The importance of open emergency surgery in the treatment of acute mesenteric ischemia.

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 <12 h delay group, 20 % (n = 5) in the 12-24 h delay group, and 50 % (n = 7) 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.

Successful surgical management of a recurrent leiomyosarcoma of the inferior vena cava.

The leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumour of the venous system. The recurrence of the tumour after previous initial surgical resection is common and occurs in more than half of the patients. Surgical resection of a local recurrence is poorly described in the literature and the available data are restricted to a small number of cases. We report the case of a 62 year old woman, who was referred to our vascular surgical unit for recurrence of a leiomyosarcoma of the inferior vena cava, 35 months after diagnosis and initial surgical treatment. We performed an extensive local resection and circumferencial replacement of the IVC. 18 months after the second operation and adjuvant radiotherapy, the patient is in a very good physical condition and CT-scans show no evidence of tumour recurrence.

[Occlusive aortic disease as coral reef aorta--experience in 80 cases]. / Der stenosierende Aortenprozess als Coral Reef Aorta--Erfahrungen in 80 Patienten.

BACKGROUND: Coral reef aorta (CRA) is described as rock-hard calcifications in the visceral part of the aorta. These heavily calcified plaques grow into the lumen and can cause significant stenoses, leading to malperfusion of the lower limbs, visceral ischaemia or hypertension due to renal ischaemia. PATIENTS/METHODS: From 1/1984 to 11/2008, 80 patients (26 m, 54 f, mean age 61.6, range 14 to 86 years) underwent treatment in the Department of Vascular Surgery and Kidney Transplantation, Heinrich-Heine-University Hospital for CRA. The present study is based on a review of patient records and prospective follow-up in our outpatient clinic. RESULTS: The most frequent finding was renovascular hypertension (n=33, 41.3%) causing headache, vertigo and visual symptoms. Intermittent claudication due to peripheral arterial occlusive disease was found in 35 cases (43.8%). 15 patients (18.8%) presented with chronic visceral ischaemia causing diarrhoea, weight loss and abdominal pain. 79 patients (98.7%) underwent surgery; in 73 (93.7%) aortic reconstruction was achieved with thromboendarterectomy, on an isolated suprarenal segment in 7 (9.3%), an infrarenal segment in 21 (26.6%), and the supra- and infrarenal aorta in 45 cases (60%). Desobliteration of renal arteries was performed in 47 (one-sided n=8, 10.1%; both arteries n=39, 49.4%); the aortic bifurcation was desobliterated in 37 (46.8%), extension into iliac arteries was necessary in 29 cases (one-sided n=4, 5.1%; both arteries n=25, 31.6%). The coeliac trunk was desobliterated in 43% (n=34), the superior mesenteric artery in 44.3% (n=35) and the inferior mesenteric artery in 20.3% (n=16). In 15 cases additional revascularisation (bypass, transposition, graft interposition) was necessary. Surgical access was via a left-sided thoracoabdominal incision in 56.4% (n=45) and via laparotomy in 41.8% (n=33). The 30-day lethality was 8.7% (n=7). Postoperative complications requiring corrective surgery occurred in 11 patients (13.9%). Almost ⅓ of the patients (n=19, 27.5%) returned for follow-up after a mean of 52.6 months (range 3 to 215 months). Of these, there was significant clinical and diagnostic improvement in 16 (84.2%) and 3 (15.8%) were unchanged. Impairment was not observed. CONCLUSION: In spite of the existing and improving surgical techniques for the treatment of CRA, procedures are challenging and should be performed in centres with expertise.

Surgical treatment for agenesis of the vena cava: a single-centre experience in 15 cases.

OBJECTIVE: Agenesis 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 METHODS: Between 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). RESULTS: No 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. CONCLUSION: A surgical approach to restore venous patency is effective and appears to prevent the deterioration of CVI over time.

[Retrograde aortomesenteric loop bypass behind the left renal pedicle ("French bypass") in the treatment of acute and chronic mesenteric ischemia. Clinical experiences and long-term follow-up in 27 patients]. / Der retrograde aorto-mesenteriale Bypass mit links retrorenalem Verlauf ("französischer Bypass") bei der Behandlung der akuten und chronischen viszeralen Ischämie. Klinische Erfahrung und Langzeitverlauf bei 27 Patienten.

