[Hybrid prosthesis for vascular reconstruction of the internal carotid artery near the skull base after radical excision of a very rare malignant glomus caroticum paraganglioma]. / Hybridprothese als schädelbasisnahes Interponat für die A. carotis interna bei radikaler Entfernung eines äußerst seltenen malignen Glomus-caroticum-Paraganglioms.

BACKGROUND: Neck tumors are challenging regarding the diagnostic and therapeutic management particularly in cases of malignant growth near relevant vessels to achieve R0 resection status and the best prognosis. AIM: The aim of this case report on a patient with a rare malignant tumor of the glomus caroticum (paraganglioma) is to present the successful outcome of a demanding interdisciplinary surgical approach (otorhinolaryngology and vascular surgery). Surgical re-intervention was necessary due to malignant tumor growth (detected in the histopathological investigation of the first specimen) including vascular resection using a hybrid graft for vascular reconstruction of the internal carotid artery near the skull base. CASE REPORT: A 38-year-old male patient underwent magnetic resonance angiography and digital subtraction angiography to clarify the diagnosis of a tumor in the right neck. This was preoperatively embolized and subsequently resected including vascular reconstruction using a prosthetic interposition graft (7 cm; W.L. Gore, Putzbrunn, Germany) between the common and internal carotid arteries. HISTOLOGY: malignant paraganglioma 40 mm in diameter with haemangiosis et lymphangiosis carcinomatosa demonstrating lymph node metastasis and prompting re-operation (neck dissection levels II, III, IV, V). This was followed by a novel vascular reconstruction using a GORE® hybrid vascular graft prosthetic stent (W.L. Gore) as interposition graft because of the short extracranial stump of the distal internal carotid artery near the skull base and to limit clamping time. Early postoperative outcome revealed no complications and after 24 months there were no signs or symptoms of recurrent tumor growth. CONCLUSION: Extended resections, if necessary including vascular (arterial) segments, aim at achieving R0 classification as shown in this extremely rare and usually challenging malignant tumor. Hybrid vascular prostheses are suitable for time-saving vascular reconstruction (>50%) to provide sufficient blood supply.

[Differential Vascular Medical Management of Visceral Artery Aneurysms in a Single-Centre Consecutive Patient Cohort as Part of an Ongoing Disease-Specific Systematic Clinical Prospective Observational Study]. / Differenzielles gefäßmedizinisches Management des Viszeralarterienaneurysmas anhand einer unizentrischen konsekutiven Patientenkohorte im Rahmen einer laufenden krankheitsspezifischen, klinisch-systematischen, prospektiven Observationsstudie.

AIM, PATIENTS AND METHODS: By means of a systematic single-centre prospective observational study, spectrum (symptomatology, frequency) and diagnostics of the different visceral artery aneurysm sites as well as the postinterventional course of the various therapeutic options used according to local finding and patient's clinical status as well as risk factors were analysed to contrast the different procedures (conservative, image-guided radiological intervention, open vascular surgery) in consideration of their decision-making criteria and their early postinterventional outcome (on the basis of complication rate, peri-interventional morbidity and hospital lethality) including relevant references from the literature. RESULTS: During a time period of 14 years, 22 patients (sex ratio: 12 males/10 females; mean age: 54.3 [range: 22-76] years) were registered. Most frequently, visceral artery aneurysms occurred in the splenic artery (50 %). The gastroduodenal artery, the hepatic artery and the right renal artery were affected in each with 13.6 % (n = 3/22), the superior mesenteric artery in 9.1 % (n = 2/22). The majority of patients (54.5 %) were treated with image-guided radiological intervention, whereas in 31.8 %, the patient underwent open vascular surgery and 13.6 % of cases were managed with "watchful waiting". While morbidity was 21.1 % (n = 4/19), overall lethality was 9.1 % (n = 2/22). CONCLUSION: Decision-making for a specific therapeutic approach should be made (i) after adequate diagnostic measures (transabdominal ultrasound, MR angiography, duplex ultrasonography, CT-A/DSA if required), (ii) on an individual case-adapted base, (iii) in a vascular surgical centre, (iv) case-associated to the specific local finding (in particular, according to size/specific probability of rupture [cave: gravidity]) and (v) according to the individual risk profile using the whole spectrum of therapeutic options (conservative vs. interventional; image-guided radiological intervention [endovascular repair such as embolisation, stent or stent graft] vs. open vascular surgery [according to a step-up approach]; open vascular ligation vs. reconstruction after exclusion of the aneurysm) including sufficient quality assurance of the treatment results as well as control investigations (duplex ultrasonography; MR-A if required) in a specialised vascular surgical out-patient centre within appropriate time intervals.

