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Interventional radiology has an increasing spectrum of indications, in particular, for vascular medical problems. By Seldinger's puncture via the right femoral artery, an aneurysm of the right common iliac artery stump was sufficiently excluded with coil embolization. As a complication, an iatrogenic bleeding at the aneurysmatic neck was effectively stopped after the first interventional step with injection of an occlusion emulsion according to the bleeding site. Image-guided interventional measures in radiology allow a minimal invasive approach in a former classical field of vascular surgery. Furthermore, procedure-related complications can be increasingly controlled.

Introduction: Ischaemia of the visceral arteries is considered to be an extraordinary challenge in the interdisciplinary therapeutic management., Aim and Method: Using a case series of patients with chronic ischaemia of the visceral arteries, our diagnostic and therapeutic experience was analysed with regard to postoperative quality of life (increase of body weight, frequency in daily diarrhoea), perioperative morbidity and hospital mortality in dependence on the type of surgical reconstruction of the visceral arteries., Results: During a time period of 2 years, 3 patients (male/female=1:2; mean age, 61.7 years) underwent surgical interventions on the visceral arteries from a total of 1118 vascular interventions (main indication revealed by colonoscopy and pathohistology of mucosal biopsy: ischaemic colitis). In all cases, symptomatology was affected by abdominal angina. Duplex sonography, angiography, and multislice CT scan revealed the combination of an occlusion of the coeliac trunk and of the superior mesenteric artery by atherosclerosis in 2 cases. In the remaining case, there was an isolated occlusion at the origin of the superior mesenteric artery. For revascularisation, the aortomesenteric reconstruction was subdivided according to the: i) target vessel: -combination of revascularised common hepatic artery and superior mesenteric artery (n=1) with an autologous Y-vein bypass ("reversed technique"), -exclusive revascularisation of the superior mesenteric artery (n=2)-prosthetic bypass; ii) origin of the bypass: -from the supracoeliac aortic segment (antegrade) n=3 (primarily in patients 1 and 3; as a redo operation in patient 2); -from the infrarenal segment (retrograde) n=1 (initial surgical intervention in patient 2) using an autologous venous bypass. In all cases, a significant improvement of the quality of life was observed as indicated by an increase of body weight (n=3; +no further abdominal angina) and primary wound healing in all 3 cases (hospital mortality, 0)., Conclusion: Chronic ischaemia of the visceral arteries is characterised by an increasing incidence and a stealthy onset and requires an interdisciplinary approach to find the correct diagnosis using all available diagnostic procedures including sufficient periodic follow-up investigations. We favour the antegrade aortomesenteric revascularisation from the supracoeliac aortic segment as a promising surgical option in chronic ischaemia of visceral arteries.

Background: Tumor lesions of the inferior vena cava (IVC) can originate from the vein or can develop by malignant tumor infiltration from the surrounding tissue. In this context, particular attention should be paid to tumor lesions with pegs into or within the IVC. The aim of this series of a single surgical center was to analyze the perioperative management, the individual-specific and -adapted surgical technique, as well as the outcome including prognostic considerations in IVC-associated malignant tumor lesions., Patients and Methods: Over a 6-year time period, all consecutive patients with IVC-associated malignant tumor lesions and their patient- and finding-specific characteristics were registered, data and parameters of the diagnostic and therapeutic management were documented, and both the short- and long-term outcomes (complication rate, perioperative morbidity/mortality, tumor recurrence rate, survival) were assessed with periodic follow-up investigations., Results: Overall, 12 patients were enrolled in the study from 1/1/2001-31/12/2006:6 primary IVC-tumors (leiomyosarcomas, 50%) and 6 secondary IVC-tumors (2 retroperitoneal tumor lesions, 16.7%, 3 renal cell carcinomas 25% and 1 carcinoma of the adrenal gland, 8.3%). 4 of the secondary tumors had pegs into the IVC. The RO resection rate was 83%. The perioperative morbidity was 33%; whereas, the hospital mortality was 8.3% (n = 1). Surgical reconstruction of IVC was achieved in each case (100%). There was a mean postoperative observation period of 20 months (range, 1-58 months). Complete follow-up documentation was obtained for all of the patients (100%). Three patients experienced recurrent tumor growth (27.5% out of n = 11). While the overall mortality through the follow up observation period was 27.5%, the tumor-specific mortality was 16%., Conclusions: The primary surgical aim is RO resection to provide a long-term outcome with no tumor recurrence including the reconstruction of the IVC based on a reasonable risk-to-benefit ratio. The favorable outcome of this case series demonstrates that IVC-associated tumor lesions can be approached if there is an appropriate expertise of the surgical team, a sufficient perioperative management and an adequate financial background with a reasonable survival rate. The variable prognosis of the various tumor lesions depends on tumor entity, stage, resection status and individual risk factors.

