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Background: This retrospective propensity score matched study presents the perioperative mortality and long-term survival up to 9 years after endovascular (EVAR) and open (OAR) repair of patients with ruptured abdominal aortic aneurysm (rAAA) in Germany using health insurance data., Materials and Methods: 2170 patients treated between January 1st, 2010 and December 31st, 2016, for rAAA within 24 hours of hospital admission and receiving blood transfusions were enrolled in the study and tracked until December 31st, 2018. For better comparability of EVAR and OAR, a 1:1 propensity score matching with 624 pairs according to patient age, sex and comorbidities was carried out using the R program (Foundation for Statistical Computing, Vienna, Austria)., Results: In the unadjusted groups, 29.1% (631/2170) of the patients were treated with EVAR and 70.9% (1539/2170) with OAR. EVAR patients had a significantly higher overall rate of comorbidities. After adjustment, EVAR patients showed significantly better perioperative survival (EVAR 35.7%, OAR 51.0%, p = 0.000). Perioperative complications occurred in 80.4% of EVAR patients and 80.3% of OAR patients (p = 1.000). At the end of follow-up, Kaplan-Meier estimated that 15.2% of patients survived after EVAR vs. 19.5% after OAR (p = 0.027). In the multivariate Cox regression analysis, OAR, age ≥ 80 years, diabetes mellitus type 2 and renal failure stages 3 to 5 had a negative impact on overall survival. Patients treated on weekdays had a significantly lower perioperative mortality than patients treated during the weekend (perioperative mortality on weekdays 40.6% vs. 53.4% during the weekend; p = 0.000) and a better overall survival as estimated by Kaplan-Meier., Conclusion: Significantly better perioperative and overall survival was observed with EVAR than with OAR in patients with rAAA. The perioperative survival benefit of EVAR was also found in patients older than 80 years. Female gender had no significant influence on perioperative mortality and overall survival. Patients treated on weekends had a significantly poorer perioperative survival than patients treated on weekdays, and this lasted through the end of follow-up. The extent to which this was dependent on hospital structure was unclear., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Road traffic accidents are the main cause of traumatic aortic ruptures, mostly in combination with other severe injuries. The pre-hospital mortality rate is high. Suspected aortic trauma, following a high traumatic aortic injury score, is an indication for computer tomography. Injuries are triaged and the treatment priority of the aortic trauma is ascertained based on the severity of the aortic and concomitant injuries and the condition of the patient. Until definitive treatment of the aortic lesion is completed, the blood pressure of the patient must be kept low. Grade I and II lesions can be managed under strict monitoring with initial conservative treatment in individual cases. Grade III (contained perforation) and grade IV (open rupture) lesions need surgical or interventional treatment as swiftly as possible. In selected cases, a delayed treatment can also be advantageous.The endovascular stent graft therapy has established itself as the preferred form of treatment.

Introduction: Although the perioperative management has been optimised over the past few decades, there has not been a remarkable improvement in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA). The aim of this retrospective trial was to define pre-, intra- and postoperative parameters which influence the perioperative and long-term outcome of patients and which can be modified by the operating team. Methods: A retrospective database analysis was performed in 49 patients who had undergone an operation of rAAA in our certified centre of vascular surgery between the beginning of 2006 and the end of 2012. The minimal follow-up period was 30 months. The statistical analysis was done univariately using the Kaplan-Meier method and a log-rank-test, and multivariately with the Cox model. Results: Intrahospital mortality was 40.8 %, perioperative mortality (30 postoperative days) was 28.9 %. The survival rate for 1 year was 52.4 %; the survival rate for 5 years was 45.3 %. In the univariate analysis, significant differences in the early postoperative survival rates were found depending on preoperative systolic blood pressure, preoperative haemoglobin (< 10 vs. ≥ 10 g/dl), the intraoperative need of blood and frozen plasma transfusions, type of perforation, type of AAA, the need for further surgical interventions, postoperative MOF, acute kidney failure and postoperative septicaemia. The late survival rates were significantly influenced by the type of perforation and AAA, pre-existing coronary disease and diabetes mellitus in fully identified patients discharged from hospital (n = 27). In the multivariate analysis pursuant to the Cox model, patients with pre-existing coronary disease had a 3.9-fold higher relative risk to die after the operation of rAAA, while patients with a free perforation of the rAA had a 10-fold higher relative risk. Conclusion: The high mortality of rAAA is caused by haemorrhagic shock and its complications, which are mostly non-surgical. Therapeutic efforts should focus on those perioperative parameters which can be modified by the treating teams. Alongside the centralisation of rAAA in high-volume-departments of vascular surgery, the systematic sonographic screening for asymptomatic AAA in the population older than 65 years should be enforced. A possible advantage of EVAR in rAAA has yet to be shown by trials in progress such as IMPROVE, AJAX and RCAR., (Georg Thieme Verlag KG Stuttgart · New York.)