[Prospective, Systematic Observational Study on the Daily Use of Cilostazol (Pletal) in Clinical Vascular Surgical Practice - Significant Improvement of Walking Distance and Quality of Life for Patients with PAOD, Stage II b]. / Prospektiv-systematische Beobachtungsstudie zur Anwendung von Cilostazol (Pletal) in täglicher klinisch-gefäßchirurgischer Praxis - signifikante Verbesserung von Gehstrecke und Lebensqualität bei Patienten mit pAVK Stadium II b.

AIM, PATIENTS AND METHODS: Through a defined time period, all consecutive vascular surgical patients with indicated and initiated medication with cilostazol (PAOD, stage II b) were registered and controlled clinically within 3-month time intervals to investigate the therapeutic effect in a representative, specifically vascular surgical group of patients using a systematic prospective, unicentre clinical observational study. In particular, maximum walking distance, subjective (semiquantitative) assessment of the quality of life, impact of accompanying diseases as well as the occurrence of adverse effects and their impact onto the treatment were studied. RESULTS: Out of the 146 registered patients with initiated medication of cilostazol, 93 subjects were finally evaluated. Three months after initiation of cilostazol medication, maximum walking distance increased by 108 m (159.7 %) based on the initial 181 m. After 6 and 9 months, walking distance increased by 181 m (200 %) and 168 m (192.8 %), respectively. After 12 months, there was no further increase of the walking distance by 126 m (169.6 %) compared with months 6 and 9 but still with a significant difference to the initial distance. There was a trend of an improved walking distance from the 3rd to the 6th month (p = 0.1055) and a significant difference between the 3rd and the 9th month (p = 0.0094; no further significant differences between the time points 3rd/12th, 6th/9th, 6th/12th and 9th/12th month). While an improved quality of life was reported in 80.7 % of patients after 3 months, the rate varied between 82.6, 72.9 and 80.9 % at 6, 9 and 12 months, respectively, i.e., always in the majority of cases. There were no hints for safety concerns with regard to severe adverse effects, in particular, bleeding episodes. Subgroup analyses on accompanying diseases such as diabetes, hyperlipidemia or nicotine abuse did not reveal any impact on the improved walking distance (ABI - no feasible parameter). CONCLUSION: Medication with cilostazol led to a significant increase of the maximum walking distance (p < 0.0001) compared to the initial distance, which was further increased through one year (however, the effect became weaker) accompanied by a dominating improvement of the quality of life. The effects can be observed longer than 3-6 months.

[Alterations of vertebrocerebral arterial branches in children and adolescents - current aspects of epidemiology, diagnostics, treatment, outcome and follow-up including a representative case report]. / Alterationen hirnversorgender Arterien bei Kindern und Jugendlichen - aktuelle Aspekte von Epidemiologie, Diagnostik, Therapie, Outcome und Nachsorge inkl. repräsentativem Fallbericht.

INTRODUCTION: Vascular alterations such as arterial lesions themselves or caused by injuries (external site) occur only rarely in children and adolescents. By means of a narrative review including our own clinical experience and a representative case report, vascular alterations in children and adolescents are discussed. Complex Patient- & clinical Finding-associated Aspects: - Dissections of vertebrocerebral arterial branches: usually, the aetiopathogenesis reveals external factors or primary alterations of the vascular wall. The therapeutic approach comprises anticoagulation or surgical, sometimes endovascular intervention in cases of recurrent ischaemic symptoms. - Aneurysm of the carotid artery: the therapeutic approach is characterised by surgical and interventional treatment according to the individual case-specific finding, alternatives in vascular reconstruction can be derived from the classification by de Jong et al. Representative Case Report: An 11 year old boy was diagnosed with intracranial dissection of the left vertebral artery initially treated with anticoagulation (6 months) and a consecutive neurosurgical approach (trepanation and coverage of the dissecting aneurysm) and, subsequently (within the 16th year of age), he underwent interventional treatment (coil embolisation) because of an expansion of the aneurysm. In addition, an aneurysm of the right internal carotid artery was found, which was approached surgically with interposition of a vena-saphena-magna segment. CONCLUSION: Vascular alterations such as dissections and aneurysms of vertebrocerebral arterial branches in children and adolescents are challenging. Dissections should be treated with anticoagulation. In the case of recurrent ischaemic symptoms or in cases of pressure phenomenon including neurological alterations, interventional or surgical treatment is indicated. In the case of an aneurysm of the carotid artery, there is an indication for surgical treatment: In children and teenagers, venous segments for interposition and single-stitch sutures are usually used. Competent decision-making for treatment and periinterventional management require appropriate interdisciplinary expertise.

