Local compression of the sciatic nerve by a vascular malformation as a rare cause of sciatica: A case report and review of literature.

Background: Sciatica is typically caused by disc herniations or spinal stenosis. Extraspinal compression of the sciatic nerve is less frequent. Case Description: We report a rare case of sciatica with compression of the sciatic nerve by a low-flow vascular malformation in a 24-year-old female patient. The special feature of this case was sciatica along the S1 dermatome, which only occurred in the sitting position and inclination because of compression of the sciatic nerve between the vascular malformation and the lesser trochanter. Spinal imaging showed no abnormal findings. Surgery was performed interdisciplinary and included neurosurgery, vascular surgery, and trauma surgery. After surgery, the patient became symptom-free. Conclusion: Rare and extraspinal causes of local compression of the sciatic nerve should be considered, especially in cases of lacking spinal imaging correlation and untypical clinical presentation. Interdisciplinary surgical cooperation is of special value in cases of rare entities and uncommon locations.

Short and long-term outcome after common femoral artery hybrid procedure in patients with intermittent claudication and chronic limb threatening ischemia.

Background: This study aimed to evaluate the differences between the outcomes of patients with intermittent claudication (IC) and chronic limb threatening ischemia (CLTI) who underwent a hybrid procedure comprising common femoral artery endarterectomy and endovascular therapy. Patients and methods: This was a retrospective single-center study of all patients with peripheral arterial occlusive disease (PAD) who underwent the hybrid procedure between March 2007 and August 2018. The primary endpoint was primary patency after 7 years. The secondary endpoints were primary-assisted patency, secondary patency, limb salvage, and survival. Results: During the follow-up period, 427 limbs in 409 patients were treated. A total of 267 and 160 patients presented with clinical signs of IC and CLTI, respectively. The 30-day mortality was 1.4% (IC: 0% vs. CLTI: 3.8%, p=0.001). The overall 30-day major amputation rate was 1.6% (IC: 0% vs. CLTI: 4.4, p=0.001). The rates of primary and secondary patency after 7 years were 63% and 94%, respectively, in the IC group and 57% and 88%, respectively, in the CLTI group; the difference was not significant. Limb salvage (94% vs. 82%, p=0.000) and survival (58% vs. 29%, p=0.000) were significantly higher in the IC group. In a multivariate analysis, CLTI was the only risk factor for major amputation. CLTI and single vessel run-off were risk factors for death. Statin therapy was a protective factor. Conclusions: The hybrid procedure provides excellent results as a treatment option for multilevel lesions in patients with PAD. However, patients with CLTI had a shorter long-term survival and lower limb salvage rate.

Long-Term Outcome of Common Femoral Artery Endarterectomy In Octogenarians and Non-Octogenarians.

OBJECTIVE: Arteriosclerotic disease of the common femoral artery can be treated by surgical or endovascular intervention. Elderly patients are said to have a worse outcome if treated by surgical means; however, data to support this theory are missing. METHODS: Retrospective analysis of all patients who underwent common femoral artery endarterectomy between March 2007 and July 2018 in our clinic. Group 1 included all patients <80 years and Group 2 included all patients ⩾80 years. Endpoints were patency rates, limb salvage, and overall survival. RESULTS: During this time period, 977 common femoral artery endarterectomies were performed. Indication was claudication in 61.5% and critical limb ischemia in 38.5%. Group 1 included 805 cases (82.4%) and Group 2 included 172 cases (17.6%). Thirty-day mortality was 2.7% (Group 1 = 1.6% versus Group 2 = 7.6%; p < 0.001) and 30-day major amputation was 1.1% (Group 1 = 0.7% versus Group 2 = 2.9%; p = .043). Primary patency and secondary patency were 84.2% and 96.8%, respectively, after 7 years. Limb salvage (93.7%, Group 1 = 94.1% versus Group 2 = 91.8%; p = .088) and overall survival (52.0%, Group 1 = 59.1% versus Group 2 = 15.7%; p = .006) were significantly different after the same time period. Multivariable analysis showed female gender to be a risk factor for loss of primary patency. Age ⩾ 80 years and ulcer or gangrene were risk factors for death. Statin use was beneficial to survival. CONCLUSIONS: Common femoral artery endarterectomy is a safe procedure with excellent long-term results. Octogenarians have an increased risk for perioperative mortality and major amputation.