BACKGROUND: In 2001 Leschi et al. published a new method to improve perfusion of the superior mesenteric artery (SMA) in operative therapy of acute and chronic visceral ischemia. They presented a retrograde aorto-mesenteric bypass following an arcuate course behind the left renal pedicle. Due to the intricate correct anatomic description of this vascular reconstruction this loop bypass was named the "French bypass". PATIENTS AND METHODS: In our department 84 patients underwent surgery because of an acute or chronic visceral ischemia between January 2002 and December 2007. Out of these patients 27 received a "French bypass". The pre-, intra-, and postoperative data were collected from the patient hospital files retrospectively. The follow-up consisted of a review of the patient history and clinical findings in an outpatient setting, combined with a duplex sonography of the visceral arteries. RESULTS: The group of 27 patients had an average age of 55.0 years: (range: 29-81 years) and consisted of 21 women (78.6 %) and 6 men (21.4 %). The cardinal symptom of all patients was abdominal pain of variable intensities. 14 patients complained about an increased pain post ingestion (abdominal angina) and 12 patients about an involuntary loss of weight. Bypass material was autologous saphenous vein in 18 patients (66.7 %) and in 9 patients (33.3 %) an 8-mm ring-enforced PTFE prosthesis. Apart from 10 patients who only received the French bypass, we performed comprehensive visceral revascularisations in 12 patients. Overall hospital mortality was 18.5 %; 4 out of the 5 deceased patients had undergone surgery due to acute visceral ischemia. The mortality of patients with acute visceral ischemia was 30.8 % and of patients with chronic visceral ischemia 7.1 %. Eight patients had a revision before -discharge from hospital (surgery n = 6, interventional n = 2). Primary and secondary patencies of the bypasses of the surviving patients were 54.6 % (12 out of 22 patients) and 81.8 % (18 out of 22 patients), respectively. Concerning the end-point "freedom from abdominal complaints" 14 out of 27 patients (51.9 %) benefited after a mean follow-up of 38.9 months (range: 3-84 months), 7 patients each in the acute and chronic visceral ischemia group. CONCLUSIONS: The implantation of a "French bypass" represents a good option to reconstruct the SMA, combining the advantages of ante- and retrograde visceral bypasses. Furthermore this -bypass procedure allows to reconstruct distal segments of the -superior mesenteric artery in cases when long distance and peripheral stenosis impeded local thromendarterectomy. Perioperative morbidity and mortality are acceptable when the acute clinical situation is taken into account. The long-term benefit for the patients with regard to the prevention of intestinal ischemia and also the freedom from complaints is high.

[Pulmonary embolism and deep vein thrombosis in the inferior vena cava affected by a rare anomaly]. / Embolisierende Thrombose bei Fehlbildung der V. cava inferior.

Persistent left-sided inferior vena cava (VCI) is a rare venous anomaly, its prevalence being estimated at 0.2-0.5%. Thrombotic occlusion of a VCI has been reported in only a few of these cases. We report the case of a 24-year old woman who suffered an acute thrombosis in a left-sided VCI and recurrent pulmonary embolism. After thrombectomy the course was uneventful. The diagnostic approach and the treatment strategy are discussed with reference to the literature.

Differential regulation of hyaluronic acid synthase isoforms in human saphenous vein smooth muscle cells: possible implications for vein graft stenosis.

