H. Loeprecht

PTA arid stenting of benign venous stenoses in the pelvis: Long-term results

AbstractPurpose: To provide follow-up data on endovascular intervention for venous stenoses in the pelvis. Methods: Between 1985 and 1995, 35 patients presented with 42 stenoses of the pelvic veins after operative thrombectomy and creation of an arteriovenous fistula, combined with intraoperative venous angioscopy. All patients underwent angioplasty and, if unsuccessful, percutaneous insertion of an endovascular stent (n=7). Results: Angioplasty with and without endovascular stenting was technically successful in 34 of 35 patients (97%). Average length of the stenoses was 20.6 mm (range 10–90 mm), average diameter before dilation 4.1 mm (range 2–6 mm), and average diameter after dilation 10.1 mm (range 5–18 mm). Intraoperative angioscopy showed pathologic findings (intimal laceration or residual thrombotic material) in 14 patients. After an average follow-up period of 4.13 years. 24 (69%) patients had patent veins. The difference in the primary patency rate between patients with angioscopically abnormal veins (6 of 14 patients, corresponding to a patency rate of 43%) and patients with angioscopically normal veins after thrombectomy (18 of 21 patients, corresponding to a patency rate of 86%) was statistically significant (p<0.01, log rank test). Conclusions: Percutaneous transluminal angioplasty and/or stenting are good treatment modalities for pelvic vein stenosis following surgical thrombectomy. Angioscopically abnormal veins have a poorer long-term patency, regardless of the type of intervention.

Intraoperative imaging techniques in infrainguinal arterial bypass grafting: Completion angiography versus vascular endoscopy

This prospective study was designed to establish whether vascular endoscopy would provide more information on the graft lumen than standard completion angiography during infrainguinal bypass surgery. Ninety-nine patients with 102 infragenicular bypass grafts who underwent both angiography and angioscopy intraoperatively were evaluated. In 99 of the 102 patients the indication was critical limb ischaemia. Of the 102 bypass grafts, 81 were autogenous vein. Distally, 24 grafts were anastomosed to the below-knee popliteal segment, 64 extended to the crural and 14 to the pedal arteries. On completion of the distal anastomosis, grafts were first evaluated by angiography and then by angioscopy. The images obtained with the two monitoring modalities were compared by the operating surgeon and re-explorations were performed immediately if necessary. Completion angiography and angioscopy produced images of good quality in 96 and 97 cases, respectively. In 12 cases completion angiography showed abnormalities. Of these, five were located below the distal anastomosis and were not accessible to angioscopic examination. Conduit defects were found in seven instances. In one of them angioscopy showed the angiogram to be false-positive. Of the 90 grafts with normal completion angiograms, seven were found to show significant pathology on angioscopy. Compared to angioscopy, the sensitivity and specificity of angiography to detect abnormalities within the graft was 46% and 98%, respectively. Our results suggest that vascular endoscopy is superior to angiography for disclosing conduit defects, but that it does not provide adequate information about the distal arterial anatomy.

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.

Technique and Results of Vascular Endoscopy in Arterial and Venous Reconstructions

In an effort to maximize results, vascular endoscopy was used in our institution to monitor arterial and venous reconstructions. Since 1982, angioscopy was applied as a control method in 182 venous thrombectomies to treat iliofemoral thrombosis and 114 aortoiliac thromboendarterectomies. Of the cases with venous thrombectomy reviewed, 50% were incomplete by endoscopic evidence; of these, in 80% the remaining clots could be partly or completely removed. Additionally, in six patients a venous spur was found. Of 114 attempted aortoiliac thromboendarterectomies, only 91 could be completed. In the remainder, endoscopic evidence of persistent intimal flaps forced us to bypass the affected segments. With further miniaturization of the angioscopes, the method was also applied to check vessel repair on small-caliber arteries. In an initial study with 220 femorodistal bypasses we were unable to find a statistically significant difference of primary patency in grafts that were endoscopically controlled or not. In the learning phase with the in situ technique, we identified competent valve remnants in 40%, but this rate could be reduced to 12.7% with growing experience in valvulotomy. We conclude from our data that angioscopy is very helpful in assessing the morphological integrity of aortoiliac thromboendarterectomies and venous thrombectomies. The actual value in infrainguinal arterial reconstructions still remains to be proven.

