[Show abstract][Hide abstract] ABSTRACT: to determine if local, in addition to systemic antibiotic prophylaxis (compared to that provided by systemic prophylaxis alone) provides additional benefit in terms of reducing graft infection.
gelatin-sealed Dacron grafts were interposed in the infrarenal aorta of 36 mongrels and inoculated with 1 ml of a S. aureus suspension. Group 1 (control group) received no prophylaxis and were inoculated with 1 ml containing 10(9)cfu/ml. Group 2 (n=6) received systemic prophylaxis (1 g cephamandole) and were inoculated with 10(5) cfu/ml (n=3) or 10(7) cfu/ml (n=3). Group 3 received systemic prophylaxis (1 g cephamandole) and were inoculated with 109 cfu/ml. Group 4 received systemic prophylaxis (2 g cephamandole) and were inoculated with 10(9)cfu/ml. In group 5 and 6 grafts were soaked in a rifampicin solution before use and inoculated with 10(9) cfu/ml. Group 5 received no systemic prophylaxis and group 6 received systemic prophylaxis (1 g cephamandole). Grafts were harvested at 2 weeks, and peritonitis, perigraft abscess, anastomotic disruption and graft occlusion recorded. Swabs were taken of the graft, the perigraft tissues and the peritoneal fluid. Graft segments were incubated in broth medium.
inoculation with 10(9) cfu/ml ensured graft infection. Systemic or local prophylaxis alone failed to prevent graft infection. Only systemic and local antibiotic prophylaxis provided significant better results than no prophylaxis at all (p<0.01) and local prophylaxis alone (p<0.05). However, total "graft sterility" was not achieved as bacteriologic analysis of the graft segments showed low bacterial counts (<10 bacteria/graft) in 5 of 6 grafts.
local and systemic prophylaxis provided more protection as demonstrated by the significant decrease in the incidence of "overt" graft infection. Total "graft sterility" cannot be expected in the case of an overwhelming bacterial challenge.
European Journal of Vascular and Endovascular Surgery 02/2002; 23(2):127-33. DOI:10.1053/ejvs.2001.1571 · 3.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Einleitung: Mit der vorliegenden Studie soll die Leistungsfähigkeit der Gefäßchirurgie bei der Behandlung von Aneurysmen der A. poplitea
(PAA) und gleichzeitig die Berechtigung einer konservativen Therapie beleuchtet werden. Patientengut und Methoden: Von 1/1985 bis 12/1996 wurden 87 Patienten wegen PAA operiert. Die Krankenunterlagen wurden retrospektiv analysiert und die
Patienten zu einer Nachuntersuchung eingeladen, wobei durch Pulstastbefund und Dopplersonographie die Funktionstüchtigkeit
der Gefäßrekonstruktionen geprüft wurde. Mittels der Krankenunterlagen wurden die Patienten hinsichtlich Gefäßausstrombahn,
Symptomatik und Gefäßersatzmaterial kategorisiert und ein Vergleich zum Nachuntersuchungsergebnis angestellt. Ergebnisse: Die nach Kaplan-Meier berechnete kumulative Überlebensrate war 70% nach 10 Jahren. Die asymptomatischen Patienten zeigten
die besten, die Patienten mit akuter Ischämie die schlechtesten Resultate. Im gleichen Sinne waren die Ergebnisse bei erhaltener
Gefäßausstrombahn bzw. verschlossener Ausstrombahn sowie bezüglich der Verwendung autologen und heterologen Gefäßersatzmaterials.
Schlußfolgerung: Schon bei asymptomatischen und vaskulär unkomplizierten PAA sollte die Operationsindikation gestellt werden. Nur bei PAA
unter 2 cm Durchmesser und ohne Thrombussaum besteht eine Indikation zur konservativen Therapie.
Introduction: The efficacy of vascular surgery in the treatment of popliteal arterial aneurysms (PAA) and the justification of conservative
therapy was investigated in the present study. Materials and methods: From January 1985 to December 1996, 87 patients were operated on for PAA. The clinical records were reviewed retrospectively
and patients were categorized concerning PAA-related symptoms, vascular run-off, and material used for vascular reconstruction.
