Role of aorto(bi)femoral bypass in treatment of patients with critical limb threatening ischemia.

PURPOSE: To analyse the long-term outcome of open aortic procedures in patients with critical limb threatening ischemia. METHODS: Retrospective analysis of all patients with aortoiliac TransAtlantic Inter-Society Consensus II (TASC II), type D (TASC D) lesions extending to the femoral artery who underwent aortic bypass procedures for critical limb threatening ischemia (CLTI) or intermittent claudication (IC). RESULTS: Over a period of 10 years, 87 patients with IC and 45 patients with CLTI received a total of 56 aortounifemoral and 76 aorto-bi-femoral bypass procedures. After 7 years, overall primary patency (82.2% [CLTI] vs. 80.5% [IC], p = .918) and overall secondary patency (88.9% [CLTI] vs. 88.5% [IC], p = .851) were similar between patients with CLTI and those with IC. Long-term-survival (66.7% vs. 71.3%, p = .356) as well as limb salvage (86.7% vs. 94.3%, p = .104) was considerably lower in the CLTI-group, but the difference was not statistically significant. In the subgroup analysis, patients with CLTI and ischemic lesions (Rutherford class 5-6) had the poorest outcome after 84 months, in terms of secondary patency (92.1% vs. 73.7%, p = .015), limb salvage (97.4% vs. 73.7%, p = .000), and long-term survival (75.0% vs. 26.3%, p = .000) compared to patients with IC. Multivariate analysis revealed significant associations for patients with Rutherford class 5-6 in terms of secondary patency (p = .037) and limb salvage (p = .015). There was a significant difference in primary patency between graft limbs with superficial femoral artery occlusion and graft limbs with patent superficial femoral artery (84.6% vs. 93.0%, p = .017). CONCLUSIONS: Aortic bypass procedures can be used in the treatment of patients with CLTI. Moreover, results are satisfactory in patients with ischemic rest pain. However, less invasive treatments should be considered for patients with ischemic lesions.

Comparison of Long-term Outcomes of Heparin Bonded Polytetrafluoroethylene and Autologous Vein Below Knee Femoropopliteal Bypasses in Patients with Critical Limb Ischaemia.

OBJECTIVE/BACKGROUND: Endovascular first is the preferred therapy approach to critical limb ischaemia (CLI). However, in spite of new endovascular techniques, bypass surgery still plays an important role, especially in patients with complex anatomy in whom endovascular therapy is not considered feasible, or has failed. The goal of this study was to analyse the outcomes of prosthetic or autologous vein for femoropopliteal (P3) bypasses performed under the abovementioned conditions. METHODS: A retrospective analysis of patients who underwent a femoropopliteal (P3) bypass for CLI (March 2007-December 2015) was conducted. Endovascular therapy was not possible. Patency rates, limb salvage, major adverse limb event (MALE) free survival, and survival after 5 years were analysed. RESULTS: In total, 151 cases were included in the analysis (rest pain 35.8%, ulcer/gangrene 64.3%). The graft material was autologous vein in 76 cases (vein group) and heparin bonded expanded polytetrafluoroethylene (HePTFE) in 75 cases (HePTFE group). Indications, risk factors, previous revascularisation procedures, and runoff vessels were similar in both groups. Thirty day mortality was 6.6% in the vein group and 5.3% in the HePTFE group (p = .508), early graft occlusion (6.6% vs. 5.3%; p = .508) and 30 day major amputation rate (0% vs. 2.7%; p = .245) were similar between the two groups. Overall primary patency was 51.7% (55.5% [vein group] vs. 51.7% [HePTFE group]; p = .897) and overall secondary patency was 64.2% (74.6% [vein group] vs. 55.6% [HePTFE group]; p = .119), all without significance after 5 years. However, limb salvage (79.1%) was significantly different (90.0% [vein group] vs. 62.9% [HePTFE group]; p = .021). Survival was similar between the groups (47.3% vs. 42.9%; p = .582) as well as MALE free survival (69.4% vs. 55.0%; p = .348). CONCLUSION: Bypasses to the below knee popliteal artery show good results in patients with CLI unsuitable for endovascular therapy. Vein is still the first line graft material.

Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: Do asymptomatic restenoses > 70% after carotid endarterectomy (CEA) and carotid stenting (CAS) increase the risk of late ipsilateral stroke? METHODS: Systematic review identified 11 randomised controlled trials (RCTs) reporting rates of restenosis > 70% (and/or occlusion) in patients who had undergone CEA/CAS for the treatment of primary atherosclerotic disease, and nine RCTs reported late ipsilateral stroke rates. Proportional meta-analyses and odds ratios (OR) at end of follow-up were performed. RESULTS: The weighted incidence of restenosis > 70% was 5.8% after "any" CEA, median 47 months (11 RCTs; 4249 patients); 4.1% after patched CEA, median 32 months (5 RCTs; 1078 patients), and 10% after CAS, median 62 months (5 RCTs; 2716 patients). In four RCTs (1964 patients), one of 125 (0.8%) with restenosis > 70% (or occlusion) after CAS suffered late ipsilateral stroke over a median 50 months, compared with 37 of 1839 (2.0%) in CAS patients with no significant restenosis (OR 0.87; 95% CI 0.24-3.21; p = .8339). In seven RCTs (2810 patients), 13 out of 141 (9.2%) with restenosis > 70% (or occlusion) after CEA suffered late ipsilateral stroke over a median 37 months, compared with 33 out of 2669 (1.2%) in patients with no significant restenoses (OR 9.02; 95% CI 4.70-17.28; p < .0001). Following data correction to exclude patients whose surveillance scan showed no evidence of restenosis > 70% before stroke onset, the prevalence of stroke ipsilateral to an untreated asymptomatic > 70% restenosis was seven out of 135 (5.2%) versus 40 out of 2704 (1.5%) in CEA patients with no significant restenosis (OR 4.77; 95% CI 2.29-9.92). CONCLUSIONS: CAS patients with untreated asymptomatic > 70% restenosis had an extremely low rate of late ipsilateral stroke (0.8% over 50 months). CEA patients with untreated, asymptomatic > 70% restenosis had a significantly higher risk of late ipsilateral stroke (compared with patients with no restenosis), but this was only 5% at 37 months. Overall, 97% of all late ipsilateral strokes after CAS and 85% after CEA occurred in patients without evidence of significant restenosis or occlusion.

A comparison of tibial and peroneal venous and HePTFE bypasses in diabetics with critical limb ischemia.

OBJECTIVE: In this study we analyzed the outcome of tibial and peroneal venous and heparin-bonded expanded polytetrafluoroethylene (HePTFE) bypasses in diabetics with critical limb ischemia (CLI). We aimed to verify our hypothesis that HePTFE grafts will achieve acceptable 1-year patency and limb salvage results in patients who lack an adequate vein. METHODS: We conducted a retrospective analysis for all diabetics who underwent tibial bypass surgery in our department between October 2007 and October 2012. The study includes 97 grafts. All these patients were not suited for an endovascular therapy. We used autologous veins in 56 cases (Vein-Group) and HePTFE grafts in 41 cases (HePTFE-Group). Study endpoints were primary and secondary patency, limb salvage, and survival at 2 years postoperatively. RESULTS: Risk factors and indications were similar in both groups. The comparison between HePTFE- and Vein-Group showed significantly different patency rates. At 2 years, primary patency was 39.3% in HePTFE-Group vs. 78.5% in Vein-Group (P = .003) and secondary patency was 47.4% vs. 81.9% (P = .002). Limb salvage at 2 years was 79.3% vs. 87.4% (P = .073) and survival was 64.6% vs. 62.9% (P = .593) at the 2-year mark, with no significant differences. 30-days mortality, graft occlusion and major amputation rate showed no significant differences, either. CONCLUSIONS: This study shows that HePTFE bypasses are a viable option for diabetics undergoing tibial bypass surgery when no adequate vein is available.

Nutritional enhancement of leaves by a psyllid through senescence-like processes: insect manipulation or plant defence?

Some herbivores can modify the physiology of plant modules to meet their nutritional requirements. Induction of premature leaf senescence could benefit herbivores since it is associated with the mobilisation of nutrients. We compared the effects of nymphal feeding by Cardiaspina near densitexta on Eucalyptus moluccana with endogenous processes associated with senescence to assess the relative merits of an insect manipulation or plant defence interpretation of responses. Evidence supporting insect manipulation included increased size of fourth and fifth instar nymphs (in the latter the effect was restricted to forewing pad length of females) on leaves supporting high numbers of conspecifics and feeding preventing leaf necrosis. Intra-specific competition negated greater performance at very high densities. High and very high abundances of nymphs were associated with increased concentrations of amino acid N but only very high abundances of nymphs tended to be associated with increased concentrations of six essential amino acids. Contrary to the insect manipulation interpretation, feeding by very high abundances of nymphs was associated with significant reductions in chlorophyll, carotenoids and anthocyanins. Evidence supporting plant defence included the severity of chlorosis increasing with the abundance of nymphs. Leaf reddening did not develop because ambient conditions associated with photoinhibition (high irradiance and low temperature) were not experienced by leaves with chlorotic lesions. Leaf reddening (from anthocyanins) alone is not expected to adversely affect nymphal survival; only leaf necrosis would kill nymphs. For senescence-inducing psyllids, nutritional enhancement does not fit neatly into either an insect manipulation or plant defence interpretation.