Autologous saphenous vein bypass grafts (SVG) are frequently compromised by neointimal thickening and subsequent atherosclerosis eventually leading to graft failure. Hyaluronic acid (HA) generated by smooth muscle cells (SMC) is thought to augment the progression of atherosclerosis. The aim of the present study was (1) to investigate HA accumulation in native and explanted arterialized SVG, (2) to identify factors that regulate HA synthase (HAS) expression and HA synthesis, and (3) to study the function of the HAS2 isoform. In native SVG, expression of all 3 HAS isoforms was detected by RT-PCR. Histochemistry revealed that native and arterialized human saphenous vein segments were characterized by marked deposition of HA in association with SMC. Interestingly, in contrast to native SVG, cyclooxygenase (COX)-2 expression by SMC and macrophages was detected only in arterialized SVG. In vitro in human venous SMC HAS isoforms were found to be differentially regulated. HAS2, HAS1, and HA synthesis were strongly induced by vasodilatory prostaglandins via Gs-coupled prostaglandin receptors. In addition, thrombin induced HAS2 via activation of PAR1 and interleukin 1beta was the only factor that induced HAS3. By small interfering RNA against HAS2, it was shown that HAS2 mediated HA synthesis is critically involved in cell cycle progression through G1/S phase and SMC proliferation. In conclusion, the present study shows that HA-rich extracellular matrix is maintained after arterialization of vein grafts and might contribute to graft failure because of its proproliferative function in venous SMC. Furthermore, COX-2-dependent prostaglandins may play a key role in the regulation of HA synthesis in arterialized vein grafts.

Intraaortic balloon pump counterpulsation after implantation of infrarenal and thoracoabdominal aortic protheses.

Highly complex vascular surgery interventions have nowadays become possible due to sophisticated operative techniques and modern intra- and postoperative anesthesiological strategies. Accordingly, the number of high risk vascular surgery interventions rises continuously and thus, the number of secondary complications after high risk interventions increases as well and requires likewise extraordinary treatment concepts. We report of a 68-year old patient who 6 months previously was operated on a ruptured abdominal aneurysm, before he was admitted to our institution for the treatment of a type IIIb (Crawford classification) thoracoabdominal aneurysm. Intraoperatively we implanted a 26 mm Dacron prosthesis which was anastomosed with the previously existing infrarenal graft. Postoperatively the patient suffered from a hemodynamically significant myocardial infarction and acute coronary catheter intervention was necessary. However, circulatory stability could not be reestablished by interventional measures and we therefore decided to implant the intraaortic balloon pump despite the presence of two synthetic aortic grafts. However, the chance of success of such a manoeuver as well as the effectiveness of intraprosthetic counterpulsation was unclear and our literature research undertaken to predict the risk of such a manouver was unsatisfactory. We therefore want to report this case and compile the literature dealing with perceptions and complications of intraaortic counterpulsation after the implantation of synthetic aortic prostheses, since such a treatment option comes to an increased clinical application in comparable constellations.

Combined open heart surgery and replacement of the brachiocephalic trunk. A safe method for simultaneous central revascularization.

OBJECTIVE: We investigated the feasibility of open heart surgery with combined central vascular surgery and present the results from 9 years of experience. PATIENTS AND METHODS: Of a total of nine patients, eight received coronary artery bypass grafting and one patient aortic valve replacement. Concerning vascular surgery a replacement of the brachiocephalic trunk using a Dacron prosthesis as an end-to-end anastomosis or as a bifurcations prosthesis was performed. Two patients underwent additional ipsilateral desobliteration of the internal carotid artery. RESULTS: The hospital stay was between 8 and 30 days (median 15). The duration of the whole operation was median 318 min (range: 294-345 min), perfusion time 67 min (range: 62-146 min), myocardial ischemic time 27 min (range: 11-83 min). There was no case of in-hospital death. Follow-up was available up to 7.5 years in 7 patients. Five patients show a satisfactory cardiac status. A sign for ischemic cerebral events or embolization was not observed. CONCLUSION: Due to the low complication rate, we conclude that concomitant open heart surgery with replacement of the brachiocephalic trunk can be performed with low risk; it allows-in contrast to direct endarterectomy-complete central revascularization and hence should be preferred compared to surgical therapy in separate settings.

[Interdisciplinary operative procedure-pelvis and abdomen]. / Operative Interdisziplinarität-Becken und Abdomen.