Patients were examined, and the patency of the vascular reconstruction was checked by palpation and Doppler sonography. Results: The cumulative survival calculated using the Kaplan-Meier curve was 70% after 10 years. Asymptomatic patients had the best
results and patients with acute ischemia, the worst. The outcome concerning patent vs. occluded run-off and autologous vs.
heterologous bypass material was similar. Conclusion: Asymptomatic and uncomplicated PAA should be treated surgically. Only PAA with a diameter less than 2 cm, and without thrombus
on the vessel walls can be treated conservatively.
[Show abstract][Hide abstract] ABSTRACT: Zusammenfassung Die Thrombose der unteren Hohlvene wird als selten angesehen. Bevorzugtes therapeutisches Vorgehen ist die Antikoagulation,
nicht selten kombiniert mit der Implantation von Cavaschirmfiltern. Die venöse Thrombektomie ist nur sehr selten beschrieben
Material und Methode: 70 Patienten (35 Frauen, 35 Männer, mittleres Alter 36 ± 17,2 Jahre, 11–73 Jahre) mit Thrombose der unteren Hohlvene (unilateral
+ V. cava 36, bilateral 30, andere 4) wurden mittels transperitonealer Cavathrombektomie und/oder transfemoraler venöser Thrombektomie
in einem 15-Jahres-Zeitraum behandelt. Die wahrscheinliche Thromboseursache konnte in 78,6% nachgewiesen werden; 3 Patienten
litten unter einer septischen Thrombose, einer an einer Phlegmasia coerulea dolens. Zuvor war in 25,7% eine aggressive Vorbehandlung
erfolgt; 32 Patienten (45,7%) hatten bereits vor Zuweisung eine Lungenembolie erlitten.
Frühergebnisse: Bei 64 Patienten wurde eine transfemorale Thrombektomie mit AV-Fistel-Anlage vorgenommen, ein zusätzlicher transabdomineller
Zugang erfolgte in 41 Fällen. Bei 6 Patienten erfolgte eine isolierte Cavathrombektomie. 3 Patienten verstarben perioperativ
(4,3%). Eine intraoperative Lungenembolie wurde bei 3 Patienten angenommen, wovon einer verstarb. Eine frühe unilaterale Rethrombosierung
wurde in 16 Fällen festgestellt, wovon 12 erneut thrombektomiert wurden (9 erfolgreich). Eine Cavaoffenheitsrate von 87,1%
konnte postoperativ erzielt werden.
Spätergebnisse: 58 Patienten (82,9%) konnten im Verlauf beobachtet werden (mittlere Beobachtungszeit 44 ± 35 bzw. 3–120 Monate). 3 Patienten
waren während der Beobachtungszeit verstorben. Bei 47 Patienten (69 Extremitäten, >1 Jahr postoperativ) wiesen 17,4% der Extremitäten
keine Beschwerden auf, 40,6% zeigten ein leichtes PTS, 30,4% ein mittelschweres PTS und 11,6% ein schweres PTS (Ulcus cruris
Schlußfolgerung: Die Thrombose der unteren Hohlvene ist selten, stellt jedoch infolge eines hohen Embolierisikos eine bedrohliche Situation
dar. Die transabdominelle und/oder transfemorale Thrombektomie (mit AV-Fistel) ist eine sichere, indizierte und gelegentlich
eine lebensrettende Maßnahme. Die Offenheit der Hohlvene kann in den meisten Fällen erreicht werden. Das intraoperative Embolierisiko
ist gering. Die Spätergebnisse sind zufriedenstellend. Die Langzeitoffenheitsrate ist gut, periphere venöse Stauungsbeschwerden
sind nicht selten.