[Trauma-associated vascular injuries and the vascular surgical/interventional options for vascular reconstruction]. / Traumaassoziierte Gefäßverletzungen und deren gefäßchirurgische/interventionelle Rekonstruktionsmöglichkeiten.

AIM: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations. METHOD: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options. RESULTS: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival. CONCLUSION: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

[Increasingly individualised therapeutic options in the rare isolated aneurysm of the iliac artery--vascular surgical versus image-guided endovascular intervention]. / Zunehmend individualisierte Versorgungsmöglichkeiten des seltenen isolierten Iliakalarterienaneurysmas--gefäßchirurgisch-operativ oder endovaskulär radiologisch-interventionell.

BACKGROUND: Isolated aneurysms of the iliac artery are rare but in case of rupture potentially life-threatening. AIM, PATIENTS AND METHODS: The aim of this systematic, clinical, prospective observational study was to retrospectively evaluate prospectively collected perioperative data obtained in consecutive patients with an isolated iliac artery aneurysm with regard to the diagnostic and therapeutic management including the outcome characterised by periinterventional morbidity, lethality, and overall survival over an intermediate time course of the follow-up. RESULTS: From 01/01/2002 to 03/31/2013, overall 35 patients with an isolated iliac artery aneurysm were diagnosed (females, n = 3 [8.6 %]; mean age, 70 [46-83] years). The mean hospital stay was 13 days. There were 24 aneurysms at the common iliac artery (AIC; 69 %), 8 at the internal iliac artery (AII; 23 %) and 3 at the external iliac artery (AIE; 9 %). Three patients (9 %) with an aneurysmatic rupture were admitted. The therapeutic options comprised: 12 patients underwent open resection and subsequent implantation of a prosthesis (34 %), 17 individuals were treated with an endovascular repair (49 %); 5 cases were managed with a "wait and see" policy (14 %). There was no lethality among the elective interventions whereas the lethality of emergency cases was 33 % (n = 1). Subdividing the patients treated with open surgery versus endovascular repair indicates significant differences of the preoperative characteristics, e.g., of the proportions of AIC in the distribution of aneurysmatic sites (75 % vs. 59 %; p = 0.007) reflecting the differential indication. CONCLUSIONS: Isolated iliac artery aneurysms can be approached with open surgery or with an endovascular repair depending on elective or emergency circumstances. In addition, clinical status of the patient and personal experience need to be taken into account. Depending on aneurysmatic site, extension, combination with accompanying findings and implantation sites at the proximal and distal sites of the aneurysm, the less invasive and less traumatic image-guided radiological approach can provide acceptable therapeutic success with regard to the sufficient exclusion of the aneurysm and can be increasingly used according to the individual patient and his/her findings.

[Lack of experienced surgeons in vascular surgery-A joint task]. / Der Fachkräftemangel in der Gefäßchirurgie ­ eine gemeinsame Aufgabe.

INTRODUCTION: An increasing shortage of specialists and training assistants is also being lamented in vascular surgery. Despite a continuous increase in the number of physicians and medical students in Germany in recent years, the need for specialists and training assistants in vascular surgery is enormous in a sustained manner. METHODS: Professional policy analysis from a medical vascular surgery perspective including currently available statistics, especially from the Federal Statistical Office, the Federal Medical Association, the Saxony-Anhalt (SA) State Medical Association and selective references from current medical scientific literature on epidemiological topics. RESULTS: In 2022, according to the basic data of the Federal Statistical Office 200 vascular surgery departments provided a total of 5706 beds for care. In 2021, 1574 physicians with the regional and specialist title in vascular surgery were registered by the medical associations. In the following years, there was an increase of 404 vascular surgeons. The recognition of the specialist title for vascular surgery fell from 166 in 2018 to 143 in 2021. There are 23 vascular surgery care units in Saxony-Anhalt (SA). At the SA Medical Association, there were 52 registered doctors with the specialist title in vascular surgery in the inpatient sector in 2021. In comparison, at the North Rhine Medical Association in 2021 there were 362 registered doctors with regional and specialist titles in vascular surgery overall and 292 in the inpatient sector. The age-standardized hospital incidence of peripheral arterial occlusive disease (PAOD) rose from approximately 190 to over 250 per 100,000 inhabitants in Germany between 2005 and 2016 and plateaued at this level. This corresponded to a relative increase of 33%. During the same observational period, the number of procedures performed doubled, mainly due to a strong increase in the number of endovascular interventions (approximately 140% increase) and interventions for arterial embolism/thrombosis (approximately + 80%). A research report commissioned by the German Hospital Society (DKG) in 2010 predicted a replacement requirement for physicians of approximately 108,000 by 2019 and an additional requirement of almost 31,000 physicians. While 14.6-27.2% of those employed in 2008 will have retired by 2020, between 45.6% and 68.5% will retire by 2030. Despite the statistically verifiable improvement in the staffing situation of specialists in vascular surgery in the inpatient and outpatient sectors in Germany, it can be assumed that there is a problem in recruiting young specialists. In order to target the recruitment of junior staff, it is first necessary to comprehensively record basic data on the staff situation and staff development in the area of residents in vascular surgery. In addition, further work should be done on implementing the recommendations for action already put forward years ago by scientific reports at state and federal levels.

