury. Vessels have to be thoroughly prepared before cross clamping to prevent injury by vascular clamps. Veins can often be ligated. Endovascular repair is also a possibility to control the bleeding, but nowadays it is often a definitive therapy method. For example, resuscitative endovascular balloon occlusion is useful to stabilize the patient and then to initiate vascular repair. Depending on the type of surgery performed, different vessels are concerned. Severe bleeding is usually located retroperitoneal affecting the aorta, renovisceral and iliac vessels. Predisposing urologic operations are lymphadenectomy, nephrectomy and (cysto)prostatectomy and also the laparoscopic approach can cause bleeding complications.

Objectives To investigate the feasibility and the mid-term outcomes of the chimney-graft technique for the revascularization of supra-aortic branches in patients with thoracic aortic pathologies involving the aortic arch. Methods A retrospective analysis of a prospectively maintained database between January 2010 and July 2016 was performed. Primary endpoints were 30-day and overall mortality. Secondary endpoints were technical success, target vessel patency, stroke/transitory ischemic attack and type I/III endoleak rate. Results A total of 30 patients (80% male, median age 70.0 years) were treated using the chimney-graft technique for the supra-aortic branches. The indication was a degenerative aneurysm in nine patients (32%) and a type B Stanford aortic dissection and a penetrating aortic ulcer in the descending aorta in seven patients (23%), respectively. In six patients (20.0%), the indication was an type Ia endoleak after previous endovascular thoracic repair, whereas a pseudoaneurysm after previous open repair of the descending aorta was the indication in one patient (3%). Twenty-three patients (77%) were treated electively, five (17%) emergently and two (7%) urgently because of free rupture. Technical success was achieved in 90% of patients. The 30-day/in-hospital mortality was 17% (5/30). A retrograde dissection was presented in five patients. Four patients experienced a cerebrovascular event. Eight patients had type Ia endoleak and 10 had type II. During the median follow-up of 16 months (range: 0-56), four further patients died: one in respiratory insufficiency, one due to a ruptured abdominal aortic aneurysm, one in meningitis and the last one for unknown reason. The chimney-graft patency was 100%. According to the Kaplan-Meier curve, the estimated survival at one year was 66 ± 9%. Conclusions The chimney-graft technique, despite a technically demanding strategy, is a useful tool as bailout procedure in our armamentarium for high-risk patients, unsuitable for open or hybrid repair.

