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ispartof: INTERNATIONAL ANGIOLOGY vol:41 issue:2 pages:91-104 ispartof: location:Italy status: published

A patent vascular access is of crucial importance for patients on dialysis. There is no literature describing the success rate and complications of creating dialysis fistulae in a paretic arm. In addition, the risk for non-maturation of dialysis fistula is thought to be high due to the inactivity, muscle atrophy, vascular changes, and higher risk of thrombosis in paretic limbs. Here we describe a case of a successful creation and maturation of a native dialysis fistula.

Zusammenfassung Fragestellung Mit dieser Übersichtsarbeit über die aktuellsten Leitlinien zur Shuntchirurgie von Patienten mit chronischer Niereninsuffizienz (NKF-KDOQI, ERBP, GEMAV und ESVS) soll unter anderem geklärt werden, ob es sinnvoll und erforderlich ist, Leitlinien für den deutschsprachigen Raum zu erarbeiten. Material und Methoden Hierfür wurden diese vier Leitlinien hinsichtlich Methodik, Themenspektrum und Evidenzlage verglichen, um Gemeinsamkeiten, Unterschiede und Besonderheiten aufzuzeigen. Sowohl die fachliche Zusammensetzung der Autorenschaft wie auch die Methodik (PICO-/GRADE-System) der einzelnen Leitlinien sind sich ähnlich. Ergebnisse Arbeitsgruppen, die viele Nephrologen im Team hatten (NKF-KDOQI, GEMAV), haben das gesamte Spektrum der Kathetereinlage in ihre Leitlinien aufgenommen. Die Leitlinien der ESVS stellen die chirurgischen Aspekte der Shuntchirurgie in den Vordergrund. In den ERBP-Leitlinien, die bei der Themenwahl auch Patientenbedürfnisse einbeziehen, ist die Fistelreifung und Kanülierung ein wichtiges Thema. Die neuen NKF-KDOQI-Leitlinien zeigen Algorithmen, wie ein individualisiertes Dialysekonzept über die Zeit aussehen könnte. Allen Leitlinien ist gemeinsam, dass viele Empfehlungen aufgrund fehlender Evidenz und fehlender aktueller Studien nur auf Expertenmeinungen beruhen. Schlussfolgerungen Die Evidenzlage muss durch neue randomisierte Studien verbessert werden. Es wäre wünschenswert, wenn mit standardisierten Verfahren und kontinuierlicher Analyse aktualisierte und online abrufbare Empfehlungen zur Verfügung stünden. Um ein solches Projekt zu realisieren, ist eine internationale Kollaboration unabdingbar. Leitlinien für den deutschsprachigen Raum würden sich so erübrigen.

This discussion looks in some depth at the heavily revised second edition, posthumously published in 1802, of Cowper's translation of Homer. For editors and critics it has never displaced the first edition of 1791, yet Cowper's revisions served to correct many of the flaws they diagnosed. It is argued that Cowper's increasing responsiveness to criticism by laymen and scholars alike was neither a symptom of his deteriorating mental state, as Robert Southey claimed, nor a mere expression of his desire to appease hostile reviewers, but rather an extension of the same collaborative modus operandi that helped him produce the translation in the first place. The lack of scholarly attention to the 1802 edition has, until now, prevented proper understanding of Cowper's achievement in translating the Homeric epics.

Inspired by bone conduction implants, which have a low infection rate, a bone-anchored port (BAP) system for hemodialysis was designed.To demonstrate the surgical procedure for the BAP and to present preliminary results of the clinical investigation.Patients with end-stage renal disease and contraindications for an arteriovenous forearm fistula were recruited for BAP implantation. A workflow specifically developed for implantation was followed. Postoperative evolution, the dialysis procedure, the functionality of the implant, and signs of infection were monitored.So far, five patients have been implanted with the BAP system. Hemodialysis with the BAP was unproblematic in all five patients, on average starting from the 9th day after implantation (range 2 to 15 days). Up to now, 1789 cumulative patient days (average 355 days, range 154 to 448 days) have been recorded. One patient died 14 months after implantation, from a cardiac arrest unrelated to the system. Dialysis was painless, and no catheter-related infections have occurred.BAP implantation can be safely performed but requires an interdisciplinary team. No infections related to the device have occurred.The presented system is a promising addition to the choices of vascular accesses for hemodialysis patients.

Retroaurikular fixierte Horhilfen sind in der Regel wenig anfallig fur Infekte im Gegensatz zu Kathetern fur die Hamodialyse (HD), welche transkutan/subkutan eingelegt werden. Diese weisen haufig Infekte als Komplikation mit der dazugehorigen Morbiditat und Mortalitat auf. Ein neu entwickelter retroaurikular am Knochen fixierter Port in Kombination mit einem konventionellen tunnelierten HD-Katheter wird aktuell bezuglich Sicherheit und Funktionalitat fur die HD getestet. Im April 2016 wurde der seit 2010 von Arzten und Industrie entwickelte retroaurikular fixierte Port („bone-anchored port“, BAP) erstmals einem Menschen implantiert. In dieser Phase-I/II-Studie geht es darum, die entworfenen Standards zur Implantation dieses Systems zu uberprufen und ggf. anzupassen, aber auch deren Handhabung und die Dialysequalitat mit prospektiven Daten zu erfassen. Bisher konnten 4 Patienten uber diesen Zugang durchschnittlich ab dem 9. Tag nach Implantation (Range 2–15) problemlos dialysiert werden. Bis dato haben wir 985 (O 246, Range 138–445) Patiententage erreicht. Ein Patient ist unabhangig vom System 14 Monate nach der Implantation verstorben. Probleme mit dem Subventil fuhrten beim ersten Patienten zu einer Anpassung des Systems. Die Implantation eines retroaurikular fixierten Ports braucht ein interdisziplinares Team, kann aber mit der notigen Sicherheit durchgefuhrt werden und wird von den Patienten und Pflegenden wegen der einfachen Handhabung sehr geschatzt. Es braucht eine gute Schulung des chirurgischen Teams und des Pflegefachpersonal, damit sich diese Methode weiter etablieren kann und mehr Daten zur Funktionalitat und Performance dieses Systems erfasst werden konnen.

