[Percutaneous transluminal hydrodynamic thrombectomy--the initial results]. / Perkutane, transluminale hydrodynamische Thrombektomie--erste Ergebnisse.

PURPOSE: First clinical applications in the femoro-popliteal vessels of a new system for percutaneous, transluminal hydrodynamic thrombectomy are presented. MATERIAL AND METHOD: Three patients suffering from femoro-popliteal thromboembolic obstruction were treated. A new hydrodynamic 8-F catheter with two lumina was used. The jet leaving at the tip of the catheter shredded the thrombotic material. Using the Venturi effect the thrombus was collected. The shredded material was transported outside through the second channel of the catheter. RESULTS: All obstructions could be removed. Underlying degenerative vessel disease and older thromboemboli needed additional therapy like PTA or aspiration thrombectomy (PAT). CONCLUSIONS: The new catheter is helpful in removing arterial femoro-popliteal thromboembolic obstructions. Additional interventions may be necessary. More clinical experience is needed.

[Percutaneous hydromechanical thrombectomy in acute and subacute lower limb ischemia]. / Perkutane hydromechanische Thrombektomie bei akuter und subakuter arterieller Beinischämie.

PURPOSE: A prospective study should evaluate the primary and 2-year results of treating acute and subacute lower-limb ischemia with hydromechanical thrombectomy (HTE). MATERIALS AND METHODS: Consecutively 64 patients, 12 with viable and 52 with threatening limb ischemia and onset of symptoms within 8 +/- 9 days, were treated and controlled for 24 months. An 8 F hydromechanical thrombectomy device (HTK), was used. It sucks and shreds the thrombi. The shredded particles are transported to the outside. RESULTS: In 8 patients a total, in the others a partial restoration of the vessel lumen up to 70-50% was achieved in a mean time of 34 minutes. Residual thrombi, underlying atherosclerotic vessel disease and occluded arteries with a small diameter made adjunctive interventions (balloon angioplasty, percutaneous aspiration thrombectomy, lysis) necessary. Clinical symptoms and the ankle-brachial index improved significantly (p < 0.01). Primary patency was 72%, 70%, 67%, and 65%; the limb salvage rates were 81%, 78%, 75%, and 73% for one, 3, 12, and 24 months respectively. Device-induced complications did not occur. CONCLUSIONS: The HTK allowed a rapid reduction of fresh thrombotic material without complications. In 78% of the cases adjunctive therapies are required for wall-adherent thrombi and when tibial vessels with smaller lumina are included. Long-term results are comparable to literature data for fibrinolytic or operative regimens. The advantage, however of the HTK seems to be the reduction of intervention time and intra-arterial dosage of fibrinolytic drugs.

[Percutaneous transluminal angioplasty (PTA) of isolated crural arterial stenoses in critical arterial occlusive disease]. / Perkutane transluminale Angioplastie (PTA) isolierter Unterschenkelarterienstenosen bei kritischer arterieller Verschlusskrankheit.

PURPOSE: Retrospective analysis of the results after infrapopliteal PTA of isolated crural limb artery stenoses in patients with critical crural limb ischaemia. PATIENTS AND METHODS: Between 1989 and 1994 70 infrapopliteal dilatations of isolated crural limb artery stenoses in 44 patients (47 PTA procedures) were done with small diameter balloon catheters. 45 patients were stage IV according to Fontaine's classification, two patients were stage III. No patient had a relevant obstruction up to the popliteal artery. Follow up ranged from 1-50 months (mean 13.3 months). RESULTS: A technical success with a residual stenosis below 30% compared to the original vessel diameter was achieved in 80% of patients (n = 56). The cumulative limb-salvage rate was 76.6% after 6 to 36 months after PTA. RESULTS: In patients with chronical critical crural limb ischaemia PTA of isolated crural limb artery stenoses is an efficient therapy modality for limb-salvage. In many cases PTA is the last alternative method to amputation surgery if there is no sufficient distal vessel for a bypass.