Introduction: Re-interventions are still the Achilles' heel of endovascular aneurysm repair (EVAR). Ectatic common iliac arteries (CIA) can be treated with flared iliac limbs but a dilated artery used as sealing zone could increase the risk of a late type 1b endoleak. The aim of the present analysis was to evaluate the risk of late type 1b endoleak after EVAR in patients with CIA limbs ≥20 mm compared with those <20 mm., Methods: A retrospective analysis was performed of patients treated by EVAR at the study institution between 2006 and 2012, including patients with available information about the type of iliac stent grafts and a minimum follow-up (FU) of 3 years with contrast enhanced CT, or those that had developed a type 1b endoleak earlier. The cohort was divided into two groups: Group I included iliac limbs with a distal diameter <20 mm, and Group II included all iliac limbs with a distal diameter ≥20 mm., Results: Of 692 limbs (346 patients), 239 limbs (34.5%) from 129 patients were included in the analysis. Mean CT FU was 53 months, 178 had an iliac stent graft diameter <20 mm (Group I), and 61 a diameter of ≥20 mm (Group II). Mean oversizing for iliac limbs was 17.2% (IQR 14) and there was no case of immediate type 1b endoleak. For the whole group, 18 type 1b endoleaks occurred during FU (7.5%) after a mean of 37.7 months (range 4-96). Eleven of 61 (18%) iliac limbs in Group II developed a type 1b endoleak during FU in contrast to 7/178 (3.9%) in Group I (OR 5.3, 95% CI 1.98-14.59, p = 0,001). The ROC curve analysis indicated a limb diameter of 19 mm as a cutoff value for a higher probability of developing a type 1b endoleak., Conclusion: Patients treated with iliac limbs ≥20 mm had a fivefold higher risk of late (mean 37 months) type 1b endoleak compared with patients treated with a distal iliac limb diameter <20 mm., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The influence of endovascular aneurysm repair (EVAR) on renal function is of high concern. The question whether stent graft fixation type plays a significant role in renal outcome after EVAR is still debated. However, other factors, such as repeated contrast medium exposure, should also be considered., Methods: We performed a two-center, stratified-cohort case control study to evaluate the influence of last-generation abdominal endografts with suprarenal (SR) vs infrarenal (IR) fixation on renal function., Results: From a total of 276 patients, 134 were treated with IR fixation (group A) and 142 with SR fixation (group B) stent grafts. There was no significant difference in intraoperative contrast medium use (mean 120.0 mL group A vs 104.8 mL; P = .087) between the two cohorts. Overall, 11.2% of the patients (31/276) showed a relevant decline (≥20%) of estimated glomerular filtration rate (eGFR) postoperative and 11.5% (31/269) after 12 months. Furthermore, 19/134 (14.2%) patients in group A and 12/142 (8.5%) patients in group B showed a postoperative decrease of eGFR ≥20% (P = .132). Comparing the 12-month follow up, there was also no significant difference between the two groups (group A, n = 18/134; group B, n = 13/135; P = .329). Patients with only one contrast-enhanced computed tomography scan postoperatively (4/102; 3.9%) showed significant less renal deterioration after 12 months compared with the rest of the study collectively (27/166; 16.9%; P = .002). Comparing IR vs SR fixation in these patients, there was no significant difference between the two groups. One patient (1/35; 2.9%) with IR fixation (group A) and 3/67 (4.5%) with SR fixation (group B) showed a decline in eGFR values of ≥20% after 12 months (P = 1.0)., Conclusions: Our study showed no significant difference in renal impairment between SR and IR fixation in EVAR for IR abdominal aortic aneurysm. However, significantly more renal deterioration was observed in patients with increased postoperative contrast medium expose. Therefore, alternatives such as contrast- enhanced duplex ultrasound or magnetic resonance imaging for EVAR surveillance should be considered., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Fenestrated endovascular aneurysm repair (F-EVAR) has increased the number of patients with aneurysmal disease and a short or no existing neck being eligible for endovascular treatment. The aim of the study is to report experience using the Anaconda fenestrated device with special emphasis on target vessel patency and pitfalls with the device., Methods: Between 2011 and 2016, 48 F-EVAR procedures were performed in 37 males and 11 females under general anaesthesia using the Anaconda custom made device (CMD). Cerebrospinal fluid drainage was performed in selected cases only. Primary endpoints were 30 day mortality and any stent graft related complications., Results: The median aneurysm diameter was 56 mm. Most of the patients had a juxtarenal aneurysm and six had an aorto-iliac aneurysm. The primary technical success was 94% with three unsuccessful cannulations of reno-visceral arteries, two of which were successfully performed later. In the third patient an open repair was necessary because of occlusion of the main graft. The 30 day mortality was 4% because of colonic ischemia with two thrombotic occlusions of the superior mesenteric artery. Thirty day morbidity included four cases (8%) of acute limb ischemia: one with a complete limb occlusion caused by a torsion of the main body; two cases (4%) of assumed temporary spinal cord ischemia; six cases (12%) of acute renal failure; and 16 endoleaks (33%) (15 type II, 1 type III). During the median 24 months (range 0-53) follow up, three patients died (6%). One had migration of the stent graft, leading to open repair and post-operative multi-organ failure. The second had graft limb occlusion and died because of multi-organ failure caused by post-operative thrombosis of the reno-visceral stents. The third patient died of an unrelated cause. Two occlusions of the right renal stent/artery were detected. Moreover, there were three cases (6%) of late partial and seven cases (15%) of total graft limb thrombosis, with one being bilateral., Conclusions: "Real world" feasibility of the fenestrated Anaconda stent graft is demonstrated with 4% peri-operative mortality. Target vessel patency is in line with other series; however, limb thrombosis during follow up is of concern., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

A persistent sciatic artery is a very rare vascular anomaly with an estimated incidence of 0.025-0.06% and with less than 200 described cases in the literature. During early embryonic development, the sciatic artery delivers the major blood supply to the lower limb and usually disappears when the superficial femoral artery has developed properly. The usual form of presentation in adults is the aneurysmal degeneration of the sciatic artery or less frequently with another complication (thrombosis, embolism, neuralgia). We describe three cases of a complete sciatic artery (two cases are bilateral and one is unilateral) associated with lower limb ischemia caused by embolism from the aneurysmal degeneration of the sciatic artery at the buttock level in two cases and atherosclerotic degeneration of the lower limb arteries in the third case. We also describe two combined therapy methods consisted of limb revascularization with vein-graft bypass and endovascular embolization of the aneurysm with vascular plug in the first case, in the second case combination of localized thrombolysis therapy followed by a bypass and an ilio-pedal vein bypass in the third one. And we discuss later the reported clinical outcome after surgical and endovascular treatment of this anomaly in the literature., (© The Author(s) 2015.)

