Prospective 2-years follow-up quality of life study after infrageniculate bypass surgery for limb salvage: lasting improvements only in non-diabetic patients.

OBJECTIVES: To assess health-related quality of life (HRQoL) up to 24 months after successful infrageniculate bypass surgery for limb-threatening ischaemia. METHODS: 89 patients with infrageniculate bypass surgery for limb-salvage were studied. HRQoL was assessed using the Short Form (SF)-36v1 questionnaire before, 6, 12, and 24 months after revascularisation. RESULTS: 47 patients (53%) with intact limb and functioning graft were assessed after 24 months, 27 patients (30%) died, further 7 required secondary amputation, 3 suffered irremediable graft occlusion, and 4 were lost to follow-up. The 24-months HRQoL-values were significantly improved in 4 domains: physical functioning (p<0.01), bodily pain (p<0.01), mental health (p=0.04), and social functioning (p=0.01). Except for baseline-values, HRQoL remained inferior in diabetics compared to non-diabetics throughout follow-up. Maximum improvement of HRQoL was delayed in diabetics (12 months vs. 6 months) and less pronounced. After 24 months non-diabetic patients maintained improvement in 5 domains and diabetic patients only in bodily pain. CONCLUSIONS: Improvement in HRQoL is sustained for more than 12 months after successful infrageniculate bypass surgery. Therefore, an aggressive approach towards revascularisation seems to be justified from the patient's perspective. However, this benefit in quality of life is less in diabetic patients, despite similar limb-salvage rates.

[Incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in the treatment of peripheral arterial occlusive disease in a German referral center 1996-2003]. / Inzidenzen von Major-Amputationen, Bypass-Operationen und perkutanen transluminalen Angioplastien (PTA) zur Behandlung der peripheren arteriellen Verschlusskrankheit in einer deutschen Klinik der Maximalversorgung 1996-2003.

PURPOSE: To determine the current incidence of major amputations, bypass procedures and percutaneous transluminal angioplasties (PTA) in a study population of patients with peripheral arterial occlusive disease in a German referral center. MATERIALS AND METHODS: In a retrospective study, we recruited patients with peripheral arterial occlusive disease who underwent an amputation, bypass procedure, or PTA in the region of the pelvis or lower limbs between 1996 and 2003 at the Augsburg Medical Center. Patients were identified via the hospital database. This was performed with the help of the International Classification of Diseases (ICD 9 and 10), the operation code (OPS), and appropriate invoices. The incidence of PTAs was further estimated with 200 charts. RESULTS: Of 5379 patients, 627 underwent amputation, 1832 a bypass procedure, and 2920 a PTA. The incidence of PTAs increased during the study period from 51.3/100 000/year to 64.4/100 000/year (p < 0.01), while the number of amputations and bypass procedures remained stable. The incidence of PTAs was exceeded by that of bypass procedures only in patients older than 85 years. The age of the amputees decreased during the study period from 72.2 to 70.5 years (p < 0.01). The age of patients who underwent a bypass procedure increased from 67.2 to 69.4 years, and the age of patients who underwent PTA increased from 66.3 to 69.8 years (p < 0.01). Bypass procedures and PTAs were performed in men 6.3 years earlier than in women (p < 0.01). CONCLUSION: The result is a population-corrected need of 8.4/100 000/year major amputations, 23/100 000/year bypass procedures and 64.4/100 000/year PTAs for patients with peripheral arterial occlusive disease within the referral area of our hospital. The performance of major amputations and bypass procedures stagnates, while the incidence of PTAs is increasing.

Risk factors for survival in patients with end-stage renal disease undergoing infrainguinal bypass surgery.

