Endovascular treatment of a post-traumatic thoracic false aneurysm in an adolescent. A case report

A 17 year old healthy young man suffered a motor-vehicle accident with severe polytrauma. During the rehabilitation a slight hypertension and a blood pressure difference of 30-40 mmHg between arms and legs was recognized. Mindful of a possible aortic lesion, an angio-magnetic resonance imaging (MRI) showed a 2.7x4.2 cm thoracic false aneurysm at the descending aorta. About 1 month after initial trauma, a Talent stent was implanted. The postinterventional period was uneventful. The patient was discharged on the 5th postoperative day.

Extraanatomic lateral reconstruction to the popliteal vessels

OBJECTIVES

To describe the lateral approach to the popliteal artery in reconstructions after soft tissue sarcoma resection in the thigh.

DESIGN

Case reports. Subjects Four patients with soft tissue sarcoma.

METHODS

Extraanatomic reconstruction of the resected artery and vein in the medial part of the thigh was performed. Vessel reconstruction was performed before tumor resection to avoid leg ischemia.

RESULTS

In all four patients the artery was replaced by using the contralateral saphenous vein, while the femoral vein was replaced in two cases using e-PTFE. Post-operative complications included one large lymphatic collection and a deep wound infection. Arterial primary graft patency was 100% after 1-7 years. Patency of the e-PTFE-venous graft was 0% without further consequences.

CONCLUSIONS

The extraanatomic lateral replacement of the vessels in the thigh is an elegant method in difficult vascular reconstructions after soft tissue sarcoma resection or debridement for deep vascular infections.

Aminoterminal propeptide of type III procollagen and matrix metalloproteinases-2 and -9 failed to serve as serum markers for abdominal aortic aneurysm

OBJECTIVES

Matrix-metalloproteinase (MMP)-2 and -9 and aminoterminal propeptide of type III collagen (NIIINP) have been reported to be elevated in patients with abdominal aortic aneurysm (AAA). The aim of our study was to test NIIINP, MMP-2 and -9 as potential serum markers for AAA in a large population group at risk for AAA.

METHODS

Fifty-five to 70 year old men were screened for AAA by abdominal ultrasound. Simultaneously, blood samples were taken and the patients were interviewed for known risk factors for AAA. Patients with a dilatation of the infrarenal aorta of > or =25mm (Group 1, n=76) were compared to randomly assigned patients with normal aortic diameters (Group 2, n=83). A third group consisted of patients scheduled for operation of AAA (n=19).

RESULTS

A total of 987 men were investigated with ultrasound. Seventy-six (7.7%) had an aortic dilatation > or =25mm. Aortic dilatation was correlated with age (P=0.0001). However, serum levels of NIIINP and MMP 2 were not different between the three groups of patients. For MMP-9 there was a weak inverse correlation with lower serum levels in patients with aortic dilatation (P=0.043).

CONCLUSIONS

Both MMP-2 and -9 and NIIINP failed to show relevance as serum markers for aortic dilatation. Our results are, therefore, in contradiction to previous published results. AAAs cannot be diagnosed with a simple blood test.

Circumferential removal of the adventitia for cystic degeneration of the popliteal artery

Did not result in aneurysmal degeneration

The incidence of iliac aneurysms in patients with abdominal aortic aneurysms: comparison of four centers in Europe and the USA

BACKGROUND

The purpose of this study was to compare the anatomy of the aortoiliac vessels in patients scheduled for infrarenal abdominal aortic aneurysm (AAA) repair in four different countries.

MATERIAL AND METHODS

Consecutives series of 100 preoperative CT-scans were evaluated at each center. Diameters of the suprarenal aorta, maximal diameter of the aneurysm, right and left common and external iliac artery as well as the hypogastric arteries were recorded and compared between each center.

RESULTS

Configuration of the AAA above bifurcation was similar at each center. The dimensions of the aortic bifurcation and the common iliac arteries were different among the centers. Common iliac arteries with diameters over 25 mm were significantly more common at center 1 (p < 0.001, p = 0.002 and p < 0.001). Among centers 2, 3 and 4 there was no significant difference in common iliac diameters.

CONCLUSIONS

Configuration of the iliac arteries in AAA was significantly different for Swiss patients compared to American, Austrian and German patients. Reasons for these differences are unclear, epidemiological or genetic factors may be responsible.

Present status of infrainguinal arterial bypass procedures following an all autogenous policy--long-term results of a single center

OBJECTIVES

The direction of vein grafts for infrainguinal arterial reconstruction is controversial. Long-term results of a single center following an all autogenous tissue policy in infrainguinal arterial reconstruction are reported with special attention to possible advantages for the in situ and non-reversed bypass using angioscopy.