The ruptured abdominal aortic aneurysm (AAA) has still a high hospital mortality rate of about 50 % (intervention and non-corrective treatment combined). With an easy non-invasive and inexpensive measure such as the ultrasound screening rupture threatened aneurysms can be recognized in time and then treated prophylactically, hemorrhagic shock can be avoided. Screening programs in England and Sweden currently describe an AAA prevalence of 1.5 % among screened 65-year-old males. With an absolute risk reduction for aneurysm-related death of 15.1 per 10,000 men invited for screening and a cost of £ 7,370 per quality-adjusted life year (QALY), screening for this target group is highly cost-effective. Comprehensive AAA screening requires defined criteria for the quality of the aortic ultrasound examination and for the surgical treatment of detected large AAA. These interventions should be concentrated in centers obligated to quality registry documentation. Patients with smaller AAA, requiring no repair, should be included in a surveillance program, also with registry of their long-term data., (© Georg Thieme Verlag KG Stuttgart · New York.)

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of complicated acute type B aortic dissection, descending thoracic aortic aneurysms, thoracoabdominal aortic aneurysms as well as asymptomatic and ruptured abdominal aortic aneurysms.

Background: Since its introduction, endovascular aortic aneurysm repair (EVAR) has proved as a favourable alternative to open surgery (OR) in the treatment of abdominal aortic aneurysms (AAA). Long-term outcomes of EVAR and OR are similar while complications are more likely to develop after EVAR. Risk factors for mortality and complications after AAA surgery have been identified, however, a general overview is lacking., Methods: In a systematic literature search via PubMed, we identified publications on the topic of factors influencing the postoperative outcome of AAA surgery., Results: Patient age > 80 years was found to be a significant predictor of increased mortality, whereas the influence of aneurysm diameter on OR remains moderate, the outcome of EVAR performed in AAA > 6.5 cm is associated with higher mortality and increased complication rates. In patients with ruptured AAA the postoperative mortality is higher than in those with intact aneurysms. Preoperative haemodynamic instability has a crucial influence on patient outcome and is strongly associated with intra- and postoperative death. The prevalence of cardiovascular co-morbidity leads to increased long-term mortality. Preoperative statin medication was found to reduce short- and long-term mortality by the factor of 0.5. Patients suffering from chronic lung disease such as COPD and patients with a deficiency in renal function are more likely to experience adverse events including death. While the prevalence of cerebrovascular disease is associated with an increase in mortality by the factor of 1.5 or higher, findings on patients with diabetes mellitus are conflicting with no definite point to be made., Conclusion: Several factors influencing the outcome of surgery for AAA present a condition developed from factors involved in the pathogenesis of AAA. The impact of non-disease factors like patient age and aneurysm diameter can be reduced by the means of population-wide screening for AAA, and optimised treatment of disease-related risk factors can reduce mortality. Studies comparing the outcome of EVAR and OR in patients with risk factors should be performed to support decision-making about the ideal individual treatment., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The treatment of patients with aneurysms of the ascending aorta and aortic arch often represents a challenge due to their complexity. The clinical picture is characterized by further progression of the disease and severe complications, such as acute aortic dissection or even aortic rupture are not uncommon., Objectives: This article gives a review of definitions, etiology and indications for operative treatment of patients with aneurysms of the ascending aorta and aortic arch., Results and Discussion: An aortic aneurysm of the ascending aorta is defined as a dilatation of all wall layers of the aorta of more than 50 % in comparison to the normal diameter. This is dependent on age, sex, body surface area and the underlying diseases. In most cases the cause is the presence of atherosclerosis. Connective tissue diseases, bicuspid or monocuspid aortic valves and aortitis represent additional risk factors. Surgical treatment of the ascending aorta, aortic root and aortic arch is carried out in patients without connective tissue diseases and a diameter of ≥ 55 mm and for patients with Marfan syndrome and bicuspid aortic valves with a diameter of ≥ 50 mm. Earlier indications for surgery are present with an aortic diameter of ≥ 45 mm in patients with the following risk factors: familial disposition for aortic dissection (often unrecognized as sudden cardiac death), annual growth rate of the aortic diameter of > 2 mm, comorbid severe aortic valve or mitral valve insufficiency and female patients with a desire to have children. The standard surgical procedures include aortic root replacement, aortic valve reconstruction with aortic root or ascending aorta replacement and partial or total aortic arch replacement depending on the extent of the aneurysm. The so-called hybrid procedures for aortic arch surgery include frozen elephant trunk (ET) techniques and debranching procedures. Good perioperative and postoperative results can be achieved by early diagnostics and an assessment of the indications depending on the individual etiology. Individual and valve-preserving treatment strategies have a favorable influence on the operative outcome.

Acute aortic syndrome (AAS) is a life-threatening disease. Quick and accurate diagnosis is crucial. Patients should be transferred to a competence center without any delay as soon as AAS is suspected. Immediate onset of tearing chest pain, mediastinal widening on chest radiography and pulse/blood pressure differentials are predictive for aortic dissection. A CT scan is the diagnostic tool of choice; alternatively, in hemodynamically unstable patients echocardiography may be preferred. Associated mortality is excessively high within the first few days. Urgent surgical consultation should be obtained for all patients presenting with AAS. Initial medical therapy is aimed to reduce pain and decrease wall stress in the aorta. Aortic dissection involving the ascending aorta should be treated by immediate surgery. Aortic dissection limited to the descending or thoracoabdominal aorta should be treated medically, initially. However, when associated with complications, endovascular treatment is recommended. A symptomatic intramural hematoma, a penetrating atherosclerotic ulcer or pending aortic rupture are associated with a substantial risk. Therefore, surgical or endovascular therapy is recommended.