[Hybrid operating rooms: only for advanced endovascular procedures?]. / Angio-Hybrid-Operationsraum: Grundvoraussetzung nur für komplexe endovaskuläre Eingriffe?

The evolution of endovascular techniques has led to the concept of the "hybrid operating room" (hybrid OR). A hybrid OR combines the sterility of an OR in an operating theatre environment with a high-quality fixed imaging system. On the basis of these advantages it would be desirable that an angio-hybrid OR becomes a standard requirement for endovascular surgery. In Great Britain guidelines have already been published that require a hybrid OR even for normal endovascular management of the infrarenal aorta. However, in Germany there are no guidelines from professional societies or formal rules from the federal joint committee, thus in this article a classification of endovascular procedures according to their complexity and the necessary infrastructures are proposed in order to define particular procedures that should only be performed in an angio-hybrid OR. According to our experience, endovascular procedures can be classified into four categories based on their complexity and the requirements regarding fluoroscopy: level 1: standard EVAR, TEVAR, iliac and popliteal artery procedures; level 2: iliac branched (IBD) and standard (2 fenestrations for the renal arteries and a scallop for the superior mesenteric artery) fenestrated stent-grafting; level 3: more complex fenestrated procedures (three or four fenestrations); and level 4: branched stent-grafting for TAAA. At this moment it is still acceptable to perform level 1 and level 2 procedures outside of a hybrid OR. In our opinion, it is not recommended to perform level 3 and level 4 endovascular procedures without a hybrid OR.

Necrosis of the leg after intraarterial drug injection.

Inadvertent intraarterial injections in the context of drug abuse can cause damage to the vascular system. The clinical picture depends on the drug properties and ranges from partial ischemia to necrosis of the affected extremity. There are no current evidence-based guidelines regarding the management of intraarterial drug injections. In many cases the concept of solving vasospasm after injection is based on the use of intraarterial application of prostaglandins. We report a case in which a mixture of drugs was injected into the left femoral artery. The patient arrived 24 hours later with ischemia of the left leg at our emergency department. Angiography showed that there was no blood flowing in the leg. Despite intraarterial application of vasodilatators, regional neurolysis and thrombolyis with urokinase major amputation was unavoidable. The outcome after inadvertent injection depends on certain drug properties and the delay between injection and the beginning of therapy.

VEGF: a surrogate marker for peripheral vascular disease.

This study aims to evaluate the value of VEGF as a surrogate marker for peripheral vascular disease (PVD). Prior to treatment, serum VEGF levels were evaluated by enzyme-linked immunosorbent assay (ELISA) in 293 PVD patients. Risk factors and clinical parameters of PVD were documented. Twenty-six age-matched healthy volunteers served as controls. Serum VEGF values strongly correlated with Fontaine stages (p<0.006, stage IV vs. controls). High VEGF values prior to treatment were associated with poor outcome. Serum VEGF appears to indicate the severity of PVD and might serve as a surrogate indicator of disease severity.

Anthropogenic extinctions conceal widespread evolution of flightlessness in birds.

Human-driven extinctions can affect our understanding of evolution, through the nonrandom loss of certain types of species. Here, we explore how knowledge of a major evolutionary transition-the evolution of flightlessness in birds-is biased by anthropogenic extinctions. Adding data on 581 known anthropogenic extinctions to the extant global avifauna increases the number of species by 5%, but quadruples the number of flightless species. The evolution of flightlessness in birds is a widespread phenomenon, occurring in more than half of bird orders and evolving independently at least 150 times. Thus, we estimate that this evolutionary transition occurred at a rate four times higher than it would appear based solely on extant species. Our analysis of preanthropogenic avian diversity shows how anthropogenic effects can conceal the frequency of major evolutionary transitions in life forms and highlights the fact that macroevolutionary studies with only small amounts of missing data can still be highly biased.