Hemorrhage caused by tumor invasion of the axillary artery is a rare, but serious complication. A 70-year-old female with a history of inflammatory breast cancer was diagnosed with hypovolemic shock caused by arterial bleeding into the left axilla. After successful reanimation an emergency arteriography was performed. The bleeding site was localized in the proximal part of the axillary artery. A self-expanding endoluminal graft was positioned across the lesion. The final angiography showed a correct placement of the stent with excellent distal flow, and no signs of bleeding. On the seventh day, the patient was discharged with ambulatory follow up.

Primary sarcoma of the gallbladder is a very rare neoplasm, and there are few instances of its diagnostic and therapeutic management. We describe a 66-year-old male patient with a sarcoma of the gallbladder. He initially underwent a laparoscopic cholecystectomy, converted to an open procedure. Histology showed a primary sarcoma of the gallbladder (NOS). A relaparotomy, with resection of the cystic stump, anatomical hepatic resection of the fifth segment, including the bed of gallbladder, and lymphadenectomy was performed a few days later. The two surgical interventions were done with no major complications, and a radical resection status was achieved. Histological investigation revealed a malignant mesenchymal tumor lesion, which was classified as a myogenous sarcoma with a hemangiopericytomatous pattern. After an 11-month, uneventful, postoperative course, local tumor recurrence was diagnosed. Palliative chemotherapy was scheduled, but the patient died of advanced tumor recurrence 10 days after this diagnosis. Despite a poor overall prognosis, extensive surgical resection is favored for myogeneous sarcoma of the gallbladder; this procedure is based on precise clarification of the histopathological diagnosis, and can be followed by attempts with radiation of chemotherapy if early diagnosis-finding has failed. This approach allowed, in our patient with this rare neoplasm, a remarkable tumor-free survival of almost 1 year.

Inadequate analgesia or anxiety may induce an increased stress response in patients undergoing carotid endarterectomy (CEA) under regional anesthesia (RA). Central alpha2 adrenoceptor agonists have significant sedative and analgesic properties, which may attenuate sympathoadrenal activation during CEA and improve the quality of RA. We randomly assigned 80 patients to 2 groups receiving either RA plus placebo (n = 40) or RA plus clonidine 1 microg/kg as the initial loading dose followed by 1 microg.kg(-1).h(-1) (n = 40). RA was performed as combined deep and superficial cervical plexus blockade. Hemodynamic and neurological variables were assessed before, during, and after CEA. Arterial blood samples were collected at defined time points for the determination of plasma concentrations of epinephrine, norepinephrine, cortisol, and creatinine kinase and creatinine kinase-MB. Throughout the study, all patients responded easily to neurological evaluations. Before and during clamping mean arterial blood pressure and heart rate were not different between the groups, but mean arterial blood pressure was lower in the clonidine group (P < 0.01) at skin closure and postoperatively in the intensive care unit. In the placebo group, cortisol, epinephrine, and norepinephrine plasma concentrations were increased significantly (P < 0.05) and more patients required antihypertensive treatment (P < 0.01). Postoperatively the incidence of hypertension (P < 0.001) and development of neurological deficits (P < 0.05) was significantly decreased in the clonidine group. We conclude that 1 microg.kg(-1).h(-1) clonidine suppresses the hyperadrenergic response to CEA without adverse effects on hemodynamics or clinical neurological monitoring.