Surgical treatment of iliofemoral vein thrombosis technical aspects. Possible secondary interventions.

From October 1982 to February 1989 148 patients underwent venous thrombectomy. Priority for surgery was given especially in patients under 40 years with posttraumatic, postoperative and postpartum thrombosis where lysis was not possible. Our standardized operative technique includes atraumatic exposure of the vessels, clot extraction by balloon catheter and ring stripper, endoscopic control of the lumen and establishment of a temporary arteriovenous fistula. Postoperative angiography revealed that more than 10% of the patients needed secondary dilatation of iliac vein stenosis which can be carried out easily at the time of closing the fistula. Functional and anatomical parameters as well as the clinical outcome after 12 months show good to excellent results which confirm venous thrombectomy as a useful treatment modality at an acceptable risk level.

[Follow-up of infra-inguinal bypass operations: value of the peak systolic velocity and arm-ankle index for evaluation of femorodistal reconstructions]. / Verlaufskontrolle infrainguinaler Bypassoperationen: Bedeutung von systolischer Spitzengeschwindigkeit und Arm-Knöchel-Index für die Bewertung femorodistaler Rekonstruktionen.

In a prospective study, the efficacy of noninvasive surveillance techniques including measurement of ABI and duplex-derived velocity parameters was studied after 74 infrainguinal arterial reconstructions. A decrease of ABI > or = 0.2 compared with prior examinations was considered abnormal. Results of the duplex scan were interpreted as abnormal when PSV was less than 45 cm/sec or greater than 200 cm/sec or when an interval decrease of greater than 30 cm/sec occurred. All patients meeting any of these criteria during the follow-up examinations were subjected to i.a. DSA. The combination of all duplex velocity criteria was significantly more sensitive to identify a failing graft than was measurement of ABI (90% vs. 18%; p = 0.00004). When independent variables (ABI- and PSV criteria, monophasic curve configuration) were entered into a logistic regression multivariate analysis, the model proved to be effective (F-value 5.551; df 4.8; R2 = 0.735; significance 98.03%; p < 0.02) in predicting angiogram findings (dependent variable). ABI measurements (significance 4.75%; p > 0.95) and the presence of a monophasic curve configuration (significance 89.58%; p > 0.1) failed to reach significance in the multivariate analysis. By excluding these latter parameters, the statistical power for the model could be improved (F-value 1036.57; df 2.1; R2 = 0.999; significance 97.69%; p = 0.0231): As a result normal PSV criteria indicated normal and abnormal angiographic findings in 83 and 17%, respectively. A PSV less than 45 cm/sec or greater than 200 cm/sec was suggestive of an abnormal angiogram in 80% and of a normal angiogram in 20%. The corresponding figures for a PSV interval decrease > 30 cm/sec were 71% and 29%. In conclusion, PSV parameters were found to be measurably more accurate to identify a failing graft than was measurement of ABI.

[The diagnostic value of angioscopy in venous thrombectomy]. / Diagnostischer Stellenwert der Angioskopie bei der venösen Thrombektomie.

Since 1983 angioscopy was applied as a control method in 187 venous thrombectomies to improve the treatment of acute iliofemoral thrombosis. In a retrospective study we tried to show the impact of angioscopy intraoperatively and the influence on long-term results. Thrombectomy was performed in 97 patients affected at three levels, in 50 cases with pelvic-femoral, in 35 with pelvic and in 43 with femoro-tibial thrombosis. The average clinical age of the thrombosis was 5 days, 66% of the patients (age 39 years) were female. The endoscopic findings were compared with phlebological results after one year using a phleboscore between 0 points (occlusion) and 5 points (normal). The phlebographies were analyzed so that the functional status of the vein was represented. After venous thrombectomy 42.8% of the cases were endoscopically classified complete but in 57.2% residual clots were observed. It was possible to completely (24.6%) or partly (18.7%) remove these clots by further thrombectomy maneuvers, non removable remnants were found in 7.5% and a venous spur in 6.4%. The statistical analysis with Kruskal-Wallace test showed significant differences in venous morphology between the endoscopically complete thrombectomies and those with residual clots. After a follow-up period of 30 months (12-64) the clinical results were very good. In 58% we observed normal findings, a cvi grade I in 35%, grade II in 4%. Crural ulcers had developed in only 3%. From our data we conclude that endoscopy is an excellent method for intraoperative quality-control in venous thrombectomy.