METHODS

From 10/88 until 12/00 540 bypasses with autogenous veins were performed on 497 patients. Veins were used in a non-reversed or in-situ direction, valve disruption was performed under angioscopic control. All grafts were prospectively included in our data base and follow-up was scheduled in our vascular lab before discharge and after 3, 6, 9, 12, 24 etc. months.

RESULTS

Primary patency of all bypasses after 108 months was 55.2%, primary assisted 76.9% (SE +/- 9.87), survival 58.4% (SE +/- 8.88) and limb salvage 81.3% (SE +/- 9.75). Perioperative mortality was 0.9% (5 pat). Patency rates (primary assisted patency) after 72 months were 81.7% (98.2%) for supragenicular, 61.5% (79.4%) for infragenicular and 56.6% (78.1%) for tibial anastomoses and for pedal reconstructions after 48 months 49.3% (68.6%).

CONCLUSION

Reviewing the literature neither the in situ and non-reversed nor the reversed grafts yielded better long-term results. Absence of size mismatch may be an advantage in smaller veins. Angioscopy may detect unsuspected vein disease.

Does fibrin glue reduce complications after femoral artery surgery? A randomised trial

OBJECTIVES

to determine whether application of fibrin glue before closure of inguinal wounds reduces the incidence of lymphatic complications.

DESIGN

we a prospective randomised trial.

MATERIALS AND METHODS

224 consecutive patients were enrolled. The wounds were randomly assigned to standard closure (group A, n = 134) or closure with application of fibrin glue (group B, n = 132). The incidence of local lymphatic and non-lymphatic complications, the amount of lymphatic fluid collected, and the time to drain removal were compared in the groups.

RESULTS

the incidence of lymphatic complications was 19% in group A and 10% in group B (p = 0.027). The average drain output and the time to drain removal did not differ in the two groups. The total incidence of non-lymphatic local complications was 10% and did not differ in the two groups.

CONCLUSIONS

fibrin glue application is associated with a significant reduction in lymphatic complications.

Infrainguinal arterial reconstruction: female gender as risk factor for outcome

OBJECTIVES

the effect of gender on the long-term results of infrainguinal arterial reconstruction are poorly investigated.

METHODS

all patients undergoing infrainguinal arterial reconstruction with an autogenous vein are as 11 years period was prospectively evaluated.

RESULTS

four hundred and fifty reconstructions (292 man, 160 women) were performed as on 416 patients. Thirty-day mortality was 1.1% (n=5). Women were on average older (74 vs 68; p<0.001) and disease was more advanced (81 vs 68%,p =0.013 with stage of critical ischaemia). Primary (58 vs 61%) and primary assisted patency rates (82 vs 84%) were comparable. Limb salvage and survival after 60 months were not different. On multivariate analysis age and stage of the disease were independent variables for patency and survival. Diabetes and gender reached statistical significance as predictors of limb salvage only.

CONCLUSION

age and stage of the disease were independent predictors for patency and survival, diabetes and gender for limb salvage.

Athletes with lower limb ischaemia

The case of a young healthy sportsman and acute exacerbation of chronic infragenicular pain is presented. Further investigation revealed an obstruction of the tibiofibular trunk due to an osteochondroma, arising from the fibula, which was immediately resected. Osteochondroma is observed in 1-2% of the population and may present with vascular complications. In young patients and athletes, leg pain may be of vascular origin due to an entrapment or compression and should always be considered.

Long-term results of infrainguinal arterial reconstruction with spliced veins are equal to results with non-spliced veins

OBJECTIVES

to determine the long term patency of spliced and non-spliced infrainguinal vein grafts.

METHODS

a prospective registry of all patients undergoing infrainguinal arterial reconstruction with autogenous vein material was retrospectively interrogated.

RESULTS

between October 1988 and August 2000, 515 infrainguinal arterial reconstructions were performed on 472 patients. A total of 429 bypasses were performed with uninterrupted greater saphenous vein, 86 reconstructions using spliced vein segments. There was no significant difference in primary (63% vs 57%) and primary assisted patency (81% vs 81%) of limb salvage (88% vs 91%) at 5 years. Limb salvage was not different (88% and 91% respectively). CONCLUSION the splicing of vein grafts does not compromise patency of limb salvage.

[Differential diagnosis of groin pain: isolated, symptomatic dissection of the infrarenal aorta and iliac arteries]

INTRODUCTION

Pelvic and inguinal pain are a rare manifestation of arterial disease.

METHODS

Description of four patients with acute or chronic pelvic or inguinal pain due to symptomatic dissection of the infrarenal aorta and/or iliac arteries.