BACKGROUND: A poor longevity and high perioperative morbidity make lower extremity revascularization questionable in patients with end-stage renal disease (ESRD). Therefore, careful selection of patients for surgery is essential. Aim of this study was to assess negative predictors of survival in patients with ESRD undergoing infrainguinal bypass grafting for critical limb ischemia (CLI). PATIENTS AND METHODS: We reviewed the records of 49 consecutive patients with ESRD who underwent infrainguinal bypass grafting for limb salvage. Rates were computed with life-table analysis and compared by log-rank test. Effects of demographic and disease variables on the survival rate were evaluated by Cox proportional hazard regression model. RESULTS: Indications for surgery were rest pain in two (4.1%) and tissue loss in 4 7 patients (95.9%). Median follow up was 7.8 months (IQR, 2.43 to 16.23). Perioperative (30-day) morbidity and mortality for all patients were 6.1% and 12.2%, respectively. Primary and secondary patency at two years both were 81.4%. Cumulative survival rate at two years and four years were 24.9% and 9.3%, respectively Limb salvage rate and amputation-free survival rate at two and four years were 80.4%, 53.6%, 21.8% and 14.6%, respectively. Myocardial infarction and congestive heartfailure in the patients medical history both had an adverse effect on survival rate with a hazard ratio of 5.52 (95% CI, 1.94 to 15.69) and 3.12 (95% CI, 0.99 to 9.81), respectively. CONCLUSIONS: In the presence of myocardial infarction or congestive heart failure in the medical history survival rate is especially poor for patients with ESRD undergoing infrainguinal revascularization. Therefore, bypass surgery for CLI is hardly indicated in this group of patients.

Duplex scanning criteria for selection of patients for internal carotid artery endarterectomy.

BACKGROUND: The value of carotid endarterectomy for stroke prevention depends on reliable identification of patients at higher risk for stroke from their internal carotid artery (ICA) occlusive disease than from surgery. This selection of patients is based on the degree of ICA stenosis. Therefore, preoperative diagnostic measures should strive for a prevalence independent probability for disease of 100%. Aim of this prospective study was to obtain clinically applicable duplex scanning criteria for ICA stenosis > or = 70% with a probability for disease of 100%. PATIENTS AND METHODS: In 124 ICA in 62 patients (79% male) angiography and duplex scanning were performed. Degree of stenosis was classified in 4 categories: I < 50%; II 50%-69%; III 70%-99%; IV 100%. Cohen's kappa statistic was used to estimate agreement between both methods within categories. To improve accuracy post-test likelihood for disease was calculated for each point on the receiver operating characteristics (ROC)-curve for peak systolic (PSV) and end-diastolic velocity (EDV), and cut-off points for velocity criteria were set at a positive likelihood of 100%. RESULTS: Diagnostic agreement was good with kappa = 0.77 (95% CI, 0.64-0.90; p < 0.001). For EDV a criterion of > or = 150 cm/sec was associated with a post-test likelihood for disease of 100%. For PSV no appropriate criterion could be detected. CONCLUSIONS: A probability of 100% for ICA stenosis > or = 70% can be achieved by mere preoperative duplex scanning. Vascular laboratory specific validation of duplex scanning criteria should consider prevalence independent post-test likelihood for disease to ensure the value of CEA for stroke prevention.

[Percutaneous transluminal angioplasty (PTA) of isolated crural arterial stenoses in critical arterial occlusive disease]. / Perkutane transluminale Angioplastie (PTA) isolierter Unterschenkelarterienstenosen bei kritischer arterieller Verschlusskrankheit.

PURPOSE: Retrospective analysis of the results after infrapopliteal PTA of isolated crural limb artery stenoses in patients with critical crural limb ischaemia. PATIENTS AND METHODS: Between 1989 and 1994 70 infrapopliteal dilatations of isolated crural limb artery stenoses in 44 patients (47 PTA procedures) were done with small diameter balloon catheters. 45 patients were stage IV according to Fontaine's classification, two patients were stage III. No patient had a relevant obstruction up to the popliteal artery. Follow up ranged from 1-50 months (mean 13.3 months). RESULTS: A technical success with a residual stenosis below 30% compared to the original vessel diameter was achieved in 80% of patients (n = 56). The cumulative limb-salvage rate was 76.6% after 6 to 36 months after PTA. RESULTS: In patients with chronical critical crural limb ischaemia PTA of isolated crural limb artery stenoses is an efficient therapy modality for limb-salvage. In many cases PTA is the last alternative method to amputation surgery if there is no sufficient distal vessel for a bypass.

