Mansur Duran

Subclavian carotid transposition: immediate and long-term outcomes of 126 surgical reconstructions.

BACKGROUND Subclavian carotid transposition (SCT) is a safe, effective, and durable treatment in atherosclerotic disease of the proximal subclavian artery. We report about our experience in SCT in a retrospective study with a long-term outcome in 126 cases and discuss our results with the current literature. METHODS From January 1995 to December 2013, we treated 126 patients (51 men, 75 women; mean age, 60.9 years; range, 25-80 years) for proximal subclavian atherosclerotic lesions. Preoperative angiography revealed 58 stenoses (46.0%) and 68 occlusions (54.0%). We performed 126 SCTs. The following parameters were documented through a retrospective chart review: demographic data, occlusion site, preoperative symptoms, cardiovascular risk profile, coexisting cerebrovascular disease, and postoperative outcome. Continuous variables are summarized as mean. Categoric variables are expressed as frequency and percentage. Survival and patency rates were estimated using Kaplan-Meier analysis. RESULTS Four immediate occlusions and 1 hemodynamic relevant stenosis (4.0%) occurred postoperatively. Thrombectomy was successful in 2 and a carotid axillary bypass was performed in 3 cases. Three strokes occurred, one during concomitant carotid endarterectomy. The 30-day mortality was 0%. Follow-up data were obtained on 106 of 126 patients (84.0%). The mean follow-up period was 53.8 months (range, 3-159 months). Twenty-three (18.3%) late deaths occurred. Estimated survival was 121.48 ± 6.86 months (range, 3-112 months). Ninety-five percent reported continuous resolution of symptoms. Primary patency rate was 96.0% and secondary patency rate was 100% at 30 days. The long-term patency rate was 96.3% at a mean follow-up of 53.8 months. CONCLUSIONS SCT is safe, effective, and durable in the long term. SCT is a standard procedure for occlusion and stenosis. Vessel occlusions, ineffective angioplasty, and preparation for thoracic stent grafting make SCT an important procedure in the surgeons repertoire.

Vascular Challenges in Renal Transplantation

BACKGROUND The increasing demand for transplantable organs, especially kidneys, has led to expanded criteria for renal transplant donors. As a result of the expanded criteria, more organs with vascular anomalies and/or pathologies are available for transplant. This retrospective study evaluated the impact of vascular repair on the outcome in kidney transplantation in a single center over a 15-year period. MATERIAL AND METHODS Between January 1997 and May 2012, 1134 deceased donor renal transplantations were performed in the Department for Vascular and Endovascular Surgery of the University of Düsseldorf, Germany. RESULTS A vascular reconstruction of some type was necessary to repair renal vessels or to prepare the recipient site for transplantation in 374 of 1134 (33.0%) renal transplantations. The iliac artery in 12.3% (139/1134) of cases and the renal artery in 10.1% (115/1134) of cases showed severe atherosclerosis and a thrombo-endarterectomy was required. Organ loss occurred in 13 cases (1.1%) due to vascular failure. The 5-year graft survival for kidneys with reconstructed renal arteries was 84.3% in deceased donor renal transplantations (86.1% without arterial reconstruction). CONCLUSIONS The demand for renal transplants has led to more marginal-quality organs and older donors and/or recipients waiting for a second or third transplantation. Thus, the expertise of a vascular surgeon is extremely helpful in a transplantation center because it allows for marginal organ transplantation with acceptable 5-year graft survival rates.

Isolated dissection of the superior mesenteric artery treated using open emergency surgery

BackgroundIsolated dissection of the superior mesenteric artery (IDSMA) remains a rare diagnosis. However, new diagnostic means such as computed tomography makes it possible to detect even asymptomatic patients. If patients present symptomatic on admission, the risk of bowel infarction makes immediate therapy necessary. Today, endovascular techniques are often successfully used; however, open surgery remains important for special indications. In this paper, we present two cases with IDSMA and show why open surgical repair is still important in current treatment concepts.MethodsTwo cases with ISDMA that presented in our department from January 1, 2014 to June 1, 2014 are described. Data collection was performed retrospectively. Additionally, a review of articles which reported small cases series on patients with IDSMA within the past five years is provided.ResultsBoth patients underwent open surgical repair following interdisciplinary consultation. Both patients were transferred to the intensive care unit after surgical repair and needed bowel rest, nasogastric suction and intravenous fluid therapy. CT scans were performed within the first week after operation. Platelet aggregation inhibitors were used in both cases as postoperative medication. Both patients survived and are able to participate in everyday activities.ConclusionOpen surgical repair remains important in cases of anatomic variants of visceral arteries and suspected bowel infarction. Therefore, it is important that knowledge about open surgical techniques still be taught and trained.

