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To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion.All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3-4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality.The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011).Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Objectives To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. Design Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. Materials and methods From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: −1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. Results Technical success rate of AMI endografting was 95.65% ( n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1–Q3: 1.3–9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1–Q3: 17–69 months). Conclusions Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

BACKGROUND: In this long-term follow-up of a prospective randomized multicentric trial, warp-knitted gelatin-coated double-velour Dacron (GEL-D), warp-knitted collage-coated double-velour Dacron (COL-D) and stretch PTFE bifurcation grafts implanted in patients with abdominal aortic aneurysms (AAA) were compared for their long-term results and their dilatation was evaluated by CT. METHOD: Between 1991 and 1998, 164 AAA patients were prospectively randomized and stratified for age, gender, diabetes, run-off and nicotine consumption. Of these, 55 received GEL-D grafts, 51 COL-D grafts and 58 stretch PTFE grafts. Thirty of them underwent follow-up CT (Computerized Tomography) and graft dilatation was evaluated. RESULTS: The median follow-up time was 77 months. No significant differences were found between the 3 graft materials in median survival and patency rates. The primary 8-year patency rate was 98% for PTFE, 94% for COL-D and 92% for GEL-D (p = 0.4). In 30 patients who had CT scan at a median follow-up at 61 months, graft dilatation was significantly less common with PTFE grafts. Mean inner diameters of the graft body were 110 ± 25% of the original package size for PTFE vs. 132 ± 12% for GEL-D and 131 ± 9% for COL-D. CONCLUSIONS: The 3 graft materials were comparable in long-term patency and complication rates. Graft dilatation was less common with PTFE grafts.

Thromboembolic events are a known complication in inflammatory bowel disease (IBD). We report on 2 young women with IBD and aortic mural thrombi as a source of arterioarterial embolization to the lower limbs resulting in significant morbidity. The first case was a 36-year-old woman with severe ulcerative colitis who presented with signs of microembolism into two toes of her right foot. A thrombus in the otherwise normal infrarenal aorta with occlusion of the inferior mesenteric artery was revealed by computed tomography (CT) and intrarterial angiography. The digital ischemia resolved without sequelae. The second case was a 41-year-old woman with Crohn's disease complicated by fistulas. She developed acute ischemia of her right leg. Arteriography and CT revealed infrapopliteal embolic occlusions and a thrombus in the distal otherwise normal abdominal aorta and the left iliac artery. A primarily successful thrombectomy had to be repeated 5 times because of reocclusion. Eventually the leg was exarticulated at the knee. In both patients no further thromboembolic event occurred during follow-up of 4 1/2 years and 5 1/2 years, respectively, and aortic thrombi had resolved at follow-up CT scans. Extensive work up for hypercoagulability was negative in both patients. We consider IBD as the most likely trigger for arterioarterial embolization in the absence of thrombophilia in both patients. Finally we give an overview of the literature of similar cases with aortic mural thrombi in IBD patients.

We compared effects of vascular endothelial growth factor-121 (VEGF121) and vascular endothelial growth factor-165 (VEGF165) on generation of NO in HUVEC and the involvement of NO in VEGF121- and VEGF165-induced angiogenesis. VEGF stimulated synthesis of NO within seconds, reaching peak concentrations of 450 +/- 25 and 180 +/- 15 nmol/l for VEGF121, and VEGF165, respectively. The VEGF121 increased NO production for about 40 s while VEGF165-stimulated NO release lasted only for about 20 s. Accordingly, cGMP elevation was stronger in VEGF121- than in VEGF165-treated cells. The VEGF121 was a very weak mitogen but strong chemoattractant for HUVEC, whereas VEGF165 potently induced both cell proliferation and migration. NO appeared to be involved in the endothelial migration and morphogenesis but not in the proliferation. NO was also a permissive molecule for VEGF121- but not for VEGF165-induced capillary sprouting in spheroid culture. In conclusion, VEGF121 is a stronger stimulator of endothelial nitric oxide synthase (eNOS) activity, and angiogenic potential of VEGF121 is more reliant on NO contribution.

Objectives: to investigate whether appropriate selection in patients with infrarenal abdominal aortic aneurysms (AAA) for transfemoral endovascular aneurysm management (TEAM) or open graft replacement (OGR) may decrease in-hospital mortality rates (MR).Design: analysis of a clinical series over three periods in an university vascular center. Conclusions of the second period were drawn and prospectively applied in a third period and compared.Methods: during the period 1989–1994 only OGR was available (n=170). In the interval 1995–2000 either OGR or TEAM were carried out (n=454). During the period 01/2001–07/2002 the conclusions concerning selection of treatment modality were drawn and prospectively applied in 132 consecutive patients. MR were recorded and possible significant differences were checked.Results: during the first period MR was 6.5%. Overall MR decreased to 3.7% in the second interval. Overall MR of the last period was improved to 1.5% (p

Hintergrund Bei der Behandlung des rupturierten abdominellen Aortenaneurysmas (rAAA) wurde wahrend der letzten 50 Jahre eine nahezu unveranderte Mortalitatsrate zwischen 40% und 50% publiziert. Ziel dieser Analyse war es festzustellen, welche Patientensubgruppen von der offenen Operationstechnik profitieren und bei welchen trotz postulierter Optimierung im Management keine Verbesserung der Mortalitatsrate zu erzielen und damit eine Anderung der Behandlungsstrategie zu erwagen ist.

Delivery of DNA mixed with a degradable matrix carrier was supposed to improve transgene expression. Using a rabbit hind-limb ischemia model, we tested the angiogenic potency of plasmid encoding human vascular endothelial growth factor (pSG5-VEGF165) entrapped in fibrin sealant. Animals were injected intramuscularly with 500 μg of pSG5-VEGF165 or control plasmid, dissolved in saline (PBS) or fibrin glue. After 14 days, presence of delivered constructs and expression of transgene was confirmed in injected muscles of all animals. There were no significant differences in the levels of human VEGF mRNA and protein between VEGF-PBS and VEGF-fibrin groups (Mann-Whitney test). Accordingly, pSG5-VEGF165 regardless of the way of delivery, induced similar increases in capillary density within treated muscles (ANOVA). Control plasmid did not show any effects. In conclusion, injection of pSG5-VEGF165 into ischemic adductor muscle leads to synthesis of human VEGF and increases the number of capillaries. Fibrin carrier does not influence its angiogenic potential.

