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Copyright of Der Diabetologe is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Internist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Gefaesschirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Internist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Diabetologe is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Gefaesschirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Lower extremity arterial disease (LEAD) is a frequent manifestation of atherosclerosis with a high risk for cardiovascular events. The measurement of the ankle-brachial index (ABI) should be used as a screening method for LEAD. A differentiation is made between a stable stage of intermittent claudication and the stage of critical limb ischemia. The control of cardiovascular risk factors is crucial. Particular emphasis should be placed on smoking cessation and lipid-lowering treatment with statins and a target low-density lipoprotein (LDL)-cholesterol level of <55 mg/dl as a core element. In patients with symptomatic LEAD an inhibition of platelet aggregation is indicated. In addition to treatment with clopidogrel 75 mg or with acetylsalicylic acid (ASS) 100 mg in high risk patients the combination of ASS 100 mg and rivaroxaban 2 × 2.5 mg can be indicated. In critical limb ischemia revascularization (percutaneous intervention, operation) is always indicated to prevent amputation. First-line treatment in patients with intermittent claudication is exercise training. Revascularization can be indicated in patients with a severe limitation of walking distance.

Peripheral artery disease (PAD) is the most frequent cause for reduced perfusion in peripheral arteries. Patients with PAD have often manifestations of atherosclerosis in other vascular territories. Typical symptoms are intermittent claudication or rest pain and acral lesions in patients with critical limb ischemia. The majority of PAD patients are clinically asymptomatic; therefore, it makes sense to screen for PAD in patients with cardiovascular risk factors. The ankle brachial index (ABI) is regarded as an easy and cost-effective method for baseline diagnostics. If ABI measurement confirms the suspected PAD, a detailed diagnostic pathway should follow in which duplex sonography plays a central role. In some cases, additional radiologic imaging preferably by magnet resonance imaging is necessary to complete the diagnostic workup or to plan therapeutic procedures.

Basic diagnostics includes inspection of the skin, palpation of leg and foot pulses and determination of the ankle-brachial-index. The hemodynamic relevance of the circulation problem is important for the therapeutic decision. For its determination several noninvasive procedures are available. Treadmill test can help to differentiate between vascular and other causes of walking limitation.