[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.

[Therapeutic options for haemangiomas of infancy]. / Überblick der Therapiemöglichkeiten im Management von Säuglingshämangiomen.

The necessity of haemangioma treatment in infants has been controversially discussed for years. One reason is the favoured clinical observation of a potential spontaneous involution without any therapeutic approach or medical treatment, thus avoiding their specific risks. On the other hand, there are several reports on serious cases with -rapidly growing haemangiomas including severe consequences. There are potential complications such as loss of visus in cases of periorbital manifestation. A basic problem is the lack of a unique systematic classification, on the basis of which -diagnostic measures, therapeutic indications and modes could be compared. Such a classification would be much more competent including a sufficient comparison of treatment results. The basic aim in management is to achieve control of the haemangioma growth and induction of its sub-sequent involution back to only a cosmetic detraction. Each threatening functional loss can be classified as an urgent indication for treatment. There is a need to consider the treatment options and their values; in particular, cryotherapy or laser therapy in localised manifestations are mostly -favoured because of the convincing evidence from available data. In the case of a more disseminated haemangioma manifestation, the initiation of propranol medication is possible, a novel drug for this indication. However, there are no follow-up data on the mid-term or long-term outcome available at this time. Further studies on the subject are therefore required.

[Interims analysis of a prospective observational study on the use of cilostazol (Pletal®) in daily clinical vascularsurgical practice]. / Interimsanalyse einer prospektiven Beobachtungsstudie zur Anwendung von Cilostazol (Pletal®) in täglicher klinisch-gefäßchirurgischer Praxis.

BACKGROUND AND AIMS: Peripheral arterial occlusion disease (PAOD) has undergone a systematic classification of findings and stage-adapted sequential therapy. After the former limited otions of a conservative, rather medication-based approach, Cilostazol has led to more flexibility in the non-interventional therapeutic profile in angiologically clearly defined indications. The aim of this first interims analysis was to evaluate the preliminary results of the prospective observational study on the effect of Cilostazol (Pletal®, 2 × 100 mg; UCB Pharma Deutschland GmbH, Monheim, Germany - primary / secondary end points: increase of walking distance / quality of life including side effects) used according to its appropriate indication in daily clinical practice (effectiveness), which were obtained in a representative group of exclusively vascular surgical patients in a centre for vascular medicine. PATIENTS AND METHODS: Through a defined study period, all consecutive patients were enrolled in whom a Cilostazol medication was initiated after official approval of the pharmakon in the Division of Vascular Surgery or outpatient clinic because of PAOD, stage  II b, indicated by a subjective walking distance of < 200 m with a minimal observational study period of 6  months, a 12-week study-appointment interval (as recommended to each) and a reliable compliance with regard to patient data and medication. Primary study end point was the absolute increase of pain-free walking distance (as measured on the treadmill under standardised conditions, statistically tested by ANOVA for repeated measurements as well as pairwise t tests); secondary end point was the change of quality of life (determined semiquantitatively by the requested assessments "worse - equal - better"). In addition, the side effect profile and the spectrum of accompanying diseases with its possible alterations of impact on the Cilostazol effect were registered. RESULTS: Over 1.5  years, 40  patients were documented (male / female = 23 : 17 [67.5 / 32.5 %]) with a mean age of 65.7 ±â€Š9.1 (range: 41-88; median: 47.1) years. In the spectrum of accompanying diseases (registration rate, 95 %; n = 38), arterial hypertension (n = 25; 62 %), hyperlipoproteinaemia (58 %; n = 23), diabetes (28 %; n = 11), obesity (25 %; n = 10) and nicotine misuse (23 %; n = 9) predominated. On average, treatments lasted 235 (range: 3-566) days. Overall, there was a continuous prolongation of the walking distance up to 12 months after initiation of Cilostazol. The objective walking distance (treadmill) was 250 m at time "0", after 3 and 6  months + 114 m (P = 0.009) and + 157 m (P = 0.001), respectively - all statistics are based on completely documented data of the single study patients over the observational time period). Quality of life reached a statistically detectable improvement after 6  months. In smokers, there was no detectable significant increase of walking distance under Cilostazol. In 11 / 38 individuals (registration rate, 95 %), side effects were reported: Hyperglycaemia and tachycardia was found in 2  cases (5.3 % each); diarrhoea, anxiousness, headache, changing blood pressure, jaundice, nausea, n = 1. The AB index was not a feasible parameter (not shown). DISCUSSION: Use of Cilostazol in daily clinical practice is safe, effective and causes an early increase of the walking distance (after 3  months) and, but delayed, an improvement of the quality of life also in vascular surgical patients. CONCLUSION: Cilostazol medication can be considered a suitable tool as: (i) an initial step in the sequential therapeutic algorithm in stage II b of PAOD, (ii) a therapeutic alternative in exhausted vascular surgical (interventional) options. Further study-based clinical observations on the use of Cilostazol appear to be indicated.

