Access recirculation in a native fistula in spite of a seemingly adequate access flow.

True access recirculation (AR) measured by ultrasound dilution technique is usually absent in well-working shunts. It occurs with low access flows (Qa). High access flow rates are assumed to prevent AR. Two major exceptions to these rules are known: presence of intra-access strictures and inadvertently reversed blood lines. We present an additional exception in which true access recirculation occurred in a native arteriovenous (AV) fistula with correct placement of bloodlines. Surprisingly, access blood flow exceeded pump blood flow (Qb) almost threefold. The situation was clarified by a magnetic resonance angiogram showing a collateral forming a functional loop. This loop led to true access recirculation in one branch, although overall blood flow through both branches appeared to be adequate. The different findings in this shunt over time give insight into the often complex pathophysiology of native fistulae. This case proves that seemingly adequate access flow does not necessarily prevent access recirculation in native AV fistulae. We suggest monitoring both access flow and recirculation in hemodialysis accesses on a regular basis.

Complications in endoluminal repair of abdominal aortic aneurysms.

In this review the technical and systemic complications occurring during endoluminal repair of abdominal aortic aneurysms are summarized. According to the data in the literature the technical success-rate of the endoluminal procedure should be >90% and the overall complication-rate <10%. It should be differentiated between complications which have an adverse effect on the outcome of the procedure, and technical problems, which complicate the procedure but do not affect the outcome. The majority of the technical problems can be solved endoluminally. The 30-day mortality rate should be in the same range as elective open surgical repair. One major factor influencing the immediate results is the experience of the interventional team.

[Endoluminal therapy of infrarenal aortic aneurysms with the Talent system--initial experiences with a new endoprosthesis]. / Endoluminale Therapie infrarenaler Aortenaneurysmen mit dem Talent-System--Erste Erfahrungen mit einer neuen Endoprothese.

PURPOSE: To report the early clinical experience with the Talent stent-graft system in the treatment of infrarenal aortic aneurysms. MATERIALS AND METHODS: The study group comprised 15 males aged from 51-79 years. A bifurcated Talent stent-graft was implanted in 9 patients with type B or C aneurysms, a tube graft in 6 patients with a type A aneurysm. The stent-grafts were introduced via a surgical femoral cut-down, for a bifurcated graft a bilateral surgical access was needed. All procedures were performed as teamwork by radiologists and vascular surgeons under general anaesthesia in the angiography suite. RESULTS: Primary and secondary technical successes were 80 and 86%, respectively. Technical failures were due to access site problems (n = 1; elective open repair), malpositioning of the prosthesis (n = 1; immediate conversion to open surgery), and primary distal leakage (n = 1; elective occlusion by means of distal stent-graft extension). One patient died 15 days after an uneventful stent-graft insertion (30-day mortality 6%). No complications were observed during a mean follow-up period of 7.8 months. The aneurysmal diameter decreased in 6 patients and remained unchanged in the others. CONCLUSIONS: The Talent system revealed satisfactory early results which are comparable to competitive stent-graft systems. An advantage of this stent-graft device is the availability in a wide range of dimensions. A major disadvantage is the large introducer system (french size 22-27).

Aplasia of the vena cava inferior as a cause for recurring thrombosis of the lower extremities and pelvic veins.

Congenital anomalies of the caval vein are often associated with other abnormalities such as heart defects, situs inversus or a polysplenia-asplenia-syndrome. An isolated, congenital malformation like aplasia of the inferior vena cava is a rare finding. A review of the embryology and abnormalities, diagnostics, clinical signs and treatment is given together with the histories of two patients having thrombosis of the lower extremities and pelvic veins, caused by aplasia of the inferior vena cava. After thrombotic complications caused by vena cava aplasia there is high risk of recurrence. Those patients should be anticoagulated for lifetime.

Endovascular stentgraft infection--a life-threatening complication.

The implantation of covered stents or stentgrafts has increased greatly in the last few years for the endovascular reconstruction of arterial aneurysms. We report of three patients experiencing severe septic complications after stentgraft implantation. Endovascular stentgraft infection is a serious complication with high morbidity and mortality. General antibiotic prophylaxis seems to be indicated when implanting stentgrafts.

Femoral artery infection associated with a percutaneous arterial suture device.

This is a case report of a femoral artery infection with fatal outcome after using a percutaneous suture mediated closure device: A 77-year old patient underwent diagnostic angiography of his thoracic and abdominal aortic aneurysm, the puncture site was closed with the Perclose system. He developed a staphylococcal femoral artery infection with groin abscess, requiring surgical intervention with debridement and removal of the Perclose suture. After stent graft exclusion of the thoracic and abdominal aortic aneurysm a staphylococcal sepsis occurred and the patient died of aneurysm rupture months later despite long term antibiotic therapy. Since the use of the Perclose device carries an increased risk of femoral artery infection with septic endarteritis and bacteremia, it should not be used in routine diagnostic angiography.