Purpose: To report successful endovascular management of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 40 months after primary stent-grafting. Case Report: A 64-year-old man presented with hypotension, severe back pain, and abdominal distension. Immediate computed tomography revealed a proximal type I endoleak due to distal migration of the stent-graft with subsequent rupture of the aneurysm. The patient was hemodynamically unstable, and open surgery was refused because of severe comorbidities that were the indications for initial endovascular repair. The diameter of the proximal aneurysm neck required the use of a thoracic stent-graft that was overly long, which led to occlusion of the contralateral stent-graft limb supplying not only the left leg but also a left kidney transplant. A crossover bypass was implanted to revascularize both. Conclusions: Minimally invasive strategies, even when challenged by complex vascular reconstructions, offer the possibility of managing ruptured aortic aneurysms in patients unsuitable for open surgery.

Background— Although transfemoral endovascular aneurysm management (TEAM) of infrarenal abdominal aortic aneurysms (AAA) is widely performed, open graft replacement is still considered the standard of care. The aim of this study was to investigate whether clear indications for TEAM can be established in patients with significant comorbidities without investigating differences in relative procedure efficacy or durability. Methods and Results— A propensity score–based analysis of 454 consecutive patients treated electively for AAA from January 1995 through December 2000 was performed. Of those 454 patients, 248 received open surgery and 206 received TEAM. In-hospital mortality rates (MRs) were compared. After adjusting for propensity scores, a Cox proportional hazard model (COX) was employed to test the influence of the respective treatment on postoperative 900-day survival estimates (SEs). Several potential preoperative risk factors were used as covariates. The MR of all patients was 3.7%. Explorative analysis demonstrated that patients treated by TEAM presented with significantly more risk factors. In American Society of Anesthesiologists class IV patients, a significant difference in MR was detected (4.7% for TEAM versus 19.2% for open surgery; P P P P P Conclusions— TEAM represents a less invasive procedure for AAA therapy in patients with significant preoperative risk factors. Especially in geriatric patients with multiple morbidities, TEAM offers a method of therapy with acceptable MRs and SEs, making active treatment possible in otherwise incurable patients.

Background: Ischaemia/reperfusion (I/R) injury is characterized by the production of oxygen free radicals and the loss of high energy phosphates. α-Tocopherol (vitamin E) has been reported to play a protective role against free radical damage. Therefore, its i. v. supplementation prior to onset of ischaemia was investigated in an established I/R injury model. Methods: New Zealand white rabbits were subjected to a bilateral hind limb ischaemia/reperfusion of 2.5 h/2 h without any treatment (IR group), whereas in the VE group the vitamin E emulsion Tocovenos® was given i. v. for 10 min in a dose of 3 mg/kg bw. A SHAM group served as a control. Intramuscular phosphocreatine (PCr) and adenosine triphosphate (ATP), muscle interfibre area (MIFA), and microvessel cross-sectional area (MVCSA) were determined and electron microscopy was performed. Results: In the IR group, PCr decreased by 65 % of the initial level after 2.5 h of ischaemia and a further depletion was noticed after 2 h of reperfusion (20.9±1.1 vs 6.3±3.0 µmol/g wet wt,P

Background: Any surgical manoeuvre that involves cessation of blood supply to an organ with subsequent re-establishment of blood flow can result in ischaemia/reperfusion (I/R) injury. The consequences of such injury are local and remote tissue destruction.

Background: New blood vessel development can be induced by supplementation with angiogenic growth factors. In some older diabetic or hypercholesterolaemic patients, however, endothelial cells are defective and cannot support angiogenesis.

Head and neck surgeons hesitate to resect the carotid artery because of the postoperative risk of neurologic sequelae. However, there is no curative therapeutic option for head and neck neoplasms involving the carotid artery, with the exception of complete tumor removal. To evaluate the benefits and risks of carotid revascularization techniques in locally advanced head and neck tumors we performed a retrospective analysis in an institutional, tertiary care medical center. Seven patients (5 males, 2 females) with a median age of 58 years underwent en bloc removal of locally advanced head and neck tumors, including carotid resection and revascularization, in the University of Vienna General Hospital, over a 15-year period. In six patients carotid reconstruction was accomplished by bypass grafting (five autologous grafts, one synthetic graft) and in one patient angiopatchplasty was used. There were no perioperative neurologic complications or deaths. Survival was > 12 months in 5/7 patients; the other 2 patients died within 6 months due to untractable progression of cancer. We conclude that carotid revascularization techniques offer the possibility of better local control for advanced head and neck tumors without additional risks of neuromorbidity or mortality.

To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration.A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion.An average time of 52.2 months (median 46.9, IQR 0.0-92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0-17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero.Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Background. A prospective randomized multicenter trial was performed to compare knitted gelatin-coated Dacron bifurcation grafts, knitted collagen-coated Dacron grafts, and stretch polytetrafluoroethylene (PTFE) grafts. Methods. Between 1991 and 1998, 315 elective patients were randomized by age, gender, diabetes, runoff, indication (aneurysm, aortoiliac occlusive disease), and nicotine consumption at 3 centers of vascular surgery in Austria. The patients received gelatin-coated Dacron (GEL-D) grafts (n = 109), collagen-coated Dacron (COL-D) grafts (n = 100), or stretch PTFE grafts (n = 106). Results. No intraoperative deaths occurred. The 30-day mortality was 3%. No difference was found between the 3 graft materials in long-term patency. The primary 5-year patency rates were 92% for GEL-D, 89% for COL-D, and 91% for stretch PTFE (P =.6001). The secondary 5-year patency rates also differed: 97% for GEL-D, 100% for COL-D, and 97% for stretch PTFE (P =.2062). Early occlusions were observed overall in 3% and late occlusions in 5% of patients. When both Dacron grafts were compared collectively with stretch PTFE, a difference was found in infection rate: Dacron 3% (6/209) versus PTFE 0% (0/106); P

Aneurysmen der oberen Extremitaten sind selten. Es wird der Fall echter Aneurysmen der A. brachialis berichtet. Bei einem 45 Jahre alten Patienten war vor 13 Jahren eine End-zu-End-Cimino-Brescia-Fistel zwischen A. radialis und V. cephalica am Unterarm zur chronischen Hamodialyse bei terminaler Niereninsuffizienz wegen Glomerulonephritis angelegt worden. Der Shunt war nach erfolgreicher Nierentransplantation (1991) noch 4 Monate in Funktion und ist seither verschlossen. Die beiden 4 cm im maximalen Durchmesser haltenden Aneurysmen wurden durch eine Kompression des N. ulnaris symptomatisch. Die aneurysmatisch veranderte A. brachialis wurde elektiv reseziert und durch ein V.-saphena-magna-Interponat ersetzt. Im eigenen Krankengut nierentransplantierter Patienten wurde kein weiterer Fall eines Brachialisaneurysmas gesehen. Die Inzidenz von aneurysmaassoziierten Komplikationen ist unbekannt. Dennoch erscheint ein Screening auf arterielle Aneurysmen der oberen Extremitat, im Rahmen der im chronischen Hamodialyseprogramm durchgefuhrten dopplersonographischen Untersuchungen der AV-Fistel, wegen des Schweregrades der moglichen Komplikationen gerechtfertigt.