[A rare aneurysm of the popliteal vein]. / Seltenes Aneurysma der V. poplitea.

BACKGROUND: A popliteal venous aneurysm is rare but needs to be considered a silent threat due to the risk of pulmonary embolism. CASE REPORT AND METHOD: Using the report of an exemplary case, the diagnostic and therapeutic management including outcome is described. In particular, the favourable, case-adapted surgical approach of aneurysma resection and direct suture of the vascular wall because of the extraordinary aneurysma of the right popliteal vein is emphasised. RESULTS AND CLINICAL COURSE: A 50-year-old woman underwent duplex ultrasonography because of pain in the right popliteal fossa, which revealed an aneurysm of the popliteal vein. The diagnosis was confirmed by phlebography. During the surgical approach, the popliteal vein was explored and the aneurysm subsequently excised. The defect in the wall of the popliteal vein was directly sutured avoiding a stenotic segment of the vein. The postoperative course was uneventful. Postoperatively, oral anticoagulation with coumarins was initiated for 6 months; follow-up investigations using duplex ultrasonography at 6 and 12 months showed a patent popliteal vein with no thrombotic changes. CONCLUSION: According to the recommendations from the international literature, surgical approach using venorrhaphy or resection is absolutely indicated to prevent pulmonary embolism, especially in the mostly younger patients.

Hybrid approach: vascular surgical and image-guided intervention for BroCa-induced superior vena cava syndrome (SVCS).

BACKGROUND: The aim of this study was to compare the outcome of a novel hybrid technique with the results of conventional approaches when treating tumor-induced superior vena cava syndrome (SVCS). The failure of a thrombectomy via transjugular aspiration led to an interdisciplinary approach to treat malignant SVCS. METHODS: The technique is relatively unknown but is performable if vascular surgeons and interventional radiologists work side by side in the operating room. We give an in-depth description of the hybrid technique, including surgical thrombectomy of the SVC, left brachiocephalic vein and left subclavian vein, occlusion balloon placement, stenting of the SVC and left brachiocephalic vein and the imaging controls. The equipment needed for this approach must be in the operating room and may only be available in bigger hospitals. RESULTS: Tumor-induced SVCS is an urgent case that sometimes cannot wait for radiotherapy or chemotherapy to reduce the tumor mass compressing the SVC. The results of our hybrid technique included almost complete relief of SVCS symptoms within 24 hours. The patient was discharged two days after surgery. CONCLUSION: Treatment provided the advantages associated with limited invasiveness, i.e., a faster and complication-free recovery period. The procedure may be a suitable alternative to open surgical intervention, as it involves less invasive trauma and has a reasonable risk-benefit ratio with a good chance of technical and clinical success. Further studies are warranted to better assess the complication rates with this hybrid technique.

[Spectrum of indications and perioperative management in i. v. port-a-cath explantation--alternative administration of taurolin in case of i. v. port-a-cath infection]. / Indikationsspektrum und perioperatives Management bei i. v.-Portsystemexplantation--Alternative Taurolingabe bei i. v.-Portsysteminfektion.

