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Background: Craniotomy and surgical clipping is the standard modality of treatment in patients of cerebral aneurysms. However, the surgical clipping of aneurysm may pose serious difficulties in the case of a bilateral carotid artery occlusion. The endovascular treatment has shown promising results in this disease. Methods: A retrospective study of all patients of posterior circulation aneurysms in the background of carotid occlusive disease at our department was performed. The aim of this study was to describe the clinical, radiological characteristics, and the treatment of this rare entity. Results: Four patients were treated from January 2009 to October 2015. The mean age of our patients was 34 years with ages that ranged from 17 to 45 without any gender predominance. The mean period between onset of symptoms and diagnosis was 6 weeks. Angiographic localization of the disease was observed in all patients. All patients were treated by endovascular techniques. The postoperative course has been satisfactory with a complete neurological recovery in all patients. Conclusions: Rupture of posterior circulation aneurysms in the setting of bilateral internal carotid artery occlusion is extremely rare. Treatment is exclusively endovascular intervention. The functional outcome of ruptured posterior circulation aneurysms in setting of bilateral carotid occlusive disease is particularly favorable with good neurological recovery.

Objective The use of ultrasound waves in conjunction with local thrombolysis may accelerate clot resolution and serve as an important therapeutic adjunct in the treatment of venous occlusive disease. Our goal was to provide a larger sample population over a 5-year period to evaluate our experience with the EkoSonic endovascular system (EKOS, EKOS Corporation, Bothell, WA). We suspected that ultrasound-accelerated thrombolysis (UAT) using EKOS would provide excellent thrombolysis and midterm patency rates with minimal thrombolytic complications. Methods A retrospective study was conducted to provide a case series with UAT using EKOS. Data were collected over a 5-year period. Primary end points included degree of thrombolysis. Secondarily, we analyzed thrombolytic usage, complication rates, and midterm patency, over a 1-year period. Results A total of 48 limbs were treated with UAT. Forty cases were diagnosed as acute, whereas the remaining 8 were chronic. Complete thrombolysis was successful in 38/48 (79%) of patients, and partial thrombolysis was accomplished in 10/48 (21%) of patients. Overall mean infusion time was 22.4 hours ±3.6. There were a total of three complications (6%), all of which were minor bleeding. One-year patency was shown to be 87% with no signs of valvular reflux. Conclusion UAT using EKOS demonstrated effective rates of thrombolysis with very few complications. In addition, our 1-year patency rates were comparable to published data using conventional catheter-directed thrombolysis. UAT provides lytic therapy by utilizing the benefits of ultrasonic waves to help augment the fibrinolytic process. Our institution currently favors the use of EKOS as the treatment of choice in patients that are appropriate thrombolytic candidates.

This study was done to determine the usefulness of the American Society of Anesthesiologists (ASA) classification, the comorbidity Charlson index unadjusted (CCIu),the comorbidity Charlson index adjusted by age (CCIa), and the Glasgow aneurysm score (GAS) for postoperative morbimortality and survival in patients treated with aorto-bifemoral bypass (AFB) for aorto-iliac occlusive disease (AIOD). A series of 278 patients who underwent AFB were restrospectively studied. For the CCIu, CCIa, ASA, and GAS, receiver operating characteristics curve analysis for prediction of morbidity showed area under the curves of 0.61 (p = 0.004), 0.59 (p = 0.026), 0.569 (p = 0.087), and 0.63 (p = 0.001), respectively. Additionally, univariate analysis showed that CCIa (p = 0.016) and GAS (p = 0.006) were associated significantly with an increased risk of developing complications. Furthermore, CCIa (p

The aim of this study was to evaluate clinical features, angiographic findings, surgical treatment, and the long-term results of surgical procedures in chronic phase of Takayasu Arteritis. Between 1989 and December 2000, 14 young female patients (mean age, 31 years) with occlusive lesions caused by Takayasu Arteritis were observed and treated at our department. All patients met the American College of Rheumatology 1990 criteria of classification of Takayasu Arteritis. Systemic symptoms were reported in fewer than 15%. All patients were evaluated by a routine full aortography. Occlusive disease was dominant (92.8%) and the subclavian and carotid arteries were mostly involved. All our patients underwent surgery and 30 vascular procedures were done. Polytetrafluoroehylene was the most common synthetic graft. The ipsilateral carotid artery was the most common proximal anastomotic site and the ascending aorta was used twice. Follow-up ranged from 1 to 9 years (mean 6 years) and there was no death. All patients had serial duplex and 6 at least one postoperative angiogram. Twenty percent of the bypass procedures were followed by complications. There was no difference between the complication rate using synthetic grafts or autologous veins. The actuarial graft patency rate was 96.4% at one year and 72% at 4 years. At side of the medical treatment which remains, to date, a subject of discussion, the long-term prognosis of Takayasu Arteritis depends on an elective surgical treatment, which requires full and accurate assessment of the lesions, best done by digital full arteriography. Surgical results are excellent with minimal morbidity and mortality.

