[Management of complications after revascularization due to peripheral arterial occlusive disease : Prophylaxis and consistent adequate therapy after timely diagnostics]. / Management von Komplikationen nach Revaskularisation wegen peripherer arterieller Verschlusskrankheit : Prophylaxe und konsequente adäquate Therapie nach zeitgerechter Diagnostik.

BACKGROUND: Complications are a threat to successful revascularization for treatment of perpheral arterial occlusive disease (PAOD) and must, therefore, be either primarily prevented or effectively treated after having occurred. OBJECTIVES: The aim of this article is to give a survey of possible complications after revascularization for treatment of PAOD and their management. MATERIAL AND METHODS: A systematic literature review was performed in PubMed and Medline. The analysis mainly considered recent publications with a higher level of evidence. RESULTS: Revascularization for treatment of PAOD can basically be performed by an open surgical approach, an endovascular approach or as a combination of both methods (hybrid operation). The spectrum of possible complications varies accordingly. A differentiation can be made between bleeding, ischemic and systemic complications as well as between vascular and non-vascular complications. Optimal management of complications begins with primary prophylaxis and further includes a timely diagnosis and treatment of established complications. The best prophylaxis consists of a high quality of indications and performance of revascularization. CONCLUSION: Optimal management of complications is essential and of utmost importance for successful revascularization to treat PAOD.

[Aneurysms of the abdominal aorta and iliac arteries: paradigm shift - operative therapy, if possible endovascular?]. / Aneurysmen der Bauchaorta und der Beckenarterien: Paradigmenwechsel - operative Therapie, wenn möglich endovaskulär?

BACKGROUND: Therapy of abdominal aortic aneurysms (AAA) is currently based on a high level of evidence. This is not true in the same manner for iliac artery aneurysms (IAA) which are frequently associated with AAAs and occur only rarely as isolated lesions. The therapeutic principles apply in the same way to both aneurysm locations. OBJECTIVES: New findings, improved perioperative care and the rapid development of minimally invasive techniques require a constant update which is the aim of this article concerning the therapy of AAAs and IAAs. MATERIAL AND METHODS: A systematic literature review was performed in PubMed and Medline and priority was given to recent publications with a high level of evidence. RESULTS: Endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) result in a similar long-term survival. The perioperative survival advantage with EVAR persists only during medium-term postoperative courses. The reintervention rate after EVAR is substantially higher compared to OAR. For older patients and those who are considered unfit for OAR the expected benefits from EVAR has not been proven to date. Aneurysmal ruptures after EVAR demonstrate that a life-long surveillance of these patients is necessary. CONCLUSION: Therapy of AAAs and IAAs is increasingly being performed by EVAR. Even the majority of complex aneurysms are amenable to minimally invasive treatment. Nevertheless, indications for OAR continue to exist. Screening for AAAs results in a decrease of aneurysmal ruptures for which EVAR is also gaining importance.

[Aneurysms of the deep femoral artery: a systematic review of literature]. / Aneurysma der A. profunda femoris - Eine systematische Literaturanalyse.

INTRODUCTION: True aneurysms of the deep femoral artery (APFA) are rare and are usually presented as case reports. Recommendations for diagnostics and therapy of APFAs are based on low-level evidence only. The purpose of this paper was to summarise the existing world experience with APFA. MATERIAL/METHODS: On the occasion of our own case a systematic review of the literature was performed for diagnostics and therapy for true APFA. Publications retrieved from PubMed, EMBASE, and the Cochrane Collaboration as well as by hand search from their references were reviewed. RESULTS: From 2002 onwards 25 papers on true APFAs were published in the English and German literature. Apart from two retrospective studies over a longer period of time these were exclusively case reports. A total of 55 true APFAs were reported in 47 patients with a mean age of 63 years. Therapeutic intervention was due to a rupture in 10 cases (18 %). The mean maximal diameter of APFA at presentation was 5.4 cm (2-18 cm). APFAs that were not ruptured presented frequently as a painful pulsatile mass in the groin and thigh. Therapeutic options for APFA included, apart from surgical resection with or without reconstruction of the deep femoral artery, the endovascular repair. DISCUSSION: Symptoms of swelling and pain in the presence of a mass at the proximal thigh should raise the suspicion of an APFA. Surgical therapy should be performed electively in APFAs with a diameter of more than 2 cm or in cases of rapid progression as well as in all symptomatic or ruptured cases. The endovascular approach should be considered as an alternative option in all cases.

Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta--an unusual source of arterial embolism.

