Successful surgical management of a recurrent leiomyosarcoma of the inferior vena cava.

The leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumour of the venous system. The recurrence of the tumour after previous initial surgical resection is common and occurs in more than half of the patients. Surgical resection of a local recurrence is poorly described in the literature and the available data are restricted to a small number of cases. We report the case of a 62 year old woman, who was referred to our vascular surgical unit for recurrence of a leiomyosarcoma of the inferior vena cava, 35 months after diagnosis and initial surgical treatment. We performed an extensive local resection and circumferencial replacement of the IVC. 18 months after the second operation and adjuvant radiotherapy, the patient is in a very good physical condition and CT-scans show no evidence of tumour recurrence.

Surgical treatment for agenesis of the vena cava: a single-centre experience in 15 cases.

OBJECTIVE: Agenesis of the inferior vena cava (IVC) is a rare vascular malformation. Deep vein thrombosis (DVT) and bilateral pelvic thrombosis develop quite frequently, making surgical therapy necessary. PATIENTS AND METHODS: Between 1982 and 2006, 15 patients (nine male, six female, mean age 28 standard deviance 9 years) with agenesis of the IVC (IVCA) were treated surgically because of acute or subacute DVT. These patients underwent bilateral transfemoral ante- and retrograde thrombectomy of the iliofemoral and sometimes popliteal veins and replacement of the IVC with an external ring supported PTFE-graft. Bi- or unilateral arteriovenous fistulae were created in the femoral region. The fistulae were closed, on average, 8 months after trans-arterial venography was performed. These patients were examined clinically and by duplex ultrasound imaging during follow-up to assess graft patency and to allow CEAP classification. Patients were assessed for the development of post-thrombotic syndrome (PTS). RESULTS: No patient died during any part of their treatment or within 60 days. Primary patency of the venous reconstruction was 53%, secondary and long time follow-up patency was 83%. The mean duration of follow-up was 41 SD 12 months. Minor complications were observed in five cases (33%). PTS showed no progression during a follow-up of 41 SD 12 months in all patients. There was no change in the CEAP clinical stage during follow-up nor did any leg ulcer develop. CONCLUSION: A surgical approach to restore venous patency is effective and appears to prevent the deterioration of CVI over time.

[Occlusive aortic disease as coral reef aorta--experience in 80 cases]. / Der stenosierende Aortenprozess als Coral Reef Aorta--Erfahrungen in 80 Patienten.

BACKGROUND: Coral reef aorta (CRA) is described as rock-hard calcifications in the visceral part of the aorta. These heavily calcified plaques grow into the lumen and can cause significant stenoses, leading to malperfusion of the lower limbs, visceral ischaemia or hypertension due to renal ischaemia. PATIENTS/METHODS: From 1/1984 to 11/2008, 80 patients (26 m, 54 f, mean age 61.6, range 14 to 86 years) underwent treatment in the Department of Vascular Surgery and Kidney Transplantation, Heinrich-Heine-University Hospital for CRA. The present study is based on a review of patient records and prospective follow-up in our outpatient clinic. RESULTS: The most frequent finding was renovascular hypertension (n=33, 41.3%) causing headache, vertigo and visual symptoms. Intermittent claudication due to peripheral arterial occlusive disease was found in 35 cases (43.8%). 15 patients (18.8%) presented with chronic visceral ischaemia causing diarrhoea, weight loss and abdominal pain. 79 patients (98.7%) underwent surgery; in 73 (93.7%) aortic reconstruction was achieved with thromboendarterectomy, on an isolated suprarenal segment in 7 (9.3%), an infrarenal segment in 21 (26.6%), and the supra- and infrarenal aorta in 45 cases (60%). Desobliteration of renal arteries was performed in 47 (one-sided n=8, 10.1%; both arteries n=39, 49.4%); the aortic bifurcation was desobliterated in 37 (46.8%), extension into iliac arteries was necessary in 29 cases (one-sided n=4, 5.1%; both arteries n=25, 31.6%). The coeliac trunk was desobliterated in 43% (n=34), the superior mesenteric artery in 44.3% (n=35) and the inferior mesenteric artery in 20.3% (n=16). In 15 cases additional revascularisation (bypass, transposition, graft interposition) was necessary. Surgical access was via a left-sided thoracoabdominal incision in 56.4% (n=45) and via laparotomy in 41.8% (n=33). The 30-day lethality was 8.7% (n=7). Postoperative complications requiring corrective surgery occurred in 11 patients (13.9%). Almost ⅓ of the patients (n=19, 27.5%) returned for follow-up after a mean of 52.6 months (range 3 to 215 months). Of these, there was significant clinical and diagnostic improvement in 16 (84.2%) and 3 (15.8%) were unchanged. Impairment was not observed. CONCLUSION: In spite of the existing and improving surgical techniques for the treatment of CRA, procedures are challenging and should be performed in centres with expertise.