Die ischämische Form des diabetischen Fußsyndroms

ZusammenfassungDiese Übersicht befasst sich mit direkt und indirekt revaskularisierenden Maßnahmen zur Behandlung der ischämischen Form des diabetischen Fuß-Syndroms. Der Schwerpunkt der Darstellung betrifft infrainguinale Bypassoperationen bei Diabetikern mit kritischer Beinischämie, deren Häufigkeit im letzten Jahrzehnt rapide zugenommen hat. Auch wenn sich die Bypassoffenheit in kontemporären Serien nicht mehr von der bei Nichtdiabetikern erreichten unterscheidet, wird bei Diabetikern noch immer ein schlechteres klinisches Ergebnis unterstellt. In dieser Arbeit soll deshalb neben dem technischen Aspekt der Bypassdurchgängigkeit v. a. der klinische Status von Diabetikern nach infrainguinaler Rekonstruktion untersucht werden. Dazu wird in einer vergleichenden Analyse das Abheilungsverhalten der pedalen Läsionen, der Beinerhalt sowie das Überleben von Patienten mit und ohne Diabetes dargestellt.AbstractIn this review, direct and indirect methods of revascularisation in diabetics with ischaemic foot lesions are discussed. This work focuses on infrainguinal arterial reconstructions in diabetic patients with critical limb ischaemia, the frequency of which has increased rapidly during the last decade. Even though graft patency seems to be comparable with non-diabetics in modern series, an inferior clinical outcome is often assumed for the diabetics.The aim of this evaluation, in addition to discussing the technical aspect of graft permeability, is therefore to elucidate the clinical status of diabetic patients following infrainguinal arterial bypass surgery. For this purpose, the healing process of pedal lesions, limb salvage rate, and the survival in diabetics is analyzed and then compared with the clinical outcome in non-diabetics.

Significance of transcranial doppler CO2 reactivity measurements for the diagnosis of hemodynamically relevant carotid obstructions

Transcranial Doppler ultrasonography can be used to determine CO2 reactivity in the large basal cerebral arteries. CO2 reactivity is expressed as percentage increase of mean flow velocity above one volume percent of CO2, using a reference value of 40 mmHg pCO2 normalized autoregulatory reserve. A normalized autoregulatory value of 15 as the lower limit of the normal range clearly separates patients with internal carotid artery obstructions ≥ 70% from the control group. Stenoses of the ipsilateral internal carotid artery of ≥ 70% result in a significant decrease of normalized autoregulatory reserve in the middle cerebral artery, which can be normalized by removal of the upstream flow obstacle using a carotid thromboendarterectomy. The scatter of normalized autoregulatory values in severe internal carotid obstructions indicates the variability of collateral circulation. A retrospective comparison of normalized autoregulatory reserve and ipsilateral ischemic symptoms in the supply area of the internal carotid artery reveals a significant correlation between clinical symptoms and reduced normalized autoregulatory reserve.

60. Kann das EEG-Monitoring mit dem Trend-Analyzer die Stumpfdruckmessung in der Carotischirurgie ersetzen?

Description of the EEG-trend-analyzer as an intraoperative monitoring during carotis surgery. Criteria for the evaluation of the findings are presented. In a prospective study 92 patients underwent monitoring with the EEG-trend-analyzer as well as the measuring of the internal carotid artery stump pressure. EEG monitoring shows a sensitivity of 100% for ischemic events, compared to 67% for the stump pressure measurement with a threshold of 50 mm Hg. EEG monitoring shows false positive results in 25% but no false negative results. Stump pressure investigation of the internal carotid artery is a very unreliable parameter for cerebral ischemia and inferior to the results of EEG-monitoring.SummaryDescription of the EEG-trend-analyzer as an intraoperative monitoring during carotis surgery. Criteria for the evaluation of the findings are presented. In a prospective study 92 patients underwent monitoring with the EEG-trend-analyzer as well as the measuring of the internal carotid artery stump pressure. EEG monitoring shows a sensitivity of 100% for ischemic events, compared to 67% for the stump pressure measurement with a threshold of 50 mm Hg. EEG monitoring shows false positive results in 25% but no false negative results. Stump pressure investigation of the internal carotid artery is a very unreliable parameter for cerebral ischemia and inferior to the results of EEG-monitoring.ZusammenfassungBerichtet wird über das intraoperative Monitoring bei der Carotisdesobliteration mit dem EEG-trend-analyzer. Beschreibung der Funktionsweise und der Auswertungskriterien. Bei 92 Patienten wurde prospektiv sowohl ein kontinuierliches Monitoring mit dem EEG-Trend-Analyzer durchgeführt, wie auch die Stumpfdruckmessung der A. carotis interna. Während das EEG eine Sensitivität von 100% aufwies, bezogen auf ischämische Läsionen, lag diese bei der Stumpfdruckmessung bei 67%, angenommen einem Schwellenwert von 50 mm Hg. Allerdings zeigt die EEGAuswertung falsch positive Werte in einer Rate von 25%, jedoch keine falsch negativen Werte. Die Stumpfdruckmessung ist wenig verläßlich und der EEG-Trend-AnalyzerUntersuchung unterlegen.

