Arteriovenous shunts as venous access in children with haemophilia.

INTRODUCTION: Venous access is essential in patients with haemophilia for administration of factor concentrates. Peripheral venipuncture may be challenging, particularly in young children or during immune tolerance induction (ITI). Central venous access devices (CVADs) carry a significant risk for complications. An alternative for venous access is peripheral arteriovenous shunts (AVSs), but there is sparse documentation in the literature. The aim of this study was to document our experience with AVS over 12 years in 27 boys with severe haemophilia. METHODS: For AVS creation, a subcutaneous vein is connected end-to-side with an artery at the wrist (Cimino) or at the forearm (Gracz shunt). Factor concentrates were substituted as for intermediate size surgery. To prevent shunt occlusion, heparin (5 units/kg/h) was given during the first 3 days. RESULTS: Indications for AVS creation were prophylaxis start (n = 20) and ITI (n = 7). Age at shunt insertion was median 1.5 years (minimum 8 months; maximum 11.7 years). Shunt maturation was achieved within a median of 3 weeks after surgery (1.5 weeks; 18 weeks). Age when home treatment was established was median 2.1 years (9 months; 11.7 years). Four patients required AVS revisions due to stenosis, but 26 of 27 patients (96%) achieved good long-term shunt function. There were few other complications. CONCLUSION: Arteriovenous shunts provide a good alternative to CVAD and carry a lower risk of complications. AVSs allow earlier start of prophylaxis and home therapy with an improved quality of life for patients and families.

Preoperative duplex vein mapping (DVM) reduces costs in patients undergoing infrainguinal bypass surgery: results of a prospective randomised study.

OBJECTIVES: Surgical site infections (SSIs) after bypass procedures provoke major costs. The aim of this prospective randomised trial was to assess if preoperative duplex vein mapping (DVM) reduces costs generated by SSI. MATERIALS/METHODS: Patients undergoing primary infrainguinal bypass were randomised to DVM of the ipsilateral greater saphenous vein (group A) or none (group B). Costs were calculated by the hospital's accounting department. RESULTS: From December 2009 to April 2011, 130 patients (65 each group) were enrolled. Both cohorts were equal regarding demographics, risk factors and costs for primary bypass surgery, respectively. SSIs were classified minor (A: n = 13 vs. B: n = 13, P = n.s.) and major (A: n = 1 vs. B: n = 12, P = .0154). Preoperative DVM was the only significant factor to prevent major SSI (P = .011). Theatre costs for SSI: A: 537 € versus B 6553 € (P = .16). Recovery room/intensive care unit (ICU) costs for SSI: A: 0 € versus B: 8016 € (P = .22). Surgical ward costs for SSI: A: 2823 € versus B: 22 386 € (P = .011). Costs for outpatient visits due to SSI: A: 6265 € versus B: 12 831 € (P = .67). Total costs of patients without SSI: 8177 € versus major SSI: 10 963 € (P < .001). CONCLUSION: DVM significantly reduces costs generated by re-admission in patients suffering from major SSI.

Proximal common carotid artery lesions: endovascular and open repair.

OBJECTIVES: Management of proximal common carotid artery (pCCA) lesions is infrequently reported. We described open and endovascular treatment with regard to the neurological outcome and patency in patients suffering from atherosclerotic pCCA lesions. METHODS: Data were collected prospectively and analysed in a retrospective manner. RESULTS: From November 1991 to January 2010, 52 procedures, 24 surgical (11 bypasses, 12 transpositions and retrograde endarterectomy) and 28 endovascular (13 open transcervical and 15 transfemoral stent implantations) were performed (40.4% female, mean age 62.3 years, 65.4% left-sided). A total of 25 lesions (48.1%) were symptomatic (13 stenoses and 12 occlusions); 27 (51.9%) lesions were asymptomatic (22 stenoses and five occlusions). Two bypasses occluded within 30 days. Two early ipsilateral strokes were observed (3.8%). There was one perioperative death due to myocardial infarction after transcervical stent (1.9%). Mean follow-up was 61 months. In one transposition and two stent implantations, late redo interventions were performed. Fourteen of 48 patients died during follow-up. CONCLUSION: pCCA repair for atherosclerotic lesions is associated with a substantial perioperative risk (combined stroke/death rate: 5.7%). Endovascular intervention is the preferred invasive treatment option in patients suffering from stenotic pCCA lesions. In cases of pCCA occlusion, open surgery is a valid alternative. Late survival in patients suffering from pCCA lesions is poor.

Subclavian to carotid artery transposition: medial versus lateral approach.

