[Vascularsurgical Long-term Outcome - Comparison of Orthotopic and Extraanatomic Reconstructions in Unilateral Occlusions of Iliac Artery over 10 Years]. / Gefäßchirurgische Langzeitergebnisse ­ Vergleich orthotoper und extraanatomischer Rekonstruktionen bei unilateralen Beckenachsenverschlüssen über 10 Jahre.

In PAOD, several vascular regions are usually affected, the pelvic axis in 35% of cases. Interventional-radiological/endovascular or hybrid interventions have been established for recanalization, so that bypass procedures are increasingly taking a back seat, but are not losing their importance.To study unilateral iliac artery occlusions (inclusion criterion) that were repaired either by implantation of an orthotopic or extraanatomic bypass (oBP/eaBP).Over a defined period of time, the rate of open vessel, complications (frequency, type, severity) to characterize morbidity and mortality as well as the extent of clinical improvement after BP implantation were analyzed in a clinical-systematic, single-center observational study (for vascular surgical quality assurance and contribution to vascular medical-clinical health care research). The study method was not explicitly based on the STROBE criteria, but essentially corresponds to them.Over 10 years, 122 PAOD patients (50% in stage IIb-stage III and IV equally distributed; mean age: 63 [range, 44-87] years; majority ASA III) were included with the same number of reconstructions: 71 patients received an eaBP ("crossover"), 51 patients an iliacofemoral (orthotopic - oBP) bypass (neither significant difference regarding frequency nor number of risk factors per patient).The oBP is not superior to eaBP with regard to the analysis parameters of openness, complication rate and mortality. Furthermore, extraanatomic revascularization does not have to be reserved for polymorbid patients only.

Uncommon diagnosis of multinodular goiter - isolated extrapulmonary manifestation of sarcoidosis in thyroid gland (scientific case reports).

AIM: By means of the scientific description of two uncommon cases who underwent. surgical resection of multinodous goiter and following histopathological investigation revealing isolated extrapulmonary manifestation of sarcoidosis, this uncommon diagnosis including symptomatology, clinical findings, diagnostic and therapeutic management is to be illustrated. CASE DESCRIPTIONS: Diagnostics: Scintigraphy of the thyroid gland with a left-thyroid cold node; ultrasound-guided puncture (cytological investigation, non-suspicious). THERAPY: Elective thyroidectomy with no macroscopic anomalies und no abnormal aspects with regard to surgical tactic and technique. Histopathological investigation: Complete resection specimen of the thyroid gland with granulomatous inflammation consistent with sarcoidosis. CLINICAL COURSE: Uneventful with no further manifestations of sarcoidosis in the following diagnostics. DIAGNOSTICS: Ultrasound, inhomogeneous node (37×30×35 mm) of the right thyroideal gland with echo-poor parts and peripheral vascularization; scintigraphy showing marginally compensated unifocal autonomy of the thyroid gland (laboratory parameters, increased serum level of thyroglobulin [632 ng/mL]). THERAPY: Planned right hemithyroidectomy with confirmed nodous structure of thyroid parenchyma, without suspicious lymph nodes. Histopathological investigation: 33-mm follicular, nodular, encapsulated structure of thyroid parenchyma (diagnosed as follicular adenoma); 2nd opinion: low-grade differentiated carcinoma of thyroid gland with angioinfiltrating growth and granulomatous inflammation of sarcoidosis type. Procedural intent: After tumor-board consultation, completing thyroidectomy was performed within a 5-weeks interval (pT2 pN0[0/1] V1 L0 G3 R0) with subsequent ablating radio'active iodine therapy; 18 F-FDG-PET-CT (several atypical infiltrates within the right upper lobe of the lung) and bronchoscopy with no detection of further manifestation of sarcoidosis. CONCLUSION: Sarcoidosis is considered a rare granulomatous multi-locular, systemic disease of not completely known etiopathogenesis with substantial heterogeneity. In most cases, it is associated with the lung, but which can become manifest in various organs. Frequently, extrapulmonary manifestations are usually detected as histological findings by coincidence, which require further investigation to find out additional manifestations as well as to exclude florid infection or other granulomatous processes (clarifying competently differential diagnosis). Therapy is only indicated in symptomatic organ manifestations, taking into account the high rate of spontaneous healing and possible side effects.