[Transposition of the subclavian artery with endovascular stent graft implantation for therapy of acute type B aortic dissection]. / Die Transposition der Arteria subclavia mit endovaskulärer Stentgraft-Implantation zur Therapie der akuten Aortendissektion Typ B.

We report about a patient with a thoracic aneurysm caused by an acute type-B dissection. Due to the concomitant affections the risk of surgery was distinctly increased, the reconstruction was performed endo vascular by stentgraft implantation (Talent, World Medical Systems, Sunrise FL) after transposition of the left subclavian artery to create a sufficient neck for the proximal stent placement. Endoluminal treatment seems to be a promising, less invasive alternative method in the treatment of acute aortic dissections.

Perioperative myocardial cell injury: the relationship between troponin T and cortisol.

STUDY OBJECTIVE: To investigate whether there is an association between Troponin T (TnT), reflecting myocardial cell injury, and cortisol, reflecting the degree of surgical trauma and associated stress, in light of our recent evaluation of TnT as a marker of perioperative myocardial cell injury. DESIGN: Prospective, cohort study. PATIENTS: 70 patients (67.4 +/- 8.7 yrs) with definite or at-risk coronary artery disease (CAD) undergoing elective noncardiac surgery (vascular n = 38, abdominal n = 21, orthopedic n = 8) with general (n = 63) or regional (n = 4) anesthesia with postoperative on-demand analgesia. MEASUREMENTS AND MAIN RESULTS: Morning blood samples for TnT (upper limit of normal: <0.2 ng/mL), CK-MB (reference range

[Rupture of internal iliac artery aneurysm -- a rare cause of life-threatening rectal bleeding]. / Ruptur eines Aneurysmas der Arteria iliaca interna. Seltene Ursache einer lebensbedrohlichen, rektalen Blutung.

Isolated aneurysms of the iliac arteries are rare. Located deep in the lesser pelvis, they are diagnosed late or in a symptomatic stage. Because of their manifold anatomic relationships to pelvic structures, iliac aneurysms may cause different symptoms such as obstipation, hydronephrosis, venous thrombosis, and entrapment neuropathy. Aneurysm rupture is associated with high mortality. The rupture of an iliac aneurysm into the rectum with massive lower intestinal bleeding is extremely rare. We report a patient with 6-year follow-up after aneurysm resection, extra-anatomic bypass, and suture repair of the rectum with temporary colostomy.

[Primary bacterial infection of an artery]. / Die primär bakteriell infizierte Arterie.

INTRODUCTION: Primary bacterial infection of an artery is difficult to diagnose, especially at the beginning of the illness. Most of the patients come for emergency treatment in the phase of rupture. METHODS: The course of illness in four patients serves as background for discussion of the problems of diagnosis and therapy. RESULTS: Bacterial infection of arteries shows a high rate of complications and, for the aorta, high mortality. CONCLUSION: If fever of uncertain origin is combined with pain of the stomach or of the back, or with a painful reddish swelling on a limb, this rare disease should be considered in the differential diagnosis.

Results and complications in endovascular treatment of abdominal aortic aneurysms--a single center experience.

Between September 1996 and February 2000 five female and 62 male patients with an abdominal aortic aneurysm, requiring therapy, underwent endoluminal treatment. Their age ranged from 51 to 81 years (mean 72 years). Preoperative evaluation was done with spiral computed tomography (CT) and angiography. All procedures were performed under general anesthesia in a radiologically adapted operating room. Postoperative complications occurred in 28.4%. The total conversion rate was 13.4%, the 30-day lethality rate was 1.4%. During the mean follow-up of 15.1 months 19 secondary interventions were necessary in 13 patients. The results presented in this study do not justify the wide use of this method and indicate a stricter form of patient selection.

Cement embolization into the vena cava and pulmonal arteries after vertebroplasty: interdisciplinary management.

PURPOSE: To report interdisciplinary management in a case of cement embolization into the inferior vena cava and peripheral pulmonary arteries after percutaneous vertebroplasty. CASE REPORT: A 50-year-old female patient with an osteoporotic compression fracture of the second lumbar vertebra underwent percutaneous vertebroplasty with polymethylmetaacrylate. Thereafter, CT scanning revealed small asymptomatic cement emboli in peripheral pulmonary arteries, along with a hook-shaped cement fragment in the inferior vena cava. Due to the risk that the large cement fragment could migrate to the pulmonary arteries and cause serious complications, they were retrieved from the inferior vena cava by an endovascular technique and extracted through a surgical groin incision. The patient received anticoagulant treatment for 3 months and is free of complaints after 1 year. CONCLUSION: This case shows that this rare complication following vertebroplasty can be successfully managed with an interdisciplinary approach.

Surgical conversion of abdominal aortic stent-grafts--outcome and technical considerations.