Background: Vitamin K antagonists not only influence the synthesis of coagulation factors but also the activation of other vitamin K dependent proteins. Among other possible side effects, arterial calcification has been focused on in recent years., History and Findings: Four patients under long-term anticoagulation for more than 10 years developed medial calcific sclerosis. In case 1 we identified an unexplained medial calcific sclerosis on x-ray after a trauma by chance. After that we examined the ankle-brachial index of blood pressure in all patients who had received long-term anticoagulation for more than 10 years. Where the index exceeded 1,3 we performed a x-ray-examination of the forefoot. Of the four described patients no one suffered from diabetes mellitus, renal failure or hyperparathyreoidism. Serum calcium was normal in all patients. The severity of the medial calcific sclerosis could not be explained by the initial vascular risk factors., Conclusion: In certain patients, even at low vascular risk, a medial calcific sclerosis can appear under long-term anticoagulation with vitamin K antagonists. We conclude that vitamin K antagonists inhibit several proteins which protect the vessels from calcification leading to medial calcific sclerosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Soft tissue management is of paramount importance in ankle surgery. As such, full thickness necrosis of the soft tissue envelope represents a severe complication following total ankle joint arthroplasty (TAA) potentially leading to implant exposure, infection and thus, substantially compromised patient outcomes. One of the main factors leading to soft tissue complications is an undetermined arterial perfusion of the lower leg or ankle joint. We report on clinical cases suffering soft tissue complications following TAA with the respective plastic surgical therapy regimen and present a simple algorithm for preoperative perfusion evaluation., Methods: The medical records of 30 consecutive primary TAA patients were retrospectively reviewed after observing a higher than expected rate of severe soft tissue defects which have been referred to our plastic surgery department., Results: 3 patients (10%, all females, age 63 ± 5 years; BMI 27 ± 3 kg/m2) presented with a soft tissue defect leading to angiography revealing one case of severe arterial obstruction. Wound closure could be reached in one case by conservative therapy consisting of regular dressing changes. In the further patients definite soft tissue reconstruction could only be performed by surgical intervention. One could be covered by split-thickness skin grafting and one by a microsurgical transplantation of a free latissimus dorsi flap. On the basis of these complications we established an easy algorithm for the preoperative evaluation of the arterial perfusion in the ankle region. First, (I) the pulses of the dorsal foot artery and posterior tibial artery should be examined. In the case of not palpable pulses (II) the ankle-brachial index should be performed. Values of <0.9 or >1.2 recommend (III) to perform angiography. In the case of stenosis or complete obstruction (IV) the arterial blood flow should be reconstituted by interventional radiological stenting or vascular surgical procedures., Conclusion: The identification of the arterial perfusion status of patients undergoing TAA using a straightforward clinical algorithm might overcome TAA-related soft tissue complications and improve patient-related outcome measures., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Surgical decompression of nerves of the lower leg should facilitate swelling-related pressure in diabetic polyneuropathic similar to carpal and cubital tunnel syndrome. Pain reduction, reduced need for pain medication, improved pedal sensitivity, improved balance and proprioception, and potential prevention of ulcerations and amputations are the objectives of the operation., Indications: Diabetic polyneuropathy with positive Hoffmann-Tinel sign over the tarsal tunnel and an ankle-brachial index >0.7., Contraindications: No Hoffmann-Tinel sign over the tarsal tunnel, no pain, no sensibility disorders, ankle-brachial index <0.7, body weight >140 kg. Relative contraindication: venous stasis and postthromobitic syndrome., Surgical Technique: Under general or spinal anesthesia, tourniquet, decompression of nerves of the lower leg in three locations: (1) common peroneal nerve at the fibula head with incision of the peroneus longus muscle, (2) tarsal tunnel with its four tunnels: (a) tibial nerve in the tarsal tunnel, (b) medial plantar nerve in the medial plantar tunnel, (c) lateral plantar nerve in the lateral plantar tunnel, (d) Rr. calcaneare in the calcaneal tunnel, (3) dorsum of the foot with decompression of the peroneus profundus nerve with excision of the extensor hallucis brevis muscle., Postoperative Management: No weight bearing for up to 3 weeks, suture removal after 3 weeks, water aerobics starting postoperative week 4., Results: A total of 12 patients (64±9 years) were operated and were followed up for 12±6 months. Procedure time was 83±27 min. Pain reduction on a visual analogue scale improved from 7.1±1.2 preoperatively to 3.3±2.4 postoperatively. Balance improved on a Likert scale (1=best, 6=worst) from 5±1 to 2±1, while sensory impairment improved from 5±2 to 3±1. There were no ulcerations or amputations. Two secondary wound healing problems at the ankle and one lower leg venous thrombosis 2 weeks following discharge were managed conservatively.

The basis for the new procedure is the simultaneous transcutaneous measurement of the peri-ulceral oxygen partial pressure (tcPO(2)), using a minimum of 4 electrodes which are placed as close to the wound margin as possible, additionally, as a challenge the patient inhales pure oxygen for approximately 15 minutes. In order to evaluate the measurement data and to characterise the wounds, two new oxygen parameters were defined: (1) the oxygen characteristic (K-PO(2)), and (2) the oxygen inhomogeneity (I-PO(2)) of a chronic wound. The first of these is the arithmetic mean of the two lowest tcPO(2) measurement values, and the second is the variation coefficient of the four measurement values. Using the K-PO(2) parameter, a grading of wound hypoxia can be obtained. To begin with, the physiologically regulated (and still compensated) hypoxia with K-PO(2) values of between 35 and 40 mmHg is distinguished from the pathological decompensated hypoxia with K-PO(2) values of between 0 and 35 mmHg; the first of these still stimulates self-healing (within the limits of the oxygen balance). The decompensated hypoxia can be (arbitrarily) divided into "simple" hypoxia (Grade I), intense hypoxia (Grade II) and extreme hypoxia (Grade III), with the possibility of intermediate grades (I/II and II/III).Measurements were carried out using the new procedure on the skin of the right inner ankle of 21 healthy volunteers of various ages, and in 17 CVI (chronic venous insufficiency) wounds. Sixteen of the 17 CVI wounds (i.e., 94%) were found to be pathologically hypoxic, a state which was not found in any of the healthy volunteers. The oxygen inhomogeneity (I-PO(2)) of the individual chronic wounds increased exponentially as a function of the hypoxia grading (K-PO(2)), with a 10-fold increase with extreme hypoxia in contrast to a constant value of approximately 14% in the healthy volunteers. This pronounced oxygen inhomogeneity explains inhomogeneous wound healing, resulting in the so-called mosaic wounds. The hypoxia grades found in all of the chronic wounds was seen to be evenly distributed with values ranging from 0 to 40 mmHg, and therefore extremely inhomogeneous. In terms of oxygenation, chronic wounds are therefore inhomogeneous in two respects: (1) within the wound itself (intra-individual wound inhomogeneity) and (2) between different wounds (inter-individual wound inhomogeneity). Due to the extreme oxygen inhomogeneity, single measurements are not diagnostically useful. In healthy individuals the oxygen inhalation challenge (see above) results in synchronised tcPO(2) oscillations occurring at minute rhythms, which are not seen in CVI wounds. These oscillations can be interpreted as a sign of a functioning arterial vasomotor system.The new procedure is suitable for the routine characterisation of chronic wounds in terms of their oxygen status, and correspondingly, their metabolically determining (and limiting) potential for healing and regeneration. The oxygen characteristic K-PO(2) can furthermore be used as a warning of impending ulceration, since the oxygen provision worsens over time prior to the demise of the ulcerated tissue, thus making a controlled prophylaxis possible.