[Show abstract][Hide abstract] ABSTRACT: The authors report a rare, recently diagnosed and atypical mishap during one-lung ventilation (OLV) via a double lumen tube (DLT) and left-sided thoracotomy: an ipsilateral pneumothorax during ventilation of the right lung. This occurred in a 63-year-old patient with chronic obstructive airway disease who was scheduled for urgent repair of a descending thoracic aortic aneurysm. Anaesthesia and surgery were uneventful until aortic cross-clamping release. The common presentation of increased intrathoracic extrapleural pressure owing to a pneumothorax in patients with mechanically ventilated lungs is a rapid decrease in oxygen saturation, followed or paralleled by haemodynamic deterioration. Although the above presentation could be seen in this case, the diagnosis of a tension pneumothorax was delayed twice. First, symptoms were initially obscured by haemodynamic changes resulting from a head-down tilt and aortic declamping. Second, since the lack of consolidation after aortic declamping focused attention on the airway problems, complications resulting from the use of a DLT were primarily considered. In particular, since breathing sounds were detectable initially, malposition or torsion of the DLT had to be excluded by fibre-optic bronchoscopy, which involved a further delay. Finally, two observations led to the diagnosis of a right-sided tension pneumothorax: (1) bullae of the contralateral lung, detected during thoracotomy; (2) the finding that ventilation of both lungs and the left lung subsequently increased arterial (SaO2) and mixed venous oxygen saturation (SvO2) and the circulatory status, but ventilation of the right lung caused a deterioration. Chest radiography and insertion of a chest tube with drainage of air, thereafter, validated our hypothesis. The time course of oxygen desaturation during OLV and tension pneumothorax was as severe as expected; the time course of haemodynamic deterioration, however, appeared quicker and had more impact than expected. Assuming that mediastinal deviation was not hindered by contralateral intrathoracic pressure during thoracotomy, we believed that circulation should be depressed later or to a lesser extent in patients with an intraoperative pneumothorax. Yet, during thoracotomy, decrease in cardiac filling and output during tension pneumothorax in OLV obviously results primarily from the immovability of the mediastinum owing to mediastinal fixation and is at least as decisive as the contralateral intrathoracic pressure in closed-chest patients. In summary, a tension pneumothorax during one-lung ventilation and thoracotomy is a rare, but disastrous complication during the use of a DLT, which has not, to our knowledge, been reported previously. We recommend that tension pneumothorax be added to the list of complications and problems during OLV by the use of a DLT, especially in patients with structural lung diseases.
Der Anaesthesist 02/1997; 46(1):43-5. · 0.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Zusammenfassung
Die Verwendung von Doppellumentuben zur Einlungenbeatmung bei Eingriffen an der thorakalen Aorta hat die Inzidenz von Lungentraumen
gesenkt und die Operationsbedingungen verbessert. Intubationsschwierigkeiten des linken Hauptbronchus, insbesondere bei großen
Aortenaneurysmen, und Beatmungsprobleme infolge Dislokation während der Operation sind bekannte Verfahrensnachteile. Im vorliegenden
Fallbericht wird über einen ipsilateralen Pneumothorax bei Einlungenbeatmung berichtet, dessen Diagnose und definitive Therapie
verzögert wurde durch einen operationsspezifischen Blutdruck- und Sauerstoffsättigungsabfall infolge Aortenfreigabe und durch
ein verfahrensspezifisches Problemlösungsverhalten (Bronchoskopie bei vermeintlicher Tubusfehllage). Eine für den Patienten
kritische Hypoxämie konnte durch Beatmung der anderen Lunge verhindert werden.
Der Anaesthesist 01/1997; 46(1):43-45. DOI:10.1007/s001010050370 · 0.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: From January 1, 1980 to December 31, 1992, 7970 vascular prostheses have been implanted at the Department for Vascular Surgery and Kidney Transplantation of the University of Düsseldorf. In the same period of time, 99 patients had to be reoperated for (type Szilagyi III ) graft infection (1,2%), out of which 70 patients have had their previous operation in our institution (0,9%). The infection became apparent within 30 days in 14 cases, within one year in 54 cases, and in 31 cases within a maximum of 8 years postoperatively. Localisation of the infection was the groin in 70 patients, abdominal aortic prostheses were involved in 16, crural or extraanatomic prostheses in 13 cases. Treatment consisted in most cases of axillofemoral bypass (n = 23) and obturator-bypass (n = 21). In-situ-implantation of vascular prostheses was performed in 8 cases, 4 of these prostheses were intraoperatively soaked with an antibiotic. 47 patients had various reconstructions, such as cross-over bypasses, atypical reconstructions or local treatment. Postoperatively 27 amputations were necessary. 30-days mortality rate was 12%. At the end of the follow-up (May 1994) we found a 54% total mortality rate (mean follow-up: 4.6 +/- 4.59 years). Main cause of death in the first year was sepsis. In only 67% of patients discharged from hospital, the peripheral arterial conditions were described as "good" by angiography, ankle-brachial index or clinical examination. We conclude, that vascular graft sepsis threatens the patient in the early phase because of limb loss or death, and during the first year after the operation for the sequelae of sepsis or recurrence. Revascularisation with antibiotic-soaked grafts in a limited number of cases showed good results in preserving limbs and lives of our patients. Future experience will show, whether antibiotic-soaked grafts should be used more generously in vascular surgery.
