Training in vascular trauma surgery for non-vascular surgeons: Vascular trauma surgery skills course.

Background: The experience of general and trauma surgeons in vascular trauma management has decreased with sub-specialization of surgery and working hours restrictions. We introduce a vascular trauma surgery skills course established to train German military surgeons prior to their deployment to conflict areas. Methods: The intention and implementation of the vascular trauma course for non-vascular surgeons is described in detail. Results: In hands-on courses, participants learn and train basic vascular surgical techniques on more realistic extremity, neck, and abdominal models with pulsatile vessels. A fundamental and an advanced course each provide military as well as civilian surgeons from different non-vascular specialties with a surgical skill set including direct vessel sutures, patch angioplasty, anastomosis, thrombectomy, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in order to render them capable of managing major vascular injuries. Conclusion: The experiences of this vascular trauma surgical skills course, initially established for military surgeons, can also be of use to all civilian general, visceral, and trauma surgeons occasionally facing traumatic or iatrogenic vascular injuries. Thus, the introduced vascular trauma course is valuable for all surgeons working in trauma centers.

Pseudoxanthoma elasticum overlaps hereditary spastic paraplegia type 56.

PURPOSE: Pseudoxanthoma elasticum (PXE) is a recessive disorder involving skin, eyes and arteries, mainly caused by ABCC6 pathogenic variants. However, almost one fifth of patients remain genetically unsolved despite extensive genetic screening of ABCC6, as illustrated in a large French PXE series of 220 cases. We searched for new PXE gene(s) to solve the ABCC6-negative patients. METHODS: First, family-based exome sequencing was performed, in one ABCC6-negative PXE patient with additional neurological features, and her relatives. CYP2U1, involved in hereditary spastic paraplegia type 56 (SPG56), was selected based on this complex phenotype, and the presence of two candidate variants. Second, CYP2U1 sequencing was performed in a retrospective series of 46 additional ABCC6-negative PXE probands. Third, six additional SPG56 patients were evaluated for PXE skin and eye phenotype. Additionally, plasma pyrophosphate dosage and functional analyses were performed in some of these patients. RESULTS: 6.4% of ABCC6-negative PXE patients (n = 3) harboured biallelic pathogenic variants in CYP2U1. PXE skin lesions with histological confirmation, eye lesions including maculopathy or angioid streaks, and various neurological symptoms were present. CYP2U1 missense variants were confirmed to impair protein function. Plasma pyrophosphate levels were normal. Two SPG56 patients (33%) presented some phenotypic overlap with PXE. CONCLUSION: CYP2U1 pathogenic variants are found in unsolved PXE patients with neurological findings, including spastic paraplegia, expanding the SPG56 phenotype and highlighting its overlap with PXE. The pathophysiology of ABCC6 and CYP2U1 should be explored to explain their respective role and potential interaction in ectopic mineralization.

Vascular reconstruction after retroperitoneal and lower extremity sarcoma resection.

PURPOSE: Soft tissue sarcomas (STS) of the retroperitoneum and the lower limb with invasion of major blood vessels are very rare malignancies. This study analyses the outcome of patients with vascular replacement during resection of STS of the retroperitoneum and the lower extremity with either arterial or concomitant arterial and venous infiltration. METHODS: Patients with vascular replacement during resection of sarcoma of the retroperitoneum and the lower extremity between 1990 and 2014 were included in this retrospective single center study. Patients with a sole infiltration of a major vein were excluded. The follow up was obtained from medical records, the general practitioner and a clinical examination whenever possible. The main endpoints were survival, graft patency and the rate of major amputations. RESULTS: Fourty seven patients were included in this study. Twenty patients have received an operation for a retroperitoneal STS, twenty seven for a STS of the lower extremity. The median follow-up was 24.5 months. The median survival was 113 months with a median tumor-free survival of 25 months. The two-year patency for arterial bypasses in the retroperitoneum and the lower extremity was 88% and 66%, respectively. Limb salvage rate was 89%. CONCLUSIONS: Invasion of major blood vessels is no contraindication for a resection of a STS in the retroperitoneum and the lower extremity, but it is accompanied by a high postoperative morbidity. Since surgical resection is the only curative therapy in these patients, it should also be offered to patients with infiltration of major blood vessels.