[Outpatient and "Admission-Substituting" Interventions in Vascular Surgery - What is Feasible and Where are the Limits? Previous and New Legal Requirements and their Implementation in Practice]. / Ambulante und stationsersetzende Eingriffe in der Gefäßchirurgie ­ was ist machbar und wo liegen die Grenzen? Bisherige und neue gesetzliche Vorgaben sowie deren Umsetzung in der Praxis.

INTRODUCTION: In vascular surgery too, more services and procedures will have to be shifted from the previous inpatient to the outpatient sector in the future. Therefore, the previous and new legal requirements as well as their implementation in vascular surgery will be explained and evaluated. MATERIAL AND METHODS: Professional policy analysis from a perspective of medical vascular surgery. RESULTS: The AOP catalog from 01.01.2023 was extended by 208 additional OPS codes. The inpatient performance of services which, according to the AOP contract, must be regularly performed on an outpatient basis, are now to be justified on the basis of context factors.A special sector-equivalent remuneration, which is independent of whether the remunerated service is performed on an outpatient or inpatient basis, is a prerequisite for a cost-covering expansion of outpatient operations and inpatient-replacing services. The rehabilitation of primary varicosis under outpatient conditions is undoubtedly the standard. The majority of AV shunt installations are performed as inpatient procedures. No new OPS codes were added to the 2023 AOP catalog for varicose vein, shunt and endovascular surgery. DISCUSSION: The shift of inpatient services to the outpatient sector can be a feasible path, based on the experience of other European countries. However, the structures, economic conditions and incentives should first be created to successfully promote transfer to outpatients. Integrated care offers the possibility for the health insurance funds to conclude contracts with the service providers named in § 140a of the Social Code, paragraph 3, for special care. The use of telemedicine in the sense of tele-premedication or tele-monitoring can be a way to expand outpatient surgery, especially in rural regions. In order to enable therapy concepts from one expert in vascular medicine, the outpatient service billing of interventional procedures must also be demanded by vascular surgeons and specialists. CONCLUSION: The potential to transform inpatient services into the outpatient setting of service provision is realisable in vascular surgery in the core areas of varicose vein surgery, shunt surgery and peripheral interventional procedures under specific conditions.

[Topicality of the fundamental and determining importance of chronic critical ischemia of the extremities and its restorative treatment using crural/pedal bypasses in Germany and in Saxony-Anhalt]. / Aktualität der grundlegenden und determinierenden Bedeutung der chronisch-kritischen Extremitätenischämie sowie ihrer sich reetablierenden Behandlung mittels kruraler/pedaler Bypässe in Deutschland und in Sachsen-Anhalt.

INTRODUCTION: Currently, there is an increase in severe stages of peripheral arterial occlusive disease (PAOD) with critical ischemia. This seems to correspond to the general demographic change as well as a consequence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic of the last 3 years. The now established and accepted interventional/endovascular approach for severe lower leg PAOD in experienced hands is still considered the first-line treatment but from the authors' perspective crural/pedal venous bypass is experiencing a renaissance. MATERIAL AND METHODS: Compact narrative review of the current state of crural/pedal bypass surgery in Germany and Saxony-Anhalt (SA) combined with selective references from the current scientific medical literature and own clinical experiences. RESULTS: The current statistics of case-related diagnosis-related groups (DRG) data show that, especially with the occurrence of the corona pandemic, a decrease in inpatient case numbers of patients with PAOD stage IIB can be observed nationwide and also in SA. The severe PAOD stages have remained approximately the same in case numbers but increased in SA. The risk stratification based on the wound, ischemia and foot infection (WIFI) classification offers the possibility to be able to make statements about the risk of amputation, benefits and type of revascularization measures. The length of the occlusion, occlusion site of the affected vessels and degree of calcification are taken into account in the global limb anatomic staging system (GLASS) to assess the prognosis. The evaluation of the case-based hospital statistics from 2015 to 2020 showed a constant use of femorocrural/femoropedal bypass surgery in Germany as well as a slight increase in reconstruction using femorocrural bypasses in SA, which seems to correlate with the tendency for an increase in the number of cases of severe PAOD. Parameter-based objectification of the severity of critical limb ischemia should be included in the indications for placement of a crural/pedal bypass. The WIFI classification and GLASS are suitable for this purpose as a relative prognosis of success is also possible. The treatment of critical limb ischemia by crural/pedal bypass surgery continues to find a constant application in Germany and SA.