RESULTS

In two cases the dissection was limited to the left iliac artery with an entry at the beginning of the common iliac artery. The re-entry was located in the distal external iliac or common femoral artery. In one patient additionally a infrarenal abdominal aortic aneurysm was found. In the other two patients the entry of the spontaneous dissection was in the position of the infrarenal aorta, with extension in one iliac artery. In two patients the diagnosis of Erdheim-Gsell media necrosis was histologically confirmed.

CONCLUSIONS

Spontaneous arterial dissection should be considered in patients with pelvic or inguinal pain. Absence of thoracic symptoms is possible if the entry of the dissection is distal, within the infrarenal aorta or iliac arteries. Prompt diagnosis with duplex sonography, CT, arteriography or MRA is indicated. The type of reconstruction depends on the extent of the dissection and the concomitant arterial disease.

Cervical nerve injury after carotid endarterectomy

OBJECTIVE

to determine the extent and direct significance of cervical nerve injury after carotid endarterectomy.

MATERIAL AND METHODS

fifty-two patients (61 operations) were followed by means of patient history and neurological examination between 3 and 55 months following carotid endarterectomy.

RESULTS

sixteen operated sites showed normal sensitivity. Patients assessed 3-6 months after surgery showed on average a neurological loss of 3.4 points (scale from 0-4). Patients assessed after 7-12 months had on average a deficit of 2.1 points. After 13-24 months the score was at 1.4 and after the second postoperative year the score yielded only 0.4 points.

CONCLUSION

loss of cervical nerve sensation is always present after carotid endarterectomy but tends to improve with time. However, the timing and extent of this improvement is unpredictable. Patients are usually not disturbed by these changes.

Infrainguinal arterial reconstruction with autologous vein grafts: are the results for the in situ technique better than those of non-reversed bypass? A long-term follow-up study

BACKGROUND

The aim of this study was to answer the question if the in situ technique in infrainguinal arterial reconstruction is better than the non reversed one in long-term follow-up.

METHODS

Patients were included in a prospective study at operation. 387 infrainguinal arterial reconstructions in 367 patients performed from 10-88 to 12-98 were retrospectively analysed.

RESULTS

280 non-reversed and 107 in situ bypass procedures were performed. Primary patency rates at 60 months were 63.3% for non-reversed and 57.9% for in situ grafts (p=n.s.). Primary assisted patency rates were 81.8% and 84.5% respectively (p=n.s.). Limb salvage rate was not different in either group. The 30-day mortality was 1.9% in the in situ group and 0.7% in the non-reversed group (p=n.s.).

CONCLUSIONS

There is no difference in outcome between in situ and non-reversed vein grafting. Absence of statistical difference between the two procedures may be mainly due to the routine use of angioscopic quality control.

Reduction of groin lymphatic complications by application of fibrin glue: preliminary results of a randomized study

Lymphoceles and lymph fistulas are common complications after exposure of the common femoral artery in the Scarpa triangle because of operative transsection of overlying lymphatics. The purpose of this prospective randomized study was to determine the incidence of groin lymphatic complications and to assess the impact of routine application of fibrin glue on lymphatic structures and subcutaneous tissue prior to closure. All patients undergoing exposure of the common femoral artery in the Scarpa triangle were included in this study. They were divided into two groups according to closure technique. In group A, closure was performed without fibrin glue. In Group B, fibrin glue was applied to lymphatic structures prior to closure. The efficacy of fibrin glue application was estimated on the basis of two criteria: incidence of local complications and amount of lymphatic fluid in the Redon drain. The preliminary findings suggest that application of fibrin glue leads to a significant reduction in the incidence of lymphatic complications after femoral artery exposure in the Scarpa triangle.

Preconditioning with short cycles improves ischemic tolerance in rat fast- and slow-twitch skeletal muscle

AIM

The aim of this study was to investigate whether the efficacy of ischemic preconditioning (IP) in rat skeletal muscle depends on the duration of the preconditioning cycles.

METHODS

Rats were divided into four groups (n = 10 each). The right hindlimb of rats in group A were subjected to 2.5 h of tourniquet ischemia followed by 2 h of reperfusion (I-R). Thereafter, muscular function was analyzed in vitro and high-energy phosphates (HEP) were determined by HPLC. Before I-R, right hindlimbs of rats in groups B-D subjected to IP with three cycles each consisting of 2.5, 5 or 10 min of ischemia followed by reperfusion for the same duration.