[Prevention of aortic erosion by a bone cement skid : Thoracic endovascular aortic repair following kyphoplasty]. / Pelottierung der A. thoracica descendens durch einen Zementsporn : Endovaskuläre Behandlung nach Kyphoplastie.

The underlying case report describes the successful endovascular prevention of an aortic injury by a bone cement skid after kyphoplasty. The intervention was performed in order to prohibit fatal aortic rupture or embolisation and underlines the role of vascular surgery techniques in interdisciplinary clinical networks.

[Management of bleeding and infections in the context of visceral surgery]. / Management von Blutungen und Infektionen im Rahmen viszeralchirurgischer Operationen.

Bleeding and vascular infections are serious potential complications during abdominal general surgery. The management of bleeding depends on the extent and localization and can range from the application of hemostatics to vascular sutures, interpositioning and ligatures. The use of prosthetic biomaterials implanted endoluminally or during open reconstruction permits palliation of potentially fatal conditions. The overall incidence of infections involving vascular prostheses is relatively low because of routine antibiotic prophylaxis prior to surgery, refinements in sterilization and packaging of devices and careful adherence to aseptic procedural and surgical techniques. When infections occur detection and definitive therapy of the vascular prosthesis are often delayed and the management is complex and tedious. Infections involving vascular prostheses are difficult to eradicate and in general, surgical therapy is required often coupled with excision of the prosthesis. Keys to success include accurate diagnostics to identify the organism and extent of graft infections, specific long-term antibiotic therapy and well-planned surgical interventions to excise and replace the infected graft and sterilize the local tissue. Regardless of the technique used to eradicate graft infections, success is measured by patient survival, freedom from recurrent infection and patency of revascularization. Even when treatment is successful, the morbidity associated with vascular graft infections is considerable. Aortoenteric fistulas (AEF) are a rare (incidence < 1.5 %) but often fatal complication. Primary diagnosis of AEF remains difficult. Computed tomography (CT) and fluorodeoxyglucose positron emission tomography CT (FDG-PET-CT) are the diagnostic tools of choice. Therapy consists of an urgent individualized interdisciplinary surgical approach with primary axillofemoral bypass and secondary prosthesis explantation or in situ replacement and subsequent bowel resection. Endovascular aortic repair (EVAR) is reserved for primary aortoenteric fistulas in patients with no signs of infection or in emergency cases as a bridging method.

Cross-flow determination by transcranial Doppler predicts clamping ischemia in patients undergoing carotid endarterectomy.

AIM: Aim of the paper was to assess the reliability of preoperative cross-flow determination by transcranial Doppler measurement (TCD) to detect clamping ischemia in patients undergoing carotid endarterectomy with selective shunting. METHODS: Retrospective one-to-one matched-pair analysis of 72 patients undergoing carotid endarterectomy with preoperative TCD scanning. Matching criteria were gender, degree of contralateral stenosis and the type of stenosis (asymptomatic or symptomatic). RESULTS: Patients in need for a secondary shunt insertion had significantly less cross-flow in preoperative TCD measurement (N.=14; 38.89%) compared to the control group (N.=32; 88.89%: P=0.0001%). The sensitivity of the cross-flow determination to predict clamping ischemia was 88.9%, the specificity 61.1%. The risk of developing a clamping ischemia in the absence of a cross-flow was 12 fold higher (OR: 12.6; 95% CI: 3.7-43.3). The existence of circulatory impairment of the MCA was associated with the presence of a collateral flow in the ACoA (OR 3.21; P=0.0531; likelihood ratio test 0.0481). Other factors like renal insufficiency, the degree of stenosis or the stump pressure showed no association with a cross-flow of the ACoA in a multivariate model. CONCLUSION: TCD scanning is highly reliable to detect cross-flow prior to carotid surgery and thus helpful to identify patients at risk for clamping ischemia and need for shunting.