Improved stability of steerable sheath access by femoro-femoral crossover wire in branched stent graft repair of complex thoraco-abdominal aortic aneurysms.

PURPOSE: The purpose of this study was to describe a technique to catheterize antegrade branches of a branched aortic endograft by using a steerable sheath stabilized by a through-and-through wire via a femoral access. TECHNIQUE: After implantation of a branched endovascular graft, a steerable 8.5 F sheath is advanced from the femoral access. After placing the sheath proximal to the branches, a 0.014″ through-and-through wire is established to the contralateral femoral access which is held under slight traction after the curved tip of the sheath is brought into the 180° position. Then catheterization, wire exchange and deployment of the bridging stent is done in standard fashion. CONCLUSION: The use of a through-and-through wire with a steerable sheath for retrograde femoral access adds stability and precision to this technique. It has the potential to reduce the risk of preoperative stroke in complex aortic endovascular repair by avoiding upper extremity access.

Treatment of Lymphatic Complications after Common Femoral Artery Endarterectomy.

BACKGROUND: This study analyzes the outcome of lymphatic complications after a standard vascular procedure. METHODS: This is a retrospective study including patients who had a lymphatic complication after endarterectomy and patch of the common femoral artery in our clinic between March 2007 and June 2018. Therapy of choice was selected according to wound situation and amount of lymphatic liquid. If signs of a wound infection occurred, a surgical therapy was performed; in all other cases a nonsurgical treatment (conservative treatment, radiotherapy) was chosen. RESULTS: We performed 977 index operations, a lymphatic complication occurred in 112 cases (11.5%). In 69 cases the lymphatic complication presented as lymphatic fistula (Group 1), in 43 cases as lymphorrhea from the wound (Group 2). Nonsurgical treatment was done in 66 cases (Group 1: 76.8% vs. Group 2: 30.2%; P < 0.000), and a surgical treatment was necessary in 46 cases (Group 1: 23.2% vs. Group 2: 69.8%; P < 0.000). Indication for surgery was Szilagyi 1 infection in 25 cases, Szilagyi 2 infection in 11 cases, and Szilagyi 3 infection in 10 cases. Patients with Szilagyi 1 infections received negative wound pressure therapy (NWPT). A muscle flap in combination with an NWPT was performed in patients with Szilagyi 2 infections. In Szilagyi 3 infections, the patch was replaced; additionally, a muscle flap and an NWPT were performed. The median hospital stay was 13 days in the nonsurgical group and 22.5 days in the surgical group. We had no bleeding complications and no reinfection during follow-up. The median observation period was 23.0 months. Age ≥80 years was associated with an increased risk for lymphatic complications. CONCLUSIONS: The therapy of lymphatic complications should be done in accordance with clinical symptoms. A nonsurgical treatment is often sufficient. However, in cases of a wound infection different surgical treatments are necessary.

Results of hybrid procedures for treatment of aortoiliac Trans-Atlantic Inter-Society Consensus II D lesions with self-expanding covered heparin-bonded stent grafts.

BACKGROUND: According to the guidelines aortoiliac TASC D lesions should be treated by bypass. The purpose of this study was to examine the results of hybrid procedures with the use of a self-expanding covered heparin-bonded stent graft (Viabahn) in patients with extensive aorto-iliac lesions who were not considered to be suitable for open aorto-iliac surgery. METHODS: All patients who received a hybrid procedure in combination with a Viabahn stent in our clinic to treat aortoiliac lesions between October 2011 and April 2017 were included in this retrospective analysis. Study endpoints were primary patency, amputation-free survival (AFS) and major adverse limb event (MALE) free survival after 2 years. RESULTS: We included 23 hybrid procedures (endarterectomy of the common femoral artery or cross over bypass and aortoiliac stent) in 20 patients (median age 59 years). Indication was critical limb ischemia in 70.0%. The reasons why patients were on high risk for alternative open aortoiliac revascularization were hostile abdomen in 35.0%, cardiopulmonary contraindications in 35%, cancer in 10.0%, age >80 years in 10.0% and alcoholic cirrhosis in 10.0%. The 30-day mortality was 15.0%, the major amputation rate was 4.3%. We had no early graft occlusion. After 2 years primary patency was 100%, AFS 58.2% and MALE free survival 95.7%. CONCLUSIONS: A hybrid procedure with the use of a Viabahn stent in severe aortoiliac pathologies showed good patency results in this selected patient group. Therefore, it should be considered a feasible alternative to aortoiliac bypass surgery in surgical high-risk patients.