Background: Different therapies in consecutive patients (1987–1992) with chronic critical limb ischemia at a department of medical angiology, their short- and long-term outcome were investigated. Patients and methods: 190 patients (112 males, 78 females; age: 67 ± 12 years); 78 in grade II, 112 in grade III according to Rutherford’s classification. Therapeutic regimen: 1. vascular recanalisation by percutaneous transluminal angioplasty [PTA], local or systemic lysis; 2. surgical vascular reconstruction in case of impossibility or failure of catheter procedures; 3. prostanoids and/or antibiotics; 4. local wound treatment including amputations. Results: Vascular recanalisation was attempted in 156/190 (82.1%): PTA in 116/190, surgical vascular reconstruction in 50/190, local in 24/190 and systemic lysis in 8/190 patients. Prostanoids were applied in 89/190 and antibiotics in 73/190 patients. At the time of dismissal 164/190 (86.3%) patients were clinically improved; 11/190 (5.8%) unchanged, 13/190 (6.8%) had undergone major amputations and 2/190 (1.1%) had died. After 2,6 ± 2,2 years 77 of the 141 patients, who were still alive, were reexamined. Among these 77 patients 84.4% were in grade 0 or I, 15.6% in chronic critical limb ischemia. Furthermore 13.0% had been amputated since dismissal. Forty-nine of 190 (25.8%) patients had died 3,2 ± 1,9 years after dismissal from hospital. Conclusion: Catheter techniques, mostly PTA, is possible in the majority of patients with chronic critical limb ischemia. Cooperation with vascular surgeons in case of technical impossibility or failure of catheter recanalisation is mandatory. Such a regimen yields satisfactory short- and long-term results and a low rate of complications.

The cell surface glycoprotein MUC18MCAM/CD146 was originally defined as a marker of melanoma progression and has been suspected to be directly linked to the metastatic process of this malignancy. In order to address this question, 2 MCAM negative human melanoma cell lines, SK-2 and XP44RO(Mel), were transfected with MCAM-encoding cDNA. Surface MCAM expression on SK-2 and XP44RO(Mel) transfectants was similar to that observed in naturally occurring MCAM positive human melanoma cells and transfectants demonstrated MCAM-dependent increase in homotypic adhesion in vitro. The growth behavior of 7 MCAM transfectants and their respective vector controls was evaluated in SCID mice. Tumor size at 4-5 weeks after s.c. implantation was highly variable, but did not correlate with MCAM expression. Despite massive primary tumor formation at the injection site, no spontaneous metastasis was observed with any of the investigated MCAM transfectants. The influence of MCAM expression on lung metastases formation in an experimental metastasis assay was system dependent, converting only XP44RO(Mel) transfectants into metastatic cells, although increased homotypic adhesion, leading to formation of tumor cell clusters, was observed with transfectants of both cell lines in vitro. Our findings indicate that MCAM expression of human melanoma cells has an influence on later stages of the metastatic process only, namely, extravasation and establishment of new foci of growth, but is per se not sufficient for this process.

Purpose: To investigate the reasons for endoleaks after transluminal infrarenal abdominal aneurysm management and the potential for transluminal interventions in subsequent management. Methods: Prospective analysis of 50 consecutive patients undergoing endovascular aneurysm repair at a single institution with Stentor® and Vanguard® grafts from March 1995 to March 1997. Setting: Academic teaching hospital Results: Two procedures were converted for other reasons than leak. In the remaining 48 successful procedures endoleaks were detected in 11 (22.9%): proximal aortic leak (2.1%), distal aortic leak (8.3%), iliac leak (12.5%). Leaks were treated at the initial procedure in five patients, resulting in 87.5% excluded aneurysms. Twelve and a half per cent were discharged with a primary leak. Redo was performed on all iliac leaks within 7 weeks. All aortic leaks showed spontaneous thrombosis within 3 months, but reappeared with local aneurysm expansion. Aortic redo-procedures were performed by proximal tubular extension or converting a tube graft into a bifurcation graft. All rescue procedures were successful. Secondary leaks have been observed twice in this series, both treated by endovascular means. Conclusions: Endovascular treatment of primary and secondary endoleaks is possible, and may be a safe alternative to a difficult open procedure.

The purpose of this study was to compare median somatosensory evoked potentials (SEP) in patients undergoing carotid endarterectomy (CEA) with routine shunting and nonshunting (excluding the option of selective shunting) and to evaluate the significance of a decrease in the amplitude of the cortically generated waveforms of the SEP and/or an increase in the central conduction time (CCT) on the one hand, and that of a loss of the cortical SEP, on the other. Somatosensory evoked potentials were recorded in 32 patients before, during, and after CEA with routine shunting or nonshunting. The N13 and N20 latency, the CCT, and the N20/P25 amplitude were evaluated. In addition, a meta-analysis of 15 previous studies was performed comprising a total of 3,136 patients. The intraoperative cortical SEP showed no differences between shunted and nonshunted patients, apart from the preclamping value of the N20/P25 amplitude which was lower in the nonshunted subjects. The number of patients with decreased and/or delayed cortical SEP (findings frequently used as criterion for selective shunting) was similar in the two study groups. A loss of the cortical SEP occurred in one patient operated on without an indwelling shunt. None of these patients had a new neurologic deficit after surgery. In the meta-analysis, the positive predictive value of decreased and/or delayed cortical SEP was extremely poor, that of absent cortical SEP was poor to moderate and the prevalence of new neurologic deficits was similar in patients undergoing CEA with routine shunting-nonshunting and those with selective shunting-nonshunting. Our study suggests that decreased and/or delayed cortical SEP are unreliable predictors of the neurological outcome of CEA patients and consequently an unsuitable criterion for selective shunting. The meta-analysis confirms this finding and shows that the neurologic outcome is not improved by using an indwelling shunt selectively based on SEP monitoring.

