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Background Subclavian carotid transposition (SCT) is a safe, effective, and durable treatment in atherosclerotic disease of the proximal subclavian artery. We report about our experience in SCT in a retrospective study with a long-term outcome in 126 cases and discuss our results with the current literature. Methods From January 1995 to December 2013, we treated 126 patients (51 men, 75 women; mean age, 60.9 years; range, 25–80 years) for proximal subclavian atherosclerotic lesions. Preoperative angiography revealed 58 stenoses (46.0%) and 68 occlusions (54.0%). We performed 126 SCTs. The following parameters were documented through a retrospective chart review: demographic data, occlusion site, preoperative symptoms, cardiovascular risk profile, coexisting cerebrovascular disease, and postoperative outcome. Continuous variables are summarized as mean. Categoric variables are expressed as frequency and percentage. Survival and patency rates were estimated using Kaplan–Meier analysis. Results Four immediate occlusions and 1 hemodynamic relevant stenosis (4.0%) occurred postoperatively. Thrombectomy was successful in 2 and a carotid axillary bypass was performed in 3 cases. Three strokes occurred, one during concomitant carotid endarterectomy. The 30-day mortality was 0%. Follow-up data were obtained on 106 of 126 patients (84.0%). The mean follow-up period was 53.8 months (range, 3–159 months). Twenty-three (18.3%) late deaths occurred. Estimated survival was 121.48 ± 6.86 months (range, 3–112 months). Ninety-five percent reported continuous resolution of symptoms. Primary patency rate was 96.0% and secondary patency rate was 100% at 30 days. The long-term patency rate was 96.3% at a mean follow-up of 53.8 months. Conclusions SCT is safe, effective, and durable in the long term. SCT is a standard procedure for occlusion and stenosis. Vessel occlusions, ineffective angioplasty, and preparation for thoracic stent grafting make SCT an important procedure in the surgeon's repertoire.

Hintergrund Das Wilkie-Syndrom, auch A.-mesenterica-superior-Syndrom oder Duodenumkompressionssyndrom genannt, ist selten. Charakteristisch ist eine Kompression des dritten Abschnitts des Duodenums durch den engen Abgangswinkel der A. mesenterica superior (AMS). Symptome sind Ubelkeit, Erbrechen, Vollegefuhl, Gewichtsverlust mit nachfolgender Kachexie und postprandiale Bauchschmerzen. Die gewohnliche chirurgische Therapie ist eine Gastro-/Duodenojejunostomie oder eine Y-Roux-Rekonstruktion, um die normale Darmpassage herzustellen.

Zur Verhinderung einer Lungenembolie bei tiefer Venenthrombose gilt die Antikoagulation als Verfahren der Wahl. Cava-Filter werden insbesondere in den USA vermehrt bei multiplen Indikationen eingesetzt. Die Evidenz, die einen solchen Einsatz rechtfertigen wurde, ist leider gering. In dieser Ubersicht wird die aktuelle Literatur bezuglich der moglichen Indikationen dargestellt.

