[Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia]

Spontaneous dissection of the external iliac artery due to fibromuscular dysplasia. A case of spontaneous dissection of the external iliac artery due to fibromuscular dysplasia is presented. In a 45-year-old man with a history of sudden onset of intermittent claudication a dissection of the right external iliac artery was found by duplex ultrasound. The patient, who was first treated with conservative therapy, subsequently required operative treatment because of further progression of the dissection. Considering the age of the patient a retrograde thrombendarterectomy manoeuver over guide wire was performed. Angiographic control at the end of operation demonstrated a good reconstructive result without any changes in the right common iliac artery and the aorta. Histopathological examination of the removed material showed fibromuscular dysplasia of the media. In the postoperative course the patient was clinically asymptomatic with ankle/brachial pressure indices of 1.0 on both legs. But shortly after discharge the intermittent claudication in the right leg recurred. Angiography and duplex ultrasound revealed focal stenosis of the right common iliac artery as well as retrograde dissection of the right common iliac artery extending into the distal aorta. Conservative therapy was recommended to the patient by the local hospital and no further progression of clinical and duplex findings within the last six months was found.

[Venous bypass: gold standard with excellent results]

Since 1974 we have performed 1104 in situ vein bypasses for the reconstruction of femoropopliteal or femorotibial occlusions. The venous valves were made incompetent by using our Insitucut. An intraoperative completion angiography is mandatory. The primary cumulative patency rate is 93.5% at one year and 64.9% at five years. The permeability is depending on the quality of the outflow tract. The patency of femoropopliteal in situ bypasses with a three vessel runoff is 82.2% at five years, whereas bypasses with a single vessel runoff show a patency of 56%. The own results are comparable with the results of reversed and non-reversed vein bypasses given in the literature.

[Reconstructive venous valve surgery]

The indication for venous valves surgery has to consider morphological and functional aspects. 36 reconstructive valve repair procedures and the long-term results are reported. The procedures need surgical skill and a meticulous operation technique. Primary idiopathic valvular incompetence can be treated with a direct valvuloplasty (Kistner). The leaflets of the floppy valve become shortened either by an open repair or with a closed procedure. Patients suffering from post-thrombotic syndrome showing intact valves in the deep femoral vein may undergo a transposition operation. In this case the superficial femoral vein is implanted end to side into the deep femoral vein distally to a proximal valve. The best results in post-thrombotic syndrome are achieved with a free transplantation of a venous valve from the axillary vein into the superficial femoral or into the popliteal vein (Taheri). Postoperatively the patients are anticoagulated and have to wear a compressing stocking (Grade III). The results of direct valvuloplasty (Kistner) and valve transplant (Taheri) are satisfactory, whereas the results of transposition seem to be disappointing. Good results are depending mostly on a correct indication for the operation and on avoiding the contraindications.

[Combination of profundaplasty and pharmacotherapy in stage III/IV peripheral arterial occlusive disease]

This prospective randomized study shows that adjuvant 3-week i.v. PGE1 treatment substantially improves the short-term results in patients undergoing profundaplasty. Compared with placebo, PGE1 approximately doubles the number of patients returning from stage III/IV to stage IIb of PAOD. Five years after surgery, the outcome with respect to limb salvage and patient survival rate was significantly better in patients additionally treated with PGE1.

[Aneurysms of the subclavian artery in thoracic outlet syndrome]

The true subclavian artery aneurysm is a rare but dangerous complication of TOS. During a 20 years time period we observed 18 patients with subclavian artery aneurysms. 12 of these patients showed cervical ribs. Half of the patients (n = 9) presented with a critical ischemia of an upper extremity, nine patients were operated on electively. The acute ischemia makes the desobliteration of the outflow tract necessary first. The next step ist the transaxillary exarticulation of the first rib and the resection of the aneurysm. The reconstruction of the subclavian artery is performed by using autologous vein material or PTFE prostheses. In two cases both with an acute embolic critical ischemia major amputations were unavoidable. 13 patients could be reexamined in 1996: 11 bypasses proved to be functioning, 2 were definitely occluded.