[Vascular surgery care in rural areas-Adaptation to demographic and epidemiological requirements]. / Gefäßchirurgische Versorgung im ländlichen Raum ­ Anpassung an die demografischen und epidemiologischen Erfordernisse.

Introduction: The demographic development in Germany, especially in Saxony-Anhalt (SA), also poses challenges for vascular surgery, as the incidence of vascular diseases has increased following demographic change. For example, the prevalence of peripheral arterial occlusive disease (PAOD) in industrialised countries is estimated at around 10-20% in people over 60 years of age; thus, the number of people affected will also increase here with demographic change. Especially in rural areas, it seems to be more difficult for patients to reach appropriate specialist treatment. Material and methods: A compact narrative brief review, based on selective references from the current medical-scientific literature and our own experiences from daily practice in setting up a vascular surgery department in a rural area. Results: In 2020, the population in the rural district of Jerichower Land (SA) was approximately 89,403 (male: 44,489; female: 44,914). The age distribution in the age groups relevant for PAOD is as follows: 65-74 years-total, 12.38%; 75 years and older-total, 13.85%; average age, 48.36 years (population density, 56.4/km2). According to the SA Association of Statutory Health Insurance Physicians, there were 605 patients for every doctor in Burg (SA) in 2019.There was a total of 5087 people in need of long-term care in the district in 2019. With such a low population density, low doctor density, high mean age, high proportion of people over 75 years of age and a high number of people in need of care, limited mobility and accessibility to vascular surgery care are to be expected, which was also reflected in the high number of PAOD of stage IV (FONTAINE) in the initial patient clientele.Every establishment of a vascular surgery department is associated with a considerable financial and material investment, which the provider of the facility must be prepared to make.In addition to the material investment, the availability of appropriately qualified staff to implement and maintain continuity of care must also be seriously considered. Conclusion: The high proportion of residents at risk of and suffering from PAOD in a rural area with low population and doctor density allows investment in the establishment of a new vascular surgery department to ensure local care in this patient group with limited mobility and self-help, thus, ultimately from an appropriate health policy perspective but also from the perspective of a relevant revenue outlook.

[Specifics of teaching in vascular surgery in an interdisciplinary surgical setting]. / Spezifika der Lehre in der Gefäßchirurgie im interdisziplinär-chirurgischen Setting.

OBJECTIVE: The complex changes in vascular surgical teaching and commonalities are to be outlined and discussed, in particular, similarities/differences to general surgery, specifics of teaching/teaching content and its university requirements. METHOD: Compact narrative overview RESULTS: Vascular surgical teaching component at Magdeburg University Hospital comprises 10 academic teaching hours and includes the following topics: PAD, embolism/thrombosis, vascular injury, compartment syndrome, mesenteric ischemia, aortic aneurysm and venous surgery. This puts vascularsurgical teaching here well above the average of 6.1 academic teaching hours in Germany. The strength of (vascular)surgical training lies in the fact that the knowledge gained at the bedside can be linked to visual impressions and simultaneous explanations in the operating theatre. Close integration of the student into the team is the high art of promoting acceptance of surgery as a profession and vocation. The prerequisites for successful teaching are a didactically competent teacher with specialist expertise, a proactive teaching attitude, knowledge of the specific learning objectives, the curriculum, modern teaching methods and awareness of the special role model function for students. Classical teaching by means of lecture, seminar, practical course and textbook is justified and should be strengthened but it is increasingly supplemented by the use of internet-based learning platforms, libraries and video portals. CONCLUSION: In the coming years, vascular surgical teaching will (have to) shift to a (rather) multimodal/-media approach with more practice-oriented components and intensive integration of students into everyday clinical practice.

