Search

We report a case of an isolated atherosclerotic true aneurysm of the profunda femoris artery. The aneurysm was surgically ligated. The clinical presentation, diagnostic algorithm and therapeutic options are discussed in the scope of the English-language literature.

Objectives: Late aneurysm formation has been reported after every type of surgical coarctation repair, with rupture of such aneurysms being responsible for approximately 7% of all deaths. Secondary surgical repair carries a significant mortality and morbidity. According to the positive experience with endovascular therapy of atherosclerotic thoracic aortic aneurysms, it is worthwhile to evaluate the concept of minimally invasive endovascular stent grafting for secondary repair of postsurgical aneurysms., Methods: Data were collected prospectively on consecutive patients who presented with postcoarctation false aneurysms., Results: Since 1999, in a cohort of 46 endovascularly treated patients with thoracic aortic pathologies, 3 patients with postcoarctation false aneurysms underwent endoluminal stent-graft placement. All of these procedures were technically successful without 30-day or 1-year procedure-related mortality. After a mean follow-up of 19 months (range, 7.8-33.5 months), all aneurysm remain excluded without endoleak., Conclusions: According to the current limited experience of small series and short periods of follow-up, the endoluminal repair seems to be a promising alternative to redo operations for postsurgical thoracic aneurysms associated with coarctation repair. Long-term follow-up is required to assess the durability of the stent-graft treatment.

Objectives: The aim of this study was to investigate if radiation therapy (RT) favorably modulates wound healing at vein graft anastomoses., Materials and Methods: Jugular vein grafts were sewn into carotid arteries in 32 rats which were randomly divided into two groups: RT (gamma source, 14 Gray, n=16) and control (C, sham irradiation, n=16). Grafts and adjacent arteries were analyzed at 2 (n=8) and 8 weeks (n=8) by histology, immunohistochemistry, and morphometry., Results: Although, RT did not reduce the overall occurrence of intimal hyperplasia, the distribution differed. RT led to a reduction of intimal hyperplasia in arterial segments (median: C: 41.873 microm2; RT: 6.452 microm2, p < 0.0007). In contrast, RT augmented intimal hyperplasia in vein grafts (median: C: 30.287 microm2; RT: 90.455 microm2, p < 0.014). Vein graft diameters after RT were enlarged (median: C: 2.098 microm; RT: 3.381, p < 0.031). Over 80% of the cells were of mesenchymal origin in both groups., Conclusions: RT reduced intimal hyperplasia in arterial segments. However, RT led to graft dilatation and increased intimal hyperplasia in vein grafts. RT did not favorably modulate the vascular wound healing response in this model.

For the endovascular therapy of abdominal aortic aneurysm an increasing number of publications deal with the subject of device-related outcome and aneurysm sac behaviour. The present study was designed to investigate whether, and to what extent, aneurysm sac behaviour of thoracic aortic aneurysms and perioperative outcome is influenced by the different types of stent grafts. Bibliographic search and analysis was performed. A systematic MEDLINE search on thoracic aortic aneurysms produced a total of 2,884 references with abstracts between 1990 and 2004. Restricted by using the additional terms of ''descending'' and ''stent graft'' the result condensed to 152 papers. Each reference was analyzed according to predetermined criteria. The majority of articles were published in the English language. Two publications summarized the results of nation-wide or continental registers of endoluminally treated patients with descending aortic dissections or thoracic aortic disease. Several series were partial and/or updated reports from the same authors and/or on the same patients. A total of 48 centres reported about the endovascular treatment of more than 3,000 patients with pathological thoracic aortic entities (Approximately 1,650 degenerative thoracic aortic aneurysms, Approximately 1,000 aortic dissections, Approximately 400 miscellaneous aortic pathologies). The heterogeneity among the series precluded any relevant comparison. Only 4 centres have presented study groups of more than 100 treated patients, but 3 series contained several treated aortic pathologies. Without a differentiation to the underlying pathology, the bibliographic research documented a rate of technical success in a range of 76% to 100%. Summarizing the data of par-procedural and in-hospital mortality the bibliographic research documented a mortality rate of 6.8% for all reported procedures. The rate of paraplegia for all procedures was 1.7%. In conclusion the presented bibliographic search and analysis demonstrated the technical feasibility of the endoluminal stent grafting of a great variety of thoracic aortic pathologies. The short-term results are promising, but data of mid-term results are rare and long-term results are missing. Moreover, the question about the influence of different types of stent grafts on the outcome can not be answered.

Aim: Aim of the study is to illustrate current therapeutic options for aneurysms of the extracranial carotid artery., Methods: From 1987 until 2003 14 patients (average age: 60 years) with an aneurysm of the extracranial internal carotid artery were treated. The aneurysm diameter ranged from 5 mm to 60 mm. Thirteen patients underwent elective surgery. One patient was operated upon because of acute severe cervical bleeding., Results: Most patients (10/14) presented with an asymptomatic pulsatile cervical mass. The aneurysm was diagnosed 3 times during carotid angiography. The underlying etiology was atherosclerosis in 10 patients. In 3 cases the aneurysm was considered mycotic. Ten aneurysms were localized at the carotid bifurcation whereas 2 each were found in the retrostyloideal region and at the base of the skull. Vascular continuity could be restored in 10 patients while in 3 the carotid artery had to be occluded (twice surgically and once radiologically). The final patient underwent stent insertion for post-traumatic distal aneurysm. In 5 patients perioperative neurological complications were noted which persisted in a single patient (dysphagia due to a lesion of the hypoglossus nerve). All hemispheric complications recovered completely. During follow-up (median 48 months ranging from 3 to 103 months), 1 patient died of unrelated cause. Another patient developed a contralateral ischemic insult., Conclusions: When adjusting treatment to the various etiological conditions and localizations, aneurysms of the extracranial carotid artery can be managed with a low complication rate and satisfying long-term results. However, success mainly depends on the timely diagnosis and availability of a range of surgical and radiological therapeutical options.