Finite element analysis in asymptomatic, symptomatic, and ruptured abdominal aortic aneurysms: in search of new rupture risk predictors.

OBJECTIVES: To compare biomechanical rupture risk parameters of asymptomatic, symptomatic and ruptured abdominal aortic aneurysms (AAA) using finite element analysis (FEA). STUDY DESIGN: Retrospective biomechanical single center analysis of asymptomatic, symptomatic, and ruptured AAAs. Comparison of biomechanical parameters from FEA. MATERIALS AND METHODS: From 2011 to 2013 computed tomography angiography (CTA) data from 30 asymptomatic, 15 symptomatic, and 15 ruptured AAAs were collected consecutively. FEA was performed according to the successive steps of AAA vessel reconstruction, segmentation and finite element computation. Biomechanical parameters Peak Wall Rupture Risk Index (PWRI), Peak Wall Stress (PWS), and Rupture Risk Equivalent Diameter (RRED) were compared among the three subgroups. RESULTS: PWRI differentiated between asymptomatic and symptomatic AAAs (p < .0004) better than PWS (p < .1453). PWRI-dependent RRED was higher in the symptomatic subgroup compared with the asymptomatic subgroup (p < .0004). Maximum AAA external diameters were comparable between the two groups (p < .1355). Ruptured AAAs showed the highest values for external diameter, total intraluminal thrombus volume, PWS, RRED, and PWRI compared with asymptomatic and symptomatic AAAs. In contrast with symptomatic and ruptured AAAs, none of the asymptomatic patients had a PWRI value >1.0. This threshold value might identify patients at imminent risk of rupture. CONCLUSIONS: From different FEA derived parameters, PWRI distinguishes most precisely between asymptomatic and symptomatic AAAs. If elevated, this value may represent a negative prognostic factor for asymptomatic AAAs.

A novel strategy to translate the biomechanical rupture risk of abdominal aortic aneurysms to their equivalent diameter risk: method and retrospective validation.

OBJECTIVE: To translate the individual abdominal aortic aneurysm (AAA) patient's biomechanical rupture risk profile to risk-equivalent diameters, and to retrospectively test their predictability in ruptured and non-ruptured aneurysms. METHODS: Biomechanical parameters of ruptured and non-ruptured AAAs were retrospectively evaluated in a multicenter study. General patient data and high resolution computer tomography angiography (CTA) images from 203 non-ruptured and 40 ruptured aneurysmal infrarenal aortas. Three-dimensional AAA geometries were semi-automatically derived from CTA images. Finite element (FE) models were used to predict peak wall stress (PWS) and peak wall rupture index (PWRI) according to the individual anatomy, gender, blood pressure, intra-luminal thrombus (ILT) morphology, and relative aneurysm expansion. Average PWS diameter and PWRI diameter responses were evaluated, which allowed for the PWS equivalent and PWRI equivalent diameters for any individual aneurysm to be defined. RESULTS: PWS increased linearly and PWRI exponentially with respect to maximum AAA diameter. A size-adjusted analysis showed that PWS equivalent and PWRI equivalent diameters were increased by 7.5 mm (p = .013) and 14.0 mm (p < .001) in ruptured cases when compared to non-ruptured controls, respectively. In non-ruptured cases the PWRI equivalent diameters were increased by 13.2 mm (p < .001) in females when compared with males. CONCLUSIONS: Biomechanical parameters like PWS and PWRI allow for a highly individualized analysis by integrating factors that influence the risk of AAA rupture like geometry (degree of asymmetry, ILT morphology, etc.) and patient characteristics (gender, family history, blood pressure, etc.). PWRI and the reported annual risk of rupture increase similarly with the diameter. PWRI equivalent diameter expresses the PWRI through the diameter of the average AAA that has the same PWRI, i.e. is at the same biomechanical risk of rupture. Consequently, PWRI equivalent diameter facilitates a straightforward interpretation of biomechanical analysis and connects to diameter-based guidelines for AAA repair indication. PWRI equivalent diameter reflects an additional diagnostic parameter that may provide more accurate clinical data for AAA repair indication.