Background: Preoperative risk stratification of the immediate postoperative death after surgery may be helpful for the decision-making for patients with ruptured AAAs (rAAs). The purpose of this study was to apply and validate the Glasgow aneurysm score (GAS) and the Hardman Index (HI) in predicting 30-day/in-hospital mortality in open surgical repair (OSR) and endovascular repair (rEVAR) of rAAAs., Methods: We conducted a retrospective review of a prospectively created database including all patients with a rAAA referred to our Institution between August 1998 and December 2014. Primary outcome was 30-day/in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the HI and GAS in predicting 30-day/in-hospital death., Results: A total of 150 patients (130 patients received OSR, 20 patients rEVAR) were included in our analysis. The 30-day/in-hospital mortality was 34.0 % for the entire cohort: 36.15 % for OSR group and 20.0 % for rEVAR group (p 0.210). A multivariate analysis in the OSR group evidenced that unconsciousness was a statistically significant [adjusted odds ratio (OR) 8.00] predictor of 30-day/in-hospital mortality. The mean GAS was 86.9 ± 16.1 for the OSR group and 88.1 ± 11.2 for the rEVAR group (p 0.773). The AUC for GAS was 0.805 among OSR patients and 0.975 among rEVAR patients. The mean HI in the OSR group was 1.11 ± 1.0 and the AUC for HI was 0.82., Conclusions: Surgical repair of rAAAs is still associated with a considerable mortality rate. We confirmed the great discriminative ability of GAS in patients with rAAAs treated with OSR. With regard to HI, this scoring system could accurately predict early mortality after OSR in our cohort but failed to identify patients at highest risk for postoperative mortality.

Background: The endovascular aneurysm repair (EVAR) is becoming the preferred method to treat an aortic aneurysm with its better short-term postoperative mortality and morbidity rates in comparison with the open repair. A main drawback of this method is the need to use a nephrotoxic iodinated contrast medium to visualize the aorta and its side branches., Case Report: An 83-year-old man with an asymptomatic infrarenal aortic aneurysm of a 51-mm diameter accompanied by a 42-mm aneurysm of the left common iliac artery was treated with combined fenestrated EVAR (FEVAR) and iliac side branch stent graft (ISBG) under guidance of image fusion (IF) without the intraoperative use of iodinated contrast agent., Conclusions: Complex EVAR (FEVAR and ISBG) using computed tomography angiography IF is feasible and together with the use of CO2 angiography may help to abstain from need to nephrotoxic contrast medium., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: In patients undergoing transfemoral transcatheter aortic valve implantation, previous endovascular interventions bear a risk for the valve frame to get stucked to the aortic stents., Case Presentation: We report on a 75-year-old frail patient with severe aortic stenosis and a rapid increase of an infra-renal aneurysm. He had a history of multiple endovascular interventions on the aorta. Due to his frail preoperative status we decided to perform a transfemoral transcatheter aortic valve implantation in combination with a simultaneous surgical abdominal aneurysm repair. To allow an atraumatic passage of the Edwards SAPIEN 3 valve across the endovascular stents we used a special technique., Conclusions: The transfemoral approach in patients with previous endovascular stenting can be performed successfully by a partial inflation of the distal balloon.

The purpose of the present study was to compare the functional change of erectile dysfunction after endovascular repair (EVAR) and open repair (OR) of abdominal aortic aneurysm.Between April 2009 and December 2011, male patients admitted for elective treatment of an asymptomatic infrarenal abdominal aortic aneurysm were included. The erectile function was evaluated by using a validated KEED questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after one year.The number of patients with an increase of erectile dysfunction was 8 (26.6%) to 16 (53.3%) in open repair group vs. 30 (42.6%) to 40 (58.8%) in endovascular aneurysm repair. There was no statistically significant difference between open repair and endovascular aneurysm repair groups in order of new incidence of erectile dysfunction (p = 0.412). The study showed an increase in the mean value of Erectile Dysfunction -Score postoperatively in both the groups as well.The present study showed an increase of erectile dysfunction postoperatively, but the difference between the two groups was not statistically significant., (© The Author(s) 2015.)