[COVID-19 infection-Risk of thromboembolic complications]. / COVID-19-Infektion ­ Risiko für thrombembolische Komplikationen.

While the COVID-19 syndrome triggered by the SARS CoV­2 was initially seen predominantly as a pulmonary disease, the number of reports of vascular complications has recently increased. The aim of the present review article is to summarize the most relevant vascular complications in COVID-19 patients. These include venous and arterial thromboembolic events as well as local thromboses, which can form directly on the endothelium at the site of cytokine release. A generalized coagulopathy also appears to promote this thrombogenic condition. With a rate of approximately 20%, deep vein thrombosis (DVT) of the leg is one of the most common thromboembolic events in COVID-19 patients requiring intensive care treatment. In addition, arterial events, such as stroke or acute coronary syndrome were also observed in COVID-19 patients with pre-existing vascular disease. Children rarely have vascular complications, but a systemic immune response similar to the Kawasaki syndrome and toxic shock syndrome has been reported. According to current data, the risk of thromboembolic events in hospitalized COVID-19 patients is significantly increased, making thrombosis prophylaxis with low molecular weight or unfractionated heparin necessary. If pharmaceutical thrombosis prophylaxis is contraindicated, intermittent pneumatic compression should be used. In addition, in patients admitted to the hospital with suspected or proven SARS-CoV­2 infection, the determination of D­dimers and, in the case of positive results, broad indication for compression sonography of the deep leg veins are recommended. This allows to detect and treat DVT at an early stage. The treatment of thromboses should be carried out according to current guidelines with therapeutic anticoagulation. Further studies and registries are needed to improve the understanding of the relationship between COVID-19 infection and the occurrence of thromboembolic events.

Biosynthetic vascular graft: a valuable alternative to traditional replacement materials for treatment of prosthetic aortic graft infection?

BACKGROUND AND AIMS: To report the experience of a tertiary vascular surgery center using Omniflow II® biosynthetic vascular grafts for treatment of prosthetic aortic graft infection. MATERIALS AND METHODS: Retrospective analysis of all patients with prosthetic graft infections who underwent in situ aortic reconstruction using Omniflow II® grafts or other conduits between March 2015 and May 2017. Early and late mortality, perioperative complications, and reinfection rate were analyzed. RESULTS: Sixteen patients (14 males, median age 68.5, range 57-89) with prosthetic aortic graft infection were treated at our center. Eight patients received an Omniflow II® biosynthetic graft, two patients silver-triclosan coated grafts, three patients bovine pericardial tube grafts, and three patients composite bovine pericardial tube grafts with Omniflow II® graft extensions. Perioperative complications occurred in seven patients (43.8%). Early mortality rate was 18.7% (n = 3). In addition, four patients died during follow-up after a median of 11 months (range 0-34 months). We did not observe any reinfections. Bypass grafts were patent in all patients. No major limb amputations were performed during follow-up. CONCLUSION: Treatment of prosthetic aortic graft infection with Omniflow II® vascular grafts is feasible. Graft material seems to have an excellent resistance to infection and might be a valuable alternative to traditional replacement materials. Especially long-term durability has to be continuously monitored and documented.

Retrojugular versus ventrojugular approach to carotid bifurcation for eversion endarterectomy: a prospective randomized trial.

OBJECTIVES: The aim of this prospective randomized study was to demonstrate the comparability of retrojugular access for carotid eversion endarterectomy compared to the conventional ventrojugular procedure. PATIENTS AND METHODS: Due to the expected minor and major complication rate of 5% in patients undergoing carotid surgery, a patient cohort of 600 study patients was planned. All patients underwent standard preoperative and postoperative assessment including clinical investigation and fiberoptic laryngoscopy. The 6 month follow-up examination included an evaluation of patient contentment, a duplex scan, clinical investigation and a fiberoptic laryngoscopy. RESULTS: After the first interim evaluation of 101 patients, the study was stopped because of a significant increase in temporary ipsilateral vocal cord motility dysfunction in the retrojugular access group (31% vs. 6%, p=0.0014). This early postoperative impairment was, however, not statistically significant at the follow-up examination at 6 months (2.4% vs. 0%). No other significant differences concerning major complications (death or stroke), other cranial nerve injuries, wound healing, or patient satisfaction was observed neither in the early postoperative phase nor at follow up. CONCLUSION: Due to the high incidence of temporary ipsilateral vocal cord dysfunction in patients undergoing retrojugular exposure of the carotid artery, we recommend the conventional ventrojugular approach, which can be performed by incision along the anterior border of the sternomastoid muscle or by transversal skin incision.