The expression of glycophorin A and osteoprotegerin is locally increased in carotid atherosclerotic lesions of symptomatic compared to asymptomatic patients.

The aim of this study was to evaluate in detail the histopathological characteristics of endarterectomized carotid atherosclerotic lesions in symptomatic versus asymptomatic patients. Twenty carotid lesions, 10 from asymptomatic and 10 from symptomatic patients who underwent carotid endarterectomy were classified according to histomorphological features. Samples were analyzed for intraplaque localization and for the expression of proteins associated with inflammation, such as CD68, interleukin (IL)-1ß, tumor necrosis factor-α (TNF-α), pentraxin-3 (PTX-3), nuclear factor-κB (NF-κB), C-reactive protein (CRP) and transforming growth factor-ß (TGF-ß), as well as for proteins associated with vascular remodelling, such as matrix-metalloproteinase-9 (MMP-9), glycophorin A (GYPA), osteoprotegerin (OPG), vascular cell adhesion molecule-1 (VCAM-1), endothelin-1 (ET-1), vascular endothelial growth factor (VEGF) and vascular smooth muscle cell actin (VSMA). Corresponding expression scores were compared between the symptomatic and asymptomatic patients and evaluated statistically. The expression of all 14 evaluated markers was significantly elevated in the border zone adjacent to the mixed plaque compared with the unaffected control area of the same sample (p<0,016). The expression scores of GYPA and OPG were significantly higher in the border zones around the calcified (GYPA, p=0.035; OPG, p=0.043) and mixed (GYPA, p<0.001; OPG, p=0.007) plaque zones of symptomatic patients compared to asymptomatic patients. No difference in expression scores was observed for any of the analyzed inflammatory marker proteins between the border zones of symptomatic and asymptomatic patients. In conclusion, the increased expression of GYPA, indicating intraplaque hemorrhage, and OPG, indicating the transdifferentiation of vascular cells, in carotid atherosclerotic lesions may be associated with an increased risk of plaque instability.

[Endovascular therapy of para-anastomotic aneurysms of the aorta. Technical options]. / Endovaskuläre Therapie paraanastomaler aortaler Aneurysmen. Technische Möglichkeiten.

BACKGROUND: Open repair of para-anastomotic aneurysms (pAAA) after conventional aortoiliac repair is associated with a high perioperative mortality and morbidity. Endovascular treatment options have evolved over the last decade. The aim of this article is to demonstrate and review these endovascular strategies. MATERIAL AND METHODS: Between 01/2009 and 06/2012, a total of 12 patients received endovascular treatment for proximal (n = 7) or distal (n = 5) pAAA (n = 2 contained rupture). A retrospective analysis of these patients was performed. Median age was 71.5 years (range 55-87 years). The median time interval between primary operation and endovascular repair of the pAAA was 15 years (range 1-31 years) and median follow-up was 1.3 years (range 0 days - 3 years). Endovascular exclusion of the pAAA was achieved by implantation of an aortouniiliac endograft (n = 6), chimney graft (n = 1), fenestrated endograft (n = 2) and iliac extension (n = 3). RESULTS: Technical success could be achieved in all patients and in-hospital mortality was 16.8  % (n = 2). No patient required a reintervention but during follow-up one additional patient died due to gastrointestinal bleeding. No primary or secondary type I/III endoleaks were observed. CONCLUSIONS: Despite a not negligible mortality rate endovascular treatment of para-anastomotic aneurysms and anastomotic pseudoaneurysms appears to be a safe alternative for conventional open repair.

Decision-making and techniques in hypogastric artery revascularization.

The aim of this article was to describe and discuss the currently available endovascular and open surgical techniques to preserve or occlude the hypogastric artery during aortoiliac aneurysm repair and thus support the process of decision-making in hypogastric artery revascularization.

Novel SPG10 mutation associated with dysautonomia, spinal cord atrophy, and skin biopsy abnormality.

