P. Polterauer

Endografting increases total volume of AAA repairs but not at the expense of open surgery: experience in more than 1000 patients.

Purpose: To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. Methods: A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeons discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001–2002 after the introduction of “high-risk” screening criteria (age ≥72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. Results: While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p>0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p=0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p= 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p>0.05) and fell still further to 1.2% in the most recent period (p=0.021 versus pre EVAR). Conclusions: The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.

Aortomonoiliac endografting after failed endovascular aneurysm repair: indications and long-term results.

OBJECTIVES To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. DESIGN Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. MATERIALS AND METHODS From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: -1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. RESULTS Technical success rate of AMI endografting was 95.65% (n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1-Q3: 1.3-9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1-Q3: 17-69 months). CONCLUSIONS Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

Der Vena-saphena-magna-Bypass

ZusammenfassungGrundlagenAnhand einer retrospektiven Analyse eigener Ergebnisse soll der Stand der chirurgischen Technik diskutiert werden. Grundlage für die Diskussion sind die am Workshop “Der Venenbypass” 1991 in Linz gehaltenen Referate.MethodikZwischen 1970 und 1991 wurden an der I. Chirurgischen Universitätsklinik Wien 590 reversierte Venenbypässe angelegt. Anschlußgefäß war in 39% die supragenuale, in 31% die infragenuale A. poplitea, in 30% ein krurales Gefäß.ErgebnisseDie 30-Tage-Letalität betrug 2%, die mediane Nachbeobachtungszeit 65 Monate. Die Gesamtfunktionsrate nach 60 Monaten betrug 55%, die sekundäre Funktionsrate 70% für alle Patienten. Die primäre Funktionsrate für supragenuale Venenbypässe betrug 61%, für infragenuale 49% und für krurale 52%. Der Beinerhalt nach 60 Monaten war in 88% gewährleistet.SchlußfolgerungenEin Literaturüberblick diskutiert die verschiedenen Trends auf dem Gebiet der Venenbypasschirurgie zur Revaskularisation der unteren Extremität. Große prospektive, randomisierte Studien werden benötigt, um die beste Technik für distale Rekonstruktionen der unteren Extremität zu evaluieren, daher muß die Wahl des Vorgehens derzeit der Präferenz des Chirurgen überlasen werden.SummaryBackgroundDuring a 20-year period between 1970 and 1991 590 reversed vein bypass grafts were performed for claudication (40%) and for limb salvage (60%).MethodsOutflow anastomoses were constructed to the suprageniculate popliteal (39%), infrageniculate popliteal (31%) and crural arteries; the technique was reversed vein bypass graft.ResultsThe 30-day mortality rate was 2%, the median fllow-up 65 months. At 60 months primary graft patency was 55% overall; secondary graft patency was 70%, respectively. Primary cumulative patency rates at 60 months depending on the outflow site were as follows: suprageniculate popliteal 61%, infrageniculate popliteal 49% and crural 52%. Cumulative limb salvage at 60 months was 88% overall. A literature review on current trends in lower limb vein bypass surgery is given.ConclusionsA 5-year graft patency rate of 55% and a limb salvage rate of 88% were achievable with the reversed vein bypass. Literature shows, that the performance of the reversed vein graft and the in situ technique yield similar results. Further prospective randomized studies are needed to find out the superior technique for lower limb revascularization.

Aortouni-iliac endografting as an alternative salvage procedure to open conversion in failed endovascular aneurysm repair.

Purpose To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration. Methods A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion. Results An average time of 52.2 months (median 46.9, IQR 0.0–92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done <30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0–17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero. Conclusion Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Endovascular Treatment of Delayed Rupture Following Prior Abdominal Aortic Aneurysm Repair Achieves Better Survival Rates

Purpose To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion. Methods All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3–4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality. Results The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011). Conclusion Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Bifurkationsprothese: Dacron versus Teflon (PTFE)