Intraarterial gadolinium-enhanced magnetic resonance angiography of the renal arteries in humans: feasibility, contrast agent reduction, and accuracy for detection of stenoses.

OBJECTIVE: Feasibility of intraarterial MR angiography of the renal arteries and comparison of the accuracy of intraarterial MR angiography with selective intraarterial digital subtraction angiography (DSA) for detection of stenoses. MATERIALS AND METHODS: Ten consecutive patients (mean, 68 years) with suspected renal artery stenosis underwent a digital subtraction angiography and an intraarterial gadolinium-enhanced MR angiography, performed on a 1.5-T system. For intraarterial MR angiography 60 ml diluted contrast agent (10 ml gadodiamide in 50 ml 0.9% saline solution) was injected through a conventional angiography catheter placed in the suprarenal abdominal aorta using a flow rate of 3.5 ml/s. A three-dimensional (3D) gradient-echo sequence was performed. Differences in the quantitative measurement of stenoses of lesions between DSA and intraarterial MR angiography were evaluated by three observers. Overall impression of the intraarterial MR angiography was documented on a four-point scale (1 = excellent to 4 = poor). Interobserver variability was calculated. RESULTS: Intraarterial MR angiography of the renal arteries was feasible in all patients (100%) with a mean overall impression of all images of 1.8 (SD: 0.71). One of 9 accessory renal arteries was not visualized with intraarterial MR angiography. The overall sensitivity/specificity for detection of significant stenoses (>or=50% stenosis) were 83%/87%. Interobserver variability of intraarterial MR angiography ranged between fair and substantial (0.359-0.622). CONCLUSION: Intraarterial MR angiography of the renal arteries in humans is feasible and has an acceptable sensitivity in detecting stenoses using injections of diluted contrast agent at concentrations as low as 17%.

Early experience shows rapid shrinking of abdominal aortic aneurysms after endovascular treatment with Anaconda device.

BACKGROUND: The Anaconda prosthesis is a new endovascular device for abdominal aortic aneurysms repair. AIM: of the study was to evaluate successful access to the arterial site, safety and efficacy of stent placement and fixation, assessment of endoleaks, patency of the graft due to twists, kinks or obstruction within the first 30 days after the procedure. Secondary objectives were the assessment of clinical success after 6 months due to graft patency and aneurysm exclusion without endoleak as well as the continuing clinical success without showing aneurysm expansion or any graft failure. PATIENTS AND METHODS: Between 2003 and 2006 a total of 14 patients with infrarenal aortic aneurysm (median diameter prior to endovascular treatment: 56.7 mm (range: 50 to 70 mm) were treated with the Anaconda endovascular device. 8 of these patients were treated in accordance to a prospective Phase II clinical study protocol (Anaconda ANA 004). 6 more patients received the same endovascular device after CE-certification. RESULTS: Primary and secondary objectives were achieved in 12 of 14 patients after 6 months. In one patient insertion of the graft system was impossible due to kinking and circular calcification of the iliac arteries. Iliac access utilizing an alternative stent graft system (Cook, Zenith) was also unsuccessful. This patient underwent a conversion to open surgery and died. Another patient died 6 months after treatment unrelated to the procedure. A significant reduction of the median aneurysm diameter from 56.7 to 49.0 mm (range: 45 to 54 mm) was achieved after 6 months (p = 0.05). No endoleak was seen in the follow up. CONCLUSIONS: Early results show that he Anaconda endovascular device for aneurysm repair is a safe and effective device for patients with suitable abdominal aortic aneurysms and proper distal access vessels which results in significant aneurysm diameter decrease and a low complication rate after 6 months of follow-up.

A primary tumor promotes dormancy of solitary tumor cells before inhibiting angiogenesis.

Mechanisms that regulate the transition of micrometastases from clinically undetectable and dormant to progressively growing are critically important but poorly understood in cancer biology. Here we examined the effect of a primary tumor on the growth of solitary tumor cells in the mouse liver, as well as on the development of tumor angiogenesis in a dorsal skin-fold chamber. s.c. placement of a CT-26 (BALB/c-derived mouse colon carcinoma) primary tumor markedly inhibited development of liver metastasis in BALB/c mice after subsequent intraportal injection of tumor cells. Dorsal skin-fold chamber experiments showed that this growth inhibition paralleled a strong antiangiogenic effect by the primary tumor. Furthermore, intravital microscopy of the liver after intraportal injection of green fluorescent protein-expressing tumor cells showed that primary tumors promoted dormancy of single tumor cells for up to 7 days. Immunohistological staining for Ki-67 confirmed that these solitary cells were indeed dormant. In contrast, in the absence of a primary tumor, GFP-expressing tumor cells quickly developed into micrometastases. Thus, primary CT-26 tumor implants nearly abrogated tumor metastasis by inhibition of angiogenesis and by promoting a state of single-cell dormancy. Knowledge of the mechanism underlying this dormancy state could result in the development of new therapeutic tools to fight cancer.