Bei der Therapie des in seiner Genese komplexen Ulcus cruris mixtum steht die Behandlung der arteriellen Durchblutungsstorung an erster Stelle. Sie schafft die Voraussetzung fur die anschliesende Sanierung des venosen Leidens. Hierfur ist die Kompressionstherapie von entscheidender Bedeutung. Chirurgische und konservative Masnahmen zur Wundtherapie beeinflussen den Therapieverlauf in entscheidender Weise und helfen die Behandlungszeit zu verkurzen. In chronic leg ulcers in which the venous genesis is complicated by arterial disorders therapy is very complicated. First step should be the therapy of arterial occlusive disease. It is followed by therapy of the venous disease. Most important for that is compression therapy of the leg. Further the wound therapy is influenced and accelerated by surgical and conservative methods.

In the last few decades the surgical therapy of aortic diseases has enormous improved. However, aortic surgery still carries a high risk of complications. Nearly 80 % of patients with aortic diseases are older than 65 years. Every year the number of operated old and multimorbid patients increases. Nowadays there are two surgical methods available: the endovascular and open repair of aortic diseases. Besides the usual hazards of any anesthesia and operation, there are several particular postoperative problems which may arise following aortic grafting for aneurysm, dissection or occlusive disease. The most common complications may be classified as those that occur after open and endovascular repair, including bleeding, intestinal, kidney and spinal ischemia, graft infection, aortoenteric fistula and impotence and those that appear only after endovascular stent graft repair, including endoleaks, postimplantation syndrome, stent thrombosis, complications due to contrast media and exposure to radiation and cholesterol crystal embolism. The endovascular and open repair have different advantages and the indication for one of them depends of individual patient‘s risk-benefit analysis. That is why both surgical methods should be considerd as complementary procedures in the aortic surgery.

Hintergrund: Durch Fast-track-Rehabilitationsprogramme konnte bei grosen Operationen, wie z. B. in der kolorektalen Chirurgie eine Reduzierung der Mortalitat und Morbiditat erreicht werden. Bislang wurde nicht untersucht, ob ein Fast-track Rehabilitationsprogramm auch bei Patienten nach grosen gefaschirurgischen Eingriffen durchfuhrbar ist und welchen Einfluss ein solches Programm auf die Mortalitat und Morbiditat hat. Methode: 35 Patienten (durchschnittlich ASA III) wurden zwischen Mai 2005 und Juni 2006 nach konventioneller aortoiliakaler Operation (21 mit Aneurysma, 14 mit AVK) mit einem strukturierten Fast-track Programm behandelt, bestehend aus: Intra- und postoperativer PDA, Beginn des oralen Flussigkeits- und Kostaufbaus sowie der Mobilisation ab dem OP-Tag. Erfasst wurden tagliche Trinkmenge, Mobilisation, Kostaufbau, Zeitpunkt des ersten Stuhlgangs, PONV, Schmerzzufriedenheit in Ruhe, bei Belastung und Mobilisation sowie die Fatigue mittels VAS (1–10). Zusatzlich die Komplikationen und die 30-Tage-Mortalitat. Ergebnisse: Die 30-Tage-Mortalitat betrug 0 %, und die Morbiditatsrate 14,8 %, bei 9 % pulmonalen und je 2,9 % kardialen und renalen Komplikationen. Die Mobilisation konnte sicher durchgefuhrt werden. Am OP-Tag wurden durchschnittlich 329 ml Flussigkeit getrunken, am zweiten postoperativen Tag bereits 1 160 ml. Der Kostaufbau war am vierten postoperativen Tag bei 33 Patienten (94 %) abgeschlossen. Die durchschnittliche Schmerzzufriedenheit und die Fatigue lagen in allen Kategorien unter 4. Diskussion: Fast-track-Rehabilitation ist auch bei Hochrisikopatienten nach konventionellen aorto-iliakalen Operationen sicher durchfuhrbar. Der fruhzeitige Kostaufbau und die Mobilisation verbessern die Fatigue. Die thorakale PDA fuhrt zur suffizienten Schmerzfreiheit. Background: Fast-track rehabilitation programs have resulted in a decrease in mortality and morbidity after major surgical procedures, e. g., in colorectal surgery. It is not known whether fast-track rehabilitation can safely be applied in major vascular surgery. Method: 35 patients (mainly ASA III) who underwent open aorto-iliac reconstruction (21 for abdominal aneurysm, 14 for aorto iliac occlusive disease) between May 2005 and June 2006 were treated with a fast-track protocol including PDA, early postoperative oral fluid and food supply, early postoperative mobilisation, all starting on the day of operation. The average daily oral fluid amount, duration of mobilisation, step of oral nutrition, day of first defecation, PONV, pain levels while resting, under effort and mobilisation, and fatigue were monitored. Results: The 30-day mortality was 0 %, overall morbidity was 14.8 % with 9 % pulmonary, 2.9 % cardiac and 2.9 % renal complications. Mobility was safely achieved. The oral fluid consumption was 329 mL on the day of operation and 1160 mL on the second day after operation. 33 patients (94 %) achieved total oral nutrition on day four after operation. The average pain level in all categories and the fatigue were below 4 on the VAS. Conclusion: Fast-track rehabilitation can safely be applied to patients undergoing conventional aorto-iliac reconstruction. Early onset of oral nutrition and mobilisation influence the fatigue in a positive way. Thoracal PDA leads to acceptable pain levels.