INTRODUCTION: Mural thrombus of the thoracic aorta is a rare clinical finding in the absence of aneurysm or atherosclerosis. METHODS: The medical records of all patients diagnosed with a thrombus of a non-aneurysmatic and non-atherosclerotic descending thoracic aorta (NAADTA) and treated by the senior author between 04/1997 and 04/2010 were reviewed. RESULTS: Eight patients with mural thrombus of the NAADTA were identified. Arterial embolism was the main clinical finding in all cases and involved the lower extremities (n = 6), mesenteric (n = 3) or renal arteries (n = 2). Hypercoagulable disorders were present in 3 cases and a concurrent malignancy in another 3. Two patients underwent open surgery while 4 patients were treated conservatively with anticoagulation. Of the remaining 2 patients, one was treated with a thoracic stent-graft and aorto-biiliac bypass and the other one with transfemoral thrombectomy. Technical success was achieved in all surgical cases and thrombus resolution or stable disease in the conservative management group. No thrombus recurrence was observed during a mean follow-up of 49 months. CONCLUSION: The management of mural thrombus in NAADTA represents a challenge, especially in case of malignant disease or hypercoagulable disorder as a potential underlying pathology and should be individualized. Although no consensus exists in the literature, therapeutic anticoagulation is proposed as first-line therapy. The indication for surgical intervention results from contraindication to anticoagulation, mobile thrombus or recurrent embolism. Whenever possible, endovascular therapy should be preferred.

Resection of ectopic mediastinal parathyroid glands with the da Vinci robotic system.

BACKGROUND: Mediastinal ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism, traditionally treated by open surgery. Thoracoscopic access is associated with reduced morbidity in mediastinal surgery. The aim of this study was to evaluate the feasibility and effectiveness of robot-assisted dissection for mediastinal ectopic parathyroid glands. METHODS: Two patients with recurrent secondary hyperparathyroidism and three with complicated primary hyperparathyroidism were operated on between July 2004 and August 2008 for ectopic mediastinal parathyroid glands. Fusion of single-photon emission computed tomography and computed tomography led to an exact identification of the culprit glands. Surgery was performed thoracoscopically with the da Vinci robotic system using a three-trocar approach. RESULTS: All procedures were completed successfully with the robotic system. No perioperative morbidity or mortality was noted. Median operating time was 58 (range 42-125) min. Intraoperative parathyroid hormone reduction indicated complete resection. Median hospital stay was 3 (range 2-4) days. CONCLUSION: Robot-assisted dissection is a promising approach for resection of ectopic parathyroid glands in remote narrow anatomical locations such as the mediastinum.

[Role of endovascular therapy for redo surgery in patients after aortoiliac aneurysm exclusion]. / Stellenwert der endovaskulären Therapie bei Reeingriffen nach Ausschaltung aortoiliakaler Aneurysmata.

INTRODUCTION: Redo surgery or reintervention following conventional or endovascular aortoiliac reconstruction often requires exclusion of new aneurysms. In the present study the potentials of endovascular management of such lesions are investigated. METHODS: All patients with endovascular reoperation for of newly developed aortoiliac aneurysms were identified from a prospectively run data-base. The indications and results of endovascular therapy were analysed retrospectively. In detail, data were analysed for the type of original operation, interval until and kind of reoperation, and results concerning survival, technical success and complications. RESULTS: From 12 / 2003 through 3 / 2007 195 patients with aortoiliac aneurysms were operated. Endovascular repair was performed in 15 cases of previously excluded aneurysms. Mean age of these 15 patients (12 men) was 73 (64-85) years. Ten patients had a primary conventional (group A) and 5 patients had a primary endovascular (group B) aneurysm repair. The mean time interval between the first and second operation was 8.9 (1-26) years. The secondary endovascular therapy in group A was successful in all cases. In group B endoleaks type I a (n = 1), I a / b (n = 1), II (n = 2) and III (n = 1) were treated. One type II endoleak could only be treated successfully by conversion to open repair, the other one was successfully treated by reintervention. All but one patient are alive and -remained free of pathological findings during a median follow-up of 13 (2-39) months. DISCUSSION: Because of the clearly elevated operation risk of redo surgery after conventional or endovascular aneurysm repair, endovascular aneurysm exclusion represents the method of first choice. The reasonable selection and combination of procedures allows for an optimal adaptation of therapy to the individual case.

[Minimally invasive thymus surgery]. / Minimal-invasive Chirurgie des Thymus.

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.