Objective: To compare the results of elective open surgical repair (OSR) and total endovascular repair of juxtarenal aortic aneurysms (JAA), with either the Cook Zenith or the Vascutek Anaconda fenestrated stent grafts (F-EVAR) in a university hospital setting., Patients and Methods: Between April 1999 and July 2014, of 926 patients with an abdominal aortic aneurysm, 69 were juxtarenal, where 34 had an elective OSR and 35 had F-EVAR. A post-operative rise of baseline creatinine by >50% and/or deterioration of estimated glomerular filtration rate by 25% were defined as renal failure., Results: The demographics of the patients were similar except for heart insufficiency, peripheral arterial disease, and pre-existing renal artery stenosis (p < .05). Median aneurysm diameters were 57 mm (range 50-80 mm) and 56 mm (range 36-64 mm) (p = .194), respectively, and the median pre-operative serum creatinine levels were 94 μmol/L (range 65-286 μmol/L) and 96 μmol/L (range 57-333 μmol/L) (p = .871) with median estimated glomerular filtration rate of 68 mL/min (range 21-117 mL/min) and 70 mL/min (range 18-114 mL/min) (p = .308) in the open and endovascular groups, respectively. The technical success (OSR versus F-EVAR) was 100% versus 94.3% with complete exclusion of the aneurysms in all cases. Median procedure time was 171 versus 188 min. During median in hospital stay of 11 versus 7 days (p = .05), mortality was 0 versus 2.9% and new onset of post-operative renal insufficiency was detected in 26.5% versus 8.5% patients (p = .05), although with 11.8% versus 5.7% being persistent (p = .428). During follow up, statistically similar new (late or persistent post-operative) renal insufficiency was detected in 14.7% versus 8.8% with dialysis in 3% of patients in each group with similar mortality within the 24 months., Conclusions: This retrospective analysis demonstrates that OSR might be combined with more acute post-operative renal impairment than F-EVAR for JAA, but with similar intermediate term procedure related mortality and renal outcomes., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Even though early transplantation is still the first-line therapy in paediatric patients with end-stage renal disease (ESRD), up to 30% of these patients still require haemodialysis (HD). Creating an arteriovenous fistula (AVF) is quite challenging, particularly in children, leading to disproportional use of catheters. In this paper, we describe our experience in the creation of AVF with currently no in-dwelling catheters in children and adolescents on HD., Methods: From January 2009 to December 2013, there were 34 patients rated as unfit for transplantation for at least the next 6 months or who had already been on HD through a central venous catheter (CVC). Three patients aged between 12 months and 3 years and weighing 9-12 kg were not suitable for AVF. Finally 31 patients, from 6 to 19 years of age with a mean weight of 43.3 ± 14.5 kg (19-80 kg), were assigned to the alternative of AVF., Results: During the above-mentioned time period, 31 patients were provided with 32 AVFs; 26 received a distal radiocephalic fistula, five a Gracz-type fistula and one a brachio-basilic fistula. All but two fistulae matured primarily, within an average time of 45 (range: 16-191) days until the first dialysis. The fistula's 1-year primary and primary assisted patency rates were 78% and 94%, respectively., Conclusions: The creation of a native vascular access is an effective and durable procedure in paediatric and adolescent patients. It reduces using of CVCs and is appropriate both for long-term treatment and as a bridging procedure until renal transplantation.