Remote iliac artery endarterectomy with selective stent use at the proximal dissection zone in TransAtlantic Inter-Society Consensus C and D lesions.

BACKGROUND: Remote iliac artery endarterectomy (RIAE) is a challenging technique in the treatment of arterial occlusive disease. The impact of proximal transection zone stenting on patency rates is still unclear. METHODS: This is a retrospective analysis of all patients who underwent RIAE in our hospital between March 2007 and October 2017. A stent was used in cases with a dissection flap or a stenosis at the proximal transection zone after RIAE. In all other cases, we did not use a stent. Study end points were patency rates, limb salvage, and survival after 5 years. RESULTS: There were 115 RIAEs performed in 108 patients. All lesions were TransAtlantic Inter-Society Consensus C (61.7%) or D (38.3%) lesions. The median follow-up time was 38.5 months (range, 0-117 months). The indications were claudication in 67.0% and critical limb ischemia in 33.0%. Group 1 (n = 56) included all patients without a stent; group 2 (n = 59) included all patients with stenting of the proximal dissection zone. Risk factors were similar between the groups. The 30-day morbidity and mortality rates between the groups were not significantly different. The primary patency rate was 81.6% (group 1, 76.2%; group 2, 87.6%; P = .286), the primary assisted patency rate was 91.9% (group 1, 94.0%; group 2, 90.0%; P = .512), and the secondary patency rate was 93.8% (group 1, 94.0%; group 2, 91.6%; P = .435) after 5 years. Limb salvage (97.2%; group 1, 100%; group 2, 94.5%; P = .084) and survival time (57.1%; group 1, 66.7%; group 2, 43.5%; P = .170) were also not significantly different between the groups. A restenosis at the transection zone occurred in 14.3% in group 1 and 1.7% in group 2 (P = .013) during follow-up. A newly formed occlusion of the hypogastric artery was seen in 5.2% of patients after RIAE. CONCLUSIONS: RIAE is a safe procedure with excellent patency rates. However, the restenosis rate is higher in cases without stenting.

[Management of Endograft Infection After EVAR and TEVAR - a Case Series and Literature Review]. / Management von Stentprotheseninfektionen nach EVAR und TEVAR ­ Fallserie und Literaturübersicht.

Introduction Endograft infection after EVAR (Endovascular aortic repair) or TEVAR (Thoracic endovascular aortic repair) is a rare but severe complication with high mortality. As the number of patients with endovascular aneurysm repair has increased over the last decade, the number of patients with endograft infection might also have increased. However, no guideline defines the treatment of endograft infection. Diagnosis is difficult and depends on clinical symptoms, radiological imaging and blood cultures. Surgery with graft excision, debridement and revascularisation should be proposed. Several techniques and graft materials are used. Additionally long term antibiotic therapy under close control of inflammation markers is always required. Methods We conducted a retrospective analysis of all patients treated for infected aortic endografts in our hospital between January 2008 and May 2017. Study endpoints were freedom from reinfection, survival and primary patency. An extensive electronic health database search was performed to identify articles reporting endograft infection after EVAR and TEVAR. Results We detected aortic endograft infection in three patients (100% male, median age 77 years). In all cases, infrarenal endovascular aortic aneurysm repair had been performed. The infected stent grafts were removed and anatomical revascularisation performed. One homograft and two xenografts were used as graft material. No patient was treated conservatively. A causative organism was found in 2 of the 3 cases. The patients received antibiotics for 12 weeks. Thirty day mortality was 0%. During follow-up, one patient died from bowel perforation after 2 months and another from lung cancer after 92 months. There were no reinfections. Primary patency of the reconstructions was 100%. Publications report high mortality after conservative therapy of endograft infection. There is evidence for lower mortality in patients who underwent surgery. Conclusions Removal of the infected graft, anatomical revascularisation and antibiotic therapy are important for long term survival after aortic endograft infection. Conservative therapy is only warranted in patients unsuitable for surgical treatment.