Background Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE). Methods A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done. Results Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan–Meier estimates for long-term survival between groups were comparable ( P = .36). Conclusions Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

To regain blood shed intraoperatively, two different systems are clinically established: washing and centrifuging red blood cells to produce autologous erythrocyte concentrates and devices for immediate reinfusion of whole blood after mere filtration. In a prospective-randomised study to compare both methods regarding their efficiency, adverse effects, and economy, 20 patients of our department undergoing elective aortoiliac surgery received intraoperative autotransfusion by means of either cell-washing (CS) or salvage of whole blood (WB). Patients were preoperatively randomized into one of the two groups and were evaluated with respect to standard metabolic and haematological laboratory parameters preoperatively, during surgery, after transfer into the recovery room, 24 h after surgery, after transfer into the recovery room, 24 h after surgery, and at discharge. Both patient groups were well comparable in demographics, preoperative laboratory data, and indication for operation. Handling was easier, the set-up time was shorter with the whole blood filtration device (10.2 +/- 2.3 versus 21 +/- 1.9 min, p = 0.0023), and no additional personnel was needed to run the system. The whole blood device also allowed a greater percentage of aspirated blood to be returned intraoperatively compared to cell washing (73.5% +/- 7.2 versus 51.1% +/- 6.5, p = 0.03). Thrombocytopenia occurred in 7 (CS) and 3 (WB) patients intraoperatively with a significant difference in platelet count between the two groups (118 +/- 17 [CS] versus 170 +/- 12 [WB]*10(9)/L, p = 0.025). Expected changes in the perioperative course of the clotting parameters such as highly increased PTT levels and moderately prolonged prothrombin times occurred in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative angioscopic control was performed in an early series of 27 patients undergoing peripheral vascular surgery. The majority were complex or re-do operations; reversed saphenous vein and PTFE-grafts were used as bypass material exclusively. Angioscopic findings were compared to conventional angiography with respect to the detection of technical problems leading to further surgical procedures. Angioscopy was feasable in 92.5%, it failed twice due to irrigation problems, which was before we used a dedicated angioscopy roller-pump. In 6 patients relevant findings requiring further surgical manipulations were only detected angioscopically, in 2 patients such findings were detected by angioscopy as well as by angiography. Such findings included technical problems (graft rotation [n = 1], anastomotic narrowing [n = 2]), balloon catheter injuries after thromboembolectomy (n = 2) and residual thrombi after local thrombectomy (n = 3); 5 of these patients had undergone previous vascular procedures in the same operation field. After local correction (n = 5) or placement of a new bypass (n = 3) there was no early graft failure. This early angioscopic experience confirmed previous reports that satisfactory visualization and specific recognition of angiographically unsuspected problems after peripheral reconstructions can be obtained by intraoperative angioscopic control. This was seen very distinctively in more complex and re-do operations, which we see as the cases most needing routine angioscopic control.

Grundlagen In folgender Untersuchung soll die Frage gepruft werden, ob eine postoperative Pharmakotherapie (Azetylsalizylsaure [ASS] oder Phenprocoumon) die Resultate von gefasrekonstruktiven Masnahmen im femoro-popliteokruralen Bereich bessert. Methodik Dafur wurde das EDV-gestutzt dokumentierte Krankengut (n=1200) der Jahre 1970 bis 1990 zur Beurteilung herangezogen. Es wurde eine logistische multivariate Regressionsanalyse, gefolgt von 2 prospektiv randomisierten klinischen Prufungen aus einem einzigen Zentrum durchgefuhrt. Gepruft wurden 3 × 500 mg ASS (n=298 Patienten) bzw. Phenoprocoumon (n = 130 Patienten), gegenuber unbehandelten Kontrollgruppen verglichen. Ergebnisse Das praoperative klinische Stadium (p

Grundlagen Anhand einer retrospektiven Analyse eigener Ergebnisse soll der Stand der chirurgischen Technik diskutiert werden. Grundlage fur die Diskussion sind die am Workshop “Der Venenbypass” 1991 in Linz gehaltenen Referate. Methodik Zwischen 1970 und 1991 wurden an der I. Chirurgischen Universitatsklinik Wien 590 reversierte Venenbypasse angelegt. Anschlusgefas war in 39% die supragenuale, in 31% die infragenuale A. poplitea, in 30% ein krurales Gefas. Ergebnisse Die 30-Tage-Letalitat betrug 2%, die mediane Nachbeobachtungszeit 65 Monate. Die Gesamtfunktionsrate nach 60 Monaten betrug 55%, die sekundare Funktionsrate 70% fur alle Patienten. Die primare Funktionsrate fur supragenuale Venenbypasse betrug 61%, fur infragenuale 49% und fur krurale 52%. Der Beinerhalt nach 60 Monaten war in 88% gewahrleistet. Schlusfolgerungen Ein Literaturuberblick diskutiert die verschiedenen Trends auf dem Gebiet der Venenbypasschirurgie zur Revaskularisation der unteren Extremitat. Grose prospektive, randomisierte Studien werden benotigt, um die beste Technik fur distale Rekonstruktionen der unteren Extremitat zu evaluieren, daher mus die Wahl des Vorgehens derzeit der Praferenz des Chirurgen uberlasen werden.

Between 1980 and 1990, 354 aortoiliac repair procedures were performed with polytetrafluorethylene (PTFE), which had become available in 1980. This retrospective analysis was designed to show whether anticoagulation or antiaggregant treatment had beneficial effects on patient survival and graft function. In patients with unilateral aortoiliac grafts, antithrombotic therapy with phenprocoumone or acetylsalicylic acid (ASA) improved graft function (Breslow, p=0.038; Mantel, p=0.013) and long-term survival (Breslow, p=0.013; Mantel, p = 0.009). However, the results concerning survival are devaluated, because the members of the control group were older (65.9 years vs 61.1 years, Chi square test p=0.01). In patients with PTFE bifurcation grafts, in whom risk factors and age were well balanced, survival was also significantly prolonged by postoperative drug treatment in the early years of the follow-up (Breslow, p=0.038; Mantel, p=0.298), but graft function was unaffected. These results suggest that postoperative anticoagulant therapy with ASA or phenprocoumone may be of some benefit in patients undergoing iliac PTFE grafting procedures. Based on these retrospective data, a randomized prospective trial was initiated to study the effects of different drugs suppressing coagulation, ie, anticoagulants and antiaggregants, on allogenous grafts.

Um festzustellen, ob eine Langzeitbehandlung mit oralen Antikoagulanzien erfolgreich in der Lage war, die Funktionswahrscheinlichkeit zu bessern und das Uberleben zu verlangern, wurde eine kontrollierte klinische Prufung an einem einzigen Zentrum durchgefuhrt.