[Retrograde aortomesenteric loop bypass behind the left renal pedicle ("French bypass") in the treatment of acute and chronic mesenteric ischemia. Clinical experiences and long-term follow-up in 27 patients]. / Der retrograde aorto-mesenteriale Bypass mit links retrorenalem Verlauf ("französischer Bypass") bei der Behandlung der akuten und chronischen viszeralen Ischämie. Klinische Erfahrung und Langzeitverlauf bei 27 Patienten.

BACKGROUND: In 2001 Leschi et al. published a new method to improve perfusion of the superior mesenteric artery (SMA) in operative therapy of acute and chronic visceral ischemia. They presented a retrograde aorto-mesenteric bypass following an arcuate course behind the left renal pedicle. Due to the intricate correct anatomic description of this vascular reconstruction this loop bypass was named the "French bypass". PATIENTS AND METHODS: In our department 84 patients underwent surgery because of an acute or chronic visceral ischemia between January 2002 and December 2007. Out of these patients 27 received a "French bypass". The pre-, intra-, and postoperative data were collected from the patient hospital files retrospectively. The follow-up consisted of a review of the patient history and clinical findings in an outpatient setting, combined with a duplex sonography of the visceral arteries. RESULTS: The group of 27 patients had an average age of 55.0 years: (range: 29-81 years) and consisted of 21 women (78.6 %) and 6 men (21.4 %). The cardinal symptom of all patients was abdominal pain of variable intensities. 14 patients complained about an increased pain post ingestion (abdominal angina) and 12 patients about an involuntary loss of weight. Bypass material was autologous saphenous vein in 18 patients (66.7 %) and in 9 patients (33.3 %) an 8-mm ring-enforced PTFE prosthesis. Apart from 10 patients who only received the French bypass, we performed comprehensive visceral revascularisations in 12 patients. Overall hospital mortality was 18.5 %; 4 out of the 5 deceased patients had undergone surgery due to acute visceral ischemia. The mortality of patients with acute visceral ischemia was 30.8 % and of patients with chronic visceral ischemia 7.1 %. Eight patients had a revision before -discharge from hospital (surgery n = 6, interventional n = 2). Primary and secondary patencies of the bypasses of the surviving patients were 54.6 % (12 out of 22 patients) and 81.8 % (18 out of 22 patients), respectively. Concerning the end-point "freedom from abdominal complaints" 14 out of 27 patients (51.9 %) benefited after a mean follow-up of 38.9 months (range: 3-84 months), 7 patients each in the acute and chronic visceral ischemia group. CONCLUSIONS: The implantation of a "French bypass" represents a good option to reconstruct the SMA, combining the advantages of ante- and retrograde visceral bypasses. Furthermore this -bypass procedure allows to reconstruct distal segments of the -superior mesenteric artery in cases when long distance and peripheral stenosis impeded local thromendarterectomy. Perioperative morbidity and mortality are acceptable when the acute clinical situation is taken into account. The long-term benefit for the patients with regard to the prevention of intestinal ischemia and also the freedom from complaints is high.

Differential regulation of hyaluronic acid synthase isoforms in human saphenous vein smooth muscle cells: possible implications for vein graft stenosis.

