Creation of an Arterialized Cephalic Vein as Autologous Bypass for Below-Knee Reconstruction in Critical Limb Ischemia.

Two cases of below-knee bypasses using an arterialized cephalic vein (CV) are presented. Both patients had critical ischemia, but no greater or lesser saphenous veins (LSVs) were usable. According to ultrasound, the CVs were thin but regularly positioned. Four weeks after wrist fistula was created, ultrasound showed adequate maturation, and the bypass operations were performed. Both patients had uneventful courses and were discharged after a few days with patent bypasses since then (35 and 18 months). As this report shows, creation of a fistula can be a useful option to gain autologous bypass material in case of critical limb ischemia.

Continuous irrigation as a therapeutic option for graft infections of the groin.

BACKGROUND: Wound infections following vascular procedures occur in 1-7 % of patients and can lead to severe problems including amputation and death. There are no established treatment options for this complication. The aim of our study was to introduce continuous irrigation as a new treatment technique. METHODS: We retrospectively evaluated patients who had undergone bypass surgery involving the groin and had been treated with continuous irrigation because of deep wound infections. The irrigation solution was saline in all cases. The patients were additionally treated with antibiotics. The end point of the study was either complete wound healing or complications such as recurrent infection, amputation, or death. RESULTS: Wound complications occurred in 65 (15.3 %) of 424 operations. Overall, 20 patients (4.7 %) developed a deep wound infection involving prosthetic graft material. They were treated with continuous irrigation. Complete wound healing was achieved in 13 cases (65.0 %). One patient died. No amputations were necessary. CONCLUSIONS: Based on our results, constant irrigation may be a therapeutic option in patients with deep wound infections. The main advantages of continuous irrigation over other treatments are ongoing bacterial reduction despite primary wound closure and the ability to measure the remaining colonization by microbiologic examination of the irrigation fluid.

Proximalization of the arterial inflow: new treatment of choice in patients with advanced dialysis shunt-associated steal syndrome?

Dialysis-associated steal syndrome (DASS) is a potentially devastating complication. As a new surgical technique, proximalization of the arterial inflow (PAI) has been described recently to be of good effect in case of DASS. As there has not yet been much general familiarity with this technique, our aim with this prospective study was to establish its indication for a special group of patients who developed advanced DASS (finger necrosis) following autogenous hemodialysis access (HA). Twenty-three patients (18 brachial, five wrist HA) with advanced DASS underwent PAI. Graft material included either heparinized (13 patients) or nonheparinized (10 patients) polytetrafluoroethylene prosthetic material. Vascular function was evaluated pre- and postoperatively with duplex ultrasound. Procedural success was determined by restitution of limb circulation and preservation of the HA. In 15 cases (65%) symptoms of DASS disappeared completely, and in six patients (26%) adequate wound healing with improvement of symptoms was achieved. Symptoms were persistent in two patients (9%) who had tissue loss >1 cm at the fingertips. Overall there was a significant increase in radial artery flow velocity (from 35.65 +/- 7.69 to 55.21 +/- 8.51 cm/sec, p < 0.005) after PAI. A decrease of fistula flow (from 1.38 +/- 0.48 to 0.94 +/- 0.14 L/min, p = 0.003) was measured in patients with elbow HA but not in patients with wrist HA. Secondary patency after 18 months was 85%. PAI effected an improvement in distal radial artery circulation with an additional banding component in elbow HA. We found that PAI led to good clinical success, especially in patients developing small finger necrosis as a form of advanced DASS. However, in case of severe tissue loss (>1 cm in diameter), PAI was not successful (n = 2). In such situations, other treatment options have to be discussed.

Dialysis shunt-associated steal syndrome (DASS) following brachial accesses: the value of fistula banding under blood flow control.

BACKGROUND: Dialysis shunt-associated steal syndrome (DASS) is a rare complication of hemodialysis access (HA) which preferably occurs in brachial fistulas. Treatment options are discussed controversially. Aim of this study was to evaluate flow-controlled fistula banding. MATERIALS AND METHODS: Patients treated between 2002 and 2006 were included in this prospective survey. According to a classification we established, patients were typed DASS I-III (I: short history, no dermal lesions; II: long history, skin lesions; III: long history, gangrene). Surgical therapy was HA banding including controlled reduction (about 50% of initial flow) of HA blood flow (patients type I and II). Patients with type III underwent closure of the HA. RESULTS: In 15 patients with relevant DASS, blood-flow-controlled banding was performed. In ten patients (all type I), banding led to restitution of the hand function while preserving the HA. In five patients (all type II), banding was not successful; in two patients, closure of the HA was performed eventually. In five patients (type III), primary closure of the HA was performed. Four patients with DASS type II but only two with DASS type I had diabetes mellitus (p = 0.006). CONCLUSIONS: Banding under blood flow control resulting in an approximately 50% reduction in the initial blood flow is an adequate therapeutic option in patients with brachial HA and type I-DASS. In type II-DASS, banding does not lead to satisfying results, more complex surgical options might be more successful. Diabetes is associated with poor HA outcome in case of DASS.

