Treatment of patients with peripheral arterial occlusive disease Fontaine stage IV with intravenous iloprost and PGE1: a randomized open controlled study.

In a randomized open controlled study the clinical effects and tolerability of prostaglandin E1 (PGE1) and the stable prostacyclin (PGI2) analogue, iloprost in the management of diabetic and non-diabetic patients with advanced peripheral arterial occlusive disease (PAOD Fontaine stage IV) were compared. 267 patients were enrolled in this multicentre study and treated for 21-28 days, either by daily infusions of 6 h with iloprost or 2 x 2 h with PGE1. At the end of treatment patients were assessed for evidence of improvement of trophic lesions, relief of rest pain and change of global clinical status. 228 patients were considered as evaluable for efficacy analysis, which revealed 52.7% responders in the iloprost group and 43.1% for PGE1 (p = 0.148). Whereas iloprost showed similar effects in diabetics and non-diabetics (53.3% and 51.4% response rates, respectively), the diabetics treated with PGE1 had a considerably poorer outcome (36.6% versus 53.3%). At 6 months follow-up 62.2% of patients in both groups were alive with a viable limb. Slightly more iloprost patients underwent major amputation (32.1% versus 27.2%), but the number of deaths was reduced by 50% in the iloprost group compared to the PGE1 group (7.5% versus 14.6%, p = 0.10). Side-effects such as headache, flushing and gastrointestinal symptoms were significantly more common in the iloprost group (73.9%) than in the PGE1 group (31.0%), particularly during the first 3 days of dose titration. No specific toxic or unexpected reactions were reported in either group.

[Ablation of venous valves with Nd-Yag laser--an alternative to conventional valvulotomy?]. / Venenklappenablatio mit Nd-Yag Laser--eine Alternative zur konventionellen Valvulotomie?

The careful removal of venous valves during in situ venous bypass procedures is a problem that has not been completely solved. In this experimental study, valve ablation with the Nd-Yag laser was compared with conventional valvulotomy. The investigation was performed in vitro using human vein segments with a length of 20 cm. Conventional valvulotomy was performed 16 times, 20 valves were removed with a 400 mu-fibre and 26 with the hot tip. The results were evaluated by endoscopy, light and electron microscopy. There were no vein perforations with the valvulotome and the hot tip. Endothelial damage was documented in 85% with the valvulotome and was reduced significantly to 58% with the 400 mu-fibre. With the hot tip endothelial lesions were seen in only 30%. Valve remnants were always present with the valvulotome and in no more than 15% with the hot tip. Electron microscopy supported these results in general. There was no endothelial damage in 69%.

Angioscope-guided neodymium yttrium-aluminium-garnet laser valvulotomy for in situ vein bypass.

Valvulotomy for in situ vein bypass is commonly performed with a valvulotome. Although the procedure can be controlled through an angioscope, the dangers of intimal damage and valve remnants remain. An experimental study was designed to evaluate angioscopic laser valvulotomy compared with standard mechanical valvulotomy (n = 16). Two different laser probes, a bare 400-microns fibre (n = 20) and a 2-mm hot-tip (n = 26) were tested. Results were investigated by histology and scanning electron microscopy. Hot-tip laser valvulotomy achieved significantly better results than the 400-microns fibre. The Insitucat valvulotome yielded the worst results, with valve remnants in all cases and an 88 per cent rate of intimal damage. It is concluded that laser valvulotomy can be performed simply and safely with a very low incidence of valve remnants and intimal damage.

[Results of vascular surgery treatment of vertebrobasilar insufficiency]. / Ergebnisse gefässchirurgischer Therapie bei vertebrobasilärer Insuffizienz.

A retrospective analysis of the data of 64 patients with vertebral-basilar insufficiency is presented who were operated between 1980 to 1919 in our institution. Surgery for vertebral-basilar insufficiency comprises only 5.2% of all 1422 supra-aortic reconstructions performed during this period. The leading symptom was vertigo which was present in 41%. Disturbances of vision occurred in 9.8%. 29 bypass procedures and 35 arterial transpositions were performed. A mean follow up of 5.1 years revealed a patency rate of 83.3% in bypass procedures, 92.8% in subclavian transpositions and 100% in vertebral artery transpositions. These good haemodynamic results correlated with marked improvement of the clinical symptoms in 80% of the patients.

[Diagnosis and treatment of visceral and renal embolisms]. / Diagnostik und Behandlung von viszeralen und renalen Embolien.