Objective Renal artery (RA) aneurysm (RAA) is a rare and complex disease. Treatment options for a RAA include endovascular surgery and open surgery with ex vivo repair or in situ reconstruction. This study evaluated the long-term outcome after vascular reconstruction of RAAs using the tailoring technique. Tailoring or aneurysmorrhaphy means a partial resection of the aneurysm with direct suture of the remaining arterial wall. Methods A single-center retrospective study was conducted between January 1990 and December 2015. The tailoring technique was used to surgically repair 88 RAAs in 80 patients (52 women) with a mean age of 52.9 years. Patients' demographic data, vascular therapy, and renal function during follow-up were retrospectively evaluated. Results The localization of the RAA was at the right kidney in 58 patients. The mean size of the aneurysm was 21.4 ± 9.7 mm (range, 8-67 mm). Hypertension was diagnosed in 56 patients, and 23 were asymptomatic. One RAA was ruptured. The overall morbidity rate was 16.3%, including bleeding (n = 4), RA stenosis (n = 3), RA occlusion (n = 4), RA dissection (n = 1), and myocardial infarction (n = 1). One patient died of myocardial infarction for a 30-day mortality rate of 1.3%. The 30-day primary patency rate was 90.0%. The 30-day secondary patency rate was 95.0%. Follow-up data were obtained from 71 patients who underwent tailoring in 78 RAAs. The mean follow-up period was 60.7 months (range 2-229 months). In 76.4% of patients with RAA and hypertension, RAA reconstruction contributed to the cure or improvement of hypertension. The long-term patency after RAA reconstruction was demonstrated in a Kaplan-Meier curve, with cumulative patency rates of 98.7%, 97.4%, 94.8%, and 92.3% after 18, 24, 36, and 48 months, respectively. Estimated survival rates were 98.8%, 97.5%, and 96.3% after 12, 48, and 60 months, with an estimated mean time of 216.5 ± 7.2 months. Conclusions The tailoring technique is a safe and effective procedure with good long-term outcomes. RAA reconstruction contributed to the cure or improvement of renovascular hypertension.

Goal was to engineer biological, arterial grafts with antithrombotic, autologous endothelial luminal surface combined with extraluminal smooth vascular muscle layer (VSMC) and to test in vivo. (1) Different decellularisation methods described in literature were compared to identify the most suitable one with focus on the preservation of extracellular fibre matrix. (2) Endothelial precursor cells (EPC), isolated from bone marrow and VSMC from small venous segments of donor animals were cultivated. Cells were seeded sandwich-like on homologous decellularized venous scaffolds and conditioned under pulsatile circulation in a bioreactor. (3) The semiautologous grafts were implanted in carotidal position on both sides in five Beagle dogs (n = 10; group 2) as interposition. A group of five animals, receiving only acellular grafts in both carotid positions (n = 10; group 1) served as controls. Comparison of four in literature described decellularisation methods showed different preservation of elastic and collagen fibres compared with native veins, whereas decellularity was similar in all methods. This forced us to choose a decellularization protocol with the best preservation of the extracellular matrix. The in vivo experiments showed in group 1 (control) already after one week a complete thrombotic occlusion of the decellularized implants, whereas in group 2 9/10 semiautologous grafts were patent after 98 ± 4 days in ultrasound, angiography and histology (p = 0.0001). A complete incorporation of semiautologous grafts in the surrounding tissue could be shown. The seeding with two different cell types preserved an aneurysmatic degeneration under arterial conditions with patency without anticoagulation.

Ziel Ziel der Studie war die Untersuchung der Carboanhydrase IX (CA IX), somatosensorisch evozierter Potenziale (SSEP) und ihrer Kombination zur Erkennung und zum Verstandnis ungunstiger neurologischer Verlaufe nach Operation (Op.) eines thorakoabdominalen Aortenaneurysmas (TAAA). Im Blick standen insbesondere die verzogerte Paraplegie und eine mogliche Vorhersage mittels Untersuchung des zerebrospinalen Liquors.

Operative Ausschaltungen von thorakoabdominellen Aortenaneurysmen sind signifikant mit technischen Risiken behaftet, die meistens durch verlangerte Aortenklemmperioden und durch die Schwierigkeit gekennzeichnet sind, alle relevanten renoviszeralen und spinal versorgenden Gefase zu erkennen und rechtzeitig wieder mit dem Blutstrom zu verbinden. Eine Reihe von adjuvanten Techniken wurde mit dem Ziel entwickelt, die Morbiditat zu senken. Hierzu gehoren der maschinell unterstutzte atriofemorale bzw. der pulmonal-arteriofemorale, extrakorporale Bypass, die subarachnoidale Liquordrainage, die epidurale Kuhlung und der unilaterale, axillofemorale Bypass. In dieser Arbeit werden physiologische, amaschinelle und an mehr als 100 Patienten angewandte Techniken beschrieben, die entwickelt wurden, um die distale Perfusion wahrend der Ausschaltungsoperation zu gewahrleisten, beginnend vom proximalsten Aspekt des Aneurysmas, endend an der linken A. iliaca. Diese Techniken haben das Potenzial, hamodynamische Instabilitaten zu minimieren, wahrend die Ischamiezeit der Becken- und Bauchorgane sowie der Extremitaten deutlich verkurzt werden. Diese Methoden zeigen weitere Optionen zur operativen Therapie von thorakoabdominellen Aortenaneurysmen auf, v. a. dann, wenn ein Linksherzbypass oder eine Zentrifugalpumpen nicht zur Verfugung stehen bzw. nicht zum Einsatz kommen sollen.