Aim: To investigate whether the routine use of fibrin glue applied onto the hepatic resection area can diminish postoperative volume of bloody or biliary fluids drained via intraoperatively placed perihepatic tubes and can thus lower the complication rate., Methods: Two groups of consecutive patients with a comparable spectrum of recent hepatic resections were compared: (1) 13 patients who underwent application of fibrin glue immediately after resection of liver parenchyma; (2) 12 patients who did not. Volumes of postoperative drainage fluid were determined in 4-h intervals through 24 h indicating the intervention caused bloody and biliary segregation., Results: Through the first 8 h postoperatively, there was a tendency of higher amounts of fluids in patients with no additional application of fibrin glue while through the following intervals, a significant increase of drainage volumes was documented in comparison with the first two 4-h intervals, e.g., after 12 h, 149.6 mL +/-110 mL vs 63.2 mL +/-78 mL. Using fibrin glue, postoperative fluid amounts were significantly lower through the postoperative observation period of 24 h (851 mL +/-715 mL vs 315 mL +/-305 mL)., Conclusion: For hepatic resections, the use of fibrin glue appears to be advantageous in terms of a significant decrease of surgically associated segregation of blood or bile out of the resection area. This might result in a better outcome.

The indication of vena cava filter implantation is controversially discussed. On the basis of the available literature and our own results a critical analysis of this issue is given. Between 1994 and 2003, we inserted a total of 29 vena cava filters; 24 temporary and 5 permanent filters. In twelve patients, the placement of the filter was indicated due to pulmonary embolism and a contra-indication to dose adjusted heparin therapy. Seven additional patients experienced a recurrent pulmonary embolism despite adequate heparin therapy. An additional prophylactic filter insertion was carried out in ten patients. The temporary vena cava filters were left in place between 7 to 38 days with an average of 17 days. Total implantation time of temporary filters was scheduled until complete mobilisation of the patients, generally in conjunction with an effective dosage of oral anticoagulants. No patient died in connection with the insertion of the filter and no further pulmonary embolisms occurred. One case of inferior vena cava thrombosis occurred in each group of temporary and permanent filters. In one third of the removed filter systems, thrombi in the filter were found. Local infections of the catheter and introducer sets were observed in two patients. Moreover, in one case the strut of a temporary filter broke and subsequently dislocated 17 days after insertion. However, there is little evidence concerning vena cava filters, and further investigations are necessary. Until additional data are available, filters should generally be restricted to patients with deep venous thrombosis and pulmonary embolism who cannot receive anticoagulation, and highly selected cases.

Aim: Differential diagnosis and management of the lower extremity compartment syndrome as a potentially devastating complication of prolonged surgery in the lithotomy position., Case Report: A 55-year-old patient underwent radical cystoprostatovesiculourethrectomy including reconstruction of an ileal conduit because of a multifocal recurrent tumor of the urinary bladder (operating time > 8 hours). On the first postoperative day, the patient complained about swelling within the right calf leading to the suspicion of a deep vein thrombosis. Phlebography of the right leg revealed: i) thrombosis-untypical occlusion of the distal popliteal vein and ii) no detection of the deep vein within the right calf (femoral and iliac veins were with no pathological finding). Tissue pressure was as follows: right, 55 mmHg/left, 11 mmHg, underlining clinical suspicion of compartment syndrome. The patient underwent a fasciotomy of the right calf. Over the following 5 days, muscle edema decreased, allowing subsequent mobilization of the patient. On the 8 (th) postoperative day, the patient died unexpectedly due to an acute myocardial infarction., Conclusion: In case of a swelling of the lower extremity after long-lasting surgical interventions performed in lithotomy position, a compartment syndrome is one of the possible differential diagnoses, the consequences of which can be avoided by an early diagnostic and adequate treatment.

Introduction: This work presents initial experimental results obtained with co-incubation of human neutrophilic granulocytes from patients with various diseases (5 patients each group) and collagen- or silver-coated polyester grafts (25 patients each graft)., Methods: After two-hour co-cultivation of the graft with human granulocytes of different patients (normal controls; peripheral occlusive vascular disease; diabetes mellitus; carcinoma/chemotherapy; sepsis), the following parameters were determined by flow cytometry: CD11b, CD62L, fMLP, CXCR2., Results: The change in the receptor expression was taken as a measure of responsiveness, with statistically significant differences seen within and between the groups. For the silver-coated graft, such differences were mainly noted for the fMLP receptor (p=0.01). For the two-hour incubation with collagen coating, the receptors CD62L and CXCR2 were indicative of differences between the various diseases (CD62L p=0.01; CXCR2 p=0.01). Comparison between the grafts revealed statistically significant differences for the CXCR2 and the fMLP receptors (CXCR2 p=0.00; fMLP p=0.03)., Conclusions: The differences noted between the grafts and between the patients groups are suggestive of an altered responsiveness of the granulocytes to the grafts. This enables new aspects with respect to the genesis of accompanying clinical symptoms.