In der vorliegenden retrospektiven Analyse wurden die Patienten der I. Chirurgischen Universitatsklinik in Wien von 1975 bis 1988 analysiert und die beiden extrathorakalen Verfahren, namlich Subklavia-Karotis-Transposition (TRP) und Karotis-Subklavia-Bypass (BYP), miteinander verglichen. Bei 32 Patienten kam die Transposition, bei 19 Patienten das Bypassverfahren zur Anwendung. Hinsichtlich der Uberlebenswahr-Scheinlichkeit, intraoperativen Blutkonservenverbrauchs und Dauer der Anasthesie gab es keinen signifikanten Unterschied. Da Patienten mit Lasionen der proximalen Subklavia verglichen mit Patienten nach Karo-tisthrombendarteriektomie eine hohere Lebenserwartung haben und daher alle moglichen Spakomplikationen vermehrt auftreten konnen, ist ein dauerhaftes Rekonstruktionsverfahren anzustreben. Alle Transpositionen sind in Funktion geblieben, wahrend Patienten, die mit dem Bypassverfahren behandelt wurden, 5 Verschlusse (3 Sofort- und 2 Spatverschlusse) hatten. Sowohl die von Reokklusionen freie Nachbeobachtungszeit (Breslow: p

Zwischen 1980 und 1990 wurden 471 Thrombendarteriektomien der A. carotis interna an 437 Patienten durchgefuhrt. Kriterien zur Indikationsstellung waren: 1. hamodynamisch relevante Karotisstenose oder embolisierende Plaques in kausaler Beziehung mit der Klinik, 2. Ausschlus von schweren Begleiterkrankungen, intrazerebralen Blutungen und frischen Apoplexien. Es wurde in Allgemeinanasthesie ohne Shuntapplikation operiert.

Occlusion of an infrainguinal saphenous vein bypass presents an unresolved problem of further treatment in patients with threatened limbs. The implantation of alloplastic grafts is an attempt to possibly avoid amputation. The authors report 56 patients who were treated by secondary alloplastic grafts after occlusion of their vein bypass. All secondary procedures were performed for limb salvage. The median time of patency of sequential combined saphenous vein plus an additional alloplastic bypass was sixteen months. Following a reocclusion of the secondary grafts, 45 % required major amputation. Nevertheless, the median period of limb salvage was fifty-four months. Therefore, secondary alloplastic grafts seem to be a reasonable procedure in the treatment of threatened limbs after occlusion of an infraginguinal saphenous vein bypass, if one takes the limited life expectancy of sixty-four months into account for these patients.

Some surgeons feel that femoro-femoral suprapubic crossover bypass (FF) is the treatment of choice in unilateral artery disease, whereas others reserve this procedure for the rare high risk patient. Results and their evaluation seem to differ depending upon the indications and the patients elected for comparison. We analysed 57 consecutive patients, who received a FF-PTFE graft between 1977 and 1989 (age 48-95 years; male/female 47/10; preoperative clinical status [Fontaine Classification] St. II: 19%, St. III: 58%, St. IV: 23%; diabetics: 14; smokers: 40). The estimated cumulative primary and secondary patency according to the Kaplan-Meier method were 52 +/- 10% (three grafts at risk) and 63 +/- 10% (six grafts at risk), respectively at 5 years. There was no statistical difference in the secondary patency comparing patients with a good and bad run-off (Breslow, Mantel-Cox). The cumulative 5-year survival was 35 +/- 7% (nine patients at risk). The results were compared with those obtained in a group of 150 patients, in whom an unilateral ilio-femoral (IF) retroperitoneal orthotopic graft had been implanted for the same indication and within the same period. Comparing the primary patency of FF and IF patients (55 +/- 6%; 24 grafts at risk) no significant difference could be seen at 5 years. But there was a significant difference in the 5-year survival rates, being in favour of the IF-group (43 +/- 5%; 43 patients at risk) suggesting that both groups were not comparable.(ABSTRACT TRUNCATED AT 250 WORDS)

In the treatment of ruptured abdominal aortic aneurysm (rAAA), the results of open graft replacement (OGR) have remained constant but discouraging for the last 4 decades. Provided suitable anatomy, elective endovascular abdominal aortic aneurysm repair (EVAR) is less invasive and leads to improved perioperative mortality. Thus, it is reasonable to assume that endovascular treatment should improve the results of rAAA therapy.To determine whether the use of both endovascular and open repair of rAAA leads to improved results.A single-center, retrospective analysis of 89 patients suffering from rAAA treated either by EVAR or OGR.From October 1999 until July 2006, a consecutive series of patients with rAAA were analyzed. Time was divided into 2 periods of 41 months. During the first period, 42 patients were treated by OGR exclusively. Period 2 started with the availability of an EVAR protocol to treat rAAA; 31 patients received open repair while 16 patients underwent EVAR.Kaplan-Meier survival estimates were calculated and compared.Survival estimates showed a statistically significant reduction in overall postoperative mortality following the introduction of EVAR (P.03). The 90-day overall mortality rate was reduced from 54.8% to 27.7% during the second period (P.01). Survival of patients older than 75.5 years was especially improved (75% vs 28.6%; P.01). There was a parallel pattern of significant reduction of the mortality rate after OGR to 29% (P.03).Offering both EVAR and OGR to patients with rAAA leads to significant improvements in postoperative survival.

Objectives The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. Design Retrospective analysis of database. Material and Methods Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5 cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. Results Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p Conclusions Patients with small aneurysms (≤5.5 cm) have an improved long-term survival than patients with larger aneurysms.

Two treatment options are available for abdominal aortic aneurysms (AAAs): open surgical technique with graft replacement and endovascular aortic aneurysm repair (EVAR) as a minimally invasive procedure. The intention of this review is to highlight the advantages of both procedures and to demonstrate that offering both procedures is beneficial for the patient when he or she makes the important decision regarding which treatment to select. A comparative evaluation of both treatment options is offered as well as a short description of the risk of rupture and its consequences. The authors discuss the latest literature as well as their own experiences. An innovative statistical approach-the propensity score-based Cox model-is presented to evaluate the 2 treatment options. The benefits of offering both EVAR and open surgery permit optimal management of AAA for the individual patient and tailor the treatment to his or her organ dysfunctions and impaired physical status. In addition, EVAR offers a treatment option for otherwise incurable high-risk patients.