Alternative Mobilization by Means of a Novel Orthesis in Patients after Amputation. / Alternative Mobilisation mithilfe einer "Freihandorthese" bei Patienten nach Amputation.

INTRODUCTION: The mobilization of patients with diabetic foot syndrome after surgical treatment by debridement or partial amputation is usually difficult in daily practice and in inpatient care. AIM AND METHOD: A case report - with a representative case showing the innovative possibilities of an alternative mobilization option by means of a new orthesis ("iWALK 2.0®"; IWALKFree® Inc., Mansfield, Ontario, Canada) after surgical therapy of diabetic gangrene, exemplified by the successful clinical course. RESULTS: The inpatient admission of a 59-year-old male patient revealed septic gangrene of the right foot in insulin-dependent diabetes mellitus. After admission and initial diagnosis, the calculated antibiotics therapy and initial surgical rehabilitation of the right foot took place. After stabilization and control of the infection, the minor amputation was performed at the Bona-Jäger line without primary wound closure, wound care was provided by vacuum sealing. Complicated by pre-existing peroneal paralysis of the contralateral leg following herniated disc, mobilization could be accomplished out of the wheelchair using a novel "free-hand" orthesis "iWALK 2.0" and a walker with physiotherapeutic support. Thus, while simultaneously relieving the operated foot, self-sufficient mobilization at a later time was possible. This gave the patient a positive attitude to life in addition to more independence. CONCLUSION: The successful application of the "free-hand" site "iWALK 2.0" under the listed clinical constellation thus suggests that it is a clear alternative of "postoperative rehabilitation" in the diagnosis of a surgically treated diabetic foot gangrene after minor amputation with a consolidated wound while ultimately serving to achieve a more comprehensive level of experience for targeted use with a clearly defined indication.

[Modern Management of Arterio-Visceral/Arterio-Lumenal Fistulas - Selection of Representative Clinical Situations and Cases]. / Das moderne Management arterioviszeraler/-lumenaler Fisteln ­ eine Auswahl repräsentativer Fallkonstellationen.

INTRODUCTION: Circuits of abdominal arteries to adjoining lumenal organs, especially in triggering circumstances, are rare diseases that are increasingly evident in endovascular therapies and complex viscero-/tumor-surgical procedures with subsequent lengthy adjuvant therapies. Their care is a challenge and involves frequent complications and mortality. METHOD: Narrative overview on the basis of current scientific references and our clinical and surgical experience. RESULTS: Uretero-arterial fistulas are usually associated with recurrent and intermittent gross haematuria. The diagnostic test of choice continues to be angiography with the potential for endovascular therapy, which has displaced open surgical procedures due to minimal invasiveness, low morbidity and mortality. Aorto-oesophageal fistulas may result from underlying infectious and malignant diseases as well as open and endovascular therapies of the aorta. Multi-line contrast CT of the thorax/abdomen and gastroscopy have priority in diagnostic testing. Endovascular procedures can only be understood as bridging procedures, and only the removal of prostheses with aortic and gastrointestinal reconstruction are curative. Aorto-enteric fistulas are secondary complications of open and endovascular aortic surgery. Contrast enhanced multi-line CT has high sensitivity and specificity. In contrast, open surgical therapy involves in-situ reconstruction of extra-anatomical reconstructions with aortic ligature. Endovascular therapy is reserved for exceptional cases. Inflammatory aneurysms of visceral arteries may be associated with adjacent inflammatory processes, most commonly pseudoaneurysms. The most suitable diagnostic procedure is contrast-enhanced thin-film CT angiography. The treatment of choice is endovascular ablation using covered stents or embolisation. CONCLUSION: Arterio-visceral/arterio-lumenal fistulas are similar in pathogenesis, predisposing factors and clinical symptoms. An interdisciplinary consultation is employed to identify individualised therapy. Endovascular/interventional procedures are safe and effective, and open surgical rehabilitation is mostly curative.