Autologous saphenous vein bypass grafts (SVG) are frequently compromised by neointimal thickening and subsequent atherosclerosis eventually leading to graft failure. Hyaluronic acid (HA) generated by smooth muscle cells (SMC) is thought to augment the progression of atherosclerosis. The aim of the present study was (1) to investigate HA accumulation in native and explanted arterialized SVG, (2) to identify factors that regulate HA synthase (HAS) expression and HA synthesis, and (3) to study the function of the HAS2 isoform. In native SVG, expression of all 3 HAS isoforms was detected by RT-PCR. Histochemistry revealed that native and arterialized human saphenous vein segments were characterized by marked deposition of HA in association with SMC. Interestingly, in contrast to native SVG, cyclooxygenase (COX)-2 expression by SMC and macrophages was detected only in arterialized SVG. In vitro in human venous SMC HAS isoforms were found to be differentially regulated. HAS2, HAS1, and HA synthesis were strongly induced by vasodilatory prostaglandins via Gs-coupled prostaglandin receptors. In addition, thrombin induced HAS2 via activation of PAR1 and interleukin 1beta was the only factor that induced HAS3. By small interfering RNA against HAS2, it was shown that HAS2 mediated HA synthesis is critically involved in cell cycle progression through G1/S phase and SMC proliferation. In conclusion, the present study shows that HA-rich extracellular matrix is maintained after arterialization of vein grafts and might contribute to graft failure because of its proproliferative function in venous SMC. Furthermore, COX-2-dependent prostaglandins may play a key role in the regulation of HA synthesis in arterialized vein grafts.

[Pulmonary embolism and deep vein thrombosis in the inferior vena cava affected by a rare anomaly]. / Embolisierende Thrombose bei Fehlbildung der V. cava inferior.

Persistent left-sided inferior vena cava (VCI) is a rare venous anomaly, its prevalence being estimated at 0.2-0.5%. Thrombotic occlusion of a VCI has been reported in only a few of these cases. We report the case of a 24-year old woman who suffered an acute thrombosis in a left-sided VCI and recurrent pulmonary embolism. After thrombectomy the course was uneventful. The diagnostic approach and the treatment strategy are discussed with reference to the literature.

Intraaortic balloon pump counterpulsation after implantation of infrarenal and thoracoabdominal aortic protheses.

Highly complex vascular surgery interventions have nowadays become possible due to sophisticated operative techniques and modern intra- and postoperative anesthesiological strategies. Accordingly, the number of high risk vascular surgery interventions rises continuously and thus, the number of secondary complications after high risk interventions increases as well and requires likewise extraordinary treatment concepts. We report of a 68-year old patient who 6 months previously was operated on a ruptured abdominal aneurysm, before he was admitted to our institution for the treatment of a type IIIb (Crawford classification) thoracoabdominal aneurysm. Intraoperatively we implanted a 26 mm Dacron prosthesis which was anastomosed with the previously existing infrarenal graft. Postoperatively the patient suffered from a hemodynamically significant myocardial infarction and acute coronary catheter intervention was necessary. However, circulatory stability could not be reestablished by interventional measures and we therefore decided to implant the intraaortic balloon pump despite the presence of two synthetic aortic grafts. However, the chance of success of such a manoeuver as well as the effectiveness of intraprosthetic counterpulsation was unclear and our literature research undertaken to predict the risk of such a manouver was unsatisfactory. We therefore want to report this case and compile the literature dealing with perceptions and complications of intraaortic counterpulsation after the implantation of synthetic aortic prostheses, since such a treatment option comes to an increased clinical application in comparable constellations.

The importance of open emergency surgery in the treatment of acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) is a complex disease with a high mortality rate. A patient's chance of survival depends on early diagnosis and rapid revascularization to prevent progression of intestinal gangrene. We reviewed our experience with open surgery treatment in 54 cases of AMI. METHODS: A monocentric retrospective study was conducted between 01/01/2001 and 04/30/2014; 54 AMI patients with a mean age of 56.6 years underwent surgery (26 women and 28 men). Retrospectively, the risk factors, management until diagnosis, vascular therapy and follow-up were evaluated. RESULTS: The symptom upon admission was an acute abdominal pain event. The delay time from admission to surgery was, on average, 13.9 h (n = 34). The therapeutic procedures were open surgical operations. The complication rate was (53.7 %) (n = 29). The 30-day mortality was 29.6 % (n = 16). The late mortality rate was 24.1 % (n = 13), and the cumulative survival risk was 44.6 %. Survival was, on average, 60.54 months; however, in the over 70-year-old patient subgroup, the survival rate was 9.5 months (p = 0.035). The mortality rate was 27 % (n = 22) in the <12 h delay group, 20 % (n = 5) in the 12-24 h delay group, and 50 % (n = 7) in the > 24 h delay group. CONCLUSIONS: The form of therapy depends on the intraoperative findings and the type of occlusion. Although the mortality rate has decreased in the last decade, in patients over 70 years of age, a significantly worse prognosis was seen.

Surgical treatment of septic deep venous thrombosis.