History and Clinical Findings: A 72-year-old man received treatment with amoxicillin/clavulanic acid because of fever and abdominal pain as an outpatient setting. Salmonella enteritidis infection was confirmed by a positive blood culture. The febrile patient showed abdominal tenderness on palpation., Investigations: CT and PET scans revealed an aneurysmatic soft tissue inflammation which was interpreted as infectious aortitis in the context of salmonella bacteraemia., Treatment and Course: After several weeks of antibiotic treatment with ceftriaxone, an elective reconstruction using xenopericard with replacement of the mesenterial vessels was performed. After a postoperative course of antibiotics the patient recovered completely., Conclusion: In patients with positive blood cultures for Salmonella in combination with fever, back or abdominal pain a workup for infectious aortitis and a rapid treatment is recommended., (© Georg Thieme Verlag KG Stuttgart · New York.)

The occurrence of aortic dissections after deceleration trauma is commonplace but aortic injuries after blunt trauma are extremely rare complications. We report a case of an acute aortic rupture accompanied by a type B dissection after a skiing accident with blunt thoracic trauma and renal contusion. The leading symptom was the onset of hematuria 12 h later. The computed tomography (CT) angiography permitted the exact diagnosis and the patient was transferred for acute thoracic endovascular aortic repair. This regimen resulted in the patient achieving a stable condition and potentially harmful complications could be avoided.

Background: Open repair of para-anastomotic aneurysms (pAAA) after conventional aortoiliac repair is associated with a high perioperative mortality and morbidity. Endovascular treatment options have evolved over the last decade. The aim of this article is to demonstrate and review these endovascular strategies., Material and Methods: Between 01/2009 and 06/2012, a total of 12 patients received endovascular treatment for proximal (n = 7) or distal (n = 5) pAAA (n = 2 contained rupture). A retrospective analysis of these patients was performed. Median age was 71.5 years (range 55-87 years). The median time interval between primary operation and endovascular repair of the pAAA was 15 years (range 1-31 years) and median follow-up was 1.3 years (range 0 days - 3 years). Endovascular exclusion of the pAAA was achieved by implantation of an aortouniiliac endograft (n = 6), chimney graft (n = 1), fenestrated endograft (n = 2) and iliac extension (n = 3)., Results: Technical success could be achieved in all patients and in-hospital mortality was 16.8  % (n = 2). No patient required a reintervention but during follow-up one additional patient died due to gastrointestinal bleeding. No primary or secondary type I/III endoleaks were observed., Conclusions: Despite a not negligible mortality rate endovascular treatment of para-anastomotic aneurysms and anastomotic pseudoaneurysms appears to be a safe alternative for conventional open repair.

Background: This overview comments on gender-specific differences in prevalence, treatment and outcome in patients with peripheral arterial disease (PAD), carotid stenosis, and abdominal aortic aneurysm (AAA)., Method: For the literature review, the Medline database (PubMed) was searched under the key words "peripheral arterial disease AND gender", "carotid stenosis AND gender" and "abdominal aortic aneurysm AND gender"., Results: 1.) Women (preferably black women) with PAD experience rather than men bypass failure or amputation. Nevertheless, gender should not constitute a selection criterion for revascularisation therapy. Despite an older age and more advanced stages of disease in women, infrainguinal arterial reconstructions could achieve, in published series, patency and limb salvage rates which did not differ from those of men. 2.) The benefit of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is less for women compared with men. However, registries exhibited at best for symptomatic women an increased perioperative risk of CEA compared with men, with CEA especially in women better than carotid artery stenting. The treatment of AAA shows significant gender differences. The risk of rupture for small aneurysms is significantly greater in women compared with men, and they have higher in-hospital mortality rates for both open and endovascular repair of ruptured and intact AAA. Yet women also benefit from endovascular repair of AAA compared to open repair, although their eligibility for endovascular repair is less than that of men due to anatomic conditions., Conclusion: As a rule, for the mentioned diseases less favourable results were reported in women. This may reflect biological disparities, or the differences are based on the fact that women develop arteriosclerotic changes later in life, requiring treatment in older age, with more advanced disease, and with higher comorbidity than men. In addition gender-related differences in the use of secondary medical prevention of PAD have been described. Future studies on the potential impact of gender on the results of vascular surgery are needed., (Georg Thieme Verlag KG Stuttgart · New York.)

