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Fur die Therapieplanung und den Therapieerfolg werden nicht nur physikalische Grosen zur Beurteilung herangezogen. Ein entscheidendes Mas fur das arztliche Handeln ist die Lebensqualitat der Patienten. Sie ist auch in der Gefaschirurgie die Messlatte fur den Erfolg einer Therapiemasnahme. Zur Beurteilung der Lebensqualitat nach gefaschirurgischem Eingriff wurde eine Fragebogenaktion bei 55 Patienten mit PAVK durchgefuhrt. Die Befragung samtlicher Patienten zum Gesundheitszustand erfolgte praoperativ und 3 Monate postoperativ mit dem Fragebogen SF-36. Der SF-36 ist ein krankheitsubergreifendes Messinstrument zur Erfassung der gesundheitsbezogenen Lebensqualitat. Er erfasst konzeptionell die Bereiche “korperliche Gesundheit” und “psychische Gesundheit”. Hierzu zahlen “korperliche Funktionsfahigkeit”, “korperliche Rollenfunktion”, “korperliche Schmerzen”, “allgemeine Gesundheitswahrnehmung”, “Vitalitat”, “soziale Funktionsfahigkeit”, “emotionale Rollenfunktion” und “psychisches Wohlbefinden”. 50 Patienten (91%) haben den Fragebogen beantwortet. Drei Monate nach der gefaschirurgischen Therapie belegt die Auswertung des SF-36 eine erhebliche Verbesserung der psychischen und korperlichen Gesundheit. Alle Patienten profitieren von der gefaschirurgischen Therapie durch verminderte krankheitsspezifische Beschwerden und eine erhohte Lebensqualitat. Die Untersuchungsergebnisse sind deshalb auch unter dem Gesichtspunkt der Lebensqualitat eine eindrucksvolle Rechtfertigung fur eine gefaschirurgische Behandlung.

Ziel der Untersuchung war es, die Aussagefahigkeit der Messung der CO2-Reservekapazitat mittels TCD bezuglich der Hirnperfusion bei Patienten mit hochgradigen Karotisstenosen zu erfassen und ggf. durch die Beobachtung des Langzeitverlaufs den Einfluss der Karotisoperation auf die Vasomotorenkapazitat zu bestimmen. Von 40 bilateral untersuchten Patienten konnten 1 Jahr postoperativ 24 nachuntersucht werden. Mittels TCD zeigte sich ausgehend von 57±45% auf der operierten Seite ein nichtsignifikanter Abfall postoperativ; 1 Jahr spater zeigte sich tendenziell ein Anstieg auf durchschnittlich 102±80%. Kontralateral stieg die Reservekapazitat ebenfalls. Patienten mit unilateraler Stenose (n=11) zeigten ipsilateral nach initialem Abfall von 51±35% auf 42±38% 1 Jahr spater eine Erholung auf 65±46%. Bei bilateraler Stenose (n=9) zeigte sich nach initial deutlichem Abfall ipsilateral (von 70±60% auf 48±21%) 1 Jahr spater ein signifikanter Anstieg auf 115±77% (p=0,02). Der signifikante postoperative Anstieg der Vasomotorenreserve bei bilateralen Stenosen auf beiden Seiten und die langfristige Verbesserung bei einseitigen Stenosen belegen die Effektivitat der Karotisoperation nicht nur als Embolieprophylaxe, sondern gerade auch zur Verbesserung der zerebralen Durchblutung unabhangig von der Symptomatik.

Bisher gibt es keine zuverlassige nicht-invasive Methode zur kontinuierlichen Uberwachung der Offenheit peripherer arterieller Gefasrekonstruktionen. In der vorgelegten Studie wurde untersucht, ob das Impedanz-Puls-Monitoring (IPMTM) eine solche Uberwachung ermoglicht. Beim IPM werden nach dem Prinzip der Impedanzplethysmographie die pulssynchronen Schwankungen des induktiven Gewebewiderstands gemessen; 123 periphere Gefasrekonstruktionen wurden mit dem IPMTM-1 (Fa. EDI, Burbank, CA) uberwacht. Gemessen wurde praoperativ sowie kontinuierlich fur 24 h postoperativ. Die Pulskurve wurde auf einem Standardpatientenmonitor angezeigt. Die Methode erbrachte in 4,1% der Falle keine verwertbaren Ergebnisse aufgrund von Ulcus cruris, Varikosis oder spastischer Parese. Nachgewiesen wurden eine signifikante Abhangigkeit der IPM-Amplitude vom Pulsstatus und von der Durchgangigkeit eines Leitgefases, sowie eine Korrelation mit AVK-Stadium, Gehstrecke, Dopplerdruck und Arm/Bein-Index. Fur die Erkennung eines Verschlusses betrug die Sensitivitat 92,9% und die Spezifitat 96,3%. Bei Patienten mit Profundarekonstruktionen versagte die Methode. Die Ergebnisse zeigen, das das IPMTM eine einfach anwendbare, kostengunstige und zuverlassige Methode zum kontinuierlichen, nicht-invasiven Offenheitsmoni-toring peripherer arterieller Gefasrekonstruktionen darstellt.