William Wordsworth's attempt at translating Virgil's Aeneid reached as far as Book 4, and mostly survives in manuscript drafts. The literary influences behind it can be illuminated through the poet's correspondence, and analysed more fully by tracing verbal echoes and other resonances in his translation. Despite the hostility he expressed towards Dryden and Pope, the foremost translators of the previous age, Wordsworth followed them in using heroic couplets, and, as has previously been argued, his translation draws increasingly on Dryden's Aeneis the further he advanced with his project. But Wordsworth owes an equally large debt, hitherto unrecognized, to the eighteenth-century blank verse renderings by Joseph Trapp and others, who anticipated many of his supposed stylistic innovations.

Kompetenz bezieht sich nicht nur auf Wissen und Fertigkeiten einer Person, sondern auch auf deren Handlungsfahigkeit im klinischen Alltag, insbesondere unter Stress. Deshalb sollten wir die Kompetenzprofile der Mitarbeiter kennen. Die shuntchirurgischen Behandlungskonzepte beruhen heute mehr auf Eminenz als auf Evidenz, weil die Zahl randomisierter Studien beschrankt ist. Es konnen etablierte Simulationskurse belegt werden, um Fertigkeiten in der Shuntchirurgie zu trainieren. In diesem Artikel werden am Beispiel der Shuntchirurgie „entrustable professional activities“ (EPAs) formuliert. Mit diesen „anvertraubaren professionellen Tatigkeiten“ konnen Kernkompetenzen im klinischen Alltag abgebildet werden. Diese EPAs erlauben es dem Vorgesetzten einzuschatzen, wie eigenverantwortlich eine Person arbeiten kann. Wiederholt man diese Beurteilung uber die Zeit, konnen Veranderungen des Kompetenzprofils eines Kandidaten uber eine langere Periode beobachtet werden.

Introduction: In order for Mini-Clinical Evaluation Exercise (Mini-CEX) and Direct Observation of Procedural Skills (DOPS) to actually have a positive effect on trainees’ learning, the way in which the tools are implemented is of key importance. However, there are many factors influencing their implementation. In this study, we aim to develop a comprehensive model of such factors. Methods: Using a constructivist grounded theory approach, we performed eight focus groups. Participants were postgraduate trainees and supervisors from three different specialties; all were experienced with Mini-CEX and/or DOPS. Data were analyzed for recurring themes, underlying concepts and their interactions using constant comparison. Results: We developed a model demonstrating how the implementation of Mini-CEX and DOPS for trainees’ learning is influenced by 13 factors relating to four categories: organizational culture (e.g. value of teaching and feedback), work structure (e.g. time for Mini-CEX and DOPS, faculty development), instruments (e.g. content of assessment), and users (e.g. relationship between trainees and supervisors), and their interaction. Conclusions: We developed a complex model of influencing factors relating to four categories. Consideration of this model might support successful implementation and trainees’ learning with Mini-CEX and DOPS.

INTRODUCTION In Switzerland, the outcome of vascular access creation in the 4500 current dialysis patients is unknown, mainly because there is no prospective registry for patients undergoing vascular access surgery for renal replacement therapy. The aim of the study was to assess the quality of vascular access creation and to compare it with the current literature and guidelines, in order to define strategies to improve clinical outcome. METHODS Retrospective single-centre study in a tertiary referral centre. All consecutive patients over 18 years of age undergoing primary vascular access creation between January 2013 and December 2014 were included. Follow-up data for at least 12 months were collected. RESULTS During the study period, 365 patients had a surgical intervention for renal replacement therapy. A primary vascular access was created in 74 patients (20%), who were further analysed in our study: 63 (85%) had an arteriovenous fistula (AVF) and 11 (15%) an arteriovenous graft (AVG). The intervention-free survival (primary patency rate) of the primary vascular access at 1 year was 46% (95% confidence interval [CI] 33-58%) for AVF and 30% (95% CI 7-58%) for AVG, with a secondary patency rate at 1 year of 75% (95% CI 63-84%) for AVF and 50% (95% CI 18-75%) for AVG. Twenty-seven patients (36%) with primary vascular access underwent central venous catheter (CVC) placement (tunnelled or non-tunnelled) before the access creation. Thirty-seven (50%) patients had their first dialysis through a CVC. Thirty-one patients (42%) never received a CVC. CONCLUSIONS The primary patency of vascular access was unexpectedly low, and the number of CVC requests unexpectedly high. In light of this, we consider it essential that centres creating vascular access should register their activities and compare their outcomes with current guidelines to check and improve clinical management. To facilitate this, there is an initiative starting in 2018 encouraging all Swiss vascular surgeons to provide data on vascular access interventions, including 1-year follow-up, in the national online registry "SwissVasc 2.0".

