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ZusammenfassungDie operative Behandlung thorakoabdomineller Aortenaneurysmen (TAAA) ist eine komplexe Prozedur und erfordert eine entsprechende Planung. Die TAAA werden entsprechend der Crawford-Klassifikation (Typen I bis V) eingeteilt. Typ-II-TAAA erfordern den ausgedehntesten Eingriff und weisen dementsprechend die höchste postoperative Morbidität und Mortalität auf. Die Perfusionsstrategie der Viszeralorgane und des Rückenmarks ist bei der operativen Versorgung der TAAA von zentraler Bedeutung. Die distale arterielle Perfusion, die selektive viszerale Perfusion und die additiven protektiven Maßnahmen mit Liquordrainage und hämodynamischem Management zur möglichst frühzeitigen Etablierung eines pulsatilen Flusses spielen dabei eine wesentliche Rolle. Die Techniken der extrakorporalen Zirkulation mit Herz-Lungen-Maschine oder Linksherzbypass werden mit ihren Vor- und Nachteilen diskutiert. Die Möglichkeiten zur viszeralen Organperfusion werden vorgestellt.

ZusammenfassungNeben der klinischen Tätigkeit haben an einem universitären Standort Forschung und Lehre einen großen Stellenwert. Durch die Etablierung eines neuen Forschungslabors an der Universitätsklinik für Gefäßchirurgie der Medizinischen Universität Innsbruck wurden die infrastrukturellen Voraussetzungen zur Gestaltung eines neuen Forschungsschwerpunkts geschaffen. Die Kooperation mit nationalen und internationalen Partnern war für diesen Prozess essenziell. Nicht nur in der Planung und Ausstattung der Räumlichkeiten, sondern auch in der Entwicklung von Studienprotokollen und zur kritischen Diskussion von Ergebnissen ist der Aufbau eines Netzwerkes von großer Bedeutung. Durch die Etablierung der experimentellen Gefäßchirurgie Innsbruck ist nun die Realisierung von Projekten der Grundlagenforschung und der translationalen Forschung an diesem universitären Standort möglich. Zudem spielt die Lehrforschung eine immer größere Rolle, insbesondere um die Ausbildungsstruktur möglichst praxisnah zu gestalten, Nachwuchs anzuwerben und die immer komplexer werdenden Techniken auch praxisnah zu vermitteln.

Zusammenfassung Hintergrund Die Universitätsklinik Innsbruck (Österreich) ist ein Traumazentrum mit großem Einzugsgebiet. Wir analysierten retrospektiv Aspekte der präklinischen Versorgung der PatientInnen mit traumatischen Extremitätenarterienverletzungen (Entfernung des Unfallorts, boden- vs. luftgebundener Transport, direkte vs. indirekte Einlieferung) und deren möglichen Einfluss auf Ergebnisparameter (Letalität, Extremitätenerhalt, Folgeoperationen und Länge des Krankenhausaufenthalts). Material und Methoden Retrospektive Kohortenstudie unter Einschluss aller PatientInnen mit rekonstruierten Extremitätenarterienverletzungen, die in der Zeit vom 01.01.2004 bis zum 31.12.2018 behandelt worden waren. Ausschlusskriterien waren iatrogene Gefäßverletzungen, konservativ behandelte Läsionen, mittels Ligatur oder Embolisation behandelte Läsionen und Läsionen an Seitenästen der Hauptarterien. Ergebnisse Insgesamt wurden 113 PatientInnen eingeschlossen, davon 59 an der oberen und 54 an der unteren Extremität. Unfallmechanismen waren 34,5 % Sport- und Freizeitunfälle, 23 % Arbeitsunfälle und 20,4 % Verkehrsunfälle. Der PatientInnentransport erfolgte signifikant häufiger direkt als indirekt (59,3 % vs. 40,7 %; p Schlussfolgerung Unsere retrospektive Datenanalyse zeigt, dass die Zentralisierung der Versorgung von traumatischen Extremitätenarterienverletzungen keine Nachteile für PatientInnen, aus entfernteren Landesteilen nach sich zieht. Ebenso gibt es keinen Unterschied der Ergebnisse hinsichtlich der direkten Einlieferung oder späteren Zutransferierung nach zügig durchgeführter Erstversorgung und Erstuntersuchung auswärts.