Surgery for tumors in the abdomen, retroperitoneum, and pelvis requires technical skills and expertise sometimes beyond the capability of a single surgeon. This holds especially true if curative tumor resection involves replacement of arteries and veins, which needs careful planning to avoid long periods of ischemia, and the selection and provision of vascular substitutes according to anatomical position, postsurgical therapy, and adjuncts to avoid thrombosis and infection of vascular grafts. Since the works of Fortner, the value of close collaboration between general and vascular surgeons has been demonstrated, but many of the former even today continue to attempt the operation alone, although the result is not always a masterpiece. The authors refer to their experience in major tumor surgery in either the single management of vascular complications or collaboration. The potential value of close collaboration is presented by negative examples, and a plea is made for a less "eminence"-based management of these sometimes difficult cases, which is based on vast positive experience with vascular diseases of the aorta and the visceral and iliac arteries and veins, including safety measures and adjuncts.

[Mycotic visceral artery aneurysm: clinical picture, diagnosis, differential therapy, and discussion of the literature]. / Das mykotische Viszeralarterienaneurysma. Klinik, Diagnostik und Differenzialtherapie mit Darstellung der Literatur.

Bacterially infected arterial aneurysms were named mycotic aneurysms by William Osler in 1885 due to their morphology. This rare vascular disease is mainly localized in the femoral artery but also occurs in the aorta and visceral arteries. After the first surgically treated mycotic visceral aneurysm in 1949, we found 36 casuistics in the literature. We report on two patients treated in our department with mycotic visceral aneurysms and discuss the literature concerning topography, differential diagnosis, and surgical management.

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

OBJECTIVE: in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients. MATERIAL AND METHODS: two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading. RESULTS: diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004). CONCLUSIONS: our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.

[Surgical reconstruction of high grade carotid stenosis: a safe procedure?]. / Die operative Rekonstruktion der hochgradigen Karotisstenose: ein sicheres Verfahren? Ergebnisse aus 2.162 Eingriffen.

Carotid surgery is still controversial. Some large randomized trials have demonstrated the benefit of surgery in correlation to conservative treatment alone, but these positive results depend on how specific the diagnosis is and a low complication rate. This study presents the results of 2162 patients (male n = 1596 (74%), female n = 566 (26%), mean age 65 +/- 9 years), who underwent carotid surgery between 1990 and 1999. Forth-three percent of these patients had no ipsilateral neurological symptoms with high-grade carotid artery stenosis (Stage I). Thirty-eight percent appeared with prior ipsilateral TIA or PRIND--symptomatology (Stage II) and 19% suffered from stroke with persisting deficits (Stage IV). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure in 1967 patients (91%). In 1324 patients segmental resection of the internal carotid artery was performed. Carotid endarterectomies and other reconstructions for coronary artery disease including abdominal aortic aneurysm were combined during the same operation in 11% of the patients. The rate of postoperative ipsilateral neurological events was 4.1%. On the ontralateral side neurological symptoms appeared among 0.8%, and 0.4% of the patients had bilateral symptoms. Twenty patients (0.9%) died as a result of postoperative stroke. In relation to preoperative staging of the cerebrovascular occlusive disease in stage I, postoperative neurological symptoms appeared in 2.8% (mortality 0.6%), stage II in 5.7% (mortality 1.0%) and stage IV in 7.8% (mortality 1.2%) of the patients. These results confirm the importance of carotid reconstruction as a measure in the prevention of cerebral infarction in patients with asymptomatic or symptomatic high-grade carotid artery stenosis. The complication rate was lower than the data reported in the literature and the results were clearly better than under conservative treatment alone. In our opinion, the indication for carotid artery reconstruction should be made by a team of vascular surgeons, neurologists and neuroradiologists taking all patient-specific factors into consideration. Only by optimal patient selection and minimal complication rates will a significant benefit for the patient be achieved.

Reconstructive surgery for carotid artery occlusive disease in the elderly--a high risk operation?