We demonstrate for the first time the technical feasibility of total endovascular aneurysm repair for juxtarenal and pararenal aortoiliac aneurysms by combining the Vascutek Anaconda custom-made fenestrated stent graft with the Cook Zenith iliac side-branched stent graft. Three patients (two male and one female) presented with asymptomatic pararenal aortoiliac aneurysm in the first case and juxtarenal aorto-left iliac aneurysms in the second and third cases. We successfully deployed the Anaconda fenestrated and the iliac side-branched stent graft combined with Atrium Advanta V12 stent grafts for renal, superior mesenteric, and hypogastric arteries. Postoperative computed tomography demonstrated excluded aneurysms with patent renovisceral and hypogastric arteries and no signs of endoleak., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective/background: Endovascular aneurysm (EVAR) repair of an aortic aneurysm extending to the iliac artery remains a challenge. Interventional occlusion of the internal iliac artery (IIA) intending to create a distal landing zone in the external iliac artery is a common approach with inherent morbidity (e.g., buttock claudication, impotence). Alternatively, iliac side-branched stent grafts can maintain pelvic blood supply, but the applicability is limited. The objective was to investigate the morphological applicability of the Cook Zenith branched graft (ZBIS) among patients with aorto-iliac or isolated iliac aneurysms., Methods: This was a retrospective single centre analysis of 66 patients (60 men; median age 74 years, range 53-90 years) undergoing repair of aorto-iliac aneurysms (open repair, IIA occlusion prior to EVAR and ZBIS) between January 2008 and December 2012. All available computed tomography angiograms with post-processing imaging were compared with the criteria for morphological applicability to (i) the manufacturer's instruction for use (IFU), and (ii) to criteria published in the literature, as well as (iii) to the institutional protocol., Results: In 66 patients, 88 targeted iliac aneurysms were studied. Of these, 36/88 (40.9%) were compliant with the manufacturer's IFU, 35/88 (39.8%) were compliant with the published criteria, and 51/88 (58.0%) were compliant with the in house protocol. The most common morphological exclusion criterion was an aneurysmal IIA., Conclusion: In the present cohort with aorto-iliac aneurysm, a maximum of 58% could have been treated with an iliac side branch based on the current experience. In particular, an aneurysmal IIA seems to be a limiting factor for the use of the iliac side-branched stent graft., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection-related complications and long-term survival., Methods and Results: All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39-86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella-positive culture as predictors for late infection-related death., Conclusions: Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella-positive blood cultures were more likely to die from late infection., (© 2014 American Heart Association, Inc.)

Objective: Proximalization of arteriovenous inflow (PAI) is an established technique for treating patients with access-induced hand ischemia. However, a prosthetic graft, used as arterial inflow, could minimize the benefits of a purely native fistula. In this study, a new PAI technique is reported, which avoids the use of prosthetic grafts in patients with matured basilic and cephalic veins., Patients and Methods: Eight patients (seven men, one woman; mean age 62 (45-82) years old) with grade III/IV critical dialysis access-related ischemia (DARI) and with a pre-existing Gracz fistula underwent an operation using modified PAI. The basilic and cephalic veins were preoperatively matured. During the operation, the former arteriovenous anastomosis was closed and the basilic vein was used as arterial inflow., Results: All procedures were technically successful. All patients but one could be discharged with a warm, neurologically improved extremity with a significant reduction in pain. After a mean follow-up of 43.5 (0-52) months, there were no recurrent steal symptoms and all necrotic hand lesions healed. Two patients died during the follow-up, but with well-functioning fistulae. One fistula failed during follow-up and one further fistula was ligated because of chronic neurological damage, which was not improved after the PAI procedure. Four AVFs are still available for hemodialysis., Conclusions: The modification of the PAI technique with a basilic vein as presented here showed similar results to the original PAI procedure. This new procedure does not require prosthetic grafts as in the original PAI technique or a central venous catheter and leads to the enlargement of the puncture site as a result of the superficialization of the basilic vein. Therefore, it is believed that this new technique could be a good option for those patients with matured cephalic and basilic veins who suffer from severe access-related ischemia., (Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Rupture of an abdominal aortic aneurysm (rAAA) is associated with a high mortality both before and after admission to hospital. In spite of the use of expensive intensive medical therapeutic interventions 30 - 50 % of the operated patients still die. The ASA score is one of the most used scores world-wide. Use of the Glasgow aneurysm score (GAS) and the Hardman index (HI) is frequently reported in the literature to predict survival after surgical management of rAAA. With regard to the comorbidity factor severity score (CSS) no evaluated data on the mortality in cases of rAAA are available. On the basis of our own patient collective we intended to assess to what extent the risk score could give an answer to the question of therapeutic options., Methods: In a retrospective study (7/1998 - 8/2007), 94 patients (m : f = 78 : 16) were assessed after operative management of rAAA. The validity of preoperative risk assessments on the basis of the ASA score, the CSS, the GAS and the HI with regard to intra- or postoperative death in the initial hospitalisation period was examined. Sensitivity and specificity of the score systems were determined by receiver operating characteristics (ROC) analyses., Results: The age of the patients was 72.3 ± 9.5 years (mean ± SD). Thirty-five (37.2 %) patients died in the immediate postoperative period. The areas under the receiver operating characteristics curves for ASA, GAS, HI and CSS were 0.598, 0.787, 0.742 and 0.614, respectively., Conclusions: This study revealed clear differences in the prognostic predictions of the various scores. In accord with the literature, no score gave a 100 % positive result with regard to mortality. Thus, an individual decision or, respectively, a therapeutic option cannot be reached with the help of the investigated scores. Further parameters need to be evaluated in order to make decisions about postoperative therapy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Ruptured abdominal aortic aneurysm (rAAA) remains a challenging problem: 2,410 cases were treated in Germany in 2010. Ruptured abdominal aortic aneurysm should be suspected in patients over age 50 who complain of pain in the abdomen or back and in whom examination reveals a pulsatile abdominal mass. The incidence of hospitalization for rAAA is 12 per 100,000 persons over age 65 per year (statistics for Germany, 2010), and rAAA carries an overall mortality of 80%., Methods: The current state of knowledge of rAAA was surveyed in a selective review of pertinent literature retrieved by an electronic search in the PubMed, Web of Science, and Cochrane Library databases with the keywords "abdominal aortic aneurysm," "ruptured," "open repair," and "endovascular." Publications in English or German up to and including March 2012 were considered, among them the Clinical Practice Guidelines of the European Society for Vascular Surgery (1)., Results and Conclusions: Recent reports show that the treatment of rAAA is still fraught with high mortality and high perioperative morbidity. Improvement is needed. It would be advisable for the care of rAAA to be centralized in specialized vascular centers implementing defined treatment pathways. Systematic screening, too, would be beneficial. An increasing number of reports suggest that endovascular treatment with stent prostheses improves outcomes; more definitive evidence on this matter will come from prospective, randomized trials that are now in progress.