[Percutaneous balloon dilatation of isolated lesions of the calf arteries in critical ischemia of the leg]. / Perkutane Ballondilatation bei isolierten Läsionen der Unterschenkelarterien mit kritischer Beinischämie.

Between 1990 and 1993 we performed 42 percutaneous transluminal balloon angioplasties (PTA) in 30 patients with isolated lesions of crural arteries and limb threatening ischaemia. The average age of the patients was 70.5 years, 90% were diabetics. With low-profile balloon catheters between 2 and 4 mm we dilatated 15 tibioperoneal trunks, 12 anterior tibial arteries, 3 posterior tibial arteries and 12 peroneal arteries. Initial success was achieved in 83% of the dilatations with an average increase of ankle-brachial index of 0.18. After PTA two groin haematomes as the only complications were observed. In 22 cases healing of the acral lesions under local surgical treatment was seen. Two of the clinical unsuccessful patients required popliteopedal bypass surgery and 5 below-knee amputation because of lacking reconstructive possibilities. The follow-up period varied from 1 to 35 months (mean 10.3 months). Life table analysis showed a cumulative limb salvage rate of 82% after one and two years. The PTA of infrapopliteal artery stenoses and occlusions is considered as an effective and safe therapy modality to avoid below-knee amputation in patients with limb threatening ischaemia.

Transperitoneal versus retroperitoneal approach for treatment of infrarenal aortic aneurysms: is one superior?

BACKGROUND: As endovascular treatment of asymptomatic infrarenal abdominal aortic aneurysm (AAA) increasingly competes with surgical repair, it is necessary to optimize the surgical technique. The aim of this study was therefore to evaluate the superiority of either retroperitoneal (RP) or transperitoneal (TP) approach. PATIENTS AND METHODS: Intra- and peri-operative data from 80 patients with infrarenal AAA and tube graft repair were analysed retrospectively. The RP-approach was used in 37 patients and in 43 the transperitoneal. RESULTS: There was no relevant difference in demographic data and anaesthetic regime; exceptions were differences between the two groups in terms of age (median RP 72.31 vs. TP 68.58 years, p = 0.0174), hypertension (RP 26/37 vs. TP 40/43, p = 0.0019), smoking (RP 25/37 vs. TP 38/43, p = 0.0462), pulmonary diseases (RP 15/37 vs. TP 7/43, p = 0.0232), and previous abdominal surgery (RP 3/37 vs. TP 12/43, p = 0.042). No patient died during the first 30 post-operative days. The RP-group had a longer cross-clamping time (median RP 50 vs. TP 45 min, p = 0.0115) but no difference was found in operating time. Intra-operative blood loss was higher in the RP-group (median RP 800 vs. TP 500 ml, p = 0.033) with an increased need for blood substitutes (median RP 1 vs. TP 0 packed red cells, p = 0.0068). Time spent in ICU was shorter (median RP 24 vs. TP 46 hours, p = 0.0104), but duration of hospitalisation was longer for the RP-group (median RP 13 vs. TP 10.5 days, p = 0.0156). No differences were found in the need for analgesics, the frequency of procedure related complications, and post-operative recovery. CONCLUSIONS: Surgical repair of AAA in selected patients by tube graft placement is a safe procedure independent of the approach. In particular, our findings do not support previously reported superiority of the RP-approach.

