Abstracts - Chirurgie Kongress

Methods: Design: A non-randomized, retrospective, single-centre study. Material: From January 2000
to December 2005, 79 allografts were implanted into critically ischemic limbs of 57 patients. There
were 44 cryopreserved arterial homografts, 15 cryopreserved venous homografts, 8 cold-stored venous
homografts and, 12 arterial xenografts. The indication for reconstruction was rest pain (90%), tissue
lost (60%) or infection of previous graft (8%). 43% of the procedures was performed as secondary
or tertiary reconstruction, and 56% of grafts were anastomosed to tibial or pedal arteries. Mean patient
follow up was 32 months (range 3 to 7 years). Follow up was performed until December 31, 2008.
Results: The reoperation rate was 32%, but amputation rate remained low, 15%. Arterial homograft
aneurysm occurred in 5/44 (11%) grafts. Actuarial graft patency was 87.3% at 1 month, 72.1% at
6 months, 65.5% at 1 year, 45.6% at 3 years and 33.2% at 5 years. Limb salvage at 3 years was
excellent, 84.4%. The xenograft had the highest occlusion rate followed by the cold-stored venous homograft
which had the highest amputation rate.
Conclusion: Allografts have a place in the treatment of critical limb ischemia when an autologous
vein conduit is not available or suitable. The arterial cryopreserved homograft seems to have a better
patency rate compared to the other allografts, but the risk of aneurysm formation has to be considered.
Good limb salvage rate can be achieved.
42.5
Symptomatic perigraft seroma after conventional repair of infrarenal abdominal aneurysm
C. Rouden, L. Gürke, P. Stierli, T. Wolff, T. Eugster (Aarau/Basel)
Objective: Perigraft seroma (PGF) is rare and particularly complex but a well known complication
following aortic surgery. Defined as a sterile fluid collection confined in a non secretory fibrous pseudomembrane
surrounding the prosthetic vascular graft, it may occur after both use of prosthetic material
like Polytetrafluoroethylene (PTFE) and Dacron
Methods: Four years after elective open repair of a 11,5cm AAA (abdominal aortic aneurysm) with
a bifurcated PTFE-graft, a 81 years old man was admitted in emergency with a 24 hours history of
acute diffuse abdominal pain and nausea. Clinical examination found a large pulsating mass in the
left middle abdomen. Peripheral vascular pulses were present. The spiral computed tomography (CT
scan) demonstrated a large fluid collection of 14cm and low density around the prosthesis, corresponding
to an expansion of the original aneurysm sac. Graft compression’s signs were suggested. There
was neither rand enhancement nor sign of blood extravasation. Laboratory tests were all in normal
range.
Results: Due to severe abdominal pain the patient was operated in urgency. At laparotomy a big pulsing
retroperitoneal mass was found. Citrine liquid under high pressure spurted out after incision of the
aortic sac. The prosthesis was covered with a viscous, gel like substance. No haematoma or bleeding
was observed and no sign of inflammation or infection could be detected. Remarkably, the graft was
not incorporated into the surrounding tissues. A partial resection of the aortic sac was performed. An
omentum pedicle from the colon transversum was formed and placed transmesocolic on the graft. The
rest of the aortic sac was readapted over the omentum flap fixing it within the former perigraft cavity.
The rest of the hospital stay was uneventful, all the intra-operative cultures remained sterile. The patient
was discharged home on the 7. postoperative day. Three months later the patient remained asymptomatic
but unfortunately the CT scan control showed a recurrence of the PGF.
Conclusion: In cases of PGF after conventional repair of infrarenal abdominal aneurysm, it is essential
to remove as much as possible of the membrane, perform an endarterectomy of the rest, and not
readapt the aortic sac over the omentoplasty.
42.6
Clinical outcome of below-knee pre-cuffed polytetrafluoroethylene grafts
D. Danzer, F. Dick, B. Gahl, N. Diehm, M. Widmer, J. Schmidli (Bern)
Objective: Pre-cuffed polytetrafluoroethylene (PTFE) bypass grafts were designed to improve the disappointing
patency and limb salvage rates associated with the use of conventional prosthetic grafts
for distal arterial reconstructions. Aim was to establish mid-term clinical outcome of this pre-cuffed
alternative.