Aim: Evaluation of the diagnostic and therapeutic management of peripheral steal syndrome after placement of an autologous arteriovenous (av-) fistula and presentation of treatment results after its surgical correction., Methods: During a time period from 1994 to 1999, 1 253 av-fistulas for hemodialysis were placed in our surgical department. Twenty-one patients (1.68 %) underwent service operations because of considerable lower perfusion of the hand. In 14 patients the av-fistula was ligated, whereas in 7 patients, a polytetrafluorethylene (PTFE) sleeve was implanted at the venous site for fistula "banding" to diminish blood flow. In addition to the clinical finding, pre-, intra- and postoperative blood flow rates were determined using Duplex ultrasonography., Results: In patients showing flow rates of < 250 ml (carefully disclosed empiric value) ligation was chosen, whereas in cases with distinctly increased flow rates, banding of the arterialized vein was performed (authors' individually selected borderline flow). The extension of the banding was specified according to the intraoperatively determined flow rates. Recurrent steal syndrome was not observed over the entire postoperative observation period of 1-3 years., Conclusion: Arterial steal syndrome is a rare complication after placement of an av-fistula. In the majority of cases, surgical therapy is necessary. Pre- and intraoperative analysis of flow rates using Duplex ultrasonography may help to select the appropriate surgical approach and may, thus, determine the success rate of service operation.

Placement of arteriovenous (av) fistulas has been executed at the reporting surgical department for 3 years. Calculation of the reimbursement by the insurance companies is based on the so-called "Unique Evaluation Table" (Einheitlicher Bewertungsmassstab). The aim of the study was to evaluate the efficiency of the placement of av fistulas in an out-patient setting and the acceptance of this approach in the patients. The costs based on an average of the duration of the intervention and treatment at the out-patient clinic per time unit for surgeon, nurse and operating room, as well as costs for use of specific materials were listed, summarized, and compared with the amount of money which was reimbursed by the insurance companies according to the "Unique Evaluation Table". During the 3-year time period, 67 patients underwent 70 placements of av fistulas in an out-patient setting (in total, 532 interventions). Patients answered a questionnaire, and procedures were evaluated for average costs. Based on the table-dependent reimbursement of DM 274.00 (according to the "Unique Evaluation Table"), costs of DM 497.94 (DM 445.50 for 54 min of mean duration of surgical procedure plus DM 52.44 for materials) were determined, indicating that no full reimbursement was found despite the fact that there was only a minimal rate of early complications (thrombosis, n = 2 [3%]) (infection, n = 1 [1.5%]). The expenses were 81.7% on average above the level of the reimbursement. In conclusion, despite high acceptance of an out-patient setting for placement of av fistulas in patients (82%), it is not efficient from an economic point of view and can be only provided for specifically selected cases. Therefore, it is not advisable at present to place av fistulas at German out-patient clinics with no following admission of the patients, to avoid financial disadvantages for the surgical department. New negotiations between the medical profession and the insurance companies are urgently needed to ensure an improved financial outcome for the clinics.

We report the course of 2 patients with ruptured aneurysms of the iliac artery admitted in hemorrhagic shock which were treated successfully. These 2 cases demonstrate that a rupture of a retrogradely perfused aneurysm as a late complication of aortobifemoral bypass grafting is possible even after 10 years. Wether these aneurysms are causally connected with the peripheral run-off remains unclear. In our opinion, these 2 examples underline the importance of long-term follow up after resection of abdominal aortic aneurysms with femoral end to side bypass anastomoses. The goal is the early detection and therapy of metachronous iliac aneurysms before rupture.

Simultaneous treatment of Salmonella typhimurium-induced symptomatic abdominal aortic aneurysm with associated spondylitis. Bacterially infected aneurysms associated with local spondylitis, while representing a potentially fatal clinical picture, are an operative challenge for vascular surgeons and orthopaedic surgeons alike. In this context, the concurrent occurrence of an infection with Salmonella typhimurium as a causative agent is a rare observation. The case report gives an outline of the simultaneous vascular and orthopaedic surgical procedure. The subrenal mycotic aneurysm was removed in a first step. The continuity of the aorta was restored centrally through an autogenic aortic graft with caudal anastomosis to a dacron vascular prosthetic tube. Initially, the latter was chosen of excessive length so as to facilitate the orthopaedic surgeon's approach. Upon completion of stabilising surgery of the vertebral column, the dacron tube was reduced in length as necessary and the surgical area was enclosed with an omentum majus plastic mesh. No complications were noted during the 18-month follow-up period.