Patients over 80 yr of age may require carotid surgery for symptomatic or critical asymptomatic carotid artery occlusive disease.A total of 2262 operations were performed between 1990 and 1999; 76 (3.4%) were carotid reconstructions in 70 patients over 80 yr of age. Twenty patients (26%) presented with asymptomatic critical stenosis. Transient ischemic symptoms were the reason for presentation in 35 patients (46%). Progressive stroke was documented in two patients (3%) and a stroke with persisting neurological deficit was demonstrated in 19 cases (25%). Coronary artery disease was present in 47 patients (38%) and arterial hypertension in 55 (72%). Fifty-nine patients (84%) were classified as ASA group 3. Seventy-one thromboendarterectomies of the carotid bifurcation with vein-patch closure were performed. Five patients had other types of reconstruction. Simultaneous operations (aorto-coronary vein-bypass, aortic interposition graft etc.) were performed in nine patients. Postoperative complications occurred in three patients. One had a transient neurological deficit and another a lethal stroke; the third patient died from myocardial infarction. The in-hospital mortality was 2.9%, which was not significantly higher than the results of the other 2186 reconstructions (1.5%). Surgery for carotid artery occlusive disease can be safely performed in selected patients of more than 80 yr of age.

[Simultaneous surgical intervention for occlusion of the internal carotid artery and coronary disease--reasonable or high-risk combination?]. / Simultane operative Behandlung von A. carotis interna-Stenosen und koronarer Herzerkrankung. Sinnvolle oder zu risikoreiche Kombination?

BACKGROUND AND OBJECTIVE: Carotid artery stenosis as risk factor for postoperative stroke after cardiac surgery is confirmed in recent publications. Nevertheless indications for combined procedures in carotid occlusive disease and coronary artery disease are discussed controversely in the literature. Based on our own experiences since 1992 the risk factors are reviewed. PATIENTS AND METHODS: The data of 104 patients (80 male, 24 female, age 67 +/- 7 years), with 106 combined operations performed between 1992 and 1999, were evaluated retrospectively. 36% of the patients had symptomatic and 64% had asymptomatic carotid artery stenosis. RESULTS: Seven patients (6.6%) developed postoperative neurological deficits. One patient (1.0%) died as result of a stroke. In three patients a stroke occurred in the ipsilateral hemisphere, whereas two of three patients with cerebral infarction in the contralateral hemisphere had no significant carotid artery stenosis on this side. One patient had multiple bilateral embolism. Cardiac complications occurred in seven patients (6.6%). The inhospital mortality for non-stroke related complications was 3.8%, the total mortality 4.8%. CONCLUSION: From our experiences the combined approach for carotid artery occlusive disease and coronary artery disease can be recommended in selected patients. The rate of complications seems to be lower than in staged procedures. The spontaneous course of the disease can be improved and the patient is spared a second operation.

Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases.

OBJECTIVE: A mycotic aneurysm of the aorta and adjacent arteries is a dreadful condition, threatening life, organs, and limbs. With regard to the aortic segment involved, repair by either in situ replacement or extra-anatomic reconstruction can be quite challenging. Even when surgery has been successful, the prognosis is described as very poor because of the weakened health status of the patient who has developed this type of aneurysm. The aim of our study was to find out whether any progress could be achieved in a single center over a long time period (18 years) through use of surgical techniques and antiseptic adjuncts. MATERIAL AND METHODS: From January 1983 to December 1999, a total of 2520 patients with aneurysms of the thoracic and abdominal aorta and iliac arteries underwent surgery for aortic or iliac replacement at our institution. During that period, 33 (1.31%) of these patients (mean age, 64.3 years) were treated for mycotic aneurysms of the lower descending and thoracoabdominal (n = 13), suprarenal (n = 4), and infrarenal (n = 10) aorta and iliac arteries (n = 6). Twenty (61%) of these 33 patients had histories of various septic diseases; in the other 13 (39%), the etiology remained uncertain. Preoperative signs of infection, such as leukocytosis and elevated C-reactive protein, were found in 79% of the patients, and fever was apparent in 48%; 76% of the patients complained of pain. At the time of surgery, eight (24%) mycotic aneurysms were already ruptured, and 20 (61%) had penetrated into the periaortic tissues, forming a contained rupture. Five (15%) aneurysms were completely intact. The predominant microorganisms found in the aneurysm sac were Staphylococcus aureus and Salmonella species. Careful debridement of all infected tissue was essential. In the infrarenal aortic and iliac vascular bed, in situ reconstruction was performed only in cases of anticipated "low-grade" infection. Alternative revascularization with extra-anatomic procedures (axillobifemoral or femorofemoral crossover bypass graft) was carried out in eight of 16 cases. All four suprarenal and all 13 mycotic aneurysms of the thoracoabdominal aortic segment were repaired in situ. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics. RESULTS: In-hospital mortality was 36% (n = 12). Because of the smallness and heterogeneity of the sample, we could not demonstrate significant evidence for any influence of aneurysm location or type of reconstruction on patients' outcome. However, survival was clearly influenced by the status of rupture. During long-term follow-up (mean, 30 months; range, 1-139 months), 10 patients (48%) died-one (4.8%) probably as a consequence of the mycotic aneurysm, the others for unrelated reasons. Eleven patients (52%) are alive and well today, with no signs of persistent or recurrent infection. CONCLUSIONS: A mycotic aneurysm of the aortic iliac region remains a life-threatening condition, especially if the aneurysm has already ruptured by the time of surgery. Although the content of the aneurysm sac is considered septic, as was proved by positive cultures in 85% of our patients, in situ reconstruction is feasible and, surprisingly, was not more closely related to higher morbidity and mortality in our series than ligation and extra-anatomic reconstruction, although most of the aneurysms repaired in situ were located at the suprarenal and thoracoabdominal aorta. We assume that our operative mortality rate of 36%, which relates to a rupture rate of 85%, could be substantially lowered if the diagnosis of mycotic aneurysm were established before rupture.

