[Hemostyptics for treatment of junctional vascular injuries : Management of traumatic vascular injuries at the transition from trunk to extremities]. / Hämostyptika zur Behandlung der "junctional vascular injuries" : Versorgung traumatischer Gefäßverletzungen am Übergang vom Körperstamm zur Extremität.

BACKGROUND: Uncontrolled post-traumatic bleeding is still the leading cause of death among trauma patients. In situations of mass casualty incidents (MASCAL) and military conflicts the treatment of uncontrolled critical bleeding is a challenge and associated with a worse outcome due to the austere environment; however, even under optimal treatment circumstances in situations of individual medicine the severity of vascular trauma is underestimated. As a consequence, this leads to a poorer prognosis for patients with (vascular) injuries. From this perspective it was reasonable to intensify the training of physicians, paramedics (Advanced Trauma Life Support©) and first responders (Hartford consensus) for handling of critical bleeding in traumatized patients. Furthermore, the main emphasis of the revised S3 clinical guidelines on polytrauma/severely injured treatment from 2016 of the German Society for Trauma Surgery is on the preclinical treatment. Despite a renaissance and increasing use of tourniquets, the treatment of bleeding in the transition from the trunk to the extremities (junctional vascular injuries), which are inaccessible to placing a tourniquet, remains a problem. CONCLUSION: It was the military that in addition to the development of special tourniquets, intensified research programs and the implementation of hemostatic devices and dressings in this anatomical region. This article deals with junctional vascular injuries at the transition between the trunk and the extremities. In addition to the anatomical situation, this article gives the reader an overview of the currently available hemostyptics and their mode of action.

[Transcardiac Access Routes for Endovascular Treatment of Ascending Aortic Pathologies]. / Transkardiale Zugangswege zur endovaskulären Versorgung der Aorta ascendens.

Gold standard for treatment of pathologies of the ascending aorta is still open surgery with extracorporal circulation in moderate to deep hypothermia. These procedures are associated with high morbidity and mortality, especially if performed in older patients or after previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment option for thoracic aortic pathologies of the descending aorta even in high-risk patients with severe comorbidities resulting in reduced morbidity and mortality compared to open repair. Despite the continuous development of endograft technology an adequate arterial access still poses a relevant limitation of this treatment option accentuated in the proximal segments of the aorta. The transfemoral access may be limited due to severe kinking or arteriosclerotic plaque stenosis of femoral or iliac vessels. Furthermore, the long distance between femoral access vessels and the aortic lesion impairs device torsibility and exact deployment of the stent graft. To provide a practical alternative endovascular access to the ascending aorta, antegrade transcardiac access routes including transapical or transseptal techniques have recently gained increasing interest.

[Fluorescence angiography for esophageal anastomoses : Perfusion evaluation of the gastric conduit with indocyanine green]. / Fluoreszenzangiographie bei Ösophagusanastomosen : Perfusionsbeurteilung des Magenschlauchs mit Indocyaningrün.

BACKGROUND: The incidence of esophageal cancer continues to increase. Despite increasing experience in esophageal surgery and perioperative management, anastomotic leakage remains a frequent and severe complication. OBJECTIVE: The aim of this article is to demonstrate the current role of fluorescence angiography (FA) with indocyanine green (ICG) in the assessment of esophageal anastomoses. The main focus is on the evaluation of the perfusion situation. MATERIAL AND METHODS: A systematic search was carried out in PubMed and Medline on FA and ICG, especially with respect to current subjective and objective interpretation approaches of FA against the background of own research. RESULTS: The rate of anastomotic leakage remains high despite modern surgical procedures. Assessment of neoesophageal perfusion with FA can significantly reduce the rate of anastomotic leakage. At present, FA is mostly subjectively applied in small case studies. The study situation is heterogeneous. Randomized studies do not so far exist. CONCLUSION: The use of FA with ICG is suitable for evaluation of perfusion of the gastric tube. The implementation is simple and can be standardized. Prospective, randomized trials and objective quantification are needed in the future in order to clarify the potential of the technique.

Staged procedures for prevention of spinal cord ischemia in endovascular aortic surgery.

BACKGROUND: Spinal cord ischemia with development of paraplegia is the most relevant complication of thoracoabdominal aortic surgery caused by compromising the segmental arteries. To prevent this devastating complication in endovascular aortic surgery, staging procedures have been developed to reinforce collateral blood flood to the spinal cord. RESULTS: In patients with a medium to high risk for spinal cord ischemia, staged aortic repair is recommended. The classical staged repair is the two-step repair with delayed implantation of the aortic stent grafts. Additionally, more recent methods for short-term salvage of segmental artery perfusion by leaving an endoleak have been developed. Perfusion branches, delayed bridging stents as well as the open branch technique are among these methods. The latest option of staged repair is minimally invasive segmental artery embolization. CONCLUSION: Besides the nonsurgical options for monitoring and therapy of spinal cord ischemia, various staging procedures are available, which can be implemented depending on the patient and the aortic anatomy. Evidence that underlines staged repair for endovascular treatment of thoracoabdominal aortic pathologies is mostly based on retrospective studies.