Purpose: We compared occlusion of the internal iliac artery (IIA) using coils or the Amplatzer vascular plug (AVP) II prior to endovascular aortic aneurysm repair., Materials and Methods: Occlusion of the IIA was performed in 32 patients (aged 74 ± 8 years) using coils (N = 17) or the AVP II (N = 15). We retrospectively compared procedural data, initial success, and clinical outcome in a 12-month follow-up., Results: Occlusion was successful in all patients without detection of an endoleak after 12 months. Procedure time and fluoroscopy time for coils versus plugs were 77 ± 35 versus 43 ± 13 minutes and 36 ± 19 versus 18 ± 8 minutes, respectively (P < .003). Incidence of initial buttock claudication (BC) for coils versus plugs was 47% versus 27% and was significantly more severe after coil occlusion (P = .03). After a 12-month follow-up, 2 patients of each group reported of mild BC., Conclusion: Occlusion of the IIA is safe and effective using coils or plugs. Initial BC is significantly more severe when coils are used, but after a 12-month follow-up, there is no significant difference. Using a plug is associated with a significant reduction of procedure time and radiation exposure.

We examined the safety and efficacy of vessel occlusion of the Amplatzer Vascular Plug 4 (AVP-4) in patients with arteriovenous fistulas after in-situ saphenous vein bypass grafts. We treated 18 fistulas of seven patients (four women, mean±standard deviation age 76±7 years, range 63-88 years). All fistulas were detected within 14 days after surgery. Initial diagnosis and follow-up was established by sonography. We measured the diameter of the feeding vessel and the time of vessel occlusion after plug deployment. Additionally, we recorded procedure time and the dose area product. Additional interventional procedures were necessary in three patients. We successfully used 19 AVP-4 for occlusion of all fistulas without thromboembolic complications. There was no need for recapturing the device, and we did not observe dislocation. Mean occlusion time was 9.6 min (range 5-22 min). Mean diameter of the feeding vessels was 3.5 mm (range 2.6-5.1 mm). Plug sizes ranged from 4-8 mm (mean 5.5 mm) resulting in an oversizing of 33-88%. Mean procedure time for patients with and without additional intervention was 91±38 min and 35±18 min, respectively. Mean dose area product was 11,790 cGy/cm2 (range 1,850-23,500 cGy/cm2). Permanent occlusion of the fistulas was confirmed by ultrasound after a mean follow-up of 4 months (1-6 months). Occlusion of arteriovenous fistulas with an AVP-4 seems to be effective and safe in patients with in-situ saphenous vein bypass grafts. The AVP-4 is well suited for this purpose because of the appropriate diameter of the feeding vessels.