The treatment of thoracic aortic diseases has undergone a paradigm shift due to the introduction and further development of interventional techniques in recent years. Thoracic endovascular aortic repair (TEVAR) of the descending aorta has significantly lower mortality and complication rates compared to open repair. Meanwhile this endovascular approach is the first option for the treatment of the majority of thoracic aortic diseases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Marfan syndrome is a hereditary disease with a prevalence of 2-3 in 10,000 births, leading to a fibrillin connective tissue disorder with manifestations in the skeleton, eye, skin, dura mater and in particular the cardiovascular system. Since other syndromes demonstrate similar vascular manifestations, but therapy may differ significantly, diagnosis should be established using the revised Ghent nosology in combination with genotypic analysis in specialized Marfan centres. The formation of aortic root aneurysms with the subsequent risk of acute aortic dissection type A (AADA) or aortic rupture limits life expectancy in patients with Marfan syndrome. Therefore, prophylactic replacement of the aortic root needs to be performed before the catastrophic event of AADA can occur. The goal of surgery is the complete resection of pathological aortic tissue. This can be achieved with excellent results by using a (mechanically) valved conduit that replaces both the aortic valve and the aortic root (Bentall operation). However, the need for lifelong anticoagulation with Coumadin can be avoided using the aortic valve sparing reimplantation technique according to David. The long-term durability of the reconstructed valve is favourable, and further technical improvements may improve longevity. Although results of prospective randomised long-term studies comparing surgical techniques are lacking, the David operation has become the surgical method of choice for aortic root aneurysms, not only at the Heidelberg Marfan Centre. Replacement of the aneurysmal dilated aortic arch is performed under moderate hypothermic circulatory arrest combined with antegrade cerebral perfusion using a heart-lung machine, which we also use in thoracic or thoracoabdominal aneurysms. Close post-operative follow-up in a Marfan centre is pivotal for the early detection of pathological changes on the diseased aorta.

We present a patient with an aortic aneurysm and the epidemiology, etiology, screening, symptoms and therapeutic options of abdominal aortic aneurysms are discussed. A widening of the abdominal aorta >3 cm is termed aortic aneurysm. As patients with aortic aneurysm are mostly oligosymptomatic until rupture occurs and an estimated 30,000 patients annually die from ruptured aortic aneurysm in the US a screening of the population at greatest risk (smokers, familial predisposition) is recommended. Screening is best done by ultrasound. Noninvasive therapy is limited to antiplatelet therapy and optimal adjustment of risk factors. For definitive treatment endovascular aortic repair (EVAR) is considered an established alternative to open surgery with lower 30 days mortality but higher reintervention rate.

Heparin-induced thrombocytopenia (HIT) type II is a life-threatening complication of heparin therapy. The present case report describes the therapeutic management of HIT type II with thrombosis using the direct thrombin inhibitor argatroban in an intensive care patient after successful surgery of a ruptured infrarenal abdominal aortic aneurysm. Despite high dosing and long-term application of argatroban, anticoagulation remained uncritical and was well controllable by monitoring the activated partial thromboplastin time. In consideration of the pharmacological characteristics, therapy suspension due to invasive interventions and switching to an oral vitamin K antagonist by defined algorithm resulted in an effective management.

Secondary aortobronchial or aorto-enteral fistulas have an incidence of 0.36-4% and are a rare but life-threatening complication after endovascular aorta reconstruction. Due to the rarity of the disease and the heterogeneity of the patients (age, risk profile, localization) individual-specific solutions are necessary. The primary symptomatic, differential diagnosis and individual therapy concepts will be presented and discussed based of five case reports (2 aorto-esophageal fistulas, 2 aortobronchial fistulas and 1 aorto-duodenal fistula).

Up to 3% of patients receiving unfractioned heparin develop heparin-induced thrombocytopenia (HIT). We report on a polytrauma patient who developed severe HIT with bilateral pulmonary embolism. Lepirudin treatment resulted initially in rapid improvement. Ten days after discharge the patient complained of abdominal pain. A large subcapsular hepatic hematoma was diagnosed, requiring repeat surgery and ending in secondary sclerosing cholangitis. This process can potentially be avoided by regular tests of lepirudin concentration and coagulation.

Introduction: Redo surgery or reintervention following conventional or endovascular aortoiliac reconstruction often requires exclusion of new aneurysms. In the present study the potentials of endovascular management of such lesions are investigated., Methods: All patients with endovascular reoperation for of newly developed aortoiliac aneurysms were identified from a prospectively run data-base. The indications and results of endovascular therapy were analysed retrospectively. In detail, data were analysed for the type of original operation, interval until and kind of reoperation, and results concerning survival, technical success and complications., Results: From 12 / 2003 through 3 / 2007 195 patients with aortoiliac aneurysms were operated. Endovascular repair was performed in 15 cases of previously excluded aneurysms. Mean age of these 15 patients (12 men) was 73 (64-85) years. Ten patients had a primary conventional (group A) and 5 patients had a primary endovascular (group B) aneurysm repair. The mean time interval between the first and second operation was 8.9 (1-26) years. The secondary endovascular therapy in group A was successful in all cases. In group B endoleaks type I a (n = 1), I a / b (n = 1), II (n = 2) and III (n = 1) were treated. One type II endoleak could only be treated successfully by conversion to open repair, the other one was successfully treated by reintervention. All but one patient are alive and -remained free of pathological findings during a median follow-up of 13 (2-39) months., Discussion: Because of the clearly elevated operation risk of redo surgery after conventional or endovascular aneurysm repair, endovascular aneurysm exclusion represents the method of first choice. The reasonable selection and combination of procedures allows for an optimal adaptation of therapy to the individual case., (Georg Thieme Verlag Stuttgart.New York.)