Objectives: Photodynamic therapy (PDT) is a promising strategy to limit restenosis. PDT depletes the resident cells from the vessel wall without adventitial cell ingrowth. This study was undertaken to further explore the mechanisms by which PDT of matrix acts on key mechanisms in the development of restenosis., Materials and Methods: Control and PDT-treated collagen type-I matrix gels were prepared. Thereafter, untreated human fibroblasts were seeded on matrix gels (n=12). Fibroblast proliferation and invasive migration were quantified by calibrated phase contrast microscopy. Fibroblast bFGF and TGF-beta1 mRNA expression were analyzed using a quantitative real-time reverse transcription polymerase chain reaction., Results: Fibroblast proliferation on PDT-treated matrix gels was reduced by 30 and 76% after 3 and 7 days, respectively (3 days: P

Purpose: To report the systematic comparison of magnetic resonance imaging (MRI) with contrast-enhanced computed tomography (CT) for evaluating 8 different aortic stent-graft models., Methods: MR angiography (MRA) was performed using a 1.5-T whole body system within 2 days of a CT examination (4 detector row scanner) on 8 patients with one of these stent-graft models: AneuRx, Endofit, PowerLink, Excluder, LifePath, Talent, Vanguard, or Zenith. Using a 4-point scale (maximum score 112 points), 4 independent readers (1 vascular surgeon and 3 radiologists) rated the impact of stent-related artifacts on the diagnostic quality of each imaging method for 28 parameters: length, diameter, collateral aortic side branches, stent-graft prostheses, and contrast. Each examiner also scored his personal diagnostic confidence with each stent-graft model., Results: The scores for diagnostic confidence in the CT imaging were 4 points for each stent-graft, with the exception of the LifePath (3 points). The diagnostic confidence in the MR images was mainly poor, with a median score of only 1; however, 3 stent-grafts (AneuRx, Excluder, and Vanguard) received > or =3 points. The total scores for comparative assessment were significantly different (p<0.05) between CT imaging (111.5) and MR (58.5). CT studies of all stent-grafts received >101 points, while only 3 devices acquired >80 points (AneuRx, Excluder, and Vanguard). Bland-Altman analysis showed that the reliability of the 4 readers was higher using the CT method. The total assessment scores of the stent-graft systems were related only on the different imaging methods (p<0.0001) and not to the different readers (p=0.983)., Conclusions: CT and MRI are fast, reliable means of providing all relevant information for stent-graft surveillance. Of 8 different stent-graft models, only 3 could be adequately assessed by MRA. Therefore, the potential advantages of the MR technique (e.g., use of minimally nephrotoxic contrast media, lack of ionizing radiation) are available only to a small proportion of patients.

Objective: To evaluate the prognostic value of angiographic criteria and internal carotid artery (ICA) stump pressure for shunt placement in carotid surgery under local anaesthesia., Design: Prospective clinical trial at a university hospital., Materials and Methods: In 120 patients a cerebral angiography was initiated before undergoing carotid surgery. Seventy-five percent of the patients were neurologically asymptomatic, 13% had transient ischaemic attacks and 12% suffered from previous strokes. The operation was exclusively performed under local anaesthesia and prior to cross-clamping the ICA stump-pressure was measured. A shunt was inserted only if hemispheric symptoms or unconsciousness occurred independent of the angiographic findings or stump pressure., Results: In 23% (27/120) a shunt became necessary and significantly (p<0.001) more often when there was a cross-flow towards the contralateral hemisphere (12/20=60%) or if the contralateral ICA was occluded (9/13=69%). The sensitivity for not needing a shunt in case of cross-flow towards the side of operation was 91% (52/57) whereas the specificity was 35% (22/63). ICA stump-pressure was significantly reduced in patients requiring a shunt (31 mmHg) compared to those not needing a shunt (53 mmHg) (p<0.001), but no definitive threshold value was found determining the need for shunting. Intraoperatively, no persistent neurological complication developed., Conclusions: Angiographic cross-flow was a good, but not perfect predictor for the need of an intraoperative shunt.