BACKGROUND: Septic deep venous thrombosis (SDVT) is an uncommon but occasionally lethal disease caused by systemic complications. In most cases reported in the literature SDVT is caused by intravenous drug abuse or transvenous catheter lines. Conservative management with antibiotic drugs and systemic anticoagulation is usually successful, and the surgical approach is regarded as not indicated or unnecessary. Occasionally, however, conservative management fails, thrombosis progresses, and septic embolism develops. METHODS: In a 7-year period five patients (three male and two female; mean age, 21.2 years), three with severe systemic complications of SDVT (femoropopliteal, 1; iliofemoral, 1; iliofemoral+vena cava, 3), were treated by venous thrombectomy in addition to intravenous antibiotic administration. Simultaneous transabdominal caval thrombectomy was performed twice. RESULTS: Two patients suffered from respiratory failure caused by previous septic embolization. One patient had experienced multiorgan failure before thrombectomy was performed. Intensive care was necessary for all patients (mean, 28 days). All patients survived. CONCLUSIONS: In complicated cases of SDVT without improvement or even impairment after conservative management, venous thrombectomy is a lifesaving treatment.

[Fresh homologous arterial transplant as aorto-iliac-femoral vascular replacement in prosthesis infection]. / Frisches homologes Arterientransplantat als aorto-iliako-femoraler Gefässersatz bei Protheseninfektion.

A patient with late graft infection in the groin following aorto-bifemoral-Dacron-bypass and recurrent infection of extra-anatomic bypasses is presented. Despite the evidence or graft infection (by preoperative imaging studies and intraoperative perigraft purulence) cultures did not identify the infective organism. Retrospectively a graft infection with Staphylococcus epidermidis is supposed as the most likely cause. A graft replacement with freshly harvested, not cryopreserved arterial homograft was performed. The perfusion of the extremities was excellent, the wounds healed perfectly. In special indications freshly harvested cadaveric arterial homografts are an acceptable substitute for infected aorto-femoral grafts.

[Surgical treatment of peripheral arterial occlusive disease in diabetes mellitus; in situ saphenous vein bypass versus reverse bypass procedure--a retrospective study]. / Operative Behandlung der peripheren arteriellen Verschlusserkrankung bei Diabetes mellitus; in-situ-Saphena-Bypass versus Umkehrbypassverfahren--eine retrospektive Studie.

The scope of reconstructive possibilities in the treatment of patients with peripheral occlusive arterial disease and diabetes mellitus had been increased thanks to further development of surgical methods. It is especially the in-situ-bypass procedure which has opened the path to new anastomotic sites at the level of the foot. Our own experience with 86 bypass procedures in 84 patients has given us an early patency rate of 82% in non-diabetic arterial occlusions and of 80% in diabetics. The amputation rate was 7% in the former group, 14% in diabetics with atherosclerotic occlusion. In comparison to the reversed bypass the early graft occlusion rate fell from 26% to 14% and the amputation rate from 13 to 9%. Thus, operative mortality fell from 9 to 2.4%, although the average age had risen from 61 to 67 years and the percentage of stage IV disease from 38% to 51%. Patency of bypass procedures with anastomosis to distal calf arteries was 83% und rose to 92% if the distal anastomosis was to arteries in the vicinity of the ankle. The caveat in this study is the fact that an apparent superiority of the in-situ-bypass is based on retrospective comparison of somewhat widely separated historical groups.

Healing characteristics of small-calibre vascular prostheses coated with plasmin-treated fibrin--an experimental study.

BACKGROUND: The autogenous vein represents the graft material of choice in crural and pedal bypass surgery. Because of the numerous problems concerning the graft harvesting and the quality of autogenous vein material an equally good allogenous graft is urgently needed. Up to the present times no such graft material has been able to achieve the success of vein grafts. METHODS: We investigated the knitted polyester prosthesis Terumo PF-V (Terumo Comp., Japan), diameter 5 mm with outer reinforce, which is characterized by a new coating of plasmin-treated fibrin. Grafts were implanted as bypass into the ligated carotid (n = 10) and femoral arteries (n = 10) of 10 dogs (beagles). As a control 5 mm-ePTFE-prostheses (Impra Carboflo) were implanted simultaneously on the contralateral side. RESULTS: After 6 months, seven of 20 PF-V-grafts and 8 of 20 PTFE-grafts were patent. All prostheses presented with good macroscopic healing characteristics. In the patent grafts, angiography showed no substantial stenoses. The histological examination of the material was performed using light microscopy, transmission polarising microscopy, scanning electron microscopy, and transmission electron microscopy. Both types of prostheses showed the typical pattern of graft healing by migration of mesenchymal cells through the prosthesis, formation of capillaries, and growing of a neointima with endothelium-like cells. All failed bypass grafts presented with an occluding proliferation from the arterial wall into the anastomotic region. CONCLUSIONS: Using clinically or histologically evaluation, neither graft demonstrated superiority over the other. The results indicate that the coating plays only a minor role for graft healing if any. For proper graft function, the arterial wall proliferation at the anastomotic region, which is not dependent on the type of prosthesis, appears to be most important. The overall results concerning both types of prostheses were disappointing.