Der Chirurg 02/1996; 67(1):37-43. · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For validation of differential renal vein renin determinations in the diagnosis of renovascular hypertension (RVH), we investigated 102 patients suspected of suffering from RVH before and 1 h after administration of 25 mg captopril. Sensitivity, specificity and posterior probability for renin ratio (RR) and renin secretion (RS) were calculated based on 44 patients with proven RVH and 58 patients with primary hypertension (PH) using discriminant analysis. There is good (> 95%) and identical specificity of both variables under all conditions, whereas sensitivity remains poor even after Captopril administration (RR 23% vs. 32%; RS 20% vs. 34%). The posterior probabilities obtained by discriminant analysis revealed a cut-off point of 2.5 for the renin ratio and of 1.9 for the renin secretion. No change is observed after ACE inhibition. We conclude that the acute blockade of the renin system by captopril in differential renin sampling yields no advantages in diagnosing RVH and that there is no difference between RR and RS in the diagnosis of RVH.
Scandinavian Journal of Urology and Nephrology 02/1996; 30(1):69-72. DOI:10.3109/00365599609182352 · 1.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Angioscopy was applied as a way of intra-operative assessment after surgical reconstruction of renal and visceral arteries in 15 patients. Angioscopy resulted in relevant findings, which in part, demanded immediate intra-operative consequences. Angioscopy turned out to be a sensitive way of surveillance, the findings were easy to interpret.
[Show abstract][Hide abstract] ABSTRACT: Aortic replacement for thoraco-abdominal aneurysms remains a major challenge in vascular surgery. Related symptoms, maximal diameter > 6 cm, progression, aneurysm sac containing none or excentric thrombi and uncontrollable hypertension are factors in favour of surgery, if the general condition of the patient allows the operation. Patients with aneurysms < 5 cm maximal diameter, tube-size aneurysms, heavy calcification of the aortic wall, concentric thrombi within the aneurysmal sac and significant cardiopulmonary risks should be treated conservatively. Patients in good general condition with aneurysms around 5 cm maximal diameter should be controlled by computed tomography in 6 to 12 months intervals and in the case of progression surgery can be recommended despite missing symptoms. Crawford developed the 'graft-inclusion-technique', which combines the 'ingraft'-technique with reattachment of renal, visceral and segmental arteries. The 'clamp and repair' principle is used in patients with sufficient cardiac function. Otherwise shunt or left sided heart bypass are used to reduce cardiac afterload. According to the literature local cooling (flush perfusion), cytoprotective drugs and numerous methods to maintain or ameliorate distal aortic perfusion during clamping ischemia have been used in patients successfully for prevention of ischemic spinal complications. In physiological settings these methods may prove valuable, but under pathophysiological conditions of TAAA-repair one must doubt the efficacy, because the individual risk is difficult to assess. In our hands flush perfusion and cooling of the kidneys proved to be helpful. In animal experiments we have shown prolongation of ischemia tolerance time using eicosanoides to protect the kidneys and the spinal cord. If shunt or left-sided heart bypass can protect the spinal cord during clamping, is unknown, because the risk of paraplegia in the individual patient can be known only, if the function of the spinal cord is monitored. We have developed a spinal neuromonitoring system and found, that only one third of all TAAA-patients is at high risk to develop paraplegia during aortic clamping. The surgeon is guided by continuous recording of spinal evoked somatosensory potentials and can adapt the operative technique by early reimplantation and eventually subsequent separate reimplantation of segmental arteries supplying blood to the spinal cord, in order to reduce spinal ischemia time. Our results in 260 TAAA-patients are presented. In a high-risk population of patients with aneurysms type I-III (Crawford's classification) it was possible, to reduce the paraplegia rate from 7 to 3.5%, the risk of paraparesis from 15 to 6%, while the operative mortality was only reduced from 19 to 10%.