a Central Laboratory Animal Facility b Institute of Clinical Chemistry and Laboratory Medicine c Institute of Medical Microbiology and Hygiene, Johannes Gutenberg University, Mainz, Germany d Klinik fur Gefaschirurgie und Nierentransplantation, Heinrich Heine Universitatsklinik, Dusseldorf, Germany e Zentrum fur Medizin und Biowissenschaften, Forschungszentrum, Borstel, Germany f Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland g Department of Molecular Pathology, Graduate School of Medicine and Engineering, University of Yamanashi, Japan

Die Atherosklerose ist eine Erkrankung mittelgroser und groser Gefase. Fruhlasionen sind gekennzeichnet durch die Adhasion und subendotheliale Emigration zirkulierender Monozyten, die als Schaumzellen Wegbereiterfunktionen fur spatere komplexe Plaques ubernehmen. Solche Lasionen sind bereits im Kindes- und Jugendalter zu finden. Der nachste Schritt der Atherogenese ist die Proliferation glattmuskularer Zellen innerhalb der Intima und der Media und damit ein gradueller Verschluss des Gefaslumens. Fibroblastare Zellen tragen ferner zum Lasionswachstum bei, indem sie exzessive Mengen extrazellularer Matrix bilden. Derartige Lasionen sind meist klinisch inapparent. In einer nachsten Phase kommt es zur Degeneration der Lasion, zur Ausbildung zentral nekrotischer Lipidseen aus Cholesterylkristallen. Entzundungszellen sowie Zelltrummern. Eine fibrose Kappe trennt den Lipidsee von zirkulierendem Blut und verhindert die Ahasion und Aggregation von Blutplattchen an dem hochproaggregatorischen Lipidmaterial. Nur wenn diese Kappe im Bereich der Schulter einreist, kommt es zur raschen Ausbildung eines Apositions- oder (im Koronarsystem oft) eines Okklusionsthrombus mit der entsprechend dramatischen klinischen Symptomatik.

Introduction Popliteal artery aneurysms (PAA) are rare. Different surgical techniques for open surgical repair are possible. This study presents a single centre experience using open surgical repair with a medial approach (MA) and outlines differences between symptomatic (SLS) and asymptomatic (ALS) legs. Methods Data collection was performed retrospectively. The investigation period was from 1 January 1996 to 1 January 2013. Patients presented in the Outpatient Department and received a questionnaire concerning their quality of life. Data are presented as mean ± standard deviation. Mann–Whitney test and Cochran–Armitage test for trend was used for data analysis. Kaplan–Meier method was used to calculate limb salvage rates. p, Highlights • 30 day Primary patency rate: 100% asymptomatic legs; 92% for symptomatic legs. • Better quality of life quality for asymptomatic legs in the follow-up. • Better ankle-brachial index for asymptomatic legs on control examination.

