Aortomonoiliac endografting after failed endovascular aneurysm repair: indications and long-term results.

OBJECTIVES: To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. DESIGN: Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. MATERIALS AND METHODS: From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: -1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. RESULTS: Technical success rate of AMI endografting was 95.65% (n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1-Q3: 1.3-9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1-Q3: 17-69 months). CONCLUSIONS: Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

Elective abdominal aortic aneurysm repair: does the aneurysm diameter influence long-term survival?

OBJECTIVES: The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. DESIGN: Retrospective analysis of database. MATERIAL AND METHODS: Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. RESULTS: Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p<0.0016). CONCLUSIONS: Patients with small aneurysms (< or =5.5cm) have an improved long-term survival than patients with larger aneurysms.

Plaque imaging of the internal carotid artery - correlation of B-flow imaging with histopathology.

BACKGROUND AND PURPOSE: The noninvasive identification of plaque types prone to cause symptomatic disease is of great interest to improve the effectiveness of surgical or interventional management. The purpose of the present prospective pilot study was to evaluate the association between the results of imaging-the novel sonography technique B-flow imaging (BFI), B-mode, and color Doppler imaging (CDI)-and histopathologic examination in the characterization of internal carotid artery (ICA) plaques. METHODS: Twenty-eight consecutive patients with high-grade internal carotid artery stenosis scheduled for carotid endarterectomy were included. BFI, B-mode, and CDI images were used to classify the plaques applying the standardized scores of Beletsky et al and the American Heart Association (AHA), to calculate the gray-scale median (GSM) and to detect potential ulcerations; histopathologic examination results of explanted plaques served as the "gold standard." RESULTS: Based on the classification of Beletsky et al, BFI and histopathologic examination results agreed in 21 (75%, kappa = 0.61, P < .001) patients, and the corresponding results for B-mode were 19 (68%, kappa = 0.52, P < .001) patients, respectively. Corresponding results for the AHA classification revealed inferior agreements for BFI (19 patients/68%, kappa = 0.38, P = .003) and B-mode (17 patients/61%, kappa = 0.25, P = .045). The median GSM for BFI and B-mode correlated significantly (r = 0.95, P < .001). The sensitivity of BFI for the detection of ulcerated plaques was 100% and the specificity was 95.8%; corresponding values for CDI were 100% and 92.7%, respectively. CONCLUSION: BFI and the combination of B-mode and CDI exhibit comparable results in the assessment of ICA plaque components and plaque ulceration as well as in the determination of GSM levels.

Endovascular versus open surgical AAA exclusion techniques the importance of individual patient selection criteria.

Abdominal aortic aneurysms (AAA) are managed by two different treatment options, i.e. open graft replacement (OGR) as open surgical technique or endovascular aneurysm repair (EVAR) as minimally invasive procedure, to avoid fatal rupture. The intention of this review was to show how by offering electively either OGR or EVAR - adjusted to the patient's individual risk profile--a benefit for the individual patient could be obtained and overall mortality rates of elective AAA repair could be significantly reduced. A comparative evaluation of both treatment regimes is offered, latest literature as well as own research is presented. Our own risk adjusted patient selection regime is described as well as its statistically significant impact on overall mortality rates in elective AAA exclusion. As conclusion, the benefit of offering both EVAR and OGR is the capability to select and recommend the optimal AAA management for the individual patient with respect to the individual risk profile. The result is a decrease in the overall mortality rate while simultaneously the number of treated patients increases. Furthermore EVAR offers a treatment option for otherwise incurable high risk patients.

Urokinase antigen in plasma of patients with liver cirrhosis and hepatoma.

Plasma urokinase antigen levels were studied in 78 patients suffering from liver diseases. Blood was drawn before any specific medication was initiated. Impairment of liver function was comparable in all patients. In both groups of cirrhotic liver disease (alcoholic and non-alcoholic), normal levels of plasma urokinase antigen were found as compared to age-matched control groups. In both groups of patients with hepatomas (with or without a history of liver cirrhosis), however, significantly increased plasma urokinase antigen levels could be determined. These data indicate that an increase in plasma urokinase antigen might rather relate to malignant growth in liver disease than to impaired liver function.