Purpose: The main problem with the treatment of arterial stenoses by percutaneous transluminal angioplasty (PTA) or stent implantation is the relatively high restenosis rate. The objective of this prospective single-center study was to evaluate a mechanical rotational catheter (Straub Rotarex®) for its safety and efficacy in the treatment of in-stent reocclusions., Materials and Methods: 78 patients with a mean age of 64.2 ± 8.3 years (42 - 85) were treated by means of the Rotarex® catheter. All patients had in-stent reocclusions of the femoropopliteal arteries. The preinterventional Rutherford stage was on average 3.36 (2 - 5). The mean lesion length was 14.7 cm (6 - 30 cm). The ankle-brachial index (ABI) was determined prior to and after the intervention, as well as after 12 months. An additional follow-up was performed using color-coded duplex sonography., Results: The technical success rate was 97.4 % (76 / 78). In 52 / 76 patients (68.4 %), adjunctive balloon dilation was performed, and 8 / 76 (10.5 %) patients required a stent implantation. Clinically, there was an increase in the ankle-brachial index from 0.61 ± 0.17 to 0.85 ± 0.15 post-interventionally. After 12 months, it was 0.78 ± 0.16, and the average Rutherford stage fell to 1.65 (1 - 3). During the follow-up observation period, there were 14 (18.4 %) restenoses. Two dissections after Rotarex were recorded as peri-interventional complications. No distal embolizations were observed. There were no amputations or deaths during the entire period of the study., Conclusion: The recanalization of in-stent reocclusions of femoropopliteal arteries using the Rotarex® system is safe and effective. The low rate of restenosis at 12 months appears to be promising., (© Georg Thieme Verlag KG Stuttgart · New York.)

History and Findings: A 30-year-old woman presented to our emergency department with severe headaches, dizziness and uncontrolled hypertension. She had arterial hypertension and a known heart murmur since adolescence. Previous medical work up did not reveal any cause for secondary hypertension. Recently her blood pressure had been difficult to control. A systolic murmur as well as absent inguinal and feet pulses were notable at the physical examination., Investigations: When performing doppler ultrasound the closing pressures of the dorsalis pedis arteries were only 70 mm Hg compared to a blood pressure reading of 160 mm Hg on the upper arms. Thoracic magnetic resonance imaging showed subtotal aortic coarctation causing the differences in blood pressures. Echocardiography and cardiac catheterization additionally revealed a moderately stenosed bicuspid aortic valve, the pressure gradient across the coarctation was 30 mm Hg., Therapy and Course: Despite the severity of the coarctation an interventional approach was favoured instead of a classical operative therapy. Balloon dilatation with stent implantation was performed without complications. Since the intervention blood pressure have remained normotensive, the coarctation gradient being markedly reduced., Conclusions: In young patients with arterial hypertension, as well as in cases of severe and refractory hypertension, causes of secondary hypertension must be looked for and excluded. Especially when hypertension occurs in adolescence, aortic coarctation should be taken into account, in addition to renal or endocrine causes. A thorough physical examination with cardiac auscultation and checking of all peripheral pulses is the crucial step to the diagnosis., (© Georg Thieme Verlag KG Stuttgart · New York.)