Low-dose iloprost infusions compared to the standard dose in patients with peripheral arterial occlusive disease Fontaine stage IV. DAWID Study Group

BACKGROUND

Intravenous iloprost, titrated from 0.5 up to 2.0 ng/kg/min has been shown in patients with PAOD III/IV to significantly improve healing of trophic lesions, relief of rest pain, and reduce the rate of major amputation or death at 6 months as compared to placebo. The effect is considered related to improvement of the microcirculation. The aim of the present trial was to identify an optimum dose regarding treatment response and tolerability, by studying 4 doses of 25, 50, 75 and 100 micrograms iloprost daily.

PATIENTS AND METHODS

302 patients with PAOD IV were randomised via a double-blind fashion to one of the 4 doses. The primary endpoint was the responder rate at end of treatment. Responders were defined as patients with very good or good global efficacy, as judged by lesion healing and pain relief. Side effects were documented and a pre-defined benefit/risk index was calculated.

RESULTS

No dose-dependency of iloprost regarding primary or secondary endpoints was observed. The rate of responders ranged between 48.7-53.5%. Side effects, mainly related to vasodilation, increased dose-dependently (p < 0.001, chi 2-test), with a significant decrease of the benefit/risk index from 2.19 +/- 1.19 to 1.64 +/- 0.97 (p = 0.012, ANOVA). Responders had a better outcome at 6 months than non-responders (2.6 fold higher rate of major amputation or death; life table analysis).

CONCLUSIONS

It is concluded that iloprost should be titrated to the optimum rather than maximum tolerated dose, since a higher incidence of side effects not associated with an increased treatment response was observed at higher doses.

Improvement in the quality of life after i.v. PGE1 therapy for intermittent claudication

BACKGROUND

Increasingly and justifiably, clinical studies are now being expected to investigate the influence of therapeutic measures also on the quality of life of the patient.

PATIENTS AND METHODS

Since no data on the variability of changes in the quality of life of the patient following PGE1 treatment are so far available, the initial investigation was designed as an uncontrolled pilot study. 104 patients (median age 64.5 years) with a maximum of walking distance on the treadmill (3 km/12%) of 50-250 m were included and given a daily intravenous infusion of 60 micrograms PGE1 (Prostavasin) over a period of 4 weeks excluding weekends. This was followed by a treatment-free follow-up period of 3 months. Changes in the quality of life were recorded with both the newly developed disease-specific questionnaire PAVK-86, and the generic questionnaire SF 36; in addition, the pain-free and maximum walking distances on the treadmill were also established prior to and immediately following treatment, as also at the end of the follow-up period.

RESULTS

The quality of life was significantly improved in all dimensions (functional status, complaints, pain, mood, anxiety, social life, treatment expectations) in addition to a marked increase in the median pain-free walking distance from 77 to 108 m (p < 0.001) and the maximum walking distance from 118 to 171 m (p < 0.001). At the end of the 3-month observation period, the improvement was essentially still demonstrable.

CONCLUSION

The study has shown for the first time that treatment with intravenous PGE1 brings about not only the already known increase in the walking distance, but also a clinically relevant and significant improvement in the patient's quality of life.

Effects of adjuvant PGE1 therapy following profundaplasty in patients with severe limb ischaemia. Early and long-term results

BACKGROUND

In patients with peripheral arterial occlusive disease (PAOD) of stage III/IV and three-level occlusion, the outcome of vascular surgery is still unsatisfactory. Therefore, the aim of our study was to determine both the short-term results and the long-term outcome, in terms of limb salvage and patient survival, of adjuvant intravenous prostaglandin E1 (PGE1) treatment in patients undergoing profundaplasty.