In the course of reconstruction of peripheral arterial occlusion processes, two gelatin-coated Dacron grafts and one collagen-coated Dacron patch were implanted in a 52-year-old male patient. Eight days following low-dose heparinization (5 days prior to surgery, 3 days postoperatively) with unfractionated heparin, with no clinical symptoms present, a dramatic isolated thrombocyte depression occurred, from 212 Gpt/l prior to surgery to 14 Gpt/l on postoperative day 3. Laboratory tests verified an HIT type II [heparin-induced platelet aggregation assay (HIPAA) and ELISA]. Despite immediate discontinuation of heparin and commencement of an anticoagulant therapy with Revasc and Refludan, an 8-week thrombocyte depression occurred which was eliminated only temporarily by administration of gammaglobulin. The specific antibody tests turned out positive for more than 5 months. Having ruled out other causes of thrombocytopenia, we assume that the case presented was either due to an interaction not elucidated to date or triggered by the grafts (gelatin/collagen/Dacron). The manufacturers of the grafts have disputed a heparinoid action.

We analyzed reasons, numbers and results of arterial lesions accompanying fractures (n = 21) and luxations (n = 6) in a 6-year-period (1993-1998) retrospectively. Traffic accidents were in nearly 50% responsible for the injuries. 8 patients had suffered multiple injuries. In 17 patients the lower, and in 10 patients the upper extremities were affected. The vascular wall was completely disrupted or severed in 74%. In 7 cases (26%), patients had suffered blunt or indirect arterial trauma with intima- and media-lacerations due to subcapital fracture of the humerus (n = 2), fractured femoral bone (n = 1), luxation of the knee joint (n = 3) or the elbow (n = 1). The mean preoperative time period was 6 hours and 20 minutes (2 to 16 hours) in patients with complete ischaemia. Vascular reconstruction was performed by interposition of an autologous vein graft or an autologous venous bypass (n = 20), by direct reconstruction and primary suturing (n = 2), by use of a venous patch plasty (n = 2) and, in a single case, by autologous bypass procedure. In one case, a crural artery was ligated, in another case with a Mangled Extremity Severity Score (MESS) of 7 points a primary amputation of the lower leg was necessary. In 5 patients (19%) secondary amputations were performed. No patient died. The final outcome is mostly influenced by the preoperative period of ischaemia.

Ergotamine-containing drugs are widely used in the treatment of acute migraine attacks. Spastic vasoconstriction is one of the possible side effects usually affecting the lower extremities and sometimes leading to gangrene. A 28-year-old woman was hospitalized for severe acute arterial insufficiency of the limbs. The initial surgical approach was not successful since the diagnosis was missed. Overuse of ergotamine derivative was acknowledged by the patient, who had a long history of migraine headaches. Therefore, the patient was treated conservatively with intravenous heparin and prostaglandin infusion and sympatheticolysis via epidural catheter. The vascular complications, angiographic findings, and different modalities of treatment of ergotamine-induced peripheral vascular insufficiency of the lower limb are reviewed.

Purpose: To report the endovascular repair of concomitant aneurysms of the abdominal aorta and both internal iliac arteries., Case Report: A 72-year-old man with a 5.5-cm abdominal aortic aneurysm (AAA) extending to the right common iliac artery also presented with separate aneurysms of both internal iliac arteries. The patient refused conventional surgery, so an endovascular strategy was devised. Initially, the iliac aneurysms were sequentially coil embolized, allowing several weeks to elapse between the embolization sessions to encourage collateral development. A bifurcated Talent endograft was inserted successfully 8 months after the initial intervention; no evidence of endoleaks or mesenteric ischemia has been seen over a 1-year follow-up., Conclusions: This case illustrates the feasibility of inducing collateralization prior to endovascular AAA repair that would jeopardize internal iliac artery circulation bilaterally. Sequential embolization of the internal iliac arteries over several months initiates this response, paving the way for eventual endovascular repair of the primary aortic aneurysm.