Der Chirurg 10/1995; 66(9):845-56. · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hemodynamically relevant lesions of the innominate artery can be treated either by extraanatomic bypass or by intrathoracic repair. 32 patients were retrospectively evaluated after ascending aorta to innominate artery interposition graft. In all except 6 cases additional bypass-procedures to extracranial vessels were necessary for complete revascularisation. The patency rate was 100% after a mean follow up period of 871 days. Only one patient suffered from a perioperative stroke with upper extremity paresis which resolved after 2 weeks. There were 3 wound complications which required reoperation. In conclusion we believe that direct intrathoracic repair for innominate artery occlusion can be recommended as a treatment of choice with a high long-term patency rate.
Zentralblatt für Chirurgie 02/1995; 120(3):205-9. · 1.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Caval interruption is widely regarded as the treatment of choice for the prevention of recurrent pulmonary embolism (PE). The safety, ease of insertion and "convenience" of the devices are the main arguments for filter placement. Today many filters are placed for prophylactic reasons, sometimes without an established diagnosis of pulmonary embolism or underlying deep venous thrombosis. Early and late complications have been published but the rate is reported to be low, although only limited numbers of patients have been followed. In an 18-year period 11 patients with problems following caval interruption were treated, 10 with acute complications, one with chronic caval occlusion. Six were treated conservatively, five underwent venous thrombectomy and a.v.-fistula. The device was removed in four. During the same period only three permanent filters were placed in our hospital (two with complications). Caval interruption is useful in selected high-risk patients and is the least invasive but not necessarily the best treatment. Provided stringent criteria are applied, the early and late complications can be accepted in order to prevent sudden death in patients with threatening massive PE. Extended or more liberal indications for caval interruption are neither necessary nor justified.
European Journal of Vascular Surgery 10/1994; 8(5):617-21. DOI:10.1016/S0950-821X(05)80601-2
[Show abstract][Hide abstract] ABSTRACT: A patient with late graft infection in the groin following aorto-bifemoral-Dacron-bypass and recurrent infection of extra-anatomic bypasses is presented. Despite the evidence or graft infection (by preoperative imaging studies and intraoperative perigraft purulence) cultures did not identify the infective organism. Retrospectively a graft infection with Staphylococcus epidermidis is supposed as the most likely cause. A graft replacement with freshly harvested, not cryopreserved arterial homograft was performed. The perfusion of the extremities was excellent, the wounds healed perfectly. In special indications freshly harvested cadaveric arterial homografts are an acceptable substitute for infected aorto-femoral grafts.
[Show abstract][Hide abstract] ABSTRACT: Symptomatic atherosclerotic lesions of the subclavian artery are rare. A special treatment is necessary and consists today of various extrathoracic bypass procedures or a subclavian-carotid-transposition. The latter is our preferred kind of therapy. 116 patients (57 female, 59 male, mean age 59.1 years, 116 operations) underwent subclavian-carotid-transposition for symptomatic subclavian artery lesion of the first segment. In 33.6% a thrombendarterectomy of the ipsilateral carotid bifurcation and in 19% an open or eversion thrombendarterectomy of the second segment of the subclavian artery and/or the vertebral artery had to be performed. 3 patients (2.6%) died perioperatively (myocardial infarction 2, cerebral infarction 1). In 3 out of 4 early postop, thrombosed transpositions patency was restored successfully. 70 patients (74.5% of the patients alive) were followed for in the mean 58.6 +/- 41.5 months. The transposition was found to be patent in 67 (95.7%) patients, a mild stenosis presented 2, an occlusion 1 (occluded perioperatively). The cumulative patency rate (126 months) was 95%. Subclavian-carotid transposition is in contrast to bypass procedures a more difficile treatment for symptomatic subclavian lesions with various advantages. Besides an orthograde inflow to subclavian and vertebral artery and the construction of simply one anastomosis with wall segments of identical compliance the main advantage is the avoidance of any autogenous or artificial bypass material. Excellent long-term results underline that this therapy is the more elegant and better concept treating subclavian artery lesions of the first segment.