Ischemia/reperfusion (I/R) injury is characterized by the production of oxygen-free radicals leading to disturbances in vasomotility (microvascular constriction) and microvascular permeability (interstitial edema formation). The objective was to evaluate the effect of the combined antioxidative and enzymatic preparation Phlogenzym on I/R injury of skeletal muscle.A rabbit hindlimb model of I/R (2.5/2 h) was used (IR group). Phlogenzym, containing rutin, trypsin, and bromelain, was applied enterally (60 mg/kg body weight) as a bolus 30 min prior to ischemia (Ph group). Sham-operated animals served as controls (CO group). Plasma malondialdehyde, potassium, and microvascular perfusion (monitored by laser flowmetry) were assessed. Histomorphometry and electron microscopy were performed from major adductor muscles.Two hours after reperfusion, potassium levels were significantly elevated in IR compared to Ph group (6.7 +/- 1.2 versus 4.9 +/- 0.9 mmol/l, P0.006). Enhanced lipid peroxidation, apparent by increased plasma malondialdehyde levels, was ameliorated in the Ph group (1.0 +/- 0.1 versus 0.7 +/- 0.1 nmol/ml, P0.0001). No-reflow (reduction of blood flow by 62% in IR group) was not observed in the Ph group (P0.004). Phlogenzym treatment prevented microvascular constriction (17.6 +/- 2.3 versus 12.6 +/- 1.1 microm(2), P0.0001) and mollified interstitial edema (21.5 +/- 2.0 versus 26.0 +/- 3.7%, P0.017), resulting in mild ultrastructural alterations in contrast to pronounced sarcolemmal and mitochondrial damage in untreated rabbits.Phlogenzym had a protective effect on skeletal muscle during I/R injury expressed by prevention of no-reflow and preservation of muscle tissue.

PURPOSE To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. METHODS A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeon's discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001-2002 after the introduction of "high-risk" screening criteria (age > or = 72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. RESULTS While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p > 0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p = 0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p = 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p > 0.05) and fell still further to 1.2% in the most recent period (p = 0.021 versus pre EVAR). CONCLUSIONS The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.

Enhanced production of superoxide in L-arginine-depleted environments and concomitant reduction of nitric oxide (NO) concentration are involved in ischemia-reperfusion (I/R) injury. Treatment with L-arginine or antioxidative vitamins alone and in combination was used to mollify I/R injury in skeletal muscle. Untreated rabbits were compared with those treated with L-arginine/antioxidative vitamin cocktail Omnibionta only, or a combination of L-arginine/ antioxidative vitamins during hind limb I/R (2.5 hours/2 hours). NO was continuously measured in vivo. Plasma malondialdehyde (MDA) served as the measure of oxygen free radical formation. Interstitial edema formation, microvessel diameter alterations, microvessel plugging, and blood flow changes were used as indicators of I/R injury. The MDA level in untreated animals 2 hours after reperfusion was significantly higher than in control animals (0.81 micromol/L +/- 0.14 micromol/L vs 0.57 micromol/L +/- 0.11 micromol/L; P

Background: Arterial intimal hyperplasia and following restenosis may be inhibited by estrogens. We investigated the effect of a synthetic steroid hormone, Tibolon: (a) on intima hyperplasia and restenosis in vivo, and (b) on production of endothelial nitric oxide synthase (eNOS), vascular endothelial growth factor (VEGF), endothelial cell proliferation and apoptosis in vitro. Methods: Influence of Tibolon treatment (0.1 mg/kg body weight, during 3 days before and 3 weeks after the operation as a drinking solution once daily) on neointimal formation (measured by morphometry) and arterial wall damage (by qualitative histology) were investigated in vivo using an animal model of balloon injury of carotid artery. In human umbilical vein endothelial cells (HUVEC) and human microvascular endothelial cells (HMEC-1), the effect of Tibolon (0.1 µg/ml) on eNOS and VEGF was assessed by ELISA. Cell proliferation was induced by VEGF165 and measured by BrdU incorporation assay, cell apoptosis was detected colorimetrically measuring DNA fragmentation. Results: Balloon injury resulted in neointima formation and prominent damage of the carotid artery wall. Treatment with Tibolon increased luminal area, decreased intimal area and intima to media ratio, and promoted better reparation of damaged vessel wall. In vitro, Tibolon treatment did not influence the expression of eNOS protein in HUVEC as well as cell proliferation rate but reduced apoptosis of endothelial cells by about 40%. Additionally, this treatment suppressed basal and IL-1β-stimulated synthesis of VEGF in HMEC-1. Conclusions: Tibolon treatment suppressed neointimal formation and promoted better reparation of damaged vessel wall in carotid artery after balloon injury. This positive effect seems to be associated with improved endothelial cell survival resulting possibly in increased NO production. It might be also related to the decrease of VEGF generation.

Postoperative mortality rates between 40% and 50% have been invariably reported for the treatment of ruptured abdominal aortic aneurysms (rAAA) over the last 50 years. The aim of this analysis was to investigate which patient subgroups benefit from open surgery and in which subgroups a change of treatment strategies should be considered due to lack of improvement despite optimal patient management.From 1980 to 2002 a total of 230 patients underwent surgery because of a ruptured AAA. The observation period was divided into 3 intervals to achieve an approximately equal distribution of patients. The effect of the observation period and of baseline parameters on mortality rates were investigated.Between 1980 and 1990, 72 patients were operated with a mortality rate of 38.9% (n = 28). During the second period (1991-1996) surgery was performed in 72 patients with a mortality rate of 40.3% (n = 29). In the third observation interval (1997-2002) 86 patients underwent surgery with an unvaried high mortality rate of 40.7% (n = 35). By applying a logistic regression model including age, gender, modality of rupture, location of cross-clamping and type of operation, only the modality of rupture and the patient's age, which are uncontrollable by the surgeon, could be shown to have a significant impact.Summing up these findings, open surgical repair of rAAA only leads to acceptable results when performed in younger patients without supposed comorbidities. Survival appears to be accidental in patients with advanced age and increased prevalence of relevant comorbidities/underlying diseases. Minimally invasive techniques may offer promising treatment options to those patients, as they do in elective interventions.