In 32 patients presenting symptoms of arterial occlusive disease, 50 lower limbs were examined both by ultrasonography and angiography (DSA). Sonography was performed using a 5.0 MHz real-time scanner; common femoral, superficial femoral and deep femoral arteries were visualized continuously in whole length. In 84% both the results from sonography and digital subtraction angiography verified or excluded arterial occlusion. Since lack of pulsation is the ultrasonic criterion of occlusion, real-time ultrasound does not differentiate between haemodynamically effective high-grade stenosis and total occlusion.

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

Objective As hyperhomocysteinaemia is known to be an important risk factor in the early onset of arteriosclerotic occlusive disease and leg-vein thrombosis, we investigated the prevalence of hyperhomocysteinaemia in patients with thromboangiitis obliterans (TAO), a condition predominantly affecting peripheral arteries and veins. Patients and methods Plasma homocysteine (HC), before and after administration of methionine (0.1 g/kg) as well as serum folic acid, vitamins B6 and B12 were measured in 15 patients with TAO (12 men, 3 women; mean age 33.3 years: group 1), in 15 non-smokers without peripheral vascular disease (group 2) and 15 smokers without peripheral vascular disease (group 3). At the time of the study, of those in group 1 seven were active smokers, seven were ex-smokers and one was a non-smoker. Results Before methionine administration four patients (27%), none of the healthy non-smokers and one smoker without vascular disease (7%) had increased HC levels (> 13.9 nmol/ml). The difference between groups 1 and 2 was statistically significant (P or = 31 nmol/ml) were measured in nine patients but in none of the healthy controls. The difference between patients and the two control groups without vascular disease was clearly significant (P = 0.0107). There was a difference in folic acid levels between the patients and the smokers without vascular disease: in eight patients (53%) the levels were in the lower third of normal, in six (40%) they were in the middle and in one (7%) in the upper third. Corresponding levels in group 3 were: four (27%), three (20%) and eight (53%). Conclusion Hyperhomocysteinaemia occurs frequently in patients with TAO. It may play an important and nicotine-independent role in its pathogenesis.

The introduction of guidelines for carotid surgery into praxis. Early experiences with the clinical pathway. With the use of DRG's for reimbursements, a new organization of clinical pathways may play an increasingly important role in the delivery of health care. The impact of clinical pathways as a management tool in the treatment of patients with carotid occlusive disease was studied. Representatives of all involved disciplines identified in which sequence, where, when, by whom and which care a patient with carotid disease should receive. The individual steps of care were analysed, estimating their utility and determining a new plan for a patient's care. The clinical pathway specifies a target time window, defining exactly the internal and external logistics. The early experiences demonstrate that clinical pathways can be a useful tool for improving the quality of health care by improving cost and process transparency. Hospital length of stay was reduced by 2.3 days.

UNLABELLED Long-term results after carotid reconstruction in patients with completed stroke caused by cerebrovascular occlusive disease. BACKGROUND AND OBJECTIVE In patients with completed stroke caused by cerebrovascular occlusive disease the reconstruction of high grade carotid artery stenosis is discussed as prophylaxis for prevention of recurrent stroke. The operative complications of all patients who underwent surgery for carotid occlusive disease in the Heinrich Heine University between 1990 and 1999 were evaluated in this study. PATIENTS AND METHODS We present the results of 596 reconstructions in 537 patients (404 men, 133 women; mean age 64,5 plus minus 9,4 years). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure. RESULTS A postoperative ipsilateral neurological deficit was observed in 41 patients (6,9 %): 4,7 % permanent, 2,2 % transitory. Thirtyeight percent of the permanent deficits appeared after reconstructions performed within six weeks after stroke and only 9 % after surgery between six and twelve weeks. The in-hospital mortality was 0,7 % for neurological and 1,0 % for cardiopulmonary complications. During long-term follow-up (mean follow-up time 50 plus minus 34 months) only 17 (3,7 %) of 462 patients, which could be evaluated, presented with a new neurological event for the reconstructed side. Fifty-eight percent had none or minimal neurological deficits. 115 Patients (24,0 %) died during follow-up. CONCLUSION Even after completed stroke carotid reconstruction can be carried out successfully in selected patients with an acceptable complication rate in prophylaxis of recurrent stroke. In our retrospective study the optimal time for surgery seems to be between six and twelve weeks after stroke, but new imaging techniques may alter in the future the time window for operation in patients with an unstable neurological situation early after stroke. The reduction of social mobility and the high mortality in follow-up in correlation to patients without stroke are mostly related to accompanying severe cardiopulmonal risk factors.