Background Guidelines for the treatment of long femoropopliteal lesions are not based on a high level of evidence and recent randomized controlled trials (RCTs) challenge vein bypass (VBP) as the recommended therapy. This study compared prosthetic (PTFE) bypass, VBP and angioplasty with nitinol stents in long femoropopliteal lesions. Methods Pooled data from a RCT and a retrospective database with the same inclusion criteria were analyzed with primary and secondary patency as well as freedom from target lesion revascularization (TLR) as primary endpoints. Results Between 2016 and 2018 a total of 172 lesions were treated in three groups (PTFE: n = 62, VBP: n = 55, stent: n = 55). Clinical and lesion characteristics were similar with mean lesion lengths between 260 and 279mm. Technical success rate in the stent group was 87%. There were no significant differences between the groups in patency rates, freedom from TLR, limb salvage and survival during 2-year follow-up. The primary patency rates for the PTFE, VBP and stent groups were 50%, 56% and 60% at 2 years. The PTFE group had significantly less complications compared to the other groups and a shorter hospital-stay compared to the VBP group. Clinical improvement was significantly better in the PTFE and VBP group compared to the stent group. Conclusions The 2-year results indicate that the role of VBP as the recommended therapy for long femoropopliteal lesions may not be unchallenged due to the similar results in all three groups. Further RCTs are needed to determine the best revascularization modality for long femoropopliteal lesions.

Purpose Vascular injuries in lower extremity trauma, especially with involvement of the popliteal artery, are associated with considerably high rates of limb loss, especially with blunt trauma mechanisms. The aim of this study was to evaluate the risk of amputation in patients with traumatic popliteal artery lesions with special focus on the validity of the Mangled Extremity Severity Score (MESS). Methods In this retrospective study, all patients treated for isolated lesions of the popliteal artery following trauma between January 1990 and December 2020 at a high-volume level I trauma center were included. Primary outcome was limb salvage dependent on MESS and the influence of defined parameters on limb salvage was defined as secondary outcome. The extent of trauma was assessed by the MESS. Results A total of 50 patients (age 39.2 ± 18.6 years, 76% male) with most blunt injuries (n = 47, 94%) were included. None of the patients died within 30 days and revascularization was attempted in all patients with no primary amputation and the overall limb salvage rate was 88% (44 patients). A MESS ≥ 7 was observed in 28 patients (56%) with significantly higher rates of performed fasciotomies (92.9% vs. 59.1%; p 0.01) in those patients. MESS did not predict delayed amputation within our patient cohort (MESS 8.4 ± 4.1 in the amputation group vs. 8.1 ± 3.8 in the limb salvage group; p = 0.765). Conclusion Revascularization of limbs with isolated popliteal artery injuries should always be attempted. MESS did not predict delayed amputation in our cohort with fasciotomy being an important measure to increase limb salvage rates.

Introduction Compartment syndrome of the lower extremity following arterial vascular trauma can cause irreversible damage to muscle as well as nerve tissue leading to long-term functional impairment of the extremity or worse limb loss. Prompt diagnosis and treatment of compartment syndrome is mandatory to preserve muscle tissue and prevent limb loss. The aim of the study was to analyze the fasciotomy rate of our patient cohort and to perform a predictors analysis for the need of fasciotomy. Material and Methods In a retrospective study all patients treated for arterial vascular trauma since 1990 were identified. Demographics, clinical data and outcome were analysed. After separation in a fasciotomy and non-fasciotomy group, a Bayes Network was used to arrive at a predictor ranking for the need of fasciotomy via a gain ratio feature evaluation. Results In the period of 28 years, 88 (73.9%) of a total of 119 patients, predominantly male (80.7%) and aged under 40 years (37.5 ± 17.5), required fasciotomy after arterial vascular trauma. Patients of the fasciotomy group presented at higher Rutherford categories (grade III 34.1% vs. 9.7%, p = 0.005), varied in terms of the type of arterial vascular injury (dissection 25% vs. 61.3%, p Conclusions Arterial vascular trauma requiring fasciotomy for compartment syndrome accounted for 73.9% of all cases. Immediate diagnosis and treatment is mandatory to prevent long-term functional impairment or limb loss. The above mentioned predictors should help identifying patients at risk for developing a compartment syndrome to provide best possible treatment.

