[Diagnosis and management of peripheral vascular injuries]. / Diagnostik und Management peripherer Gefäßverletzungen.

Peripheral vascular injuries are the cause of high morbidity in trauma patients. Up to 5 % of all patients with injuries of the extremities present with concomitant vascular lesions. While open peripheral vascular injuries are associated with a high mortality at the scene of the accident, closed vascular injuries present the danger of developing critical tissue ischemia with a high risk of amputation and limb loss. Early diagnosis is crucial in order to rapidly restore and maintain adequate blood flow and downstream tissue perfusion. A correct diagnosis and early treatment of peripheral vascular injuries place enormous demands on interdisciplinary teams consisting of emergency physicians, orthopedic surgeons, vascular surgeons, anesthesiologists and radiologists. The top priority in the context of emergency care is hemorrhage control by applying direct pressure and dressings until definitive surgical treatment. Hypovolemic shock, reperfusion injury and compartment syndrome are complications of peripheral vascular injuries that must be recognized and treated in the early stages.

[Does a type  II endoleak occur after surgical elimination of a popliteal artery aneurysm? An Analysis of 42  patients and a comparison with current literature]. / Gibt es das Endoleak Typ II nach operativer Ausschaltung des Poplitealarterienaneurysmas? Analyse von 42  Patienten im Spiegel der aktuellen Literatur.

UNLABELLED: In a clinical follow-up of our therapeutic results for popliteal artery repair, there were 2  recurrences. Angiomorphologically the results could be classified as an endoleak type  II form. METHOD: In a retrospective analysis of 56  popliteal artery aneurysms in our vascular surgery department between September 2000 and 2010, 47  cases underwent surgical and 9  cases endovascular repair. The average age of the patients was 70.2  years (49-88  years); males were in the majority (92.8 %) in comparison to females (7.2 %). In the ambulatory follow-up, 2  patients that had had surgery showed an increase in size of the operated popliteal artery. Duplex sonography, angio-CT scan and selective angiography were used to verify the results. RESULTS: 47  cases were treated with surgical repair. In 42  cases a proximal and distal surgical exclusion with ligation of the aneurysm was performed via a medial approach. In 5  cases a dorsal approach was used for the aneurysmectomy. In the post-operative follow-up period 2  surgically repaired popliteal aneurysms showed persistent reperfusion. In both these cases the medial approach was chosen, leaving the aneurysm in situ. The reperfusion was proved with the help of an angio-CT scan. A selective DSA (Doppler sonography) confirmed the results. Both recurring aneurysms were re-operated firstly due to the increase in size and secondly due to the diagnosis of an imminent rupture. CONCLUSION: The retrospective analysis showed that in the follow-up 2 (3,6 %) primarily repaired popliteal aneurysms had a recurrence with an increase in size. They were both repaired via a medial approach. In both cases the recirculation was diagnosed via the geniculate vessels. According to the endoleak classification of endovascularly repaired aortic aneurysms, the diagnosis is equivalent to an endoleak type  II classification. [nl]The ligation alone, without the occlusion of the geniculate branches, lead to a persistent back flow and reperfusion with increase in size of the aneurysms. The therapeutic option of such recurrences, due to the presence of active genicular recirculation ought to be the occlusion of these vessels that supply the aneurysm. The safest method to prevent such recurrences is without doubt the extirpation, the aneurysmo-endorraphy as well as the proximal and distal ligation, that definitely occludes the genicular vessels. As a rule the duplex sonography examination is advisable to control repaired popliteal aneurysms in situ.

[Surgical and interventional therapeutic possibilities in aneurysms of the subclavian artery]. / Chirurgische und interventionelle Therapiemöglichkeiten von Aneurysmen der Arteria subclavia.

Aneurysms of the subclavian artery are extremely rare and most commonly caused by arteriosclerosis, trauma or thoracic outlet syndrome. Less frequently seen causes also include syphilis, cystic media necrosis or tuberculosis or congenital anomalies. The presence of a subclavian aneurysm can give rise to various symptoms such as a pulsating supraclavicular mass, peripheral embolism or brachial plexus compression. Generally, surgical intervention is undertaken involving ligation and extirpation of the aneurysm followed by interposition of either a saphenous vein- or synthetic vascular graft. Recent diversifications in potential therapeutic strategies include the clinical application of transluminally positioned stents for the treatment of vascular lesions. In the literature review we found more than 260 published cases of surgically treated subclavian aneurysms and additional 17 subclavian aneurysms treated by endoluminal stent application. From 1992-1997 5 subclavian aneurysms were resected in our hospital. In four cases a vein graft of the vena saphena magna and in one case a PTFE graft were used. The sensory ischaemic deficit regressed in the further follow up in four of the five cases. Patency was checked postoperatively by ultrasound sonography, angiography or MR-angiography.