Zusammenfassung: Hintergrund: Aneurysmen und Pseudoaneurysmen von Hämodialysezugängen treten mit einer Häufigkeit von bis zu 6% auf. Es besteht ein enger Zusammenhang mit der jeweiligen Punktionstechnik. Wegen der zunehmenden Anzahl an Dialysepatienten, wird die Zahl der Fisteloperationen auch in Zukunft steigen. Ziel: Anhand einer Literaturübersicht und gestützt auf eigene Erfahrungen soll die Behandlung von echten und falschen Aneurysmen von Hämodialyseshunts dargestellt werden. Material und Methode: Es erfolgte eine systematische Literaturrecherche in Pubmed/Medline. Folgende Suchbegriffe wurden teils in Kombination verwendet:"arteriovenous fistula”,"arteriovenous aneurysm”,"arteriovenous graft”,"haemodialysis access” und"vascular access surgery”. Ergebnisse: Eine einheitliche Definition und klare Empfehlungen zur Therapie finden wir in der Literatur nicht. Je nach Art, Größe und Lokalisation des Aneurysmas kann die Shuntfunktion gefährdet sein und es besteht Interventionsbedarf. Rupturen können sogar lebensbedrohlich werden. Schlussfolgerung: Bedingt durch stetes Punktieren, neigen AVF zur Dilatation bis hin zur Aneurysmabildung. Solche Veränderungen müssen nur dann korrigiert werden, wenn die Haut über dem Shunt gefährdet ist, wenn eine Massenblutung droht oder aufgrund einer Wandthrombosierung eine nur ungenügende Punktionsstrecke vorhanden ist. Die Implantation eines ePTFE-Interponats war bisher ein gängiges Verfahren, doch hat die Aneurysmorrhaphie vermehrt Anhänger gefunden, weil damit ohne Fremdmaterial ein Shunt funktionstüchtig gehalten werden kann. Bei Pseudoaneurysmen, meist verursacht durch punktionsbedingte, lokale Zerstörung eines PTFE-Grafts, kann ein lokaler Graftersatz erfolgen oder eine partielle Neuanlage mit Umfahrung, wenn zusätzlich ein lokaler Infekt vermutet wird. Alternativtherapien zur Chirurgie wie Stentgrafts sind aktuell noch nicht etabliert und müssen ihren Stellenwert erst noch beweisen

Durch den demografischen Wandel gewinnt die Shuntchirurgie eine zunehmende Bedeutung in der gefaschirurgischen Weiterbildung. Einerseits steigt die Zahl der Eingriffe, andererseits die Komplexitat der Falle. Neue Arbeitszeitmodelle und Dienstzeitregelungen fuhren zu einem Mangel an praktischer Weiterbildungszeit im Operationssaal. Welchen Stellenwert haben Simulationstrainings in der Weiterbildung und welchen Einfluss haben sie auf die Patientensicherheit. Literaturreview und Analyse von zwei 1½-tagigen Shuntkursen am Modell. Um die geforderten Qualitatsstandards zu erreichen, bekommen Simulationstrainings zunehmend Bedeutung. Auch aus Sicht der Patientensicherheit sind solche Trainings sinnvoll. Weltweit gibt es unseres Wissens kaum strukturierte Kurse, um Techniken der Shuntchirurgie zu trainieren. Um die Patientensicherheit zu gewahrleisten, mussen Leitlinien entwickelt werden, die im klinischen Alltag Umsetzung finden. Daneben sollten institutionsintern die Ablaufe geklart, Checklisten befolgt und Sicherheitsnetzte geschaffen werden, um fur die Patienten eine sichere Behandlung zu gewahrleisten. Die Simulation wird dabei in der Zukunft eine wichtige Rolle in der chirurgischen Weiterbildung einnehmen und die Bestrebungen fur mehr Patientensicherheit unterstutzen.

When classic arteriovenous fistulas or grafts fail, dialysis patients have a vital requirement for a catheter to ensure vascular access. Permanent central venous catheters penetrate the cervical and thoracic soft tissues and the skin without rigid fixation. The infection rate for such devices is high, often requiring explantation. Bone anchored hearing aids are an established treatment in patients with conductive hearing loss. The implant is firmly fixed on the temporal bone and the abutment permanently penetrates the skin. Severe infections requiring explantation are very rare. We suppose that one of the main reasons for the low complication rate is the firm fixation of the implant to the temporal bone, which minimizes the movement of the skin relative to the underlying bone. Based on the experience with implantable hearing devices we developed a percutaneous bone anchored port fixed to the skull in the region of the temporal bone. Such a bone anchored port could be a beneficial alternative to conventional central venous catheters for patients undergoing hemodialysis. In the course of the development process we investigated the individual anatomy to locate the correct implantation site with sufficient bone thickness; we studied screw stability in bone; we developed the titanium implant that houses the port system as well as the surgical tools and procedure for save implantation; we tested flow rate, leak tightness and purification on mockups; we defined the Seldinger-insertion of the catheter into the internal jugular vein via a small neck incision. Our results show the technical feasibility of a temporal bone anchored port and form the basis of a now-approved clinical pilot study., Für Patienten an der Hämodialyse ist nach Versagen der klassischen arterio-venösen Fisteln oder Shunts ein direkter Gefässzugang mittels Katheter lebensnotwendig. Permanente zentralvenöse Katheter penetrieren die Hals- und Thoraxweichteile und die Haut ohne rigide Befestigung. Die Infektionsrate ist hoch und führt oft zur Explantation. Knochenverankerte Hörgeräte sind zur Behandlung bei Schalleitungsschwerhörigkeit etabliert. Das Implantat sitzt fest im Felsenbein und der Aufsatz penetriert die Haut. Schwere Infektionen, die eine Explantation nötig machen, sind sehr selten. Wir nehmen an, dass einer der Hauptgründe für die tiefe Komplikationsrate die starke Befestigung des Implantats am Knochen ist, wodurch die Hautbewegungen relativ zum Knochen minimiert werden. Basierend auf den Erfahrungen mit implantierten Hörsystemen haben wir einen perkutanen knochenverankerten Hämodialysezugang im Bereich des Felsenbeins als vorteilhafte Alternative zum herkömmlichen zentralvenösen Katheterzugang entwickelt. Dabei wurde die Felsenbeinanatomie und Knochendicke zur Lokalisierung des idealen Implantationsortes untersucht; die Schraubenstabilität im Knochen getestet; ein Titanimplantat inklusive Ventile und Katheter, sowie chirurgische Instrumente zur sicheren Implantation entwickelt. Der knochenverankerte Hämodialysezugang wurde auf Flussrate, Dichtigkeit und Reinigung getestet; die Platzierung des Katheters mittels Seldingertechnik in die V. jugularis interna über eine Halsinzision festgelegt. Die Resultate unserer Arbeit zeigen die technische Machbarkeit eines im Felsenbein verankerten neuartigen Hämodialysezuganges und bilden die Grundlage einer inzwischen bewilligten klinischen Pilotstudie.

