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Objective The present study tested scoring models for ruptured abdominal aortic aneurysms (rAAAs) in patients treated by open surgical repair (OSR). Scores were tested in a European population to validate their applicability for predicting outcome. Methods Between 2002 and 2013, 92 patients with rAAAs underwent OSR and medical records were reviewed retrospectively. The Edinburgh Rupture Aneurysm Score (ERAS), Vascular Study Group of New England (VSGNE) rAAA risk score, Hardman Index, and Glasgow Aneurysm Score (GAS) were calculated and analyzed according to in hospital mortality. The discriminatory power and calibration of all models were assessed by applying the receiver operating characteristic and the Hosmer–Lemeshow test χ 2 . Results An ERAS ≤1 ( n = 55), 2 ( n = 15) and 3 ( n = 16) was associated with a mortality of 27%, 47%, and 69%, respectively. The calibration was the best of all tested scores (χ 2 = 0.44; p = .81) and the area under the curve (AUC) was 0.71 (95% CI 0.6–0.82; p = .001). A VSGNE rAAA risk score = 0 ( n = 19), 1 ( n = 15), 2 ( n = 19), 3 ( n = 25), and ≥4 ( n = 9) was associated with a mortality of 11%, 20%, 32%, 72%, and 56%, and an AUC of 0.76 (95% CI 0.66–0.87; p = .001). The calibration was reduced (χ 2 = 6.9; p = .08). The GAS and Hardman Index increased stepwise with increasing in hospital mortality, but were inferior to ERAS and the VSGNE rAAA risk score. The Hardman Index showed the smallest AUC (0.68; 95% CI 0.56–0.80; p = .011) and demonstrated a lack of fit (χ 2 = 8.2; p = .04). The GAS showed good discrimination (AUC = 0.75; 95% CI 0.64–0.85; p 2 = 0.85; p = .66); however, the parametric scale of GAS limits its use to classifying patients according to their risk. Conclusion The present study revealed remarkable differences in survival between subgroups (10–70%) and underscores the need for risk stratification. The ERAS was favorable with striking ease of use and high accuracy in predicting outcome.

BACKGROUND Arterial allografts are used as vascular conduits in the treatment of prosthetic graft infection. Immunosuppression decreases their rupture risk rate. However, immunosuppression can be unprofitable in florid infection. Previously, we confirmed inhibition of cell-mediated destruction of rat aortic grafts by delayed use of tacrolimus. In this work, we studied the influence of this protocol on the antibody-mediated rejection. MATERIAL AND METHODS Flow cytometry was used for the retrospective analysis of day 0, 14, and 30 sera obtained from Lewis rat recipients of isogeneic fresh infrarenal aortic grafts (group A) or Brown-Norway rat aortic grafts (group B,C,D) for the presence of donor-specific anti-MHC class I and II antibodies. Tacrolimus in daily dose of 0.2 mg/kg was administered from day 1 to day 30 (group C) or from day 7 to day 30 (group D). RESULTS Inhibition of fluorescence-labeled anti-BN MHC class I and MHC class II antibodies binding to BN-splenocytes was observed only by day 14 and day 30 sera of allogeneic non-immunosuppressed Lewis rats (group B). The day 30 sera significantly decreased anti-MHC I (42±3%) and anti-MHC II antibody binding (56±3%) compared to day 0 (76±9%, p=0.005 and 79±5%, p=0.003, respectively). Deposition of immunoglobulins G into the tunica media was observed only in non-immunosuppressed aortic allografts on day 30. CONCLUSIONS Fresh aortic allografts induce donor-specific anti-MHC class I and anti-MHC class II antibody production. Delayed administration of tacrolimus completely suppressed antibody production and antibody-mediated destruction of aortic allografts.