Background. In this prospective randomized multicenter trial, knitted gelatine-coated Dacron, knitted collagen-coated Dacron, and stretch polytetrafluoroethylene (PTFE) aortic bifurcation grafts were compared for their long-term results. Methods. Between 1991 and 1998, 149 patients undergoing elective revascularization for aortoiliac occlusive disease were prospectively randomized at 3 tertiary referral centers of vascular surgery. The patients received either gelatine-coated Dacron (GEL-D) grafts (n = 52), collagen-coated Dacron (COL-D) grafts (n = 49), or stretch PTFE grafts (n = 48). Results. No intraoperative deaths were recorded. The 30-day mortality was 4%. The mean follow-up time was 97 months. Primary patency rates were 77% for GEL-D, 78% for COL-D, and 79% for PTFE at 8 years. The differences were not different (P >.8). Secondary corrected 8-year patency rates were also not significantly different (P >.5): 91% for GEL-D, 96% for COL-Dm and 90% for PTFE. Five Dacron and 1 PTFE grafts were affected by infections. Conclusions. Bifurcation grafts for revascularization of aortoiliac occlusive disease using these 3 materials were comparable in terms of primary and secondary patency and long-term complication rates. (Surgery 2003;134:80-5.)

It is well established that high expression of the antiapoptotic Bcl-2 family proteins Bcl-2 and Bcl-xL can significantly contribute to chemoresistance in a number of human malignancies. Much less is known about the role the more recently described Bcl-2 family member Mcl-1 might play in tumor biology and resistance to chemotherapy. Using an antisense strategy, we here address this issue in melanoma, a paradigm of a treatment-resistant malignancy. After in vitro proof of principle supporting an antisense mechanism of action with specific reduction of Mcl-1 protein as a consequence of nuclear uptake of the Mcl-1 antisense oligonucleotides employed, antisense and universal control oligonucleotides were administered systemically in combination with dacarbazine in a human melanoma SCID mouse xenotransplantation model. Dacarbazine, available now for more than three decades, still remains the most active single agent for treatment of advanced melanoma. Mcl-1 antisense oligonucleotides specifically reduced target protein expression as well as the apoptotic threshold of melanoma xenotransplants. Combined Mcl-1 antisense oligonucleotide plus dacarbazine treatment resulted in enhanced tumor cell apoptosis and led to a significantly reduced mean tumor weight (mean 0.16 g, 95% confidence interval 0.08–0.26) compared to the tumor weight in universal control oligonucleotide plus dacarbazine treated animals (mean 0.35 g, 95% confidence interval 0.2–0.44) or saline plus dacarbazine treated animals (mean 0.39 g, 95% confidence interval 0.25–0.53). We thus show that Mcl-1 is an important factor contributing to the chemoresistance of human melanoma in vivo . Antisense therapy against the Mcl-1 gene product, possibly in combination with antisense strategies targeting other antiapoptotic Bcl-2 family members, appears to be a rational and promising approach to help overcome treatment resistance of malignant melanoma.

Background. Cell membrane rupture by oxygen-derived free radicals is a systematic feature of ischemia/reperfusion (I/R) injury. High taurine concentration gradients in skeletal muscle prompted us to evaluate whether plasma taurine levels (pTau) are a useful marker of I/R injury after different periods of ischemia. Methods. Rabbits were randomly assigned to either 1 or 2.5 hours of hind-limb ischemia followed by 2 hours of reperfusion (groups IR1 [n = 12] and IR2.5 [n = 13], respectively). Corresponding sham groups (SHAM1 [n = 8] and SHAM2.5 [n = 9]) were used as controls. Analyzed parameters included histomorphometry and electron microscopy of skeletal muscle biopsies, pTau, and plasma level of malondialdehyde. Skeletal muscle function was assessed 3 weeks after I/R injury. Results. No significant morphologic changes were detectable at the end of ischemia. After reperfusion, mild interstitial edema with intact muscle cell membranes developed in IR1 group; pTau was not increased. IR2.5 group, by contrast, showed severe interstitial edema formation (interfiber area increased by 112%, P

Background/Aim: Local blood flow failure (no-reflow phenomenon) during ischemia/reperfusion (I/R) injury may be mediated by interstitial edema formation (passive vasoconstriction) and/or microvascular spasm (active vasoconstriction). The development of the no-reflow phenomenon in the rabbit hind limb I/R model and the influence of treatment with L-arginine and/or antioxidative vitamins were investigated. Methods: Untreated rabbits were compared with those treated with L-arginine (4 mg/kg/min) or antioxidative vitamins (0.4 ml/kg) alone or in combination during hind limb I/R (2.5/2 h). Interstitial edema formation and microvessel diameter alterations were measured morphometrically. Capillary blood perfusion was measured continuously with laser Doppler flowmetry. Results: I/R injury was expressed by interstitial edema formation (interstitial space increase by 80%), microvascular constriction (microvessel cross-sectional area decrease by 30%), and development of no-reflow phenomenon (blood flow reduction by 60%). Treatment with antioxidative vitamins alone or L-arginine alone reduced interstitial edema by 22 and 31%, consequently, while combined L-arginine/antioxidative vitamin treatment showed a more pronounced edema reduction by 40%. Treatment with only antioxidative vitamins failed to influence the development of no-reflow, although interstitial edema formation was reduced. L-Arginine treatment alone or in combination with antioxidative vitamins prevented microvascular constriction and preserved blood flow after reperfusion without development of no-reflow despite still apparent interstitial edema. Conclusions: Affections of active vasomotility and not merely passive changes of external pressure (i.e., interstitial edema formation) should be considered important in the development of microvascular constriction during ‘no-reflow’ phenomenon.