I-SWOT as instrument to individually optimize therapy of thoracoabdominal aortic aneurysms: Effective, norm-compliant and meeting the needs.

BACKGROUND: Guidelines summarize medical evidence, they identify the most efficient therapy under study conditions and recommend this therapy for use. The physician now has the challenge to translate a therapy that is efficient under laboratory conditions to a patient who is an individual person. To accomplish this task the physician has to make sure that (I) the ideal typical therapy is applicable and effective in this individual patient taking the special features into consideration, that (II) therapy is compliant with the norm including guidelines, laws and ethical requirements (conformity) and that (III) the therapy meets the patient's needs. OBJECTIVE: How can physicians together with the patients translate the medical evidence into an individually optimized therapy? MATERIAL AND METHODS: At the German Aortic Center in Hamburg we use I­SWOT as an instrument to identify such individually optimized therapy. With I­SWOT, we present an instrument with which we have developed an (I) efficient, (II) conform and (III) needs-oriented therapeutic strategy for individual patients. RESULTS: I-SWOT cross-tabulates strengths (S) and weaknesses (W) related to therapy with opportunities (O) and threats (T) related to individual patients. This I­SWOT matrix identifies four fundamental types of strategy, which comprise "SO" maximizing strengths and opportunities, "WT" minimizing weaknesses and threats, "WO" minimizing weaknesses and maximizing opportunities and "ST" maximizing strengths and minimizing threats. We discuss the case of a patient with asymptomatic thoracoabdominal aneurysm to show how I­SWOT is used to identify an individually optimized therapy strategy.

Chronic type B aortic dissection: indications and strategies for treatment.

Chronic type B aortic dissection is a distinctive condition that needs individual treatment strategies and different considerations than in therapy of acute or subacute type B aortic dissection. The most common indication for treatment of this complex disease is aneurysmal dilatation of the dissected aortic segment. While open repair of the enlarged dissected aorta remains the best option for good-risk patients and patients with connective tissue disorders in high-volume centers with respective expertise, endovascular management of chronic type B aortic dissection with postdissection aneurysms has significantly gained ground in the past years. But the concept of TEVAR with implantation of a tubular stent-graft into the thoracic aorta to seal the proximal entry tear and reroute the blood flow into the true lumen alone, is not associated with satisfactory results. This is mainly due to the sparse remodeling capacity of the aortic tissue compared to earlier stages of the disease as the aortic wall and the dissection membrane are thickened and more rigid. On the other hand, it is restricted by the most limiting factor for endovascular success in chronic type B aortic dissection: persistent false lumen perfusion. This problem also affects patients with residual dissection after surgical repair of a DeBakey type I aortic dissection or dissection after ascending aortic repair for other pathologies. Hence, it is evident that strategies to achieve endovascular false lumen occlusion are of increasing importance and novel techniques have been introduced to solve the problem of persisting false lumen flow. Thus, the evolution of a large variety of techniques to address the false lumen perfusion issue indicates that complicated chronic type B dissection involves a high diversity in clinical presentation and morphology. A large armamentarium of catheter skills as well as critical individualized treatment strategies are required to address the heterogenous morphological disease pattern for each individual patient. The rapid development in endovascular techniques gives new directions for treatment indications and strategies in chronic aortic dissection and enables new insights into this old disease.

[Screening of carotid arteries before surgery: when does preoperative duplex ultrasound make sense?]. / Karotisscreening vor chirurgischen Eingriffen : Wann ist eine präoperative Duplexsonographie sinnvoll?

Carotid artery stenosis is a marker for generalized atherosclerosis with high cerebrovascular and cardiovascular morbidity and mortality rates. There is an estimated increase in prevalence of moderate stenosis for older age and male sex. Asymptomatic carotid artery stenosis is a risk factor for perioperative neurological events during general surgery. Planning of effective preoperative screening of populations at risk for asymptomatic carotid artery stenosis is best evaluated for cardiac surgery. General screening is not recommended; however, preoperative screening for asymptomatic carotid artery stenosis should be performed in high-risk patients with options for surgical or interventional treatment. These are patients with clinical signs of peripheral arterial disease and patients over 65 years old with at least one of the risk factors coronary artery disease, smoking and hypercholesterinemia. Preoperative screening in patients with carotid bruits may also be useful. Preoperative carotid artery screening may be beneficial in detecting occult carotid artery stenosis and thereby reducing perioperative neurological events.

Acute ischemia and bypass occlusion: current options.