Implantation of an Iliac Branch Device After EVAR via a Femoral Approach Using a Steerable Sheath

Purpose: To describe a contralateral femoral approach for iliac branch device implantation using a steerable sheath in the setting of an existing bifurcated stent-graft. Technique: The method is demonstrated in an 80-year-old man who developed a 4-cm iliac aneurysm 3 years after implantation of an Endurant bifurcated stent-graft. Both femoral arteries were cannulated after surgical cutdown. The steerable sheath was advanced from the contralateral side over the neobifurcation of the bifurcated stent-graft. A 0.014-inch Roadrunner wire was used as a through-and-through wire to stabilize the curve of the sheath and to get proper push. The bridging stent-graft for the iliac branch was advanced over this sheath to seal the iliac aneurysm. During the entire procedure, the sheath was stable over the neobifurcation without pulling it down. Conclusion: The contralateral femoral approach for iliac branch graft implantation is feasible in cases with an extant bifurcated stent-graft using a steerable sheath and a through-and-through wire.

Long-term results of open repair of popliteal artery aneurysm

Introduction Popliteal artery aneurysms (PAA) are rare. Different surgical techniques for open surgical repair are possible. This study presents a single centre experience using open surgical repair with a medial approach (MA) and outlines differences between symptomatic (SLS) and asymptomatic (ALS) legs. Methods Data collection was performed retrospectively. The investigation period was from 1 January 1996 to 1 January 2013. Patients presented in the Outpatient Department and received a questionnaire concerning their quality of life. Data are presented as mean ± standard deviation. Mann–Whitney test and Cochran–Armitage test for trend was used for data analysis. Kaplan–Meier method was used to calculate limb salvage rates. p < 0.05 was considered statistically significant. Results We analyzed 16 ALS and 26 SLS with an average age of 63.5 ± 10 years. Preoperative ankle-brachial index (ABI) was 1.0 ± 0.2 for ALS (on control examination: 1.12 ± 0.24) and 0.08 ± 0.18 for SLS (on control examination 0.94 ± 0.14) (p < 0.05). Limb salvage rate was 100% for ALS and 86.7% for SLS (overall 93.3%). Primary patency rate for SLS was 85%, for ALS rate of 100%, respectively (overall 92.5%). ALS reached an average of 13.1 ± 2.7 points (SLS 11.4 ± 2.8) on a numeric point scale. Conclusion Open surgery is therapy and prevention of acute ischaemia all in one, especially for asymptomatic patients and delivers good long-term results. Endovascular therapies offer an alternative but long-term results are pending. Open surgery should still be considered as a gold standard therapy.

Acute Limb Ischemia—Much More Than Just a Lack of Oxygen

Acute ischemia of an extremity occurs in several stages, a lack of oxygen being the primary contributor of the event. Although underlying patho-mechanisms are similar, it is important to determine whether it is an acute or chronic event. Healthy tissue does not contain enlarged collaterals, which are formed in chronically malperfused tissue and can maintain a minimum supply despite occlusion. The underlying processes for enhanced collateral blood flow are sprouting vessels from pre-existing vessels (via angiogenesis) and a lumen extension of arterioles (via arteriogenesis). While disturbed flow patterns with associated local low shear stress upregulate angiogenesis promoting genes, elevated shear stress may trigger arteriogenesis due to increased blood volume. In case of an acute ischemia, especially during the reperfusion phase, fluid transfer occurs into the tissue while the vascular bed is simultaneously reduced and no longer reacts to vaso-relaxing factors such as nitric oxide. This process results in an exacerbative cycle, in which increased peripheral resistance leads to an additional lack of oxygen. This whole process is accompanied by an inundation of inflammatory cells, which amplify the inflammatory response by cytokine release. However, an extremity is an individual-specific composition of different tissues, so these processes may vary dramatically between patients. The image is more uniform when broken down to the single cell stage. Because each cell is dependent on energy produced from aerobic respiration, an event of acute hypoxia can be a life-threatening situation. Aerobic processes responsible for yielding adenosine triphosphate (ATP), such as the electron transport chain and oxidative phosphorylation in the mitochondria, suffer first, thus disrupting the integrity of cellular respiration. One consequence of this is irreparable damage of the cell membrane due to an imbalance of electrolytes. The eventual increase in net fluid influx associated with a decrease in intracellular pH is considered an end-stage event. Due to the lack of ATP, individual cell organelles can no longer sustain their activity, thus initiating the cascade pathways of apoptosis via the release of cytokines such as the BCL2 associated X protein (BAX). As ischemia may lead to direct necrosis, inflammatory processes are further aggravated. In the case of reperfusion, the flow of nascent oxygen will cause additional damage to the cell, further initiating apoptosis in additional surrounding cells. In particular, free oxygen radicals are formed, causing severe damage to cell membranes and desoxyribonucleic acid (DNA). However, the increased tissue stress caused by this process may be transient, as radical scavengers may attenuate the damage. Taking the above into final consideration, it is clearly elucidated that acute ischemia and subsequent reperfusion is a process that leads to acute tissue damage combined with end-organ loss of function, a condition that is difficult to counteract.