Apart from daily clinical work and patient care, research and student teaching are essential assignments of a university hospital. The implementation of a completely new research laboratory at the Department of Vascular Surgery at the Medical University of Innsbruck led to the creation of a novel infrastructure for the design and set-up of a newly founded research focus. The cooperation with national as well as international research collaborators was essential for this process. The construction of a research network is not only important for the design and conception of a new research laboratory but also for the development of new study protocols and exchange and discussion of results. After the successful implementation of Experimental Vascular Surgery in Innsbruck, the realization of basic research projects as well as translational research projects is possible at this university location. Moreover, simulation training is an emerging field of research that aims to add more realistic surgical skills to residency programs, attract future residents and teach more complex novel techniques.

ZusammenfassungGefäßchirurgische Zentren in Österreich (n = 15) wurden Mitte April 2020 mit erklärendem Begleitschreiben des Vorstands der Österreichischen Gesellschaft für Gefäßchirurgie (ÖGG) eingeladen, an einer Onlineumfrage über die Implikationen der COVID-19-Pandemie teilzunehmen. Insgesamt 12 Zentren (80 %) haben den Fragebogen ausgefüllt.Alle Zentren waren mit positiv getesteten Patienten und 75 % auch mit positiv getesteten Mitarbeitern konfrontiert. Deutlich seltener war dies jedoch an den gefäßchirurgischen Abteilungen (positiv getestete Patienten in 25 %/Mitarbeiter in 33 %). Elektive Eingriffe wurden an allen Abteilungen entweder gestoppt (abgesagt oder verschoben) oder selektiv eingeschränkt. Dies betraf u. a. auch symptomfreie Patienten mit Karotisstenose, Aortenaneurysma kleiner 7 cm, peripherem Aneurysma, PAVK im Stadium II nach Fontaine oder Varikose. In allen Zentren wurden weiterhin uneingeschränkt gefäßchirurgische Notfälle behandelt. Uneinheitlich war das Vorgehen bei chronischen Ulzera, chronischer Mesenterialinsuffizienz, symptomfreiem Aortenaneurysma größer 7 cm und in der Shuntchirurgie.Insgesamt war v. a. die zum Zeitpunkt der OP-Verschiebungen unklare Befristung der Maßnahmen problematisch, somit war auch das Risiko der abgesagten bzw. hinausgezögerten Behandlung nicht leicht abschätzbar. Für die Indikationen mit uneinheitlichem Vorgehen sollte unizentrisch und multizentrisch das Ergebnis der Patienten analysiert werden, auch hinsichtlich der mit der Verschiebung assoziierten psychologischen Belastung. Zudem bedürfen auch die aufgrund der COVID-19-Pandemie erfolgten Veränderungen im Alltag einer kritischen Auswertung, auch hinsichtlich demografischer und geografischer Unterschiede. Es ist anzunehmen, dass die Auswirkungen der COVID-19-Pandemie langfristig bedeutsam sind.

Bei Patienten mit peripherer arterieller Verschlusskrankheit (PAVK) kommt es zu einer ischamiebedingten Myopathie mit Veranderung der Mitochondrienfunktion. Mit hochauflosender Respirometrie (HRR) kann die Mitochondrienfunktion untersucht werden. Uberblick uber In-vivo- und In-vitro-Untersuchungsmethoden der Mitochondrienfunktion. Ausfuhrliche Beschreibung der Methodik der HRR. Darstellung der mitochondrialen Veranderungen bei PAVK. Fur die HRR wird eine Muskelbiopsie von PAVK-Patienten mit Indikation zur invasiven Behandlung oder von gesunden Probanden entnommen. Der Mitochondriengehalt im M. gastrocnemius und im M. vastus lateralis wird durch die Citrat-Synthase-Aktivitat bestimmt. Die HRR zeigt die Aktivitat der mitochondrialen Atmungskette durch Messung der Abnahme der Sauerstoffkonzentration in der Reaktionskammer. Durch Zugabe von Inhibitoren oder Substraten konnen die einzelnen Komplexe der Atmungskette untersucht werden. Bei Patienten mit PAVK im Stadium IIb nach Fontaine kommt es im Vergleich zur gesunden Kontrollgruppe zu einem verminderten Mitochondriengehalt im Versorgungsgebiet der kompromittierten Arterie bei gleichzeitig erhohter Aktivitat. Diese Veranderungen sind durch Revaskularisation reversibel. HRR erlaubt die differenzierte, quantitative Untersuchung der mitochondrialen Atmungskette. Bei PAVK kommt es zu pathologischen Veranderungen der Mitochondrienfunktion, die in vitro trotz Uberangebot von Sauerstoff und Substraten bestehen und die durch eine erfolgreiche Revaskularisation reversibel sind. Die HRR kann zur Aufklarung der Pathophysiologie der PAVK beitragen.