Open surgery or endovascular treatment of the abdominal aortic aneurysm--quality assurance is urgently needed.

PURPOSE: The endovascular treatment of the abdominal aortic aneurysm (AAA) seemed to promise great advantages over the open surgery. The current results do not show an improvement compared to the conventional therapy. New kinds of complications have appeared. Their significance especially in the longterm course cannot be assessed today because sufficient clinical data are missing. METHODS: Between 1991 and 1997, 784 patients were electively operated on for infrarenal AAA. The clinical data of these patients were analysed retrospectively and compared to the current results of endovascular surgery in the literature. RESULTS: In the 784 patients treated by conventional surgery the mortality was 2.4%, the morbidity was 20.3%. The mortality of endovascular treatment ranged between 0 and 8.9%, the morbidity was 20 to 74%. Endoleaks existed in up to 32% of patients, and up to 21% of interventions were initially not successful. The mortality of conversion to open surgery was reportedly amounting 43%. CONCLUSION: To confirm new standards in the therapy of AAA an overall quality assurance of endovascular and open surgery is necessary. Additionally randomised studies have to be demanded. Only that way the indications of both methods can be based upon scientific facts.

[Results of conventional surgical therapy of abdominal aortic aneurysms since the beginning of the "endovascular era"]. / Ergebnisse der konventionellen chirurgischen Therapie des abdominellen Aortenaneurysmas seit Beginn der "endovasculären Ara".

INTRODUCTION: In 1990 the new method of endovascular graft treatment of abdominal aortic aneurysms (AAA) emerged. For this reason we analyzed the results of open surgery for AAA in our department to consider the question of standard therapy. METHODS: In a retrospective study the medical data of 941 consecutive patients treated by open surgery in a single center from 1990 to 1997 (mean age 67 years, 14.5 % female, 3.2 % suprarenal AAA) were analyzed. Operations were performed electively in 778 asymptomatic patients, urgently in 104 symptomatic patients, and as emergency operations (immediately after admission) in 59 symptomatic patients (45 patients presenting with rupture). RESULTS: Mortality was 1.54 % (elective operations), 8.65 % (urgent operations), and 35.6 % (emergency operations, rupture). Morbidity was 15.9 % (elective operations), 28.8 % (urgent operations), and 66.7 % (emergency operations, rupture). Mortality was not increased in patients undergoing additional procedures of the renal, iliac, femoral, or crural arteries. CONCLUSION: Because of its low mortality and morbidity today open surgical repair remains the standard therapy for AAA.

[Esophagus resection without thoracotomy in cancer. Report of experiences with 100 cases]. / Die Oesophagusresektion ohne Thoracotomie beim Carcinom. Erfahrungsbericht über 100 Fälle.

Between 1980 and 1984 126 patients were admitted to the surgical department of the University of Düsseldorf for cancer of the esophagus. 100 (= 79%) patients were operated upon. In the majority of cases we dealt with advanced tumors (76% stage III and IV UICC). In 87 patients the esophagus was removed by transhiatal blunt dissection. In 13 patients the tumor bearing esophagus was bypassed by the substernally transferred stomach. Overall mortality was 20%. Varying with tumor stage the median time of survival was 5,5 months, again with wide variation depending of tumor stage. Only in stage I and II tumors there is a chance of significant prolongation of life or even cure. The majority of our patients and their relatives considered the outcome of the operation as a success, even if the time of survival was only short.

[Interdisciplinary operative procedure-pelvis and abdomen]. / Operative Interdisziplinarität-Becken und Abdomen.