RESULTS

Postischemic function of the extensor muscle was significantly improved with all three preconditioning protocols. Postischemic function of the soleus muscle was only improved by IP with three cycles of 5 min of ischemia and 5 min of reperfusion. Postischemic HEP tissue levels were not influenced by IP.

CONCLUSION

This study shows for the first time that IP increases ischemic tolerance not only of fast-twitch but also of slow-twitch skeletal muscle. The efficacy of IP seems to be less dependent on the duration of the single preconditioning cycle than on the number of cycles performed. Three cycles each of 2.5, 5 or 10 min ischemia and reperfusion significantly improved postischemic skeletal muscle function. Tissue levels of HEPs, however, were not influenced by IP indicating that preservation of HEPs does not play a major role in the effects of IP on rodent skeletal muscle.

Mechanisms of ischemic preconditioning in skeletal muscle

BACKGROUND

Ischemic preconditioning (IP) (one or more cycles each consisting of a short period of ischemia and a short period of reperfusion, before the sustained ischemia) reduces ischemia-related organ damage in heart and skeletal muscle but the underlying mechanisms are not clear. This study was intended to assess the possible involvement of K(ATP) channels and of adenosine receptors in IP of skeletal muscle in a rat model of skeletal muscle ischemia.

MATERIALS AND METHODS

Groups of 8-15 rats were given the following in vivo treatments: ischemia-reperfusion (I-R: 2.5 h tourniquet-induced ischemia of the right hindlimb, then 2 h reperfusion); IP (three cycles of 5 min ischemia, then 5 min reperfusion) before I-R; cromakalim and I-R; glibenclamide, cromakalim, and I-R; glibenclamide, IP, and I-R; [R]-N(6)-[1-methyl-2-phenylethyl]adenosine (R-PIA) and I-R; adenosine and I-R; and glibenclamide, IP, and I-R. Parameters of muscle function (postischemic maximal force, performance, contraction index, and force after 1 min of stimulation) were then assessed in vitro in the extensor digitorum longus muscle.

RESULTS

Pretreatment with either IP or the K(ATP) channel opener cromakalim significantly improved postischemic muscle function. The protective effect of cromakalim was not seen when the K(ATP) channel blocker glibenclamide was added. Glibenclamide, however, did not block IP-induced protection. Pretreatment with the adenosine A(1) receptor agonist 8-(p-sulfophenyl)-theophyllin (8-SPT) or with adenosine did not improve postischemic muscle function. The adenosine receptor agonist did not block IP-induced protection against ischemic damage.

CONCLUSIONS

The results show significant improvements in postischemic skeletal muscle function after IP or cromakalim pretreatment but they do not support a role for K(ATP) channels or for adenosine receptors in IP of skeletal muscle.

Function of fast- and slow-twitch rat skeletal muscle following ischemia and reperfusion at different intramuscular temperatures

Fast- (peroneal) and slow-twitch (soleus) skeletal muscles of anesthetized Wistar rats were subjected to 3 h of tourniquet ischemia. The intramuscular temperature of the leg was adjusted to 22, 30 or 35 degrees C (n = 12 per group) during ischemia. After 2 h of reperfusion, the muscles were electrically stimulated in vitro and muscular function was analyzed for maximal force, performance, contractility and fatigue. Contralateral nonischemic muscles served as controls. Three hours of ischemia at 30 degrees C did not reduce the function of the peroneal muscles compared to nonischemic controls. The same ischemic stress significantly reduced the function of the soleus muscles compared to nonischemic controls. The postischemic function of the soleus muscles declined with increasing temperature. The postischemic function of the 35 degrees C group of peroneal muscles was significantly reduced compared to the 22 and the 30 degrees C groups, which did not differ. These results provide evidence that fast-twitch muscles are more resistant to ischemia than slow-twitch muscles. They furthermore show a fiber type-specific dependency of postischemic muscle function on intramuscular temperature during ischemia. Hypothermia-sensitive fast-twitch fibers predominate in the skeletal muscles of the extremities. Mild hypothermia could, therefore, reduce tourniquet ischemia-induced injury after surgery of the extremities.

[Fibromuscular dysplasia of the brachial artery--2 case reports and review of the literature]

Yet being an uncommon disease in general, the manifestation of the fibromuscular dysplasia (FMD) in the upper extremities is exceedingly rare. Two patients with FMD of the brachial artery are presented and the literature concerned is reviewed. In this location the formation of microthrombi with subsequent embolization into the periphery instead of progressive vessel stenosis seems to be the leading pathophysiological principle. Therapeutic options are discussed.

