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Introduction: Visceral artery aneurysms (VAAs) are rare but have a high mortality rate in cases of rupture, especially for pancreaticoduodenal artery aneurysms (PDAAs). A hybrid approach is presented for a challenging case with inferior PDAA (iPDAA) with concomitant coeliac artery (CA) occlusion and a variant arterial supply to the liver. Report: A 61 year old patient complained of postprandial pain associated with elevated liver enzymes and impaired hepatic synthesis capacity. The left hepatic artery (LHA) originated from an occluded CA, whereas the right hepatic artery (RHA) originated directly from the superior mesenteric artery (SMA) proximal to the iPDAA. Due to the anatomical variant, an endovascular only approach via iPDAA embolisation could have posed a critical risk to the arterial supply of the liver. Therefore, the initial plan was to first secure liver perfusion via endovascular revascularisation of the CA, before conducting a coil embolisation of the iPDAA. However, endovascular CA revascularisation failed due to a complete and fixed occlusion. As an alternative therapeutic approach, open surgical aorto-visceral autologous bypass ensured arterial supply of the liver, which now enabled safe exclusion of the iPDAA via interventional coil embolisation. This two stage hybrid strategy resulted in iPDAA exclusion and was followed by symptom relief and normalised hepatic synthesis capacity. Discussion: This case demonstrates the continued need for open visceral bypass surgery to ensure organ perfusion, if the latter depends on an aneurysmal artery. In such a situation, visceral bypass surgery can be considered in challenging anatomical scenarios, which demonstrates the relevance of endovascular and open procedures. In conclusion, both procedures can be combined in individualised therapy approaches to maximise patient benefit.

Background/Objectives: Patient-specific diagnostic and therapeutic approaches are important in the care of people with chronic wounds. The heterogeneity of underlying disease profiles and the diversity of the wound micro-environment make generalized approaches difficult. While high-throughput molecular diagnostic methods are increasingly widespread and available, the analysis of objective biomolecular disease patterns has not found its way into everyday wound management. The aim of this study is to evaluate the use of wound swab samples for the analysis of biomarkers and disease patterns in people with chronic wounds. Methods: A sample cohort from the multicenter “Wound-BIOME” project was analyzed. The project aims to comprehensively investigate the local micro-environment of chronic wounds of various entities, healing tendencies and regeneration stages at the biomolecular level. A sample collection and handling protocol suitable for everyday use was tested and evaluated regarding feasibility for multiplex immunoassay, proteomics, small RNA sequencing (miRNA) and metagenome analyses (microbiomics). Results: It could be shown that standard wound swabs are well-suited for the analysis of the complex wound micro-environment using various high-throughput methods. Despite the sample heterogeneity, the quality was adequate to analyze biomolecular patterns. Conclusions: Initial analyses of protein signatures, microbial wound communities and miRNA patterns show promising results for future individualized diagnostics and targeted interventions.

Abstract Background Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis, bleeding, and possible leg amputation. Current data on irradiation of lymphatic fistulas lack recommendation on the appropriate individual and total dose, the time of irradiation, and the target volume. Presumably, a dose of 0.3–0.5 to 1–12 Gy should be sufficient for the purpose. Currently, radiotherapy is a “can” recommendation, with a level 4 low evidence and a grade C recommendation, according to the DEGRO S2 guidelines. As part of a pilot study, we analyzed the impact and limitations of low-dose radiation therapy in the treatment of inguinal lymphatic fistulas. Patients and methods As a part of an internal quality control project, patients with lymphatic fistulas irradiated in the groin area after vascular surgery for arterial occlusive disease (AOD) III-IV, repair of pseudo aneurysm or lymph node dissection due to melanoma were selected, and an exploratory analysis on retrospectively collected data performed. Results Twelve patients (10 males and 2 females) aged 62.83 ± 12.14 years underwent open vascular reconstruction for stage II (n = 2), III (n = 1), and IV (n = 7) arterial occlusive disease (AOD), lymph node dissection for melanoma (n = 1) or repair of a pseudoaneurysm (n = 1). Surgical vascular access was obtained through the groin and was associated with a persistent lymphatic fistula, secreting more than 50 ml/day. Patients were irradiated five times a week up to a maximum of 10 fractions for the duration of the radiation period. Fraction of 0.4 Gy was applied in the first 7 cases, while 5 patients were treated with a de-escalating dose of 0.3 Gy. There was a resolution of the lymphatic fistula in every patient without higher grade complications. Conclusion Low-dose irradiation of the groin is a treatment option for persistent lymphatic fistula after inguinal vascular surgery.