The combination of open surgery with endoluminal catheter techniques offers new chances in the treatment of multi-staged arterial occlusive disease. We report our experiences in 205 patients. In n = 125 patients TEA or bypass were undertaken in the groin with simultaneous catheter intervention proximally or distally. In 31 patients the operation was carried out above knee and in 49 cases below knee. 94 patients with an open operation in the groin and simultaneous iliac catheter interventions are in the follow up. For these interventions the combined secondary patency rate was 77 % after three years.

Ziel: Ziel der vorgestellten Untersuchung war es, die Wertigkeit der kontrastmittelverstarkten MR-Angiographie der Becken- und Beingefase unter Verwendung eines dedizierten Spulensystems zur peripheren Angiographie zu uberprufen. Material und Methoden: Bei 45 Patienten wurde eine kontrastmittelgestutzte MR-Angiographie (ceMRA) der unteren Extremitat durchgefuhrt. Die Untersuchung erfolgte an einem 1,5 T Magnetom Symphony (Siemens) mit Einzelmessung der Beckenetage und davon getrennter Messung von Ober- und Unterschenkel in Schrittverschiebetechnik mit einer zweiten Kontrastmittelinjektion. Fur die Signalerfassung der Beine wurde eine dedizierte Spule zur Angiographie bestehend aus 8 Arrays verwendet. Das Kollektiv bestand aus zwei Gruppen. Bei 20 Patienten wurde die ceMRA mit der DSA verglichen. Bei 25 Patienten wurde ausschlieslich eine ceMRA durchgefuhrt. Ergebnisse: Im Vergleich zur DSA betrugen Sensitivitat und Spezifitat fur Stenosen ≥ 50 % und Gefasverschlusse (in Klammern): fur die Beckenarterien 94,7 %, 96,8 %, (100 %, 100 %), fur die Oberschenkelarterien 92,3 %, 93,3 % (87,5 %, 100 %) und fur die Unterschenkelarterien 96,5 %, 95,8 %, (95,2 %, 96,8 %). Die Therapieentscheidung konnte aus den ceMRA abgeleitet werden. Die periphere Ausstrombahn war auch bei proximalen Gefasverschlussen gut beurteilbar. Schlussfolgerungen: Die ceMRA ist in der vorgestellten Technik als Alternativverfahren zur DSA in der Diagnostik bei Patienten mit arterieller Verschluskrankheit einsetzbar. Purpose: To evaluate contrast enhanced magnetic resonance angiography (ceMRA) of the pelvic and peripheral arteries with a dedicated peripheral vascular coil system and automated table-feed technique in patients with arterial occlusive disease. Methods: Three-dimensional gadolinium-enhanced MR angiography in a two-step automatic table feed technique was performed in 45 patients using a 1.5 Tesla imager (Magnetom Symphony, Siemens). The pelvic arteries were imaged with a single injection of contrast material. The upper and the lower leg were imaged with a second injection of contrast material in an automated table feed technique using a dedicated vascular coil system. In 20 patients ceMRA was compared with digital subtraction angiography (DSA) as the standard of reference and in 25 patients ceMRA was performed solely. Results: Sensitivity and specificity for grading significant stenoses ≥ 50 % and occlusions (in parenthesis) were in the pelvic arteries 94.7 %, 96.8 %, (100 %, 100 %), in the arteries of the upper leg 92.3 %, 93.3 % (87.5 %, 100 %) and in the arteries of the lower leg 96.5 %, 95.8 %, (95.2 %, 96.8 %), respectively. Depiction of the runoff vessels of the lower leg was excellent in ceMRA. CeMRA was of diagnostic quality in all the patients. Conclusion: Contrast-enhanced MRA using a dedicated peripheral vascular coil system increases the diagnostic quality of the lower leg. The runoff vessels can be evaluated. Thus, ceMRA in the presented technique is a diagnostic alternative to arterial angiography.

Purpose: To assess the effectiveness and mid-term patency of VIP balloon expandable stents in patients with iliac occlusive disease. Material and Methods: Between August and December 1997, 26 balloon-expandable VIP (Medtronic) stainless steel vascular stents were implanted in 19 patients with iliac occlusive disease. 22 lesions in common iliac (n=11), external iliac (n = 5), common iliac plus contralateral external iliac (n = 1), and unilateral common and external iliac (n = 2) arteries were stented, allowing 20 limbs for assessment. There were 18 stenoses and 4 occlusions in 7 female and 12 male patients (mean age 65 years, range 45-80). Results: All lesions were treated satisfactorily, yielding a technical success rate of 100%. Primary patency was 91 % (20/ 22) at 6 months. In 2 lesions restenoses (90% and 70%) were observed, requiring repeated angioplasty. Color Doppler analysis at 12 months revealed no further restenoses. Conclusion: The new VIP balloon-expandable stents achieve very good initial technical success and good mid-term patency in the treatment of iliac occlusive disease.