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IntroductionAcute lower limb ischemia (ALI) is a limb- and potentially life-threatening condition which requires urgent evaluation and treatment. Contemporary data on optimal therapy and prognosis of ALI are lacking, while surgical, hybrid, and foremost endovascular techniques have rapidly evolved over the past decades. Available clinical guidelines are not based on high-level evidence and do not fully reflect day-do-day practice. Contemporary data on etiology, procedural strategies as well as patient outcomes in ALI are urgently needed to improve care and prevent limb loss. The current study was initiated by the European Vascular Research Collaborative (EVRC), established by young European vascular specialists, and aims to provide insight into contemporary treatment strategies in ALI and its clinical results within Europe. In this manuscript we report the rationale and a detailed study protocol.Material and MethodsThe proposed study is a prospective, international, multicenter, observational study on ALI (PROMOTE-ALI) (ClinicalTrials.gov - NCT05138679). Patients with ALI (Rutherford classification grade I -III) of one or both lower extremities will be included in the study. The primary endpoint of the study is amputation-free survival (AFS) at 30 d. Secondary endpoints are freedom from target limb reintervention, freedom from complications, clinical outcome of the index leg, and limb salvage and survival at 30 and 90 d after diagnosis of ALI.ConclusionsALI remains a challenging condition and due to the heterogeneous etiology, clinical presentation and treatment strategies, a large multicenter study on this topic is needed to gain contemporary data on clinical outcomes and prognosis, especially for modern endovascular techniques. PROMOTE-ALI is expected to provide these data and set a benchmark for future randomized controlled trials (RCTs).

Recent evidence demonstrates an involvement of impaired mitochondrial function in peripheral arterial disease (PAD) development. Specific impairments have been assessed by different methodological in-vivo (near-infrared spectroscopy, 31P magnetic resonance spectroscopy), as well as in-vitro approaches (Western blotting of mitochondrial proteins and enzymes, assays of mitochondrial function and content). While effects differ with regard to disease severity, chronic malperfusion impacts subcellular energy homeostasis, and repeating cycles of ischemia and reperfusion contribute to PAD disease progression by increasing mitochondrial reactive oxygen species production and impairing mitochondrial function. With the leading clinical symptom of decreased walking capacity due to intermittent claudication, PAD patients suffer from a subsequent reduction of quality of life. Different treatment modalities, such as physical activity and revascularization procedures, can aid mitochondrial recovery. While the relevance of these modalities for mitochondrial functional recovery is still a matter of debate, recent research indicates the importance of revascularization procedures, with increased physical activity levels being a subordinate contributor, at least during mild stages of PAD. With an additional focus on the role of revascularization procedures on mitochondria and the identification of suitable mitochondrial markers in PAD, this review aims to critically evaluate the relevance of mitochondrial function in PAD development and progression.

Spinal cord ischemia (SCI) is a devastating and unpredictable complication of thoracoabdominal aortic repair. Postischemic Toll-like receptor 3 (TLR3) activation through either direct agonists or shock wave therapy (SWT) has been previously shown to ameliorate damage in SCI models. Whether the same applies for pre- or postconditioning remains unclear. In a model of cultured SHSY-5Y cells, preconditioning with either poly(I:C), a TLR3 agonist, or SWT was performed before induction of hypoxia, whereas postconditioning treatment was performed after termination of hypoxia. We measured cytokine expression via RT-PCR and utilized Western blot analysis for the analysis of signaling and apoptosis. TLR3 activation via poly(I:C) significantly reduced apoptotic markers in both pre- and postconditioning, the former yielding more favorable results through an additional suppression of TLR4 and its downstream signaling. On the contrary, SWT showed slightly more favorable effects in the setting of postconditioning with significantly reduced markers of apoptosis. Pre- and post-ischemic direct TLR3 activation as well as post-ischemic SWT can decrease apoptosis and proinflammatory cytokine expression significantly in vitro and might therefore pose possible new treatment strategies for ischemic spinal cord injury.

