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Almost 10 % of the population are concerned in the course of her life by chronic wounds, mortality resulting from this amount to 2.5 %. The Vacuum assisted closure (V.A.C.) therapy represents a modern procedure for the treatment of chronic wounds. Also in some first appearing offering no prospects cases hereby the Major amputation can be prevented and the majority of chronic therapy-resistant wounds can be healed. Due to first experiences with the V.A.C. therapy with the treatment of infected vascular grafts in the stage II and III after Szilágyi it also offers a success - promising option to concern the extremity and the life of the patient and to receive but also the infected graft in situ.

The unilateral distal arterial lesions still give problems in classification and differential diagnosis specially in younger patients. We report on a 45 years old male patient with an aneurysm of the distal ulnar artery and superficial palmar arch. The chronic occupational trauma of the artery led to the clinical picture of hypothenar hammer syndrome.

We report the successful thrombectomy of the internal carotid artery. A 33-year-old woman suffered from ovarian hyperstimulation syndrome after treatment with FSH/HCG for in-vitro fertilization. She developed a transient left hemiparesis. This was caused by a floating thrombus located in the internal carotid artery. Open surgical treatment with thrombectomy prevents recurrent neurological symptoms.

Long-term results of femoral angioplasty and stenting are not as successful as open surgical procedures. Transfemoral retrograde recanalisation of the iliac vessel by semiclosed endarterectomy is a low-invasive procedure. Certainly the outcome is characterised by a number of early occlusions caused by dissections or remaining intimal flaps. Recent advances in endovascular management of occlusive disease have changed the situation. Intraoperative control of lumen by angioscopy and removal of occlusive material via TV-monitored endoscopic manipulation has induced better results of endarterectomy. In addition to this more effective recanalisation, the proximal intimal step, mostly at the level of the iliac bifurcation, is managed by intraoperative balloon dilatation and stenting. This combined approach has reduced the necessity of reoperation by about 15%. The cumulative 5-year patency rate for this combined procedure is 88%.

Acute occlusion of the aortic bifurcation by a sattle embolus, as a complication of infective Endocarditis, is a very rare, extremely serious event. The treatment of choice consist in an immediate simultaneous bilateral femoral embolectomy. The indication for operation must be realised without delay based on anamnesis and physical examination.

Focal idiopathic renal arterial dissection (RAD) is a rare event. Nevertheless, a RAD should always be considered in the differential diagnosis in patients with flank pain or acute abdomen, since only an immediate diagnosis and correction can guarantee the maintenance of kidney function. Early operation is also necessary because other clinical pictures with a similarly dramatic clinical course and similar symptoms can likewise only be treated surgically. These include a renal arterial aneurysm with endo-aneurysmatic thrombus and poststenotic dilatation in fibromuscular dysplasia. We describe the case of an isolated idiopathic RAD which could only be diagnosed in the context of abdominal pain symptoms. Clinical, pathophysiological and therapeutic aspects of RAD are discussed with reference to the case report and the international specialist literature.

In combined chronic occlusive lesions at the aortoiliac and femoropopliteal level, partial repair of the central vessels in combination with profundaplasty and lumbar sympathectomy represents a more simple and shorter procedure than does the previously preferred total correction of both segments. In a retrospective study of 403 limbs, Stages II, III and IV, the triad procedure results in a cumulative patency rate of 77 versus 39 percent for total repair. In limb salvage operations, Stages III and IV, the corresponding figures for the amputation rate were 8 versus 36 per cent and for reoperation, 7 versus 23 per cent. Prerequisites for this type of repair are an improved technical approach and a critical selection of patients with a receiving segment of the popliteal artery and a sufficient runoff below the knee.

The profundaplasty has recently advanced to a widely used surgical approach for revascularisation of the lower extremities, both for claudication and limb salvage. The effectiveness of this simple time saving procedure depends on a critical selection of patients and the use of an improved surgical technique. Main prerequisites are the simultaneous aorto-iliac inflow repair, using thromboendarterectomy or bypass, the patency of the so-called "receptor segment" of the popliteal artery and a sufficient run- off in the distal arterial tree. An additional lumbar sympathectomy has proved as a protective adjunct which results in an additional increase of flow in the restored deep femoral artery. In combined occlusive lesions of the aorto-iliac and femoro-popliteal segment the late results of a proximal inflow repair in combination with profundaplasty and lumbar sympathectomy are significantly superior to the total repair of both arterial segments. A profundaplasty is contraindicated if this artery is seriously diseased or in the presence of total occlusion of the popliteal artery (receptor segment) and of more than two main arteries below the knee. This is the place where long distal grafts are still justified for limb salvage. In over 80% of patients with arterial occlusive disease of the leg arteries the profundaplasty (with or without aorto-iliac inflow-repair) has proved as an effective alternative to time-consuming extensive arterial reconstructions with equivocal outcome.