Rapidly growing technical developments and working time constraints call for changes in trainee formation. In reality, trainees spend fewer hours in the hospital and face more difficulties in acquiring the required qualifications in order to work independently as a specialist. Simulation-based training is a potential solution. It offers the possibility to learn basic technical skills, repeatedly perform key steps in procedures and simulate challenging scenarios in team training. Patients are not at risk and learning curves can be shortened. Advanced learners are able to train rare complications. Senior faculty member's presence is key to assess and debrief effective simulation training. In the field of vascular access surgery, simulation models are available for open as well as endovascular procedures. In this narrative review, we describe the theory of simulation, present simulation models in vascular (access) surgery, discuss the possible benefits for patient safety and the difficulties of implementing simulation in training.

The partial shift from patient to model is a reasonable and necessary paradigm shift in surgery in order to increase patient safety and to adapt to the reduced training time periods in hospitals and increased quality demands. Since 1991 the Vascular International Foundation and School has carried out many training courses with more than 2,500 participants. The modular build training system allows to teach many open vascular and endovascular surgical techniques on lifelike models with a pulsatile circulation. The simulation courses cannot replace training in operating rooms but are suitable for supporting the cognitive and associative stages for achieving motor skills. Scientific evaluation of the courses has continually shown that the training principle established since 1991 can lead to significant learning success. They are extremely useful not only for beginners but also for experienced vascular surgeons. They can help to shorten the learning curve, to learn new techniques or to refine previously used techniques in all stages of professional development. Keywords Advanced training · Advanced training regulations · Training model · Vascular International · Certification, Der zumindest partielle „shift“ vom Patienten zum Modell ist für die Chirurgie ein sinnvoller und notwendigen Paradigmenwechsel, um die Patientensicherheit zu erhöhen und den verkürzten Weiterbildungszeiten in den Kliniken und den gestiegenen Qualitätsansprüchen gerecht zu werden. Seit 1991 wurden von der Vascular International Foundation & School zahlreiche Trainingskurse mit mehr als 2500 Kursteilnehmern durchgeführt. Das modular aufgebaute Trainingssystem ermöglicht das Erlernen einer Vielzahl offen-gefäßchirurgischer und endovaskulärer Operationstechniken an lebensechten, pulsatil durchströmten Modellen. Die Simulationskurse können das Training im OP zwar nicht ersetzen, sie sind aber geeignet, die kognitive und die assoziative Stufe des Erreichens motorischer Fähigkeiten zu unterstützen. Die wissenschaftliche Evaluation der Kurse zeigt durchgehend, dass das seit 1991 etablierte Trainingsprinzip zu signifikanten Lernerfolgen führen kann. Sie sind nicht nur für Anfänger sinnvoll, sondern auch für erfahrene Gefäßchirurgen. Sie können in allen Stadien der professionellen Entwicklung helfen, die Lernkurve abzukürzen, neue Techniken zu erlernen oder bereits angewandte Operationstechniken zu verfeinern. Schlüsselwörter Weiterbildung · Weiterbildungsordnung · Trainingsmodelle · Vascular International · ZertifikatModular training

Arteriovenous access ischaemic steal (AVAIS) is a serious and not infrequent complication of vascular access. Pathophysiology is key to diagnosis, investigation and management. Ischaemia distal to an AV access is due to multiple factors. Clinical steal is not simply blood diversion but pressure changes within the adapted vasculature with distal hypoperfusion and resultant poor perfusion pressures in the distal extremity. Reversal of flow within the artery distal to the AV access may be seen but this is not associated with ischaemia in most cases. Terminology is varied and it is suggested that arteriovenous access ischemic steal (AVAIS) is the preferred term. In all cases AVAIS should be carefully classified on clinical symptoms as these determine management options and allow standardisation for studies. Diabetes and peripheral arterial occlusive disease are risk factors but a ‘high risk patient’ profile is not clear and definitive vascular access should not be automatically avoided in these patient groups. Multiple treatment modalities have been described and their use should be directed by appropriate assessment, investigation and treatment of the underlying pathophysiology. Comparison of treatment options is difficult as published studies are heavily biased. Whilst no single technique is suitable for all cases of AVAIS there are some that suit particular scenarios and mild AVAIS may benefit from observation whilst more severe steal mandates surgical intervention.