UNLABELLED: In surgical practice, about 15% of all emboli are visceral emboli. Diagnosis is frequently delayed or established at autopsy. ETIOLOGY: The most common cause are atrial arrhythmias with intraatrial thrombus formation, less frequently, ventricular thrombus after myocardial infarction or in an aneurysm, emboli from vegetations due to infective endocarditis, from atrial myxomas and, occasionally, from arteriosclerotic plaques, aortic tumors or mural aortic thrombi. Cholesterol embolism: Cholesterol embolism or the multiple cholesterol emboli syndrome (MCES) is of particular importance. There are three large groups of symptoms: a peripheral manifestation with livedo reticularis, renal manifestation with progressive renal failure and visceral manifestation with intestinal bleeding and segmental infarction. The only possibility for treatment is surgical removal of the source of embolization through infrarenal aortic replacement or suprarenal aortic arteriectomy. Renal embolism: Acute traumatic interruption of the renal perfusion in otherwise healthy subjects usually leads to loss of the organ due to the limited ischemia tolerance. On the other hand, the results of renal artery embolectomy can be favorable even after 24 hours of ischemia since, as a rule, embolism does not completely occlude the vascular lumen and, in patients with arteriosclerosis, collateral vessels are usually present. The clinical presentation usually encompasses acute onset of flank or back pain, tenderness to percussion of the kidneys, nausea, vomiting and hematuria. In 25% of the cases, the course of renal embolism is bland. The low specificity of the complaints requires delineation of high-risk patients. At the first level of diagnostics, other causes of the complaints should be ruled out with catheterization of the bladder, ultrasound, intravenous pyelography and computer tomography with intravenous contrast medium.(ABSTRACT TRUNCATED AT 250 WORDS)

[Color duplex sonography of the penis--examination technique and clinical results]. / Farb-Duplexsonographie des Penis--Untersuchungstechnik und klinische Ergebnisse.

40 patients with suspected vasculogenic impotence were examined with color duplex sonography. Penile vascular anatomy was mapped and peak velocity was determined in both cavernosal arteries before and after intracorporeal injection of 15 mg papaverine and 0.5 mg regitine. A peak velocity exceeding 25 cm/sec was considered normal. In 20 patients the results could be compared with internal iliac angiography as the gold standard. In 18 of 20 patients, color duplex sonography and angiography led to identical evaluation of penile blood supply. Two false-negative findings were due to significant lesions of the internal iliac and pudendal artery with extensive collaterals to the penile arteries. One color dulex finding was false positive. Color duplex sonography is a sensitive and non-invasive method for evaluation of arteriogenic impotence. Only angiography, however, can delineate proximal arterial lesions. It remains indispensible if revascularisation is planned.

[Technique and value of digital subtraction angiography in erectile dysfunction]. / Technik und Wertigkeit der DSA bei erektiler Dysfunktion.

Arteriography of penile arterial supply is of decisive importance in the diagnostic evaluation of arteriogenic impotence. Technique and results of penile arteriography by means of high-resolution DSA in 26 impotent men are reported. In comparison to direct serial angiography on large-scale films, high-resolution DSA with 1024(2)-matrix provides the advantages of reduced investigation-time and reduction of contrast media load. Additional detailed views in different projections can be easily obtained. In 15 of 26 patients (mean age 54.9 years) a total of 34 steno-occlusive vessel changes were found (57.7%). 65.4% showed anatomic variations. In all patients, DSA provided clear vascular diagnosis. Thus, additional large-scale serial filming never became necessary. Results are comparable to those reported by other authors. In conclusion, high-resolution DSA can completely replace large-scale serial angiography in the evaluation of penile arterial supply.

[Crural bypass as reoperation]. / Der crurale Bypass als Rezidivoperation.

A retrospective study of 93 patients who have had repeat surgery at the tibial level for critical limb ischemia was carried out. In 21 patients a pseudoocclusion with a patent bypass graft was diagnosed and treated by PTA, thrombendarterectomy, or distal extension of the graft. The 5-year bypass patency was 60%, compared to 38% in those 72 patients that required a new bypass at the tibial level. Vein bypasses were better than prosthetic grafts. The number of previous operations did not negatively influence the outcome. However, the distal anastomosis should be placed on an artery that was not previously thrombectomized or operated on.

[What are the prerequisites for surgery of asymptomatic carotid stenosis?]. / Unter welchen Voraussetzungen dürfen wir asymptomatische Carotisstenosen operieren?

