I. Töpel

Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift?

Purpose To review the literature reporting open surgical and endovascular treatment of juxtarenal aortic aneurysm (JAA). Methods A systematic search of the PubMed database was carried out to identify English-language articles published between January 2001 and July 2012 on the management of JAA with open surgery, fenestrated endovascular aneurysm repair (F-EVAR), and the chimney graft technique (Ch-EVAR). The search found 20 studies with a total of 1725 patients (76% men; age range 66–74 years) undergoing open surgery, 10 studies detailing 931 patients (87.6% men; age range 72–75 years) receiving F-EVAR, and 5 studies comprising 94 patients (75% men; age range 68–82) reporting Ch-EVAR. Results A total of 2465 vessels were targeted with fenestrations and 151 with chimney grafts (CG); intraoperative target vessel preservation was 98.6% and 98.0%, respectively. Cumulative 30-day mortality was 3.4%, 2.4%, and 5.3% for open surgery, F-EVAR and Ch-EVAR, respectively (p=NS). Impaired renal function was noted in 18.5%, 9.8%, and 12% following open surgery, F-EVAR, and Ch-EVAR, respectively (open vs. F-EVAR: p<0.001). New-onset dialysis was required postoperatively in 3.9%, 1.5%, and 2.1%, respectively (open vs. F-EVAR: p<0.001). Postoperative cardiac complications were noted in 11.3%, 3.7%, and 7.4%, respectively (open vs. F-EVAR: p<0.001). The incidence of ischemic stroke was 0.1% and 0.3% following open surgery and F-EVAR, but 3.2% after Ch-EVAR (open vs. Ch-EVAR: p=0.002; F-EVAR vs. Ch-EVAR: p=0.012). Early proximal type I endoleak was lower after F-EVAR compared to Ch-EVAR (4.3% vs. 10%, respectively, p=0.002). Conclusion Open surgery remains a safe and effective treatment option for good risk patients with JAA. F-EVAR is associated with low operative mortality, compares favorably to open surgery in terms of morbidity, and current midterm data indicate that it can be a valid treatment option in both low- and high-risk patients. Early results of Ch-EVAR demonstrate feasibility only. In view of the limited number of reports and the lack of long-term data, the technique should be considered only in acute poor surgical risk patients, as a bailout in case of unintentional renal artery coverage, or in elective poor surgical cases that are not suitable for F-EVAR.

Surgical strategy in aortoesophageal fistulae : Endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts

Objective:The surgical treatment of aortoesophageal fistulae (AEF) has a high morbidity and mortality rate. We report our experience with the sequential use of endovascular thoracic stentgrafts and cryopreserved aortic homografts for in situ repair of the descending thoracic aorta. Methods:In a 7-year period, 6 patients with AEF were treated at our center. After primary endovascular repair in all cases, 4 patients subsequently underwent in situ repair of the descending thoracic aorta with cryopreserved homografts. Long-term antibiotic therapy was given in all cases. Recent clinical status and radiologic findings on follow-up studies of each patient were analyzed. The mean follow-up time was 35 months (range, 2–76). Results:Endovascular stentgraft repair was technically successful in all cases. Two patients were not candidates for open surgical repair because of their medical condition; they both died within 8 weeks after discharge from the hospital, 1 from recurrent septic episodes, and the other from upper gastrointestinal bleeding. One of 4 patients who had undergone open surgical repair died 1 year later from upper gastrointestinal bleeding that occurred presumably due to an infectious degeneration of the homograft after secondary infection with a methacillin-resistant Staphyloccocus aureus. In 1 case persistent paraplegia and in another case persistent renal failure occurred. Conclusion:The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.

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.

Use of biosynthetic prosthesis (Omniflow II®) to replace infected infrainguinal prosthetic grafts--first results.