Prostaglandin E1 reduces ischemia/reperfusion injury by normalizing nitric oxide and superoxide release.

To test the effects of prostaglandin E1 on 2.5 h of ischemia followed by 2 h of reperfusion, continuous nitric oxide measurements (electrochemical) were correlated with intermittent assays of superoxide and peroxynitrite levels (chemiluminescence) and ischemia/reperfusion injury in rabbit adductor magnus muscle. Administering prostaglandin E1 (1 microg/kg) before or during ischemia/reperfusion caused normalization of the release of nitric oxide, superoxide, and peroxynitrite to slightly above preischemic levels. This pattern was dramatically different from that observed during ischemia/reperfusion alone, where nitric oxide concentration increased three times above its basal level. Normalization of constitutive nitric oxide synthase activity in the presence of prostaglandin E1 was associated with a significant reduction of superoxide and peroxynitrite production and subsequent reduction of ischemia/reperfusion injury. At 2 h of reperfusion, vasoconstriction associated with ischemia/reperfusion injury was eliminated, and edema was significantly mollified but still apparent. Prostaglandin E1 treatment does not directly inhibit constitutive nitric oxide synthase, like the inhibitor N(omega)-monomethyl-L-arginine. Some phenomenon associated with ischemia turns on endothelial constitutive nitric oxide synthase to start transforming L-arginine and oxygen into nitric oxide, but prostaglandin E1 seems to inhibit this phenomenon. Thus, essential local L-arginine pools are not depleted, and normal basal levels of essential nitric oxide are maintained, whereas cytotoxic superoxide and peroxynitrite production by L-arginine-deficient constitutive nitric oxide synthase is prevented.

Irradiation-induced changes in the subclavian and axillary arteries after radiotherapy for carcinoma of the breast.

Three case reports are reviewed to illustrate the possibility of treating irradiation-induced lesions of the subclavian-brachial vascular segment (aneurysm and segmental occlusions) 14, 20, and 26 years after radical mastectomy and subsequent radiotherapy. All patients had an extraanatomic vein bypass graft from the carotid to the brachial artery crossing the shoulder near the acromioclavicular joint, with the advantage that the tissue changed by radiotherapy or infected by ulceration could be circumvented. There were no postoperative complications, with adequate function of the grafts (follow-up, 17, 24, and 20 months, respectively).

The influence of anticoagulant treatment on the probability of function in femoropopliteal vein bypass surgery: analysis of a clinical series (1970 to 1985) and interim evaluation of a controlled clinical trial.

During the years 1970 to 1985, 463 patients with obliterative atherosclerosis at the femoropopliteal level underwent elective surgery. The operation performed was an autologous saphenous vein bypass using the reversed technique. The vascular surgical treatment was documented in reasonable detail (both baseline and follow-up) in accordance with the documentation system of the Austrian Society of Vascular Surgery. On-line data entry with use of SAS data-base management software was used. The patency curves were estimated in accordance with the Kaplan-Meier method; possible differences were checked by means Breslow's and Mantel's tests. The preoperative clinical status (claudicants, n = 200; limb salvage, n = 263) influenced the postoperative results in a statistically significant manner (Breslow p less than 0.01; Mantel p less than 0.03). All the other risk factors analyzed (site of distal anastomosis above versus below the knee, n = 231, and n = 232, respectively; Breslow p less than 0.58, Mantel p less than 0.58. Presence [n = 122] or nonpresence [n = 341], of diabetes mellitus [Breslow p less than 0.77, Mantel p less than 0.68]; smoking habits [nonsmokers, n = 93, smokers n = 370, Breslow p less than 0.68, Mantel p less than 0.69;]) did not reach statistical significance. Anticoagulant treatment (n = 101) had no effect (Breslow p less than 0.93, Mantel p less than 0.72), even when the therapy was restricted to cases with disease at advanced clinical stages (stages III, IV; n = 50; Breslow p less than 0.55, Mantel p less than 0.95). On the basis of these analyses, a prospective trial was initiated in 1979. Eighty-eight patients were studied; those in group I (n = 42) received dicumarol, and those in group II (n = 46) were controls who did not receive anticoagulant treatment. At present, the median follow-up time is at 30 months. Treatment with dicumarol favorably influenced graft patency (Breslow, p less than 0.03, Mantel p less than 0.07; one-tailed tests). The patients' preoperative clinical status affected the results of surgery (Breslow p less than 0.03, Mantel p less than 0.02; one-tailed tests). In relation to the preoperative clinical status, a therapeutic effect was observed in stages III and IV (n = 45; Breslow p less than 0.03, Mantel p less than 0.07; one-tailed tests), while no effect of therapy was demonstrable in claudicants (n = 43; Breslow p less than 0.3, Mantel p less than 0.4; one-tailed tests).(ABSTRACT TRUNCATED AT 400 WORDS)