ZusammenfassungNach 3 Jahren erfolgte eine präliminäre Auswertung einer prospektiven randomisierten Studie zwischen PTFE-Y-Prothesen und Dacron-Y-Bifurkationsprothesen bezüglich Funktion, Komplikationsrate und Materialbeschaffenheit. Sowohl die funktionellen Frühergebnisse wie auch die Komplikationen ergaben keinen signifikanten Unterschied in beiden Gruppen. Bei allen Patienten mit Schenkelverschlüssen (ein Sofortverschluß und 4 Spätverschlüsse) sind nach Korrekturoperationen die Interponate in Funktion. Da nun auch die Dacronprothese den wesentlichen Vorteil von PTFE (keine Vorkoagulation) besitzt, sind beide Materialien als qualitativ ebenbürtig zu betrachten.SummaryAfter 3 years a preliminary evaluation of a prospective randomized study between PTFE-Y- and Dacron-Y-grafts in regard to function rate, complication and quality of material was performed.Both, function rate and complications showed no significant differences between both groups. In all patients with graft limb occlusion (1 early and 4 later occlusions) the function was gained by successful thrombectomy. Today Dacron-Y-prosthesis is available as collagen coated dacron double veloure graft, so presenting the same most important advantage PTFE prosthesis did (no preclotting). In cause of those above mentioned material characteristics both grafts seem to be equal in quality.

Secondary modification into aortouniiliac configuration to salvage failed endovascular aneurysm repair is safe and effective but not associated with higher intervention rates during long-term follow-up

BACKGROUND Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE). METHODS A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done. RESULTS Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan-Meier estimates for long-term survival between groups were comparable (P = .36). CONCLUSIONS Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

Gefäßchirurgische Behandlung der Krampfadern

ZusammenfassungGrundlagen: Krampfadern sind eine weit verbreitete Erkrankung, die Beschwerden und Komplikationen verursachen kann. Deshalb sind adäquate diagnostische und therapeutische Verfahren wichtig. In der letzten Dekade haben sich die nicht invasiven diagnostischen Methoden rapide entwickelt. Mittels Duplex-Ultraschalluntersuchung kann man die Morphologie des Venensystems, die Lokalisation der insuffizienten Klappen und Thrombosen sowohl in oberflächlichen als auch in tiefen Venen darstellen. Heute gibt es im Wesentlichen zwei Möglichkeiten, eine medizinisch bedeutende, krankhafte Varikose operativ zu behandeln: „radikale Varizenoperation = 4-Schritt-Operation“ (Crossektomie, Stripping, Ligatur der Vv. Perforantes, Phlebektomie) und die hohe Ligatur der Vena saphena magna (ohne Stripping). Methodik: Der aktuelle Stand der chirurgischen Behandlung variköser Venen wurde untersucht. Die Langzeit-Ergebnisse der „radikalen Varizenoperation“ wurden mit denen der „hohen Ligatur“ verglichen. Ergebnisse: Die publizierten Ergebnisse bestätigen die Überlegenheit der Radikaloperation gegenüber der „hohen Ligatur“. Die exakte Identifikation und Ligatur aller Seitenäste an der sapheno-femoralen Mündung und die Ligatur der relevanten Vv. Perforantes sind wichtige Schritte der „radikalen Varizenoperation“, um einer Rezidivvarikose vorzubeugen. Schlußfolgerungen: Die Radikaloperation ermöglicht eine effektivere Kontrolle des Reflux, erzielt ein besseres Resultat, hat langfristig gesehen eine geringere Rezidivrate und sollte als optimale Technik der chirurgischen Behandlung einer Varikose gelten.SummaryBackground: Varicose disease is widely prevalent, causing discomfort and disability of patients. Therefore, adequate diagnostic and treatment modalities are important.In the last decade, non-invasive diagnostic methods developed rapidly. Duplex-ultrasonographic examination shows the morphology of the venous system, distribution of insufficient valves and reveals thrombosis in the both superficial and deep veins. Today there are two different methods of surgical treatment of varicose veins: radical operation (crossectomy, stripping, ligature of the insufficient perforating veins, phlebectomy) and high ligation of the saphenous vein without stripping. Methods: The current status of surgery for varicose veins is reviewed. “Radical operation” is compared to “high ligature” in terms of long-term outcome. Results: The published results are convincing evidence of the superiority of radical operation over high ligature. Accurate identification and ligation of all tributaries at saphenofemoral junction, ligation of relevant perforating veins are important steps of the radical operation in preventing recurrent varicose. Conclusions: Radical surgery of varicose veins provides good results of treatment, prevents better the recurrence of the disease and should be considered the optimal method of treatment.