[Statins and their influence on inflammatory processes in internal carotid artery stenosis]. / Statine und ihr Einfluss auf entzündliche Prozesse in arteriosklerotischen Plaques bei Patienten mit Stenose der Arteria carotis interna.

Arterio-arterial emboli originating from a high-grade stenosis of the internal carotid artery are a common cause for cerebral ischemias. Inflammatory processes are not only pivotal in the development of atherosclerotic vessel wall changes, but also for their clinical destabilization. Inflammatory cells, like macrophages, can turn a chronic high-grade carotid stenosis into a high-risk area for the development of arterial thromboses by way of a complex pathogenesis involving the elevation of proinflammatory factors, biosynthesis of collagen-degrading matrix metalloproteinases and expression of prothrombotic tissue factor. This process could affect the occurrence of perioperative complications during carotid endarterectomies. Statins are potent cholesterol-lowering agents. Among other lipid-independent effects, statins appear to play a significant role in preventing cardiovascular events. A number of studies have shown that statins possess plaque-stabilizing effects and that they improve cerebral autoregulation. A growing evidence supports the preoperative administration of statins in patients with high-grade stenoses of the internal carotid artery.

[Endovascular therapy of an abdominal aortic aneurysm in a renal transplant recipient]. / Endovaskuläre Therapie eines infrarenalen Aortenaneurysmas bei heterotopem Nierentransplantat.

INTRODUCTION: The indications for endovascular aortic aneurysm repair (EVAR) are mainly established in hostile abdomen, in patients with significant comorbidities which affect the general operability of the patient and, given the necessary infrastructure, also in ruptured aneurysm. Along to those, we present another possible indication in the presence of a kidney allograft in patients with aortic aneurysm. METHODS: Based on a case report of aorto-biiliac stent-graft repair of an infrarenal aortic aneurysm in a patient with renal allograft, a systematic review of the literature was performed of all similar cases concerning surgical therapy in this constellation. RESULTS: EVAR was performed using an aorto-biiliac system (Zenith) Trifab, COOK) in a 61-year-old male patient 11 years after heterotopic renal allotransplantation in the right iliac fossa. Preoperative renal function was normal. Because the donor renal artery was anastomosed to the recipient's external iliac artery the stent-graft was implanted from the left common femoral artery to minimize temporary allograft ischemia. The intra- and postoperative course was uneventful with a follow-up of presently 12 months. A primary type-II endoleak (retroleak from a lumbar artery) is being treated conservatively so far with embolization being a future option. At present there are 15 cases of EVAR in renal allograft patients that have been reported, all of them being successful. DISCUSSION: All data existing in the literature reported to date as well as our own experience justify the first choice of EVAR in morphologically suitable cases. One major advantage of EVAR in this constellation is the avoidance of aortic cross clamping which poses the graft at risk of ischemia. Long-term results will be most important for definite assessment of EVAR. However, contrast media application during the operation and for CT surveillance should be considered as a major disadvantage.

Successful endovascular treatment of infrarenal aortic rupture after chemotherapy of a mesenchymal periaortic tumor.

PURPOSE: To report the first successful endovascular repair of a non-aneurysmal aortic rupture due to periaortic tumour regression. CASE REPORT: A 58-year-old man developed spontaneous infrarenal aortic rupture following chemotherapy which led to regression of a periaortic mesothelioma that had been diagnosed during explorative laparotomy 11 months earlier. Stent-graft placement was performed with intentional conversion of a bifurcated (Zenith, COOK) into an aorto-uni-iliac system. No complications were encountered during a 40 months follow-up. CONCLUSION: Endovascular repair should be considered as a treatment option in non-aneurysmal aortic rupture.

[Renal carcinoma with invasion of the suprahepatic vena cava (Staehler stage III and IV): surgical treatment and results]. / Nierenzellkarzinom mit suprahepatischem V.-cava-Befall (Stadium III und IV nach Staehler). Operative Therapie und Ergebnisse.