[Follow-up of infra-inguinal bypass operations: value of the peak systolic velocity and arm-ankle index for evaluation of femorodistal reconstructions]. / Verlaufskontrolle infrainguinaler Bypassoperationen: Bedeutung von systolischer Spitzengeschwindigkeit und Arm-Knöchel-Index für die Bewertung femorodistaler Rekonstruktionen.

In a prospective study, the efficacy of noninvasive surveillance techniques including measurement of ABI and duplex-derived velocity parameters was studied after 74 infrainguinal arterial reconstructions. A decrease of ABI > or = 0.2 compared with prior examinations was considered abnormal. Results of the duplex scan were interpreted as abnormal when PSV was less than 45 cm/sec or greater than 200 cm/sec or when an interval decrease of greater than 30 cm/sec occurred. All patients meeting any of these criteria during the follow-up examinations were subjected to i.a. DSA. The combination of all duplex velocity criteria was significantly more sensitive to identify a failing graft than was measurement of ABI (90% vs. 18%; p = 0.00004). When independent variables (ABI- and PSV criteria, monophasic curve configuration) were entered into a logistic regression multivariate analysis, the model proved to be effective (F-value 5.551; df 4.8; R2 = 0.735; significance 98.03%; p < 0.02) in predicting angiogram findings (dependent variable). ABI measurements (significance 4.75%; p > 0.95) and the presence of a monophasic curve configuration (significance 89.58%; p > 0.1) failed to reach significance in the multivariate analysis. By excluding these latter parameters, the statistical power for the model could be improved (F-value 1036.57; df 2.1; R2 = 0.999; significance 97.69%; p = 0.0231): As a result normal PSV criteria indicated normal and abnormal angiographic findings in 83 and 17%, respectively. A PSV less than 45 cm/sec or greater than 200 cm/sec was suggestive of an abnormal angiogram in 80% and of a normal angiogram in 20%. The corresponding figures for a PSV interval decrease > 30 cm/sec were 71% and 29%. In conclusion, PSV parameters were found to be measurably more accurate to identify a failing graft than was measurement of ABI.

[Percutaneous balloon dilatation of isolated lesions of the calf arteries in critical ischemia of the leg]. / Perkutane Ballondilatation bei isolierten Läsionen der Unterschenkelarterien mit kritischer Beinischämie.

Between 1990 and 1993 we performed 42 percutaneous transluminal balloon angioplasties (PTA) in 30 patients with isolated lesions of crural arteries and limb threatening ischaemia. The average age of the patients was 70.5 years, 90% were diabetics. With low-profile balloon catheters between 2 and 4 mm we dilatated 15 tibioperoneal trunks, 12 anterior tibial arteries, 3 posterior tibial arteries and 12 peroneal arteries. Initial success was achieved in 83% of the dilatations with an average increase of ankle-brachial index of 0.18. After PTA two groin haematomes as the only complications were observed. In 22 cases healing of the acral lesions under local surgical treatment was seen. Two of the clinical unsuccessful patients required popliteopedal bypass surgery and 5 below-knee amputation because of lacking reconstructive possibilities. The follow-up period varied from 1 to 35 months (mean 10.3 months). Life table analysis showed a cumulative limb salvage rate of 82% after one and two years. The PTA of infrapopliteal artery stenoses and occlusions is considered as an effective and safe therapy modality to avoid below-knee amputation in patients with limb threatening ischaemia.

[The diagnostic value of angioscopy in venous thrombectomy]. / Diagnostischer Stellenwert der Angioskopie bei der venösen Thrombektomie.