Surgery for tumors in the abdomen, retroperitoneum, and pelvis requires technical skills and expertise sometimes beyond the capability of a single surgeon. This holds especially true if curative tumor resection involves replacement of arteries and veins, which needs careful planning to avoid long periods of ischemia, and the selection and provision of vascular substitutes according to anatomical position, postsurgical therapy, and adjuncts to avoid thrombosis and infection of vascular grafts. Since the works of Fortner, the value of close collaboration between general and vascular surgeons has been demonstrated, but many of the former even today continue to attempt the operation alone, although the result is not always a masterpiece. The authors refer to their experience in major tumor surgery in either the single management of vascular complications or collaboration. The potential value of close collaboration is presented by negative examples, and a plea is made for a less "eminence"-based management of these sometimes difficult cases, which is based on vast positive experience with vascular diseases of the aorta and the visceral and iliac arteries and veins, including safety measures and adjuncts.

[Infection of a vascular prosthesis--a retrospective analysis of 99 cases]. / Gefässprotheseninfekte--eine retrospektive Analyse von 99 Fällen.

From January 1, 1980 to December 31, 1992, 7970 vascular prostheses have been implanted at the Department for Vascular Surgery and Kidney Transplantation of the University of Düsseldorf. In the same period of time, 99 patients had to be reoperated for (type Szilagyi III [14]) graft infection (1,2%), out of which 70 patients have had their previous operation in our institution (0,9%). The infection became apparent within 30 days in 14 cases, within one year in 54 cases, and in 31 cases within a maximum of 8 years postoperatively. Localisation of the infection was the groin in 70 patients, abdominal aortic prostheses were involved in 16, crural or extraanatomic prostheses in 13 cases. Treatment consisted in most cases of axillofemoral bypass (n = 23) and obturator-bypass (n = 21). In-situ-implantation of vascular prostheses was performed in 8 cases, 4 of these prostheses were intraoperatively soaked with an antibiotic. 47 patients had various reconstructions, such as cross-over bypasses, atypical reconstructions or local treatment. Postoperatively 27 amputations were necessary. 30-days mortality rate was 12%. At the end of the follow-up (May 1994) we found a 54% total mortality rate (mean follow-up: 4.6 +/- 4.59 years). Main cause of death in the first year was sepsis. In only 67% of patients discharged from hospital, the peripheral arterial conditions were described as "good" by angiography, ankle-brachial index or clinical examination. We conclude, that vascular graft sepsis threatens the patient in the early phase because of limb loss or death, and during the first year after the operation for the sequelae of sepsis or recurrence. Revascularisation with antibiotic-soaked grafts in a limited number of cases showed good results in preserving limbs and lives of our patients. Future experience will show, whether antibiotic-soaked grafts should be used more generously in vascular surgery.

[Acute aortic dissection. Diagnosis and therapy of ischemic complications]. / Die akute Aortendissektion. Diagnostik und Therapie von ischämischen Komplikationen.

AIM OF THE STUDY: About 30% of the patients with acute aortic dissection suffer from organ or limb ischemia. We analyzed the influence of ischemic localization and method of operative treatment (aortic fenestration or extraanatomic bypass revascularization) on morbidity and mortality. PATIENTS AND METHODS: From 1 May 1987 to 31 December 1998 21 patients with 24 vascular complications such as renal or intestinal ischemia, lower extremity ischemia and paraplegia following acute aortic dissection were treated at our institution. Recruitment was retrospective in 16 and prospective in 5 patients. In 5 patients (24%) the complication was associated with Stanford A, in 16 (76%) with Stanford B dissection. Ten patients (48%) complained of malperfusion of only one region, whereas 11 patients (52%) suffered from ischemia of two or three different regions. Aortic fenestration and resection of the dissected membrane was performed in nine cases (37%). Fifteen patients (63%) were treated with extraanatomic bypass techniques. RESULTS: One third of the patients died, four of them due to aortic penetration or perforation and two due to visceral ischemia. During follow-up of 32 (1-110) months two patients developed aortic complications. One died of aortic perforation, while the other developed a thoracoabdominal aneurysm and had to be treated by a tube graft replacement. CONCLUSIONS: Outcome depended more on the spontaneous course of aortic dissection and on prompt diagnosis and therapy of the complications than on the different operative techniques.

[Surgical reconstruction of high grade carotid stenosis: a safe procedure?]. / Die operative Rekonstruktion der hochgradigen Karotisstenose: ein sicheres Verfahren? Ergebnisse aus 2.162 Eingriffen.