INTRODUCTION: Subclavian to carotid transposition (SCT) is gaining importance as an adjunct for thoracic endovascular aortic repair (TEVAR). Two different anatomical approaches are described. We reviewed our experience with both approaches to evaluate the occurrence of complications and long-term outcome. MATERIALS/METHODS: We report the outcome of 150 SCTs carried between October 1979 and April 200710/79 at 2 university based tertiary care centers. Independent neurologic evaluation was performed. RESULTS: Lateral and medial approaches were used in 83 (55.4%) and 67 (44.6%) cases, respectively. The internal thoracic artery and the thyrocervical trunk were sacrificed more frequently when the lateral approach was used (1.5% vs 39.8%; p=0.0001 and 1.5% vs 49.4%; p=0.0001, respectively). The medial approach was associated with significantly less complications (8, 11.9%, compared to 24, 28.9%, p=0.012). Thirty day mortality was 0.7%. Median follow-up was 36 months (1-227), and no subclavian artery occlusions were identified. CONCLUSIONS: SCT is a durable procedure for the management of occlusive pathologies of the proximal subclavian artery occlusion. The medial approach is associated with significantly fewer complications.

Acute phase reactants in patients with abdominal aortic aneurysm.

BACKGROUND: There is increasing evidence that an inflammatory process is present in abdominal aortic aneurysms (AAAs) to varying degrees. The aim of this study was to compare acute phase reactants in patients with asymptomatic AAA, symptomatic AAA without rupture and ruptured AAA. METHOD: Two hundred and twenty-five consecutive patients treated because of AAA were included in this case-control study. Polynomial logistic regression analysis was applied to compare admission C-reactive protein (CRP) and white blood count (WBC) measured in 111 asymptomatic outpatients, 52 symptomatic patients without rupture and 62 patients with rupture of the aneurysm. We adjusted for the potentially confounding effect of age, sex, haemoglobin levels and aneurysm diameter. RESULTS: Patients with symptomatic AAA and patients with ruptured AAA had significantly elevated CRP (p=0.002) and WBC (p<0.0001) levels compared to asymptomatic patients. There was no statistically significant difference in CRP and WBC between patients with symptomatic AAA and ruptured AAA. Median CRP values of asymptomatic, symptomatic and ruptured AAA were <0.5 (interquartile range (IQR) <0.5-0.85), 1.1(IQR <0.5-4.0) and 2.4 mg/dl (IQR 0.65-8.6), respectively, and median WBC values were 6.5 (IQR 5.5-8.0), 8.7 (IQR 6.8-11.2) and 13.2 (IQR 10.5-17.0), respectively. CONCLUSION: A significant elevation of CRP and WBC could be found in patients who presented with symptoms or rupture of an AAA. These indicators of inflammation were not observed in asymptomatic patients with AAA.

Levamisole induced apoptosis in cultured vascular endothelial cells.

To better understand the anticancer activity of Levamisole (LMS), which serves as an adjuvant in colon cancer therapy in combination with 5-Fluorouracil, this study analyses LMS' ability to induce apoptosis and growth arrest in cultured human micro- and macrovascular endothelial cells (ECs) and fibroblasts. Cells exposed (24 h) to Levamisole (range: 0.5 - 2 mmol l(-1)) alone or in combination with antioxidants (10 mmol l(-1) glutathione or 5 mmol l(-1) N-Acetylcysteine or 0.1 mmol l(-1) Tocopherol) were evaluated for apoptosis ((3)H-thymidine assays, in situ staining), mRNA/protein expression (Northern/Western blot), and proliferation ((3)H-thymidine incorporation). Levamisole dose-dependently increased apoptosis in ECs to 230% (HUVECs-human umbilical vein ECs), 525% (adult human venous ECs) and 600% (human uterine microvascular ECs) but not in fibroblasts compared to control cells (set as 100%). Levamisole increased in ECs integrin-dependent matrix adhesion, inhibited proliferation (-70%), reduced expression of survival factors such as clusterin (-30%), endothelin-1 (-43%), bcl-2 (-34%), endothelial NO-synthase (-32%) and pRb (Retinoblastoma protein: -89%), and increased that of growth arrest/death signals such as p21 (+73%) and bak (+50%). LMS (2 mmol l(-1))-induced apoptosis was inhibited by glutathione (-50%) and N-Acetylcysteine (-36%), which also counteracted reduction by Levamisole of pRb expression, suggesting reactive oxygen species and pRb play a role in these processes. The ability of LMS to selectively induce apoptosis and growth arrest in endothelial cells potentially hints at vascular targeting to contribute to Levamisole's anticancer activity.

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.

Human growth hormone kinetics in critically ill patients.