Infektionen von aortalen Gefasprothesen und endovaskularen Grafts stellen eine zunehmende Herausforderung in der Gefaschirurgie dar. Neben der Versorgung mit extraanatomischen prothetischen Bypassen kommt der anatomischen Rekonstruktion mit infektresistenten Materialien eine besondere Bedeutung zu. Die Verwendung von arteriellen Homografts ist eine an vielen Zentren etablierte Methode zur In-situ-Rekonstruktion bei Gefasprotheseninfektion. Historisch zum elektiven Gefasersatz genutzt, geriet die Bedeutung der arteriellen Homografts mit der Entwicklung von synthetischen Gefasprothesen in den Hintergrund. In den 90er-Jahren des vergangenen Jahrhunderts fand die Verwendung als Gefasersatz bei Infektionen eine erneute, rasche klinische Akzeptanz. Diskussionen uber den Einsatz von sogenannten „frischen“ Homografts ohne Konservierung wurden durch europaische Richtlinien in 2003 beendet, obwohl Vorteile im Langzeitverlauf absehbar waren. Gegenwartig konnen aufgrund des deutschen Gewebegesetzes ausschlieslich sogenannte „kryokonservierte“ Homografts verwendet werden. Grosere, teilweise kontrollierte Studien zeigten jedoch hiermit vergleichbare Ergebnisse zur Anwendung von Silberprothesen bei deutlich geringeren Re-Infektions-Raten. Offen bei der Verwendung von arteriellen Homografts bleibt weiterhin die Frage nach einer notigen Immunsuppression. Veranderungen aufgrund immunologischer Prozesse konnen zu Veranderungen der Transplantate fuhren. Die im Langzeitverlauf beobachteten aneurysmatischen Veranderungen lassen sich jedoch mit modernen endovaskularen Verfahren behandeln und haben damit wenig Einfluss auf die Langzeitergebnisse. Die Verfugbarkeit von arteriellen Homografts ist in Europa eher eingeschrankt, doch ermoglichen internationale Unternehmen gegenwartig eine akzeptable Versorgungslage. Der Einsatz von Homografts auch in nicht universitaren Institutionen zeigt die breite Akzeptanz des Materials und die Eignung zum Routineeinsatz in der Gefaschirurgie, wenn auch die Behandlung der zentralen Gefasprothesen weiterhin mit einer hohen Morbiditat und Mortalitat verbunden ist.

Einleitung: Protheseninfektionen in der peripheren Bypasschirurgie stellen ein hochsignifikantes Risiko hinsichtlich Morbiditat und Extremitatenverlust dar. Bei fehlendem Venenmaterial stellt sich die Frage nach einem geeigneten Gefasersatz. Silberprothesen, Homografts bzw. die Verwendung tiefer Venen ist mit zusatzlichen Risiken behaftet. Die Verwendung einer biosynthetischen Prothese aus Schafskollagen auf einer Dacron-Matrix („Omniflow-II®“) wurde als Alternativverfahren untersucht und die Erlossituation analysiert. Material und Methoden: In der Zeit von Dezember 2010 bis Dezember 2011 wurden 8 Patienten aufgrund eines klinisch, laborchemisch und durch Bildgebung nachgewiesenen Infekts einer funktionell offenen bzw. akut verschlossenen Gefasprothese in peripherer Lokalisation zur Behandlung aufgenommen. Eingeschlossen wurden Patienten, bei denen eine In-situ-Rekonstruktion der infizierten Prothese moglich war. Das infizierte Material wurde in toto entfernt, eine mikrobiologische Probe gewonnen und bei fehlenden korpereigenen oberflachlichen Venen eine biosynthetische Kollagenprothese („Omniflow-II®“) implantiert. Das Follow-up der Patienten wurde anhand der Dokumentation aufgearbeitet. Die Erlossituation wurde vor und nach Optimierung untersucht. Ergebnisse: Die technische Durchfuhrbarkeit war in allen Fallen gegeben. Ein mikrobiologischer Nachweis von Erregern gelang in 5 von 8 Fallen. Bei einer mittleren Nachbeobachtungszeit von 8 Monaten zeigten 7 von 8 Patienten eine klinische Ausheilung des Infekts. Die primare Offenheitsrate betragt 63 %, die sekundare 75 %, der Beinerhalt liegt bei 88 %. Ein Patient musste bei drohender Sepsis oberschenkelamputiert werden, ein weiterer wurde nach 12 Monaten frustran thrombektomiert. Bei 4 PET-CT-Verlaufsuntersuchungen zeigte sich eine deutliche Minderung der Glukoseutilisation im betroffenen Bereich. Zur ausreichenden Erlosgenerierung ist differenziertes Kodierungswissen im DRG-Kontext notig. Diskussion: Die Behandlung des Protheseninfekts in der peripheren Bypasschirurgie stellt bei fehlendem korpereigenen Material in leicht zuganglicher Lokalisation hohe Anspruche an das zu verwendende Ersatzmaterial. Die vorliegende Untersuchung zeigt ermutigende Ergebnisse bei der Verwendung einer biosynthetischen Kollagenprothese. Bei fehlenden Langzeitergebnissen sollte das Verfahren jedoch nur nach entsprechender Aufklarung des Patienten durchgefuhrt werden. Der zu erreichende Erlos deckt die hoheren Kosten des Transplantats.