Ergebnisse nach kombiniert-sequentieller Karotis-TEA und kardiochirurgischer Operation

ZusammenfassungDas einzeitige, kombiniert-sequentielle Vorgehen bei kardiochirurgischen Erkrankungen und koexistenten hochgradigen Karotisstenosen ist nach wie vor in der Diskussion. Zielsetzung dieser Arbeit war deshalb eine Bestandsaufnahme unserer diesbezüglichen Resultate anhand der perioperativen (≤ 30 Tage) Zielgrößen “neurologische Morbidität” und “Geamtletalität” sowie ein Vergleich der Ergebnisse mit der kontemporären Literatur. Insgesamt wurde während einer Narkose bei 63 Patienten eine Karotis-TEA im Vorlauf vor einem Klappenersatz (n=3) bzw. einer Myokardrevaskularisation bei unmittelbar therapiebedürftiger KHK (n=60) vorgenommen. In jeweils 18 Fällen lag eine hochgradige symptomatische bzw. bilaterale asymptomatische Karotiserkrankung vor; die übrigen Patienten wiesen eine unilaterale asymptomatische Karotisstenose auf. Innerhalb der ersten 30 Tage nach dem Eingriff erlitten 6 Patienten einen ischämischen Schlaganfall (ipsilateral 2, kontralateral 3, Hirnstamm 1), von denen 2 tödlich verliefen. Aus kardialer Ursache verstarben 3 Patienten. Die neurologische Komplikationsrate betrug somit 9,5%, die kombinierte Morbidität/Letalität belief sich auf 14,3%. Von den im Rahmen einer univariaten Analyse untersuchten Risikofaktoren erwies sich lediglich das Vorliegen einer thorakalen Aortensklerose im Clampingbereich als signifikante Determinante für das Auftreten eines perioperativen Insultes (p=0,0058).Die von uns beobachtete erhebliche Komplikationsrate veranlasste uns zu einer restriktiveren Indikationsstellung: In der derzeitigen Situation wird eine einzeitige Operation nur bei unaufschiebbarer Myokardrevaskularisation und symptomatischer bzw. bilateraler Karotiserkrankung erwogen.AbstractThe combined-sequential approach in patients requiring both cardiac surgery and carotid endarterectomy (CEA) is still under debate. The aim of this study was, therefore, to review our immediate outcome (30 days) with this procedure in terms of neurologic morbidity and mortality and to compare the results with those found in the current literature. In a total of 63 cases, CEA was performed during the same anesthesia prior to valve repair (3) or in patients requiring immediate myocardial revascularisation for severe coronary artery disease (n=60). In 18 cases each a tight, symptomatic carotid stenosis or a bilateral asymptomatic lesion was found; in the remainder, unilateral asymptomatic carotid disease was present. During the first 30 days, 6 patients experienced an ischemic stroke (ipsilateral 2, contralateral 3, brain stem 1); 2 of these were fatal. In addition, 3 patients died as a result of low cardiac output. Altogether, the neurologic morbidity was 9.5% and the combined morbidity/mortality rate amounted to 14.3%. Univariate analysis of factors possibly predicting adverse outcome revealed proximal aortic atherosclerosis as the only significant determinant of postoperative stroke (p=0.0058). The substantial morbidity and mortality rate observed in our study prompted us to restrict our indications for surgery: At present, only patients requiring prompt myocardial revascularization in the presence of symptomatic or bilateral carotid disease are still considered to be candidates for a combined procedure.