The indication for carotid endarterectomy in patients with unilateral stenotic lesions as well as the operative risk in patients with bilateral disease is still controversial among experts. We performed a retrospective analysis in our patients with bilateral carotid endarterectomy. 578 patients underwent carotid endarterectomy at our institution from 1986-1992: 54 patients (9.3%) had bilateral carotid disease. 30% of these patients were asymptomatic and 16% had symptoms from both sides. Surgical results concerning the optimal restoration of blood supply (75%) and the occurrence of recurrent stenosis (8%) were comparable for patients with unilateral and bilateral carotid endarterectomy. On the contrary, in patients with bilateral carotid disease, both the operative morbidity (2.8%) and mortality (1.8%) were increased as compared to the total study population (1.9% and 0.45% resp.). Carotid endarterectomy is very effective in preventing stroke especially in patients with multiple vessel disease as compared to the natural history of these lesions.

The traditional method of a semiclosed endarterectomy deserves new interest in the reconstructive vascular surgery of femoro-popliteal arteriosclerotic occlusions. The meticulous operative technique is essential: A smooth proximal and distal transition (patchplasty) from the endarterectomy to the adjacent vessels, a smoothened inner surface, and intraoperative confirmation of a complete endarterectomy (angiography, angioscopy) determine the success of the procedure.

An analysis of the relevant data from the Veterans Affairs Cooperative Study Group in asymptomatic patients, showed that 26 of the 32 ipsilateral strokes occurred during the first two years of clinical follow-up. Furthermore, as observed in the medical group, half the neurologic outcome events were strokes and were not preceded by transient ischemic attacks. In the North American Symptomatic Carotid Endarterectomy Trial over a 2-year period, 45 percent of those with occlusion had a stroke compared to 15 percent in the surgical group. These data dispel the traditionally held view that patients with severe contralateral disease should not be subjected to surgery. However, the referral of patients to centers capable of low rates of surgical complications is essential in a plan that includes carotid endarterectomy with optimal medical management.

The careful removal of venous valves during in situ venous bypass procedures is a problem that has not been completely solved. In this experimental study, valve ablation with the Nd-Yag laser was compared with conventional valvulotomy. The investigation was performed in vitro using human vein segments with a length of 20 cm. Conventional valvulotomy was performed 16 times, 20 valves were removed with a 400 mu-fibre and 26 with the hot tip. The results were evaluated by endoscopy, light and electron microscopy. There were no vein perforations with the valvulotome and the hot tip. Endothelial damage was documented in 85% with the valvulotome and was reduced significantly to 58% with the 400 mu-fibre. With the hot tip endothelial lesions were seen in only 30%. Valve remnants were always present with the valvulotome and in no more than 15% with the hot tip. Electron microscopy supported these results in general. There was no endothelial damage in 69%.

Von November 1975 bis Dezember 1991 wurde lOlmal die Indikation zur Gliedmasenreplantation gestellt. 12 Extremitaten erwiesen sich intraoperativ als nicht replantierbar. 58 von 70 replantierten Armen heilten ohne wesentliche Komplikation ein. Die Beurteilung der Funktionsergebnisse erfolgte nach der Klassifikation von Chen (World J Surg 1978, 2:513–524).

Our experiments describe the flow patterns in translucent models of AV fistulas. The elasticity of the models is similar to human vessels walls. Dying of particular flow threads with methylene blue visualizes the flow and its disturbances in 4 classical models. The flow dynamics were investigated with parallel inflow. The volume flow was constant at 200 and 400 ml/min, with a volume flow ratio of 80:20. The flow pattern in side to side fistulas and in end to side fistulas with a narrow angle show regions of separation. This may lead to microthrombus formation and early failure. High shear stress causes endothelial lesions and thus induces stenosing intimal reactions. A favourable flow pattern was seen in end to side fistulas with a broad angle, as well as in end to end fistulas.

Der femoro-popliteale Bypass auf das P-II-Segment der Poplitealarterie ist eine weithin in Vergessenheit geratene Alternative. Vorteil dieser Anschlussmoglichkeit ist jedoch, dass die Biegungsbelastung des Bypasses durch Gelenkuberschreitung vermieden wird und dass dieses Segment deutlich spater erkrankt als das P-I-Segment. Bei einer gut erhaltenen Ausstrombahn infragenual kann diese Anschlussmoglichkeit in ausgewahlten Fallen eine Alternative darstellen.