PATIENTS AND METHODS

A prospective randomized placebo-controlled study was conducted in 83 patients with PAOD of the lower extremities (stage III or IV according to Fontaine). Profundaplasty was carried out in all patients. Starting on the day of surgery and continuing for three weeks, patients of the PGE1 group (n = 42) received twice daily a 2-hour intravenous infusion of 60 micrograms PGE1 in 250 ml of physiological saline. Patients of the control group (n = 41) were given only saline by the same regimen. Following discharge from hospital, patients were re-examined after 6 weeks and subsequently every 6 months for a period of up to 5 years.

RESULTS

Short-term results: In the PGE1 group, rest pain disappeared and necrotic lesions healed in a significantly larger proportion of patients as compared with the control group (62% vs 37%; p = 0.05). Moreover, the number of minor amputations, such as toe and forefoot amputations, was significantly smaller in patients treated with PGE1 (7 vs. 19; p < 0.001). Long-term results: By the end of the 5-year follow-up period, a significantly larger percentage of patients was still alive in the PGE1 group as compared with control (55% vs. 34%; p = 0.046). Moreover, significantly less major amputations became necessary during follow-up in the PGE1 group (8 vs. 16; p = 0.0088).

CONCLUSIONS

In patients undergoing profundaplasty because of severe limb ischemia due to three-level occlusion, adjuvant intravenous 3-week treatment with PGE1 substantially improves not only the short-term results, but also the long-term outcome after five years in terms of patient survival and limb salvage.

Efficacy of a new prostaglandin E1 regimen in outpatients with severe intermittent claudication: results of a multicenter placebo-controlled double-blind trial

For the first time efficacy and safety of a new prostaglandin E1 (PGE1) regimen in the treatment of intermittent claudication were evaluated in a randomized, double-blind, placebo-controlled multicenter clinical trial. The study involved 213 outpatients with a maximum walking distance of 50 to 200 m measured on the treadmill (3 km/hr, 12% grade). After a 2-week run-in phase they received a 2-hour intravenous infusion of 60 micrograms PGE1 or placebo 5 days a week for 4 weeks. It was followed by a 4-week interval treatment with the same medication administered only twice a week. Patients were monitored for 3 months when they received no study medication. In the PGE1 group the intention-to-treat analysis (n = 208) revealed an increase in walking distance after 4 weeks of 75% (placebo, 43%). At the end of the interval treatment the walking distance had improved to 101% (placebo, 60%). The results remained virtually constant during follow-up (PGE1, 104%, placebo, 63%). Between-group comparisons showed significant differences in favor of PGE1 for all three time points of measurement (p < 0.05, p < 0.01, and p < 0.05). PGE1 was well tolerated; the rate of adverse reactions related to the treatment was 12.8% (placebo, 7.7%). In summary, these results show that the new PGE1 regimen is effective and safe in the treatment of outpatients with intermittent claudication.

[Quality of life in peripheral arterial occlusive disease. Multicenter study of quality of life characteristics with a newly developed disease-specific questionnaire]

AIM

Owing to a lack of disease-specific measuring instruments, no systematic investigations of the impairment of the quality of life in patients with peripheral arterial occlusive disease (PAOD) have so far been possible. The aim of the present study, therefore, was to develop an appropriate questionnaire and to submit it to a psychometric test in a sufficiently large number of patients.

PATIENTS AND METHOD

A disease-specific questionnaire comprising 86 individual items was developed (PAVK 86) and was tested in a longitudinal study involving 308 patients with confirmed peripheral arterial occlusive disease, Fontaines's stages I to IV. At the same time, three established generic questionnaires were also employed (SF 36, NHP, Every Day Life).

RESULTS

Analysis showed that, in comparison with a normal population, the quality of life in patients with PAOD is considerably impaired, in particular by pain, anxiety, general complaints and reduced physical mobility and performance, and is comparable with that of patients suffering from renal carcinoma. In Fontaine's stage III and IV, the quality of life is significantly more greatly impaired than in patients with stage II disease. No differences in quality of life were to be found between Fontaine's stages III and IV. The psychometric test revealed that the PAVK 86 questionnaire is a sensitive, reliable, valid and practicable measuring instrument.