Introduction:Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI).Materials and Methods:Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed.Results:A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI.Conclusion:Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Background & objective: Arterial vascular trauma bears a great risk of poor functional outcome or limb loss. The aim of this study was to analyze amputation rates of patients after vascular trauma and to perform a predictor analysis for the risk of major amputation. Methods: In a single-center retrospective analysis of 119 extremities treated for arterial vascular injury between 1990 and 2018 amputation rates and factors associated with limb loss were assessed. All patients were treated for traumatic vascular injuries; iatrogenic injuries were not included in the study. Results: During the study period, a total of 119 legs in 118 patients were treated after arterial vascular trauma. The in-hospital major amputation rate was 16.8% and the mortality rate was 2.5%. In the predictors analysis, vascular re-operation (amputation rate 53.8% vs 12%, odds ratio = 8.56), a Rutherford category ⩾IIb (25.4% vs 4.2%, odds ratio = 6.43), work-related or traffic accidents (28.2% vs 0%, odds ratio = 4.86), concomitant soft tissue or bone injuries (26.7% vs 7.3%, odds ratio = 4.64), polytrauma (33.3% vs 12%, odds ratio = 3.68), and blunt trauma (18.9% vs 0% for penetrating trauma, odds ratio = 1.64) were found to be associated with amputation. Conclusions: Lower extremity arterial vascular trauma was associated with a significant major amputation rate. Several predictors for limb loss were identified, which could aid in identifying patients at risk and adapting their treatment.

Although guideline recommendations have shifted towards a transradial route, femoral puncture is still an established vascular access, especially for complex coronary interventions. The FemoSeal™ vascular closure device (FVCD) helps to reduce femoral compression time and access site complications after removal of the catheter sheath. To ensure safe use, an angiography of the femoral artery prior to FVCD deployment is recommended by the manufacturer. We postulate that omitting this angiography does not relevantly increase the risk for vascular complications. In this retrospective analysis of an all-comers population (n = 1923) including patients receiving a percutaneous coronary intervention (PCI), we could show that combined vascular complication rates without femoral angiography were low (primary endpoint 4.6%) and comparable to a randomized clinical trial that did perform angiography of the vascular access site in a cohort of patients receiving diagnostic coronary angiography only. In addition to this analysis, we could demonstrate that patients with an acute coronary syndrome, receiving periprocedural anticoagulation or anti-platelet therapy had an increased risk for the formation of arterial pseudoaneurysms; however, we did not observe any ischemic vascular event after FVCD deployment. Closure of the femoral access site after coronary angiography using the FVCD can be safely performed without femoral angiography; however, due to an increased risk for the formation of pseudoaneurysms we recommend the transradial access in situations with increased bleeding risk.

Objective Myopathy, characterised by altered mitochondrial function, is a central part of the pathophysiology of peripheral arterial disease and the aim of this study was to investigate the effect of revascularisation on mitochondrial function. Methods High resolution respirometry was used to investigate mitochondrial respiration and the results were normalised to citrate synthase activity (CSA), a marker of mitochondrial content. Ten patients with symptomatic peripheral arterial disease (study group) and 10 subjects without ischaemia (control group) were included. Ankle brachial index and ultrasound imaging were performed before and after vascular intervention to confirm technically successful revascularisation. Within the study group, muscle biopsies from the gastrocnemius muscle were taken before vascular intervention and six weeks after revascularisation. Within the control group, tissue was harvested once. Results There were no significant group differences regarding anthropometric data. CSA showed a significant increase after successful revascularisation (CSA pre-operative 281.4 (252.4–391.8) nmol/min/mg protein vs. CSA post-operative 438.5 (361.4–471.3) nmol/min/mg protein; p = .01) with post-operative return of values to the range of control subjects (CSA control 396.6 (308.2–435.9)). Mitochondrial respiration normalised to CSA in oxidative phosphorylation (P) as well as in electron transfer (E) capacity were significantly reduced post-operatively when compared with pre-operative values (P pre-operative 0.218 (0.196–0.266) pmol/(sec×mg) per CSA vs. post-operative 0.132 (0.116–0.150) pmol/(sec×mg) per CSA, p = .007; E pre-operative 0.230 (0.195–0.279) pmol/(sec×mg) per CSA vs. post-operative 0.129 (0.120–0.154) pmol/(sec×mg) per CSA, p = .005) meaning a post-operative return of values to within the range of control subjects (P control 0.124 (0.080–0.155) pmol/(sec×mg) per CSA; E control 0.121 (0.079–0.125) pmol/(sec×mg) per CSA). Conclusion With these results, it has been shown that the initially impaired mitochondrial function and content can normalise after revascularisation.