Grundlagen: Durch die steigende Lebenserwartung gewinnen Krankheiten des fortgeschrittenen Lebensalters, wie eben Gefaserkrankungen, zunehmend an Bedeutung. Daraus ergeben sich neben rein chirurgischen auch okonomische und ethische Konsequenzen. An Hand der Resultate von zwei gefaschirurgischen Standardeingriffen, i.e. die Exklusion infrarenaler Aortenaneurysmen und die Thrombendarterektomie im Bereich der Arteria carotis, soll die Sinnhaftigkeit groser Operationen auch bei geriatrischen Patienten aufgezeigt werden. Methodik: Von 947, auf Grund eines infrarenalen Aortenaneurysmas konsekutiv behandelten Patienten, waren 418 (44,1%) 70–80 und 109 Patienten (11.5%) uber 80 Jahre alt. Die postoperativen Mortalitatsraten von offenen Notoperationen, elektiven offenen Operationen und elektiven endoluminalen Eingriffen wurden in 2 Beobachtungszeitraumen untersucht. Stratifiziert nach praoperativ bestehenden Risikofaktoren wurden die Resultate der Elektiveingriffe verglichen und in Relation zur Uberlebensrate einer „gleichaltrigen Standardpopulation“ gesetzt. Auserdem wurde die postoperative Mortalitatsrate dem entsprechenden Rupturrisiko gegenubergestellt. Von 523 auf Grund einer hochgradigen Stenose der Arteria carotis interna konsekutiv operierten Patienten waren 214 (41%) 70–80 und 42 Patienten (8%) uber 80 Jahre alt. Die postoperative Mortalitatsrate sowie die postoperative Inzidenz eines permanenten zentral-neurologischen Defizits bzw. die kombinierte Komplikationsrate wurden untersucht. Ergebnisse: Die postoperative 30-Tage-Mortalitat nach offener elektiver Exklusionsoperation eines infrarenalen Aortenaneurysmas betrug bei Patienten zwischen 70 und 80 Jahren 6,3% (1995–1999), bei einer elektiven Mortalitat in allen Altersgruppen von zuletzt 2,4%. Nach Stentimplantation betrug die Mortalitatsrate 2,5%. Nach Notoperationen uberlebte nur jeder Zweite. Bei uber 80jahrigen Patienten lag die Mortalitat des offenen Elektiveingriffes bei 12.5% ab 1995. Nach Noteingriffen auf Grund stattgehabter Ruptur starben beinahe 80%. Nach endoluminaler Stentimplantation betrug die 30-Tage-Mortalitatsrate 5% bei uber 80jahrigen, obwohl etwa die Halfte der Patienten praoperative Risikofaktoren aufwies. Nach Carotis-Thrombendarterektomie betrug die 30-Tage-Mortalitatsrate bei 70–80jahrigen 0.9 bzw. 2,4% bei uber 80jahrigen. Die kombinierte Komplikationsrate betrug 1,4% bzw. 2,4%. Schlusfolgerungen: Die elektive chirurgische Behandlung eines infrarenalen Aortenaneurysmas fuhrt bei geeigneter Verfahrenswahl in Abhangigkeit der praoperativen Risikofaktoren und der Einschatzung des Rupturrisikos auch bei geriatrischen Patienten zu akzeptablen Ergebnissen. Ebenso sind die Resultate nach Thrombendarterektomie im Carotisbereich auch in hohem Alter und bei eingeschrankten Organfunktionen zufriedenstellend. Elektive grose gefaschirurgische Eingriffe sollten mit dem alleinigen Argument des fortgeschrittenen Alters nicht unterbleiben.

Purpose: Endograft technology for abdominal aortic aneurysm (AAA) repair is being applied more liberally. There is little information about the midterm performance of these grafts. This study is focused on follow-up interventions after endograft repair for AAA. Methods: Prospective follow-up analysis of a consecutive patient series (n = 173 patients) at a single center who underwent endovascular AAA repair up to 50 months after operation. Seventeen percent of the patients were regarded unfit for open surgery. Four types of commercially available grafts were used. The Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines were applied for endograft implantation and data preparation. Results: In two patients, the procedure was converted to open surgery. In one procedure, emergency repair for iliac artery rupture was performed. The 30-day mortality rate was 2.8% (n = 5 patients). An early second procedure to correct type I endoleaks was necessary in 8 cases (4.6%; 3-10 days). The following midterm results were obtained: median follow-up of the 166 remaining patients was 18 months (range, 1-50 months); 50 additional procedures were necessary in 37 patients (22.3%) for the treatment of leaks (n = 45 interventions) or to maintain graft patency (n = 5 grafts; four patients with concomitant graft segment disconnection); and 46% of the reinterventions were performed within the first year of follow-up and 74% of the reinterventions were performed within the second year of follow-up. One patient died after emergency surgery for rupture as the result of a secondary endoleak at 1 year. Although seven interventions (14%) were performed for type II endoleak, no serious complications were related to patent sidebranches. There was no statistically significant difference between the need for maintenance in different graft configurations (tubular, bifurcated, aorto-uniiliac), or number of graft segments (1, 2, 3-4, ≥5 segments). New generation grafts (after 1996) performed better than early generation grafts ( P = 0.04, chi-squared test) with regard to endoleak development. Conclusion: Endograft repair for AAA is safe but, with current technology, not as durable as open repair. Our data suggest that the use of endograft repair for AAA is becoming safer as endograft design improves. Nevertheless in 26.6% of the patients, there is need for reintervention within midterm follow-up. Close follow-up is crucial because late leaks may develop after more than 2 years after the initial procedure. Endoluminal repair should therefore be applied with caution, strict indication, and only if a tight follow-up is warranted. These findings may also affect health care reimbursement policies. (J Vasc Surg 2001;33:S46-54.)

Es wurden die elektiv mit einem AAA behandelten Patienten (n = 826) an einer Universitatsklinik in den Jahren 1965 bis 2000 unter bes. Berucksichtigung des endoluminalen Vorgehens (TEAM) analysiert. Die Datensammlung erfolgte retrospektiv. Als Beurteilungskriterium diente die Spitals — bzw. 30 Tage Mortalitat. Seit 1995 stand das TEAM zur Verfugung, wobei 45,5% der ab diesem Zeitpunkt behandelten AAA ausgeschaltet werden konnten. Das Krankengut wurde analysiert, wobei eine statistisch signifikante Verteilung der Risikofaktoren zu Ungunsten der mit TEAM behandelten Patienten festgestellt wurde. Eine conditional Regressionsanalyse lies das Operationsverfahren, die Einschrankung der Nieren-und/oder Lungenfunktion und das mediane Lebensalter (unter bzw. uber 72 J) als signifikante Risikofaktoren erkennen.

Die Entwicklung von der klassisch-mechanistischen Gefaschirurgie hin zu einer interdisziplinaren Gefasmedizin wird am Beispiel der Univ.-Klinik Wien dargestellt. Nach Grundung eines Ludwig-Boltzmann-Institutes fur interdisziplinare klinische Gefasmedizin 1998 ist die Anzahl der Vortrage der Mitarbeiter der Klin. Abt. f. Gefaschirurgie von 106 auf 188, und der Impact-Factor der Publikationen von 27,7 auf 119,0 angestiegen (Vergleich: Zeitraum 1994 bis 1996 mit 1997 bis 1999). Der Gesamt-Impact-Factor der Publikationen der Abteilungen fur Gefaschirurgie, Angiologie und Interventionelle Radiologie konnte von 147,0 auf 291,3 gesteigert werden. Die Drittmittelfinanzierung in der autonomen Rechtsfahigkeit konnte im Jahr 1999 um mehr als 60% im Vergleich zu 1996 erhoht werden.