Susanne Regus

Rupture Risk and Etiology of Visceral Artery Aneurysms and Pseudoaneurysms A Single-Center Experience

Background: The aim of this study was to analyze differences in rupture risk and etiology of visceral artery aneurysms (VAAs) and visceral artery pseudoaneurysms (VAPAs) in a single-center experience. Materials and Methods: We retrospectively reviewed all patients with a VAA or VAPA after treatment by open surgical or endovascular repair (ER) in our institution. Patient history, treatment details, and outcome were recorded and analyzed. Results: From January 1996 to April 2014, 29 (12 women) patients with 33 aneurysms (26 VAAs and 7 VAPAs) were treated in elective and urgent settings by open repair or ER. Etiology was quite different, most common was atherosclerosis (61.5%) in VAA and chronic pancreatitis (85.7%) in VAPA. Rupture rate was 19.2% in VAA and 42.9% in VAPA, whereas mean size of ruptured VAA was 4.4 cm and of ruptured VAPA was 2 cm. Open repair (suture, ligation, and aneurysmectomy with or without arterial reconstruction) and ER (coil embolization in the packing technique) were performed in half of all cases. After follow-up (72-month VAA and 82-month VAPA), aneurysm-free survival was reported to be 95% in VAA and 100% in VAPA. Conclusion: Chronic pancreatitis seems to be a prominent risk factor for the development of VAPA in this single-center experience. Modern endovascular techniques with promising short- and long-term results could broaden indications to treat asymptomatic VAA and VAPA.

Immediate changes of angiosome perfusion during tibial angioplasty.

Objective: In recent years, a controversial discussion about the clinical relevance of the angiosome concept during tibial angioplasty has developed. Therefore, we conducted a prospective study to evaluate the angiosome concept on the level of microcirculation during tibial vascular interventions. Methods: Thirty patients with isolated tibial angioplasty were examined prospectively. Macrocirculation was evaluated by measurement of the ankle‐brachial index (ABI). For the assessment of microcirculation, a combined method of laser Doppler flowmetry and tissue spectrometry (O2C; LEA Medizintechnik GmbH, Giessen, Germany) was applied. Microcirculatory parameters were measured continuously during the procedures. Measuring points were located over different angiosomes of the index foot; a control probe was placed on the contralateral leg. Results: Cumulated microcirculation parameters (sO2, flow) as well as the ABI showed a significant improvement postinterventionally (ABI, P < .001; sO2, P < .001; flow, P < .001). Assessment of the separate angiosomes of the index leg and the comparison of the directly revascularized (DR) and indirectly revascularized (IR) angiosomes showed no significant difference concerning the microperfusion postinterventionally (DR − IR: sO2, P = .399; flow, P = .909) as well as during angioplasty. Even a further subdivision of the collective into patients with diabetes (sO2, P = .445; flow, P =.758) and renal insufficiency (sO2, P = .246; flow, P = .691) could not demonstrate a superiority of the direct revascularization at the level of microcirculation in these patients (comparison DR − IR). Conclusions: There is a significant overall improvement in tissue perfusion of the foot immediately after tibial angioplasty. The effect shown in this study, however, was found to be global and was not restricted to certain borders, such as defined by angiosomes.

Pediatric patients undergoing arteriovenous fistula surgery without intraoperative heparin