Chronic Mesenteric Ischemia: Patient Outcomes Using Open Surgical Revascularization

Background: Chronic mesenteric ischemia (CMI) is a rare disease. Open treatment (OT) remains a valuable treatment option. We analyzed patient outcomes after OT and investigated health-related quality of life (HRQoL). Methods: Data were analyzed retrospectively. The investigation period was from January 1, 2001, to December 31, 2014. We investigated mortality and patency rates using Kaplan-Meier analysis. HRQoL was measured using a 36-item health survey. Various statistical methods were employed. Results: A total of 100 patients (celiac trunk [TC: n = 23], superior mesenteric artery [SMA: n = 26], or both [n = 51]) were included. Median follow-up was 5 ± 35 months. One-year survival rate for TC was 75 ± 11%, for SMA: 79 ± 10%, and for both: 96 ± 3%. TC 5-year survival was 75 ± 11% (SMA: 57 ± 16%: both: 80 ± 8%). Obesity and the length of hospital stay were independently associated with patient survival (p < 0.05). Primary 1-year patency rate was 60 ± 13% for TC (SMA: 86 ± 10%; both: 71 ± 8%) and secondary 1-year patency rate was 84 ± 9% for TC (SMA: 100%; both: 79 ± 7%). HRQoL was inferior compared to the German normative data (p < 0.05). Conclusion: CMI overlaps between gastrointestinal and vascular surgery. OT is safe, and simultaneous revascularization of the TC and the SMA does not affect mortality. Patients would not necessarily benefit from OT in terms of HRQoL.

Aktueller Forschungsstand zur akuten Extremitätenischämie

ZusammenfassungDie akute Extremitätenischämie (AEI) gefährdet sowohl die betroffene Gliedmaße als auch das Leben des Patienten und stellt eine häufige Ursache für eine Extremitätenamputation dar. Deshalb ist die AEI ein vaskulärer Notfall, der einer raschen Revaskularisation bedarf. Die Ursachen sind kardiale Embolien, lokale Thrombosen, postrekonstruktive thrombotische Gefäßverschlüsse, embolisierende Aneurysmen, Aortendissektionen und Gefäßverletzungen. Das 30-Tage-Major-Amputationsrisiko beträgt 10–30 % und die 30-Tage-Mortalität 15–30 %. Die Ausprägung des Krankheitsbilds ist abhängig von der peripheren Restperfusion. Die Einteilung nach Rutherford und die 6 Ps nach Pratt beschreiben die Klinik. Man unterscheidet eine komplette Ischämie mit voller Ausprägung der Symptomatik und eine inkomplette Form mit Erhalt der Sensibilität und Motorik. Als Folgeereignis kann es zu einem Reperfusions- oder einem Kompartmentsyndrom kommen.Bei komplexer Vorgeschichte ist eine CTA für die Therapieplanung hilfreich. Mittel der Wahl zur Diagnostik ist die Duplexsonographie und Angiographie. Als Therapieoptionen stehen die offen chirurgische Therapie, die endovaskuläre Therapie oder eine Kombination aus beidem (Hybridverfahren) zur Verfügung. Mittlerweile haben die endovaskuläre und die offenchirurgische Methode einen vergleichbaren Stellenwert bei der Behandlung einer AEI.AbstractAcute limb ischemia (ALI) is a danger to the life as well as the affected limb of the patient and has a high amputation and mortality rate; therefore, ALI is a vascular emergency which requires immediate revascularization. The causes of ALI are lower extremity embolisms originating from the heart, proximal arterial aneurysms, arterial thrombosis, thrombosis of a bypass graft, aortic dissection and arterial injury. The 30-day risk of major amputation is 10–30 % while the 30-day mortality is 15–20 %. The extent of symptoms is dependent on the presence of sufficient collateral perfusion. The clinical symptoms of ALI can be classified according to the 6 Ps of Pratt and the Rutherford classification. There are two kinds of ischemia: complete ischemia with the full extent of symptoms and an incomplete form of ischemia without sensory loss and muscle weakness. Acute limb compartment syndrome and a life-threatening reperfusion syndrome may be complications of ALI. The use of computed tomography angiography (CTA) in cases with a complex history can be helpful for therapy planning. The standard procedures for diagnostics are duplex sonography and angiography. Treatment options are open surgery, endovascular therapy and a combination of both (hybrid procedure). Endovascular therapy and open surgery now have a comparable status in the treatment of ALI.