Zentralblatt für Chirurgie 02/1994; 119(2):109-14. · 1.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thrombectomy with arteriovenous fistula was performed between 1977 and 1988 in 103 patients (41 females, 62 males, mean age 46.7 years, 114 involved extremities) with embolizing deep-vein thrombosis (DVT). The sole aim of the surgical procedure was prevention of recurrent embolization. On the basis of the proximal extent of the thrombosis the source of embolization was identified as the iliac veins or inferior vena cava in 63% of the patients; 48% presented with a post-phlebitic vein and/or an older thrombosis, and 46% had already had recurrent pulmonary emboli. Unsuccessful aggressive procedures had been carried out previously in 11%. The rate of intraoperative pulmonary embolism (PE) was 3% (one fatal case). The perioperative mortality was 6.8%, but only one death was related to the surgical treatment itself. During follow-up (8-140 months postoperatively, mean 55 +/- 34 months) late recurrent PE was confirmed in two patients (antithrombin III deficiency, contralateral DVT) and was reported as the suspected cause of death in a third (3.6%). Venous thrombectomy with arteriovenous fistula is a reliable and effective procedure for management of embolizing DVT and is indicated especially in young patients. The rates of early- and late-recurrent PE are low, introduction of artificial material into the vein can be avoided, and long-term preservation of valve function is occasionally possible.
The Clinical Investigator 01/1994; 72(1):40-5. DOI:10.1007/BF00231115
[Show abstract][Hide abstract] ABSTRACT: Based on the excellent results of experimental studies with antibiotic-bonded vascular prostheses for prevention of graft infection, gelatin-sealed grafts soaked with rifampin were implanted in situ in five patients with vascular infection. All patients were at risk for limb loss or death and could not be treated by standard techniques such as graft excision and extra-anatomic bypass. In one patient an infected aortic stump aneurysm with involvement of both renal and visceral arteries was found. He was treated by implantation of a bifurcation rifampin-soaked graft between the subdiaphragmal aorta and both renal arteries and reimplantation of celiac and superior mesenteric artery into the graft. In four patients with in-flow or runoff problems on angiography, an antibiotic-soaked graft was used for replacement of a partially or totally infected graft. Cultures were positive for Staphylococcus aureus in three and coagulase-negative staphylococci in two patients. Wound healing was uncomplicated; there was no need for amputation. After a follow-up of at least 6 months, all grafts were patent without any evidence of reinfection on computed tomographic scan. We conclude that infected vascular prostheses can be replaced in situ by rifampin-soaked grafts in patients at high risk for death or major amputation.
Journal of Vascular Surgery 05/1993; 17(4):768-73. DOI:10.1067/mva.1993.40229 · 2.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The postischemic acute renal failure is one of the most important and frequent complications after surgery for renal artery and thoracoabdominal aortic diseases. In a canine model we studied the possible beneficial effects of Prostaglandin E1 (PGE1), Diltiazem and Superoxiddismutase (SOD) on postischemic renal function. 46 dogs were exposed to 3 hours ischemia. In 35 dogs PGE1 (n = 10), Diltiazem (n = 10), Superoxiddismutase (n = 10) or both PGE1 and SOD (n = 5) were given intravenously. 11 dogs treated with normal saline served as controls. Glomerular filtration rate, renal plasma flow, plasma creatinine, blood urea nitrogen, urine volume, free water clearance and renovascular resistance were calculated before and after renal ischemia. Radionuclide studies were performed on the third postoperative day. Two weeks later clearance measurements were repeated and kidneys were removed for histology. PGE1, Diltiazem and SOD significantly attenuated the post-ischemic fall in glomerular filtration rate and renal concentrating ability as well as the postischemic changes of tubular epithelium on histology.
Zentralblatt für Chirurgie 02/1993; 118(7):412-9. · 1.19 Impact Factor