BACKGROUND The increasing demand for transplantable organs, especially kidneys, has led to expanded criteria for renal transplant donors. As a result of the expanded criteria, more organs with vascular anomalies and/or pathologies are available for transplant. This retrospective study evaluated the impact of vascular repair on the outcome in kidney transplantation in a single center over a 15-year period. MATERIAL AND METHODS Between January 1997 and May 2012, 1134 deceased donor renal transplantations were performed in the Department for Vascular and Endovascular Surgery of the University of Dusseldorf, Germany. RESULTS A vascular reconstruction of some type was necessary to repair renal vessels or to prepare the recipient site for transplantation in 374 of 1134 (33.0%) renal transplantations. The iliac artery in 12.3% (139/1134) of cases and the renal artery in 10.1% (115/1134) of cases showed severe atherosclerosis and a thrombo-endarterectomy was required. Organ loss occurred in 13 cases (1.1%) due to vascular failure. The 5-year graft survival for kidneys with reconstructed renal arteries was 84.3% in deceased donor renal transplantations (86.1% without arterial reconstruction). CONCLUSIONS The demand for renal transplants has led to more marginal-quality organs and older donors and/or recipients waiting for a second or third transplantation. Thus, the expertise of a vascular surgeon is extremely helpful in a transplantation center because it allows for marginal organ transplantation with acceptable 5-year graft survival rates.

The aim of this retrospective study was to evaluate the repair of vascular variations/pathologies in living donor kidney transplantations in a single centre over a 15-year period. Between 01/1997 and 05/2012, 338 living donor renal transplantations were performed in the Department for Endovascular and Vascular Surgery, University of Dusseldorf, Germany. Twenty-four of them showed disorders, like multiple renal arteries (MRA), atherosclerotic stenosis or fibromuscular dysplasia (FMD) needing vascular repair before transplantation. Mean age of donors was 51 ± 11.2, in recipient’s 44 ± 13.9 years. In seven transplantations, renal artery (RA) repair was performed because of MRA. Atherosclerotic stenosis of the RA was apparent in 12 cases needing a repair with disobliteration. FMD was the reason in five transplantations for vascular repair. Complications like renal vessel thrombosis, lymphocele, heamorrhage, distal urinary leakage and ureteral obstruction was not significantly associated with RA reconstruction. Comparison of renal function in kidneys with reconstructed RA compared with kidneys without vascular repair showed no significant difference in primary function and serum creatinine up to the first year after transplantation. Mean follow-up was 75.6 ± 48.1 months. The 5-year graft survival rate for kidneys with RA repair was 88.5 vs. 93.4 % without reconstruction. We could show that RA pathologies, suitable repaired, are not a contraindication for transplantation with acceptable 5-year-graft-survival rates.

This retrospective review describes the long time effect of surgical revascularization after unsuccessful early or mid-term failure of percutaneous transluminal renal angioplasty (PTRA). From January 1995 to January 2005, 60 out of 696 patients operated due to renal artery occlusive disease (17 fibromuscular dyplasia (FMD): mean age, 33.4 years; 43 atherosclerotic disease (ASD): mean age, 62.46 years) after unsuccessful PTRA underwent surgical revascularization for renal artery stenosis at our institution. The mean duration from failed PTRA to operation was 1.74 years. Out of the 68 renal arteries, 44 were pretreated with angioplasty alone (19, FMD; 25, ASD), and 24 were treated with PTRA and stent (all ASD). Operative management, response of renal function and hypertension as well as survival were compared to the literature. Fifty-nine per cent (n = 40) of the renal arteries were treated by transaortic thrombendarterectomy, 37% (n = 25) by bypass. Thirty-day and in-hospital mortality was 0% in all pretreated patients; after a mean of 4.16 years, it was 16.6% (only atherosclerotic). There was a significant decrease in systolic blood pressure values for all patients early after surgery as well as in follow-up. Creatinine remained stable in the patients with FMD, and there was an insignificant increase in creatinine level in the atherosclerotic patients. Hypertension was improved or healed in 32.5% of all pretreated patients, in cases with FMD in 54%, in atherosclerotic cases in 22.2%. Re-stenoses occurred in 26% of cases with FMD and in 18% of patients with atherosclerotic RAS. Surgical renal artery revascularization after failed PTRA is feasible and safe and systolic blood pressure can be lowered. The higher rate in re-stenoses in both the literature as well as in our own experience may be explained by the alterations in the renal artery after interventional treatment.