Reconstruction alternatives following removal of an infected aortic graft bear a high morbidity and mortality rate. Recent reports suggest that cryopreserved tissue may be implanted in infected fields and, therefore, may be suitable for replacement of infected aortic grafts. We report two cases of aortic replacement with cryopreserved allografts. Case 1: A 60-year-old woman presented with 6 months of right groin pain and a 30-1b. weight loss. She underwent aortobifemoral bypass in 1981 for occlusive disease, with revisions in 1983 and 1985. Computed tomography (CT) and indium-111 WBC scan suggested aortobifemoral graft infection. The aortobifemoral graft was removed and replaced with a cryopreserved aortoiliac allograft. Postoperatively, she had a left hemispheric stroke with right arm weakness. She recovered well, and 7 months later was doing well, with palpable distal pulses and no evidence of recurrent infection on CT scan. Case 2: Two years after placement of an aortobiiliac graft for aneurysmal disea...

In diabetes mellitus, peripheral arterial occlusive disease predominantly affects the lower leg (tibial and peroneal vessel disease). Our study suggests that this feature is related to the presence of forefoot medial arterial calcification.

PURPOSE Transcranial colour-coded duplex sonography allows differentiation of both vertebral arteries and the proximal basilar artery by transoccipital insonation. However, imaging is often incomplete. Therefore the aim of this study was to show to what extent imaging of vertebrobasilar arteries can be improved with the use of the echosignal enhancing agent Levovist (LV) in normal subjects without vascular abnormalities or occlusive disease. METHODS In 30 subjects extracranial Doppler and duplex sonography has been used to exclude hypoplasia and proximal or distal obstructions of the vertebral arteries. The intracranial vertebral arteries and the basilar artery were then examined before and after fractionated injection of LV (300 mg/ml, 4 g) by means of colour-coded transoccipital duplex sonography including videorecording. RESULTS Without LV only 17 of 90 possible segments could be imaged completely (basilar artery and both vertebral arteries in 30 subjects). After LV 72 of 90 possible segments could be demonstrated. The confluence of the vertebral arteries could be localised in 22 of 30 subjects by means of LV. The average depth was 6.7 cm (5.5 to 8 cm). Additionally branches of the main arterial trunks could be imaged. The basilar artery could be followed up to a depth of 10 cm. In most cases the distal part of the basilar artery could not be evaluated not even by means of LV enhancement. CONCLUSIONS Imaging of the vertebrobasilar arteries including the proximal basilar artery could be definitely improved by means of echosignal enhancing Levovist. Imaging of the distal basilar artery was not satisfactory. The confluence of the vertebral arteries could not be precisely localised in all cases due to the course of the arteries.

Arterial occlusive disease of supraaortic vessels, particularly the subclavian and innominate arteries, is infrequent. Hemodynamically significant proximal lesions of all supraaortic arteries are uncommon and the combination with coronary artery disease is even rarer. So far, the surgical management and operative timing of patients with coexisting severe disease of brachiocephalic and heart vessels is still a matter of debate. We report the case of a patient with severe polydistrectual atherosclerosis treated with single-stage aorto-carotid, carotid-subclavian and aortocoronary bypass.

PURPOSE: The present investigation aimed at examining changes in muscle metabolism caused by treatment of arterial occlusive disease, using dynamic 31-phosphorus methods. METHOD: 32 patients with arterial occlusive disease were examined in a 1.5 T apparatus with a 6 cm surface coil before and after treatment. The metabolic changes in the quadriceps muscles were visualised during a 36 s phosphorus spectrum during rest, exercise (isometric and isotonic) and during a period of recovery. RESULTS: Vascular therapy resulted in a significant increase in the duration of both types of exercise during dynamic phosphorus spectroscopy (isometric exercise: 282 s against 199 s: p = 0.002, isotonic exercise: 575 s against 222 s; p = 5 x 10(-6). After treatment, exercise-induced changes in pH (7.00 against 6.94; p = 0.004 and 7.00 against 6.93; p = 0.02) and the ratio Pi/PCr (0.34 against 0.44; p = 0.002 and 0.36 against 0.50; p = 0.009) were significantly smaller than before therapy, using a similar amount of exercise. Recovery time of Pi/PCr (45 s against 82 s; P = 10(-5) and 42 s against 57 s; p = 0.01) and pH value (154 s against 181 s; p = 0.14 and 173 s against 214 s; p = 0.22) showed significant reduction after treatment. CONCLUSIONS: Dynamic 31-phosphorus magnetic resonance spectroscopy indicates increased mitochondrial oxidative capacity in the quadriceps muscles as evidence for increased oxygen supply to muscle tissue following vascular therapy.