Introduction Arteriovenous fistula (AVF) creation in children could be extremely challenging for vascular surgeons due to small vessels with a high tendency of vasospasm. This could be one reason for primary failures (PF) and early access thrombosis. There exists no guideline for the need of intraoperative heparin administration during hemodialysis fistula creation. The aim of this study was to evaluate the effect of intra-operative heparin administration on immediate outcome. Methods Medical records of 42 pediatric patients aged between 7 and 17 years were retrospectively reviewed. All received an AVF under inpatient conditions by exclusively one vascular surgeon with many years of professional experience. The intraoperative anticoagulation standards changed by the years 2001 based on the decision of the vascular surgeon. Therefore, we build two groups (group 1: 14 patients with 5000 IU of intravenous heparin during surgery and group 2: 28 patients without heparin). Major complications included hematoma or bleeding leading to surgery. PF was defined as the inability to use the AVF even once due to absent maturation or occlusion within 4 weeks after creation. Results We found 6 (14%) PF with the need of immediate surgical access revision (three from group 1 and three from group 2; p = 0.350). There were no bleedings leading to surgery in all cases, but 5 (12%) hematomas without the need of surgical revision (three from group 1 and two from group 2; p = 0.736). Conclusions We found no benefit of heparin administration during clamping the arteries while performing the arteriovenous fistula in pediatric patients.

Time‐extended local rtPA infiltration for acutely thrombosed hemodialysis fistulas

Introduction: This study describes results of a modified local thrombolysis technique for acutely thrombosed hemodialysis (HD) arteriovenous fistulas (AVF), which is characterized by prolonged recombinant tissue plasminogen activator (rtPA) local exposure times. Contrary to the standard lyse‐ and‐ wait (L&W) technique with local reaction times of 20–40 minutes, the modified protocol allows timing of challenging angioplasty maneuvers to the next regular working day.

Dosing of indocyanine green for intraoperative laser fluorescence angiography in kidney transplantation

Sufficient blood supply is a crucial factor determining postoperative allograft function in kidney transplantation. Therefore, besides the surgeons individual impression, a method for evaluating the quality of the organs microperfusion is required. Laser fluorescence angiography with indocyanine green (ICG) is an emerging tool for this purpose. However, no reproducible quantification of ICG fluorescence has been performed in transplantation so far.

Retrospective cohort study of combined approach for trunk reconstruction using arteriovenous loops and free flaps

Defect reconstruction of the trunk can be performed using microsurgical free flap transplantation. In cases of missing or inappropriate recipient vessels, microsurgical defect reconstruction of the trunk can be achieved by combining free flaps with arteriovenous loops. Here we present our 5-year experience of trunk reconstruction using AV loops and free flaps in a retrospective evaluation. We analyzed 32 cases of trunk reconstruction using a combined approach of free flap transplantation and arteriovenous loops between 2011 and 2016 regarding postoperative complications and perioperative course. Twenty-one patients suffered from sternal defects, 4 from presacral defects, 3 patients presented with lateral chest wall defects, 2 patients suffered from lumbosacral defects, 1 patient had a gluteal defect and 1 patient a defect at the clavicle. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure. There were 8 thromboses of the arteriovenous loops with 4 flap failures. Only 1 flap loss was located in the sternal region, whereas one presacral flap and both lumbosacral flaps were lost. Reconstruction of large soft tissue defects of the trunk by a combined approach with an arteriovenous loop creation and consecutive free flap transplantation represents a reliable procedure in ventral and posterior cranial localization, whereas in the caudal posterior region, AV loop thrombosis can occur. Therefore, to minimize flap loss, a two-stage procedure should be performed.

Chronic popliteal entrapment with calcified lesions results in an acute occlusion after blunt knee trauma in a 17-year-old soccer player

A 17-year-old soccer player noticed intermittent claudication after reconvalescence from a severe blunt knee trauma with laceration of the anterior cruciate ligament. Physical examination revealed a pulseless right leg without rest pain. Magnetic resonance imaging documented a short occlusion of the popliteal artery with sparse but visible collaterals (A). Cross-sectional imaging demonstrated an atypical bundle or accessory insertion of the gastrocnemius muscle (popliteal entrapment syndrome type III) (B). Surgical exposure of the popliteal artery by a posterior approach showed a circumscript thickening of the vessel wall at a total length of 6 cmwith occlusion of the lumen. Thus, resection of the causative anomalous muscle or fibrous tissue was combined with an interposition of a short vein graft. Macroscopic longitudinal section of the resected popliteal segment demonstrated thickening of the vessel wall by myointimal hyperplasia (C). Surprisingly, histological examination of the specimen demonstrated not only the expected myointimal hyperplasia but also segmental areas with calcification, which are uncommon in adolescents (D).