OBJECTIVE: The purpose of this study was to evaluate the outcome of patients with stented abdominal aortic aneurysms who had to undergo open aneurysm repair with partial or total stent-graft removal. METHODS: Between October 1996 and December 2003, 117 patients with abdominal aortic aneurysms underwent endovascular repair. When open surgery was necessary during the initial and same anaesthesia as stent-graft implantation, it was defined as immediate conversion. When conversion was performed during a second anaesthesia, we defined it as late (acute or elective) conversion. RESULTS: A total of 33 patients underwent conversion to open surgery. In 7 (6%) patients, immediate conversion was necessary due to stent-graft misplacement and obstruction of the renal arteries (n=4), type Ia endoleaks (n=2) and stent-graft dislocation into the aneurysm sac (n=1). During a mean follow-up period of 39.6 months (min 0.03 months, max 80.4 months), 26 (23.6%) of the remaining 110 patients underwent late conversion to open surgery for endoleak (n=12), rupture (n=6), thrombosis (n=4), graft fatigue (n=2), aorto-duodenal fistula (n=1), and recurring peripheral embolisms (n=1). The mortality of acute conversion was 38% (5 of 13). Elective conversion did not lead to any mortality. CONCLUSION: Acute conversion of stented abdominal aortic aneurysms is associated with a high mortality. Elective stent-graft explantation with open aortic reconstruction is a safe but complex procedure.

[Traumatic aortic rupture in ankylosing spondylitis--a fatal complication]. / Traumatische Aortenruptur bei ankylosierender Spondylitis--eine letale Komplikation.

Fractures of the spine represent a severe complication particularly in patients with ankylosing spondylitis because of high morbidity and mortality. We report on a patient with a hyperextension fracture of the lumbar spine, leading to disruption of the aorta and caval vein.

[Dialock--an alternative to Permcath and access graft]. / Dialock--eine Alternative zu Permcath und Prothesenshunt.

PURPOSE: An adequate vascular access is the precondition for a well-functioning hemodialysis. Due to the increasing age and the rising co-morbidity of hemodialysis patients the number of those with grafts or central venous catheters (CVC) is steadily growing. The Dialock vascular access system provides a subcutaneously implantable device for hemodialysis that combines the advantages of central venous access with percutaneous puncture. PATIENTS AND METHODS: Over a period of 30 months 26 Dialock vascular access systems were implanted at our department. 17 patients were male, 9 patients female. In 11 patients the implantation of this system was indicated for internal medicine reasons. In 15 long-term hemodialysis patients implantation was carried out as ultimate solution because of persisting vascular access problems. In a comparable control group of 22 hemodialysis patients 47 vascular accesses were registered within the same period. In parallel, another 110 patients with grafts implanted at our department at that time but not put to hemodialysis at our clinic were analysed. RESULTS: In a comparable number of access days the graft and the central venous catheter showed a considerably higher infection rate (Exit site + blood stream infection) per 1,000 hemodialysis access days than the vascular access device. The rate of malfunctions with or without subsequent lysis was higher using the CVC than when applying Dialock or graft. Angiographies with percutaneous transluminal angioplasty (PTA), or thrombectomies, respectively were significantly more often required with the graft than changes of catheter when using the vascular access system. More than half of the 110 patients observed at the same time, who had a graft implanted at our department without subsequent hemodialysis at our clinic had to undergo another surgical or radiologic intervention. CONCLUSION: The Dialock access system represents in our experience a safe and with careful application less complicated vascular access device for the complex hemodialysis patient. With comparatively low infection and complication rates the Dialock vascular access system serves as a good alternative to the permanent CVC (Permcath) as well as to the graft.

[Primary bacterial aortitis]. / Die primär bakterielle Aortitis.

Primary bacterial aortitis represents a rare disease with a high lethality. From June 1997 to April 1999 5 patients with an abdominal aortic infection were treated by resection of the infected aorta and in-situ reconstruction or by extra-anatomic bypass. There was no treatment in one case because of the infaust prognosis. 3 patients survived, one with a paraparesis as a result of spinal ischemia. On the basis of our patients the pathogenesis, clinical symptoms with diagnosis and the therapeutic options are discussed.

[Posttraumatic aneurysm of the brachiocephalic trunk: a rare injury]. / Aneurysma des Truncus brachiocephalicus nach stumpfem Thoraxtrauma. Eine seltene Verletzung.

We report on a posttraumatic aneurysm of the brachiocephalic trunk, something which is rather rare. The injury was caused by blunt chest trauma following a car accident. Computed tomography could not find the brachiocephalic lesion. In patients with fractures of the upper ribs after blunt chest trauma, angiography should be done to exclude severe injuries of the aorta and brachiocephalic vessels.

[Posttraumatic AV fistula in the upper arm region following a foreign body injury. Sonographic diagnosis - a case report]. / Sonographischer Nachweis einer posttraumatischen AV-Fistel am Oberarm nach Fremdkörpereinsprengung.

This paper reports on the sonographic localisation of a metallic foreign body in the upper arm region and its topographic anatomic position as well as the sonographic diagnosis of an AV fistula due to a lesion of the brachial blood vessels. Ultrasonography is the method of choice for the evaluation and diagnosis of foreign body injuries and possible subsequent complications.