CONCLUSION

The PAVK 86 questionnaire is suitable for determining the course and outcome of therapeutic measures on the quality of life of PAOD patients, and can therefore be included in clinical studies. In addition, its use in combination with established generic questionnaires also permits a comparison with age-matched healthy control groups, and is thus also of importance for the assessment of aspects of health economics.

Treatment of patients with peripheral arterial occlusive disease Fontaine stage IV with intravenous iloprost and PGE1: a randomized open controlled study

In a randomized open controlled study the clinical effects and tolerability of prostaglandin E1 (PGE1) and the stable prostacyclin (PGI2) analogue, iloprost in the management of diabetic and non-diabetic patients with advanced peripheral arterial occlusive disease (PAOD Fontaine stage IV) were compared. 267 patients were enrolled in this multicentre study and treated for 21-28 days, either by daily infusions of 6 h with iloprost or 2 x 2 h with PGE1. At the end of treatment patients were assessed for evidence of improvement of trophic lesions, relief of rest pain and change of global clinical status. 228 patients were considered as evaluable for efficacy analysis, which revealed 52.7% responders in the iloprost group and 43.1% for PGE1 (p = 0.148). Whereas iloprost showed similar effects in diabetics and non-diabetics (53.3% and 51.4% response rates, respectively), the diabetics treated with PGE1 had a considerably poorer outcome (36.6% versus 53.3%). At 6 months follow-up 62.2% of patients in both groups were alive with a viable limb. Slightly more iloprost patients underwent major amputation (32.1% versus 27.2%), but the number of deaths was reduced by 50% in the iloprost group compared to the PGE1 group (7.5% versus 14.6%, p = 0.10). Side-effects such as headache, flushing and gastrointestinal symptoms were significantly more common in the iloprost group (73.9%) than in the PGE1 group (31.0%), particularly during the first 3 days of dose titration. No specific toxic or unexpected reactions were reported in either group.

Femoropopliteal and femorotibial greater saphenous vein "in situ" reconstructions in non selected patients. Life table analysis

594 non selected "in situ" reconstructions were analyzed retrospectively using the life table method. Especially after immediate occlusion the cumulative patency rate is unsatisfactory (33.1% vs 62.3% after 6 years). Patency rates are influenced by the anastomotic site and mainly by run off conditions. The number of patent tibial arteries seems to be the most important determinant. These results prove to be statistically significant.

Results of femoropopliteal and femorotibial greater saphenous vein in situ bypass. Life table analysis

Five-hundred-ninety-four nonselected "in situ" reconstructions were analysed retrospectively using the life table method. Especially after immediate occlusion cumulative patency is very unsatisfactory. After 5 years cumulative patency rate in these cases is 39.5% vs. 64.9% in all cases. Patency rates are influenced by the anastomotic site and the run-off quality. While statistically not significant, popliteal anastomoses perform a little better after 5 years than peripheral anastomoses (67% vs. 51% cumulative patency rate). The number of patent tibial arteries seems to be the most important determinant. In non-occluded run-off cases (three patent tibial vessels) the cumulative patency rate after 5 years is 82.2% vs. 56% in cases with only one patent tibial artery. The difference is statistically significant.

[Prostaglandin E1 in stage III and IV arterial occlusive diseases. results of a multicenter study]

In a controlled randomized trial at four centers, using a common protocol, 57 patients with advanced chronic arterial occlusive disease (21 in stage III, 36 in stage IV) were treated with prostaglandin E1 (PGE1) or adenosine triphosphate (ATP) for three weeks. Both substances were administered intraarterially over 60 min. Daily dose of PGE1 was 20 micrograms, of ATP 30 mg. Both produced a significant reduction in resting pain at the end of the treatment phase, in stage III significantly better with PGE1. There was also a clear reduction in the use of analgesics, significantly more so with PGE1. Healing or improvement of ulcers was significantly better with PGE1, while there was no significant differences between the two drugs as regards stage improvement. Three amputations had to be performed in the PGE1 group, nine in the ATP group, a significant difference. Side effects in the form of reddening, pain and swellings occurred in 15 patients of the PGE1 group and six of the ATP group. Final verdict by the treating doctor about the success of treatment was significantly more favorable for PGE1.