[Options and Management of Vascular Reconstruction in the Context of Abdominal Surgery and its Perioperative Care - Selection of Typical Clinical Situations and Cases]. / Möglichkeiten und Management gefäßrekonstruktiver Eingriffe im Rahmen viszeralchirurgischer Operationen und ihrer perioperativen Betreuung ­ eine selektive Auswahl repräsentativer Fallkonstellationen.

INTRODUCTION: Interdisciplinary cooperation between surgeons can help to optimise outcome in the management of complex surgical diseases. The indication for surgical intervention has gradually expanded in advanced multivisceral tumour growth, with iatrogenic vascular injuries in the field of abdominal and oncological surgery and mesenteric ischemia. Appropriate expertise in vascular surgery is then essential, although this is not always available or in all hospitals. AIM: Narrative review based on current scientific references in the relevant literature and our own clinical and surgical experiences in decision making, the approach in clinical management and various options of vascular reconstruction in abdominal surgery. RESULTS: Prognosis is still limited in pancreatic cancer. R0 resection is the only curative therapeutic option - thus, the surgeon has to provide specific intraoperative expertise. Arterial reconstruction is still controversial, due to increased postoperative morbidity and limited evidence. But in specific cases, venous reconstruction has been established in clinical practice. In addition, in retroperitoneal sarcoma with advanced/extended tumour growth, reconstruction of the infiltrated inferior V. cava or common iliac artery by means of patch plasty or autologous bypass/segmental vascular prosthesis can become necessary as part of multivisceral resections. During inflammatory processes or with tumour adhesions/infiltrations to surrounding anatomical structures, intraoperative vascular injuries or postoperative vascular alterations can occur, further complicated by anatomical variants. The extremely strict demands on the abdominal surgeons, in particular in mesenteric ischemia, are influenced by i) a competent assessment of the mesenteric vessels based on ii) adequate imaging as well as iii) appropriate time management. Prompt recanalisation can play a decisive role for the prognosis. CONCLUSION: Vascular reconstructions in abdominal surgery, in particular, in oncological surgery, require great expertise of the surgeon. In this context, competent preoperative diagnostic testing, extensive specific experience in vascular surgery/interventions, appropriate interdisciplinary case management, adequate surgical tactic and technique are all important.

Chylous complications of various severity and manifestations within diverse compartments in reconstructive vascular surgery #) #) The manuscript is dedicated to Prof. Dr. Z. Halloul.

INTRODUCTION: Chylous complications, which occur also in the profile of vascularsurgical interventions with considerable frequency, are challenging with regard to their adequate management. Aim & method: Compact short overview on epidemiological, classifying, symptomatic, diagnostic and therapeutic aspects of chylous complications in vascular surgery, based on i) own clinical experiences, ii) a current selection of relevant scientific references and iii) representative case reports from clinical practice. Results (complex patient- & clinical finding-associated aspects): - Basic treatment of lymphedema / postreconstructive edema comprises the complex physical therapy to improve edematous swelling, which need to be usually performed over years. - In case of lymphocele, wait-and-see strategy can be initially pursued to observe spontaneous clinical course. If the lymphocele and its clinical complaints persist, puncture, placement of a drainage or temporary instillation of doxycyclin or ethanol can be attempted. - In case of lymphatic fistula, vacuum-assisted closure dressing, radiation and selective ligation of lymphatic vessels after previous application of methylen blue dye can be used. - Chylascites and chylothorax should be primarily treated - as have been widely established in the mean time - with a consequently conservative approach comprising initially paracentesis / thoracocentesis, protein-enriched and low-fat diet containing middle chain triglycerides (MCT) or total parenteral nutrition combined with the application of a somatostatin analogue (surgical approach as ultima ratio only aiming at ligation of the lesioned lymphatic vessel - if necessary, including preoperative consumption of cream). SUMMARY: Chylous complications can be primarily treated with conservatice measures, which should be exploited using a step-wise approach prior to surgical intervention as ultima ratio. CONCLUSION: The experienced vascular surgeon should be aquainted with a sufficient, finding-adapted management of chylous complications. This requires a well-experienced clinician and surgeon with great expertise regarding the interdisciplinary setting comprising of interventional radiology, vascular (abdominal) surgery and partially surgical intensive care.