Objectives: Even though endovascular aneurysm repair (EVAR) creates a closed chamber except for patent branches, the intra-sac pressure is never zero. This study was designed to investigate whether, and to what extent, aneurysm wall compliance influences intra-sac pressure., Design: In vitro experimental study., Methods: Aneurysm models with six and 12 latex layers were produced, resulting in elastic and stiff circumferential compliance (3.5 +/- 0.5 and 0.9 +/- 0.3%/100 mmHg, respectively). The models with an 18 mm internal neck and maximum aneurysm diameter of 60 mm were inserted into an in vitro circulation system. The systemic mean pressure (SPmean) was varied from 50 to 120 mmHg. After the aneurysm was excluded with a knitted polyethylene graft, aneurysm sac mean pressure (ASPmean) and aneurysm sac pulse pressure (ASPpulse) were measured. Data are presented as mean +/- SD. Statistics were performed using repeated measurements of variance; p<0.05 was considered significant., Results: In the model EVAR created a closed chamber without endoleak, but with an aneurysm sac pressure related to wall compliance. In the elastic aneurysm model with six latex coats the aneurysm sac mean pressure (ASPmean) and the aneurysm sac pulse pressure (ASPpulse) at all systemic pressures were significantly lower than they were in the stiffer model with 12 latex coats (p<0.05). At a SPmean of 90 mmHg, the ASPmean was 21.0 +/- 0.9 mmHg (six latex coats) and 26.0 +/- 0.2 mmHg (12 latex coats) (p<0.05), the ASPpulse was 5.7 +/- 0.2 mmHg (six latex coats) and 8.8 +/- 0.3 mmHg (12 latex coats) (p<0.05)., Conclusions: This in vitro model demonstrated that the aneurysm sac mean pressure (ASPmean) and the aneurysm sac pulse pressure (ASPpulse) were significantly influenced by the compliance of the aneurysm wall. These data highlight the need for further studies regarding endotension.

Purpose: To investigate in an in vitro model whether and to what extent pressure is influenced by aneurysm size., Methods: Latex aneurysms of 3 different volumes (24, 30, and 81 mL) were inserted into an in vitro circulation model. The systemic mean pressure (SP(mean)) was varied from 50 to 120 mmHg. The aneurysms were excluded using a woven polyethylene graft. Aneurysm sac mean pressure (ASP(mean)) was measured., Results: In the in vitro model, endovascular aneurysm repair created a closed chamber without endoleak but showed a relevant aneurysm sac pressure. At an SP(mean) of 80 mmHg, the ASP(mean) was 42.0+/-0.6 mmHg in the 24-mL aneurysm, 40.5+/-0.5 mmHg in the 30-mL model, and 19.3+/-0.5 mmHg in the 81-mL aneurysm (p<0.05). The ASP(mean) rose with increasing SP(mean) and was inversely dependent on the aneurysm volume., Conclusions: This in vitro model demonstrated that the sac mean pressure correlated to the systemic pressure and that a greater aneurysm volume reduced aneurysm sac pressure. These data highlight the need for further studies regarding endotension.

Background: endovascular aneurysm repair (EVAR) significantly reduces, but does not abolish aneurysm sac pressure, possibly because of trans-fabric transmission., Objective: to investigate how blood pressure is transmitted through different types of grafts into the aneurysm sac., Design: experimental study, in vitro., Methods: a latex aneurysm was inserted into an in vitro circulation model. The systemic mean pressure (SPmean) was varied from 50 to 120 mmHg. The grafts used for aneurysm exclusion were: thin wall polyethylene (PE), thick wall polyethylene (PE) and thin wall ePTFE. Mean aneurysm sac pressure (ASPmean) was measured, as was pulse pressure (ASPpulse)., Results: at an SPmean of 70 mmHg, the ASPmean was 34 +/- 0.8 mmHg (polyethylene knitted, thick wall), 30 +/- 1.0 mmHg (polyethylene woven, thin wall), and 17 +/- 0.6 mmHg (thin wall ePTFE). The ASPmean increased with SPmean, the relationship depending on the graft material. Stiffer grafts were associated with lower ASPmean and ASPpulse (p<0.001)., Conclusions: the relationship between aneurysm sac mean pressure and systemic pressure (SP) depends on the graft material. These data highlights the need for further studies regarding endotension.

Purpose: To relate the mean and pulse pressures in the cross-clamped aortic aneurysm sac to the systemic pressures during open repair (OR) of abdominal aortic aneurysm (AAA). To correlate the intrasac pressures to the number of bleeding lumbar arteries (LA) and the flow pattern of the inferior mesenteric artery (IMA)., Methods: In a prospective study of 55 patients (45 men; median age 69 years, range 47-84) undergoing open repair, the IMA flow and the mean pressure in the aneurysm sac (ASP(mean)) were measured before and after aortic and iliac artery cross clamping. The systemic mean pressure (SP(mean)) was recorded simultaneously. The aneurysm sac (ASP(pulse)) and systemic pulse pressures (SP(pulse)) were calculated, as were the mean pressure ratio (ASP(mean)/SP(mean)) and the pulse pressure ratio (ASP(pulse)/SP(pulse)). Values are given as the median (range)., Results: Cross clamping of the proximal aortic neck significantly reduced the mean pressure to 31 mmHg (14-64), with a pressure ratio of 0.39+/-0.14; the pulse pressure decreased to 0 mmHg (0-13) (p<0.001). Additional cross clamping of the iliac arteries did not alter the pressure levels any further. In the patent IMA (n=23), an orthograde median flow of 43 mL/min (2-135) was measured; sequential cross clamping of the aorta and iliac arteries reduced the flow to -6 mL/min (-130 to +21) and -3 mL/min (-120 to +22), respectively. There was no correlation between the pressure ratio and IMA patency, its volume flow, or the number of backbleeding lumbar arteries., Conclusions: The aneurysm sac is still pressurized with no pulsatility after cross clamping during open AAA repair. The aneurysm mean and pulse pressures did not correlate to the number of backbleeding lumbar arteries. Finally, the pressure ratios did not correlate to the highly variable IMA flow pattern during aortic cross clamping.