Embolisierendes Aneurysma einer persistierenden A. ischiadica

Zusammenfassung Es wird der Fall einer persistierenden, unilateralen, kompletten A. ischiadica mit einem embolisierenden Aneurysma beschrieben, welches rezidivierend zu inkompletten Ischämien am linken Unterschenkel geführt hatte. Eine 66jährige Patientin erhielt dann bei kompletter Ischämie des linken Fußes einen femoropoplitealen PTFE-Bypass unter distaler Ausschaltung des Aneurysmas. Die Thrombosierung von distal nach proximal konnte aufgrund fehlender Rupturgefahr bei einem maximalen Durchmesser von 3 cm abgewartet werden. Seit 1832 wurden 114 Fälle persistierender A. ischiadicae, bei 25 Personen bilateral verlaufend, publiziert. Im frühen Embryonalstadium wird die Blutversorgung der unteren Extremität zunächst über die A. ischiadica gewährleistet, später bildet sie sich zurück und begleitet als Vas comitans den N. ischiadicus. Entwicklungsstörungen können zu einer persistierenden A. ischiadica führen, die mit dem klinischen Bild einer Claudicatio intermittens, Aneurysmabildung mit rezidivierenden Embolien oder einer Ruptur einhergehen kann. Gelegentlich führt sie zu einem pulsierenden, glutealen Tumor und zu einer Kompression des N. ischiadicus.Abstract A case of a persistent, unilateral, complete sciatic artery with an embolizing aneurysm causing severe recurrent limb ischemia is described. A 66-year-old woman was treated with an femoro-popliteal PTFE bypass and distal exclusion of the sciatic artery on the left leg after acute, complete ischemia. Because of lacking rupture risk of the aneurysm, the patient could be monitored for thrombosis from distal to proximal. Since 1832 there have been reported 114 cases of a persistent, sciatic artery, in 25 persons bilaterally. In early fetal phases perfusion of the lower extremities is conducted through the sciatic artery first and then transferred to the external iliac and femoral arteries later. The artery is then found beneath the sciatic nerve. Embryologic development can lead to to a persistent, sciatic artery with clinical signs of claudication, aneurysms with recurrent embolism or rupture, pulsatile gluteal mass and compression of the sciatic nerve.

Der Stellenwert der autologen Klappentransplantation in der Behandlung der chronisch venösen Insuffizienz im Rahmen des postthrombotischen Syndroms

Zusammenfassung Obwohl die tiefe Venenthrombose nicht mehr die schlechte Prognose wie in der Ära vor der Antikoagulation aufweist, bleibt auch heute noch eine Reihe von Patienten mit auf konservativem Weg nicht ausreichend beherrschbarem Ulcus cruris zurück. Präsentiert wird das Fallbeispiel einer 50jährigen Patientin mit chronisch venöser Insuffizienz III im Rahmen eines postthrombotischen Syndroms. Darin werden die Fortschritte in der bildgebenden und funktionellen Diagnostik des PTS dargestellt, wodurch eine zuverlässige Differenzierung hinsichtlich Obstruktion bzw. Reflux möglich ist. Die autologe Klappentransplantation wird als zur Behandlung des Reflux geeignetes Therapiekonzept beim Versagen konservativer Maßnahmen beschrieben, Mängel und Ergebnisse dieser Methode werden diskutiert.Abstract Although deep vein thrombosis now has a better prognosis than in the era before anticoagulation, a number of patients remain in whom ulcus cruris cannot be adequately controlled by conservative treatment. The case report of a 50-year-old woman with stage III chronic venous insufficiency associated with the post-thrombotic syndrome is presented. Progress in imaging techniques and functional diagnostics of the post-thrombotic syndrome make a reliable differentiation of the chronic venous insufficiency possible with respect to obstruction or reflux. If conservative treatment fails, autological valve transplantation is described as a suitable reconstructive management method in the treatment of reflux. Following this report, the results and limitations of this method are discussed.