Noninfectious aortitis: what the cardiologist needs to know.

PURPOSE OF REVIEW: To sum up a group of noninfectious inflammatory diseases of the aorta and its branches relevant to a cardiologist's daily routine. To describe pathogenetic and clinical advances as well as modern diagnostic tools. To overview most recent treatment options and patient-tailored therapies. To provide an insight in future directions of research. RECENT FINDINGS: Pathophysiology of large vessel vasculitides (LVV) are still poorly defined. At least a certain number of patients with idiopathic periaortitis seem to part of the group of IgG4-related diseases which has implications for therapy. Modern diagnostic modalities as Positron-Emission-Tomography (PET)-computed tomography and PET-magnetic resonance tomography proof to be helpful to diagnose or excluded LVV and emerge as long-term surveillance tool. Biological therapy yields varying results but is reported to be important for patients nonresponding or relapsing under glucocorticoid therapy. SUMMARY: Owing to the multifactorial pathogenesis and the small number of cases of LVV further interdisciplinary efforts are necessary to elucidate the pathogenesis of this group of diseases. Technical progress in radiology and nuclear medicine supports clinical, histological, and laboratory findings to increase diagnostic precision. There are several therapies emerging that may have the potential to support patient-tailored treatment approaches in glucocorticoid refractory or relapsing disease.

Biosynthetic Grafts To Replace Infected Prosthetic Vascular Bypasses: A Single-Center Experience.

BACKGROUND: There are only a few options to replace infected infrainguinal synthetic vascular grafts in the absence of suitable autologous veins. To use a biosynthetic vascular graft (Omniflow®II) might be a valuable alternative. METHODS: We retrospectively analyzed the clinical course of 29 patients who underwent replacement of an infected infrainguinal vascular prosthesis (Szilagyi 3) by an Omniflow®II graft. RESULTS: Because of the lack of suitable autologous veins, 15 above-knee femoro-popliteal, 5 below-knee femoro-popliteal, and 9 femoro-tibial bypasses were replaced with biosynthetic grafts. There were no in-hospital deaths, reinfections, or major amputations. The survival rate was 92% at one year and 87% at two years. During follow-up (median 24 months; range 5-66 months), no reinfections occurred. However, nine patients presented with bypass occlusions (primary patency 67.6% at one year and 61.5% at two years; secondary patency 85.3% at one year and 69% at two years). The limb salvage rate was 89% at one year and 83% at two years. CONCLUSION: Biosynthetic bypass grafts might be valuable to replace infected prosthetic grafts in the absence of a suitable vein. They have excellent re-infection resistance. Limb salvage, morbidity, and the mortality rate are similar to those obtained with autologous vein grafts in infected fields.

"En bloc" caudate lobe and inferior vena cava resection following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal and liver metastasis of colorectal cancer.

There are diverse protocols to manage patients with recurrent disease after primary cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis. We describe a case of metachronous liver metastasis after CRS and HIPEC for colorectal cancer, successfully treated with a selective metastectomy and partial graft of the inferior vena cava. A 35-year-old female presented with a large tumour in the cecum and consequent colonic stenosis. After an emergency right colectomy, the patient received adjuvant chemotherapy. One year later she was diagnosed with peritoneal carcinomatosis, and it was decided to carry out a CRS/HIPEC. After 2 years of total remission, an isolated metachronous liver metastasis was detected by magnetic resonance imaging surveillance. The patient underwent a third procedure including a caudate lobe and partial inferior vena cava resection with a prosthetic graft interposition, achieving an R0 situation. The postoperative course was uneventful and the patient was discharged on postoperative day 17 after the liver resection. At 18-mo follow-up after the liver resection the patient remained free of recurrence. In selected patients, the option of re-operation due to recurrent disease should be discussed. Even liver resection of a metachronous metastasis and an extended vascular resection are acceptable after CRS/HIPEC and can be considered as a potential treatment option to remove all macroscopic lesions.

Tibial and peroneal bypasses in octogenarians and nonoctogenarians with critical limb ischemia.