BACKGROUND The current treatment standard of infected infrainguinal prosthetic vascular grafts includes total graft explantation and autologous vascular reconstruction. In the absence of appropriate autologous venous graft material prosthetic grafts with increased bacterial resistance can be used, whereas reinfection rates are still higher than after autologous reconstruction. Biosynthetic grafts have shown low postoperative infection rates when used as elective bypass material. Their higher resistance to bacterial infection could make them an alternative to replace infected prosthetic grafts in the absence of autologous material. PATIENTS AND METHODS Between November 2009 and April 2011, 7 patients with infected infrainguinal prosthetic grafts (Szilagyi 3; 3 supragenicular and 4 infragenicular reconstructions) presented to our institution. There were 4 early (< 3 months after implantation) and 3 late infections (> 3 months after implantation. All grafts were explanted and replaced by biosynthetic grafts (Omniflow II®), because the patient had no suitable peripheral vein for complete autologous replacement. In 2 cases a composite graft with greater saphenous vein was done. In 6 cases microbiological cultures from intraoperatively obtained species were positive. The initial broad spectrum antibiotic therapy was continued according to the antibiogram for 6 to 12 weeks. RESULTS There was no early or late reinfection during follow up (mean 9 months, range 4 - 20 months). During follow up we observed graft occlusions in 3 patients (1 due to kinking of the bypass, 1 due to progressive artheriosclerotic occlusion of the outflow vessels and 1 iatrogenic by external compression with a pressure cuff during arthroscopy). There were no early or late major amputations. One patient died with pneumonia 11 months postoperatively. CONCLUSIONS In the absence of appropriate autologous material biosynthetic grafts seem to be a possible alternative to replace infected infrainguinal grafts. The different mechanical properties of biosynthetic grafts may be of certain disadvantage in infragenicular reconstructions.

Karotisendarteriektomie und Karotisstenting : Pilotstudie eines prospektiven, randomisierten und kontrollierten Vergleichs

ZusammenfassungFragestellung. In einer prospektiven, randomisierten und kontrollierten Pilotstudie werden die Karotisendarteriektomie und die Stenttherapie an einem Patientenkollektiv mit hochgradigen, symptomatischen Stenosen der extrakraniellen A. carotis interna miteinander verglichen. Methodik. Das Design der Studie sieht vor, dass symptomatische Patienten mit der Diagnose einer hochgradigen Stenose (≥70%) der A. carotis interna, die auf dem Boden einer DSA gesichert wurde, eingeschlossen werden. Vor und nach der Therapie finden während der Hospitalisationsphase jeweils eine klinisch-neurologische Untersuchung, eine Duplexsonographie der Hals- und Hirngefäße und eine MRT des Hirns statt. Das Nachsorgeprotokoll nach 1, 6 und 12 Monaten beinhaltet jeweils eine klinisch-neurologische Untersuchung und eine Duplexsonographie sowie nach 12 Monaten zusätzlich eine selektive Angiographie der behandelten Seite und eine weitere MRT des Hirns. Während eines Zeitraums von 9 Monaten wurden bisher 23 von 137 wegen einer Karotisstenose behandelten Patienten in die Studie eingeschlossen, wobei 11 Patienten dem operativen Arm und 12 Patienten dem interventionellen Arm der Studie zugeführt wurden. Ergebnisse. Bei allen 23 Patienten wurde ein Primärerfolg ohne residuelle Stenose >30% erzielt, eine zerebrale Ischämie oder Todesfall traten nicht auf. Die bislang durchgeführten 18 Nachuntersuchungen (neurologische Untersuchung einschließlich Duplexsonographie) bei insgesamt 13 Patienten (13 Kontrollen nach 30 Tagen, 5 Kontrollen nach 6 Monaten) ergaben keine relevante Restenosierung und keine zerebrale Ischämie. Schlussfolgerung. Bislang erwies sich die Stenttherapie in unserer Studie als komplikationsarmes Therapieverfahren. Aufgrund der geringen Patientenzahl kann zum jetzigen Zeitpunkt jedoch noch keine endgültige Bewertung erfolgen.AbstractIntroduction. A prospective, randomized and controlled trial is conducted to compare carotid endarterectomy and carotid stenting in high grade symptomatic carotid artery stenoses. Methods. According to the study design symptomatic patients with a angiographically highgrade (≥70%) internal carotid artery stenosis are included. Pre- and postinterventional diagnostics during the hospitalization period includes neurological assessment, duplex sonography of the cervical and cerebral arteries and magnetic resonance imaging of the brain. Follow-up examinations are scheduled after 1, 6 and 12 months and consist of a neurological assessment and duplex sonography. After 12 months selective angiography and magnetic resonance imaging of the brain will be performed additionally. During a period of 9 months up to now 23/137 patients treated for a carotid artery stenosis were included in the study, 11 patients underwent surgery and 12 patients carotid stenting. Results. Carotid stenting and endarterectomy was primarily successful without residual stenosis >30% in each patient without the occurence of stroke or death. In 18 follow-up examinations (neurological assessment including duplex sonography) of 13 patients (13 follow-up examinations after 30 days, 5 after 6 months) no relevant restenosis and no stroke occured. Conclusion. As of yet, carotid stenting was a safe procedure. Due to the small number of patients a definitive conclusion can not be drawn.