Intervention for access-induced ischemia: which option is the best?

INTRODUCTION: Access-induced ischemia is a rare but important surgical complication with potentially devastating long-term results. The question remains which therapeutic option is the best for the different forms of ischemia. METHOD: A review of the literature concerning access-induced ischemia (classification, treatment) was performed; furthermore, our own experience of more than 300 cases with ischemia was discussed. RESULTS: There are four different stages of dialysis access-induced ischemia syndrome (DAIIS) that need adequate treatment: stage I conservatively, stage II fistula banding, stage III proximalization operation or distal revascularization interval ligation and stage IV closure of the access. DISCUSSION: According to the many publications and to our own experience, there are good therapeutic options for many of the patients with DAIIS. However, in case of extended lesions/gangrene, closure of the access should be discussed in time before major amputation becomes necessary.

The value of duplex ultrasound in the prediction of brachial dialysis access induced ischemia syndrome (DAIIS).

PURPOSE: Dialysis access induced ischemia syndrome (DAIIS) is a serious complication of Vascular Access (VA) surgery. It mainly occurs in brachial VA. The aim of this prospective study was to ascertain whether early detection of DAIIS following brachial VA is possible, enabling immediate therapy. MATERIALS AND METHODS: One hundred and three patients undergoing brachial VA-surgery were surveyed. Duplex ultrasound was performed before and directly after surgery and the flow amplitudes of the distal ulnar and radial arteries were measured. Clinical follow up was performed after two months. In addition, specific patient characteristics were assessed. RESULTS: Sixteen patients (15.5%) developed DAIIS with the need for surgical intervention. Statistical analysis revealed a statistically significant correlation between post-operative flow amplitudes of the distal arteries measured by duplex ultrasound and the development of DAIIS. CONCLUSIONS: According to our data, measurement of the flow-amplitudes of distal arteries by duplex ultrasound shortly after surgery predicts the development of DAIIS. This makes immediate therapy possible. We recommend early post-operative duplex-ultrasound investigation following the creation of a brachial VA.

Late sequelae of retained foreign bodies after world war II missile injuries.

A number of people injured during the second world war harbour foreign bodies such as grenade splinters or bullets in some part of the body. Most of these metal fragments remain clinically silent. Some of them, however, may cause delayed complications. The purpose of this study was to determine the characteristics of delayed complications associated with foreign bodies after world war II injuries. 159 patients with retained foreign bodies after world war II injuries were retrospectively identified radiologically in our data bases in the time interval from 1997 to 2009. Diverse delayed complications secondary to the metal objects were diagnosed in 3 cases (2%): one patient with grenade splinter migration into the choledochal duct, one case with pseudotumoural tissue reaction, and one patient with late osteomyelitis. The time from injury to clinical presentation varied from 56 to 61 years. PubMed and Medline were screened for additional cases with delayed sequelae after foreign body acquisition during the 2nd world war. A 30 year search period from 1980 up to date was selected. 15 cases were identified here. Our study demonstrates that health consequences of the 2nd world war extend into the present time, and therefore physicians should be aware of the presence of hidden foreign bodies and their different possible late reactions.

Ischemic monomelic neuropathy: a rare but important complication after hemodialysis access placement--a review.

The creation of a vascular access for hemodialysis is a frequently performed procedure. Ischemic monomelic neuropathy (IMN) is a rare, but important complication of hemodialysis access (HA) procedures, which can lead to severe and nonreversible limb dysfunctions. Therefore, in any case of postoperative neurological malfunction, immediate neurological investigations should be undertaken. If IMN is diagnosed, improvement of distal perfusion should be established without delay. IMN is a form of hemodialysis-associated ischemic syndrome (as the so-called steal syndrome), but experiences with this complication are small. Every case of IMN should be carefully documented and if possible published, to gain more experience about this rare but important complication.

Proximalization of the arterial inflow (PAI) in patients with dialysis access-induced ischemic syndrome: first report on long-term clinical results.