Since 1983 angioscopy was applied as a control method in 187 venous thrombectomies to improve the treatment of acute iliofemoral thrombosis. In a retrospective study we tried to show the impact of angioscopy intraoperatively and the influence on long-term results. Thrombectomy was performed in 97 patients affected at three levels, in 50 cases with pelvic-femoral, in 35 with pelvic and in 43 with femoro-tibial thrombosis. The average clinical age of the thrombosis was 5 days, 66% of the patients (age 39 years) were female. The endoscopic findings were compared with phlebological results after one year using a phleboscore between 0 points (occlusion) and 5 points (normal). The phlebographies were analyzed so that the functional status of the vein was represented. After venous thrombectomy 42.8% of the cases were endoscopically classified complete but in 57.2% residual clots were observed. It was possible to completely (24.6%) or partly (18.7%) remove these clots by further thrombectomy maneuvers, non removable remnants were found in 7.5% and a venous spur in 6.4%. The statistical analysis with Kruskal-Wallace test showed significant differences in venous morphology between the endoscopically complete thrombectomies and those with residual clots. After a follow-up period of 30 months (12-64) the clinical results were very good. In 58% we observed normal findings, a cvi grade I in 35%, grade II in 4%. Crural ulcers had developed in only 3%. From our data we conclude that endoscopy is an excellent method for intraoperative quality-control in venous thrombectomy.

The importance of graft blood flow and peripheral outflow resistance for early patency in infrainguinal arterial reconstructions.

BACKGROUND: At present, the importance of functional parameters as determinants for graft patency is under debate. Therefore, in our institution a prospective study was undertaken to evaluate the influence of graft blood flow as well as the currently applied methods for outflow resistance measurement on early (< or = 30 days) graft outcome. PATIENT AND METHODS: 101 arterial revascularisations with infrageniculate graft insertion were entered into this study. After having verified the morphological integrity of the reconstruction, during temporary inflow occlusion total outflow resistance (TOR) was determined as a pressure/flow relationship by perfusion of the graft with saline (flow rates 25, 50, 100, 150 ml/min before and after papaverine) while simultaneously recording pressure generated at the distal anastomosis. In addition, after restoration of blood flow, flow index (FI) was calculated in an analogous way from the TBF through the graft and the respective mean distal anastomotic pressure. Graft patency at 30 days was determined by Duplex ultrasound. RESULTS: Functional parameters were found to be unable to differentiate between patent and failed reconstructions during the 30 day period: The mean TORaveraged values amounted to 722.5 (SD = 310) in patent and 735.9 (SD = 228.1) mPRU in occluded bypasses (T-value = 0.1681; n.s.). The corresponding figures were 176.8 (SD = 94.2) and 196.4 (SD = 93.6) ml/min for TBF (T-value = 0.7342; n.s.) and were 0.53 (SD = 0.34) and 0.45 (SD = 0.25) PRU for FI (T-value = 0.8905; n.s.). Using multiple logistic regression analysis functional parameters showed no influence on graft patency while graft length and the necessity for intraoperative graft modification emerged to be significant determinants of early graft outcome (R2 adjusted = 0.46; p = 0.006). CONCLUSION: The results of our study suggest that neither blood flow nor the presently used methods to assess outflow resistance are relevant prognostic factors for early (< or = 30 days) graft performance.

Early carotid endarterectomy in patients with a nondisabling ischemic stroke: results of a retrospective analysis.