Purpose: To compare the outcomes of open versus endovascular repair of para-anastomotic aneurysms (PAA) in the aortic and iliac arteries in a cohort of patients who fulfilled morphological criteria for endovascular repair., Methods: A retrospective review of 31 consecutive patients with PAA treated between 1985 and 2002 identified 26 (84%) patients who would have been candidates for endovascular repair based on preoperative computed tomography and angiography. Of these 26 patients, 10 (9 men; median age 65 years, range 60-75) underwent endovascular repair; the remaining 16 patients (14 men; median age 61.5 years, range 49-78) had open repair. The baseline data and outcome measures were compared between the treatment groups., Results: The patient groups were well matched for age, sex, weight, risk factors, comorbidities, aneurysm length, and elapsed time from initial graft placement. Both groups had technically successful PAA repairs; however, median blood loss (300 versus 1000 mL; p=0.05) and procedural time (100 versus 215 minutes; p<0.001) were significantly reduced in the endovascular group. Median transfusion volume was significantly greater (1000 versus 0 mL; p=0.01) in the surgically treated patients. The median stay in ICU was similar (18 versus 24 hours in the surgical cohort). Length of stay was significantly shorter in the endovascular group: 7.5 versus 17.0 days (p=0.001) after the repair and 11 versus 22 days (p=0.01) for overall hospitalization. One (10%) patient in the endovascular group died from a myocardial infarction on the third postoperative day. In the open group, there were 3 (19%) procedure-related deaths., Conclusions: Patients with PAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. If long-term follow-up demonstrates durable results, stent-graft repair may become the therapy of choice in PAAs.

Endotension leading to enlargement of the aneurysm sac following the endoluminal grafting is still handled as an exclusive phenomenon of the endovascular aneurysm repair (EVAR). We report on a case with aneurysm sac enlargement caused by endotension leading to aneurysm rupture after conventional, open aneurysm repair, a so far not described complication. In a 74-year-old patient, following open surgical standard resection and reconstruction of an abdominal aortic aneurysm, a routinely performed abdominal ultra-sonography demonstrated a slowly growing enlargement of the peri-prosthetic aneurysm sac without endoleak. During the pre-operative work-up of the cardiac and pulmonary risk profiles, he complained of abdominal pain and back pain. Control CT revealed contrast inside the aneurysm sac as well as in the right-sided retroperitoneum. At the emergency operation a retroperitoneal haematoma was noticed. Opening the ballooned aneurysm sac, a fresh haematoma was also found. Lifting up the prosthesis, back bleeding at the dorsal circumference of the proximal anastomosis was confirmed due to a 2 cm long disruption of the anastomosis. In patients who present with abdominal or back pain after conventional surgery of an abdominal aortic aneurysm, a contrast CT should be performed to exclude an endoleak as well as other pathologies. The enlargement of the aneurysm sac without endoleak could be interpreted as endotension, with the consequence of urgent re-operation to prevent rupture.

The morbidity and mortality for open treatment of thoracic aortic aneurysms have declined over the years, but it is still a major clinical problem. The reason for the mortality is in almost 50% of the cases cardiac failure. Endoluminal treatment of abdominal aortic aneurysm is widely distributed and with promising results, although not as free from complications as expected 10 years ago. This technique has also been adopted for the thoracic aortic aneurysm as the trauma is much less than in open surgery. In our own personal series no specific workup for coronary heart disease has been made and the mortality of stentgrafting of the thoracic aorta was 2.4%. A survey of the world literature, including elective and acute dissections and aneurysms revealed 642 patients treated with stentgraft with a mortality of 6.2%, although no cardiologic work up had been performed. These numbers compete well with those of open surgery, but a systematic prospective comparison would be needed in order to state the real mortality in both groups.

Symptomatic dissecting aneurysms of the extracranial internal carotid artery after blunt trauma are not frequent. Medical treatment of these lesions can be ineffective and surgical options present high morbidity. We describe a case successfully treated with endovascular therapy, using a self-expanding stent. The advantages of the endovascular treatment are outlined, the literature on carotid artery injuries by blunt trauma and management strategies are reviewed.

Background: The success of endoluminal stent grafts (ELG) is critically dependent on secure proximal fixation of the graft. Different types of stent grafts with uncovered proximal portions for transrenal fixation are obtainable. The present in vitro study was designed to elucidate how the flow parameters were altered by stent jail of the renal arteries with respect to different stent design., Methods: The experiments were performed in an in vitro pulsatile circulation model. An aortic segment with bilateral side branches (like renal arteries) constructed of an ePTFE graft was perfused in the circulation model. The flow measurements were based on the ultrasound transit-time method. By varying the frequency from 30 to 100 bpm the flow parameters were altered and recorded continuously. Renal stent jailing was carried out using different stent types: Gianturco-Z-Stent, Palmaz-Stent, Powerlink Endologix., Results: The flow in the aortic model increased from 1100 ml per minute to 3330 ml per minute depending on the pump frequency. In the control group without stent jail the renal flow was measured between 240 ml per minute up to 810 ml per minute. The ratio of renal flow was between 0.22 and 0.24 of the aortic flow. In the Palmaz group the ratio was between 0.21 and 0.24, in the Gianturco group between 0.23 and 0.25, and in the Powerlink group between 0.24 and 0.25 (unpaired-"t"-test: n.s.)., Conclusions: The covering of the renal arteries and/ or superior mesenteric artery in case of long bared proximal stent raises the question whether the stent jail may result in flow reduction in the arteries covered or not. The present in vitro study demonstrated that the flow in the renal arteries is not decreased by these stent jails.