BACKGROUND: SPG10 is a rare form of autosomic dominant hereditary spastic paraplegia (HSP) caused by mutations in the KIF5A gene, which may be involved in axonal transport. METHODS: We report the characteristics of a French family with a novel missense mutation c.580 G>C in exon 7 of the KIF5A gene. RESULTS: The proband and his sister presented with an adult onset HSP, a sensory spinal cord-like syndrome, dysautonomia, and severe axonal polyneuropathy. Contrary to the proband, his sister presented a secondary improvement in spasticity and walking. In the proband, MRI findings consisted in spinal cord atrophy and symmetric cerebral demyelination, whereas the skin biopsy suggested a defect in the number of vesicles and synaptophysin density at the pre-synaptic membrane. CONCLUSION: This study extends the phenotype of SPG10 and argues for abnormalities in the axonal vesicular transport.

Technical aspects of EVAR for infrarenal AAA.

Technical aspects are crucial for planning and performing successful endovascular repair of abdominal aortic aneurysms (AAA). Planning should be based on high-quality computed tomography angiography scans with a slice thickness of ≤ 1 mm. However, even without a workstation for image postprocessing, important angle estimations can be easily performed. Several devices are available today to treat abdominal aneurysms. In most elective cases all currently available 3rd generation devices perform comparably if minimal requirements are kept in mind. A safe and technically precise implantation requires cooperation with the involved anesthesiologist in order to manage anticoagulation, blood pressure regulation in general and in currently evolving regional anesthesia. Modern endograft implantation involves highly technical resources, for example guide wires or catheters. Beside patient selection, an optimal procedure planning, graft model choice and endovascular skills are mandatory aspects. In the near future, further improvements in device design and deployment mechanism will allow better device alignment, paving the way for an even broader application of endovascular aneurysm repair (EVAR).

[Vascular surgery in the elderly - recommendations for clinical practice]. / Gefäßchirurgie im Alter - Handlungsempfehlungen für die chirurgische Praxis.

Due to the increasingly aging populations of the industrialised countries, the prevalence of vascular disorders is increasing, with an emerging patient subgroup of 80  years and older (octogenarians), often multi-morbid with an increased risk of anaesthesiological and surgical complications. This review article presents evidence-based indications for vascular surgery in the elderly (> 80  years), and the influence of advanced age on surgical results. Guidelines for daily practice were drawn from a thorough analysis of current treatment recommendations for three vascular disorders (carotid artery stenosis, abdominal aortic aneurysm, and peripheral arterial disease) with the aim of assisting the primary care physician in deciding upon the therapeutic management. In summary, evidence indicates that CEA (carotid endarterectomy) is the gold standard therapy for carotid artery stenosis, as opposed to the "best medical treatment" and CAS (carotid artery stenting). With suitable morphology of the aneurysm, endovascular aneurysm repair (EVAR) is the therapy of choice for abdominal aortic aneurysm (AAA). In elderly patients unfit for open repair and with a life expectancy of less than 4  years, EVAR does not offer any survival benefit compared with no intervention. In such patients, conservative therapy should be taken into consideration. Due to the significantly reduced life expectancy after a major amputation, the value of infrainguinal revascularisation is high, with the exception of patients aged > 90  years.

[Open surgical therapy of thoracoabdominal aortic aneurysms and chronic expanding aortic dissections: analysis of perioperative prognostic factors]. / Offen-chirurgische Therapie thorakoabdomineller Aortenaneurysmen und chronisch expandierender Aortendissektionen : Analyse perioperativer Prognosefaktoren.