BACKGROUND: There are several recent recommendations not to delay carotid endarterectomy (CEA) for at least 4 weeks in patients experiencing a nondisabling ischemic stroke. Therefore, we re-examined if these patients could be safely operated on earlier: The aim of our study was to review the perioperative stroke and death rates of CEA performed within 30 days of stroke onset. PATIENTS AND METHODS: During a 4 year period until December 2001, in 66 neurologically stable patients suffering a nondisabling stroke ipsilateral to a carotid artery stenosis > 50% CEA was performed after a median interval of 10 (1-28) days. The modified Rankin scale (mRS) was applied to characterize the severity of impairment of daily living activities pre- and postoperatively: Any postoperative deterioration > 24 hours on the mRS was considered as a new stroke. RESULTS: Operative mortality was 0%, and postoperative neurologic worsening > 24 hours occurred in 8/66 patients (12.1%). In 5/8 patients neurologic deterioration resolved within 5 days after surgery, only one stroke was permanent (1.5%). There was no correlation between timing of surgery or the presence of acute ipsilateral cranial CT defects with the occurrence of postoperative stroke. Stroke severity grading on admission according to the mRS, however, emerged to be a significant determinant of postoperative outcome: While 6/23 patients (26%) with an initial deficit > or = 3 on the mRS developed neurologic worsening, this was the case in only 2/43 patients (4.6%) with a deficit < or = 2 (Odds Ratio 7.2; 95% CI 1.32-39.49; two-sided p = 0.01). CONCLUSION: Our results suggest that selected patients with a minor stroke (mRS < or = 2 on admission) can safely undergo early CEA.

Tibioperoneal arterial lesions and critical foot ischaemia: successful management by the use of short vein grafts and percutaneous transluminal angioplasty.

BACKGROUND: In a substantial number of mainly diabetic patients isolated crural arterial lesions are found to be the underlying cause for severe ischaemic foot lesions. Without revascularisation, patients with this specific occlusion pattern will inevitably face major amputation. To attain limb salvage in this setting, since the early eighties short vein grafts were used to bypass the occluded infrapopliteal arteries. More recently, percutaneous transluminal angioplasty (PTA) was also attempted to avoid limb loss in selected patients. PATIENTS AND METHODS: Since May 1986 in 125 patients 130 autologous bypass grafts from the BK-popliteal artery or the proximal tibioperoneal arteries to malleolar vessels were performed in the presence of extended crural arterial occlusions and critical foot ischaemia (rest pain 3, tissue loss 127). In another series in 89 limbs (rest pain 5, tissue loss 84) of 84 patients PTA was done to treat 168 focal stenoses of > 50% diameter reduction and 11 short occlusions in a total of 135 crural arteries. RESULTS: Using life-table analysis, primary and secondary cumulative patency rates for short vein grafts with distal graft origin were 90% and 98% at 30 days, 76% and 83% at one year and 46% and 49% at seven years, respectively. The corresponding limb salvage rates amounted to 95%, 80% and 63%. Initial complete or partial technical success after PTA of crural arteries could be obtained in 93%: The limb salvage rates achieved were 95% at 30 days, 82% at one year and 63% at six years. CONCLUSION: Our results suggest that--depending on the extent of lesions--both short vein grafts as well as PTA are successful complementary treatment modalities to avoid limb loss in predominantly diabetic patients with infrapopliteal artery disease and critical ischaemia.

[Patient assessments of quality of life following bypass for chronic critical limb ischaemia]. / Bypass bei chronisch kritischer Extremitätenischämie. Lohnt sich die Mühe aus Sicht des Patienten?

The value of infrainguinal bypass surgery for critical limb ischaemia (CLI) in elderly patients is being scrutinised more as medical resources decline. Despite technically successful revascularisation, patient quality of life seems impaired by delayed wound healing and repeated hospitalisation for interventions and operations. Therefore it is questionable whether these frail patients benefit from bypass surgery with respect to their health-related quality of life. This review examines current evidence of patients with CLI and summarises the effect of bypass surgery on their own quality of life assessments. All in all, patients benefit from the revascularisation because ambulation status improves and independence is preserved. From a patient's perspective these improvements in quality of life justify an aggressive approach towards revascularisation for CLI.

[Vertebrobasilar ischemia as a complication of temporal arteritis. Results of a prospective, clinical, ultrasonographic study]. / Vertebrobasiläre Ischämie als Komplikation der Arteriitis temporalis. Ergebnisse einer prospektiven klinischen und ultrasonographischen Untersuchung.