Surgical treatment of "steal syndrome" induced by arteriovenous grafts for hemodialysis

OBJECTIVE

A rare but serious complication of angioaccess surgery for hemodialysis is the so called steal syndrome presenting as ischemia distal to an arteriovenous fistula. The main problem of various surgical techniques to correct steal is subsequent thrombosis of the fistula or persistence of distal ischemia.

INTERVENTIONS

This paper describes an unknown technique for correction of ischemic steal consisting of ligation of the artery just distal to the take-off of the fistula and arterial bypass from the artery proximal to the take-off of the fistula to the artery distal to ligation.

PATIENTS

Six patients with chronic renal insufficiency (3 male, 3 female) with patent upper arm cephalic fistulas presented with severe hand ischemia.

RESULTS

Symptoms improved in all 6 patients immediately after operation. Successful hemodialysis could be maintained using the original fistula.

CONCLUSIONS

The described technique is maybe the procedure of choice for the correction of fistula induced ischemic steal.

Infrainguinal arterial reconstruction with non-reversed autologous vein after angioscopy guided valvulotomy ex situ

AIMS

The advantages of in situ autologous vein grafts for long infrainguinal arterial reconstructions are the tapered conduit, minimising size mismatch at proximal and distal anastomoses, and the possibility of using small sized veins with good results. Unfortunately, in about 30% of legs the ipsilateral saphenous vein is inadequate rendering in situ bypass grafting impossible. To profit from a valveless autologous vein graft in these cases we routinely performed ex situ valvulotomy after harvesting the contralateral saphenous vein or good quality segments of the ipsilateral saphenous vein.

METHODS

The ex situ valvulotomy was performed under angioscopic guidance using a flushing-type Mill's valvulotome.

RESULTS

Fifty non reversed grafts in 46 patients entered a prospective surveillance program. Primary and primary-assisted patency rates at 2 years were 68% and 82% respectively, early graft thrombosis 2%, late stenosis 8% and major amputation rate with a patent graft 6%. No technique related problems were noticed.

CONCLUSION

Angioscopy guided valvulotomy was safe and simple and allowed good quality control of the veins. The presented results in this study are comparable to other recently reported series of in situ bypass. The clinical use of small flexible endoscopes allows a safe and atraumatic valvulotomy and simultaneous quality control of autologous vein grafts.

Angioscopy guided in situ bypass versus angioscopy guided non reversed bypass for infrainguinal arterial reconstructions. A comparison of outcome

In situ bypass grafting depends on an adequate ipsilateral greater saphenous vein. To profit from a tapered, valveless conduit in legs without an adequate greater saphenous vein, we routinely used the contralateral saphenous vein non reversed. In some reconstructions to the infrageniculate popliteal and the proximal anterior tibial artery we used the non reversed instead of the in situ technique because of the distance between the natural course of the saphenous vein and the recipient artery. This retrospective study compares the outcome of 48 in situ bypasses to the outcome of 66 non reversed bypasses. Endoluminal manipulations in all veins were visually controlled using an angioscope. The two groups of bypasses (in situ versus non reversed) did not differ concerning age, sex, risk factors, operative mortality, indication for surgery and distribution of the recipient arteries. There was a tendency for a lower wound complication rate in "in situ" compared to non reversed bypasses (10% versus 27%; p = 0.086). There were no differences in cumulative primary and primary assisted patency rates between the two groups after two years. We prefer the angioscopy guided in situ technique for reconstructions to infrageniculate arteries because of a low wound complication rate and excellent patency rates. In the absence of an adequate ipsilateral saphenous vein and in reconstructions to recipient arteries not presenting themselves for the in situ technique, similar results can be achieved with angioscopically prepared non reversed grafts.

[Adventitia resection in cystic degeneration of the popliteal artery]

Adventitial cystic disease is a rare form of non-atherosclerotic stenosis of the popliteal artery. It is caused by synovial-like cysts in the subadventitial tissue layer of the arterial wall causing compression of the lumen. The cysts contain mucinous material similar to that found in joint-ganglia. Popliteal artery stenoses causing claudication in young patients is the leading symptom of this disease. The classical therapy is the surgical excision of the diseased artery and interposition grafting with saphenous vein. As an alternative method we present the technique of complete circumferential resection of the diseased adventitia to decompress the lumen of the artery by removing the cysts completely. This technique is called exarterectomy and has been applied in 2 patients. In both cases we could remove the cysts completely without opening the arterial lumen. Intraoperative arteriography documented complete decompression of the arterial lumen. Both patients presented with excellent results 6 months postoperatively without any symptoms or signs of recurrence. Late results of exarterectomy ar not yet available.