BACKGROUND: Elderly patients with critical limb ischemia are increasingly treated through interventional therapy. The outcome of tibial and peroneal bypasses in octogenarians who were unsuitable for endovascular therapy remains unclear. METHODS: We conducted a retrospective analysis of all patients who underwent tibial or peroneal bypass surgery in our clinic between October 2007 and April 2015. In Group 1 we included all patients 80 years and older and in group 2 all patients under 80 years. Vein was used whenever possible (diameter not less than 3 mm, not more than two segments for sufficient length). Study end points were primary and secondary patency, limb salvage and survival after 3 years. RESULTS: Indications were rest pain in 32.2% and ulcer and gangrene in 67.8%. There were 92 cases in Group 1 (median age, 85 years) and 178 in group 2 (median age, 70 years). Risk factors and indications were similar in both groups except for gender, renal insufficiency and smoking. 30-day mortality was 9.7% in group 1 and 1.1% in group 2 (P = .001). There was no significant difference in 30-day graft failure and major amputation. At 3 years primary patency in group 1 was 58.9% vs 49.7% (P = .058), secondary patency was 73.0% vs 54.7% (P = .007). Limb salvage was 80.1% in group 1 vs 73.0% in group 2 (P = .446), survival was 44.0% vs 71.2% (P = .000). CONCLUSIONS: Our analysis showed good results in octogenarians undergoing tibial and peroneal bypass surgery with regard to patency rates and limb salvage. However, octogenarians had a significantly higher perioperative mortality rate.

The influence of continuous local wound infusion on postoperative pain in patients undergoing transfemoral amputation.

BACKGROUND: This pilot study was set up to examine the effects of a continuous postoperative wound infusion system with a local anaesthetic on perioperative pain and the consumption of analgesics. PATIENTS AND METHODS: We included 42 patients in this prospective observational pilot study. Patients were divided into two groups. One group was treated in accordance with the WHO standard pain management protocol and in addition to that received a continuous local wound infusion treatment (Group 1). Group 2 was treated with analgesics in accordance with the WHO standard pain management protocol, exclusively. RESULTS: The study demonstrated a significantly reduced postoperative VAS score for stump pain in Group 1 for the first 5 days. Furthermore, the intake of opiates was significantly reduced in Group 1 (day 1, Group 1: 42.1 vs. Group 2: 73.5, p = 0.010; day 2, Group 1: 27.7 vs. Group 2: 52.5, p = 0.012; day 3, Group 1: 23.9 vs. Group 2: 53.5, p = 0.002; day 4, Group 1: 15.7 vs. Group 2: 48.3, p = 0.003; day 5, Group 1 13.3 vs. Group 2: 49.9, p = 0.001). There were no significant differences between the two groups, neither in phantom pain intensity at discharge nor postoperative complications and death. CONCLUSIONS: Continuous postoperative wound infusion with a local anaesthetic in combination with a standard pain management protocol can reduce both stump pain and opiate intake in patients who have undergone transfemoral amputation. Phantom pain was not significantly affected.

Retrograde thrombendarterectomy vs. ilio-femoral bypass in unilateral iliac TASC C and D lesions.

BACKGROUND: To compare short and long term results of retrograde Thrombendarterectomy (rTEA) and ilio-femoral Bypass (IFBP) to treat iliac TASC C and D lesions. PATIENTS AND METHODS: Retrospective analysis of 108 patients treated at a single vascular center by either rTEA (n = 42) or IFBP (n = 66) over a period of 4 years. RESULTS: Both methods did not significantly differ in 30-day (rTEA 0 % vs IFBP 2 %) or long-term mortality (rTEA 24 % vs IFBP 30 % at 4 years) with a median follow-up of 46 months. There were no procedure related deaths. Patency was similar for both groups (rTEA 93 % vs IFBP 98 % at 30 days; rTEA 83 % vs 92 % IFBP at 4 years). We could not find a significant difference in limb salvage rates (rTEA 93 % vs IFBP 100 % at 30 days and at 4 years). The incidence of prolonged lymphorrhea was significantly higher in the IFBP group (rTEA 0 % vs IFBP 21 %). In 4 IFBP patients a prosthetic graft infection occurred. CONCLUSIONS: Regarding short and long term results operative procedures as rTEA and IFBP still represent the gold standard in the treatment of TASC C and D lesions of the external iliac artery especially in patients with additional lesions in the common femoral and profundal femoral artery. Taking into account certain anatomical characteristics (heavily calcified lesions, narrow external iliac arteries or very tortuous iliac segments) and individual local conditions (prior vascular procedures involving the femoral bifurcation) the single incision retrograde approach to the EIA with rTEA may have advantages over IFBP, especially concerning postoperative complications like lymphorrhea and graft infection.