BACKGROUND: Cerebral symptoms in temporal arteritis (TA) may occur if large arteries are affected. To avoid progression of the disease, the immediate administration of adequate doses of steroids is mandatory. PURPOSE: The prevalence and severity of vertebrobasilar ischemia (VBI) and its relation to structural abnormalities of the vertebral arteries were studied. METHODS: Clinical and ultrasound data were analyzed in a hospital-based group of 91 patients who received the diagnosis of TA following standard criteria. RESULTS: In contrast to the occurrence of neuro-ophthalmological complications (27.5%), the rate of VBI was low (4.4%). TIA occurred in three cases and mild stroke in one. Ultrasound demonstrated severe occlusive disease of the extradural parts of the vertebrobasilar arteries consisting of hypoechogenic, concentric, mural thickening. The same was found in the superficial temporal arteries. CONCLUSIONS: In elderly patients presenting with VBI, TA affecting the vertebral arteries should be considered. In experienced hands, ultrasonography allows the atraumatic preliminary diagnosis of TA.

[Postoperative digital subtraction angiography after infrainguinal bypass operation]. / Die postoperative digitale Subtraktionsangiographie nach infrainguinalen Bypassoperationen.

Bypass occlusions in infrainguinal arterial reconstructions occur in up to 20% within the first postoperative month and are caused by technical defects in most cases. In a prospective study to evaluate the importance of imaging techniques in infrainguinal bypass grafting 81 of 103 bypasses were examined by intraarterial DSA 10 days postoperatively. The findings of early postoperative DSA were compared with the results of intraoperative angioscopy and completion angiography. In 11 cases (13.6%) there were additional pathological findings. In 6 patients stenoses were localized at the proximal anastomosis, which could not be visualized intraoperatively due to technical reasons. In 2 more patients postoperative DSA revealed an occlusion of the distal segment of the recipient artery with a retrograde blood flow in the proximal segment. Further pathological findings were one perianastomotic stenosis caused by a thrombus at a venous valve site and one arteriovenous fistula in an in-situ-bypass. In one more patient angiography showed a stenosis in the outflow tract. The duplex-derived PSV, however, was normal and no revision was made. At present, examination of the proximal anastomosis is possible by intraoperative DSA, but initially unrecognized and secondary bypass defects can only be identified by early postoperative DSA in asymptomatic patients. A final scrutiny of the arterial reconstruction can be achieved by postoperative DSA without any recognizable morbidity before subsequent bypass function is monitored by non invasive methods like duplex sonography.

Superior mesenteric venous aneurysm.

The case of a 50-year-old woman with an extremely rare venous malformation of the portal venous system is reported. The patient presented with a true aneurysm of the superior mesenteric vein, which has thus far been reported in no more than eight cases worldwide. This malformation may be congenital or acquired. Secondary aneurysms are thought to be due to liver disease, portal hypertension, trauma, or inflammation. Aneurysms of the portomesenteric venous system may be asymptomatic or give rise to severe, often dramatic conditions such as crampy abdominal pain, jaundice, and upper gastrointestinal hemorrhage secondary to portal hypertension. The diagnosis is usually made by ultrasound (B-mode or color flow Doppler), CT scan, and MRI. Invasive procedures such as venous phase mesenteric arteriography or splenoportography may be helpful in confirming it. In our opinion aneurysms of the portal venous system, even if they are congenital and (still) asymptomatic, require early surgical control because the prognosis for patients with these aneurysms is unpredictable and potential complications (e.g., portal hypertension, fistula, contained perforation, or rupture) may be fatal. In the case presented the mesenteric venous aneurysm was resected and the confluent veins were reconstructed.

[Intraoperative quality control in carotid surgery]. / Intraoperative Qualitätskontrolle in der Carotis-Chirurgie.