The operative treatment of patients with renal cell carcinoma (RCC) and suprahepatic infradiaphragmatic or supradiaphragmatic vena cava invasion (Staehler stage III and IV) is still an interdisciplinary challenge. The potential high complication rate and the enormous operative-technical efforts have to be brought into line with the individual benefit for the patient. In this study, we have retrospectively analyzed the operative results of 24 patients. We have further compared the patients during follow-up and immunotherapy due to metastasis with a control group of 75 patients without vena cava invasion. Perioperative mortality in the 24 patients was 4%. Four patients had metastasis at presentation and 14 further patients developed metastatic disease during median follow-up of 23.5 months. Median survival was 45 months with a 1-, 3-, and 5-year survival rate of 92, 57, and 33%, respectively. In a multivariate analysis, only the presence of metastasis (p=0.002) and marginal immunotherapy (p=0.1), but not vena cava invasion (p=0.259) or a positive lymph node status (p=0.624) were significant predictors of a poor survival. For patients with RCC and suprahepatic infradiaphragmatic or supradiaphragmatic vena cava invasion (Staehler stage III and IV), the combination of an aggressive surgical treatment combined with subsequent immunotherapy in the presence of metastatic disease offers a realistic therapeutic option with reasonable survival rates.

Successful stent-graft repair of a vertebrojugular arteriovenous fistula.

PURPOSE: To describe an apparently unreported endovascular means of treating a vertebral arteriovenous fistula (AVF) using a small-caliber stent-graft to permanently reconstruct the involved vessels. CASE REPORT: A 13-year-old girl presented with tinnitus caused by a high-flow AVF between the right extracranial vertebral artery and deep jugular vein arising from repeated internal jugular vein catheterization. A 4-mm-diameter balloon-expandable Jostent coronary stent-graft was placed in the vertebral artery via a percutaneous femoral access, with immediate and complete obliteration of the AVF and resolution of the tinnitus. Follow-up duplex ultrasonography at 15 months demonstrated patency and luminal integrity of the vertebral artery. CONCLUSIONS: Vertebrojugular AVFs are rare and usually treated with transcatheter embolization techniques, but percutaneous repair using a small-caliber stent-graft appears feasible. This minimally invasive treatment might become the method of choice for AVFs in other small-bore vessels.

[Results and complications of endovascular therapy of aortic aneurysms]. / Ergebnisse und Komplikationen nach endovaskulärer Therapie des Aortenaneurysmas.

INTRODUCTION: Endovascular repair (ER) has been established as an alternative treatment option for aortic aneurysm (AA) in case of a suitable morphology. However, there are specific problems related to diagnostic and therapeutic management including potential complications of the new procedure. PATIENTS AND METHODS: Between 8/1996 and 11/1999, 41 patients (6 female, mean age 67.9 (range 55-84) years) underwent an operation with the intention of ER. Modular, self-expanding stent-grafts were used for aorto-biiliacal (36), aorto-monoiliacal (1), and aorto-aortal (infrarenal-1, thoracic-1) aortic aneurysm (AA) exclusion. Postoperatively and during the follow-up period, diagnostic measures included clinical investigation, native X-ray, and color-coded Doppler sonography, and spiral computed tomography, and digital subtraction angiography. Results were analysed with special reference to complications and resulting therapeutic consequences. RESULTS: Technical success was achieved in 36/41 patients (87.8%). There were 2 primary distal endoleaks and 3 conversions because of lacking vascular access. Of 4 primary endoleaks, a proximal one was treated successfully by overstenting, a distal one was sealed off by iliac extension, and 2 distal ones were treated conservatively. Three secondary endoleaks, a proximal and 2 distal ones, required conversion each by retro- and transperitoneal approach. Presently, there are 4 endoleaks, with the maximal aortic diameter remaining constant except one case. Five secondary occlusions of an iliac limb (4) or artery (1) were treated by thrombectomy (1), PTA (1), PTA with overstenting (1), and cross-over (1) or ilicofemoral bypass (1). Three patients died of unrelated disease during the follow-up period. DISCUSSION: On condition of a critical indication, improved diagnostic management and further refinement of stent-graft systems ER constitutes an alternative, minimally invasive treatment option for AA. Long-term results must be obtained by means of continued prospective and comparative studies to definitely evaluate ER.

[Femoro-distal ePTFE bypass grafting using femoro-crural patch prosthesis (FCPP). Results of a prospective clinical study]. / Femoro-distale ePTFE-Bypassrekonstruktionen mittels femoro-kruraler Patchprothese (FCPP). Ergebnisse einer prospektiven klinischen Studie.