Several studies have shown that exogenous human growth hormone (HGH) exerts an anabolic effect on protein metabolism in surgical patients with mild or moderate catabolism. However, contradictory results have been demonstrated in polytrauma patients where HGH did not improve protein metabolism. Aim of this study was to evaluate whether the pharmacokinetics of recombinant biosynthetic human GH (r-HGH) are altered in critically ill patients. After an overnight fast, r-HGH was infused at a rate of 460 micrograms/h/kg/bw during 120 min to five intensive care unit (ICU) patients. The patients were catabolic (nitrogen balance -11 +/- 0.5), showed normal liver function, and only one patient had a slightly impaired kidney function (creatinine > 1.5 mg/dl). Endogenous GH secretion was suppressed by continuous infusion of 50 micrograms/m2/h somatostatin. From plasma GH curves, elimination half life (t1/2kle), whole body clearance (Cltot) and steady state distribution space (DS) were calculated in an open two compartment model. Additionally, the effects of r-HGH infusion on plasma insulin, glucagon and amino acid concentrations were evaluated. T1/2kle was 19.6 +/- 2.3 min, Cltot 2.9 +/- 0.4 ml/kg/bw/min and DS 76.4 +/- 3.8 ml/kg/bw for 90 min. The plasma levels of total amino acids including the branched chain amino acids valine, leucine and isoleucine and of glutamine were significantly higher during r-HGH infusion than during the basal and somatostatin periods. In conclusion, the elimination of r-HGH in catabolic ICU patients is not different from that of healthy volunteers.

[Determinants of pouch function after continence-preserving proctocolectomy]. / Determinanten der Pouchfunktion nach kontinenzerhaltender Proktokolektomie.

A prospective study was undertaken in 17 patients undergoing restorative proctocolectomy for ulcerative colitis (13 patients) or familial adenomatous polyposis (4 patients) to determine relationship between pre- and postoperative anal sphincter function, pouch characteristics and functional results. Postoperatively all manometric parameters were significantly reduced and remained so permanently. Only squeeze pressure rose to normal values again. The most important factor for a favourable functional outcome was pouch volume. A capacious reservoir was associated with a low stool frequency, low risk of incontinence and general success of the operation, as assessed subjectively. Perianal soreness with considerable skin problems occurred frequently when resting and squeeze pressures were markedly reduced postoperatively.

[Inguinal hernia as a diagnostic error in ruptured groin aneurysm]. / Inguinalhernie als Fehldiagnose bei rupturiertem Leistenaneurysma.

Anastomotic aneurysms observed with an incidence of 0.5% to 5.0% are considered a known complication following arterial surgery, especially when fabric grafts in the inguinal region are implanted. An anecdotal report is presented describing a 64-year old male patient, who developed, 10 years following an autologous femoro-tibial vein graft, a huge mass in the left groin. The lesion was considered an incarcerated inguinal hernia and the patient was admitted to the Department of Surgery for emergency repair. Clinical examination, duplexsonography and CT scan clarified the diagnosis of an aneurysm with a diameter of 13 cm. The aneurysm was resected, and a femoro-profundal vein graft was implanted orthotopically, the graft was covered with a sartorius muscle flap. The postoperative course was uneventful. The diagnosis is suspected by clinical examination and usually confirmed by duplexsonography. The exact etiology of suture line aneurysms is unknown; in the present case progression of the underlying arteriosclerotic arterial disease after a follow up of 10 years is likely. For the treatment the usual methods of complicated aneurysm repair and preservation of the arterial circulation--using autologous in situ methods or extraanatomic bypass grafts--with additional biologic coverage are at hand.

An empirical study of nursing in patients undergoing two different procedures for abdominal aortic aneurysm repair.

Specialized vascular nursing has to meet the challenge presented through progress and modern developments in vascular surgery. Endovascular techniques are becoming more widespread and are now available for diseases that previously have required extensive surgery. A comparative study was carried out in two groups of patients with infrarenal abdominal aortic aneurysms (N = 50), either by means of the traditional open surgical approach or by the new endovascular stented graft technology. Four problems were compared in both groups of patients: (1) length of hospital stay, (2) dependency on nursing, (3) patients mobility after surgery, and (4) analgesic requirements. Data were obtained from a designated data sheet. Analysis of the data obtained helped us in our service to optimize the nursing process for patients undergoing major aortic surgery for open, as well as endovascular, procedures, especially regarding the nursing anamnesis and nursing diagnosis.

Bail-out visceral bypass grafting for acute intestinal ischemia after endovascular stent-graft placement in a complicated type B dissection.