Intraatrial extension of thyroid cancer: technique and results of a radical surgical approach.

An occlusion of the superior vena cava by a tumor thrombus extending into the right atrium was diagnosed in three patients with a follicular thyroid cancer. All patients showed the typical clinical picture of the superior vena cava syndrome. A right parasternal thoracotomy was performed for preparation of the major vessels. The superior vena cava was opened and the entire intravascular tumor thrombus was removed. The cavotomy was closed directly in two patients. In the third patient the left brachiocephalic trunk was resected and reconstructed with a vascular (polytetrafluoroethylene) graft. This patient had bone and brain metastases and an occlusion of the graft 3 months after surgery after anticoagulation was stopped. The other two patients were clinically symptom free without local recurrence 13 and 50 months after surgery. An aggressive surgical approach is justified in grossly invasive thyroid cancer to decrease local recurrence and death rates, to correct the disturbing clinical symptoms of superior vena caval occlusion, and to prevent tumor embolism and the development of distant metastases. By reducing tumor mass, an even better basis for radioiodine treatment can be prepared.

Dacron versus polytetrafluoroethylene for Y-aortic bifurcation grafts: a six-year prospective, randomized trial.

BACKGROUND: A prospective, randomized trial was conducted to compare Dacron with expanded polytetrafluoroethylene (ePTFE) in reconstructive aortoiliac surgery. No comparable trial with a prospective, randomized design with a comparable number of patients or an equal long-term follow-up period can be found in the literature. METHODS: Between 1984 and 1989, 165 patients were randomized for either Dacron or ePTFE on the basis of age, sex, indication for surgery, diabetes, nicotine consumption, runoff, and operative approach. The two groups were well matched for randomization criteria, as well as the incidence of aneurysms. RESULTS: No statistically significant difference was found between the two graft materials in terms of patency rates (corrected 3-year patency rates: Dacron = 95% vs ePTFE = 95%; Breslow, p = 0.83; Mantel-Cox, p = 0.74). Subgroup analysis comparing long-term patency rates of the two graft materials and relating them to poor runoff, good runoff, aneurysms, and arterial occlusive disease also failed to show any significant differences between ePTFE and Dacron. Early graft failure (n = 6; 3.6% of the patient population; p = 0.045) and severe abdominal graft infection (n = 3; 1.8% of the total population) were seen only in ePTFE grafts. However, these did not affect the corrected long-term patency rate of ePTFE grafts. There were five late graft failures with PTFE (3.0%) and four with Dacron (2.4%). CONCLUSIONS: Graft materials currently available for aortoiliac repair were comparable in terms of corrected long-term patency rates. The alleged advantages of PTFE were not confirmed by our data. PTFE grafts were associated with a higher rate of complications, and more redo operations were required to duplicate the results obtained with Dacron.

Collagen versus gelatin-coated Dacron versus stretch polytetrafluoroethylene in abdominal aortic bifurcation graft surgery: results of a seven-year prospective, randomized multicenter trial.