Methods: Outcome analysis of a consecutive series of 29 patients with peripheral arterial occlusive
disease (December 2002 to January 2007, 29 limbs) who underwent distal arterial reconstruction
with pre-cuffed PTFE grafts. Median age was 76 years (interquartile range 71-84) and 18 patients were
men (62%). Indications for revascularisation were: chronic critical limb ischemia with (n=9) or without
(n=13) ischemic tissue loss, acute critical limb ischemia (n=6) and severe claudication (n=1). All
prosthetic grafts were used because of lack of suitable autologous conduits. Thirteen reconstructions
were re-do operations. In six patients, anastomoses were placed onto the distal popliteal artery, in two
onto the tibio-fibular trunc and in 21 onto tibial vessels. Median follow-up was 19 months (interquartile
range 6-33) and Kaplan Meier curves were truncated at 2 years. Study endpoints were peri-operative
mortality (i.e. 30 day or in-hospital), cumulative follow-up mortality, limb salvage, bypass patency and
morbidity including graft infections.
Results: There were no peri-operative deaths and seven patients died during follow up (24%). At two
years, the cumulative survival rate was 84%. Overall, twelve patients underwent a major amputation
of the index limb, and cumulative limb salvage in surviving patients was 77% and 63% at one and two
years, respectively. Bypass patency was documented by duplex-sonography and added up to 70%
and 53% at one and two years, respectively. Of the deceased patients, three had undergone amputation
before death and in three the bypass had occluded. We observed three graft infections during
follow-up, two of which required graft excision.
Conclusion: The use of pre-cuffed PTFE bypass grafts was associated with an acceptable limb salvage
rate and only few complications in this aged patient population with extensive vascular disease. Thus,
under certain circumstances it might be considered a safe bail-out strategy, i.e. for patients with critical
ischemia in whom all available venous conduits have already been used.
24 swiss knife 2009; special edition
42.7
Recurrent popliteal artery aneurysms: summary of nine legs
H. Kim 1 , R. Bühlmann 2 , R. Marti 1 , L. Gürke 3 , P. Stierli 1 ( 1 Aarau, 2 Baden, 3 Basel)
Objective: The most feared complications of popliteal artery aneurysms (PAA) are distal embolism,
acute ischemia and rupture. The operative treatment combines exclusion of the aneurysm and reconstruction
with a venous or prosthetic graft. If done from medial, the PAA remains in situ with only
proximal and distal ligation. In the dorsal approach an endoaneurysmorraphy is done. We report on 9
recurrent PAA (rPAA) considering aneurysm aetiology and operative treatment.
Methods: From 1987 to 2008 we operated 58 patients with 73 PAA. Clinical data were retrospectively
reviewed. 7 patients had 9 operations on different legs due to rPAA were included in this study. The
follow up consisted of clinical examination and duplex sonography.
Results: The mean age of the 6 men and 1 woman was 73 years. Comorbidity included arterial hypertension
(7), coronary heart disease (2), former smoking (4), diabetes mellitus (1) and hypercholesterolemia
(6). Other aneurysms were present in 6 patients (4 aorto-iliacal, 5 contralateral PAA). All 9
rPAA occurred after primary operation from medial with orthotop reconstruction (8 veins, 1 Dacron)
with a mean delay of 7.9 years (4-15). In 6 cases, the indication for reoperation was a growing original
PAA leading to local pain (5) or rupture (1). All were treated by endoaneurysmorraphy (5 from
dorsal, 1 from medial). One needed concurrent replacement of the dilated Dacron graft (up to 3 cm)
by vein graft. The remaining 3 cases had vein graft aneurysms at the knee level (1 with an additional
proximal anastomotic aneurysm) being symptomatic in only one case with acute ischemia. They were
treated by graft replacement (1 vein, 2 GoreTex). Mean follow up time was 4.3 years (0.5-14). Early
complications were 1 revision due to bleeding after endoaneurysmorraphy and in the patient with
acute ischemia GoreTex replacement by vein and finally amputation due to insufficient outflow. Late
complications were development of 1 anastomotic aneurysm of 2.1cm after 2 years and one patient
with two revisions due to bypass occlusion after 6 years.