We report a case of acute esophageal necrosis after endovascular stenting for acute rupture of a thoracic aortic aneurysm into the mediastinum caused by mediastinal compartment syndrome and overstenting of intercostal arteries.

Abdominal aortic aneurysms, i.e., enlargements of the abdominal aorta > 3 cm, are often the consequence of atherosclerotic vascular changes. Aneurysms of the abdominal aorta are often incidentally detected and asymptomatic. Expansion of the aneurysms are common and associated with an increased risk of rupture, resulting in a life-threatening situation. Here, we demonstrate the case of a 79-year old man being admitted to the hospital for presyncope and repeated hypotension. Before finishing the diagnostic tests, the patient's situation suddenly worsened in the emergency room, due to rupture of a huge infrarenal aneurysm not known until then. Emergency surgery, however, was not successful, confirming the bad outcome for patients in this situation. Early diagnosis and surgical repair where appropriate are essential to affect prognosis of this disease.

Background: A left recurrent nerve palsy caused by left atrium hypertrophy, dilatation of the left pulmonary artery or a thoracic aortic arch aneurysma is named Ortner's syndrome., Case Report: We report the case of a 84-year old male patient with a posttraumatic aneurysm of the distal aortic arch known for 20 years, which became symptomatic by new presentation of an acute hoarseness caused by a left sided recurrent nerve palsy due to rapid aneurysma expansion. Because of the aneurysma localization, the advanced age and the patient?s morbidity he was treated by a hybrid procedure with an extrathoracic reconstruction of the supraaortic arteries by a right to left carotid-carotid bypass and transposition of the left subclavian artery followed by endovascular implantation of aortic stent grafts for aneurysma exclusion. The left recurrent nerve palsy remained unchanged until now., Conclusions: Aneursms of the distal aortic have to be considered as a rare cause of a left-sided recurrent nerve palsy. Recent advances in endovascular therapy combined with supraaotic vascular reconstruction offers a less invasive therapeutic option for some of these patients.

Objectives: Ruptured abdominal aortic aneurysms (rAAA) still represent a life-threatening vascular disease, with high mortality despite improved diagnostic tools and perioperative patient management. The aim of this study was to reveal predictors of perioperative mortality and survival after open (conventional) rAAA repair., Patients and Methods: We analyzed data from our department containing 67 patient histories and clinical notes which were collected between January 1984 and December 2004. The study patients underwent emergent surgery for rAAA. In these cases we defined 72 preoperative, 47 intraoperative, and 39 postoperative variables for further analysis., Results: Our results indicate that the worst survival prognosis could be defined in patients with rAAA and aneurysmatic inclusion of the iliac arteries with concomitant prolonged shock who received an aorto-iliac bypass. For these patients we calculated a cumulative 30-day survival rate of 59.7% and 1-year survival of 43.3%. An influence of age and comorbidity on the mortality rate could not be proven. Furthermore the conclusion cannot be drawn that postoperative course was influenced by intra- vs retroperitoneal rupture localization., Conclusion: This study provides evidence that neither old patient age nor comorbidities influence the mortality of patients suffering from rAAA, for whom time-consuming case selection according to previous morbidities should therefore be omitted. Instead we recommend conventional surgical repair as soon as possible to maximize the chances of survival.

An abdominal aortic aneurysm is defined as the increase of infrarenal aortic diameter of 3.0 cm and more. Infrarenal aortic aneurysm is frequent in the elderly and causes 1-3% of all deaths among men aged between 65 and 85 years. These aneurysms are typically asymptomatic until the life threatening event of rupture. Therefore screening of risk populations like elderly persons and persons with cardiovascular risk factors for aortic aneurysm seems to be most important. An aortic aneurysm is usually detected by sonography. An infrarenal aortic aneurysm with a diameter of 5.0-5.5 cm should be treated either with open surgical or endovascular therapy. If surgical or endovascular therapy is indicated, additional computer tomography (CT) or magnet resonance imaging (MRI) are necessary. The mode of treatment mainly depends on patient co-morbidity and on morphology of the aneurysm according to the CT/MRI-findings and should be determined individually.

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

The goal of numeric analysis of aortic blood flow is to evaluate the mechanisms leading to an aortic aneurysm with regard to the risk of a rupture and to describe the effect of interventional therapy. Numeric analysis is based on virtual models of vascular structures and the physical characteristics of the vessel wall, of blood as fluidum, and the blood flow. Using this information, numeric analysis solves the appropriate equations. The results can be displayed quantitatively and qualitatively. The results of numeric flow simulation show that in abdominal aortic aneurysms the wall pressure, which is of vital importance for the risk of rupture, depends on several factors, one being the location of the intraluminal thrombus. In models of aneurysms after stent grafting, numeric analysis can be used to evaluate factors leading to stent migration. Although numeric analysis of aortic blood flow still has several limitations, recent studies have shown that this method has the potential for improved estimation of the rupture risk of aortic aneurysms in the near future.