Due to an increase in the number of performed endovascular procedures, the number of local access site complications is rising too. Used mainly for treatment of peripheral arterial disease and coronary heart disease, endovascular procedures are gaining importance. Access site complications include bleeding, haematoma, pseudoaneurysm, arteriovenous fistula and arterial thrombosis. Aiming to reduce immobilisation, length of hospital stay, costs and access site complications, vascular closure devices (VCD) were introduced in the mid 1990s, but current trials failed to demonstrate the superiority of these devices compared to conventional manual compression if it comes to access site complications. We retrospectively evaluated all patients who were treated surgically due to access site complications between 2001 and 2012 in our institution. In total, 522 patients needed vascular surgery to treat different access site complications. During this period, 90,538 percutaneous interventions were performed in our institution, leading to a total incidence of 0.58 % of access site complications. Depending on the frequency of application of VCDs, patients have been grouped in groups A-C. With the more frequent use of VCDs, the incidence of access site complications increased and, in particular, ischaemic complications were seen more often. In conclusion, the application of VCDs to prevent access site complications is questionable and not justified when looking at published data.

We report a 19-year-old man with rupture of the right subclavian artery after an excessive exercise of weight lifting. Imaging showed a hematothorax and hematomediastinum, a pseudoaneurysm with a maximum diameter of 4 cm, and a dissection of the right vertebral artery. As an emergency procedure an interposition graft was performed for reconstruction of the right subclavian artery. The patient's postoperative course was uneventful, and he was symptom free except for regressive hoarseness due to a paresis of the right recurrent laryngeal nerve.

A 6.5-cm asymptomatic infrarenal aortic aneurysm was detected by contrast-enhanced computed tomography (CT) scan in a 70-year–old patient. Initially, there were no signs of aortic or periaortic inflammation (Figure 1), and complete blood cell count, renal function, and C-reactive protein levels were normal. Aneurysm repair was indicated, and the patient underwent endovascular aneurysm repair using an aorto-bi-ilac stent graft (Endurant II, Medtronic Inc, Minneapolis, MN). Routine follow-up contrast-enhanced CT scan was performed on the third postoperative day and showed correct stent graft position without evidence of abnormalities (Figure 2). At routine follow-up after 3 months, the patient …

We thank Kakkos et al for their interest in our case report entitled “Periaortitis as a Rare Complication After Endovascular Aneurysm Repair.”1 Information concerning secondary periaortitis after stent graft implantation in humans is indeed rare, and only 6 cases have been published so far,2–5 although a huge number of endovascular aneurysm repair procedures are performed worldwide. Interestingly, there are similarities in all reported …

Objective: Vascular access site complications (ASCs) are an ongoing hazard of percutaneous interventions (PI). We analyzed incidence, indication, and results of operative repair of access site complications leading to acute limb ischemia (ALI) or new-onset severe claudication (CI) in our institution during an 8-year period. Methods: Retrospective analysis: demographic parameters, details of coronary or vascular intervention, use of a vascular closure device (VCD), clinical presentation, diagnosis and therapy. Endpoints: perioperative outcome (death, limb loss, and need for re-operation/intervention) and length of hospital stay. For comparison of annual operation rates, patients were grouped by the years 2001 to 2004 (no use of VCD) and 2005 to 2008 (selective use of a VCD; in all cases: Angio-Seal), and Chi-Square-test was applied. Results: Fifty-one patients (19 female; median age: 64.5 years) underwent repair of arterial ASCs causing ALI (n = 32) or new-onset severe CI (n = 19) after 58,453 catheter interventions (overall rate: 0.087%; ALI: 0.055%; CI: 0.032%). Corresponding with more widespread VCD use, the annual number of ALI and new onset CI increased significantly (P < 0.001). Perioperative outcome: 30 day mortality was 4%. No limb loss occurred. Re-operations were indicated in 10 patients (20%) for: hematoma (n = 5), local infection (n = 3), revision of fasciotomy (n = 1), and repeated thrombectomy (n = 1). Median length of postoperative hospital stay: 7 days (range: 1–28). Conclusion: ALI and new-onset severe CI due to access site complications after PI are rare, however, they are potentially threatening life and limb. The use of VCDs results in an overall increase of ischemic complications. © 2011 Wiley Periodicals, Inc.