BACKGROUND: A prospective randomized multicenter trial was performed to compare knitted gelatin-coated Dacron bifurcation grafts, knitted collagen-coated Dacron grafts, and stretch polytetrafluoroethylene (PTFE) grafts. METHODS: Between 1991 and 1998, 315 elective patients were randomized by age, gender, diabetes, runoff, indication (aneurysm, aortoiliac occlusive disease), and nicotine consumption at 3 centers of vascular surgery in Austria. The patients received gelatin-coated Dacron (GEL-D) grafts (n = 109), collagen-coated Dacron (COL-D) grafts (n = 100), or stretch PTFE grafts (n = 106). RESULTS: No intraoperative deaths occurred. The 30-day mortality was 3%. No difference was found between the 3 graft materials in long-term patency. The primary 5-year patency rates were 92% for GEL-D, 89% for COL-D, and 91% for stretch PTFE (P =.6001). The secondary 5-year patency rates also differed: 97% for GEL-D, 100% for COL-D, and 97% for stretch PTFE (P =.2062). Early occlusions were observed overall in 3% and late occlusions in 5% of patients. When both Dacron grafts were compared collectively with stretch PTFE, a difference was found in infection rate: Dacron 3% (6/209) versus PTFE 0% (0/106); P <.03. CONCLUSIONS: The bifurcation grafts of all 3 materials were comparable in primary and secondary patency rates, incidence of false aneurysms, and rate of perioperative complications. Graft infections were confined to the 2 Dacron grafts and did not occur in stretch PTFE grafts.

Revascularization of the poorly functioning kidney.

The effect of renal vascularization on renal function in kidneys with poor preoperative excretory function is summarized in this report. Twenty-five patients with kidneys having preoperative creatinine clearance of less than 30 ml/min, as determined during split renal function studies (SRFS), which were revascularized for treatment of secondary renovascular hypertension and then were reevaluated by repeat SRFS form the basis of this report. There were 13 male and 12 female patients. The type of renal artery lesion was atherosclerotic in 21 patients and fibromuscular dysplastic in four patients. Eight individuals had total renal artery occlusion. Significant contralateral renal artery disease was present in 15 patients (60%). Preoperative creatinine clearances in the affected kidneys ranged from 0.27 ml/min (mean, 16 +/- 9 ml/min). after operation, creatinine clearances ranged from 0 to 72 ml/min (mean, 32 +/- 16 ml/mn). Fifteen of the 16 kidneys with preoperative creatinine clearances less than 20 ml/min had improvement in renal function following revascularization (P less than 0.01). Improvement (60%) or cure (36%) in hypertension followed revascularization in 24 of the 25 patients. The most dependable predictor of successful management of both hypertension and retrieval of renal function in these patients was the arteriographic demonstration of a patent distal vessel without evidence of severe intrarenal stenoses. These results support an aggressive attitude toward the use of revascularization in the operative treatment of such patients with renovascular hypertension, even when the residual excretory function is minimal or absent.

The value of obturator canal bypass. A review.

OBJECTIVE: To review the value of obturator canal bypass with respect to long-term results. DESIGN: Case series and literature review. SETTING: University of Vienna Medical School in Austria. PATIENTS/METHODS: Personal experience with 34 consecutive patients and 125 cases published since 1982 with respect to patient data, patency, and survival are compared and jointly analyzed retrospectively. INTERVENTIONS: Patients received obturator canal bypass for lesions of the pelvic or common femoral vessels precluding orthotopic reconstruction. MAIN OUTCOME MEASURES: The rates of patient survival, limb salvage, and graft patency were analyzed. RESULTS: The postoperative mortality rate in the present series was 14.7%. The limb salvage rate after 5 years was 76.5%. One- and 5-year secondary patency rates were 75.3% and 54.9%, respectively. All grafts in patients without atherosclerosis were patent at a median of 34 months. For 57 cases documented in the literature, 1- and 5-year patency rates were 70.8% and 59.7%, respectively. Combined analysis of 90 obturator canal bypasses revealed rates of 72.7% and 56.9% of patent grafts at 1- and 5-years, respectively. CONCLUSIONS: The use of obturator canal bypass is recommended in deep groin infections and especially in patients with lesions of the pelvic vessels due to other occlusive vascular disease.

Diagnostic and therapeutic approaches to carotid body tumors. Review of 24 patients.