Objective: To determine the outcome and management of iatrogenic neck-vessel complications after central venous line placement (CVLP). Design: Retrospective study. Setting: Department of Cardiovascular Surgery and the Intensive Care Unit of a 1000-bed university hospital. Patients: Eleven patients with acute central venous line placement complications were identified between 1998 and 2002. Of them, eight were inadvertent arterial punctures (one cannulation of the vertebral artery, one resulting in late pseudoaneurysm formation). There were eight lacerations of carotid, subclavian, or vertebral arteries, two perforations of the superior vena cava, and one uncontrollable jugular venous bleeding. Intervention: Eight arterial cannulations were treated operatively: suture of the artery was performed in five; litigation in one; one pseudoaneurysm was reconstructed; one pleural empyema was evacuated after initial conservative management. One uncontrollable jugular vein bleeding was treated operatively, one perforation of the superior vena cava conservatively, one surgically. Results: Two patients died: one intraoperatively due to uncontrollable bleeding after inadvertent cannulation of the subclavian artery; one arterial laceration resulted in a large subpleural hematoma, which led to an empyema. The patient died from sepsis two weeks after the initial complication. Both high-risk patients suffered from pulmonary hypertension. The other surgically treated patients made an uneventful recovery. Conclusion: Arterial complications of CVLP are very rare, but may be life-threatening. Venous perforations may seal spontaneously, but bleeding can be uncontrollable. In highly selected cases, vascular surgical consultation may be advantageous, when 24-hour service is available. Open exploration or radiological intervention may be considered.

Problems of wound healing following vascular surgery through inguinal incisions include hematoma formation, infection, lymphocele and lymph fistula, and occur in up to 20% of the cases. Closure of chronic wounds is sometimes obtained only after plastic reconstructions such as muscle flaps. We have examined if the use of the less invasive method of vacuum-assisted closure (VAC) may be beneficial. Between January 1999 and May 2002, 36 (2.6%) inguinal wound healing problems were retrospectively identified among 1410 operations originally involving inguinal dissection. There were 15 (42%) females and 21 (58%) males, with a median age of 72 years (range 46–98 years). The indication for the initial operation was arterial surgery in 31 (86%), including aortofemoral reconstruction, arterial reconstruction or endarterectomy with a patch plasty of the femoral artery. Three patients (8%) were operated on for pseudoaneurysm after radiological intervention, two (6%) because of a lymph fistula. Of the 36 patients, 13 (36%) had a frank infection, 12 (33%) were deemed clinically contaminated, and 11 (31%) were non-infected. Operative strategy included vacuum-assisted closure of the wound. Change of the vacuum system was performed a median of 1.8 times (range 1–9) in the operating room. The median length of therapy was 9.2 days (range 3–29). Direct delayed secondary suture was possible in 25 (69%) cases. In 9 (25%) the defect was covered with a split-skin graft. Two patients (6%) required a secondary plastic reconstruction. One leg (2.8%), originally treated for phlegmasia coerulea dolens was amputated. One patient (2.8%) with an infected aortofemoral Dacron graft died from intractable bleeding after homograft reconstruction. No grafts were lost. Vacuum-assisted wound management led to healing of 34 (94%) wounds during initial hospitalisation. Initial strategy was changed twice (6%). Vacuum-assisted closure system is one of the most efficient tools in the treatment of problematic groin wounds in vascular surgery as well as endovascular interventions.

The mortality rate for elective infrarenal aortic surgery is on the order of 5%–7%. Most deaths are related to coronary heart disease (CAD). Significant coronary heart disease is present in some 60% of patients who need elective aortic operations. Risk-stratification scales are not particularly helpful in finding CAD. It is generally assumed that since the more straightforward cases are managed by endoprosthesis, the mortality rate related to open repair may be on the rise. We report 218 consecutive elective infrarenal aortic operations performed at the Swiss Cardiovascular Center (University Hospital, Berne) between 1998 and 2001. There were 36 (17%) females and 182 (83%) males, mean age 66.7 years (range 42–86 years). Of the patients, 87 (40%) were older than 70, 35 (16%) older than 75 years of age. A prior myocardial infarction was diagnosed in 42 (19%), 141 (65%) were hypertensive, 20 (9%) had diabetes mellitus (IDDM), 24 (11%) renal insufficiency (creatinin >13 mg/dL) and 79 (36%) chronic obstructive pulmonary disease (COPD). The initial screening was done by an in-house internist. As a result, 179 patients (82%) underwent cardiological evaluation, which in turn led to 71 (33%) stress echocardiographies, and subsequently 47 (22%) coronary angiographies. This in turn led to coronary revascularization in 24 (11%). Five carotid endarterectomies (2.3%) were performed prior to planned aortic surgery. There was no mortality related to these operations. Aneurysm repair was performed in 165 (76%) patients, surgery for atherosclerotic lesions in 53 (24%). In-hospital mortality was 1 (0.5%). There was no further 30-day mortality. We conclude that the results of open infrarenal aortic surgery can be improved by active screening by an in-house internist and treatment of underlying vascular and lung disease. This should be reflected in reimbursement policies.

Chirurgische Verfahren werden sowohl in der Prävention der chronisch venösen Insuffizienz als auch in der Therapie ihrer Komplikationen eingesetzt. Die operative Sanierung des Venensystems bei Venenklappenfunktionsstörung mit nachfolgendem Reflux oder die Beseitigung einer Obstruktion bei tiefen Venenthrombosen haben die Verhinderung oder Beseitigung einer venösen Hypertonie an der unteren Extremität zum Ziel. Die venöse Hypertonie, Schädigung der Hautkapillaren und chronische Entzündungsprozesse führen zur Sklerosierung von Haut und Unterhaut (Dermatoliposklerose) bis hin zur Faszie (Dermatolipofasziosklerose) und können schließlich zum chronischen Kompartmentsyndrom führen. Ist es zur Entstehung eines Ulcus cruris gekommen, das nach mehr als dreimonatiger konservativer Therapie keine Heilungstendenz zeigt und damit als therapieresistent eingestuft wird, stehen verschiedene chirurgische Optionen zur Verfügung. Hier umfasst die chirurgische Therapie neben der Beseitigung des venösen Hypertonus die lokale Wundtherapie z. B. mit Shaving und Vakuumtherapie sowie gegebenenfalls die Behandlung der Fascia cruris mittels Fasziotomie bis hin zur Fasziektomie zur Senkung des intrakompartimentalen Druckes.