One to four per cent of all deaths in patients over 65 are caused by aneurysmatic diseases of the abdominal or thoracic aorta. For elective surgery in abdominal aneurysms, open surgery and endovascular treatment both demonstrate brilliant overall results. In the thoracic aorta, new endovascular procedures have led to considerable reductions of postoperative morbidity and mortality. Nevertheless, in view of the endovascular procedure's high cost and the still unclear long-term behaviour of the stent device, a second opinion from a specialised centre is an absolute necessity.

Since the first endograft implantation for treatment of abdominal aneurysms the development of modern stentgrafts has progressed in many ways. In 1999 we started implantations using the PowerLink aortic stent graft by Endologix-company. The PowerLink aortic stent graft is a bifurcated, self-expanding, sutureless endovascular graft, covered with PTFE. This aortic stent graft facilitates the complete covering of the infrarenal aorta and the iliac arteries. The anatomical localization at the natural aortic bifurcation provides anti-gravitational supporting force, preventing distal migration of the device. From 1999 to 2005 we implanted 297 PowerLink aortic stent grafts. Our follow-up examinations showed a low rate of renal infarctions (3.0 %), a limb occlusion rate of 2.7 % and a total endoleakage rate of 16.8 %. Our conclusion is, that this is a very safe device for repair of abdominal aneurysms, associated with a low-risk of complications.

Four cases of proximal endostent instability after endovascular tube graft treatment of thoracic aortic disease using the TAG Gore system are reported. This potentially hazardous complication is characterized by a lack of attachment of the device to the small curvature of the aortic arch. Towering up against the hemodynamic forces in this area, the endograft could collapse and occlude the aorta. To identify this complication we recommend to perform an early postinterventional CT-scan with parasagittal reconstruction and an observation of the proximal endograft by fluorography. Endovascular solutions for the treatment of this complication may be either a proximal extension by another endograft or fixation of the proximal endograft by a balloon expandable Palmaz stent.

Aim of the Study: We examined the outcome of patients with ruptured abdominal aortic aneurysm and analysed factors that were responsible for the mortality., Patients and Methods: From January 1 (st), 1999 to March 1 (st), 2005 82 patients with ruptured abdominal aortic aneurysm were registered in the University Hospital of Pilsen. 61 men, 21 women entered the hospital, the average age of the patients ranged to 73.5+/-6.8 years. The average time interval between first symptoms and admission to the hospital ranged to 23.9 hours. In 74 patients (90,3%) a reconstruction of the vascular system was performed, in 8 patients the reconstruction was no more possible, these patients died in the operating theatre., Results: The peri- and postoperative mortality (30-day-mortality) ranged to 37.8% (31 of 82 patients). The patients were on average for 2.3+/-4 days artificially ventilated postoperatively, the mean time of hospital stay ranged to 14.5+/-16,7 days. Respiratory failure, multiple organ failure, the necessity of cardiocirculatory resuscitation, patient age and ischemic heart disease, and the hemoglobin value on admission correlated significantly with the mortality., Conclusion: The present study demonstrates that the severe situation of ruptured abdominal aortic aneurysm is not without a chance, many patients can be successfully managed. The success of treatment depends partly on factors which cannot be influenced by the surgeon, but other factors (for example hemoperitoneum und decreasing hemoglobin level) can be managed by quick diagnostics and expensive postoperative intensive care.

One of the main issues in complex thoracic aortic disease, requiring the replacement of the ascending aorta, the entire aortic arch and the descending aorta, is the vast amount of surgery necessary to cure the patient. Though one-stage repair is feasible by a clamshell thoracotomy, the associated surgical trauma and perioperative morbidity limit this approach to younger patients only. Classic surgical repair consist of a two-stage strategy, whereby, in the first step, the ascending aorta and the aortic arch are replaced via a midline sternotomy. In the second step, via a lateral thoracotomy, the descending aorta is replaced. The two stages may sum up to a mortality of 20%; furthermore, the waiting period between the stages is associated with a mortality rate of 10% of its own. Additionally, the two-stage strategy has an inherent limitation, due to the comorbidity and advanced age of the majority of patients. Therefore, the second stage cannot be offered to up to 30% of patients. New developments and improvements in aortic surgery were introduced to overcome these shortcomings and to simplify the surgical repair. The "elephant trunk" principle, introduced by Borst et al. in 1983, was an important step to facilitate surgical repair, but still required the second step. With the introduction of endovascular repair of thoracic aortic disease with stent grafts implanted retrograde via the femoral artery, new therapeutic concepts emerged. In the late 1990s, two Japanese groups reported first trials to stabilize the free-floating "elephant trunk" prosthesis by implantation of nitinol stent grafts into the vascular graft. The applied devices were purely custom-made and nonstandardized. The availability of industrially made and CE-marked stent-graft devices raised the possibility to apply them in open aortic arch surgery. The experience with stent-graft devices implanted antegrade into the descending aorta (Medtronic Talent) was reported first by the Essen and the Vienna group. The experience gained with these devices revealed the limitations of the devices designed for pure retrograde aortic delivery. This required a complete redesign and new construction of the stent graft itself as well as the introducer system. In a preliminary series of 14 patients the required stent-graft properties were presented in detail and resulted in the first industrially manufactured standardized and CE-marked Hybrid stent graft (Essen 1 prosthesis, E-vita Open, Jotec), especially made for antegrade open stent grafting of the descending aorta. This device consists of a stent graft with an integrated Dacron vascular prosthesis, enabling for direct and continuous aortic arch replacement after stent grafting of the descending aorta. From 01/2005 to 03/2006, this hybrid prosthesis was implanted in 16 patients (one aneurysm and 15 aortic dissections). In all cases, the underlying pathology within the thoracic aspect of the aorta could be excluded in a one-stage approach. In case of aortic dissection, thrombosis of the false lumen was detectable by transesophageal echocardiography already at the end of surgery. Though long-term results using this new method are not yet available, the initial promising results postoperatively are encouraging toward true one-stage repair by combining classic aortic surgery with open antegrade stent grafting utilizing the newly designed hybrid prosthesis. While surgical trauma is markedly reduced, this treatment option can be offered to elderly patients as well.