OBJECTIVE: To determine the clinical characteristics of carotid body tumors to define better a standardized proceeding in the management of carotid body tumors. DESIGN: Retrospective survey. Duration of postoperative follow-up was 4 months to 16 years (median, 57 months). SETTING: Institutional, tertiary care medical center. PATIENTS: Consecutive sample of 24 patients (10 men and 14 women) with 28 carotid body tumors treated in the University of Vienna (Austria) General Hospital in 35 years. INTERVENTIONS: Surgical resection, preoperative embolization. MAIN OUTCOME MEASURES: Initial signs, duration of symptoms, extension of the tumors, methods of investigations, and treatment modality, with special respect to the operative technique. RESULTS: Doppler color flow imaging and angiography provided essential mainstays for definite diagnosis. Computed tomography and magnetic resonance imaging contributed additional information about tumor extension. Nineteen patients (79%) underwent surgical resection of 22 tumors, 8 (42%) after preoperative embolization. There were no perioperative deaths. Hemiplegia occurred in 1 patient, and cranial nerve palsy occurred in 5 patients. Tumor recurrence was observed in 3 patients. Five patients refused surgery or tumors were unresectable. CONCLUSIONS: Our standard diagnostic procedure consists of establishing diagnosis by Doppler color flow sonography, angiography for detailing the vascularization of the tumor, and selective embolization to enable safer surgery with less bleeding. Early surgery is recommended to minimize major risks.

Vascular reconstruction for limb salvage in sarcoma of the lower extremity.

OBJECTIVES: To examine the patency and limb-salvage characteristics of vascular reconstruction in patients with sarcomas of the lower extremity who had been treated with limb-preserving resection and to examine patient survival during a long follow-up period. DESIGN: Retrospective cohort study. SETTING: University hospital, tertiary referral center. PATIENTS: From 1984 to 1992, 14 patients underwent limb-preserving resection of sarcomas in the proximal lower extremity, with 20 vascular reconstructions performed. OUTCOME MEASURES: Color Doppler scans documented patency of the vascular reconstructions. Clinical evaluation included functional results in terms of limb movement and quality of life. Local tumor control and systemic recurrence were examined by repeated radiologic examination. Overall survival as well as time and cause of death were assessed. RESULTS: A total of 13 patients had patent vascular grafts, while the venous graft became occluded in 1 patient. Limb function was rated as excellent or good in 9 patients, as fair in 3, as poor in 1, and could not be clinically estimated in 1. Postoperative thrombosis of the venous graft was detected in 3 patients and was effectively managed by thrombectomy in 2. Three patients underwent reoperation because of hematoma or complications caused by local infection. The tumor endoprosthesis had to be replaced in 3 patients. During follow-up periods that ranged from 15 to 132 months (mean, 55 months), 4 patients died. In all of these patients the cause of death was systemic recurrence in the lung. Two additional patients developed pulmonary metastases, but at the time of this report, they were still alive as long as 132 months after operative resection or chemotherapy. No local recurrence was found. CONCLUSION: Limb-preserving resection of sarcoma of the lower extremity can be performed with satisfactory function of the limb maintained, even if it becomes necessary to resect the femoral vessels. Autologous venous graft for vascular reconstruction is the treatment of choice. In spite of the high incidence of metastases, considerable long-term survival is possible.

Monitoring of median nerve somatosensory evoked potentials in carotid surgery.