[Cost saving after-care in infra-inguinal vascular reconstruction]

To assess the indications for routine colour flow duplex surveillance, 43 infrainguinal autogenous vein grafts were prospectively entered into a surveillance protocol. Screening consisted of measurements of ankle brachial indices (ABI) and colour flow duplex imaging of the entire graft length. All grafts at risk had a serial fall in resting ABI of more than 0.1. This study suggests that resting ABI measurements are a very sensitive and non-expensive primary screening procedure, provided that all grafts with ABI changes of more than 0.1 are further evaluated. About 60% of ABI-screened grafts needed further evaluation because of ABI changes of greater than 0.1, incompressibility of arteries or extension of the graft to the ankle or pedal arteries. Colour flow duplex scanning was very useful in excluding of identifying and localising graft problems and deciding on further invasive diagnostic and therapeutic procedures.

Behaviour of surgically corrected infrainguinal vein grafts

During a period of 4 years (1988-1992) we detected in a series of 114 infrainguinal vein grafts 22 bypasses (19%) with 26 hemodynamically significant (> 50%) stenoses. The secondary cumulative patency rate of 114 bypasses was 92% at 12, 84% at 24 and 84% at 36 months. Twenty-three secondary surgical procedures consisting of vein patch angioplasty (n = 10), interposition grafting (n = 3) or jump- or sequential grafting (n = 10) were performed to correct stenoses. One graft correction was technically not feasible, resulting in graft occlusion. Two patients refused surgery. All corrected grafts were prospectively studied both by ankle brachial measurements and color flow Duplex scanning every 3 to 6 months. Cumulative graft patency after reintervention in 20 grafts was 95% at 12 months and 95% at 24 months. Mild stenosis (< 50%) of revision sites was observed in 2 grafts. No single stenosis remote of revision site developed during follow-up (mean 20.4 months), confirming the opinion that stenosed vein grafts after correction do not demonstrate a higher incidence to develop strictures than normal grafts. No tertiary procedures were necessary, as all categories of secondary procedures normalized graft and limb hemodynamics. This series demonstrates that excellent long term results after surgically corrected high grade graft lesions justify an aggressive approach to these stenoses.

[Dacron prosthesis dilatation. Case report and review of the literature]

Twelve years after implantation of a subclavian-femoral Dacron prosthesis the graft had to be replaced because of diffuse aneurysmatic dilatation. There was no infection documented. Dilatation of knitted Dacron prostheses under arterial pressure is a normal event but rarely causes graft failure due to aneurysm formation. The following problems can promote graft dilatation: fabrication defects, multiple sterilization, false storage, damage during the operation, infection or/and hematoma, host vs graft reaction, constant mechanical stress due to anatomical facts, material fatigue and gliding of fibers and chemical reactions because of bioinstability. We recommend to use rather small sized prostheses in the aorto-iliac system. Some authors recommend long-term follow-up of all patients with artificial grafts.

[Value and use of pedal reconstruction in an extremity at risk for amputation]

In patients with critical limb ischemia and patent pedal arteries as a single outflow source the surgeon has to decide between primary amputation and reconstruction. From 1989 to 1991 we performed 80 infrainguinal reconstructions, 13 of them to pedal arteries. In all cases we used autogenous vein material from different sources, if possible as an in situ conduit. The perioperative mortality was 0%. After 24 months the limb salvage was 92%. The secondary cumulative patency rate was 92% after 12, 74% after 24 months. In a selected group of patients we prefer arterial reconstruction to pedal arteries instead of a primary amputation.

[Technique for endoscopic vein preparation in infra-inguinal in situ bypass]

In situ saphenous vein bypass for infrainguinal reconstructions achieves excellent results, especially for distal anastomoses. The achilles heel of the method is the complete and atraumatic disruption of the valves and the location of significant tributaries of the saphenous vein. An intraoperative quality control is necessary to mend early patency rates. Several control instruments are described: intraoperative arteriography, duplex- or Doppler sonography and angioscopy. We describe the technique of a semiclosed angioscopy guided technique with a novel flushing valvulotome. We use an angiofiberscope with 2.2 or 1.4 mm outer diameter, being introduced through the proximal exposed end of the saphenous vein. Through the distal end or a side branch a modified Mill's valvulotome with a flushing channel (flexible or non flexible) is moved upwards to the angioscope. Every valve cusp is incised under direct vision in a retrograd direction. Simultaneously relevant tributaries are angioscopically located and ligated through small skin incisions. To use the potential of angioscopy we have developed the occluder valvulotome, making endoluminal embolization of tributaries of the saphenous vein possible. Details of these techniques are described.