Objective: Severe chest injuries are still associated with significant morbidity and mortality. This systematic review assesses the early operative management of severe chest trauma in multi injured patients with special regard to the priority of the operative therapy., Methods: Clinical trials were systematically sought and collected (MEDLINE, Cochrane and hand searches). Of 618 abstracts, 46 articles were selected for detailed appraisal and were classified into evidence levels (1 to 5 according to the Oxford system)., Results: Penetrating chest injuries in haemodynamically instable patients require emergency operative therapy. A thoracotomy is also indicated in excessive chest tube output (>1500 ml). An aortic rupture can be treated either by open suture or-in borderline patients-by endovascular stenting. In selected haemodynamically stable patients delayed treatment is also possible. Lesions of the tracheobronchial system should be treated urgently with primary surgical repair. Diaphragmatic ruptures should be closed urgently. Surgical stabilisation of rib fractures with an associated flail chest reduces the ventilator days and the length of intensive care unit stay., Conclusion: A large part of early surgery for chest injuries is justified because it averts immediate threats to life (level 1c evidence). No randomised and only a few controlled trials have examined the relative value of the different surgical options so far. Long-term data are lacking especially on the safety of endovascular stenting.

History and Admission Findings: A 65-year-old man presented an acute swelling of the left leg as the main sign. A pulsatile bruit could be auscultated over the abdomen., Investigations: Doppler ultrasound suggested an aortic aneurysm with fistula. Dynamic bolus-triggered computed tomography demonstrated an aortoiliac aneurysm with a fistula into the confluence of the common iliac veins., Treatment and Course: An aorto-iliac graft was inserted surgically and and the patient recovered well., Conclusion: In patients with an acute swelling of a lower limb an aorto-iliac aneurysm, though a rare cause, should be considered.

Presented in this work is a rare injury of a blunt abdominal trauma in a child. Besides a partial rupture of the kidney and a retro-/intraperitoneal haematoma, a further injury occurred from the accident: an initially clinically indetectable tear of the A. iliaca communis which was found intraoperatively and with systematic CT analysis. Traumatic blood vessel lesions of the abdominal aorta and in particular the iliac blood vessels are very rare in children. By such violent impact injuries, it is therefore vital to perform a clinical examination of the foot pulse, systematic analysis of radiology diagnostics, and intraoperative exploration. The growth phase should be considered for therapy of the blood vessels depending on the child's age group. As the long-term results of graft implants are practically unknown, if possible a primary suture or vein patch should be performed.

Summary. In recent years, endovascular operations on infrarenal aortic aneurysm (EVAR) have not only been acknowledged as an alternative, but have become an indispensable "tool of the trade" for the vascular surgeon. As documented in many studies, perioperative morbidity is definitely much lower than in open surgery. In the long term, open surgery is also subject to complications such as rupture or aorto-enteral fistulae which necessitate secondary operations with their associated risks. There are some valid studies documenting a significantly lower mortality for EVAR than for open surgery. These datas were recently confirmed with high evidence level by the published results of UK-EVAR trial 1. The other randomized trials are currently ongoing. If the lower morbidity and lethality rate for EVAR is confirmed in these studies, the establishment of the indication for aortic aneurysm must be reconsidered with regard to the risk profile and the maximum diameter. The fact that long-term results are not yet available for the endovascular operation introduces a factor of uncertainty. Intensive follow-up observation is therefore an absolute prerequisite in patients who have undergone endovascular treatment. If the establishment of the indication is appropriate, with the new vascular prosthesis endoleaks are no longer an insoluble problem. The two methods should not be regarded as mutually competitive, but as complementary components of the treatment spectrum at every vascular center.