The intraoperative quality control in carotid surgery is performed by different methods: angiography, duplex-ultrasonography, transcranial Doppler ultrasonography, cw-Doppler, B-mode ultrasonography, pulsed Doppler with spectral analysis, angioscopy and flow-measurements. In Germany these measures are used only in one third of the carotid reconstructions. Especially with angiography and duplex-ultrasonography technical defects can be detected and differentiated if they were without clinical relevance like low-grade stenoses, small intima-flaps and residual plaques or needed to be reexplored. These are high-grade stenoses, acute thrombus-formations of the endarterectomised area and large intima-flaps. Abnormalities were detected in a mean of 17% of all carotid reconstructions by intraoperative control methods. In 5% severe irregularities lead to an immediate revision. Despite that there does not exist clear evidence whether the use of quality control methods reduces the perioperative neurological complication rate. It is not necessary to perform intraoperative quality control if meticulous operative technique with shunting and patch angioplasty is applied and a low perioperative complication rate is reached. For the documentation of the surgical result angiography can be recommended.

[Endovascular therapy in pelvic vein spur]. / Endovaskuläre Therapie bei Beckenvenensporn.

Treatment of pelvic vein spur is indicated in patients suffering from severe leg swelling and pain as well as after thrombectomy or lysis of spur-related deep vein thrombosis (DVT). In symptomatic patients without accompanying DVT, secondary patency amounted to 100% after 2 years when the spur was dilated and a self-expanding stent was implanted. In cases with successfully reopened pelvic veins after spur-induced DVT and stent application, the corresponding figure was 82%. Endovascular therapy of pelvic vein spur represents a safe and effective treatment modality. Because of its less invasive nature compared to open surgery, stent implantation has to be considered the method of first choice.

[Early and late results of transperitoneal thrombectomy in thrombosis of the inferior vena cava]. / Früh- und Spätergebnisse nach transperitonealer Thrombektomie bei Thrombose der Vena cava inferior.

Acute inferior vena cava thrombosis is a rare clinical feature with unknown incidence. A clear evidence about the best treatment does not exist. Especially the indications for surgical therapy and their clinical results are published only in a few reports. So the aim of this study was to take a look to our experience and make an evaluation of the combined transcaval and transfemoral venous thrombectomy. In a retrospective study of the past 12 years 19 patients with a mean age of 28.5 years, 15 women and 4 men, showing ascension of a iliofemoral clot to the vena cava were treated by transperitoneal and transfemoral thrombectomy. The mean thrombus age was 7 days, 2 patients had bilateral iliofemoral thrombosis. Simultaneously a transfemoral thrombectomy and transcaval thrombectomy were performed after exposure of the vena cava inferior via transabdominal approach. In all cases a venous patency could be achieved, 3 times a re-thrombectomy within 1 week was necessary. One intraabdominal hematoma was revised surgically. One patient died on the first postoperative day because of a fulminant lung embolism. After a mean follow-up of 6 years 3 patients did not have any symptoms of post-thrombotic sequelae, 13 had mild and only one patient moderate post-thrombotic syndrome. The combined transperitoneal and transfemoral venous thrombectomy of the vena cava inferior represents a safe and effective treatment of the acute thrombosis of the vena cava inferior. Severe post-thrombotic sequelae especially in young women may be avoided.

[Duplex sonographic monitoring of infra-inguinal arterial reconstructions: can a threatened bypass occlusion be detected by this method?]. / Duplexsonographische Uberwachung von infrainguinalen arteriellen Rekonstruktionen: Kann dadurch ein drohender Bypassverschluss erkannt werden?

In our institution, 95 infrainguinal arterial reconstructions were prospectively entered into a graft surveillance programme which consisted of a postoperative i.a. DSA and routine assessment of graft flow velocity (GFV) and ankle pressure indices (ABI) during the first postoperative year. An average of 4.1 GFV measurements was obtained during a mean follow-up period of 8.2 months. Abnormal GFV led to arteriography in 29 bypasses identifying--aside from three false positive findings--two graft occlusions and 24 severe (> 70%) graft stenoses. Of the latter, in only 7 cases a significant decrease in ABI was found. Unheralded graft occlusion occurred in 6 patients. Including the corrections of the above mentioned lesions, secondary patency rates were 97% at 30 days and 89% at one year.