[Treatment of recurrent inguinal hernia by implantation of a pre-peritoneal prosthesis. Results of a prospective study]

44 patients with 47 recurrent inguinal hernias entered a prospective study. All patients were operatively managed by a standardized technique using a polypropylene (Prolene) mesh inserted through a pre-peritoneal approach. Operating in the pre-peritoneal space avoids dissection of the scared cord and the "inlay" prosthetic mesh safely creates a new "fascia transversalis" with a low rate of recurrences. All patients were personally controlled every 6 months with a follow-up time of 12 to 60 months (mean 20.2 months). The low postoperative morbidity included only one seroma, no infection and no testicular complications. We observed one recurrence occurring 6 months after surgery (2%). The described operative technique using an inlay patch is recommended as the therapy of choice in all recurrent groin hernias.

[The entrapment syndrome of the popliteal artery: diagnosis, therapy, results]

The popliteal artery entrapment syndrome is caused by an anatomical anomaly in the popliteal fossa. Mostly the popliteal artery is compressed by a faulty insertion of the medial head of the gastrocnemius muscle. The main symptom is an intermittent claudication at an early age. We review our experience with four typical cases. All patients were examined because of a unilateral sudden claudication in the calf at ages between 23 and 43 years. In two patients we could find angiographically a typical stenosis, in two others a complete occlusion of the popliteal artery. Additionally a female patient showed a 6 x 8 cm poststenotic aneurysm in the popliteal fossa. Therapeutically we restored the flow of the artery on two patients by dividing the compressing gastrocnemius muscle. As a late complication two years after the first operation one of these patients had an occlusion of popliteal artery which was bypassed by a popliteo-crural vein graft. On two patients we primary inserted a vein graft. All patients were checked 6 months till 5 years after the first operation by duplex scanning, by measurement of pressure at the ankle and by pulse volume recording at the big toe. All our postoperative examinations demonstrate patency of the repairs and the patients have very few problems.

The role of colour flow duplex screening in infra-inguinal vein grafts

To assess the indications for routine colour flow duplex surveillance, 43 infra-inguinal autogenous vein grafts were prospectively entered into a surveillance protocol. Screening consisted of measurements of ankle brachial indices (ABIs) and colour flow duplex imaging of the entire graft length. Twelve significant stenoses have been detected in 10 grafts (23%) using duplex, all within 6 months of surgery. All grafts at risk had arteriography confirming the duplex findings, but detecting one additional stenosis. Two grafts at risk were not detected by duplex scanning (sensitivity 83%). All grafts at risk (12) had a serial fall in resting ABI of more than 0.1. Most of the detected graft stenoses could be corrected surgically, improving the 1 year primary cumulative patency rate of 54% to a secondary patency rate of 88%. This study suggests that resting ABI measurements are a very sensitive (sensitivity: 100%) and simple primary screening procedure, provided that all grafts with ABI changes of more than 0.1 are further evaluated. The interval specificities of ABI measurements were 77% at 3, 71% at 6, 67% at 12 and 78% at 18 months (mean 73%). About 60% of ABI-screened grafts needed further evaluation because of ABI changes of greater than 0.1, incompressibility of arteries (ABI greater than 1.3) or extension of the graft to the ankle or pedal arteries. Colour flow duplex scanning was very useful in excluding or identifying and localising graft problems and deciding on further invasive diagnostic and therapeutic procedures. Ankle brachial index measurements as the primary examination for selecting patients for colour flow duplex scanning seems to be a safe screening procedure.

[Breast saving therapy of breast cancer: sensitivity of mammography in relation to primary tumor size]

A number of patients with early breast cancer are candidates for conservative surgery and irradiation. The possibility for limited surgery has to be discussed with the patient preoperatively and depends mostly on tumor-size in relation to breast-size. We correlated mammographic and pathologic measured tumor-size in a retrospective study in 57 breast cancer patients. The sensitivity of mammography depended on the accepted range of error between mammographic and pathologic measured tumor-size. With an accepted range of +/- 20% the sensitivity was only 45%, with an accepted range of +/- 30% it was 63%. These rather bad results advise to have a very careful preoperative discussion with the patient about breast conserving or ablative surgery. Possibly there is higher sensitivity in preoperative tumor-size measurement with real-time-sonography.

Angioscopy-guided semiclosed technique for in situ bypass with a novel flushing valvulotome: early results

To allow and facilitate endoluminal vein preparation under angioscopic guidance for in situ bypass grafting, a Mill's valvulotome was equipped with a flushing channel. The advantages of the novel valvulotome are obvious: it allows perfect angioscopic view within a saphenous vein that still contained blood by adjusting the jet of lactated Ringer's solution directly to the lens of the angioscope; it permits the use of very small angioscopes without integrated flushing channels, preventing endothelial damage. The described technique was tested in 27 peripheral reconstructions in 26 patients. The secondary cumulative patency rate within a follow-up time of 4 to 30 months (mean, 14 months) was 89%. The described technique substantially facilitates in situ bypass grafting and minimizes early and late complications and further improves surgical outcome.