BACKGROUND: The aims of this systematic investigation were to analyse i) causes and complications leading to i. v. port-a-cath explantation and ii) a specific therapeutic option (taurolin administration via i. v. port-a-cath) in the case of an i. v. port-a-cath infection in a pilot study with regard to the feasibility and efficacy to finally avoid -explantation. PATIENTS AND METHODS: Based on a prospective, unicentre observational study on the implantation of an i. v. port-a-cath (daily surgical practice) enrolling consecutive patients of a representative number and through a defined study period (design, case series), besides patient and intervention-associated characteristics, we investigated 1. the spectrum of causes for an i. v. port-a-cath explantation; 2. the option of a conservative i. v. port-a-cath-maintaining, endoluminal, antiseptic local therapy in a selected number of patients with microbiologically detected infection of the i. v. port-a-cath using 2 x 5.0 ml taurolin 2.0 % / d for 3 d as an accompanying clinical observation of initial therapeutic use and its effect. Thereafter, microbe detection was again compared between blood culture and the port-a-cath catheter. RESULTS: From 2002 to 2005, overall 1588 i. v. port-a-caths were implanted at the Department of -General, Abdominal and Vascular Surgery (University Hospital, Magdeburg, Germany). 1) In -total, 117 patients (69 females vs. 48 males; sex ratio, 1.44 : 1) with complications and subsequent indication for an explantation of the i. v. port-a-cath were observed (most frequent cause: infection of the i. v. port-a-cath, 40 %). 2) Taken together, 10 patients underwent systematic administration of taurolin and follow-up investigation: In 8 of 10 patients (success rate, 80 %), the infection of the i. v. port-a-cath could be successfully treated with taurolin-administration as described and, in addition, the threatening -explantation of the i. v. port-a-cath could be avoided. CONCLUSIONS: There are various indications for the necessary -explantation of an i. v. port-a-cath, which need to be precisely analysed to avoid long-term consequences. Infection of the i. v. port-a-cath is the main reason for explantation and may be successfully treated with taurolin in selected cases under short-term clinical and microbiological control. The up to now urgently indicated explantation of an i. v. port-a-cath can thus be circumvented. However, a further systematic case series with a representative case number and intermediate, case-specific follow-up investigations appear to be desirable.

[Successful open vascular-surgical supracoeliac anastomosis of a bifurcational prosthesis with simultaneous prosthetomesenteric and renal revascularisation in Leriche's syndrome with high occlusion]. / Erfolgreiche offen-chirurgische, suprazöliakale Bifurkationsprothesen-implantation mit simultaner prothetomesenterialer und -renaler Revaskularisation bei hohem Leriche-Syndrom.

BACKGROUND: Based on an extraordinary case -report on a patient with almost symptomless supramesenteric occlusion of the aorta, the successful management and favourable outcome including almost normalised renal function (in addition to appropriate diagnostic and operative tactics) achieved by a technically challenging vascular-surgical intervention and subsequent intensive medical and nephrological care are described. RESULTS: In a 49-year-old male patient, a "high" aortic occlusion just below the branching of the coeliac trunk with arterial perfusion of the abdomen and the lower extremities via arterial collaterals from the 4 (th) to 6 (th) intercostal arteries was diagnosed. Both renal arteries were occluded leading to a consecutive renal insufficiency with need for dialysis and renovascularly induced hypertension. However, a residual perfusion of the parenchyma of the left kidney was detectable. Therapeutic measures comprised, after haemodialysis with accompanying antihypertensive medication, open supracoeliac aortobifemoral implantation of a prosthesis, revascularisation of the left renal artery (prosthetic bypass) and prostheticomesenteric bypass implantation. Postoperatively, a reestablished renal perfusion was observed in spite of the preoperatively prolonged lack of appropriate arterial perfusion (last dialysis, 11 (th) POD / discharge, 18 (th) POD). At 3 months postoperatively, the patient reported an increase of his body weight of 8 kg (at 6 months, 20 kg; improved but still elevated laboratory parameters indicating renal insufficiency; RR within normal range). Postinterventional MR angiography revealed a regular perfusion of the bifurcational prosthesis and of the bypasses to the superior mesenteric and left renal arteries. CONCLUSION: This exemplary case demonstrates impressively the individual therapeutic chances, options and the potential in the diagnostic and therapeutic interdisciplinary management and its combined expertise. The clinical course in this case indicates that the assessment of the arterial blood supply has to be included in the diagnostic of an acute renal insufficiency associated with anuria. If there is a minimal residual perfusion, which might just be sufficient for maintenance of structural integrity, there is a real chance for a restitution of renal function after successful revascularisation.

[Venous aneurysmatic malformation of the chest wall as a rare cause of pulmonary embolism--a case report]. / Kalzifizierende venös-aneurysmatische Malformation der Thoraxwand als seltene Ursache von Lungenembolien--eine Kasuistik.

This is a case report about a 66-year old man with recurrent pulmonary embolisms. Phlebography revealed a monstrous venous aneurysm of the right chest wall with several venous dilatations and calcification as the source of the embolism. Radiological embolisation and surgical ligation of the large aneurysmatic neck were performed. No further embolism episodes were registered under anticoagulation during the 23 months of the postoperative follow-up investigation.