The abdominal aortic fenestration procedure in acute thoraco-abdominal aortic dissection with aortic branch artery ischemia.

OBJECTIVE: Diagnostic work-up and treatment strategies have improved the prognosis of acute thoraco-abdominal aortic dissection. Little attention to aortic branch artery ischemia or even failed restoration following prosthetic repair of thoraco-abdominal dissection still merit a problem with high morbidity and mortality. SETTING: Department of Vascular Surgery, Technische Universität München, Germany. PURPOSE: Reflecting on visceral and neurological ischemic complications in acute thoraco-abdominal aortic dissection indications and limitations of the abdominal-aortic-fenestration procedure are discussed with a review on our own clinical experience and the results reported in the literature. CONCLUSIONS: The abdominal-aortic-fenestration procedure is accomplished with minimal deterioration of the critically ill patient. In new onset or relief of aortic branch ischemia, following initial prosthetic repair of either type A or B dissection aortic fenestration is found to be an effective and secure adjunctive procedure to restore the blood flow of compromised organs. Primary abdominal aortic fenestration is recommended instead of prosthetic repair in cases of acute type B dissection. It is the treatment of choice because of branch artery ischemia becoming the focal point of deterioration.

[Anomaly of the pancreatico-biliary junction and etiology of choledochal cysts]. / Anomalie der pankreatiko-biliären Verbindung und Atiologie der Choledochuszysten.

The etiology of choledochal cysts isn't yet clarified unequivocably. Numerous theories have been worked out. One of them is the 1969 by Babbitt postulated "common-channel"-theory, which is based on an anomaly of the pancreaticobiliary connection. In case of a fusion of ductus choledochus and ductus pancreaticus widely before the papilla of Vater and the formation of a common channel with a minimum length of 15 mm the reflux of pancreatic secretion into the off-leading biliary ducts may occur and choledochal cysts may develop. In order to check up this hypothesis we evaluated retrospectively pictures of a direct cholangiography (ERCP, PTC and/or intraoperative cholangiography) of 26 patients suffering from type I, IV and V ectasias of the biliary ducts according to Todani. We found a common channel with an abnormal length in 8 of 12 patients suffering from extrahepatic ectasias of the biliary duct type I and IV (66%), but we didn't find it in patients with type V intrahepatic ectasias of the biliary duct. This analysis may be recognized as a reference to the truth of the Babbitt-theory.

[Diagnosis and therapy of thymus tumors]. / Diagnostik und Therapie von Thymustumoren.

In this paper we report about the treatment process of thymic tumours. Dominating among our patients are thymomas with lymphocyte predominance (n = 16) followed by epithelioid (n = 8) and spindle cell (n = 2) thymomas. For classification and for estimation of prognosis all thymomas were divided into macroscopical and histological stadiums I-IV. In the long-term process a better survival rate for patients with thymomas with lymphocyte predominance and histological stadium of invasion I was 93% over seven years. The worst results were reached by patients of the infiltration groups III and IV-the survival rate was 50%. By 17 of 26 patients suffering from a thymoma the tumours were associated with myasthenia gravis. Especially frequently we found class IIB and III according to Osserman. The survival rate in this patients was 76.5% (13 patients) in the treatment process. An improvement and stabilization of myasthenia gravis was possible for 13 patients. If the complete removal is limited by the growth of the tumor and by the infiltration rate, the further additional therapy--radiation therapy and polychemotherapy--will help to improve the prognosis.

[Formaldehyde-fixed human varicose vein bioprosthesis with siliconized inner surface for hemodialysis. Clinical analysis of 165 transplants]. / Formaldehydfixierte innenflächensilikonierte Humane-Varizen-Vene (HVV)-Bioprothese zur Hämodialyse. Klinische Analyse von 165 Transplantaten.

With the submitted study of 165 HVV-vessel-transplantations the marking properties like reduced immunogenity, primary athrombogenicity, form fixated vascular lumen, ability for punction, flow reduction and stability for storage were possible to prove. Few complications (thromboses, aneurysms, infections) and also low rate of revision marks the long-term progress of this bioprosthesis. It will be stated with emphasis, that the use of this vascular device is indicated, if the patient's veins for creation of an arteriovenous vascular access is not available. In long-term progress the rate of function is better in comparison with other similar or synthetic materials for prostheses.