Summary Venous diseases are common in the general population. After a comprehensivediagnostic evaluation, an individual therapeutic approach should be selectedon the basis of the findings, with the aim of treating the diseased vein seg-ments and improving quality of life. Numerous therapeutic options are avail-able for the treatment of varicose veins. In addition to conservative methodssuch as compression therapy, exercise or drugs, surgical procedures such as tra-ditional surgery, thermal ablation techniques or sclerotherapy can be per-formed. Recent developments include the use of endoluminal water vapor ormechano-chemical endovenous ablation. Einleitung Krampfadern und die dazugehorigen funktionellen Veranderungen werden alschronisch venose Storung (CVI) bezeichnet. Venenerkrankungen und die Folge-schaden zeigen eine weite Verbreitung in der Bevolkerung. Deshalb sollte vor derTherapie eine prazise Diagnostik und eine korrekte Klassifikation von venosen Erkrankungen erfolgen [1]. Nach topographischen Kriterien werden als Krampf-adertypen die Stammvarizen, Seitenastvarizen, Perforansvarizen, retikulare Varizenund Besenreiservarizen unterschieden. Im deutschsprachigen klinischen Alltag sindvor allem die hamodynamische Beschreibung der Refluxstrecken nach Hach(Stammveneninsuffizienz) sowie die morphologischen Beschreibungen der CVI

Background We report our contemporary experiences with renal autotransplantation in patients with complicated renal vascular diseases and/or complex ureteral injuries. Since its first performance, renal autotransplantation has been steadily improved and become a safe and effective procedure. Material/methods Between 1998 and 2006, 6 renal autotransplantations in 6 patients were performed at the University Medical Center of Leipzig. After nephrectomy and renal perfusion ex vivo, the kidney was implanted standardized in the fossa iliaca. The vessels were anastomized to the iliac vessels, the ureter was reimplanted in an extravesical tunneled ureteroneocystostomy technique according to Lich-Gregoir. Demographic, clinical, and laboratory data of the patients were collected and analyzed for pre-, intra-, and postoperative period. Results Indications for renal autotransplantation were complex renovascular diseases in 2 patients (1 with fibromuscular dysplasia and 1 with Takayasu's arteritis) and in 4 patients with complex ureteral injuries. The median duration of follow-up was 9.7 years (range: 5.6-13.3). The laboratory values of our 6 patients showed improvements of creatinine, urea and blood pressure levels in comparison to the preoperative status at the end of follow-up period. Conclusions The present study reports excellent results of renal autotransplantation in patients with renovascular disease or complex ureteric injuries. After a median follow-up of 9.7 years all 6 patients present with stable renal function as well as normal blood pressure values. Postoperative complications were observed with a rate comparable to other studies.