Conclusion: rPAA has 2 manifestations: 1st as growing original PAA after proximal and distal ligation
without endoaneurysmorraphy leading to possible pain or rupture. 2nd as true vein graft aneurysm
with the same feared complications as a primary PAA. All patients with PAA need a careful follow-up,
also for other aneurysms.
42.8
Motion analysis after supra-aortic transposition - A new method can predict outcome
J. Holfeld, E. Schwartz, R. Gottardi, P. Peloschek, M. Grimm, G. Langs, M. Czerny (Wien/AT)
Objective: Total supra-aortic rerouting as well as double vessel transposition followed by endovascular
stent graft placement are now an established tool for the treatment of various pathologies affecting the
aortic arch. However, details about the motion of the aortic arch after this procedure remain unknown.
Moreover no perfectly fitting risk stratification score exists for outcome prediction of this specific patients.
In the AortaMotion project we will develop and validate the necessary measuerement techniques, will
study the aortic arch characteristics, and their predictive power for the treatment outcome.
Methods: Based on ECG triggered CT scans of the aortic arch we devised an automatic deformation
quantification algorithm working with active contour models for tracking of the vessels. Therefore we
had an automatic method for the analysis of the deformation of the aortic arch during the cardiac
cycle. The We compared deformation patterns, and in particular their change caused by supra-aortic
transposition and stent-graft placement.
Results: Specific patterns of aortic arch deformation seem to have a predictive value on the outcome
of patients, in particular concerning endoleaks at the peri-graft zone. Results of aortic deformation
measurements give the oppurtunity of establishing a risk stratification score.
Conclusion: The only force that keeps a stent-graft in place is its self-expaning force. Endoleak, defined
by the persistence of blood flow outside the lumen of the endoluminal graft but within the aneurysm
sac, are a crucial problem. Of most clinical significance are endoleaks that occurre at the beginning
or the end of an excluded segment of the aorta. These our motion analysis method may automtaically
predict in future
42.9
Management of a steal syndrome after distal venous arterialization for critical limb ischemia
V. Duruz 1 , S. Déglise 1 , F. Saucy 1 , C. Haller 2 , J.-M. Corpataux 1 (1Lausanne, 2Sion)
Objective: Approximatively 20% of patients with critical lower limb ischemia are not candidates for
distal arterial reconstruction owing to occlusion of their distal vessels. In these cases, distal venous
arterialization has been described as an effective alternative to major amputation with foot salvage
rate up to 85%. Despite recent technical advances, particularly in valves destruction, this method can
fail due to steal syndrome of the flow into the proximal saphenous vein.
Methods: Among 13 patients managed by distal venous arterialization in our department between
May 2006 and December 2008, we report one case of failure due to steal syndrome.
Results: Distal venous arterialization was performed in a 73-year old man for severe foot necrosis. The
post-operative duplex examination revealed that the bypass was patent but the majority of the blood
flow was redirected through the draining proximal greater saphenous vein, leaving minimal flow in the
dorsal venous arch. To correct this steal phenomenon, we performed a banding of the saphenous vein
using a Provena net around the vein to limit the venous drainage. This technique increased the flow
through the dorsal arch from 30 ml/min to 230 ml/min, leading to a rise of the TcPO2 from 24 mmHg
to 50 mmHg. This allowed wound healing and foot salvage after a follow-up period of 6 months.
Conclusion: Steal syndrome could in part explain the failure of some distal venous arterialization
despite patent graft and adequate valves destruction. After confirmation by duplex examination, venous
banding should be attempted as it is an easy procedure that leads to good results.