Comparison of venous and HePTFE tibial and peroneal bypasses in critical limb ischemia patients unsuitable for endovascular revascularization.

BACKGROUND: We examined short- and long-term outcomes of tibial and peroneal venous and heparin-bonded expanded polytetrafluoroethylene bypasses in patients with critical limb ischemia who were unsuitable for endovascular revascularization. METHODS: A retrospective analysis was done for all patients who underwent tibial and peroneal bypass surgery in our department between October 2007 and October 2012. Vein was the preferred graft material and used whenever possible. RESULTS: One hundred and ninety-eight crural grafts were included. Indications for the surgery were rest pain (30.3%) or ulcer or gangrene (69.7%). Autologous veins were used in 109 cases (vein group) and heparin-bonded expanded polytetrafluoroethylene grafts were used in 89 cases (heparin-bonded expanded polytetrafluoroethylene group). At three years, primary patency for the vein group was 68.2% versus 34.1% for the heparin-bonded expanded polytetrafluoroethylene group (P = .000) and secondary patency was 69.8% versus 35.5% (P = .001). Limb salvage was 81.8% for the vein group versus 56.5% for the heparin-bonded expanded polytetrafluoroethylene group (P = .000) and survival was 62.8% versus 46.7% (P = .019). CONCLUSIONS: The results of our study show that autologous vein grafts are still first choice for tibial and peroneal bypasses in patients with critical limb ischemia. If no adequate vein is available, heparin-bonded expanded polytetrafluoroethylene bypasses are an acceptable alternative to an otherwise impending major amputation.

Pedal bypass surgery after crural endovascular intervention.

BACKGROUND: Many centers choose endovascular intervention as their first-line treatment for crural occlusions in patients with critical limb ischemia (Rutherford 4-6). However, unsuccessful interventions often result in major amputation. Therefore, pedal bypass surgery should be considered as an alternative first-line treatment. We reviewed the impact of a prior endovascular intervention on the outcome of our patients' pedal bypass procedures. METHODS: A retrospective analysis was conducted for all patients who had undergone pedal bypass surgery in our department from February 2008 to October 2012. We performed 75 pedal bypass operations in 71 patients (male, 54; female, 17; median age, 72 years; range, 29-90 years). In 36 of those cases, patients had undergone a prior infrapopliteal endovascular intervention (PEI group). In 39 cases, patients underwent bypass surgery as first-line treatment because their prior angiography had resulted in either unsuccessful endovascular intervention, or intervention had been deemed 'not feasible' (BSF group). Only autologous vein grafts were used, and no retrograde intervention was done via the pedal arteries. Endpoints of the analysis were primary and secondary patency rates, mortality, and limb salvage at 1 year postoperatively. RESULTS: Overall primary patency at 1 year was 58.3%, and secondary patency was 61.3%. Limb salvage was 76.8% and survival was 80.4%. Graft occlusion within 30 days was 18.7%. Revision in those cases was futile and 78.6% of patients had to undergo major amputation. Primary patency at 1 year was 67.0% in PEI group vs 48.3% in BSF group (P = .409) and secondary patency was 73.5% vs 48.6% (P = .100). Prior endovascular intervention had no significant impact on either limb salvage (82.3% vs 71.6% at 1 year; P = .515) or graft occlusions within 30 days (19.4% vs 17.9%; P = .547). Survival rate at 1 year was 79.5% in PEI group and 81.3% in BSF group (P = .765). Risk factors and indications were similar in both groups. CONCLUSIONS: Crural endovascular intervention does not seem to have a negative impact on the outcome of subsequent pedal bypass surgery. Requirements are avoiding a destruction of the target vessel and opting for timely bypass surgery whenever endovascular treatment does not achieve a sufficient perfusion for wounds to heal. Early graft occlusions are associated with a higher risk for major amputation.

Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift?