Intravascular (post-hysterectomy) leiomyoma (IVL) as late tumor thrombus within the inferior vena cava (IVC)-A rare case primarily imposing as IVC thrombus originating from left renal vein after former left nephrectomy status.

INTRODUCTION: Intravascular leiomyoma is a rare type of myoma. It was firstly described by Birch-Hirschfeld in 1896, however, its intracardiac subtype was firstly reported by Durck in 1907. Most patients are asymptomatic. The tumor invades mostly the tributaries of the inferior vena cava (IVC) with upward extension that may approach the intracardiac space. AIM: By means of a scientific case report, a patient with the very rare diagnosis of an endocaval leiomyoma thrombus post-hysterectomy is described based on the clinical experiences obtained in the specific case management and selective references from the literature. CASE PRESENTATION: A 48-years old female was diagnosed with intravascular tumor growth within the IVC with intracardiac extension using chest and abdominal CT scan, ECG and echocardiography which was approached by an interdisciplinary (vascular and cardiothoracic) surgical intervention (278 min) including heart-lung machine (99 min) with favorable postoperative result (R0 resection status with mid-term outcome, no recurrent tumor growth). Histopathological investigation diagnosed leiomyoma origin already from ovarian vein most likely in context to the former hysterectomy (3 years ago). DISCUSSION AND CONCLUSION: Intravascular leiomyoma is a benign tumor with invasive tendency, which can be considered a diagnostic and therapeutic challenge. It should be thoroughly investigated to be planned for a radical surgical removal. By possible adherence to the intraabdominal or -thoracic organs, an interdisciplinary and eventually step-wise surgical approach (combining vascular, abdominal, thoracic and heart surgery as well as gynecology and urology), which can be demanding, is recommended to be seriously considered to i) reliably achieve R0 resection status and, thus, ii) provide best outcome, quality of life and prognosis.

[Vascular surgical aspects in abdominal surgery : Results from a tertiary care center over a 10-year time period]. / Gefäßchirurgische Aspekte in der Viszeralchirurgie : Ergebnisse aus einem tertiären Zentrum über einen Zeitraum von 10 Jahren.

AIM: To investigate the perioperative management and outcome of patients undergoing abdominal surgery with additional vascular (comorbid) alterations for internal quality assurance of the clinical results. METHODS: Over a defined study period all consecutive cases of the aforementioned profile were documented and retrospectively analyzed as part of an ongoing prospective monocentric observational study to reflect the daily surgical practice. RESULTS: Over 10 years (from January 1999 to December 2008), a total of 113 cases were registered. Pancreas resection including vascular reconstruction showed the highest percentage (30.1%). Within the target patient groups, similar outcome data were found compared with international reports. An exception was in the case of mesenteric ischemia, where open surgery was more frequently used in comparison to the study situation (included together were patients treated by surgery and interventions). The majority of vascular alterations during the postoperative course and iatrogenic lesions occurred following pancreas resection. In the therapeutic profile there are two particularly important measures, namely open surgery on one hand and image-guided radiology as well as endoscopy on the other hand. The majority of patients with a rare visceral artery aneurysm (considerable potential for rupture or erosion) were more frequently treated with image-guided interventional radiology versus open surgery. This conforms to the current well-established sequential patient (individual), results, and, in particular, risk-adapted staged treatment approach. CONCLUSION: Additional vascular surgical treatment of problematic situations during abdominal surgery or in emergency cases is not daily routine; however, it is a challenging field including a considerable potential for complications (morbidity) and definitely mortality. This requires an experienced surgeon with high expertise, if possible in a center for vascular medicine.

Surgery of inferior vena cava associated malignant tumor lesions.