PURPOSE: Proximalization of the arterial inflow (PAI) is a promising technique which was introduced several years ago as a treatment option for patients with dialysis access-induced ischemic syndrome (DAIIS). In our institutions we have been performing PAI since 2003 and have seen positive clinical results. The aim of this prospective survey is to present the long-term results of PAI. METHODS: Between 2003 and 2008, forty PAI operations were performed in our institutions: 4 patients had acute pain and sensorimotor dysfunction with no lesions, 33 had small acral lesions, and 3 had extended lesions following the creation of autogenous fistulas. In 22 cases a heparinized graft was used and in 18 cases a regular PTFE-graft. Criteria for successful treeatment of the disease course were evaluated by clinical and ultrasound examinations. RESULTS: In 36 cases (90%), PAI led to clinical success which was permanent in 33 patients (82%) seen in the follow-up period of 9 to 40 months. Primary patency was 62% after 12 months and secondary patency was 75% after 18 months. Heparinized grafts led to better patency rates. In 3 out of the 4 patients with large acral lesions, graft explantation was necessary due to infection or failing success. CONCLUSIONS: Based on our experience, clinical long-term results are successful in certain patients with DAIIS. The aim for the near future should be a better patency rate to minimize the need for reoperations. In cases of extended limb necrosis/gangrene results were poor. In such patients primary closure of the access must be discussed.

Dialysis shunt-associated steal syndrome with autogenous hemodialysis accesses: proposal for a new classification based on clinical results.

BACKGROUND: Dialysis-associated steal syndrome (DASS) is a multifactorial complication. There are several therapeutic options, although because of the lack of research decisions for certain procedures are often made individually. The aim of this retrospective survey was to propose a new classification for DASS, including therapeutic recommendations, to make standardized procedures easier. METHODS: A total of 63 patients (2001-2006) treated for DASS following autogenuous hemodialysis access (HA) were included in this survey. In 55 (87%) of these patients, surgery was performed. The courses of disease of the patients were evaluated according to clinical symptoms, HA-specific features, and therapeutic results. Statistical evaluation was performed by SSPS software. RESULTS: Eight patients with mild symptoms were treated successfully using conservative therapy. In 17 patients with pain during exercise or acute neurologic deficiencies, HA banding led to good results. In the case of acral lesions, however, banding was unsuccessful, although interruption of the retrograde flow was sufficient therapy in 94% of cases. Preservation of the HA was unsuccessful in all patients with extended tissue loss (n = 10). Statistical evaluation showed that tissue loss was generally associated with diabetes (p < 0.001) and peripheral arterial occlusive disease (p = 0.001). CONCLUSION: In addition to steal phenomenon (stage I), which can be treated conservatively, there are three stages of DASS following autogenuous HA that require surgical intervention (stage II, no acral lesions; stage III, small acral lesions; stage IV, extended acral lesions). HA banding leads to good results in stage II; in patients with stage III, interruption of the retrograde flow is indicated. However, in patients with extensive tissue loss (stage IV), closure of the HA should be considered.

Frequency of transient ipsilateral vocal cord paralysis in patients undergoing carotid endarterectomy under local anesthesia.

BACKGROUND: Especially because of improvements in clinical neurologic monitoring, carotid endarterectomy done under local anesthesia has become the technique of choice in several centers. Temporary ipsilateral vocal nerve palsies due to local anesthetics have been described, however. Such complications are most important in situations where there is a pre-existing contralateral paralysis. We therefore examined the effect of local anesthesia on vocal cord function to better understand its possible consequences. METHODS: This prospective study included 28 patients undergoing carotid endarterectomy under local anesthesia. Vocal cord function was evaluated before, during, and after surgery (postoperative day 1) using flexible laryngoscopy. Anesthesia was performed by injecting 20 to 40 mL of a mixture of long-acting (ropivacaine) and short-acting (prilocaine) anesthetic. RESULTS: All patients had normal vocal cord function preoperatively. Twelve patients (43%) were found to have intraoperative ipsilateral vocal cord paralysis. It resolved in all cases < or =24 hours. There were no significant differences in operating time or volume or frequency of anesthetic administration in patients with temporary vocal cord paralysis compared with those without. CONCLUSION: Local anesthesia led to temporary ipsilateral vocal cord paralysis in almost half of these patients. Because pre-existing paralysis is of a relevant frequency (up to 3%), a preoperative evaluation of vocal cord function before carotid endarterectomy under local anesthesia is recommended to avoid intraoperative bilateral paralysis. In patients with preoperative contralateral vocal cord paralysis, surgery under general anesthesia should be considered.