PURPOSE: To review the literature reporting open surgical and endovascular treatment of juxtarenal aortic aneurysm (JAA). METHODS: A systematic search of the PubMed database was carried out to identify English-language articles published between January 2001 and July 2012 on the management of JAA with open surgery, fenestrated endovascular aneurysm repair (F-EVAR), and the chimney graft technique (Ch-EVAR). The search found 20 studies with a total of 1725 patients (76% men; age range 66-74 years) undergoing open surgery, 10 studies detailing 931 patients (87.6% men; age range 72-75 years) receiving F-EVAR, and 5 studies comprising 94 patients (75% men; age range 68-82) reporting Ch-EVAR. RESULTS: A total of 2465 vessels were targeted with fenestrations and 151 with chimney grafts (CG); intraoperative target vessel preservation was 98.6% and 98.0%, respectively. Cumulative 30-day mortality was 3.4%, 2.4%, and 5.3% for open surgery, F-EVAR and Ch-EVAR, respectively (p=NS). Impaired renal function was noted in 18.5%, 9.8%, and 12% following open surgery, F-EVAR, and Ch-EVAR, respectively (open vs. F-EVAR: p<0.001). New-onset dialysis was required postoperatively in 3.9%, 1.5%, and 2.1%, respectively (open vs. F-EVAR: p<0.001). Postoperative cardiac complications were noted in 11.3%, 3.7%, and 7.4%, respectively (open vs. F-EVAR: p<0.001). The incidence of ischemic stroke was 0.1% and 0.3% following open surgery and F-EVAR, but 3.2% after Ch-EVAR (open vs. Ch-EVAR: p=0.002; F-EVAR vs. Ch-EVAR: p=0.012). Early proximal type I endoleak was lower after F-EVAR compared to Ch-EVAR (4.3% vs. 10%, respectively, p=0.002). CONCLUSION: Open surgery remains a safe and effective treatment option for good risk patients with JAA. F-EVAR is associated with low operative mortality, compares favorably to open surgery in terms of morbidity, and current midterm data indicate that it can be a valid treatment option in both low- and high-risk patients. Early results of Ch-EVAR demonstrate feasibility only. In view of the limited number of reports and the lack of long-term data, the technique should be considered only in acute poor surgical risk patients, as a bailout in case of unintentional renal artery coverage, or in elective poor surgical cases that are not suitable for F-EVAR.

Use of biosynthetic prosthesis (Omniflow II®) to replace infected infrainguinal prosthetic grafts--first results.

BACKGROUND: The current treatment standard of infected infrainguinal prosthetic vascular grafts includes total graft explantation and autologous vascular reconstruction. In the absence of appropriate autologous venous graft material prosthetic grafts with increased bacterial resistance can be used, whereas reinfection rates are still higher than after autologous reconstruction. Biosynthetic grafts have shown low postoperative infection rates when used as elective bypass material. Their higher resistance to bacterial infection could make them an alternative to replace infected prosthetic grafts in the absence of autologous material. PATIENTS AND METHODS: Between November 2009 and April 2011, 7 patients with infected infrainguinal prosthetic grafts (Szilagyi 3; 3 supragenicular and 4 infragenicular reconstructions) presented to our institution. There were 4 early (< 3 months after implantation) and 3 late infections (> 3 months after implantation. All grafts were explanted and replaced by biosynthetic grafts (Omniflow II®), because the patient had no suitable peripheral vein for complete autologous replacement. In 2 cases a composite graft with greater saphenous vein was done. In 6 cases microbiological cultures from intraoperatively obtained species were positive. The initial broad spectrum antibiotic therapy was continued according to the antibiogram for 6 to 12 weeks. RESULTS: There was no early or late reinfection during follow up (mean 9 months, range 4 - 20 months). During follow up we observed graft occlusions in 3 patients (1 due to kinking of the bypass, 1 due to progressive artheriosclerotic occlusion of the outflow vessels and 1 iatrogenic by external compression with a pressure cuff during arthroscopy). There were no early or late major amputations. One patient died with pneumonia 11 months postoperatively. CONCLUSIONS: In the absence of appropriate autologous material biosynthetic grafts seem to be a possible alternative to replace infected infrainguinal grafts. The different mechanical properties of biosynthetic grafts may be of certain disadvantage in infragenicular reconstructions.