Inflammatory diseases of the aorta: Part 1: Non-infectious aortitis.

Aortitis is a term which encompasses inflammatory changes to the aortic wall from various pathogenic etiologies. Large vessel vasculitis, such as Takayasu arteritis and giant cell arteritis represent the most common entities; however, there is also an association with other rheumatological diseases. Chronic idiopathic periaortitis represents a distinct disease entity and infectious aortitis is a rare but life-threatening disease. Due to the diverse clinical pictures vascular surgeons often face a significant challenge in terms of making an accurate initial diagnosis. Treatment requires an interdisciplinary approach. This article describes the pathogenesis of the various forms of aortitis as well as the diagnostic methods and treatment approaches.

Inflammatory diseases of the aorta: Part 2: Infectious aortitis.

Infectious aortitis is a rare but life-threatening disease. Due to impending local and systemic complications, prompt diagnosis and initiation of effective causal treatment are essential for patient survival. Differentiating infectious aortitis from other aortic diseases, in particular non-infectious aortitis, is of great importance. This article discusses the various causes, diagnostic tools, and therapeutic strategies for infectious aortitis.

Xenografts in septic vascular surgery.

BACKGROUND: In general, autologous veins are the optimal replacement material for an infected vascular graft in terms of handling, durability and resistance to reinfection. In the absence of suitable autologous material, several options are available, each of which has specific advantages and drawbacks with regard to these characteristics. METHODS: In recent years, xenogeneic materials (in particular pericardial patches from different species and biosynthetic grafts) have been increasingly used as replacement material in the setting of infections. Bovine and equine pericardial patches are applied in particular as self-made tube grafts in the aortic region and also in infections of iliacofemoral prosthetic grafts and shunt infections. RESULTS: The results of small clinical series on durability and resistance to reinfection are promising. CONCLUSION: It is feasible to use biosynthetic materials to replace infected intracavitary and extracavitary vascular grafts with remarkably low reinfection rates; however, the unique mechanical properties of the grafts as well as the initially increased thrombogenicity, need to be taken into consideration.

The endovascular performance spectrum of vascular surgery departments in Germany: Results of an online survey among senior department physicians.

AIM: To survey the scope of vascular surgery services in Germany. METHOD: A total of 308 senior German vascular surgeons received a 19-point questionnaire pertaining to department structure and scope of services. Of these surgeons 223 replied between 16 August 2015 and 23 October 2015 (response rate 72 %), with 62.2 % reporting an additional qualification as an endovascular surgeon according to the guidelines of the German Society for Vascular Surgery and Vascular Medicine (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin, DGG) and 43.5 % as a DGG® endovascular specialist. RESULTS: The number of respondents fully authorized to train in vascular surgery was 71.3 %, while 28.3 % were authorized for limited training. Authorization as a DGG® endovascular surgeon was reported by 24.2 % and authorization as a DGG® endovascular specialist by 17 % of respondents. All respondents performed endovascular interventions on pelvic vessels and 99.1 % also reported carrying out femoral and popliteal endovascular interventions. Endovascular procedures in crural vessels were carried out by 90.1 % and 93.7 % of vascular surgeons performed endovascular procedures in the region of the abdominal aorta (segment V), arteriovenous (AV) fistulas and shunts (85.2 %), upper extremity vessels (80.3 %), the thoracic aorta (segment III, 68.2 %), renal arteries (62.8 %) and visceral aorta (segment IV, 60.5 %). In all 43.5 % of respondents reported experience with endovascular procedures on the carotid bifurcation. Percutaneous arterial procedures formed the focus of endovascular activity, totalling on average 259 interventions per year and department, followed by diagnostic angiography (without intervention) at 166 procedures per year and hybrid arterial interventions at 141 interventions per year. CONCLUSION: This survey revealed a high level of endovascular expertise among vascular surgeons in Germany. This applies not only to the scope of endovascular activities in diagnosis and treatment but also to the number of estimated annual procedures.