Femorodistal bypass using exclusively PTFE is known to have a poor prognosis, mostly because of the development of myointimal hyperplasia (MIH). Several vein patch techniques are established but the role of hemodynamics within the anastomotic site has only been explained insufficiently and is hardly considered clinically. In a prospective study, between 6/1992 and 7/1998 129 patients (89 m/40 f, mean age 65.2 +/- 10.0 years) with critical limb ischemia and no usable saphenous vein were included to undergo femorodistal ePTFE bypass grafting with a new, hemodynamically optimized distal end-to-side anastomosis. Patients were followed at 6-month intervals with clinical investigation and color-coded Doppler sonography. Primary and secondary graft patency (PPR, SPR), limb salvage, and patient survival were calculated according to Kaplan-Meier. With a median follow-up of 45 (range 6 to 72) months, PPR and SPR at 1, 3 and 5 years were 63.0, 35.7 and 27.6% and 74.5, 44.8%, and 37.6%, respectively. Limb salvage at 1, 3 and 5 years was 86.4%, 78.7% und 73.2%. There was no perioperative mortality. Graft infection occurred in 7 patients (5.2%). ePTFE bypass grafting represents a valuable option for infragenicular and crural reconstruction in the absence of autologous vein. The new anastomotic design was feasible and represents another adjunct to possibly improve patency of femorodistal bypass allografts.

Long-term survival after radical resection of a primary angiosarcoma of the innominate vein.

The case updated here demonstrates the longest survival that has been observed so far after radical resection of primary angiosarcoma of the left innominate vein, which is the second case that has ever been reported to date. Radical resection was performed after preoperative radiotherapy. The venous continuity was restored by expanded polytetrafluoroethylene graft interposition. This case underscores that the prognosis of primary venous sarcoma, though fatal in the majority of patients, may be better in individual cases when radical surgery with curative intention is achieved.

Schwannoma with angiosarcoma. Report of a case and comparison with other types of nerve tumors with angiosarcoma.

BACKGROUND: Schwannoma with angiosarcomatous change is a rare tumor, the clinical characteristics of which have not been analyzed. METHODS: A patient with schwannoma with angiosarcoma arising in the midneck and clinically mimicking a carotid body paraganglioma is described with a literature review of all previously reported cases and a comparison of their clinical features with those of schwannoma with conventional malignant transformation and cases of neurofibroma and malignant peripheral nerve sheath tumor (MPNST) with angiosarcoma. RESULTS: There are four reported cases, including the present case. Schwannoma with angiosarcoma affects older adults, mainly men. Three tumors arose from the vagus nerve in the neck. Three of the four angiosarcomas were epithelioid in type. Treatment in all cases was surgical resection followed by radiation and chemotherapy in one case and by radiation alone in another. One patient died with residual local angiosarcoma 5 months after the diagnosis. The remaining three patients were alive and disease free at 27 months, 43 months, and 90 months, with distant metastasis (after 15 months) reported only in the patient described in this case report. CONCLUSIONS: Schwannoma with angiosarcoma should be included in the differential diagnosis of presumed carotid body paragangliomas. Like angiosarcoma alone and schwannoma with conventional malignant transformation, but unlike cases of neurofibroma and MPNST with angiosarcoma, the patients are older adults, and there is a male prevalence. Schwannoma with angiosarcoma is capable of local spread with a fatal outcome and of distant metastasis, but follow-up strongly suggests that these patients have a better prognosis than patients with neurofibroma or MPNST with angiosarcoma. Recommended treatment is attempted complete surgical resection followed by radiation therapy and chemotherapy, if it can be tolerated by the patient.

Vascular complications in acute pancreatitis assessed by color duplex ultrasonography.

We determined the sensitivity of computed tomography and color duplex ultrasonography in the detection and characterization of vascular complications in acute pancreatitis. The relationship of these complications with the etiology and activity of the disease was assessed. In a prospective study, 189 patients with acute pancreatitis seen in the Department of Gastroenterology. Charité Hospital in Berlin over a period of 38 months underwent color duplex ultrasonography every second day for 3 weeks and thereafter at least once a week for 2 months. Dynamic computed tomography was performed within 72 hours after admission, and follow-up computed tomography scans were obtained. In 45 patients (23%), at least temporary thromboses of portal venous vessels were demonstrated by color duplex ultrasonography. The incidence of venous thromboses was 30% in severe acute pancreatitis with fluid collections without necroses and 57% in necrotizing pancreatitis. In 27 of those 45 patients, a formation of collaterals was documented. In 13 patients, arterial pseudoaneurysms were demonstrated. Vascular complications were significantly more frequent in alcohol-induced than in gallstone-induced pancreatitis. Only 62% of all sonographically diagnosed thromboses and only 32% of all collaterals were demonstrated by computed tomography. The prevalence of vascular complications in acute pancreatitis was much higher as suspected. The risk of gastrointestinal bleeding was lower than previously reported. Color duplex sonography is the method of choice for the detection of vascular complications in acute pancreatitis.