Background and Aims: Two thirds of patients with an abdominal aortic aneurysm (AAA) have relevant coronary artery disease (CAD). AAAs are prevalent in up to 16% of smokers with CAD. General screening of AAA is controversial. Aim was to assess the potential of finding AAA prior to rupture among patients with known CAD. Main endpoint was whether AAA could have been found during follow-up by sonography or at other time of cardiovascular evaluation. Material and Methods: Retrospective study. 213 consecutive, formerly unknown emergently operated AAAs, treated emergently for symptoms (n = 91) or rupture (n = 122) (rAAA) between January 1998 and June 2005. Patient charts were analysed and primary care physicians contacted. Results: At presentation, mean age was 71 (+/–9) years, twenty (9%) were female. AAA had a mean diameter of 7.6 cm. Two thirds (143) were clinically obese (BMI 27 +/–5). 137 (64%) were active smokers, 32 (15%) had diabetes, 151 (71%) were hypertensive, and 80 (38%) received statin treatment. CAD had been diagnosed in 95 (45%) 9 years earlier and followed up. Thirty-five (16%) had had myocardial infarction. Echocardiography had been performed in 52 (24%). Thirty day mortality after open surgery was 25 (21%). Conclusion: All patients with rAAA had been seen by a GP or cardiologist within a year prior to presentation. The cost effectiveness of selective AAA screening should be evaluated in a larger study.

Erratum zu: Gefasschirurgie 2018 https://doi.org/10.1007/s00772-018-0418-4 In der Abbildungslegende der Abb. 2c des Beitrags wurde die rechte mit der linken Hand verwechselt. Wir bitten Sie die korrigierte Abbildungslegende zu beachten und den Fehler zu …

Cystic adventitial degeneration is a rare non-atherosclerotic cause of peripheral arterial occlusive disease, mainly seen in young men without other evidence of vascular disease. Diagnosis will be established by clinical findings and by ultrasound or angiography and can be treated by excision or enucleation of the affected arterial segment or by percutaneous ultrasound-guided aspiration. However, the etiology of adventitial cysts remains unknown. We report a case of cystic adventitial degeneration showing a connection between the joint capsule and the adventitial cyst, supporting the theory that cystic adventitial degeneration may represent ectopic ganglia from adjacent joint capsules.

Bei einem 30-jährigen Mann wurde klinisch ein Aneurysma in der A. temporalis superficialis sinistra diagnostiziert. Nach problemloser chirurgischer Sanierung wurde histopathologisch ein posttraumatisch entstandenes Pseudoaneurysma nachgewiesen. Zudem fand man eine assoziierte fibromuskuläre Dysplasie in der Tunica media. Nach unserem Wissensstand wurde diese spezielle Befundkonstellation bislang noch nie beschrieben.

PURPOSE To report two cases of life-threatening aortic infection after percutaneous endovascular coil embolization prior to endovascular abdominal aortic aneurysm (AAA) repair (EVAR). CASE REPORT Two 76-year-old patients were readmitted 5 days and 3 weeks, respectively, after technically successful percutaneous coil embolization of aortic side branches in advance of scheduled EVAR. In the first patient, the right hypogastric artery, the inferior mesenteric artery (IMA), and a lumbar artery had been embolized, whereas in the second patient only the right hypogastric artery and the IMA had been occluded. On admission, both patients presented with severe abdominal pain. Investigations revealed acute aortic infection in both patients, combined with substantial AAA enlargement in one. Open surgical infrarenal aortic replacement was performed using homografts, and antibiotic therapy was initiated. After uneventful recovery, both patients were asymptomatic, had intact aortic homografts, and showed no evidence of infection after 12 and 18 months of follow-up, respectively. CONCLUSION Endovascular infections are a potentially serious complication following percutaneous coil embolization of major aortic branches. Early diagnosis and dedicated therapy are mandatory. Immediate resection of the infected aorta and replacement with homografts in association with prolonged antibiotic treatment showed good midterm results.

When classic arteriovenous fistulas or grafts fail, dialysis patients have a vital requirement for a catheter to ensure vascular access. Permanent central venous catheters penetrate the cervical and thoracic soft tissues and the skin without rigid fixation. The infection rate for such devices is high, often requiring explantation. Bone anchored hearing aids are an established treatment in patients with conductive hearing loss. The implant is firmly fixed on the temporal bone and the abutment permanently penetrates the skin. Severe infections requiring explantation are very rare. We suppose that one of the main reasons for the low complication rate is the firm fixation of the implant to the temporal bone, which minimizes the movement of the skin relative to the underlying bone. Based on the experience with implantable hearing devices we developed a percutaneous bone anchored port fixed to the skull in the region of the temporal bone. Such a bone anchored port could be a beneficial alternative to conventional central venous catheters for patients undergoing hemodialysis. In the course of the development process we investigated the individual anatomy to locate the correct implantation site with sufficient bone thickness; we studied screw stability in bone; we developed the titanium implant that houses the port system as well as the surgical tools and procedure for save implantation; we tested flow rate, leak tightness and purification on mockups; we defined the Seldinger-insertion of the catheter into the internal jugular vein via a small neck incision. Our results show the technical feasibility of a temporal bone anchored port and form the basis of a now-approved clinical pilot study.