Reconstruction for renal artery aneurysm and its effect on hypertension.

OBJECTIVES: many renal artery aneurysms (RAA) are diagnosed incidentally in the course of investigations for hypertension and their management is controversial. AIM: to review the results of renal artery reconstruction for RAA. METHODS: between January 1978 and December 1998 111 RAR were performed in 81 kidneys in 71 patients. RESULTS: fifty-nine patients were hypertensive, three had a creatinine >2.0 mg/dl and one was on dialysis. The principal underlying pathology was fibromuscular dysplasia (39) and atherosclerosis (17). The mean RAA diameter was 2.2 (range 1-15) cm overall and 3.5 (range 2-10) cm in four patients who presented with rupture. Fifty-one patients had renal artery stenosis. Autogenous material was used in 105 RAR. There was no 30-day mortality and the morbidity rate was 16%. The 5-year cumulative patency rate was 69%. Hypertension was cured in 25% and improved in 39%. CONCLUSIONS: RAR tested for RAA treats hypertension and reduces the risk of rupture and distal embolisation.

Healing characteristics of small-calibre vascular prostheses coated with plasmin-treated fibrin--an experimental study.

BACKGROUND: The autogenous vein represents the graft material of choice in crural and pedal bypass surgery. Because of the numerous problems concerning the graft harvesting and the quality of autogenous vein material an equally good allogenous graft is urgently needed. Up to the present times no such graft material has been able to achieve the success of vein grafts. METHODS: We investigated the knitted polyester prosthesis Terumo PF-V (Terumo Comp., Japan), diameter 5 mm with outer reinforce, which is characterized by a new coating of plasmin-treated fibrin. Grafts were implanted as bypass into the ligated carotid (n = 10) and femoral arteries (n = 10) of 10 dogs (beagles). As a control 5 mm-ePTFE-prostheses (Impra Carboflo) were implanted simultaneously on the contralateral side. RESULTS: After 6 months, seven of 20 PF-V-grafts and 8 of 20 PTFE-grafts were patent. All prostheses presented with good macroscopic healing characteristics. In the patent grafts, angiography showed no substantial stenoses. The histological examination of the material was performed using light microscopy, transmission polarising microscopy, scanning electron microscopy, and transmission electron microscopy. Both types of prostheses showed the typical pattern of graft healing by migration of mesenchymal cells through the prosthesis, formation of capillaries, and growing of a neointima with endothelium-like cells. All failed bypass grafts presented with an occluding proliferation from the arterial wall into the anastomotic region. CONCLUSIONS: Using clinically or histologically evaluation, neither graft demonstrated superiority over the other. The results indicate that the coating plays only a minor role for graft healing if any. For proper graft function, the arterial wall proliferation at the anastomotic region, which is not dependent on the type of prosthesis, appears to be most important. The overall results concerning both types of prostheses were disappointing.