Simultaneous pancreas–kidney (SPK) transplantation is state-of-the-art therapy for patients with type-1 diabetes mellitus and end-stage renal failure. Improvement of long-term organ function and long-term survival after transplantation is the main focus of current research, but improvement of the early postoperative course is very important for the patient. Pancreas transplantation is associated with postoperative complications. We defined and identified donor- and recipient-specific factors related to postoperative complications. We carried out 210 SPKs from April 1995 to December 2007. The early postoperative course until first discharge from hospital was analyzed. Complications (pancreas-specific and surgical) were revisited. Donor-specific factors such as sex, age, body mass index (BMI), laboratory values, catecholamine administration, time in the intensive care unit, preprocurement blood substitution, and asystolic periods, as well as factors related to the organ donation procedure, were assessed. Recipient-specific factors such as age, sex, BMI, and blood group were correlated with the prevalence of complications and postoperative outcome. Donor-specific risk factors correlating with postoperative complications included donor age, BMI, and blood transfusion in the donor before organ donation. Graft preservation with histidine–tryptophan–ketoglutarate perfusion solution was related to a significantly higher number of surgical complications.When analyzing recipient-specific factors, pre-existing cardiac diseases influenced the prevalence of postoperative complications. The duration of the transplantation procedure was associated with significantly more complications. The anastomosis time was not significantly related to an increased prevalence of complications. The choice of immunosuppression had a significant effect on pancreas-specific complications, demonstrating that antithymocyte globulin instead of daclizumab had a negative effect. Initial immunosuppression with tacrolimus combined with mycophenolate mofetil (MMF) caused significantly fewer pancreas-related complications in comparison with tacrolimus combined with rapamycin as well as compared with cyclosporine combined with MMF. A high level of C-reactive protein within the first 7 days after transplantation was significantly related to an increased prevalence of complications. Early postoperative complications after combined pancreas–kidney transplantation have a considerable effect on short- and long-term outcomes. Several statistically relevant factors related to pancreas- or surgery-associated complications could be identified. These data may help to improve early outcome after SPK by consideration of relevant risk factors when choosing an organ and a recipient for transplantation.

The implantation of syngeneic and allogeneic veins and arteries is used in clinical cardiac and vascular surgery in broad spectrum of indications. Experiments on animals represent an important part of cardiovascular research of vessel grafts. The arterial and vein allografts models are used for both studying the pathology of their acute rejection and to test different immunosuppressive regimens in vivo. Moreover, the aortic allograft model in the rat was originally introduced as a model for chronic rejection in transplant experimental medicine. Syngeneic vein-to-artery graft models are widely used for both studying the pathology of vein graft disease and to test therapeutic strategies in vivo. In this chapter, we describe in detail abdominal aortic to abdominal aortic and iliolumbar vein to abdominal aortic transplantation models between Brown-Norway (RT1n) and Lewis rats (RT1l). These genetically inbred rats differ at major and minor histocompatibility loci resulting in massive rejection of both arterial and vein allografts. Moreover, the iliolumbar vein to abdominal aortic transplantation model between syngeneic animals is useful to study vein graft intimal hyperplasia which represents a significant clinical problem in vascular medicine.

The identification and prevention of injury to the inferior laryngeal nerve is one of the main issues in thyroid surgery. Sound knowledge of anatomic variants of the nerve is of major importance. In rare cases the nerve does not run the recurrent way and it is therefore difficult to identify the nerve. Abnormal developments of the aortic arch during embryogenesis include malformation of the great vessels and can be the reason for anatomic abnormalities. A cause for a nonrecurrent nerve on the right side is the so-called lusorian artery, a right retroesophageal subclavian artery. Left-sided nonrecurrent nerves are seldom if ever documented. Only two cases have been published so far of patients with situs inversus viscerum, where left nonrecurrent nerves were associated with inverse, left-sided lusorian arteries.