Objectives: To evaluate the effectiveness of ultrasound thrombolysis in vitro in comparison with thrombectomy, and in vivo as a pilot-study for the treatment of thrombotic occlusions of peripheral arteries., Methods: Under standardized conditions, one-day-old and five-day-old thrombi of whole blood, thrombin-induced thrombi and old organized thrombi of human blood were treated with ultrasound thrombolysis and Amplatz thrombectomy device (ATD). Four patients with arterial occlusive disease of Fontaine stage IIb-III underwent intraarterial ultrasound-thrombolysis, applied to long segmental occlusions of the superficial femoral or iliac artery ranging in duration from three days to one year., Results: The weight of the thrombi after ultrasound thrombolysis was 1.5 g +/- 0.53 (ATD: 0 g) compared to 3.65 g +/- 0.34 without treatment, with more weight reduction in five-day-old thrombi than in one-day-old thrombi. In vivo, partial recanalization was achieved in a three-day-old femoral occlusion. There was no effect in the other three patients. Urokinase thrombolysis with subsequent PTA and stenting resulted in complete recanalization in three patients., Conclusions: Ultrasound thrombolysis in vitro was significantly less effective than ATD. The results of ultrasound thrombolysis were influenced by the age of the thrombus and its in vitro formation. Intravascular ultrasound thrombolysis alone was insufficient to treat occluded peripheral arteries in vivo.

Chronic traumatic aneurysm of the thoracic aorta is an unusual occurrence. Open-chest surgery for repair of chronic traumatic aneurysms results in mortality rate of 5-18%, and a morbidity rate of 11-50% also. The evolution of endovascular technology offers the promise of a new, less invasive method to achieve aneurysm exclusion. A case of chronic traumatic aneurysm of the near isthmus thoracic aorta discovered on a chest X-ray and evaluated with chest computed tomographic scanning is presented. Stent-grafting procedure is described. Stent-grafting in chronic traumatic aneurysm of the thoracic aorta seems to be a viable minimal invasive therapeutic option for traumatic rupture of the aortic isthmus.

Objectives: To relate intra-aneurysm sac pressure during endoluminal AAA repair to early and late endoleak, as well as to the aneurysm size upon follow-up., Design: Prospective clinical investigation., Methods and Patients: In 46 patients who had their AAAs treated by a stent graft (group I), intra-operative pressure measurement was performed (aorta uni-iliac stent grafts: 25 cases, bifurcated stent grafts: 21 cases). In 18 patients with open repair (group II) flow in the inferior mesenteric artery, and the pressure in the aneurysm sac was measured, before and after aortic and iliac cross clamping. Values are given in median with range., Results: In group I, complete exclusion of AAA (no endoleak on intra-operative control angiogram) resulted in a statistically significant decrease in mean sac pressure from 74 (55-101) to 47 (4-104) mmHg. Pulse pressure reduced from 67 (34-103) to 8 (0-74) mmHg. In 11 patients a proximal type I endoleak was sealed by balloon modeling, after which the mean sac pressure reduced from 63 (14-91) to 52 (4-74) mmHg (n.s. versus patients with primary seal). Intra-operative pressure did not correlate with change in AAA diameter during twelve months follow-up. In group II, cross clamping of the proximal aorta significantly reduced mean sac pressure to 32 (21-55) mmHg, and the pulse pressure to 0 (0-13) mmHg (p < 0.05). Subsequent cross clamping of the iliac arteries did not significantly change the pressures., Conclusions: Measurement of intra-aneurysm sac pressure can help to detect and treat endoleaks during endoluminal grafting. However, the intra-operative sac pressure did not predict the fate of aneurysm during follow up. Compared to open repair of AAA, the sac pressure after endoluminal grafting remains significantly higher, in relation to pulse pressure.

Cardiovascular interventions to correct arterial occlusive disease have excellent short-term results, but long-term patency is still seriously compromised by the development of restenosis. This review will provide a portrait of the mechanisms following vascular injury, define the clinical scope of the problem and outline developments of different therapeutical strategies to prevent restenosis.

Hypothesis: The management of simultaneously occurring intra-abdominal abnormalities and abdominal aortic aneurysms or aortoiliac occlusive disease is controversial. The aim of this retrospective study was to analyze whether gastrointestinal operations performed at the same time as aortic repair increase the postoperative morbidity and mortality rate., Method: Between January 1, 1989, and December 31, 1997, a total of 42 patients underwent open aortic tube (n = 33) or bifurcated grafting (n = 9) and simultaneous surgery of 1 or more gastrointestinal abnormalities. In a matched-pairs analysis for each of the aforementioned patients, a control patient with an exclusive aortic procedure was selected. For each matched pair the following aspects were noted: the type of operative procedure, time of execution, duration of the surgical procedure, the duration of postoperative ventilatory assistance, intensive care unit and hospital stays, the number of blood units transfused, the use of antibiotics, and the main postoperative complications., Results: The comparison between the matched pairs revealed no statistically significant difference for postoperative morbidity or mortality rate or length of intensive care unit and hospital stays. There were no operative or hospital deaths. None of the patients has (median follow-up, 68 months) shown evidence of graft infection., Conclusion: A 1-stage operation management is feasible if appropriate care is given to the technical details and if the rules of antisepsis are followed.