[10 years' experience with the in situ bypass]

From October 1, 1974 to March 31, 1984 467 femoropopliteal and femorotibial in situ vein bypasses were performed. Valvular incompetence is produced by the use of modified Hall strippers. The intraoperative angiography is mandatory to localize the tributaries and to detect pathological findings of the vein and technical errors. Overall cumulative patency rates were 84, 76, 71, and 67%, at 2, 5, 8 and 10 years. Cumulative patency rates for 117 tibial bypasses separately were 72, 68, and 68% at 2, 5 and 8 years.

Direct reconstructive venous surgery

Unilateral occlusions of the pelvic veins may be corrected by a Palma operation. In the classic Palma operation the contralateral long saphenous vein is suprapubicly led to the opposite side and is anastomosed end-to-end or end-to-side with the common femoral vein of the occluded side. Just lately, spirally wall reinforced PTFE grafts showed more favourable results than Palma grafts. Circumscribed occlusions of the superficial femoral vein can be interposed by the May-Husni operation. Thereby the ipsilateral long saphenous vein is implanted end-to-side into the popliteal vein. We perform the Palma operation as well as the May-Husni operation under the protection of a temporary av-fistula. The ascending venography only permits to make a statement on the morphological operability, whereas the functional operability is indicated by means of phlebodynamometry. Phlebodynamometry and plethysmography are the best means to judge the functional result of the operation which is of importance for the patient. The results of the Palma operation can be regarded as very satisfactory, provided that the morphological and functional indication for the operation was correct. The use of the endothelium protective operative technique by Robert Mays as well as the application of a temporary av-fistula yield a success that is above 80 p.c. As against that, the May-Husni operation achieves less than 50 p.c. success, even if a temporary av-fistula is established in the area of the ancle. Less favourable are the results obtained by direct restorative interventions on the subclavian vein, so that these operations should only be indicated in exceptional cases.

Conservative treatment of inoperable arterial occlusions of the lower extremities with intra-arterial prostaglandin E1

Prostaglandin E1 has a strong vasodilator effect, it inhibits the aggregation of platelets and improves the microcirculation. The hormone is synthesized from arachidonic acid and 80-90 per cent is eliminated in the first transit of the pulmonary circulation. From 1 January 1978 to 30 June 1981 100 patients suffering from inoperable occlusion of the arteries of the lower limbs and facing amputation were treated with intra-arterial PGE1 by prolonged perfusion over an average period of 34 days. PGE1 0.1-0.2 ng kg-1 body weight min-1 was administered. Forty-seven of 100 legs were saved; 22 of 29 patients suffering from diabetes requiring insulin had to undergo amputation, but only 1 of 18 patients suffering from thromboangiitis obliterans had to have an amputation. The results of treatment in the 52 cases of uncomplicated arteriosclerosis lie in between, with 18 amputations. The complications that followed treatment were haemorrhage, arterial thrombosis, infection and mycotic aneurysms.