Intravascular ultrasound with 20 MHz/6.2-French transducer systems was used for arterial imaging via a transvenous approach. In 20 patients suffering from chronic arterial occlusive disease, 15 iliac arteries were evaluated during diagnostic angiography and 5 femoropopliteal arteries during balloon angioplasty (n = 3) and laser-assisted angioplasty (n = 2), respectively. Transvenous sonography did not allow differentiation of arterial wall layers and determination of vessel diameters as is usually possible during intraarterial sonography. Visualisation of iliac arteries was incomplete. In femoropopliteal vessels, guide wires could be detected within the arterial lumen but not in complete occlusions. Delivery of pulsed laser energy induced bright echoes near the catheter tip within a distance of 1-2 cm. Transvenous sonography is insufficient for monitoring of peripheral angioplasty; however, improved imaging quality might be possible at lower frequencies.

551 angiographic therapeutic radiological interventions were studied in detail. They included 246 patients treated by local, low dose fibrinolysis with consecutive PTA, 55 interventions treated by fibrinolysis therapy alone and 250 patients treated by angioplasty. The results of low dose, low duration fibrinolysis with or without consecutive PTA was compared with the "standard" results from PTA despite the variations in the severity of the arterial occlusive disease. The indications for local fibrinolysis are discussed and the variations from the technique reported in the literature are described ("retrograde" local fibrinolysis). We have not been able to show any statistical relationship between clot lysis and duration of history or the length of vascular occlusion. Clinical improvement of at least one stage (according to Fontaine) was achieved in 85% of cases by PTA, 60% by local lysis and 74% by lysis with subsequent PTA.

During a two-years period we have treated 6 patients where use of the internal thoracic artery for coronary artery grafting was precluded because of extrathoracic arteriosclerotic vascular lesions. In four patients with severe aorto-iliac occlusive disease preoperative digital angiography demonstrated collateralisation of the lower extremity by either the left, right, or both internal thoracic arteries (ITA). In these cases use of the ITA was excluded in order to preserve the collateral supply and coronary bypass grafting was performed using only saphenous vein. In two patients with proximal occlusion of the left subclavian artery the right ITA was used as in-situ bypass to graft the left anterior descending artery. All patients survived the operation without development of a perioperative myocardial infarction, neurological deficit, or peripheral ischemia. Although they rarely do, extrathoracic vascular disorders can exclude the use of the ITA for grafting. Especially in the case of aorto-iliac occlusive disease or proximal arteriosclerotic subclavian lesions angiographic evaluation is mandatory to prevent the development of life-threatening peripheral ischemia by harvesting an ITA and to avoid the use of an inadequate ITA graft with in-flow occlusion.

Background The current trend is to treat both inflow and outflow occlusive disease using endovascular procedures either simultaneously or in a staged procedure. The long-term benefits of a combined one-stage approach are not available. Objectives The main objectives are to investigate the risks and long-term benefits of a combined one-stage approach using endovascular techniques for iliac occlusive disease and bypass for femoropopliteal occlusive disease. Methods and results Fifty-three patients with limb ischemia underwent combined ilial stenting and distal bypass. Complications included minor wound problems in nine patients, atrial fibrillations in one patient, acute graft occlusion in one patient, toe amputation in two patients and one death. During a follow-up period of up to 96 months, eight patients required repeat distal bypass, five patients underwent revascularization on contralateral sides and four patients had repeat endovascular procedures. Conclusion These results suggest that there are few risks with a combined endovascular procedure for iliac occlusion and bypass for femoropopliteal occlusive disease. Long-term complications with the combined approach included repeat distal bypass, revascularization on contralateral sides and repeat endovascular procedure.

A patient with multiple vessel disease presented with symptoms of significant bilateral upper extremity pain and weakness that was more significant on the right side. On carotid duplex scanning, brachiocephalic artery occlusion with retrograde flow was noted through the right common carotid and right vertebral arteries at rest. Furthermore, 50% to 90% occlusion of the left internal carotid was noted. Filling of the right subclavian artery was noted to be through the right vertebral and right common carotid arteries. Unlike isolated subclavian steal syndrome, brachiocephalic artery occlusion induces significant hemodynamic alterations in extracranial arterial flow, which normally produces no symptoms at rest, but may produce symptoms with exercise. The occurrence of subclavian steal phenomenon in the presence of brachiocephalic occlusion is extremely rare. The present case is the first to report a patient presenting with bilateral upper extremity rest pain in the presence of brachiocephalic artery occlusive disease.

Materials and methods : 80 Limbs were studied with perepheral arterial occlusive disease (PAOD)BY COLOR DUPLEX SONOGRAPHY(CDS) ;and were evaluated for the presence of collaterals. Results : By CDS evaluation for collaterals;it was found that number of collaterals increased with the severity of areterial stenosis Conclusion : Number and freqency of collaterals seen in patients with PAOD depends upon severity of PAOD.