The technical success of endoluminal grafting in AAAs depends on the complete apposition of the fixation points of the stent graft with the proximal and distal aneurysm neck. Approximately 20% of patients presenting with AAAs have concomitant iliac artery aneurysms. To achieve a complete apposition at the distal landing zone without endoleak, intentional occlusion of the internal iliac artery is needed. To evaluate the inherent complications, our results of ELG were compared to those of the bibliography.

Saphenous vein harvesting remains a 20% source of morbidity in patients who require lower extremity bypass or coronary artery bypass grafting. In an attempt to reduce the complications associated with this procedure, minimally invasive video-assisted vein harvesting is propagated. The technique uses currently available endoscopic equipment with mechanical retraction to dissect the great saphenous vein with two limited incisions. The dissection is visualized on the video monitor to isolate and control side branches by clips. The vein is removed for reverse arterial bypass grafting or dissection is completed for an in situ bypass procedure. Initial experience with ten patients undergoing peripheral bypass procedures showed a mean vein-preparation time of 60 min. Two of seven in situ bypass procedures were complicated by side branch damage controlled through longer skin incision. After a mean follow-up of 12 months, all bypasses are patent. Taking our own experience as well as that reported in the literature into consideration, aspects of cost-effectiveness are discussed.

Persistent sciatic artery as a rare entity results from lack of regression of the femoral artery blood supply of the leg and is often combined with an abnormally developed superficial femoral artery. We describe the case of a complete, persistent sciatic artery with peripheral ischemia caused by thrombo-embolism from buttock aneurysmal formation. Combined therapy of catheter fibrinolysis, followed by proximal and distal ligation of sciatic artery and peripheral bypass procedure, restored regular leg perfusion.

Aim: To review the complications of CT guided lumbar sympathicolysis (CTLS) on the basis of our own experience and the available literature., Methods: 241 CTLS were performed by a standard technique according to Haaga's method. Clinical follow-up revealed 4 serious complications; these were analysed and compared with published cases., Results: Amongst our patients there were three fibrotic ureter stenoses and one retroperitoneal abscess. Analysis of the serious complications described in the literature indicates that introduction of CT guided lumbar sympathicolysis has reduced the severity and frequency of complications as compared with surgical and "blind" procedures. With CTLS, no deaths due to the procedure have been reported in the literature. The results indicate that damage to the ureters can be caused by substances used for the neurolysis., Conclusion: Provided certain safeguards are obeyed, CTLS is a very save treatment. However damage to the ureter may follow even when the procedure was technically satisfactory. Therefore, sonographic control of the kidneys after three months is recommended.

Angiomyolipomas are hamartomas that may be found sporadically or associated with tuberous sclerosis (M. Bourneville-Pringle). Clinically, this long-term asymptomatic tumor becomes evident as an acute retroperitoneal hemorrhage or by symptoms of a flank mass. Due to the high percentage of fat components in this tumor type, computed tomography is far superior to other radiological procedures. In view of two of our own case reports, the therapeutic strategies are discussed, paying regard to the actual literature in this field.

Despite diagnostic and therapeutic advances, mesenteric vascular occlusion with intestinal infarction is often fatal. Parameters determining the high mortality are seldom discussed in the literature. By univariate statistical analysis we correlated the therapeutic outcome of our patients to 20 parameters. Between 1 January 1984 and 30 April 1996 we treated 22 men and 18 women with acute bowel ischemia of vascular origin. All patients underwent laparotomy, 40% (n = 16) due to the diagnosis of mesenteric infarction. In 15% (n = 6) the laparotomy was only exploratory; in 34 cases (85%) bowel resection was carried out. Mortality for all patients was 55% (n = 22). Univariate analysis of the 20 parameters showed that the therapeutic outcome was significantly correlated to a pre-existing diabetes, the course of hospitalization, and the high ASA class. There was no correlation to the length of resected bowel. Most parameters that determine the mortality of bowel infarction are pre-existing and cannot be influenced, but survival can be achieved in some patients if radical and aggressive resection is carried out at the side of almost complete small bowel infarction and followed by an elective second-look operation. Even short-bowel syndrome can be treated. Patients can return to a near normal lifestyle with an acceptable quality of life with the aid of parenteral nutrition at home.

Common late complications after esophagectomy and gastric tube reconstruction for esophageal carcinoma are symptomatic, benign fibrotic stenoses of the cervical anastomosis, which require dilatation. Since the prognosis of esophageal carcinoma still remains poor, bad functional results such as dysphagia affect quality of life. In a retrospective analysis, our patients were evaluated with regard to the underlying effects of cervical anastomotic stenosis after esophagectomy and gastric tube reconstruction. From 1 January 1989 to 31 July 1995, 173 patients with carcinoma of the esophagus were operated in our institution. Transhiatal esophageal dissection was performed in 133 patients; 40 patients underwent transthoracic en bloc resection. The 30-day mortality rate was 7.5% (13 patients). Postoperative fibrotic stenosis of the cervical anastomosis requiring dilatation occurred in 36.4% (63 patients) 6-12 weeks after operation. Fibrotic stenosis of the cervical anastomosis did not develop in 97 patients. There was a significant difference concerning the incidence of anastomotic leaks within both groups: whereas in 23.8% of the 63 patients who developed a fibrotic stricture of the cervical anastomosis an anastomotic leak preceded this event (P < 0.001), no anastomotic leak occurred in the group of 97 patients with normal healing of the cervical anastomosis. In addition, significantly (P < 0.01) more patients (37.5%, n = 23) with preexisting diabetes mellitus could be found among the 63 patients who developed a fibrotic stricture of the cervical anastomosis, in contrast to the 97 patients without anastomotic stenosis.