This case report illustrates our experience with transapical minimally invasive aortic valve implantation in a patient with an extended aneurysm of the thoracoabdominal aorta, who had previously undergone a replacement of the ascending aorta with concomitant aortic valve reconstruction (David procedure). Endovascular stent grafting of the descending aorta was also performed. The implantation of a 23-mm SAPIEN valve (Edwards Lifesciences, Irvine, CA) did not interfere with the existing 26-mm aortic Hemashield prosthesis (Boston Scientific, Natick, MA) or the previously implanted endograft in the descending aortic position. No paravalvular leakage with aortic valve regurgitation, prosthesis instability, or coronary malperfusion was seen after valve implementation., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The indications for endovascular therapy of thoracic aortic pathologies are expanding. The complexity of cases is increasing. The individual anatomy and pathology of the thoracic aorta alone and in combination create specific difficulties in stent graft delivery, deployment, and fixation. Graft design has evolved, and several new iterations of stent grafts have been introduced into clinical practice. The assessment of these new grafts is difficult, due to the changing indications for their use and a lack of large-scale clinical trials. Currently, a number of thoracic stent graft devices are available in Europe. Variable amounts of clinical data are available to support their use.

In carotid surgery, it could be useful to know which patient will tolerate carotid cross-clamping in order to minimize the risks of perioperative strokes. In this clinical study, an artificial neuronal network (ANN) was applied and compared with conventional statistical methods to assess the value of various parameters to predict shunt necessity. Eight hundred and fifty patients undergoing carotid endarterectomy for a high-grade internal carotid artery stenosis under local anesthesia were analyzed regarding shunt necessity using a standard feed-forward, backpropagation ANN (NeuroSolutions); NeuroDimensions, Gainesville, FL) with three layers (one input layer, one hidden layer, one output layer). Among the input neurons, preoperative clinical (n = 9) and intraoperative hemodynamic (n = 3) parameters were examined separately. The accuracy of prediction was compared to the results of a regression analysis using the same variables. In 173 patients (20%) a shunt was used because hemispheric deficits or unconsciousness occurred during cross-clamping. With the ANN, not needing a shunt was predicted by preoperative and intraoperative parameters with an accuracy of 96% and 91%, respectively, where the regression analysis showed an accuracy of 98% and 96%, respectively. Those patients who needed a shunt were identified by preoperative parameters in 9% and by intraoperative parameters in 56% when the ANN was used. Regression analysis predicted shunt use correctly in 10% using preoperative parameters and 41% using intraoperative parameters. Intraoperative hemodynamic parameters are more suitable than preoperative parameters to indicate shunt necessity where the application of an ANN provides slightly better results compared to regression analysis. However, the overall accuracy is too low to renounce perioperative neuromonitoring methods like local anesthesia.

Over the last 15 years the endovascular repair of thoracic aortic pathologies has been developing as the treatment of choice, but it requires appropriate anatomy. Proximal and distal landing zones are essential for fixation and sealing. In order to extend the proximal landing zone for the stent-graft and achieve an adequate seal, the left subclavian artery (LSA) is often covered, with or without concomitant subclavian artery revascularization. In this article the authors review the LSA anatomy and consequences of LSA coverage as scenery for a discussion of the ramifications of LSA coverage during endovascular thoracic aortic repair (TEVAR). Summarizing the currently available literature, the authors reveal that there is no consensus regarding a preparatory left carotid-subclavian bypass or a transposition of the left subclavian artery to the left common carotid artery. Various management strategies are offered.

Endovascular repair of thoracic and thoraco-abdominal aortic aneurysms became apparent as an alternative to open repair. When the distal landing zone proximal to celiac artery is inadequate, a traditional open surgical approach with thoracoabdominal aortic replacement concomitant with visceral and renal bypasses is necessary. Alternatively, either an abdominal hybrid procedure with debranching of the visceral vessels with subsequent thoracic stent graft placement or complete endovascular aneurysm exclusion with branched stent grafts is required. Extending the distal landing zone might be possible by covering the celiac artery origin. In this article, the authors review the anatomy of the celiac artery (SA) and the superior mesenteric artery (SMA) and consequences of CA coverage as scenery for a discussion of the ramifications of CA coverage during endovascular thoracic aortic repair (TEVAR). Summarizing the currently available literature, we will demonstrate the feasibility of covering the celiac artery based on a diagnostic algorithm.