The purpose of this study was to compare median somatosensory evoked potentials (SEP) in patients undergoing carotid endarterectomy (CEA) with routine shunting and nonshunting (excluding the option of selective shunting) and to evaluate the significance of a decrease in the amplitude of the cortically generated waveforms of the SEP and/or an increase in the central conduction time (CCT) on the one hand, and that of a loss of the cortical SEP, on the other. Somatosensory evoked potentials were recorded in 32 patients before, during, and after CEA with routine shunting or nonshunting. The N13 and N20 latency, the CCT, and the N20/P25 amplitude were evaluated. In addition, a meta-analysis of 15 previous studies was performed comprising a total of 3,136 patients. The intraoperative cortical SEP showed no differences between shunted and nonshunted patients, apart from the preclamping value of the N20/P25 amplitude which was lower in the nonshunted subjects. The number of patients with decreased and/or delayed cortical SEP (findings frequently used as criterion for selective shunting) was similar in the two study groups. A loss of the cortical SEP occurred in one patient operated on without an indwelling shunt. None of these patients had a new neurologic deficit after surgery. In the meta-analysis, the positive predictive value of decreased and/or delayed cortical SEP was extremely poor, that of absent cortical SEP was poor to moderate and the prevalence of new neurologic deficits was similar in patients undergoing CEA with routine shunting-nonshunting and those with selective shunting-nonshunting. Our study suggests that decreased and/or delayed cortical SEP are unreliable predictors of the neurological outcome of CEA patients and consequently an unsuitable criterion for selective shunting. The meta-analysis confirms this finding and shows that the neurologic outcome is not improved by using an indwelling shunt selectively based on SEP monitoring.

Mutated N-ras upregulates Bcl-2 in human melanoma in vitro and in SCID mice.

Activation of the N-ras gene by point mutation occurs in about 15% of all human melanomas. In recently established severe combined immunodeficiency (SCID) mouse xenotransplantation models for human melanoma, we demonstrated that mutated N-ras not only contributes to tumour growth by enhancing cellular proliferation, but also by blocking apoptosis. Mutated N-ras overexpression protected human melanomas from naturally occurring apoptosis and, in a more pronounced way, from chemotherapy-induced apoptosis in vitro and in vivo. Given the potential clinical importance of these findings we sought to determine the underlying mechanism. We found that mutated N-ras specifically upregulates the expression of the anti-apoptosis gene bcl-2 in two human melanoma cell lines in vitro and in SCID mice. Neither the expression of the anti-apoptotic protein Bcl-xL nor that of the pro-apoptotic proteins Bax and Bak were altered in cells expressing mutated N-Ras. The increase in Bcl-2 expression mediated by mutated ras therefore qualifies as a rational explanation for the enhanced chemoresistance of human melanoma expressing mutated N-Ras.

On the existence of intrahepatic bile duct shunts.

A combined scintigraphic-radiological method has been used to study the existence of intrahepatic shunts between the bile ducts of the right and left duct systems. With this method no shunts were found between the left and the right system. The results are compared with the findings reported in the literature.

In vivo magnetic resonance micro-imaging of the human toe at 3 Tesla.

The feasibility of in vivo high-resolution magnetic resonance micro-imaging of fine anatomic structures of human toes was tested. Five healthy subjects were investigated on an experimental 3 Tesla whole body scanner, using standard 3D gradient echo sequences. A radio-frequency surface coil was used for signal detection. Feet, toes and surface coil were comfortably fixed using a home built device for positioning and reduction of motion artifacts. The spatial resolution of 117 x 313 x 375 microm(3) allowed detailed visualization of anatomic structures like skin layers, vessels and nerves. In addition, oval structures with diameters ranging from 500 to 1000 microm were observed in all subjects, which could represent the sensory nerve endings of Vater-Pacinian bodies. Thus, high resolution MR micro-imaging at 3 Tesla may provide improved morphologic information in distal extremities of humans in vivo.

[Value of digital subtraction angiography in extra-anatomic bypass]. / Der Wert der digitalen Subtraktionsangiographie beim extraanatomischen Bypass.

DSA is a well-established diagnostic procedure. A special indication and technique was employed in the application of DSA, using a low-dose contrast medium in 11 patients with extra-anatomic arterial reconstructions (3 axillofemoral, 4 femoro-femoral suprapubic cross-over bypasses, 4 obturator bypasses). This approach has not been previously described in literature. The authors performed direct puncture of the very proximal part of the bypass with a small (0.6 mm.) "subcutaneous" needle. Less than 2 ml of contrast medium was applied, and DSA was accomplished in several positions. In 11 patients high-quality imaging of the entire extra-anatomic bypass was achieved. Advantages of the procedure are: 1. Minimal dose of contrast medium (1-2 ml.). 2. Possibility of angiography even during anticoagulant therapy. 3. Complete imaging of extended bypass procedures with minimal discomfort to high-risk patients.