Endovascular aneurysm repair (EVAR) has been suggested in several studies to be superior to open surgery repair (OSR) for the treatment of ruptured abdominal aortic aneurysms (rAAAs), but this finding might be affected by selection bias based on aneurysm morphology and patient characteristics. We tested rAAA anatomy according to EVAR suitability in patients undergoing OSR to assess the impact on mortality.This retrospective analysis reports on 83 patients with rAAAs treated between November 2002 and July 2013. Pre-operative computed tomography (CT) scans were evaluated based on EVAR suitability and were determined by blinded independent reviewers. CT scans were lacking due to acquisition in an external institution with no availability (n = 9) or solely ultrasound evaluations (n = 8). In addition patient characteristics and outcomes were assessed.All patients who underwent OSR and who had available preoperative CT scans were included in the study (n = 66). In summary, 42 % of the patients (28/66; 95 % confidence interval [CI], 30.5 - 54.4) were considered eligible for EVAR according to pre-operative CT scans and 58 % of the patients (38/66; 95 % CI, 45.6 - 69.5) were categorized as unsuitable for endovascular repair. Patients suitable for EVAR had a significantly lower prevalence of in-hospital deaths (25 % [7/28]; 95 % CI, 9 - 41) in contrast to patients unsuitable for EVAR (53 % [20/38]; 95 % CI, 36.8 - 68.5; p = 0.02).EVAR-suitable patients had a highly significant mortality reduction undergoing OSR. Thus, the present study proposes that EVAR suitability is a positive predictor for survival after open repair of rAAA.Hintergrund: In mehreren Studien wurde bei rupturierten abdominellen Aortenaneurysmen (rAAA) ein Überlebensvorteil durch die endovaskulären Behandlung gegenüber der offen-chirurgischen Versorgung berichtet. Jedoch bleibt weiterhin unklar, ob die präsentierten Ergebnisse durch die Aneurysmenmorphologien sowie Patientencharakteristika beeinflusst werden. Wir haben daher die Anatomie von rupturierten Aneurysmen unter Berücksichtigung einer möglichen endovaskulären Behandlung untersucht, um deren Einfluss auf die Letalität nach ausschließlich offen-chirurgischer Versorgung zu erfassen. Patienten und Methoden: Die retrospektive Studie umfasst 83 Patienten mit einem rupturierten abdominellen Aortenaneurysmata, welche in der Zeit zwischen November 2002 und Juli 2013 behandelt wurden. Präoperative computertomographische Angiographien (CTA) wurden in Hinblick auf Eignung zur endovaskulären Versorgung analysiert, die durch verblindete unabhängige Untersucher bestimmt wurde. In 9 Fällen fehlten CTA aufgrund einer mangelnden Verfügbarkeit der Daten aus externen Krankenhäusern und in 8 Fällen aufgrund ausschließlich durchgeführter Ultraschalluntersuchung. Des Weiteren wurden Patientencharakteristika und Letalitätsraten ausgewertet. Ergebnisse: In die vorliegende Studie wurden ausschließlich Patienten eingeschlossen, die offen chirurgisch versorgt wurden und bei denen CTA zu Auswertung vorlagen (n = 66). Entsprechend der CTA waren 42 % der Patienten (28/66; 95 % Konfidenzintervall [CI], 30.5 - 54.4) für eine Stentgraftanlage geeignet und 58 % der Patienten (38/66; 95 % CI, 45.6 - 69.5) ungeeignet. Patienten mit der Möglichkeit einer Stentgraftanlage hatten eine signifikant niedrigere Krankenhausletalität (25 % [7/28]; 95 % CI, 9 - 41) im Vergleich zu ungeeigneten Patienten (53 % [20/38]; 95 % CI, 36.8 - 68.5; p = 0.02). Schlussfolgerungen: Endovaskulär therapierbare Patienten wiesen nach der offen-chirurgischen Versorgung eine hoch signifikante Letalitätsreduktion auf. Daraus schlussfolgernd ist die Eignung zur endovaskulären Ausschaltung eines Aneurysmas ein hoch positiver Prädiktor für eine erhöhte Überlebenswahrscheinlichkeit nach der offen-chirurgischer Therapie.