In daily practice, an atypical renal blood supply is a rare finding. An ectopic origin of the right main renal artery from the contralateral common iliac artery was observed when angiography was performed to diagnose irregularities in perfusion of the lower extremities and to determine the necessity for vascular surgical intervention in a 66-year-old man. Conservative treatment was successful in this patient, who suffered from intermittent claudication because of an obstruction of the superficial femoral arteries. The diagnostic approach with angiography is considered to be essential for revealing such anomalies. Conventional vascular surgical reconstruction would have threatened the perfusion of the right kidney in this case.

The treatment modalities for renal artery aneurysm have changed. The aim in the presented case was to evaluate the endovascular therapy in a 52-year-old woman (with hematuria as the only symptom) with a saccular aneurysm at the first bifurcation of the right main renal artery, which was diagnosed with contrast-enhanced computerized tomography and angiography. We approached the aneurysm with minimally invasive supraselective embolization. There were no postoperative complications, as confirmed with control angiography, during the intervention and after an interval of 4 weeks. In conclusion, selective coil embolization as first-line therapy to treat saccular renal artery aneurysm is feasible. In this case, minimally invasive procedure provided maximum functioning kidney tissue.

Purpose: To describe the use of a stent-graft for emergent repair of life-threatening hepatic artery hemorrhage., Methods and Results: A 57-year-old man with a 17-year history of myxoid liposarcoma underwent surgery for a recurrent abdominal mass. Multivisceral resection including a Kausch-Whipple procedure with an extended right hemicolectomy was performed. Three weeks later, an episode of gastrointestinal bleeding prompted surgical repair of the hepatic artery, which had been eroded by infection due to a leaking bilioenteric anastomosis. After 3 weeks of programmed abdominal lavage, bleeding recurred. Angiography documented another rupture of the proximal hepatic artery. After an unsuccessful attempt at coil embolization, a Hemobahn stent-graft was implanted percutaneously during simultaneous cardiopulmonary resuscitation. Hemostasis was secured, and the patient recovered. Over the 10-month follow-up, no bleeding or infection has been observed at the site of the repair, and flow through the hepatic artery endograft remains satisfactory., Conclusions: Percutaneous stent-graft placement can be employed for emergent treatment of visceral artery rupture in patients at high risk for conventional surgical repair.

The incidence and etiology of iatrogen vascular injuries have changed during the last years due to the fact that many vascular procedures, including invasive catheter procedures, minimally invasive interventions and osteosynthetic operations are more frequently performed. 66 patients who were treated between 1993 and 1997 were retrospectively analysed. The most common cause of surgical repair were lesions after catheter procedures (n = 47; 71.2%) followed by various other causes (traumatology n = 6, orthopedics n = 5, gynecology n = 4, general surgery n = 4). In patients with complicated catheterizations and need for acute vascular-surgical repair, the limb could only be preserved in 12 of 21 cases (57.1%). Vascular lesions on account of other operative specialities finally required an amputation in 3 patients. One patient in this group died. Besides the seriousness of injury one main reason for an unfavourable outcome was a delayed diagnosis with subsequent exceeding of the ischemic tolerance in 18 patients (27.3%). Some rare and serious complications are especially discussed.

Endovascular repair of AAA's using stent grafts is considered to be a minimally invasive procedure. However, in some cases deleterious inflammatory reactions, e.g., flu-like postinterventional symptoms are observed. A few patients even develop a fatal "postimplantation syndrome". It is not clear whether these postoperative complications result from a) the inflammatory and immune response to the inserted graft material, b) alterations of the vascular endothelium during the implantation procedure, c) residual thrombotic material, or d) a combination of all these causes. This clinical trial aimed to prospectively investigate the association between inflammatory mediators like interleukin-1 receptor antagonist (IL-1RA), IL-6, and HLA-DR expression on monocytes and clinical outcome in patients after repair of abdominal aortic aneurysms (AAA). Fifteen patients treated with endovascular stent grafts for abdominal aortic aneurysm (AAA-E) were compared with 15 selected control patients who underwent a conventional surgical procedure (AAA-K) during the same period. Prior to intervention, there were no significant differences in marker levels. One hour postoperatively, IL-6 (421 pg/ml vs. 21 pg/ml) and IL-1RA (10,061 pg/ml versus 407 pg/ml) were significantly increased in the AAA-K-group, whereas in AAA-E patients, these parameters increased more gradually during the first postoperative day and did not reach the same level as in the control group. There was only a slight reduction of HLA-DR expression in both groups compared with baseline and no signs indicating a postimplantation syndrome were found. No excessive inflammatory response or complicated final outcome were observed. It is unclear if this can be explained by the prophylactic use of indometacin.

