[Preventing lower limb amputations in patients suffering from diabetic foot syndrome and peripheral vascular disease - opportunities and limitations]. / Grenzen und Möglichkeiten der Vermeidung von Majoramputationen der unteren Extremität bei Diabetischem Fußsyndrom und arterieller Verschlusskrankheit durch freien Gewebetransfer.

BACKGROUND: The number of patients suffering from a diabetic foot syndrome is increasing. In many cases large plantar or heel defects can only be reconstructed by using a free flap. The free parascapular flap is an alternative to free muscle flaps in the reconstruction of plantar or heel defects. Donor site morbidity is low. Autologous bypass reconstruction or an angioplasty can increase extremity perfusion. PATIENTS AND OPERATIONS: 52 patients with a diabetic foot syndrome have been reconstructed since 2007. 23 of them required a free tissue transfer. On average these patients were 68.7 years of age. A parascapular flap was used in 15 cases, a latissimus dorsi flap with a skin graft in 4 cases, a gracilis muscle flap with a skin graft in 3 cases. In one case a free instep flap of the contralateral foot, which had to be amputated, was used. In 13 cases the flap was anastomosed to the autologous bypass, in one case an AV loop was used. RESULTS: 22 flaps healed primarily. Only 1 patient was not able to walk at discharge. There was one flap loss. 4 patients required an amputation later on due to bypass failure or infection. 2 patients died due to cardiac arrest at the rehabilitation clinic. CONCLUSION: If the correct indication is met, free flaps can prevent diabetes-derived amputations of the lower limb. The parascapular flap can be used for plantar and heel defects. Flap harvesting is quick due to the constant vascular anatomy. The donor site morbidity is low. Reconstruction requires revascularisation in an interdisciplinary setting including vascular surgeons and radiologists. Limb salvage reduces mortality and improves quality of life. Revascularisation and reconstruction should best be done in a single surgical procedure.

[Abdominal aortic aneurysm: screening and surveillance]. / Screening und Surveillance des abdominallen Aortenaneurysmas.

A screening program for infrarenal abdominal aortic aneurysm (AAA) has limited cost-effectiveness. Yet, screening of the subpopulation of smoking men aged 60-75 years, or men and smoking women with a family history of vascular diseases or other cardio-vascular co-morbidity is cost-effective and has been demonstrated. It is suited to halve the increasing mortality of AAA. Elective repair of AAA is justified at diameters larger than 5.5 cm for men, but uncertain for women. However, aortic diameters between 4.5 and 5 cm in women probably necessitate an invasive approach. Surveillance of patients who still not meet these criteria should not only include the absolute diameter of the aneurysm, but direct individuals with aneurysms at an annual expansion rate of more than 0.5 cm to elective repair.

[Justification for stents in the femoral artery: a surgical point of view]. / Indikationen für Stents in der Arteria femoralis--Sicht des Chirurgen.

Increasingly, endovascular therapy of the superficial femoral artery (SFA) is performed using stent technology. Not only short stenoses, but also longer lesions are receiving primary endovascular treatment, although several randomized studies have shown that stenting the SFA does not improve the prognosis after PTA of lesions of this size. Rather, the stent is indicated as a secondary measure to preserve the PTA-result should complications such as a dissection occur. New technical developments such as nitinol stents, sirolimus or PTFE coated stents offer the prospect of treating more complex SFA lesions (TASC Typ C). However, randomized studies reporting long term results with such stents have yet to be published and any cost-benefit analysis of stent therapy is questionable due to lack of pertinent data. Adjunctive techniques such as laser or brachytherapy have not shown convincing improvement of endovascular SFA therapy. Compound intervention carries the risk of injury to the branching profunda or the popliteal segment, which can transform an otherwise relatively harmless SFA occlusion into a lesion which may endanger the extremity. Furthermore, increasing complexity of the SFA lesion or lesions in diabetic patients result in markedly worse results when stented, in contrast to treatment employing bypass surgery. Applying evidence based criteria to treatment recommendation shows that primary stent-PTA of the SFA is, in most cases, medically and economically unjustifiable.