The importance of graft blood flow and peripheral outflow resistance for early patency in infrainguinal arterial reconstructions.

BACKGROUND: At present, the importance of functional parameters as determinants for graft patency is under debate. Therefore, in our institution a prospective study was undertaken to evaluate the influence of graft blood flow as well as the currently applied methods for outflow resistance measurement on early (< or = 30 days) graft outcome. PATIENT AND METHODS: 101 arterial revascularisations with infrageniculate graft insertion were entered into this study. After having verified the morphological integrity of the reconstruction, during temporary inflow occlusion total outflow resistance (TOR) was determined as a pressure/flow relationship by perfusion of the graft with saline (flow rates 25, 50, 100, 150 ml/min before and after papaverine) while simultaneously recording pressure generated at the distal anastomosis. In addition, after restoration of blood flow, flow index (FI) was calculated in an analogous way from the TBF through the graft and the respective mean distal anastomotic pressure. Graft patency at 30 days was determined by Duplex ultrasound. RESULTS: Functional parameters were found to be unable to differentiate between patent and failed reconstructions during the 30 day period: The mean TORaveraged values amounted to 722.5 (SD = 310) in patent and 735.9 (SD = 228.1) mPRU in occluded bypasses (T-value = 0.1681; n.s.). The corresponding figures were 176.8 (SD = 94.2) and 196.4 (SD = 93.6) ml/min for TBF (T-value = 0.7342; n.s.) and were 0.53 (SD = 0.34) and 0.45 (SD = 0.25) PRU for FI (T-value = 0.8905; n.s.). Using multiple logistic regression analysis functional parameters showed no influence on graft patency while graft length and the necessity for intraoperative graft modification emerged to be significant determinants of early graft outcome (R2 adjusted = 0.46; p = 0.006). CONCLUSION: The results of our study suggest that neither blood flow nor the presently used methods to assess outflow resistance are relevant prognostic factors for early (< or = 30 days) graft performance.

Tibioperoneal arterial lesions and critical foot ischaemia: successful management by the use of short vein grafts and percutaneous transluminal angioplasty.

BACKGROUND: In a substantial number of mainly diabetic patients isolated crural arterial lesions are found to be the underlying cause for severe ischaemic foot lesions. Without revascularisation, patients with this specific occlusion pattern will inevitably face major amputation. To attain limb salvage in this setting, since the early eighties short vein grafts were used to bypass the occluded infrapopliteal arteries. More recently, percutaneous transluminal angioplasty (PTA) was also attempted to avoid limb loss in selected patients. PATIENTS AND METHODS: Since May 1986 in 125 patients 130 autologous bypass grafts from the BK-popliteal artery or the proximal tibioperoneal arteries to malleolar vessels were performed in the presence of extended crural arterial occlusions and critical foot ischaemia (rest pain 3, tissue loss 127). In another series in 89 limbs (rest pain 5, tissue loss 84) of 84 patients PTA was done to treat 168 focal stenoses of > 50% diameter reduction and 11 short occlusions in a total of 135 crural arteries. RESULTS: Using life-table analysis, primary and secondary cumulative patency rates for short vein grafts with distal graft origin were 90% and 98% at 30 days, 76% and 83% at one year and 46% and 49% at seven years, respectively. The corresponding limb salvage rates amounted to 95%, 80% and 63%. Initial complete or partial technical success after PTA of crural arteries could be obtained in 93%: The limb salvage rates achieved were 95% at 30 days, 82% at one year and 63% at six years. CONCLUSION: Our results suggest that--depending on the extent of lesions--both short vein grafts as well as PTA are successful complementary treatment modalities to avoid limb loss in predominantly diabetic patients with infrapopliteal artery disease and critical ischaemia.

Early carotid endarterectomy in patients with a nondisabling ischemic stroke: results of a retrospective analysis.