ObjectiveAgenesis of the inferior vena cava (IVC) is a rare vascular malformation. Deep vein thrombosis (DVT) and bilateral pelvic thrombosis develop quite frequently, making surgical therapy necessary.Patients and methodsBetween 1982 and 2006, 15 patients (nine male, six female, mean age 28 standard deviance 9 years) with agenesis of the IVC (IVCA) were treated surgically because of acute or subacute DVT. These patients underwent bilateral transfemoral ante- and retrograde thrombectomy of the iliofemoral and sometimes popliteal veins and replacement of the IVC with an external ring supported PTFE-graft. Bi- or unilateral arteriovenous fistulae were created in the femoral region. The fistulae were closed, on average, 8 months after trans-arterial venography was performed. These patients were examined clinically and by duplex ultrasound imaging during follow-up to assess graft patency and to allow CEAP classification. Patients were assessed for the development of post-thrombotic syndrome (PTS).ResultsNo patient died during any part of their treatment or within 60 days. Primary patency of the venous reconstruction was 53%, secondary and long time follow-up patency was 83%. The mean duration of follow-up was 41 SD 12 months. Minor complications were observed in five cases (33%). PTS showed no progression during a follow-up of 41 SD 12 months in all patients. There was no change in the CEAP clinical stage during follow-up nor did any leg ulcer develop.ConclusionA surgical approach to restore venous patency is effective and appears to prevent the deterioration of CVI over time.

Background Congenital absence of the inferior vena cava (AIVC) is a rare malformation which may be associated with an increased risk for deep vein thrombosis (DVT). However, the role of thrombophilia in AIVC and DVT is unknown. Methods Between 1982 and 2013 41 patients (12 female, 29 male, mean age 28 S.D. 11 years) were detected at the University of Düsseldorf, Germany, with AIVC. Based on medical history, clinical examination, imaging and coagulation studies, we performed on this collective a risk characterisation. Extensive literature research added further 123 published cases during 1993 and 2013. AIVC-patients were compared with iliocaval DVT-patients without AIVC (n = 168) treated during the same period in our clinic (90 female, 78 male, mean age 38 S.D. 17 years). Results In contrast to classical DVT younger men were more often affected. Factor-V-Leiden-mutation, 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphism and hyperhomocysteinemia individually are associated with an increased risk of DVT in patients with AIVC. Aplasia/hypoplasia of the right or left kidney is also associated with IVCA. Conclusions AIVC should be considered in young patients who present with DVT involving the vena cava. Analysis of publications with AIVC and our patients yielded a typical spectrum of AIVC-associated DVT characteristics: AIVC occurs in young male adults, is revealed by proximal DVT, not necessarily accused by precipitating factors like immobilisation, and is mostly located bilateral. Hereditary coagulation abnormalities seem to be more often a contributing factor for DVT in AIVC. Electronic supplementary material The online version of this article (doi:10.1186/s13023-014-0223-4) contains supplementary material, which is available to authorized users.

Background Isolated dissection of the superior mesenteric artery (IDSMA) remains a rare diagnosis. However, new diagnostic means such as computed tomography makes it possible to detect even asymptomatic patients. If patients present symptomatic on admission, the risk of bowel infarction makes immediate therapy necessary. Today, endovascular techniques are often successfully used; however, open surgery remains important for special indications. In this paper, we present two cases with IDSMA and show why open surgical repair is still important in current treatment concepts. Methods Two cases with ISDMA that presented in our department from January 1, 2014 to June 1, 2014 are described. Data collection was performed retrospectively. Additionally, a review of articles which reported small cases series on patients with IDSMA within the past five years is provided. Results Both patients underwent open surgical repair following interdisciplinary consultation. Both patients were transferred to the intensive care unit after surgical repair and needed bowel rest, nasogastric suction and intravenous fluid therapy. CT scans were performed within the first week after operation. Platelet aggregation inhibitors were used in both cases as postoperative medication. Both patients survived and are able to participate in everyday activities. Conclusion Open surgical repair remains important in cases of anatomic variants of visceral arteries and suspected bowel infarction. Therefore, it is important that knowledge about open surgical techniques still be taught and trained.