Background: For (thoracic) endovascular aortic repair ((T)EVAR) procedures, both mobile (standard operating room (SOR)) and fixed C-arm (hybrid operating room (HOR)) systems are available. This study evaluated differences in key procedural parameters, and procedural success for (T)EVAR in the SOR versus the HOR. Methods: All patients who underwent standard elective (T)EVAR at the Clinic for Vascular and Endovascular Surgery at the University Hospital Duesseldorf, Germany, between 1 January 2012 and 1 January 2019 were included. Data were retrieved from archived medical records. Endpoints were analyzed for SOR versus HOR during (T)EVAR. Results: A total of 93 patients, including 50 EVAR (SOR (n = 20); HOR (n = 30)) and 43 TEVAR (SOR (n = 22); HOR (n= 21)) were included. The dose area product (DAP) for EVAR and TEVAR was lower in the SOR than in the HOR (EVAR, SOR: 1635 ± 1088 cGy·cm2; EVAR, HOR: 7819 ± 8928 cGy·cm2; TEVAR, SOR: 8963 ± 34,458 cGy·cm2; TEVAR, HOR: 14,591 ± 11,584 cGy·cm2 (p < 0.05)). Procedural fluoroscopy time was shorter in the SOR than in the HOR for EVAR and TEVAR (EVAR, SOR: 7 ± 4 min; EVAR, HOR: 18.8 ± 11.3 min; TEVAR, SOR: 6.6 ± 9.6 min; TEVAR, HOR: 13.9 ± 11.8 min (p < 0.05)). Higher volumes of contrast agent were applied during EVAR and TEVAR in the SOR than in the HOR (EVAR, SOR: 57.5 ± 20 mL; EVAR: HOR: 33.3 ± 5 mL (p < 0.05); TEVAR; SOR: 71.5 ± 53.4 mL, TEVAR, HOR: 48.2 ± 27.5 mL (p ≥ 0.05). Conclusion: The use of a fixed C-arm angiography system in the HOR results in higher radiation exposure and longer fluoroscopy times but lower contrast agent volumes when compared with mobile C-arm systems in the SOR. Because stochastic radiation sequelae are more likely to be tolerated in an older patient population and, in addition, there is a higher incidence of CKD in this patient population, allocation of patients to the HOR for standard (T)EVAR seems particularly advisable based on our results.

Gelatin-based hemostats have been used in various surgical fields and showed advantageous effects on central aspects of wound healing when compared to cellulose-based hemostats. Nevertheless, the influence of gelatin-based hemostats on wound healing has not been fully explored yet. Hemostats were applied to fibroblast cell cultures for 5, 30, 60 min, 24 h, 7 and 14 days and measurements were taken at 3, 6, 12, 24 h and 7 or 14 days, respectively. Cell proliferation was quantified after different exposure times and a contraction assay was conducted to measure the extent of the extracellular matrix over time. We further assessed quantitative levels of vascular endothelial growth factor and basic fibroblast growth factor using enzyme-linked immunosorbent assay. Fibroblast counts decreased significantly at 7 and 14 days independent of the application duration (p < 0.001 for 5 min application). The gelatin-based hemostat did not have a negative impact on cell matrix contraction. After application of gelatin-based hemostat, the basic fibroblast growth factor did not change; yet, the vascular endothelial growth factor significantly increased after a prolonged 24 h application time when compared to controls or to a 6 h exposure (p < 0.05). Gelatin-based hemostats did not impair contraction of the extracellular matrix or growth factor production (vascular endothelial growth factor and basic fibroblast growth factor), while cell proliferation diminished at late time points. In conclusion, the gelatin-based material seems to be compatible with central aspects of wound healing. For further clinical assessment, future animal and human studies are necessary.

Introduction Oxidized regenerated cellulose-based (ORC – TABOTAMP), oxidized non-regenerated cellulose-based (ONRC – RESORBA CELL), and gelatin-based (GELA – GELITA TUFT-IT) hemostats are commonly used in surgery. However, their impact on the wound healing process remains largely unexplored. We here assess time-dependent effects of exposure to these hemostats on fibroblast-related wound healing processes. Material and methods Hemostats were applied to fibroblast cell cultures for 5–10 (short-), 30 and 60 min (intermediate-) and 24 h (long-term). Representative images of the hemostat degradation process were obtained, and the pH value was measured. Cell viability, apoptosis and migration were analyzed after the above exposure times at 3, 6 and 24 h follow-up. Protein levels for tumor necrosis factor α (TNF-α) and transforming-growth factor β (TGF-β) were assessed. Results ORC and ONRC reduced pH values during degradation, while GELA proved to be pH-neutral. Hemostat structural integrity was prolonged for GELA (vs. ORC and ONRC). TGF-β and TNF-α levels were reduced for ORC and ONRC (vs. GELA and control) (p < 0.05). Further, exposure of ORC and ONRC for longer than 5–10 min reduced cell viability vs. GELA and control at 3 h post-exposure (p < 0.05). Similarly, cell migration was impaired with ORC and ONRC exposure longer than 60 min at 24 h follow-up (p < 0.05). Conclusions Short-term exposure to ORC and ONRC impairs relevant wound healing-related processes in fibroblasts, and alters protein levels of key mediating cytokines. GELA does not show similar effects. We conclude that GELA may be preferred over ORC and ONRC over short-, intermediate- and long-term exposures. Future validation of the clinical relevance is warranted.