Objective: The study was conducted to determine activation of coagulation in patients undergoing open and endovascular infrarenal abdominal aortic aneurysm repair (EVAR).Methods: In a prospective, comparative study, 30 consecutive patients undergoing open repair (n = 15) or EVAR (n = 15) were investigated. Blood samples to determine fibrinopeptide A, fibrin monomer, thrombin-antithrombin complex, and D-dimer were taken up to 5 days postoperatively. Routine hematologic and hematochemical parameters as well as clinical data were collected.Results: Both groups showed comparable demographic variables. Operating time was longer in open repair (249 +/- 77 minutes vs 186 +/- 69 minutes, P < .05). Perioperatively elevated markers of coagulation were measured in both groups. Fibrinopeptide A levels did not differ significantly between the groups (P = .55). The levels of fibrin monomer and thrombin-antithrombin complex were significantly higher in patients undergoing EVAR (P < .0001), reflecting increased thrombin activity and thrombin formation compared with open surgery. The D-dimer level did not differ significantly between the groups. These results were also valid after correction for hemodilution.Conclusion: These data suggest increased procoagulant activity in EVAR compared with open surgery. A procoagulant state may favor possible morbidity derived from micro- and macrovascular thrombosis, such as in myocardial infarction, multiple organ dysfunction, venous thrombosis and thromboembolism, or disseminated intravascular coagulation.

Low cardiac output impairs the hepatic arterial buffer response (HABR). Whether this is due to low abdominal blood flow per se is not known. Dobutamine is commonly used to increase cardiac output, and it may further modify hepatosplanchnic and renal vasoregulation. We assessed the effects of isolated abdominal aortic blood flow changes and dobutamine on hepatosplanchnic and renal blood flow. Twenty-five anesthetized pigs with an abdominal aorto-aortic shunt were randomized to 2 control groups [zero (n = 6) and minimal (n = 6) shunt flow], and 2 groups with 50% reduction of abdominal blood flow and either subsequent increased abdominal blood flow by shunt reduction (n = 6) or dobutamine infusion at 5 and 10 microg kg(-1) min(-1) with constant shunt flow (n = 7). Regional (ultrasound) and local (laser Doppler) intra-abdominal blood flows were measured. The HABR was assessed during acute portal vein occlusion. Sustained low abdominal blood flow, by means of shunt activation, decreased liver, gut, and kidney blood flow similarly and reduced local microcirculatory blood flow in the jejunum. Shunt flow reduction partially restored regional blood flows but not jejunal microcirculatory blood flow. Low-but not high-dose dobutamine increased gut and celiac trunk flow whereas hepatic artery and renal blood flows remained unchanged. Neither intervention altered local blood flows. The HABR was not abolished during sustained low abdominal blood flow despite substantially reduced hepatic arterial blood flow and was not modified by dobutamine. Low-but not high-dose dobutamine redistributes blood flow toward the gut and celiac trunk. The jejunal microcirculatory flow, once impaired, is difficult to restore.

Objectives. This observational study was set up to prospectively follow all bovine heterograft (ProCol ® ) fistulas implanted for hemodialysis access between 1998 and 2002. Methods. ProCol ® was implanted if autogenous vein was not available or if patients presented with a history of failed, infected or otherwise complicated ePTFE grafts and/or on immunosuppressive therapy. Fistula patency was the primary outcome; secondary outcomes were clinical events and the rate of access revisions. Results. Sixty-two ProCol ® grafts were implanted in 56 patients. The mean primary (PP) and secondary patency (SP) was 334 (SEM 57) and 528 (SEM 59) days, respectively. Coronary heart disease was associated with a significantly better SP (OR 0.2, 95% CI 0.1–0.9) whilst diabetes mellitus was associated with a significantly worse SP (OR 0.2, 95% CI 0.1–0.9). Reinterventions were performed at a mean rate of 1.23 (SEM 0.17) per fistula. The relative risk of access revision was significantly higher in patients with diabetes mellitus (OR 9.2, 95% CI 2.3–37.2). Conclusions. ProCol ® grafts, used for AV-fistulas, demonstrate acceptable patency rates in high-risk haemodialysis patients. Diabetes mellitus jeopardizes the patency of these fistulas and is associated with a high revision rate.

Since the first use of vacuum-assisted therapy (V.A.C.) in wound care, the indications of this therapy have rapidly expanded. Vascular surgery presents many types of problematic wounds. In the current cost conscious atmosphere, there is a great demand for simple and effective therapies. The V.A.C. system has a lot of potential in the management of vascular wounds. In this article we present indications for vacuum-assisted therapy in vascular surgery: chronic leg ulcers, mesh skin graft, wound care after fasciotomy for compartment syndrome, problematic inguinal wound, false aneurysms, diabetic foot gangrene and amputations with marginal circulations.

Morbidity and mortality are significant in hemodialysis patients, and every vascular access (VA) is prone to complications - some more, some less. The risk of complications rises from arteriovenous fistulae to arteriovenous grafts and peaks in nontunneled central lines. Strategies to achieve complete evaluation of the patient and precise planning mark the start of successful VA creation. Furthermore, preoperative considerations include safety checklists, team time-out procedures, and antibiotic prophylaxis. Intraoperative technical features and postoperative aspects of documentation and surveillance schemes complete careful and safe VA creation.

Today, a growing activity to improve patient safety in all domains of medicine is reality. This chapter deals with patient safety research in general, but is also about strategies to implement this evidence in the daily clinical work treating patients on dialysis. Good clinical research practice has been well established for some years. In the domain of dialysis access, further basic, clinical, epidemiological and health service research will be important to further improve patient safety as a whole.

In the last years, simulation training has become widespread in different areas of medicine due to social expectations, political accountability and professional regulation. Different types of simulators allow to improve knowledge, skills, communication and team behavior. Simulation sessions have been proven to shorten the learning curve and allow education in a safe environment. Patients on dialysis are an expanding group. They often suffer from several comorbidities and need complex surgical procedures with regard to their dialysis access. Therefore, education in evidence-based algorithms is as important as teaching of practical skills. In this chapter, we are presenting an overview of available dialysis access training modalities. We are convinced that simulation will become more important in the near future and has a substantial impact on strategies to improve aspects of patient safety.