BACKGROUND: There are several recent recommendations not to delay carotid endarterectomy (CEA) for at least 4 weeks in patients experiencing a nondisabling ischemic stroke. Therefore, we re-examined if these patients could be safely operated on earlier: The aim of our study was to review the perioperative stroke and death rates of CEA performed within 30 days of stroke onset. PATIENTS AND METHODS: During a 4 year period until December 2001, in 66 neurologically stable patients suffering a nondisabling stroke ipsilateral to a carotid artery stenosis > 50% CEA was performed after a median interval of 10 (1-28) days. The modified Rankin scale (mRS) was applied to characterize the severity of impairment of daily living activities pre- and postoperatively: Any postoperative deterioration > 24 hours on the mRS was considered as a new stroke. RESULTS: Operative mortality was 0%, and postoperative neurologic worsening > 24 hours occurred in 8/66 patients (12.1%). In 5/8 patients neurologic deterioration resolved within 5 days after surgery, only one stroke was permanent (1.5%). There was no correlation between timing of surgery or the presence of acute ipsilateral cranial CT defects with the occurrence of postoperative stroke. Stroke severity grading on admission according to the mRS, however, emerged to be a significant determinant of postoperative outcome: While 6/23 patients (26%) with an initial deficit > or = 3 on the mRS developed neurologic worsening, this was the case in only 2/43 patients (4.6%) with a deficit < or = 2 (Odds Ratio 7.2; 95% CI 1.32-39.49; two-sided p = 0.01). CONCLUSION: Our results suggest that selected patients with a minor stroke (mRS < or = 2 on admission) can safely undergo early CEA.

[Development of an illness-specific instrument for assessment of quality of life in patients with arterial occlusive disease (Peripheral Arterial Occlusive Disease 86 Questionnaire)]. / Entwicklung eines krankheitsspezifischen Instruments zur Erfassung der Lebensqualität von Patienten mit arterieller Verschlusskrankheit (PAVK-86 Fragebogen.

Impairment in health-related quality of life in patients with peripheral arterial occlusive disease (PAOD) are well-known to clinicians, but due to the lack of disease specific assessment instruments, have not been systematically investigated. We describe the development and psychometric testing of a 86-items patient-based questionnaire for the assessment of the quality of life in PAOD containing 7 dimensions: functional status, pain, symptoms, mood, disease related anxiety, social life and treatment evaluation. The questionnaire was included along with standard questionnaires in a prospective study with 308 patients suffering from PAOD in Fontaine stages I to IV before and one week into treatment. Psychometric testing pertained to reliability (internal consistency, retest), validity (convergent, discriminant) and sensitivity (treatment-related change over time). In addition patient acceptance of the questionnaire was assessed. Psychometric testing yield exellent results regarding scale structure and reliability of the newly developed questionnaire. Validity was reflected in high correlations with standard generic questionnaires and in discriminating in quality of life between patients according to disease severity. The sensitivity was reflected in improved quality of life ratings in patients with improved treadmill performance. Patients needed 20 minutes for responding and rated the questionnaire to be easily understandable and not exhausting. These results show that the newly developed PAVK-86 questionnaire is a reliable, valid and sensitive instrument for the assessment of quality of life in patients with arterial occlusive disease which can be used in clinical studies, epidemiological research and quality assurance programs.

[Gastroesophageal reflux: a factor eliciting esophageal variceal hemorrhage?]. / Der gastrooesophageale Reflux--auslösender Faktor der Oesophagusvaricenblutung?

Following a hemorrhage, ten patients with esophageal varices were examined by means of gastroscopy and functional analysis of the esophagus with special regard to gastroesophageal reflux. A pathological gastroesophageal reflux was not confirmed. These results plus previously published findings lead to the assumption that reflux is of not importance in the initiation of esophageal variceal bleeding.

[Reconstructive surgery on the venous system]. / Rekonstruktive Eingriffe am Venensystem.