Trauma-induced arteriovenous (av) communications in the cervical region involving the external carotid artery and the jugular vein are exceptionally rare. Moreover, an iatrogenic av fistula between the vertebral artery and the vein after insertion of a venous catheter into the internal jugular vein is described. The discussion includes the clinical presentation, diagnosis and management of such rare av fistulas.

Upper gastrointestinal hemorrhage is the most frequent indication for emergency endoscopy. In most of the cases the bleeding is primarily treated endoscopically. The duodenal penetration of an aortic graft implant is a rare condition, only accidentally diagnosed by endoscopy. This condition represents a difficult situation for the endoscopist since it is usually not included in the differential diagnosis. Additionally hemostasis can not be achieved by endoscopic intervention. Therefore the instant realization of this dangerous diagnosis is extremely important, because only surgical therapy in a center of vascular surgery may save the live of the patient.

In this case report, we describe an nontraumatic extracranial aneurysm of the vertebral artery at the V3 segment. Its etiology and pathogenesis could not be clarified completely. The walnut-sized aneurysm was treated surgically by proximal ligation. There were no postoperative complications.

Background: Objective evaluation of the management of patients with ruptured infrarenal aortic aneurysm in emergency situations has been described rarely., Patients and Methods: Fifty-two consecutive patients with ruptured infrarenal aortic aneurysm (mean age, 70.3 years; range, 56-89 years; SD 7.8) were admitted between January 1993 and March 1998. Emergency protocols, final reports, and follow-up data were analyzed retrospectively. APACHE II scores at admission and fifth postoperative day were assessed., Results: The time between the appearance of first symptoms and the referral of patients to the hospital was more than 5 hours in 37 patients (71%). Thirty-eight patients (71%) had signs of shock at time of admission. Ultrasound was performed in 81% of patients as the first diagnostic procedure. The most frequent site of aortic rupture was the left retroperitoneum (87%). Intraoperatively, acute left ventricular failure occurred in four patients, and cardiac arrest in two others. The postoperative course was complicated significantly in 34 patients. The overall mortality rate was 36.5% (n = 19). In 35 patients, APACHE II score was assessed, showing a probability of death of more than 40% in five patients and lower than 30% in 17 others. No patient showing probability of death of above 75% at the fifth postoperative day survived (n = 7)., Conclusions: Ruptured aortic aneurysm demands surgical intervention. Clinical outcome is also influenced by preclinical and anesthetic management. The severity of disease as well as the patient's prognosis can be approximated using APACHE II score. Treatment results of heterogeneous patient groups can be compared.

The indication of vena cava filter implantation is controversially discussed. A pure prophylactic indication is increasingly favoured, especially for temporary filter systems without any anamnestic pulmonary embolisms. On the basis of the available literature and our own results a critical analysis of this issue is given. Between 1994 and 1997, we inserted a total of 24 vena cava filters; 21 temporary and 3 permanent filters. In ten patients, the placement of the filter was indicated due to pulmonary embolism and a contra-indication to dose adjusted heparin therapy. Seven additional patients experienced a recurrent pulmonary embolism despite adequate heparin therapy. A prophylactic filter insertion was carried out in seven patients. The temporary vena cava filters were left in place between 7 to 38 days with an average of 19 days. Total implantation time of temporary filters was scheduled until complete mobilisation of the patients, generally in conjunction with an effective dosage of oral anticoagulants. No patient died in connection with the insertion of the filter and no further pulmonary embolisms occurred. One case of inferior vena cava thrombosis occurred in each group of temporary and permanent filters. In one third of the removed filter systems thrombi in the filter were found. Local infections of the catheter and introducer sets were observed in two patients. Moreover, in one case the strut of a temporary filter broke and subsequently dislocated 17 days after insertion. We conclude on the basis of these complication rates that until the results of randomised studies are available the usage of all filter systems should be limited to highly selected cases.