Carotid surgery is still controversial. Some large randomized trials have demonstrated the benefit of surgery in correlation to conservative treatment alone, but these positive results depend on how specific the diagnosis is and a low complication rate. This study presents the results of 2162 patients (male n = 1596 (74%), female n = 566 (26%), mean age 65 +/- 9 years), who underwent carotid surgery between 1990 and 1999. Forth-three percent of these patients had no ipsilateral neurological symptoms with high-grade carotid artery stenosis (Stage I). Thirty-eight percent appeared with prior ipsilateral TIA or PRIND--symptomatology (Stage II) and 19% suffered from stroke with persisting deficits (Stage IV). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure in 1967 patients (91%). In 1324 patients segmental resection of the internal carotid artery was performed. Carotid endarterectomies and other reconstructions for coronary artery disease including abdominal aortic aneurysm were combined during the same operation in 11% of the patients. The rate of postoperative ipsilateral neurological events was 4.1%. On the ontralateral side neurological symptoms appeared among 0.8%, and 0.4% of the patients had bilateral symptoms. Twenty patients (0.9%) died as a result of postoperative stroke. In relation to preoperative staging of the cerebrovascular occlusive disease in stage I, postoperative neurological symptoms appeared in 2.8% (mortality 0.6%), stage II in 5.7% (mortality 1.0%) and stage IV in 7.8% (mortality 1.2%) of the patients. These results confirm the importance of carotid reconstruction as a measure in the prevention of cerebral infarction in patients with asymptomatic or symptomatic high-grade carotid artery stenosis. The complication rate was lower than the data reported in the literature and the results were clearly better than under conservative treatment alone. In our opinion, the indication for carotid artery reconstruction should be made by a team of vascular surgeons, neurologists and neuroradiologists taking all patient-specific factors into consideration. Only by optimal patient selection and minimal complication rates will a significant benefit for the patient be achieved.

[Surgical treatment of thoraco-abdominal aneurysm. Indications and results]. / Chirurgische Behandlung des thoraco-abdominalen Aortenaneurysmas. Indikationen und Ergebnisse.

Aortic replacement for thoraco-abdominal aneurysms remains a major challenge in vascular surgery. Related symptoms, maximal diameter > 6 cm, progression, aneurysm sac containing none or excentric thrombi and uncontrollable hypertension are factors in favour of surgery, if the general condition of the patient allows the operation. Patients with aneurysms < 5 cm maximal diameter, tube-size aneurysms, heavy calcification of the aortic wall, concentric thrombi within the aneurysmal sac and significant cardiopulmonary risks should be treated conservatively. Patients in good general condition with aneurysms around 5 cm maximal diameter should be controlled by computed tomography in 6 to 12 months intervals and in the case of progression surgery can be recommended despite missing symptoms. Crawford developed the 'graft-inclusion-technique', which combines the 'ingraft'-technique with reattachment of renal, visceral and segmental arteries. The 'clamp and repair' principle is used in patients with sufficient cardiac function. Otherwise shunt or left sided heart bypass are used to reduce cardiac afterload. According to the literature local cooling (flush perfusion), cytoprotective drugs and numerous methods to maintain or ameliorate distal aortic perfusion during clamping ischemia have been used in patients successfully for prevention of ischemic spinal complications. In physiological settings these methods may prove valuable, but under pathophysiological conditions of TAAA-repair one must doubt the efficacy, because the individual risk is difficult to assess. In our hands flush perfusion and cooling of the kidneys proved to be helpful. In animal experiments we have shown prolongation of ischemia tolerance time using eicosanoides to protect the kidneys and the spinal cord. If shunt or left-sided heart bypass can protect the spinal cord during clamping, is unknown, because the risk of paraplegia in the individual patient can be known only, if the function of the spinal cord is monitored. We have developed a spinal neuromonitoring system and found, that only one third of all TAAA-patients is at high risk to develop paraplegia during aortic clamping. The surgeon is guided by continuous recording of spinal evoked somatosensory potentials and can adapt the operative technique by early reimplantation and eventually subsequent separate reimplantation of segmental arteries supplying blood to the spinal cord, in order to reduce spinal ischemia time. Our results in 260 TAAA-patients are presented. In a high-risk population of patients with aneurysms type I-III (Crawford's classification) it was possible, to reduce the paraplegia rate from 7 to 3.5%, the risk of paraparesis from 15 to 6%, while the operative mortality was only reduced from 19 to 10%.