1. The progress of reconstructive venous surgery in recent years has been mainly based on the use of changed operative techniques (atraumatic preparation and suture technique; intraoperative vascular endoscopy or venography; temporary arteriovenous fistula). As a result, the clinical indications could be remarkably increased (acute phlebothrombosis; some types of post-thrombotic syndrome; venous substitution in tumor surgery; vascular lesions). 2. A peripheral temporary arteriovenous-fistula proves the most effective protective method both in venous thrombectomy and in graft reconstruction (full lumen restoration also in cases with incomplete disobliteration due to increase of flow velocity and flow volume; improvement of graft patency). 3. In long-standing axillar or subclavian venous thrombosis, a distal arteriovenous fistula (similar to a Cimino shunt) has a curative effect (without venous thrombectomy) via stimulation of rapid recanalisation and formation of collateral pathways. 4. Persisting central venous blocks may be corrected by a bypass procedure (great saphenous vein graft for the shoulder region; expanded PTFE grafts (Gore-Tex) for the ilio-caval segment).

[The meso-caval shunt--a future standard operation?]. / Der meso-cavale Shunt--Standardoperation der Zukunft?

As a result of several retrospective and prospective studies, there have been remarkable changes in surgery for portal hypertension, namely the limitation of surgical interventions to an asymptomatic time interval (without bleeding), and the preference for distal shunt operations, aiming at a lasting reduction of the portal hypertension with minimal reduction of portal liver perfusion. These requirements are best met by the mesocaval (H-) shunt, using a vascular prosthesis with sufficient wall stability and a negatively charged inner surface, such as, for example, the expanded PTFE graft (Gore-TEX). In contrast to several types of splenorenal shunt, the H-shunt in mesocaval position is characterized by the following advantages: (a) minimal operative stress, even in high-risk patients, (b) technical ease of use, (c) reduced operative mortality, especially for interval operations, (d) minimal risk of recurrent bleeding and encephalopathy. From this preliminary report it may be expected that the technique of mesocaval expanded PTFE shunt here presented is likely to become the method of choice in both elective and emergency interventions.

[Quality of life in peripheral arterial occlusive disease. Multicenter study of quality of life characteristics with a newly developed disease-specific questionnaire]. / Lebensqualität bei peripher-arterieller Verschlusskrankheit. Multizentrische Untersuchung zur Lebensqualitätscharakteristik mit einem neu entwickelten krankheitsspezifischen Fragebogen (PAVK 86).

AIM: Owing to a lack of disease-specific measuring instruments, no systematic investigations of the impairment of the quality of life in patients with peripheral arterial occlusive disease (PAOD) have so far been possible. The aim of the present study, therefore, was to develop an appropriate questionnaire and to submit it to a psychometric test in a sufficiently large number of patients. PATIENTS AND METHOD: A disease-specific questionnaire comprising 86 individual items was developed (PAVK 86) and was tested in a longitudinal study involving 308 patients with confirmed peripheral arterial occlusive disease, Fontaines's stages I to IV. At the same time, three established generic questionnaires were also employed (SF 36, NHP, Every Day Life). RESULTS: Analysis showed that, in comparison with a normal population, the quality of life in patients with PAOD is considerably impaired, in particular by pain, anxiety, general complaints and reduced physical mobility and performance, and is comparable with that of patients suffering from renal carcinoma. In Fontaine's stage III and IV, the quality of life is significantly more greatly impaired than in patients with stage II disease. No differences in quality of life were to be found between Fontaine's stages III and IV. The psychometric test revealed that the PAVK 86 questionnaire is a sensitive, reliable, valid and practicable measuring instrument. CONCLUSION: The PAVK 86 questionnaire is suitable for determining the course and outcome of therapeutic measures on the quality of life of PAOD patients, and can therefore be included in clinical studies. In addition, its use in combination with established generic questionnaires also permits a comparison with age-matched healthy control groups, and is thus also of importance for the assessment of aspects of health economics.