Purpose: To compare radiofrequency obliteration (RFO) and conventional surgery with respect to postoperative complications, effectiveness of treatment, and quality of life (QoL)., Methods: Several healthcare databases were interrogated to identify all studies published between 1994 and 2007 comparing RFO in primary varicosis to conventional therapy with vein ligation and stripping. Of 65 articles identified, 8 studies representing 428 patients [224 (52%) endovenous RFO and 204 (48%) stripping] were eligible for the meta-analysis. Adverse events, effectiveness, and QoL outcomes were assessed at several time points up to 2 years., Results: There were significant reductions in tenderness and ecchymosis at 1 week and significantly fewer hematomas at 72 hours, 1 week, and 3 weeks associated with RFO. There was no significant difference between the RFO and surgery in immediate or complete great saphenous vein (GSV) occlusion, incomplete GSV closure, freedom from reflux, recurrent varicose veins, recanalization, or neovascularization. QoL results significantly favoring RFO over surgery included return to normal activity and return to work., Conclusion: It seems that RFO benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion, and reflux may alter with longer follow-up. The lack of such data demonstrates the need for further randomized clinical trials of RFO versus conventional surgery.

Introduction: The aim of this study was to evaluate the role of intra-operative Prostavasin application during crural bypass surgery. 68 Patients, who underwent infrainguinal autologous vein bypass surgery, were prospectively analyzed., Results: Intra-operative flow measurements and Prostavasin administration were performed in all patients. The mean flow was 105 ml / min (minimal flow 18 ml / min, maximal flow 321 ml / min). The means of maximal and minimal flow were 329 und 30 ml / min, respectively. The mean of the calculated Pulsatility index was 3.1. The mean flow volume increased after administration of Prostavasin in all patients with a mean increase of 103 %. The Pulsatility index decreased by 39 %. Primary and secondary patency rates after 1 year were 70.3 % und 73.1 %, respectively. The differentiated analyses of the region of the distal anastomoses (popliteal / crural) showed a statistically significant bigger increase of Q after Prostavasin application for infrainguinal popliteal bypasses compared to patients with crural reconstructions (p = 0.05). In addition, the decrease of the Pulsatility index was significantly higher in popliteal grafts (p = 0.03). Patients with early bypass graft failure showed a significantly smaller decrease of PI after Prostavasin application compared to the other patients., Conclusion: The profit of intra-operative arterial Prostavasin application is first of all an immediate one. The injection of Prostavasin leads to an instant vessel dilatation. This allows the surgeon to get an impression of the flow capacity of the bypass. The Pulsatility index as an indicator for resistance is an important factor for bypass patency.

Background: Decision making in abdominal aortic aneurysm repair due to open or endovascular procedure is associated to the natural course of disease and to the peri-operative mortality. Risk evaluation by scoring systems is essential for the choice of individual therapy. Aim of the presented study was to examine the SVS / AAVS Comorbidity Severity Score of the "Society for Vascular Surgery" (SVS) / "American Association for Vascular Surgery"., Patients and Methods: The Comorbidity Severity Score was applied to 328 patients undergoing abdominal aortic aneurysm repair. Additionally, comparison was made to the classification of "American Society of Anaesthesiologists Physical Status Classification Scale" (ASA classes 1-5), and the "Eagle's Vascular Surgery Low Risk Clinical Markers". The scorings were correlated to the mortality and the time of hospitalisation., Results: Patients with electively performed open repair (n = 168) showed an Comorbidity Severity Score of 6.8 +/- 3.9, ASA-Score of 2.7 +/- 0.6, and Eagle-Score of 1.04 +/- 0.9. In elective endovascular repair (n = 78) corresponding scorings were 11.6 +/- 5.0 (p < 0.05), 2.9 +/- 0.5 (n. s.), and 1.7 +/- 1.0 (n. s). Patients with elective open repair stayed significantly longer at hospital (11.1 +/- 9.2 versus 8.1 +/- 6.9 days). Mortality was 2.4 percent and 5.1 percent (p = 0.02)., Conclusions: The newly developed SVS / AAVS Comorbidity Severity Score demonstrated the high risk profile of the endovascularly treated patients with abdominal aortic aneurysms as well as the older scorings systems do. But there was no correlation demonstrable to mortality or to duration of hospitalisation.