BACKGROUND: Tumor lesions of the inferior vena cava (IVC) can originate from the vein or can develop by malignant tumor infiltration from the surrounding tissue. In this context, particular attention should be paid to tumor lesions with pegs into or within the IVC. The aim of this series of a single surgical center was to analyze the perioperative management, the individual-specific and -adapted surgical technique, as well as the outcome including prognostic considerations in IVC-associated malignant tumor lesions. PATIENTS AND METHODS: Over a 6-year time period, all consecutive patients with IVC-associated malignant tumor lesions and their patient- and finding-specific characteristics were registered, data and parameters of the diagnostic and therapeutic management were documented, and both the short- and long-term outcomes (complication rate, perioperative morbidity/mortality, tumor recurrence rate, survival) were assessed with periodic follow-up investigations. RESULTS: Overall, 12 patients were enrolled in the study from 1/1/2001-31/12/2006:6 primary IVC-tumors (leiomyosarcomas, 50%) and 6 secondary IVC-tumors (2 retroperitoneal tumor lesions, 16.7%, 3 renal cell carcinomas 25% and 1 carcinoma of the adrenal gland, 8.3%). 4 of the secondary tumors had pegs into the IVC. The RO resection rate was 83%. The perioperative morbidity was 33%; whereas, the hospital mortality was 8.3% (n = 1). Surgical reconstruction of IVC was achieved in each case (100%). There was a mean postoperative observation period of 20 months (range, 1-58 months). Complete follow-up documentation was obtained for all of the patients (100%). Three patients experienced recurrent tumor growth (27.5% out of n = 11). While the overall mortality through the follow up observation period was 27.5%, the tumor-specific mortality was 16%. CONCLUSIONS: The primary surgical aim is RO resection to provide a long-term outcome with no tumor recurrence including the reconstruction of the IVC based on a reasonable risk-to-benefit ratio. The favorable outcome of this case series demonstrates that IVC-associated tumor lesions can be approached if there is an appropriate expertise of the surgical team, a sufficient perioperative management and an adequate financial background with a reasonable survival rate. The variable prognosis of the various tumor lesions depends on tumor entity, stage, resection status and individual risk factors.

[Closure of a common iliac artery stump aneurysm after implantation of a bifurcational prosthesis. Combination of coil embolization and occlusion emulsion injection for iatrogenic bleeding]. / Aneurysmaausschaltung am Iliakalarterien-stumpf nach Bifurkationsprothesen-Implantation. Kombination vom Coil-Embolisation und Injektion von Okklusions-emulsion bei iatrogener Blutung.

Interventional radiology has an increasing spectrum of indications, in particular, for vascular medical problems. By Seldinger's puncture via the right femoral artery, an aneurysm of the right common iliac artery stump was sufficiently excluded with coil embolization. As a complication, an iatrogenic bleeding at the aneurysmatic neck was effectively stopped after the first interventional step with injection of an occlusion emulsion according to the bleeding site. Image-guided interventional measures in radiology allow a minimal invasive approach in a former classical field of vascular surgery. Furthermore, procedure-related complications can be increasingly controlled.

[Modern interdisciplinary management of a uretero-iliac artery fistula (case report)]. / Modernes interdisziplinäres Management einer uretero-iliakalen Fistel (Fallbericht).

INTRODUCTION: Abnormal links between the arterial system and other luminal systems are a challenge to those in charge of their adequate diagnostic and therapeutic management. OBJECTIVE: Scientific case report on an individual who underwent successful treatment combining vascular-surgical and interventional radiology techniques for a rare right uretero-iliac artery fistula based on personal clinical experience, a selective literature research and a detailed discussion of current recommendations for diagnostic workup and subsequent treatment. CASE CHARACTERISTICS: A 79-year-old patient was admitted with haematuria : and bladder tamponade : in the presence of bilateral actinic ureteral strictures secondary to neoadjuvant radiochemotherapy followed by abdominoperineal rectum exstirpation due to suprasphincteric rectal cancer (ypT3ypN0M0). Laboratory tests revealed anaemia; transabdominal ultrasound demonstrated bilateral urinary retention. A complementary CT scan did not reveal any manifest bleeding resulting from intermittent haemorrhage. SURGICAL PROCEDURE: Initially, the bladder haematoma was removed and ureteral catheters were changed. Due to endoluminal bleeding in the right ureter, a combined procedure was initiated, involving a vascular-surgical approach (access to the right femoral artery, ultimate disobliteration and intimal refixation in the right superficial femoral artery due to dissection) and an interventional radiology approach (insertion of an Amplatzer [AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, USA] into the right internal iliac artery and iliac stenting by a cross-over manoeuvre from the left femoral access site) although no acute bleeding was detected in the CT scan (but acute haemorrhage from the right ureteric ostium was confirmed during cystoscopy). CLINICAL COURSE: The patient stabilised in due time in response to periinterventional treatment in the ICU. He was discharged on the 15th day after surgery without evidence of recurrent haemorrhage. SUMMARY: In the presented case, this promptly initiated (vascular-surgical and interventional radiology) hybrid operation was absolutely indicated, being the approach with the best prospects for recurrent arterial bleeding with clinical manifestation of haematuria and haemorrhage within the urinary bladder due to a uretero-iliac artery fistula. CONCLUSION: Today, a minimally invasive approach with stenting is the method of choice in the sequential, urgent management of a potentially life-threatening uretero-iliac fistula in the presence of arterial endoluminal bleeding and an imminent haemorrhagic shock.