[The syndrome of retrograde venous arterialization following arteriovenous vascular anastomoses for hemodialysis]. / Syndrom der retrograden venösen Arterialisation nach arteriovenösen Gefässanschlüssen für die Hämodialyse.

In 9 patients with arterio-venous side-to-end anastomosis on the forearm as vascular access for chronic hemodialysis an uniform symptom complex was observed: retrograde flow of the ectatic vein into the periphery, swelling and pain in this area, partly with trophic skin disorders on the hand. After occlusion of the arterio-venous anastomosis these symptoms could reversed completely with exception of venous dilation.

[Factors influencing the duration of function of arteriovenous vascular anastomoses in hemodialysis]. / Einflüsse auf die Funktionsdauer arterio-venöser Gefässanschlüsse für die Hämodialyse.

The function of an arterio-venous vascular access is influenced by vascular material, hemodynamics, blood coagulation and technique and number of punctures. By careful intraoperative handling, optimal postoperative care and treatment of the vascular access during and after hemodialysis the functional duration may be influenced effectively. The technique of puncture, the puncture cannula and the skill of the "puncture" are of great importance.

[Indications for the Scribner shunt in hemodialysis]. / Indikationen zum Scribner-Shunt für die Hämodialyse.

The indication to a Scribner shunt as vascular access for hemodialysis has been reduced significantly by the use of central-venous catheters and creation of subcutaneous access methods. In 13 patients suffering from septic complications of the central-venous vascular access catheters a Scribner shunt was created for continuation of hemodialysis. After removal of infected catheters and specific antibiotic therapy the sepsis could be controlled in 12 patients within 4-18 days.

[Use of formaldehyde-preserved, silicone-coated inner surface and form-fixed bovine blood vessels as vascular transplants]. / Untersuchungen zum Einsatz formaldehydkonservierter, innenflächensilikonierter und formfixierter boviner Gefässe als Gefässtransplantate.

A total of 114 vascular transplants of formaldehyde-preserved, form-fixed bovine vessels with silicone-coated inner surface were implanted to 113 dialysis patients and to one patient with asthma bronchiale. They were used as arteriovenous bridging grafts for punctures or parts of them and as arterial bridging grafts for repair. Included were A. glutealis in 43 instances as well as A. thoracica interna, V. glutealis and V. thoracica interna in 18 instances, and A. sacralis in 53 cases. Low early-thrombosis rates were recorded from all transplants. Transplants of A. glutealis and A. thoracica interna quite often exhibited spontaneous aneurysmatic enlargement in response to repeated puncturing. Fewer complications were recordable from transplants of A. glutealis, V. thoracica interna and A. sacralis.

[Straight upper arm arteriovenous implants of allogenic vascular transplant material in various hemodynamic conditions]. / Gerade arterio-venöse Interponate am Oberarm aus allogenem Gefässersatzmaterial unter verschiedenen hämodynamischen Bedingungen.

Studies were conducted into the effects of various forms of flow reduction upon both pressure in shunt and functional properties of 134 arteriovenous bridging grafts on the upper arm for haemodialysis of deantigenised, form-fixed, preserved segments of varicose veins with silicone-coated inner surfaces. Strongest pressure reduction and best clinical results were obtained from composite grafts with a short, narrow segment on the inflow side.

[Arteriovenous interposed prostheses in children for dialysis of allogenic, aldehyde preserved, form-fixed veins with silicone-coated inner surfaces]. / Arterio-venöse Interponate bei Kindern für die Dialyse aus allogenen, aldehydkonservierten, formfixierten und innenflächensilikonierten Venen.

Arterio-venous shunts of new allogenic, aldehyde-preserved, form-fixed saphena with silicone-coated inner surfaces were applied to the upper arms of seven children aged between four months and ten years. Two children died of open shunt, and two transplants underwent thrombosis, within a follow-up period of 27 months. The causes of death and thrombosis were in no way related to the transplant material. Infection, aneurysm, and stenosis did not occur.

[Results of treatment of pyogenic liver abscesses]. / Behandlungsergebnisse pyogener Leberabszesse.

In the last 7 years 53 patients with liver abscesses were treated at surgical clinic of Charité. Since November 1982 we treated in 27 cases with solitary and multiloculary liver abscesses by percutaneous drainage of the abscess diameter more than 3 to 4 cm. 12 patients with multiloculary small biliary liver abscesses were treated by antibiotics. The bacteriological examination were performed after CT-supported puncture of the abscess. Seven patients with complicated abscesses could not be healed with CT-drainage. Surgical drainage via laparotomy was necessary. The diagnostic clarification of the dignity is important in every case. The lethality of all treated liver abscesses was 5.6% and the causes of death were the existing basic diseases.