Animal and human bites are a extremely common problem. Despite the prevalence of this problem, few systematic studies have been done. There is astounding sparsity of factual information in the literature to aid the therapeutic decision. Crucial questions regarding suturing, antibiotics, and other matters have been left unanswered. Therefore the literature was reviewed and therapeutic guidelines extracted.

Indications: The efficiency of local fibrinolysis therapy in patients with chronic and acute peripheral arterial occlusions of the lower extremities has been investigated., Patients and Methods: A total of 33 patients were examined following a local fibrinolysis therapy (in 14 cases with supplementary percutaneous transluminal angioplasty) for chronic or acute peripheral arterial occlusion of the lower extremities. The success of the intervention was first evaluated by angiography and then by subsequent controls by means of treadmill ergometry., Results: A primary intervention success was achieved in 75.8% (25 of 33 patients) of the cases. In 18.2% (6 of 33 patients) a vascular surgical operation was required within 30 days of the intervention (5 therapy failures, 1 complication of the intervention). In two further patients, vascular surgery was necessary after five or six months. In 22 of the 25 successfully treated patients (92%), the Fontaine stage was reduced by at least one step after an average of 7.6 (range: 1 to 30) months., Conclusions: Local lysis with or without PTA represents an effective alternative therapy to vascular surgery for the treatment of peripheral arterial occlusions in not immediately endangered lower extremities. On the basis of our results and a survey of the literature, an aid for selecting therapeutic measures for patients with arterial occlusion of the extremities is presented.

Hemorrhoidal disease is the most common pathophysiologic abnormality in the anus in the western civilized world. Sixty years after publication of the method in The Lancet, hemorrhoidectomy according to Milligan and Morgan and modifications of their methods are still considered the standard procedure in cases of advanced hemorrhoidal disease. During the last 5 years, 107 patients underwent hemorrhoidectomy in the Department of Surgery at the University of Cologne. In most of these patients, the operation followed Milligan and Morgan's method. There were 69 males and 38 females with a mean age of 47.9 years. Mean length of hospital stay was 4.5 days. We saw one case of postoperative bleeding that required operative review. The patients' risk profile (age, concomitant diseases, ASA classification) did not influence the length of the hospital stay. Operative hemorrhoidectomy according to Milligan and Morgan allows a short stay in hospital according to the individual needs of the patient, with a high degree of safety concerning possible postoperative complications.

Since initially being described in 1980, percutaneous endoscopic gastrostomy (PEG) has had a dramatic impact on enteral access and alimentation techniques. Knowledge of the problems makes it possible to lower the complication rate of this method. We report a case of partial penetration of the gastric wall by the internal bolster of the tube. We focus on the prevention, recognition, and management of this PEG-related problem.

Mesenteric vascular occlusion with intestinal infarction is often regarded as a fatal illness. Often the diagnosis of severe ischemia is made during laparotomy. Sometimes resection is not performed because the conditions is thought to be incurable, and in such cases the mortality is 100%. If radical and aggressive resection is carried out even at the site of almost complete small bowel infarction and followed by an elective second-look operation, survival can be achieved in some patients. The motivation to attempt treatment should be further enhanced by the observation that the short-bowel syndrome following resection can be successfully treated, giving an acceptable quality of life for the patients. Between 1 January 1979 and 31 December 1979 we treated 9 male and 6 female patients with short-bowel syndrome after mesenteric occlusive disease; their ages ranged between 4 and 78 years, and the total duration of parenteral nutrition was 30,494 patient-days. With a median of 1503 days, the longest individual periods of parenteral nutrition were 4,919 and 5,015 days. We show the problems of long-term parenteral nutrition, including catheter-associated and nutritional complications, with reference to the individual courses of patients with short-bowel syndrome after mesenteric infarction. Despite some problems, patients of all ages can return to near-normality with an acceptable quality of life with the aid of parenteral nutrition at home.

Beetween 1979 and 1994 629 respectively 223 patients were treated by home enteral and parenteral nutrition. The duration of the treatment on average was 361 days in case of enteral and 346 days for home parenteral nutrition, in special cases however up to 15 years. In enteral nutrition there were no metabolic complications and only minor technical problems. Catheter related problems represented the most challenging complications in parenteral feeding. 12 out of 14 patients treated more than 1 year with home parenteral nutrition because of non-cancerous disease died from recurrent pulmonary embolism or catheter-related septicemia.

Objective: To describe our experience with three cases of leiomyosarcoma of the inferior vena cava, and summarise current methods of diagnosis and treatment., Design: Descriptive study., Setting: University hospital, Germany., Subjects: 3 Patients with histologically confirmed leiomyosarcoma of the inferior vena cava., Interventions: Resection, with or without vascular reconstruction., Main Outcome Measures: Morbidity and mortality., Results: Case 1 was diagnosed on magnetic resonance imaging, the tumour was resected, and the vena cava replaced with a polytetrafluoroethylene (PTFE) graft. She made an uncomplicated recovery and was well and free of symptoms 10 months later. Case 2 was diagnosed at operation (the differential diagnosis on computed tomography was a retroperitoneal tumour), the tumour was resected, and the defect oversewn. She made an uneventful recovery and was well and free of symptoms 14 months later. Case 3 was diagnosed at operation (a diagnosis of pancreatic cancer had been made preoperatively), the tumour was resected, and the defect oversewn. She was well and free of symptoms 10 months after operation., Conclusions: Magnetic resonance imaging is superior to computed tomography in the diagnosis of leiomyosarcoma of the inferior vena cava. The treatment of choice is resection; small defects can be closed by suture or PTFE patch, and large defects by PTFE prostheses. Reported resectability is 40% to 60%, but the prognosis is poor; the local recurrence rate is about 36%, most patients are dead within 2.5 years, and the 5-year survival is 30%. Chemotherapy and radiotherapy will give some degree of palliation, but do not affect the outcome.