Editorial: Diagnose und Therapie von Varizen

Apparative Diagnostik der Varikose Die Diagnostik sollte sowohl eine sorgf~ltige ktinische Untersuchung als auch funktionelle und bildgebende Veffahren beinhalten. Die alleinige klinische peinlich genaue Untersuchung ist aber nicht als ausreichend anzusehen. Duplexsonographie und aszendierende Pre6phlebographie sind akzeptierte bildgebende Routinemethoden for die prfioperative Varizendiagnostik. Es sollte abet die Ultraschalluntersuehung als nichtinvasive Methode bevorzugt werden. Zwei Voraussetzungen mtissen allerdings gegeben sein: ein FarbDuplex-Ultraschall-Ger~it und ein erfahrener Untersucher. Die Ultrasonographie erm6glicht sowohl morphologische als auch funktionelle Aussagen yon diagnostischer Relevanz fiir die exakte Therapieplanung. Nur Patienten mit unklaren UltraschallErgebnissen oder Rezidivvarikosen sollten einer ergfinzenden Phlebographie unterzogen werden (1). Die Ultrasonographie erm6glicht prfioperativ eine direkte Markierung der Perforansvehen auf der Haut, was sich for den Chirurgen als unverzichtbar erweist. Ein gewisser Vortei.! des Phlebogramms gegen~iber der Duplexsonographie ist die Ubersichtlichkeit des Gesamtbildes und eine bessere Dokumentationsm6glichkeit.

Patientenumfrageergebnis nach „radikaler“ Varizenoperation der unteren Extremität

ZusammenfassungGrundlagen: Eine postoperative Patientenumfrage ist eine akzeptierte und kostengünstige Methode, den Erfolg einer Varizenoperation zu bestimmen. Die erzielten Resultate sind mit objektiven Untersuchungen vergleichbar. Methodik: Es wurden an 127 Patienten (Frauen:Männer=2,4:1), die sich zwischen 1983 und 1996 einer „4-Schritt-Operation — radikaler Varizenoperation“ (Crossektomie, Stripping der V. saphena magna, Ligatur der Vv. perforantes, Phlebektomie) unterzogen, Briefe verschickt. 2 Drittel der Patienten waren zur Zeit der Operation zwischen 30 und 55 Jahren alt, und an 22% wurde eine präoperative Sklerotherapie durchgeführt. Bei 91% der Patienten waren die Symptome der chronisch venösen Insuffizienz (Stadien II bis IV, „varicose disease“) und nicht kosmetische Gründe die Indikation zur Operation. Die mediane Zeit seit der Operation betrug 6 Jahre (Range 1 bis 14 Jahre). Ergebnisse: Ein gutes (geheilt) oder befriedigendes (verbessert) Resultat wurde von 85% der Patienten, ein unbefriedigendes (unverändert/verschlechtert) von 15% angegeben. Die guten bzw. befriedigenden Resultate waren umgekehrt proportional zur Zeit seit der Operation. Die häufigsten Gründe für ein unbefriedigendes Resultat waren: „Varizenrezidive“ (13%), Schmerzen (5%), Narbenbildung (4%), Sensibilitätsstörungen (2%). In 5% der Fälle wurde eine Reoperation wegen einer „Rezidivvarikose“ nötig. Schlußfolgerungen: Bei der Behandlung primärer Varizen verspricht die Radikaloperation in 85% gute Ergebnisse. Das Wiedererscheinen variköser Venen ist die Hauptursache eines unbefriedigenden Resultats, die selten eine Reoperation (5%) erforderlich machte.SummaryBackground: The analysis of postoperative reports from patients using follow-up letters is well accepted cost-effective form of subjective assessment of surgery for varicose veins. Obtained results parallel the findings recorded at objective examinations. Methods: The follow-up results were carried out by sending letters to 127 patients (female:male=2.4:1) who underwent radical operation (crossectomy, saphenous stripping, perforator interruption, and stab avulsion) for the primary varicose veins during 1983 to 1996. Two thirds of patients were 30 to 55 years old. 22% of patients reported sclereotherapy of varicosities before surgery. In 91% of patients the symptoms of chronic venous insufficiency, not merely cosmetic reasons, were the indication for operative treatment (stages II to IV, “varicose disease”). The median follow-up time after operation was 6 years (range 1 to 14 years). Results: Good (cured) and satisfactory (improved) results were considered by the 85% and unsatisfactory (same/worse) by the 15% of patients. Good/satisfactory results inversely correlated with the time after surgery. Frequent reasons of unsatisfactory results were: recurrent varicosities (13%), pains in the leg (5%), unsatisfactory wound scarring (4%), paresthesia/hypesthesia (2%). In 5% of cases patients required re-operation for recurrent varicose. Conclusions: Radical surgery provided good subjective results of treatment of primary varicose veins in 85% of patients. Recurrence of varicose veins was the reason of unsatisfactory results in the majority of cases which, however, rarely (5%) required reoperation.