The Nellix aneurysm sealing system aims at sealing the cavity of the sac of the aneurysm, to reduce typical complications such as migration or endoleak. We report on a case of a unique device-associated complication: rupture and displacement of the filling material into the aortic lumen, causing peripheral ischemia and imminent renal and visceral occlusion, in a patient with anastomotic ulcer after an open aortobiiliac bypass and calcified and tortuous iliac arteries. The material was removed by open surgery. The patient recovered completely. The device should be handled with great caution in cases with hostile access routes, and in secondary interventions.

Pseudoaneurysms (PAs) of crural arteries represent rare complications of vascular interventions or surgery. Management of crural PAs includes different treatment options, conservative treatment as well as open surgery or endovascular procedures. We reviewed our experience.We retrospectively analysed all patients who were diagnosed with crural PAs since 2003. We evaluated etiology, treatment and outcome. Endpoints were target vessel patency, vascular re-intervention and limb loss.A total of 30 patients were diagnosed with crural PAs. PA was caused by vascular intervention in 27 patients (90 %): open balloon thrombectomy (n = 25), subfascial endoscopic perforator vein surgery (n = 1) and transcutaneous catheter-assisted thrombus aspiration (n = 1). In 3 patients (10 %) it was caused by orthopaedic surgical procedures. Location of crural PAs were peroneal artery (n = 11; 36.7 %), posterior tibial artery (n = 10; 33.3 %), anterior tibial artery (n = 5; 16.7 %), and tibioperoneal trunk (n = 4; 13.3 %). Treatment of crural PAs included open surgery (n = 3; 10 %), endovascular procedures (n = 13; 43.3 %) such as endograft implantation (n = 9) or coil embolisation (n = 4), and conservative management (n = 14; 46.7 %). After a median follow-up period of 7 months (range: 0 - 46 months) 8 of 9 endografts were occluded, in none of these patients a minor or a major amputation was necessary. None of the surgically, endovascularly and conservatively treated patients needed a re-intervention for crural PA. A major amputation was necessary in 4 patients due to progression of peripheral arterial disease; none was a directly consequence of the crural PA.Crural PAs are mainly caused by vascular intervention, most frequently by catheter thrombectomy. As a consequence, we recommend fluoroscopic-assisted balloon thrombectomy over a guide wire as routine technique. In many cases of crural PAs, conservative management is sufficient. The choice of treatment of crural PAs depends on size, location and associated symptoms. Endovascular treatment using endografts is limited by poor long-term patency.Hintergrund: Iatrogen verursachte Pseudoaneurysmen (PA) der cruralen Arterien stellen eine seltene Komplikation von gefäßmedizinischen Interventionen dar. Zur Therapie kommen ein konservatives Management, offen chirurgische Maßnahmen und endovaskuläre Methoden in Frage. Patienten und Methoden: Wir haben mit einer retrospektiven Datenanalyse aller Patienten, bei denen seit 2003 ein iatrogen bedingtes PA der cruralen Arterien an unserer Klinik diagnostiziert wurde, Ätiologie, Therapie und Therapieergebnis analysiert. Endpunkte der Studie waren die Offenheitsrate der betroffenen Arterien, Re-Interventionen und Extremitätenverlust. Ergebnisse: Insgesamt wurde bei 30 Patienten ein PA der cruralen Arterien diagnostiziert. Bei 27 Patienten (90 %) war das PA durch eine gefäßmedizinische Intervention bedingt: Katheterthrombektomie (n = 25), endoskopische Ligatur einer Perforansvene (n = 1) und perkutaner Aspirationsversuch eines Thrombus (n = 1) waren ursächlich für das PA. Bei den verbleibenden 3 Patienten (10 %) wurde das PA durch einen orthopädischen Eingriff verursacht. Lokalisation der PAs waren die A. fibularis (n = 11; 36,7 %), A. tibialis posterior (n = 10; 33,3 %), A. tibialis anterior (n = 5; 16,7 %) und der Truncus tibiofibularis (n = 4; 13,3 %). Therapiert wurde in 3 Fällen (10 %) offfen chirurgisch, bei 13 Patienten (43,3 %) wurde endovaskulär behandelt und bei 14 Patienten (46,7 %) war ein konservatives Procedere ausreichend. Bei den 13 endovaskulär behandelten Patienten wurde bei 9 Patienten ein Endograft implantiert und bei 4 Patienten wurde der betroffene Gefäßabschnitt embolisiert. Nach einem medianen Nachkontrollzeitraum von 7 Monaten (Range 0 - 46 Monate) zeigten sich 8 der 9 Endografts verschlossen und bei keinem dieser Patienten wurde eine Amputation der betroffenen Extremität erforderlich. Bei keinem der Patienten war eine Re-Intervention notwendig. Bei 4 Patienten wurde im weiteren Verlauf der peripheren arteriellen Verschlussskrankheit eine Major-Amputation notwendig. Schlussfolgerungen: Iatrogen bedingte PAs der cruralen Gefäße sind zumeist durch gefäßmedizinische Interventionen bedingt, überwiegend durch Katheterthrombektomien. Um diesen Komplikationen vorbeugen zu können, ist ein drahtgestützes Vorgehen unter Bildwandlerkontrolle zu empfehlen. Häufig war ein konservative Therapie ausreichend, wobei die Wahl der Therapie abhängig ist von Größe, Lokalisation und Symptomen der PAs. Eine endovaskuläre Therapie von cruralen PA mittels Endograft-Implantation führte nicht zu den erhofften Langzeitoffenheitsraten.