Zusammenfassung: Hintergrund: Neben der Hämodialyse und der Nierentransplantation ist die Peritonealdialyse ein weiteres Nierenersatzverfahren, das aktuell in unseren Breitengraden zu selten angewandt wird. Ziel der Arbeit: Die Gefäßchirurgen sollen mit den Modalitäten dieser Methode als mögliche Alternative zu einem Hämodialyseshunt vertraut werden. Methode: Der Artikel gibt einen Überblick über die verfügbaren Techniken zur Peritonealdialyse. Resultate: Der durch Diffusion, Konvektion und Ultrafiltration bewerkstelligte Austausch von harnpflichtigen Substanzen unter Verwendung von heute meist glukosehaltigem Dialysat in verschiedenen Konzentrationen kann manuell oder automatisch, kontinuierlich oder intermittierend, am Tag oder während der Nacht erfolgen. Es gibt die offene, die laparoskopische oder kombinierte Katheterimplantation neben interventionellen Verfahren mit ihren jeweiligen Vor- und Nachteilen. Es stehen auch eine breite Palette von Kathetermodellen zur Verfügung, angefangen vom klassischen Tenckhoff®-Katheter bis hin zu sich selbst lokalisierenden Wolfram-Kathetern. Katheterdislokationen und -infekte sind die häufigsten Komplikationen bei diesem Verfahren. Schlussfolgerungen: Die Peritonealdialyse ist bezüglich Mortalität und Morbidität einer Hämodialyse ebenbürtig, bietet aber für den Patienten dank kontinuierlicher Dialyse einen großen Komfort und erlaubt eine ortsungebundenere Bewegungsfreiheit.

Operating room (OR) team safety training and learning in the field of dialysis access is well suited for the use of simulators, simulated case learning and root cause analysis of adverse outcomes. The objectives of OR team training are to improve communication and leadership skills, to use checklists and to prevent errors. Other objectives are to promote a change in the attitudes towards vascular access from learning through mistakes in a nonpunitive environment, to positively impact the employee performance and to increase staff retention by making the workplace safer, more efficient and user friendly.

Goal : We present the development of a bone-anchored port for the painless long-term hemodialytic treatment of patients with renal failure. This port is implanted behind the ear. Methods : The port was developed based on knowledge obtained from long-term experience with implantable hearing devices, which are firmly anchored to the bone behind the ear. This concept of bone anchoring was adapted to the requirements for a vascular access during hemodialysis. The investigational device is comprised of a base plate that is firmly fixed with bone screws to the bone behind the ear (temporal bone). A catheter leads from the base plate valve block through the internal jugular vein and into the right atrium. The valves are opened using a special disposable adapter, without any need to puncture the blood vessels. Between hemodialysis sessions, the port is protected with a disposable cover. Results: Flow rate, leak tightness, and purification were tested on mockups. Preoperative planning and the surgical procedure were verified in 15 anatomical human whole head specimens. Conclusion : Preclinical evaluations demonstrated the technical feasibility and safety of the investigational device. Significance: Approximately 1.5 million people are treated with hemodialysis worldwide, and 25% of the overall cost of dialysis therapy results from vascular access problems. New approaches toward enhancing vascular access could potentially reduce the costs and complications of hemodialytic therapy.

Der folgende Beitrag beschreibt einleitend aktuelle Probleme der Behindertenhilfe auf unterschiedlichen Systemebenen und stellt im Anschluss theoretische Bezuge zur Bearbeitung der Herausforderungen dar. Nach einem Fazit werden im Ausblick Entwicklungsrichtungen skizziert und Vorschlage fur eine Umgestaltung der Behindertenhilfe formuliert.

Background: Comparison of intrathoracic latissimus dorsi (LD) versus serratus anterior (SA) muscle transposition for treatment of infected spaces, broncho-pleural fistulae, and for prophylactic reinforcement of the mediastinum after extended resections following induction therapy. Patients and methods: Twenty LD and 17 SA transfers were performed for prophylactic reinforcement (11 LD; nine SA), and treatment of infections (nine LD; eight SA) from 1995 to 1998. Results: The 30-day mortality was 0% following prophylactic reinforcement and 29% following treatment of infections (three LD; two SA). Prophylactic mediastinal reinforcement was successful in 11 of 11 patients with LD and nine of nine with SA transpositions, and treatment of infected spaces in eight of nine patients with LD and two of three with SA transfers. Morbidity requiring re-intervention consisted of flap necrosis (one LD), bleeding (one SA), and skin necrosis over a winged scapula (one SA). Subcutaneous seromas and chest wall complaints were more frequent following LD (45 and 36%, respectively) compared with SA transfers (29 and 27%, respectively), whereas impaired shoulder girdle function was more frequent after SA than after LD transfer (27 vs. 21%). Conclusion: Intrathoracic LD and SA muscle transpositions are both efficient for the prevention or control of infections following complex thoracic surgery, and are both associated with similar and acceptable morbidity and long-term sequelae. q 2000 Elsevier Science B.V. All rights reserved.

Objectives: in a retrospective study, attempts have been made to identify individual organ-dysfunction risk profiles influencing the outcome after surgery for ruptured abdominal aortic aneurysms. Methods: out of 235 patients undergoing graft replacement for abdominal aortic aneurysms, 57 (53 men, four women, mean age 72 years [s.d. 8.8]) were treated for ruptured aneurysms in a 3-year period. Forty-eight preoperative, 13 intraoperative and 34 postoperative variables were evaluated statistically. A simple multi-organ dysfunction (MOD) score was adopted.Results: the perioperative mortality was 32%. Three patients died intraoperatively, four within 48 h and 11 died later. A significant influence for pre-existing risk factors was identified only for cardiovascular diseases. Multiple linear-regression analysis indicated that a haemoglobin