We report on the case of a 35-year-old male who underwent emergency stent-graft placement in March 2007 due to a complicated type B dissection. One week after this procedure the patient developed critical visceral malperfusion. Subsequently, autologous iliaco-mesenteric as well as iliaco-hepatic bypass grafting was performed. At 6-month follow-up, aortic remodelling has occurred and visceral perfusion is regular.

Novel SDHD germ-line mutations in pheochromocytoma patients.

BACKGROUND: SDHD germ-line mutations predispose to pheochromocytoma (PCC) and paraganglioma (PGL). MATERIAL AND METHODS: The incidence and types of SDHD germ-line mutations are determined in 70 patients with apparently sporadic adrenal and extra-adrenal PCC. RESULTS: SDHD sequence variants were identified in the germ line of five patients. Two of three novel mutations were in exon 1 and one in exon 3. One patient had a codon 1 missense mutation (M1K) and a concurrent 3-bp deletion in intron 1. Three of 10 family members had only the exon 1 mutation, whereas one had only the intron 1 mutation. The other exon 1 mutation resulted from a deletion of nucleotides 28-33 with a 12-bp in-frame insertion (c.28_33 del ins TAGGAGGCCCTA). This mutation generated a premature stop codon after codon 9 and was also present in the brother who had a bilateral PCC. The third patient with a carotid body tumour, with an abdominal and a thoracic PGL had a 12-bp deletion in exon 3 (codons 91-94, c.271_282 del). Her father carried the same mutation and had bilateral carotid body tumours. Two further patients, one with six PGL, carried a previously described H50R polymorphism, whose disease-specific relevance is currently unclear. The three patients with bona fide SDHD mutations were younger than those without germ-line mutations. CONCLUSION: SDHD germ-line mutations are rare in patients with PCC, but their identification is an important prerequisite for the clinical care and appropriate management of affected individuals and their families.

Insulin does not regulate glucose transport and metabolism in human endothelium.

BACKGROUND: Although endothelial cells express insulin receptors, it is controversially discussed whether the endothelium represents an insulin-responsive tissue. Since available data are primarily restricted to animal endothelial cells, this study tested (i) whether insulin affects glucose metabolism in human endothelium; (ii) whether insulin sensitivity is different in micro- versus macrovascular endothelial cells; and (iii) whether glucose concentration in the incubation medium affects the cells' response to insulin. MATERIALS AND METHODS: Human umbilical vein endothelial cells (HUVECs), human adult saphenous vein endothelial cells (HAVECs), human aortic endothelial cells (HAEC), and human retinal endothelial cells (HRECs) as well as human smooth muscle cells were incubated with/without insulin (0.3 nmol L(-1) or 1 micromol L(-1)). Glucose transport, glycogen synthesis, glycogen content, lactate release, and expression of phospho-Akt, Akt, and endothelial nitric oxide synthase (eNOS) were determined. RESULTS: In HUVECs and HRECs, insulin (1 micromol L(-1)) increased (P < 0.05) eNOS expression by ~70% and doubled Akt phosphorylation, but the latter was by far more pronounced in human smooth muscle cells (+1093 +/- 500%, P < 0.05). In human smooth muscle cells, insulin (1 micromol L(-1)) stimulated glycogen synthesis by 67 +/- 11% (P < 0.01). In human micro- (HRECs) and macrovascular endothelial cells (HUVECs, HAVECs and HAECs), insulin, however, failed to stimulate glucose transport, glycogen synthesis, glycogen content, or lactate release under various conditions, i.e. after glucose deprivation or in medium with normal (5.5 mmol L(-1)) or high glucose (30 mmol L(-1)). CONCLUSIONS: Insulin stimulated glycogen synthesis and Akt phosphorylation in human smooth muscle cells. In human micro- and macrovascular endothelial cells, insulin, however, failed to affect glucose uptake and metabolism under all experimental conditions applied, whereas it increased Akt phosphorylation and eNOS expression.

Thiazolidinediones inhibit proliferation of microvascular and macrovascular cells by a PPARgamma-independent mechanism.