The quality of intravenous digital subtraction angiograms was sufficient for diagnostic evaluation in 90%. The accuracy of the method was 90% for the internal carotid artery. 40% of the internal carotid arteries showed stenoses, whereas the common and external carotid arteries were not narrowed in 90%. On behalf of these data the authors consider that i.v. DSA of the carotid vessels is a suitable screening method for carotid arterial occlusive disease.

The effect of lumbar sympathectomy on regional blood-flow and on oxygen uptake of tissue has been investigated in animal experiments and in man. Lumbar sympathectomy did always result in increase of limb blood-flow, but did not significantly improve oxygen consumption of the observed extremity. This finding was manifested by marked narrowing of the arterial-venous oxyhemoglobin saturation difference suggesting that lumbar sympathectomy caused opening of arterial-venous shunts.

Angiography examinations of the extracranial cerebral arteries in patients with peripheral occlusive disease of the lower limbs indicate cerebro-vascular disease more often than might be assumed from clinical-neurological examinations alone. In total, 61.5% of the patients examined showed lesions of the extracranial cerebral arteries which necessitated an operation. The elimination of risks in an operation requiring extensive peripheral vessel reconstruction necessitates initial supraaortic vessel reconstruction. Of the 48 patients with reconstructions in both vascular systems, none has suffered any postoperative neurological dysfunction. Concomitant occlusive disease of the supraaortic and peripheral arteries should not be treated simultaneously.

Aseptic bypass graft and graft-preserving open local treatment have proved to be the 2 suitable procedures for therapy of infected grafts in vascular surgery (stage III Szilagyi) with preservation of the limb extremity. After 685 reconstructive operations (1982 to 1984) for chronic arterial occlusive disease in the supraaortic as well as in the iliac and femoral segments, 9 infections involving the graft (1.31%) occurred. These infections were more common in superficial extra-anatomical bypass. The incidence of inguinal infection was 0.44%. In 2 cases an aseptic bypass with abandonment of the infected vascular segment and in 4 cases open local treatment of the infected graft proved successful in treating the infection and led to secondary wound healing. The transplant had to be abandoned and an amputation performed in 3 patients, one of whom died. That is to say, the infection was successfully treated (with respect to the original aim of the operation) in 66.7% of cases. The aforementioned methods do not represent alternative procedures: the aseptic bypass is considered in retroperitoneal and inguinal infections, whereas the open local treatment is used in cases of superficial extra-anatomical bypass grafts and in the infrainguinal and supraaortic artery segments. The success of the latter treatment, however, depends on several preconditions. In former years, loss of the limb extremity was almost unavoidable and, because of septicemia, the outcome often lethal. By applying the above-discussed principles of management this could be drastically improved.

Nach Unterbindung der Aa. femorales superficiales wurde bei 11 Bastardhunden (10–15 kg) die Kollateralenentwicklung beobachtet, die durch erhohten arteriellen Druck mittels eines extrakorporalen Kreislaufes geoffnet wurden. In Allgemeinnarkose ist ein Teflonschlauch in eine der Aa. fem. prof, eingefuhrt worden. Das andere Ende wurde uber eine A. carotis in den Aortenbogen vorgeschoben, um arterielles Blut uber eine Rollenpumpe von der Aorta in die vermindert durchblutete Extremitat zu pumpen. Nach 40 Minuten Perfusionszeit mit einem Druck von 200 mmHg fand sich eine erhebliche Kollateralisation uber die Aste der A. fem. prof. Auf der nicht behandelten Gegenseite entstand nur eine unwesentliche Kollateralentwicklung. Die Angiogramme zeigen, das sich Kollateralen in kurzer Zeit durch erhohten Druck offnen lassen. Diese experimentelle Methode konnte sich zur konservativen Behandlung der arteriellen Verschluserkrankung auch in der Klinik anwenden lassen. In 11 mongrel dogs (10-15 kg) with ligated superficial femoral arteries the formation of collaterals induced by increased arterial pressure with an extracorporal circulation was studied. In general anesthesia a teflon tube was inserted into one deep femoral artery. The other end of this tube war introduced through the right carotid artery into the thoracic aorta and arterial blood was drawn by a peristaltic tube pump from the aorta to the femoral artery. Different arterial pressures created by the pump were used to perfuse this hind limb. After 40 minutes perfusion time with 200 mmHG pressure, there was marked increase of collateralization by the deep femoral artery. At the contralateral non treated side, only minimal developement of collaterals was visualized. These angiograms demonstrate that collaterals are opened by increased pressure within a short time interval. The experimental model might have clinical implisations and accelerate collateral formation in non-surgical treatment of arterial occlusive disease.

Increased blood and plasma viscosity was found in patients with chronic arterial occlusion in comparison with healthy probands. The measurements were done at high and low shear rates. Parenteral pentoxifylline (Trental) lowered blood and plasma viscosity of patients significantly, especially when measured at low shear rates. Application of bencyclane (Fludilat) produced variable results. A definite connection between rheological changes and alterations of the protein fractions in plasma could not be established.