Arterial injury and pseudoaneurysm formation after lesser trochanter fracture

Highlights • We report a false aneurysm of the deep femoral artery after uneventful stabilization of a hip fracture.• Plain X-ray showed displaced lesser trochanter in close proximity to the deep femoral artery as this was calcified.• CT scan confirmed an arterial lesion due to displaced lesser trochanter.• The bony spike was removed surgically and the deep femoral artery was repaired using a vein patch.

Benefits of Long Versus Short Thrombolysis Times for Acutely Thrombosed Hemodialysis Native Fistulas

Introduction: Local thrombolysis with a time of exposure to recombinant tissue plasminogen activator of 15 to 150 minutes is commonly used to declot acutely thrombosed hemodialysis fistulas. The duration of thrombolysis for the restoration of arteriovenous blood flow remains controversial. The aim of this study was to investigate the outcomes of long thrombolysis treatment (LTT, 3 hours or more) and short thrombolysis treatment (STT, less than 3 hours) in our institution. Methods: We retrospectively analyzed 86 interventional declotting procedures (28 STT and 58 LTT) applied to 86 acutely thrombosed hemodialysis fistulas. The intervention time (IT) following thrombolysis (from the initial fistulography to the end of the angioplasty maneuvers), the time of day of the intervention (ie, during working hours vs off-hours), and the need for temporary catheter placement (TCP) were assessed. Success was defined as complete access recanalization, and major adverse events were defined as ischemia, bleeding, and access rupture. Results: The ITs were reduced after LTT (63.3 [9.3] minutes) compared to STT (106.7 [24.7], P = .01), but there was no difference in success rate (85.7% STT, 89.7% LTT, P = .722). While all (100%, 58/58) of the angioplasty maneuvers after LTT were performed during regular working hours, 75% (21/28) of those following STT were managed during off-hours (P < .001). Despite the longer treatment, the need for TCP was not increased after LTT (10.7%) compared to STT (12.1%, P = .515), and the major complication rate was reduced (3.4% after LTT and 28.6% after STT, P = .004). Conclusion: Long thrombolysis treatment results in shorter and less complicated percutaneous stenosis treatments during regular working hours. Despite the LTT of up to 25 hours until access for dialysis was achieved, no increase in the risks of TCP or major adverse events were observed following LTT.

Surgeon experience affects outcome of forearm arteriovenous fistulae more than outcomes of upper-arm fistulae

Introduction There is still an ongoing discussion about the influence of vascular surgeon experience on the immediate and long-term outcome of newly created arteriovenous fistula (AVF) for patients on hemodialysis (HD). The aim of this study was to compare failure and patency rates of AVF between experienced consultants and resident trainees with special focus on location of the anastomosis on the forearm or upper arm. Methods Between November 2012 and September 2016, 159 patients (83 on HD and 76 preemptive) received an AVF (90 radiocephalic [RCAVF] on the forearm; 69 brachiocephalic [BCAVF] in the elbow) by two experienced vascular surgeons (group A; n = 74) or five residents in training with one-to-four years of experience (group B; n = 85). We compared the two groups for demographic and treatment data, immediate failures (IF), bleeding complications and patency rates. Results There were no significant differences in demographic data between the two groups. Vessel diameters were significantly lower for forearm compared to upper arm arteries (p = 0.026) and veins (p = 0.05). There was a significantly increased risk for IF in group B for RCAVF (p = 0.003), but not for BCAVF (p = 1.000). Furthermore, the cumulative primary patency was reduced in group B for RCAVF (p<0.001), but not for BCAVF (p = 0.899). Conclusion Surgeon experience seems to have more influence on the immediate and long-term outcome of newly created forearm AVF compared to those located on the upper arm.