[Did management of breast carcinoma progress in the 80s?]

During the last decade there have been important changes in diagnosis and therapy of breast cancer. Breast conserving surgery in patients with small tumors combined with radiation therapy has gained wide popularity due to better cosmetic results without significant changes in survival. Results in breast cancer treatment have been markedly ameliorated by early diagnosis and treatment. It is hoped that this will be accomplished by routine mammographic screening in asymptomatic women. In this retrospective study data of 398 breast cancers are analyzed. All patients underwent surgery between 1981 and 1988. To demonstrate changes in the stage at the time of diagnosis during the last decade, the material has been divided in two groups: group 1 represents the tumors diagnosed in 1981/82, and group 2 those diagnosed in 1987/88. Comparison of these two groups did not show any significant changes in cancer stage at operation during the last ten years. Screening programs are planned and have to be supported in order to ameliorate the results of breast cancer treatment. Intensive public information is necessary to motivate medical personnel and women for early breast cancer detection by mammography.

In situ femorodistal bypass: novel technique for angioscope-assisted intraluminal side-branch occlusion and valvulotomy. A preliminary report

To allow and facilitate complete endoluminal vein preparation under angioscopic guidance for in situ femorodistal bypass grafting, a novel instrument was constructed. In experiments in cadavers we developed the occluder valvulotome, consisting of a modified Mills' valvulotome containing a laterally-ending working channel, a retrograde cutting blade and an advanceable Teflon tube within the working channel. Using this instrument in combination with commercially available wire coils, we successfully performed five femorocrural in situ reconstructions with endoluminal valvulotomy and embolization of a total of ten thigh tributaries. The technique allows angioscope-assisted valvulotomy and simultaneous endoluminal tributary occlusion, making long skin incisions and extensive vein dissection obsolete.

[Surgically relevant complications in percutaneous transluminal angioplasty]

Seven significant surgical complications in 118 patients after PTA-treatment of the lower extremities are presented. In two cases the puncture site in the vessel had to be sutured, in three patients we had to perform a femoro-popliteal bypass, once a TEA with profundaplasty and in another case an embolectomy of the trifurcation. Our experience reveals that with the indication for PTA, the rate of significant complications and their surgical consequences has to be considered too. A close cooperation between Radiologist, Angiologist and Surgeon is of importance.

[Diagnostic and therapeutic concepts in breast neoplasms]

Therapeutic decisions in breast cancer are no longer as simple and straightforward as they were. Radical masectomy has long ceased to be a routine application to every patient. A number of patients are now candidates for conservative surgery combined with irradiation. Patients who still require total mastectomy with axillary clearance may wish to undergo immediate or delayed breast reconstruction. In our department most patients with breast tumors are first seen in the outpatient clinic, where diagnostic work-up is completed and the therapeutic concept is discussed. If necessary, consultation with the radiotherapist and the plastic surgeon is available. Our diagnostic and therapeutic concepts are summarized in Fig. 1 and Table 1.

The effects of renal pelvic pressure elevation on isotope nephrography and renal transit time, an experimental study

Radionuclide procedures are clinically used for assessing obstruction in dilated urinary tracts. The precise correlation of the isotope retention function with the level of the renal pelvic pressure is not known as yet. It was measured experimentally using 20 minipigs. By means of ureterostomies in situ reaching into the pyelon the 40 kidneys were subjected to varying pressures (seven to 62 cm. H2O) while the renal processing of 123-I-orthoiodine-hippuric-acid was recorded. The correlation of five radionuclide parameters with the pelvic pressure was computed: the time to the peak value of the isotope nephrography (t-max) and renal transit time correlated very well with high grade pelvic pressure (greater than 37 cm. H2O): r = 0.91 and 0.86 respectively, but much less well with low grade pelvic pressure (less than 37 cm. H2O): r = 0.73 and 0.62 respectively. The slope of the third phase of the isotope nephrography (tan-turn) and the time to the turning point of its tangent (t-turn) correlated only weakly with elevated renal pelvic pressure: r = 0.62 and 0.59 respectively. In conclusion, radionuclide procedures give excellent qualitative information on the level of pelvic pressure. They cannot, however, be used even as an indirect means for quantitatively assessing elevated renal pelvic pressure, which in urinary obstruction is thought to be one of the factors jeopardizing renal function.