The impact of superficial femoral artery (SFA) occlusion on the outcome of proximal sartorius muscle transposition flaps in vascular surgery patients

OBJECTIVES To demonstrate the feasibility and safety of proximal sartorius muscle rotational flaps in patients with peripheral occlusive artery disease. METHODS Retrospective analysis of 53 patients with 56 proximal sartorius muscle flaps. Indication for a flap procedure was postoperative calcitrant lymphorrhea in nine, graft at risk in 13, and graft infection in 34 procedures. Pre- and postoperative patencies of the superficial femoral artery (SFA) and profundal femoral artery (PFA) were documented. Flap viability, wound healing, and limb salvage were examined at follow-up. RESULTS In 59% of the procedures in this series, the SFA was occluded. The PFA was patent in all patients. Flap viability (100% vs 94%), rate of new (4% vs 6%), and recurrent infections (9% vs 6%), loss of vascular reconstruction rate (9% vs 9%), and limb salvage rate (100% vs 88%) did not differ significantly between the SFA patent and the SFA occluded group. There were four new infections (7%) and three recurrent infections (5.5%) during follow-up, five of which led to a loss of reconstruction. In four of those five patients, the sartorius flap was viable. Two patients died during the immediate postoperative period from septic multi-organ failure (3%). At a median follow-up of 6.4 months, 54 flaps were viable and wound closure was achieved in all surviving 51 patients. Limb salvage rate was 93%. CONCLUSIONS Biologic protection procedures as local muscle flaps are vital adjuncts to vascular surgery techniques in the treatment of complicated wounds in the groin. Occlusion of the SFA in the presence of a patent PFA is not associated with an increased risk of flap loss in proximal sartorius muscle rotational flaps.

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.

Microbial spectrum and primary resistance to rifampicin in infectious complications in vascular surgery: limits to the use of rifampicin-bonded prosthetic grafts.

There are reports that rifampicin-bonded prosthetic grafts might be a suitable alternative to autologous grafts in vascular graft infections and infectious vascular complications. We characterize the spectrum of microbial agents and susceptibility to antibiotic treatment, especially to rifampicin, in these patients. We carried out a retrospective analysis of wound-swaps and blood cultures in 48 patients with infected prosthetic vascular grafts or primary infectious vascular complications. In 15 of 48 patients (31%), the analysis showed that the microbial organism causing the infection was resistant or not susceptible to rifampicin. Rifampicin-bonded prosthetic grafts should be used with caution in acute infectious complications in vascular surgery, because in about 30% of the cases, the initiating microbial organisms are resistant or not susceptible to rifampicin. Without preoperative confirmation of susceptibility to rifampicin, autologous reconstruction should be preferred.

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.

Comparison of venous and HePTFE tibial and peroneal bypasses in critical limb ischemia patients unsuitable for endovascular revascularization

Background We examined short- and long-term outcomes of tibial and peroneal venous and heparin-bonded expanded polytetrafluoroethylene bypasses in patients with critical limb ischemia who were unsuitable for endovascular revascularization. Methods A retrospective analysis was done for all patients who underwent tibial and peroneal bypass surgery in our department between October 2007 and October 2012. Vein was the preferred graft material and used whenever possible. Results One hundred and ninety-eight crural grafts were included. Indications for the surgery were rest pain (30.3%) or ulcer or gangrene (69.7%). Autologous veins were used in 109 cases (vein group) and heparin-bonded expanded polytetrafluoroethylene grafts were used in 89 cases (heparin-bonded expanded polytetrafluoroethylene group). At three years, primary patency for the vein group was 68.2% versus 34.1% for the heparin-bonded expanded polytetrafluoroethylene group (P = .000) and secondary patency was 69.8% versus 35.5% (P = .001). Limb salvage was 81.8% for the vein group versus 56.5% for the heparin-bonded expanded polytetrafluoroethylene group (P = .000) and survival was 62.8% versus 46.7% (P = .019). Conclusions The results of our study show that autologous vein grafts are still first choice for tibial and peroneal bypasses in patients with critical limb ischemia. If no adequate vein is available, heparin-bonded expanded polytetrafluoroethylene bypasses are an acceptable alternative to an otherwise impending major amputation.