Valvulotomy for in situ vein bypass is commonly performed with a valvulotome. Although the procedure can be controlled through an angioscope, the dangers of intimal damage and valve remnants remain. An experimental study was designed to evaluate angioscopic laser valvulotomy compared with standard mechanical valvulotomy (n = 16). Two different laser probes, a bare 400-µm fibre (n = 20) and a 2-mm hot-tip (n = 26) were tested. Results were investigated by histology and scanning electron microscopy. Hot-tip laser valvulotomy achieved significantly better results than the 400-µm fibre. The Insitucat valvulotome yielded the worst results, with valve remnants in all cases and an 88 per cent rate of intimal damage. It is concluded that laser valvulotomy can be performed simply and safely with a very low incidence of valve remnants and intimal damage.

A retrospective analysis of the data of 64 patients with vertebral-basilar insufficiency is presented who were operated between 1980 to 1919 in our institution. Surgery for vertebral-basilar insufficiency comprises only 5.2% of all 1422 supra-aortic reconstructions performed during this period. The leading symptom was vertigo which was present in 41%. Disturbances of vision occurred in 9.8%. 29 bypass procedures and 35 arterial transpositions were performed. A mean follow up of 5.1 years revealed a patency rate of 83.3% in bypass procedures, 92.8% in subclavian transpositions and 100% in vertebral artery transpositions. These good haemodynamic results correlated with marked improvement of the clinical symptoms in 80% of the patients.

A clinical database, using FileMaker Pro and a network of APPLE Macintosh computers, were created for a vascular surgical unit. The databank presented here is based on proven, routine working procedures of the department. An easily learnable entry facility with hands-on, screen-oriented users' guide and help data file provide easy operability and highly efficient databank capability, along with great flexibility. This criterial and user-friendly features make staff acceptance and compliance readily achievable, thus assuring comprehensive data entry.

A retrospective study of 93 patients who have had repeat surgery at the tibial level for critical limb ischemia was carried out. In 21 patients a pseudoocclusion with a patent bypass graft was diagnosed and treated by PTA, thrombendarterectomy, or distal extension of the graft. The 5-year bypass patency was 60%, compared to 38% in those 72 patients that required a new bypass at the tibial level. Vein bypasses were better than prosthetic grafts. The number of previous operations did not negatively influence the outcome. However, the distal anastomosis should be placed on an artery that was not previously thrombectomized or operated on.

A prospective study was designed to evaluate the effect of CT-guided lumbar sympathectomy in PAOD using the following investigations: 1: laser flowmetry, 2. thermography, 3. plethysmography, 4. thallium scintigraphy. A significant improvement of perfusion was shown. The results of thallium scintigraphy disproved the often claimed steal effect of the muscle perfusion in favor of an increased skin perfusion. 80% of the treated patients experienced relief of their pain. Chemical sympathectomy proved to be as effective as the surgical procedure.

The study explored the possibility of eliminating the need for plasma replacement with expensive human albumin (HA) and fresh frozen plasma (FFP) and instead using hydroxyethyl starch (HES). Patients undergoing infrarenal aortofemoral bifurcation grafting were randomly assigned to one group, which received FFP and HA, or another group, which received HES as volume replacement. Blood specimens were collected at five time intervals: preoperatively, prior to cross-clamping of the aorta, prior to declamping, at the end of the operation, and 6 h postoperatively. Preoperative coagulation values were all within normal limits. The basic coagulation tests were generally affected by the standardized heparin dose of 5000 IU administered during the clamping phase. Euglobulin lysis demonstrated a perioperative climb that was particularly marked within the HES group at the time of clamping. Values returned to initial levels 6 h postoperatively. Plasminogen, fibrinogen, antithrombin III, and antiplasmin concentrations fell significantly in both groups; 10% to 20% lower values were determined within the HES group due to the lack of factor substitution. The reduction in the coagulation factors can be explained as a dilution effect, but there are also signs of a consumption reaction taking place at the onset of the operation involving activation of coagulation and fibrinolysis. Restricting the use of FFP and simultaneously increasing HES administration is justifiable in procedures involving the abdominal aorta with moderate blood loss.

Although portal blood has been shown to be more hepatotrophic than peripheral venous blood, the origin and nature of the factors responsible remain obscure. In this study the effect of partial ileocolectomy (IC) or partial ileal resection (I) on the regenerative response after 50% partial hepatectomy (PH) in the pig was investigated using thymidine kinase activity and mitotic figures as indices of regeneration. IC with 50% partial hepatectomy resulted in a significantly greater regenerative response on the 3rd day than hepatectomy alone or hepatectomy plus partial I. Levels of plasma insulin were elevated after PH and I but not after IC, although there were no significant differences in levels of plasma glucagon or plasma glucose. Levels of aspartate amino-transferase were similar in all groups. These results extend previous data and suggest that the proximal colon may be the source of a regeneration inhibitory factor.