A 52-year-old man had a generalized seizure resulting in fracture of two vertebrae 10 years after excision of a superficially spreading melanoma (Clark level III) on the left flank. Additional to pain on pressure over the right upper abdomen, the erythrocyte sedimentation rate was increased (41 mm) and the activity of the liver enzymes was raised. Neurological examination indicated a loss of short-term memory, signs of meningeal irritation, unsteady gait and falling tendency. Cerebrospinal fluid showed mild pleocytosis and cells suspicious of tumour. Upper abdominal ultrasonography revealed an enlarged gallbladder with contents of soft-tissue density. Magnetic resonance imaging showed numerous round lesions in the brain which looked nodular after contrast-medium injection. Cholecystectomy revealed metastases of a malignant melanoma. It was likely that the cerebral lesions also represented metastases. The confusional state increased in severity. Neither cytostatic drugs nor radiotherapy were administered, because of the poor prognosis. The patient, now fully disoriented, died 54 days after hospital admission.

Esophageal perforations are rare but most often caused by instrumental lesions during endoscopy. We describe a cases of the iatrogen esophageal perforation accompanied with perforation of the pericardium. Chest radiograph with Gastrografin swallow revealed the perforation. The principles of operative treatment and the postoperative course are demonstrated.

Laparoscopic methods are becoming increasingly popular in surgery. In the course of a review concerning laparoscopic appendectomy undertaken up to 31 December 1993 all publications were evaluated by computer-assisted research. Out of a total of 90 publications only 14 deal with the comparison of the laparoscopic versus open appendectomy. Two prospective randomized studies are published. Because of the low number of patients the evaluation of the laparoscopic method is not yet definite.

Since first described in 1883 by Fournier only 420 cases of Fournier's gangrene have been published worldwide during the last 100 years. The anatomic association between the fascies of penis, scrotum, perineum, groin and gluteal favors the fast spread of tissue necrosis. We report two cases in which the penis, scrotum and a great part of the trunk and extremities were affected. Extensive débridement, including removal of the scrotum, and antibiotic treatment permitted us to get rid of the symptoms. Reconstruction of the skin defects was done in a second step by applying mesh grafts. The histological findings correspond to those found in cases of necrotizing fasciitis. The basic difference between these two illnesses is their localization. While Fournier's gangrene, as a special form, is localized primarily in the anogenital area, fasciitis may arise in all locations. For successful treatment of Fournier's gangrene speedy radical débridement and local application of antibiotics to cover the entire area are required.

Arterial aneurysms of the infrapopliteal vessels are rare. The majority are false aneurysms caused by trauma. Presenting symptoms are calf mass and distal ischemia. Asymptomatic lesions may be found incidentally during arteriography. On the basis of a case report the procedure of surgical treatment concerning these aneurysms is described.

From January 1, 1981 to January 1, 1992 a total of 30 liver abscesses were treated in the University Clinic for Surgery in Cologne. 23 patients underwent an primary operative treatment and seven patients received a controlled guided percutaneous drainage. During the observation period four patients (13.3%) died by the effect of the liver abscess. 20 patients (66.7%) were subjected to clinical, laboratorical and computertomographical post examinations. The primary rate of operation success amounted to 47.8%, that of controlled guided percutaneous drainage of 42.8% (NS). The secondary success rate (that means after successful operative reintervention) amounted to 86.9% by the operative and to 85.7% by the percutaneous drainaged cases. During the post examination no relapse was determinated. Larger or chambered liver abscesses as well as extrahepatic spreading required operative drainage and, in cases of multifocal spreading, a resection with concomitant antibiotics. In case of solitary abscesses the controlled guided percutaneous drainage is the least harmful and low-prices method.

Spieghelian hernia is a rare rupture of the abdominal wall along the linea semilunaris. Due to the fact that the rupture is overlain by the aponeurosis of M. externus abdominis, it is often not recognized in its early stage. In most cases the rupture neck is mostly very narrow and in 24.1% of all cases an incarceration of intestinal parts has ensued which may even lead to the development of an acute abdomen. The first choice therapy will consist in an operative support including the reposition of the hernial content and a possible resection of ischaemic organs as well as removal and sealing of the hernia. Because of the rarity of this sickness we report on a patient in our clinic who was operated as an emergency.

The compartment syndrome, a well known complication in traumatized patients, is not taken enough notice of in the literature of vascular surgery despite it's obviously important pathophysiological context. Considering arterial occlusive disease the ischemia as well as the reperfusion can increase the compartmental volume respectively the tissue pressure. The subfascial pressure measurement should not lead to a false certainty, since no critical pressure values exist that can serve as a general criterion for diagnosis and treatment. The "thought about it" may be the first step to a clinical diagnosis and subsequent therapy. Decompression of all four compartments at the lower leg by the technique of Matsen represents the therapy of choice for the compartment syndrome of the lower leg.