Purpose: To report the percutaneous endovascular management of popliteal artery lesions with a new polytetrafluoroethylene (PTFE) stent-graft., Methods and Results: Three patients have undergone endovascular treatment in the popliteal region owing to: (1) an iatrogenic false aneurysm with arteriovenous fistula, (2) entrapment syndrome, and (3) an isolated arterial aneurysm. In each case, arterial occlusion was treated initially with thrombolysis. The underlying vascular lesions then were stented using the new Hemobahn endograft, a nitinol stent covered internally with PTFE. Each percutaneous procedure was completed successfully without major complications. During early follow-up (6 to 7 months), no signs of intimal hyperplasia, occlusion, or stent migration have been observed., Conclusions: Based on these early experiences, percutaneous treatment of stenotic and aneurysmal lesions in the popliteal artery using the Hemobahn endograft appears feasible and effective. Further experience and longer follow-up are required to evaluate this new prosthesis.

Postoperative iliac and popliteal arteriovenous fistulas are extremely rare. This article describes the percutaneous endovascular treatment of iatrogenically induced arteriovenous fistula in two patients with simultaneous use of intravascular ultrasound. In a 61-year-old woman, a fistula between popliteal artery and vein, inadvertently created during implantation of a prosthetic knee joint, was treated with a novel polytetrafluorethylene (PTFE) stent graft. A 48-year-old man underwent endovascular treatment of a large fistula between the right common iliac artery and the left common iliac vein, inadvertently induced during surgery on an intervertebral disc. Congestive heart failure induced by the arteriovenous communication was reduced rapidly. Our results indicate that percutaneous treatment in conjunction with intravascular ultrasound is a useful therapeutic option for vascular lesions. It is less invasive than open vascular reconstruction and has a comparably high success rate.

Rupture of a cervical carotid artery aneurysm is a rare but life-threatening event. The diagnostic evaluation and therapeutic management of a 55-year-old woman with such a lesion are described. In this case, the aneurysmal rupture was complicated by localized Staphylococcus aureus infection confirmed by bacteriologic culture of excised tissue, septicemia, and prevertebral and intraspinal abscess. Definitive diagnosis was a ruptured mycotic aneurysm of the extracranial carotid artery. The origin of the infection was probably the patient's previously infected vascular prosthesis for hemodialysis.

When studying the etiology of trauma-induced injury, it is apparent that there is an increasing incidence of iatrogenic vascular lesions. One reason for this phenomenon is that many vascular procedures, including invasive catheteral procedures, minimally invasive interventions and osteosynthetic operations, are being performed more frequently. In such emergent clinical situations, prompt and appropriate diagnostic evaluation and reconstruction of affected vessels are required for a successful outcome.

Differential diagnosis of uncertain swelling of the neck has a limited number of possibilities. Thyreoideal processes, lymphatic adenomatosis and abscesses are in most of these cases prevent. However, vascular diseases should be also considered. It is current practice to perform a sonography, completed by computertomography for establishing a diagnosis. If vascular disease is suspected also an angiography is indicated. During the diagnostic procedure we discovered a major aneurysm of the left external carotid artery. The aneurysm was resected and vascular continuity restored by PTFE patchplasty. In case of tumorous processes of the neck extracranial aneurysms of the carotid artery have to be included into the differential diagnosis in order to guarantee adequate therapy.

Less than 1% of all complications following vascular surgery of the abdominal aorta involve the lymphatic system. We report on a case of Chylous ascites following the operation of a ruptured infrarenal aortic aneurysm. The primary therapy, administered over a period of five weeks, consistent of diuretics and substitution by human albumin. However, the chylous flow did not decrease. A surgical intervention by a retroperitoneal ligation to try to stop the lymph flow also failed. Finally a total parental nutrition was followed by decrease and arrest of the lymph flow. Conservative treatment of this complication is considered as therapy of choice.

Radioresistometry, a combination of intra-operative angiography with measurement of peripheral resistance permits a simultaneous morphological and functional judgement of the terminal flow passages. The authors describe a self constructed apparatus making possible to introduce the method into the clinical program of surgical treatment of chronic peripheral arterial occlusions. In a prospective, clinical-experimental study of 106 femoro-popliteal reconstructions they prove: 1. The method completes the preoperative angiogram, enables a more exact indication for vascular reconstruction and allows the detection of surgical technical faults. 2. In extreme values of peripheral resistance (greater than 2,5 PRU) there is no indication for arterial reconstruction in the proximal segments.