AIM: Acute limb ischemia (ALI) and bypass occlusion are vascular emergencies and require immediate decisions and therapy. There are a lot of options, and the vascular therapist should be able to provide multiple alternatives. In this article we give on overview over the actual therapeutic options and present the data of a retrospective analysis of bypass occlusions. METHODS: Therapeutic options of ALI are discussed according to the current literature. For the retrospective study, patients with acute or subacute occlusion of below knee alloplastic bypass were included. Endpoints of the study were secondary patency and limb salvage rate. A prognostic index was calculated to estimate the specific risk. RESULTS: We analyzed 262 bypass occlusions; 161 patients were male. The majority of patients (N.=249) presented with threatened limb at readmission. After one year, 2/3 of the bypasses showed a reocclusion. Introducing the therapy with bypass thrombolysis enhanced the prognosis significantly. Of the factors examined, cardiac and renal insufficiency had a significant poor influence, whereas therapy with Coumadin enhanced the prognosis in terms of patency. The prognostic index was calculated using the factors identified as relevant in the multivariate analysis. DISCUSSION: Despite all new technical tools, ALI and bypass occlusion is still associated with a significant risk for limb loss and mortality. Endovascular procedures are excellent options. The prognostic index may be a helpful tool in estimating the patency or risk of limb loss.

Acute aortic syndromes: definition, prognosis and treatment options.

Acute aortic syndromes (AAS) are life-threatening vascular conditions of the thoracic aorta presenting with acute pain as the leading symptom in most cases. The incidence is approximately 3-5/100,000 in western countries with increase during the past decades. Clinical suspicion for AAS requires immediate confirmation with advanced imaging modalities. Initial management of AAS addresses avoidance of progression by immediate medical therapy to reduce aortic shear stress. Proximal symptomatic lesions with involvement of the ascending aorta are surgically treated in the acute setting, whereas acute uncomplicated distal dissection should be treated by medical therapy in the acute period, followed by surveillance and repeated imaging studies. Acute complicated distal dissection requires urgent invasive treatment and thoracic endovascular aortic repair has become the treatment modality of choice because of favorable outcomes compared to open surgical repair. Intramural hematoma, penetrating aortic ulcers, and traumatic aortic injuries of the descending aorta harbor specific challenges compared to aortic dissection and treatment strategies are not as uniformly defined as in aortic dissection. Moreover these lesions have a different prognosis. Once the acute period of aortic syndrome has been survived, a lifelong medical treatment and close surveillance with repeated imaging studies is essential to detect impending complications which might need invasive treatment within the short-, mid- or long-term.

TEVAR for chronic aortic dissection - is covering the primary entry tear enough?

Treatment-strategies for type B aortic dissection (TBAD) are rapidly developing towards endovascular treatment strategies. While TEVAR for acute TBAD shows favourable results, TEVAR in chronic TBAD following the same interventional strategies as in acute TBAD by covering the proximal entry-tear alone has shown unsatisfactory results with one third of the patients developing further false-lumen growth and mortality of 36% at 3 years. This review article describes endovascular strategies and adjunctive techniques to prevent distal false-lumen back-flow in patients with chronic TBAD, as covering the proximal entry tear has proven insufficient.

Intraoperative quality control in vascular surgery.

Since graft patency is the predominant predictor of long-term survival after vascular surgery, intraoperative graft patency control is of major importance for improving quality assurance. Intraoperative quality control is of major importance to obtain good short- and longterm results and to eliminate the need for reoperation. Currently there is no standardized approach and intraoperative quality control is not performed routinely by most surgeons. The most commonly used intraoperative assessment techniques include arteriography, duplex ultrasonography, angioscopy and transit-time flow measurement (TTFM). Fluorescent angiography (FA) using the dye indocyanine green (ICG) is a novel noninvasive technology for intraoperative visualization and documentation of vessels, bypass grafts, and perfusion with an infrared sensitive imaging device, so far validated for quality control in coronary bypass surgery. FA and TTFM are methods for quantitative assessment of blood flow measurement, which are currently exclusively used as intraoperative quality control in cardiac bypass surgery. Up to now, there are no experiences published for peripheral vascular reconstructions. However, transposition and implementation of these techniques seem to be valuable and useful. Therefore further studies for intraoperative quality control in vascular surgery are necessary.

[Endovascular therapy of chronic mesenteric ischemia]. / Endovaskuläre Therapie der chronisch mesenterialen Ischämie.

Arteriosclerosis is the most common cause of chronic mesenteric ischemia, which is characterized by postprandial pain, unintentional weight loss and food avoidance. The use of endovascular techniques for revascularization of chronic stenoses and occlusions of the mesenteric arteries has rapidly increased over the last 10 years. The results of endovascular therapy have shown less morbidity and mortality compared to open surgical procedures, such as bypass and thrombendarterectomy. Early publications have reported higher rates of restenosis, symptomatic recurrence and reinterventions but recent case series show comparable patency rates. This article reviews visceral arterial anatomy and anomalies and endovascular techniques for the revascularization of mesenteric arteries.