The tumors of the carotid body are rare in frequency but still they give many problems in preoperative diagnosis and operative management. The pathological classification and estimation of dignity is still under discussion. Based on the experience of 5 patients we try to give a comprehensive listing of important facts and a classification for clinical use. In spite of the typical clinical signs which were described by Kocher and Fontaine the carotid body tumor is the most frequently mistaken tumor in the lateral region of the neck. If a tumor of this type is suspected a carotid arteriogram should be regularely performed. The arteriogram is the most important diagnostic procedure, and gives the final diagnosis in most cases. The therapeutic principle is the early total extirpation. In spite of the small rate of malignancy (under 10%) this challenge is based on the frequent observation of local spreading of the tumor. The excision of tumors of even large size is possible under consideration of special operative technics.

Major amputation is a radical therapeutic principle which should not be undertaken without angiographic evaluation. Since the goal of limb salvage is to limit the ischemic tissue lost in an acral area, it favours minor "borderline" amputation. Of 597 stage IV patients 362 underwent arterial reconstruction (40% diabetics). Limb salvage was performed in 75% of the patients. Followup after 6 years showed that 33% of the patients were able to walk, and 17% had had a secondary major amputation.

Diagnostically and therapeutically, three types of angiodysplasias interfere with venous surgery: 1. Congenital arteriovenous fistulas (Type F.P. Weber: secondary varicosis with local gigantism)--surgical reduction of the shunt-volume is usually indicated. 2. Type Klippel-Trenaunay: Surgery for varicose veins is dangerous due to the frequent hypo- or aplasia of the deep venous system. 3. Venous hemangiomatosis (Type Servelle-Martorell or Kasabach-Merritt): Any surgical intervention is contraindicated (only external compressive therapy).

The late results of venous thrombectomy could be remarkably improved by routine use of intraoperative vascular endoscopy and additional temporary a.v.-fistula. Long-term follow-up (mean 8 y.) of 119 patients (Ulm 1970-1983) showed full patency in 75% (phlebography) and very good function in 63% (phlebodynamometrie). With improved surgical technique the preservation of values is possible. Mortality was 1,8% and the incidence of clinically relevant postoperative pulmonary embolism was lower than 2%.

Special problems in the surgical treatment of aortic coarctation may be caused by unusual morphological findings as a long hypoplastic segment, the combination with pre- or poststenotic aneurysms or by atypical localisation of the stenosis in the aortic arch, the decreasing or abdominal aorta. A bypass procedure is considered as the method of choice for the repair of coarctation in the aortic arch or the "critical zone" of the abdominal aorta (renal- and suprarenal segment). The bypass-principle allows many variations of branching and avoids cross-clamping of the aorta. The involvement of important branches as is the left common carotid, the superior mesenteric or the renal artery, necessitates a vascular reconstruction in the same session. Probably the first report about a very rare combined lesions is presented: the combination of an aortic arch coarctation in association with a complete situs inversus (right descending aorta), a common carotid trunc, an aneurysm of the left subclavian artery (first branch of the arch) and congenital cysts of the right upper lobe of the lung (Case No. 1). Usually concomitant aneurysms are found in the pre- or poststenotic aortic segment. Some of the infrarenal fusiform aneurysms (Case No. 4 and 5) are occasionally of poststenotic origin, secondary to a longstanding infrarenal coarctation. In these cases the procedure of choice is the total exstirpation and the interposition of a Dacrongraft. Important branches (as the subclavian or renal artery) can be some times inserted directly in the vascular protheses. Using the bypass technic or the patch graftplastic of Vosschulte the risk of late operation (beyond the age of 30 years) may be remarkably reduced.

The vena cava inferior was replaced by alloplastic vein replacement materials in 60 beagle dogs divided in 6 groups. The wall-porosity varied from 50 to 280 ml/cm2 per minute in the textile prostheses (water porosity) (Groups 1-3), and from 30 to 60 micron fibril length in the expanded PTFE-prostheses. All textile prostheses (woven or knitted) are clearly inferior of expanded PTFE-prostheses. The fibril length of 60 micron represents an improvement in comparison with a length of 30 micron regarding the patency rate and the incorporation process, but it needs a special external support.

4--9 years after transduodenal papillotomy an endoscopic-manometric and clinical control of the surgical result was done in 49 patients. The pressure difference of common bile duct and duodenum was of great interest. There existed a correlation between the pressure difference and other parameters so far, as air was frequently seen in those patients without pressure gradient between common bile duct and duodenum. Pathological activity of gamma-GT and a decrease of Prothrombine-time was found after a high pressure difference. It may be possible that anatomical variations of the biliary system and the duodenum have some importance for the formation of stones.

In combined chronic occlusive lesions at the aorto-iliac and femoro-popliteal level the partial repair of the central vessel in combination with profundaplasty and lumbar sympathectomy ("triad procedure") represents a simpler and shorter procedure than the previously preferred total correction of both segments. In a retrospective study of 403 limbs (stage II-IV) the triad procedure shows a cumulative patency (life table analysis) of 77% vs. 39% in total repair. The amputation rate in triad procedure--for stage III/IV--was 8% vs. 36% and the frequency of reoperation 7% vs. 23% in total repair. Prerequisites for this type of repair are an optimal technique and a correct selection of patients presenting patient "receiving segment" of the popliteal artery and a sufficient run-off below the knee.