AIM OF THE STUDY: The aim of the study was to investigate perioperative prognostic factors and long-term outcome following conventional open repair (COR) of thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD). PATIENTS AND METHODS: Between March 1993 and December 2005, 92 patients underwent elective COR for TAAA or CEAD in our institution. Passive distal aortic perfusion during cross-clamping was used in 36 patients (39%). Medical records and imaging studies of all patients were reviewed. Follow-up included history, physical examination and CT or MR angiography. Median follow-up was 40 months (range 1-139 months). RESULTS: Intraoperative, 30-day and in-hospital mortality rates were 2%, 8% and 12%, respectively. The estimated survival rate after 5 years was 70% and 43% of all deaths were cardiac related. The paraplegia rate was 10%, the rate of patients developing chronic renal failure requiring hemodialysis was 3% and 21% of patients required surgical revision. In multivariate analyses the need for surgical revision (OR: 8.465; CI: 0.802-89.318; p=0.024) and postoperative elevated serum transaminase values (OR: 1.009; CI: 1.002-1.017; p=0.017) independently predicted 30-day mortality. Peripheral arterial disease (OR: 4.41; CI:1.672-11.611; p=0.003), intraoperative complications such as disseminated intravasal coagulation and asystole (OR: 4.28; CI: 1.128-16.267; p=0.033), postoperative elevated bilirubin values >2.5 mg/dl (OR: 1.06; CI: 1.009-1.112; p=0.019), and postoperative ventilation >7 days (OR: 7.79; CI: 2.499-24.246; p<0,0001) independently predicted long-term mortality. CONCLUSION: Postoperative elevated liver values represent negative prognostic factors and may indicate a more standardized use of active shunt systems for organ perfusion.

[Ultrasoud screening in abdominal aortic aneurysm--numbers, data, facts]. / Screening des abdominellen Aortenaneurysmas mit Ultraschall--Zahlen, Daten, Fakten.

There are increasing numbers of elective surgeries not only for abdominal aortic aneurysm repair but also for emergencies because of ruptured aneurysms (rAAA). Mortality rates of rAAA up to 40-50% have remained unchanged for years. Because of the elevated incidence of complications in rAAA, the overall mortality is at least 80% and shows a dismal prognosis for this group of patients. With ultrasonography, a cost-efficient, technically simple and safe method with high sensitivity is available for detecting abdominal aortic aneurysms. On the basis on an electronic Medline literature search and evaluation of data from the "voluntary quality assurance for abdominal aortic aneurysms 2008" of the German Society of Vascular Surgery (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin DGG), this review presents critical analysis of the efficacy and cost-efficiency of an ultrasound-based screening programme for the early detection of abdominal aortic aneurysms. In this systematic review of the literature on AAA screening, a description of epidemiology and current situation concerning AAA in Germany will be given. The evaluation of 4 randomised studies for ultrasonic AAA screening is discussed and the recommendations of the German Society of Vascular Surgery concerning screening for AAA are highlighted.

[Genetic testing in asymptomatic minors: a survey among French geneticists]. / Les tests génétiques présymptomatiques chez le mineur: enquête auprès des généticiens français et position du groupe français de génétique prédictive.

Since their introduction, genetic tests have been carefully considered, with special attention to the release of information about the test and test results, the confidentiality of genetic information, the request and its motivation, and the psychological impact of the test. Careful consideration is needed when family members at risk are asymptomatic children or adolescents. Cautious reflection is warranted on whether and under which conditions genetic testing should be performed. Here, we report on the results of a survey conducted in France among 50 geneticists questioned on their opinions and practices concerning presymptomatic testing in three groups of diseases: those for which a medical benefit exists during childhood (e.g., retinoblastoma), diseases with onset during childhood for which there are no immediate medical consequences (e.g., type II/III spinal muscular atrophy), and those with onset during adulthood for which there is no medical benefit during childhood (e.g., Huntington disease). Guidelines are proposed: presymptomatic testing should not be performed in a minor without individual and direct information, all requests for presymptomatic genetic testing concerning a disease with onset in adulthood should be postponed, and all presymptomatic test requests for a minor should be addressed to a multidisciplinary team.

Treatment of an asymptomatic penetrating aortic ulcer in a young patient.

We want to report and discuss the indication for open surgery for an asymptomatic penetrating aortic ulcer (PAU) in the era of thoracic endovascular aortic repair (TEVAR). A 31-year-old female presented with the diagnosis of an aneurysm in the distal aortic arch. With respect to the patients young age, the controversial status of connective tissue disorders and in the absence of concomitant disease, open repair was indicated. There was no proof of a mycotic plaque or connective tissue disease in the microbiological-, pathological analysis and at electron-microscopy. The patient was discharged on the thirteenth postoperative day. In spite of good preliminary results of TEVAR in PAU, in selective cases there is still an indication for open surgery.