Asymptomatic patients with carotid stenoses exceeding 75% have an elevated ischemic cerebrovascular event rate of 18% per year (5% strokes). Our combined perioperative stroke and death rate (1980-1990: 1123 operations) is 1.85%. Thus prophylactic surgery may be indicated in the following cases: hemodynamically significant stenoses of 75% and more, especially with marginal or reduced autoregulatory reserve, rapidly progressing lesions in medically treated patients, lesions with a high risk of embolization (ulcerations on B-scan), clear interrelation between arterial lesions and positive (asymptomatic) intracranial findings (CT, NMR, TC, USD).

Objective: to study the primary patency rates of angioscopically controlled thromboendarterectomies of the superficial femoral artery. Design: prospective open study. Methods: between 1990 and 1995, femoropopliteal thromboendarterectomies were performed in 63 patients (41 male, 22 female). Postoperative follow up was performed at 3- to 6-month intervals using non-invasive pressure measurements plus IVDSA at 1 year. Results: eight patients were not evaluable, leaving 55 patients eligible for follow-up analysis. Postoperative complications (arteriovenous fistulas, false aneurysms) were observed in 5.4% of patients. Immediate perioperative occlusions occurred in 7.3%, early occlusions in 21.8% and late occlusions in 16.4% of all cases. The mean follow-up was approximately 57 months. The mean primary patency rate at 5 years was 44.5% (28 patients with the superficial femoral artery still open). Six patients died during the follow-up period. Conclusions: in contrast to the very positive reports found in recent literature, this prospective study shows a lower five-year patency rate for semi-closed femoropopliteal thromboendarterectomy than for bypass grafting. Thromboendarterectomy cannot be considered as a standard procedure in revascularisation of the femoropopliteal region.

The major problems besetting replantation of a limb are the very limited tolerance of muscle tissue to ischemia (in our experiences 5 h) and the possibility of severe postischemic complications either in the limb itself (capillary thrombosis, muscle necrosis) or systemically (kidney failure, speticemia). Between 1975 and 1988, 66 limb replantations (57 arms, 9 legs) were carried out. All nine legs had to be reamputated. Forty-five of the 57 reattached upper extremities (80%) healed without any major complications, 60% exhibited good or very good results (Grade II or I, Classification by Chen).

The incidence of infection among over 3,000 central venous catheters, placed over a period of 18 months, was analysed, 1,570 retrospectively and 1,581 prospectively. The Shaldon catheter had the highest infection rate of the various catheter types. Taking the findings of 983 catheters of one type, Cavafix, the infection rate was significantly higher when the internal jugular vein was the site of puncture instead of the cubital or subclavian veins. Signs of inflammation at the site of catheter entry were a further risk factor for infection. Although the clinical suspicion of catheter-induced sepsis proved groundless in nearly half the cases, early catheter removal is at present the most effective prophylactic means, while routine weekly catheter replacement did not reduce the infection rate. Catheter colonization and catheter sepsis are predominantly problems of nursing and hygiene. The infection rate was reduced through nursing and supervision by personnel specially trained in infectious precautions.

Bowel sounds have a close correlation to the bowel peristalsis. By analysing these sounds--using Heinkelmann's method--sounds can be expressed by objective and calculable figures. We compared the effect of ceruletide, a hormone, with the cholinesterase inhibitor neostigmine and the alpha-adrenergic blocking substance dihydroergotamine. One of the drugs was injected twice daily in patients following operations in the gastrointestinal tract starting on the 3rd and 4th p.o. day. A group of 10 patients received ceruletide in a dose of 0,3 micrograms/kg body weight and of 0,5 micrograms/kg body weight, another 10 neostigmine (0,5 mg per single dose) and 10 patients dihydroergotamine in a dose of 1 mg. Ceruletide proved to be superior to the other drugs in both groups. Its advantage is exciting an ordered propulsive peristalsis. In cases of prolonged postoperative bowel atony or paralysis ceruletide is a helpful drug. Severe side effects were not seen.

A perfusion system was described for maintaining isolated guinea pig livers in a stable functional state for five hours. Oxygen supply, oxygen consumption, as well as perfusate flow were within physiologic limits. Liver function was investigated by means of indocyanine green elimination and galactose elimination. Both test substances showed no significant decrease in liver function throughout perfusion. Isolated liver perfusion is a useful tool to investigate problems in organ preservation and liver transplantation.