AIMS/HYPOTHESIS: This study evaluated the hypothesis that peroxisome proliferator-activated receptor-gamma (PPARgamma) agonists, including thiazolidinediones (TZDs) and the rexinoid LG100268 (LG), directly affect human vascular cell function (proliferation, cell cycle, protein expression, lactate release) independently of (1) their PPARgamma-activating potential and (2) the cells' vascular origin. METHODS: Human umbilical vein endothelial cells (HUVECs), human adult vein endothelial cells (HAVECs), human retinal endothelial cells (HRECs) and human retinal pericytes (HRPYCs) were incubated (48 h) with 2-50 micromol/l rosiglitazone (RSG), RWJ241947 (RWJ), pioglitazone (PIO), troglitazone (TRO), 15-deoxy-Delta(12,14)-prostaglandin J2 (PGJ2) and LG. Proliferation, cell cycle distribution, protein expression, peroxisome proliferator-activated receptor responsive element (PPRE) transcriptional activity and mitochondrial effects were determined by [3H]thymidine incorporation, FACS analyses, western blots, reporter assays and lactate release respectively. RESULTS: In HUVECs, RSG, RWJ, PIO, TRO, PGJ2 and LG reduced (p<0.01) proliferation (due to a G0/G1 cell cycle arrest) by up to 23%, 36%, 38%, 86%, 99% and 93% respectively. The antiproliferative response was similar in HRPYCs and HAVECs, but was attenuated in HRECs. Whereas p21WAF-1/Cip1 and p27Kip were differently affected in HUVECs, all agents reduced (p<0.05) expression of cyclins (D3, A, E, B), cyclin-dependent kinase-2 and hyperphosphorylated retinoblastoma protein. The rank order of the antiproliferative effects of TZDs in HUVECs (RSG approximately PIO approximately RWJ

Successful type II endoleak closure by subclavian-to-carotid artery transposition after stent-graft placement of a distal aortic arch aneurysm.

Endovascular stent-graft placement has become a safe and effective treatment modality for various diseases of the distal aortic arch as well as of the descending aorta. However, its effectiveness may be limited by various kinds of endoleaks resulting in persistent or recurrent perfusion of the aneurysm sac. Subsequently, systemic pressurization leads to expansion of the aneurysm sac, exposing the patient to a recurrent risk of aneurysm rupture. We report on the case of a 57-year-old male who underwent emergency stent-graft placement in March 2001 due to a contained rupture of a distal aortic arch aneurysm involving the origin of the left subclavian artery. Due to the emergency condition, a subclavian-to-carotid artery transposition had not been performed prior to stent-graft placement. During follow-up the patient developed a type II endoleak originating from the left subclavian artery with consecutive enlargement of the aneurysm sac. The endoleak was successfully treated by subclavian-to-carotid artery transposition.

Oral anticoagulation in peripheral vascular surgery: how intense, for how long, or at all?

To evaluate the influence of postoperative pharmacotherapy (antiplatelet therapy with acetylsalicylic acid (ASA) or oral anticoagulation) following various peripheral vascular surgical interventions (femoro-popliteal reconstruction, femoro-popliteotibial venous bypass;) two clinical series of patients were analysed (A1-2) and we made the hypothesis that adjuvant therapy may be beneficial. Thereafter two clinical trials were carried out (B1-2), to assess the value of postoperative antiaggregant and anticoagulant treatment. It was not possible to demonstrate any influence of ASA on improving patency at the iliaco-popliteal level or on patient survival. It was concluded that the ASA dosage of 1500 mg daily was too high, and produced severe side-effects, probably leading to insufficient patient compliance to therapy. In the B2 trial 130 patients received a femoro-popliteal above- or below-knee vein bypass, and were assigned to the therapy group (n = 66) and treated with anticoagulants or to the control group (n = 64) which received no therapy. During the follow-up, for a maximum of 10 years, the probability of bypass function, limb salvage and patient survival were significantly in favour of the treatment. The described single centre clinical trial B-2 produced in accordance with other trials a level II evidence in favour of postoperative pharmacotherapy. Level 1 trials assessing the direct comparison of antiaggregant versus anticoagulant therapy are underway, but results are unavailable yet, similarly the results of the Antithrombotic Trialist's Collaboration (ATT) are currently unknown.

Spiral CT angiography in the assessment of abdominal aortic aneurysms after stent grafting: value of maximum intensity projections.

PURPOSE: Our goal was to evaluate the value of maximum intensity projections (MIPs) rendered from spiral CT in the assessment of abdominal aortic aneurysms after stent graft implantation. METHOD: Spiral CT of the aorta was performed in 28 patients 1 week after implantation of covered aortic stent grafts. MIPs were evaluated in a blinded fashion. Transaxial scans and intravenous angiographs were considered the reference standard. RESULTS: Stent deformity was evident on the MIPs in 5 cases and stent angulation was seen in 24 cases. The excluded aneurysmal sac was visualized in 14 (50%) cases. MIPs depicted the patent inferior mesenteric artery in 20 of 23 cases (87%). Renal artery occlusion (n = 3), leaks (n = 8), and parietal thrombi, (n = 3) were detected on the MIPs in all cases. CONCLUSION: MIPs are a valuable tool in the assessment of aortic stent grafts.