Objective Experimental coarctation of the aorta prevents the development of downstream atherosclerosis. The aim of this study was to find out whether or not atherosclerotic stenoses protect distal vascular territories from developing atherosclerosis in humans. Design and setting A total of 2125 vascular segments from angiographies of 101 patients were evaluated by calculating the maximum degree of stenosis (NASCET criteria), the degree of calcification, the degree of collaterals and the Friesinger score. Results Stenosis ≥30–49% was found in 685 vascular segments (32.2%), ≥50–69% in 490 (23.1%), ≥70–89% in 373 (17.6%) and ≥90% in 265 (12.5%). If a stenosis of at least ≥70–89% was present in the common iliac, the external iliac or the common femoral artery, the degrees of stenosis distal to it were lower than those on the contralateral side (19.8±22.3% (CI 11.7 to 28.0) vs 25.2±20.7% (CI 21.2 to 29.1); Friesinger scores 1.1±1.2 (CI 0.6 to 1.5) vs 1.4±1.1 (CI 1.2 to 1.6); degrees of calcification 0.8±1.0 (CI 0.4 to 1.1) vs 1.2±1.1 (CI 1.2 to 1.6); p

AimThe study aimed to evaluate vascular access site complications (ASCs) after percutaneous interventions (PIs) in our institution for changes in annual incidence and surgical management after increased usage of a vascular closure device (VCD; in all cases: Angioseal™).Material and MethodsAll patients who underwent repair of arterial pseudo-aneurysms or access site stenosis/occlusion leading to leg ischaemia (LI) or new-onset disabling claudication (CI) after PIs between 2001 and 2008 were included. Annual rates of procedures and methods of repair of ASC were evaluated.ResultsAfter a total of 58 453 PIs, 352 patients (0.6%) were operated on for: pseudo-aneurysms (n = 300; 0.51%); and local stenosis/occlusion leading to LI/CI (n = 52; 0.09%). Numbers increased significantly with more widespread VCD use: group A (2001–2004: 2860 VCDs; 28 284 PIs; 10.1%): n = 132 (0.47%); and group B (2005–2008: 11,660 VCDs; 30,169 PIs; 38.6%): n = 220 (0.73%) (p