Asymptomatic patients with carotid stenoses exceeding 75% have an elevated ischemic cerebrovascular event rate of 18% per year (5% strokes). Our combined perioperative stroke and death rate (1980-1990: 1123 operations) is 1.85%. Thus prophylactic surgery may be indicated in the following cases: hemodynamically significant stenoses of 75% and more, especially with marginal or reduced autoregulatory reserve, rapidly progressing lesions in medically treated patients, lesions with a high risk of embolization (ulcerations on B-scan), clear interrelation between arterial lesions and positive (asymptomatic) intracranial findings (CT, NMR, TC, USD).

[Rare combination of neurofibromatosis and Dandy-Walker syndrome]. / Uber eine seltene Kombination von Neurofibromatose und Dandy-Walker-Syndrom.

Treatment of patients suffering from neurofibromatosis (NF) is aimed, first of all, at the esthetical and functional impairment caused by neurofibromas of the skin, whereas vascular alterations are only rarely given prime consideration in the choice of treatment alternatives. Thus, the removal of an aneurysmic dilatation of the internal carotid artery and its replacement by interposing an autogenous vein graft in a patient with extensive neurofibromatosis of the right neck region and concurrent Dandy-Walker syndrome is reported. The characteristics of this syndrome and the question of a possible relationship between both clinical entities are discussed.

[Subtotal and total traumatic extremity amputation--when replantation, when amputation?]. / Subtotale und totale traumatische Gliessmassenabtrennung--wann Replantation, wann Amputation?

The major problems besetting replantation of a limb are the very limited tolerance of muscle tissue to ischemia (in our experiences 5 h) and the possibility of severe postischemic complications either in the limb itself (capillary thrombosis, muscle necrosis) or systemically (kidney failure, speticemia). Between 1975 and 1988, 66 limb replantations (57 arms, 9 legs) were carried out. All nine legs had to be reamputated. Forty-five of the 57 reattached upper extremities (80%) healed without any major complications, 60% exhibited good or very good results (Grade II or I, Classification by Chen).

[Functional results following complicated injuries of the extremities--how can they be improved?]. / Funktionsergebnisse nach komplizierten Extremitäten-Traumen--Wie lassen sie sich verbessern?

This study evaluates the critical points in the management of 48 patients with injured arteries of the lower limb between 1980 and 1986. 77% of the traumas were resultant from blunt vehicular traffic mishaps. 13 patients were treated within 6 h, 8 patients later than 6 h, 21 patients later than 24 h post injury. Delays in diagnosis occurred due to lack of or no indication for vascular trauma. Careful physical examination and aggressive use of angiography is essential in improving limb salvage rates, while doppler investigation may lead to improper diagnosis. Overall limb salvage was 69%, however, no reconstruction was possible in 6 cases (13%). 38 of the 42 arterial reconstructions required interposition of venous bypass grafts, four end to end anastomoses. Eleven patients had associated venous injuries, which in nine cases were repaired. Venous ligation in three cases was attributed with increased complication. In three cases ischemia time was shortened by the use of temporary javid shunts for rapid restoration of arterial flow. 50% of the patients were found to require fasciotomy, either pre- or postvascular repair. Early fasciotomy, however was found to be most beneficial. Fractures were treated in 15 cases with the external fixator, in 21 cases with internal fixation. Delayed revascularization after 24 h combined with aggressive debriding of muscle necrosis and the employment of vascularized muscular and skin flaps resulted in a decline in amputation rates and improved functional results.

Duodenal fistula--a rare complication following the removal of an infected aortic graft: case report.

We present a rare case of fistulation from the duodenum into the prosthesis site of an aortic Y graft removed 8 months previously owing to infection. We have verified the topographical and anatomical location of the fistulation by fistula filling and CT and MR examination. To our knowledge such a postoperative complication has not been previously documented. In evaluating and comparing our observation we discuss their significance for topographical associations and prognosis and as an indication for surgical intervention.

[The aortic aneurysm in the magnetic resonance tomogram]. / Das Aortenaneurysma im MR-Tomogramm.

Aortic aneurysms can be visualised in the transverse, sagittal and coronary planes using magnetic resonance (MR) thereby enabling their cranio-caudal distension as well as their breadth and depth to be accurately determined. The important question concerning the vessel exits of the main branches of the aorta and their involvement in the aneurysm can be reliably answered. In the case of dissecting aortic aneurysms, the two lumina as well as the dissected vessel wall can be seen in the image. By choosing suitable recording parameters it is possible to differentiate between flowing blood and a thrombus attached to the vessel wall. The thrombus is recognisable from the decrease it causes in the signal intensity of the T2-selected image, whereas flowing blood emits a stronger signal in the T2-selected image than in the T1-selected image. An indication of the flow behaviour and flow rate of blood can be obtained from the differences in the signal intensity distribution in the vessel lumen.