Using 113mIndium chloride and an Anger scintilation camera, flow rates were measured and recorded in defined distal parts of the hand. The method is a useful complement to previous diagnostic techniques and provides information regarding flow through end-arteries which cannot otherwise be obtained. Because of the low risk, even of intra-arterial injection of the tracer substance, isotope angiography can be used as a means of controlling operative and conservative treatment.

In 107 consecutive patients the frequency of peripheral arterial occlusive disease in coronary heart disease was assessed by selective coronary angiography and sonographic Doppler pressure estimation. Among 75 patients with coronary heart disease 21 (28%) had arterial occlusive disease, among 32 patients without coronary heart disease only one (3%). There was no statistically significant correlation between the severity of both diseases. 40 out of 75 patients with coronary heart disease had suffered from cardiac infarction. Infarction frequency showed a highly significant correlation with increasing severity of the coronary heart disease, but none with increasing severity or frequency of arterial occlusive disease. When there was no arterial occlusive disease all degrees of severity of coronary heart disease were found. Analysing the literature it becomes evident that coronary heart disease is frequently an isolated or premature manifestation of arteriosclerosis.

Two intravascular oxygen electrodes (of the International Biophysics Corporation and Roche) were tested in vitro and in long-term monitoring of arterial oxygen partial pressure in 19 patients. There were no complications. Both electrodes proved suitable for use for monitoring in an intensive-care situation. But both could still be improved by having greater stability and a shorter response time. Some of the indications for continuous monitoring of pO2 are mentioned: incipient respiratory failure, shock-lung, pulmonary oedema, and artificial ventilation. Haemorrhagic diatheses and arterial occlusive disease are contra-indications to its use.

A self-expanding vascular endoprosthesis (wall stent) was implanted in 26 patients with femoropopliteal occlusive disease following recurrent stenosis or occlusion after percutaneous angioplasty. Implantation was successful in all cases and there were no complications. Five of the 26 patients developed a thrombosis in the first nine days; in four of these, thrombolysis was successful. Patency rate after one month was 96%, after three months 95%, after six months 85% and after nine months 87%. In order to prevent thrombosis after implantation, anticoagulant therapy is indicated. Poor distal flow encourages intimal hyperplasia and therefore recurrences.

A case of a 66 year old patient with multiple injuries is reported. A combination of conventional trauma treatment and percutaneous transluminal angioplasty (PTR) of a segmented superficial femoral artery occlusion prevented leg amputation. When the patient died 8 weeks later from trauma sequelae the successful recanalization was demonstrated in histopathology investigation. It is concluded that PTR is an ideal accessory to the present therapeutic spectrum in vascular surgery.

125I-nuclide-absorption measurement demonstrated a statistically significant decrease in mineral content of the calcaneus in 44 patients with arteriographically proven arterial occlusive disease of the lower limbs. The loss of mineral content was dependent on the clinical degree of the vascular disorder (stages according to Fontaine's classification) and the site of the arterial occlusion. There was no demonstrable relationship between the degree of demineralisation and the duration of the vascular disorder. If treatment proved successful there was a significant rise in the mineral content of the calcaneus.

Die vorliegende Arbeit beruht auf der Auswertung von 890 praoperativen und von 400 postoperativen Angiographien bei Kranken, die wegen Arterienverschlusse der unteren Gliedmasen operiert wurden. Es wird betont, das die postoperative Kontrollarteriographie zur Routineuntersuchungsmethode gehoren sollte, weil sie unentbehrlich fur die Fruhdiagnose der verschiedenen postoperativen Komplikationen ist. Sie ist weiter notwendig fur die Indikation zur Reoperation und fur die Wahl des Operationsverfahrens. Es hat sich auch gezeigt, das die postoperative Angiographie wichtig fur die Beurteilung der Funktion der rekonstruktiven Operationen, fur das Studium der Veranderungen des Kollateralkreislaufes und fur die Entdeckung der Ursachen der Spatthrombose ist. The present paper is based on data obtained from 890 pro-operative and 400 post-operative angiograms of patients who underwent surgery for arterial occlusive disease of the lower limbs. It is stressed that postoperative angiography should be used routinely, since it is essential for the early diagnosis of various postoperative complications. It is also necessary, if a decision has to be made, to re-operate, and for the choice of appropriate surgical techniques. Post-operative angiography has also been shown to be important for evaluating function of the reconstructed vessels, for a study of changes in the collateral circulation and in order to discover causes of late thrombosis.

The author discusses the possibilities of registering the ocular pulse. With the help of sphygmography, the so-called pressure pulse can be registered. These techniques yield information about carotid arterial occlusive disease. The purpose of plethysmography is to measure the extent of intraocular blood flow. Yet quantitative determination of the intraocular blood flow rate is not yet possible. The author gives a critical review of the various methods and their limitations.