Owing to the ongoing shortage of cadaver organs, kidneys with an atypical anatomy such as horseshoe kidneys must be considered for transplantation. Owing to its low prevalence, experience with the transplantation of a horseshoe kidney is very limited. This article reports on the transplantation of a horseshoe kidney to a 58-year-old man with renal failure from chronic glomerulonephritis. Because of a relatively thick isthmus, which indicated a complex urinary collecting and intrarenal vessel system, the kidney was transplanted en bloc. Together with optimal placement of the kidney, only adequate length and positioning of the vessels, especially the venous drainage, could prevent postoperative complications such as kinking of the vessels and thrombosis. These problems could be solved by cutting the renal veins without using a vena cava patch. Careful positioning of the kidney within the intraperitoneal cavity is also necessary. The decision to transplant the kidney en bloc or after separation depends on many factors and should be made individually.

Venous diseases are common in the general population. After a comprehensive diagnostic evaluation, an individual therapeutic approach should be selected on the basis of the findings, with the aim of treating the diseased vein segments and improving quality of life. Numerous therapeutic options are available for the treatment of varicose veins. In addition to conservative methods such as compression therapy, exercise or drugs, surgical procedures such as traditional surgery, thermal ablation techniques or sclerotherapy can be performed. Recent developments include the use of endoluminal water vapor or mechano-chemical endovenous ablation.

The long-term results of liver transplantation for Budd-Chiari syndrome (BCS) and timely indication for the procedure are still under debate. Innovations in interventional therapy and better understanding of underlying diseases have improved therapy strategies. The aim of this study was the analysis of patient and disease characteristics, outcome, and specific complications. Between September 1988 and December 2006 we performed 42 orthotopic liver transplantations (OLTs) in 39 patients with BCS. A total of 29 (74%) women and 10 men (26%) had a median age of 35 years; the median follow-up period was 96 months. Etiologically, 27 patients had a preoperative diagnosis of hematologic disease, including myeloproliferative disorders (MPD), followed by factor V Leiden mutation and antiphospholipid syndrome. The actuarial 5-year and 10-year survival rates were 89.4% and 83.5%, respectively, compared to 80.7% and 71.4%, respectively, for other indications (n = 1742). Retransplantation was necessary in 3 patients (7.1%) with portal vein thrombosis or recurrent BCS. Although the number of bleeding events was similar, incidence of vascular complications was significantly higher in patients with BCS. Thrombosis of the portal vein was observed in 4.8% versus 0.8% of the patients, whereas liver veins were affected in 7.1% versus 0.2%. Our data shows that severe acute or chronic forms of BCS with liver failure can be successfully treated by OLT. Despite higher rates of vascular complications, patient and graft survival are similar or even better compared to other indication groups. In conclusion, patients with reversible hepatic damage should be treated by combined strategies, including medical therapy and surgical or interventional shunting.

Simultaneous pancreas kidney transplantation is currently the state of the art therapy for patients with type 1 diabetes mellitus and diabetic nephropathy. Up to 30% of patients loose the pancreas with a kidney graft that continues to function. Under those conditions, isolated pancreas retransplantation can be indicated. We compared the outcome of these patients with the outcome of patients undergoing primary pancreas after kidney transplantation. From 1998 to 2005, we performed 205 pancreas transplantations. Three patients were considered for isolated pancreas retransplantation; to date, two have received a new organ. One was retransplanted twice. In two cases, the reasons for the initial graft loss in the retransplantation group were pancreatitis with hemorrhagic bleeding and in the third case severe rejection. After retransplantation two of three patients lost their graft owing to bleeding and venous thrombosis. One of three organs was successfully transplanted and the patient does not require insulin. During the same time, three pancreas after kidney transplantations were performed; all are doing well und are free of insulin. The study despite the small number of cases shows a high complication rate after pancreas retransplantation. Nevertheless, pancreatic retransplantation should be considered in selected patients.