Open surgery for iliofemoral deep vein thrombosis with temporary arteriovenous fistula remains valuable

Objective We assessed outcomes of open surgical venous thrombectomy with temporary arteriovenous fistula, and the procedure’s effect on health-related quality of life. Method We retrospectively analyzed 48 (26 at long-term) patient medical records. Mortality rates, patency, and risk of post-thrombotic syndrome were analyzed using Kaplan–Meier estimation. The association between risk factors/coagulation disorders and patency/post-thrombotic syndrome along with patient health-related quality of life at long-term was analyzed employing various statistical methods. Results Patient one-year survival rate was 93 ± 4% and primary one-year patency rate was 89 ± 5% (secondary one-year patency rate 97 ± 3%). Freedom from post-thrombotic syndrome after eight years was 80 ± 12% (post-thrombotic syndrome rate 20 ± 12%). Health-related quality of life was impaired vs. normative data in the physical and social subscales, and in the mental component score (p < .05). Conclusions Open surgical venous thrombectomy appears safe compared with literature-reported outcomes in similar patients using alternative approaches. Iliofemoral deep vein thrombosis impairs physical, social, and mental health-related quality of life.

Endovaskuläre und offenchirurgische Methoden stehen komplementär zur Verfügung

vielen Dank für ihren Leserbrief und die von Ihnen vertretene Meinung. Der Beitrag ist eine Übersichtsarbeit über den akuten arteriellen Gefäßverschluss einer Extremität und legt den aktuellenStandüberdieklinischenSymptome, die Diagnostik sowie die offenchirurgischenund endovaskulärenTherapieoptionen dar. In dem Beitrag sind beide Verfahren (offenchirurgische und interventionelle Therapie) beschrieben worden. In dem Bericht wurde eine aktuelle Cochrane-Analyse zitiert, die keinenwesentlichen Vorteil für ein einzelnes Verfahren zeigte. Aus unserer Sicht sollte die Therapieentscheidung für ein einzelnesVerfahren individuell unter Berücksichtigung der Befunde und strukturellen, personellen und apparativen Gegebenheiten des jeweiligen Gefäßzentrums bzw. Standorts getroffen werden. Ein einfaches Konzept zurFavorisierungeinesVerfahrens ist aus gefäßmedizinischer Sicht nicht haltbar. Die von Ihnen zitierte S3-Leitlinie bezieht sich auf die klassische periphere arterielle Verschlusskrankheit (pAVK) und nicht auf den akuten arteriellen Gefäßverschluss. „Bei einer symptomatischen PAVK soll zuerst der proximale Verschlussprozess mit dem kleinsten zeitlichen und operativen/interventionellen Aufwand korrigiert werden. Dabei sollen endovaskuläre Techniken ,bevorzugt‘ werden, wenn kurzund langfristig die gleiche symptomatische Verbesserung erzielt werden kann wie mit einer gefäßchirurgischen Operation“ (S. 48, S3-Leitlinie „Periphere arterielle Verschlusskrankheit, PAVK, Diagnostik, Therapie und Nachsorge“). Im gleichen Kapitel der Leitlinie steht aber auch, dass sich die offene gefäßchirurgischeTherapieunddie interventionelle Therapie der PAVK ergänzen sollten. „Die offengefäßchirurgische Therapie und die interventionelle Therapie der PAVK sind sich ergänzende Behandlungsoptionen. In gefäßmedizinischen Zentren kann dies zur sinnvollen Aufgabenverteilung führen. Interdisziplinär kann für den betroffenen Patienten das geeignete Behandlungsverfahren unter Berücksichtigung des Patientenwunsches gewählt werden. Viele Gefäßchirurgen bieten „Hybrideingriffe“ als Kombination von operativen und interventionellenMaßnahmen an.“ (S. 48, S3Leitlinie „Periphere arterielleVerschlusskrankheit, PAVK, Diagnostik, Therapie und Nachsorge“). Daher entspricht die Schlussfolgerung „Die endovaskulären und die offenchirurgischen Methoden stehen komplementär zur Verfügung“ unserer Meinung nach den aktuellen Stand der Forschung, sowie der Versorgungsrealität.