Background Disseminated intravascular coagulation (DIC) can frequently be observed in patients with severe inflammatory response. It is still correlated with a poor prognosis. Activation of coagulation activity leads to occlusions of small vessels resulting in various organ failure symptoms. In addition, secondary fibrinolysis leads to an increased risk of bleedings and means a therapeutic dilemma. Here, we present a case of a 61-year-old Caucasian man with a severe case of DIC and its clinical complications. Methods We report the case of a man with a severe case of DIC. Data collection was performed retrospectively. Results We report the case of a 61-year-old Caucasian man with contact to pigeon droppings in his medical history. This was followed by a rhinopharyngitis, an exanthema, and a recurring priapism. Thrombotic occlusions were predominant on admission, and necrosis of the lower legs, the hands, and the genital resulted in amputation. Hypoperfusion of the rectum and the bladder lead to the creation of a descendostoma and an uretrostoma. Anticoagulation was managed by continuous infusion of unfractionated heparin and activated protein C supplementation. Long-term anticoagulation is managed with rivaroxaban. Conclusions Cryptococcus soil inhalation may cause severe DIC resulting in extremity amputations; however, effective anticoagulation and activated protein C supplementation might extenuate the progress. As multiple complications might occur, an interdisciplinary cooperation is essential.

Background—On the basis of our concept that atherosclerosis has an immunopathological background, we tested whether activation of the innate immune system influences its progression.Methods and Results—Hypercholesterolemic (0.5% wt/wt diet) rabbits received either repeated intravenous injections of endotoxin (Escherichia colilipopolysaccharide 1.25 to 2.5 μg, once per week) or a self-limiting cutaneousStaphylococcus aureusinfection with or without a quinolone antibiotic. Measured laboratory parameters, including LDL and HDL cholesterols, were similar in the different groups of hypercholesterolemic animals. All endotoxin-treated animals developed transient episodes of fever after endotoxin administration. The extent of atherosclerosis was evaluated by computer-assisted morphometry in the aortas en face (Sudan IV) and by histology at 8 weeks after start of the experiments. Endotoxin-treated animals exhibited significantly accelerated atherosclerosis compared with control animals (141±38 versus 45±16 mm3total lesion volume, n=7 to 9 rabbits each,PConclusions—Nonspecific stimulation of the innate immune system accelerates cholesterol-induced atherosclerosis. These data support the concept that atherosclerosis has an immunopathological component and render it improbable that a single infectious agent should assume particular importance in its initiation or progression.

Objective Acute mesenteric ischemia (AMI) is a complex disease with a high mortality rate. A patient’s chance of survival depends on early diagnosis and rapid revascularization to prevent progression of intestinal gangrene. We reviewed our experience with open surgery treatment in 54 cases of AMI. Methods A monocentric retrospective study was conducted between 01/01/2001 and 04/30/2014; 54 AMI patients with a mean age of 56.6 years underwent surgery (26 women and 28 men). Retrospectively, the risk factors, management until diagnosis, vascular therapy and follow-up were evaluated. Results The symptom upon admission was an acute abdominal pain event. The delay time from admission to surgery was, on average, 13.9 h (n = 34). The therapeutic procedures were open surgical operations. The complication rate was (53.7 %) (n = 29). The 30-day mortality was 29.6 % (n = 16). The late mortality rate was 24.1 % (n = 13), and the cumulative survival risk was 44.6 %. Survival was, on average, 60.54 months; however, in the over 70-year-old patient subgroup, the survival rate was 9.5 months (p = 0.035). The mortality rate was 27 % (n = 22) in the 24 h delay group. Conclusions The form of therapy depends on the intraoperative findings and the type of occlusion. Although the mortality rate has decreased in the last decade, in patients over 70 years of age, a significantly worse prognosis was seen.