Shoulder girdle compression syndrome

Nowadays all compression syndromes at the upper chest like the costoclavicular syndrome, the scalenus syndrome, the hyperabduction syndrome and the Page-von Schroetter syndrome are included under the term of thoracic-outlet-syndrome. Apart from a constitutional disposition (cervical rib, anomalies of the tendons, etc.), it needs special factors like professional activities, sports, trauma, etc. to develop a T.O.S. syndrome. The symptoms range from prickling paresthesia, early fatigue, pains in shoulder and neck, claudication like pains and strong tendency towards swelling and rest pain or peripheral gangrene. Among 3126 vascular-surgical operations 128 transaxillary rib resections were performed during the time from June 1st, 1975 until March 31st, 1980. On 105 occasions rib resection was combined with the thoracic sympathectomy. In only 4 cases the resection of a cervical rib was sufficient to obtain decompression; in 15 cases the first rib had to be resected with a cervical rib. In 3 cases direct reconstructions of the artery and subclavian vein was performed by way of transaxillary approach. Postoperatively, 56% of the patients remained completely asymptomatic, 32% were decidedly improved and 12% unchanged.

Arterial reconstruction for distal disease of the lower extremities by the in situ vein graft technique

From January 1st, 1975 to December 31st, 1979, 285 femoropopliteal and femorocrural bypasses have been performed in 260 patients. In 57% of all cases the operation was carried out for limb salvage. The first 100 in situ transplants were angiographically examined 2 years after the operation. 5 years after the operation all patients were examined clinically, angiologically and by ultra sound Doppler technique. The patency rate amounts to 84% after 2 years and 76% after 5 years. With a patency rate of 57% after 2 years and 38% after 5 years the results achieved in the revascularization of a single crural artery are much more unfavourable. The results may be compared with those demonstrated by other authors who use the in situ technique. Compared to the classical venous bypass, the in situ bypass comes off a little better after a five years period.

[Bypass operations in reconstructive vascular surgery, using prosthetic material (author's transl)]

Age and accumulation of risk factors in patients with arterial occlusive diseases in Fontaine's Stages III and IV do not always permit direct vascular reconstruction. A further indication for prosthetic bypass procedures is given by local infections following vascular surgical interventions, severe damage to soft parts after traumata and radiotherapy, and anus praeter in the pelvic region. In the supra-aortic region carotido-subclavian, subclavio-carotid and the carotido-carotid bypasses are already routine operations. The indications for axillo-femoral, carotido-femoral, femoro-femoral, iliaco-femoral and obturator bypasses are described and discussed with reference to our own experiences.

[Q-Fever and its complications (author's transl)]

Q-Fever recurs as localized epidemics in the German Federal Republic. The disease has not previously been observed in North Hesse. During a familial infection with Coxiella burneti a 15-year-old boy together with his parents and an aunt became ill with atypical pneumonia. After the pulmonary symptoms had subsided a deep left leg and pelvic venous thrombosis occurred in the boy in the fifth week after the onset of the disease. The thrombosis which is very rare in childhood could be successfully removed at operation.

Immediate occlusions dependent on the type of reconstruction

In 507 reconstructive procedures on patients with chronic occlusions, we saw 4.1% immediate occlusions. We performed 409 thrombendarteriectomies, 40 dacron grafts, and 32 venous bypasses. As cause of the immediate occlusion, we found in 23 cases a dissection of the intima in the distal segment of the restored artery, in one case a bleeding from a perforation was discovered. Intimal dissection was found mostly after orthograde thrombendarteriectomy of the femoral and popliteal artery. The results of orthograde TEA could be improved by intraoperative angiography or direct opening of the distal popliteal artery. Intimal dissection after bypass operations are generally the result of technical errors.

[Apoplexy and stenosis of the renal atery (author's transl)]

A 48-year old man with stenosis of the right renal artery and hypertension of the renal artery and hypertension of the renal vessels suffered an apoplectic insult under antihypertensive therapy. The cause of this insult was found to be an acute total occlusion of the right carotid artery. At the same time there were stenoses of the right vertebral, the left common carotid and the left internal carotid arteries. Thromboendarterectomy of the right internal carotid artery, subclavio-carotid bypass on the left and thromboendarterectomy of the left intenal carotid artery and aortorenal bypass on the right were performed one after the other. The blood pressure can be premanently lowered, neurological symptoms no langer appear and the patient is completely able to work again.