Herein we report our results of treatment of traumatic aortic ruptures in severely injured patients with either open surgery or endovascular stent graft repair. Data were analyzed retrospectively from the trauma registry of the DGU (Deutsche Gesellschaft fur Unfallchirurgie) over a time period from 1993 through 2002. All patients with traumatic rupture of the aorta were included and analyzed for injury severity (ISS), blood pressure (mmHg), hemoglobin (mg/%), and AIS (Abbreviated Injury Score) of the thoracic, abdominal, and upper extremity regions. Patients treated between 1998 and 2002 were further examined (operation within 24 h, duration of intervention, blood transfusion, and lethality with regard to either open surgical or endoluminal stent graft repair). Of 14,110 patients, 100 (0.7%) suffered from acute aortic rupture. Mean age was 38 years (+/-19) with an inhospital lethality of 39% (n=39). Mean ISS was 41 (+/-14); 36 patients were treated by open surgery and 5 patients by a stent-assisted endoluminal procedure. Lethality was 17% for open surgery and 0% for stent graft repair. Endovascular approach to traumatic rupture of the aorta is feasible and safe. It has been shown to reduce inhospital lethality and may offer an alternative to open surgery for severely injured patients.

This paper reviews the surgical management of vascular injuries. Precise clinical and ultrasound evaluation is mandatory during the first steps of emergency treatment. For further documentation of the extent and site of arterial injuries in hemodynamically stable patients, computed tomography and angiography are crucial in differential diagnosis. Especially during the acute phase, the latter is indicated for evaluating the interventional therapy. The key to successful treatment of vascular injuries is immediate surgical control of hemorrhaging vessels.

The ruptured abdominal aortic aneurysm is a rare, but life-threatening disease that demands fast diagnosis. We report in the following about a patient who was admitted with symptoms of urinary obstruction and an acute abdomen. Ultrasound investigation at admission confirmed urinary obstruction of the right kidney. Causative for that however was a right pararenal ruptured abdominal aortic aneurysm, which led secondarily to ureter compression. Thus, in our opinion, primary ultrasound examination represents an important instrument in differential diagnosis.

Surgical management of distinct thoracic aneurysmal lesions stands at the crossroads. Until recently, the only treatment options for thoracic aortic lesions were surgical repair or medical management. There is increasing evidence that endovascular therapy will be useful in treating thoracic aortic disease, possibly becoming the preferred approach. Endovascular surgery will affect the incidence of open thoracic aortic surgery not only by producing a lower mortality risk but also a significantly lower incidence of paraplegia. In designing adequate treatment options of complex and difficult-to-treat thoracic aortic lesions, novel three-dimensional imaging reconstructions are mandatory.

Purpose: To evaluate the main factors of the 30 days mortality rate of patients operated on for abdominal aortic aneurysm rupture (RAAA., Patients and Method: Univariate and multivariate analysis of various factors associated with RAAA was performed in a group of 73 patients operated on for RAAA between 1996-2001., Results: The 30 days mortality rate was 35.6 %. The main factors of mortality were: misdiagnosis, cardio- pulmonary-cerebral resuscitation (CPCR) on admission, configuration of RAAA, number of blood transfusions, hypotension on admission (p < 0.0001) and duration of operation, type of reconstruction and hypertension in anamnesis (p < 0.01). Important factors (p < 0.05) of postoperative mortality were also low haemoglobin level on admission, abdominal aortic aneurysm (AAA) diameter and ischaemic heart disease in anamnesis. The probability of patient's death is the highest (p < 0.003), if factors like CPCR, number of blood transfusions and aneurysm diameter are combined (multivariate analysis, stepwise method)., Conclusion: The early detection and surgical or endovascular elective treatment of AAA, the regular dispensation of patients with small AAA especially in hypertonics, the correct diagnosis of RAAA without time delay are the best tools for patients survival. The patient's chance for survival increases with highly trained prehospital resuscitation system and experienced team of vascular surgeons and anesthesiologists.

The therapeutical approach to diseases of the descending thoracic and abdominal aorta has dramatically changed over the last decade due to new stent-graft-based endoluminal techniques. In particular elderly patients with a variety of diseases, such as ruptured and asymptomatic aneurysms, acute B-dissections, acute penetrating ulcers, mycotic aneurysms or traumatic aortic injuries will benefit from these minimally invasive alternatives, which can be performed under local anesthesia. As the durability of these devices is not yet proven the patients undergoing endoluminal aortic repair will need life-long clinical and imaging follow-up.

Objective: We present the impact of multisegmental aortic clamping under distal aortic perfusion and segmental artery reimplantation on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement., Patients: During the last 14 years in 47 patients (age range: 22 to 82 years; average: 57,9 +/- 13,2 years; 16 females and 31 males) with thoracoabdominal aortic aneurysm a graft replacement was performed with adjuncts of normothermic partial bypass and multisegmental aortic clamping. As many patent segmental arteries as possible were reimplanted., Results: Five patients died during hospitalization, for an in-hospital mortality rate of 10,6 %. In the elective patients (n = 40), the hospital mortality rate was 7,5 %. The average number of segmental aortic clampings per patient was 2,83 +/- 1,19 times. In 39 patients (82,9 %), 117 segmental arteries were reimplanted or preserved by beveled anastomosis. Eighty-three out of 117 segmental arteries (70,9 %) were located between TH9 and L2. Postoperative paraplegia/paraparesis did not occur in any patient., Conclusion: In view of our results reimplantation of as many segmental arteries as possible under multisegmental aortic clamping with adequate distal aortic perfusion can be recommended for effective prevention of spinal cord ischemia in TAAA surgery.