Abstracts - Chirurgie Kongress

Results: Approximately 6 to 8 weeks after the operation both patients started to regain some movement
of the legs and some sensations returned. With intense physiotherapy the patients made slow
progress, becoming able to walk with sticks after 3 and 5 months
Conclusion: Paraplegia after AAA repair is an unpredictable complication. Less than 40 cases have
been reported in the literature. Prevention remains the mainstay, which includes gentle operative technique
to prevent embolisation, maintenance of intra-operative haemodynamics, systemic heparinisation
and avoidance of prolonged cross clamping. MRI should be done to rule out a compressive lesion.
CSF drainage should be inserted for 48 to 72 hours, but prognosis is extremely variable, ranging from
death to complete recovery which may take from months to many years.
60.8
Retroperitoneal hematoma after endovascular procedure
C. Folly 1 , M. Menth 2 , V. Bakhshi-Tahami 2 , R. Feer 2 , B. Marty 2 , B. Egger 2 ( 1 Nidau, 2 Fribourg)
Objective: A retroperitoneal hematoma is a rare but life threatening complication after endovascular
procedure with groin puncture. The incidence of such hematomas is about 0.15 % when the puncture
site is on the common femoral artery for diagnostic reason. The risk increases remarkably to about 3%
when the external iliac artery is punctured and coronary artery stent placed. A retroperitoneal hematoma
is much less painful than a groin hematoma or false aneurysm since there is a lot of place for
blood in the retroperitoneal space. This may lead to late symptoms and detection of this life threatening
complication.
Methods: We report two cases with an acute coronary syndrome admitted for an urgent coronarography.
Both were fully antiaggregated with clopidogrel, aspirin and abciximab at the beginning of
the endovascular procedure. Two drug eluting stents were implanted into the coronary vessels in both
patients. The arterial puncture site was located 2 and 4 cm above the inguinal ligament. An angiographic
control at the end of the procedure confirmed that no leak was present in the first patient, while the
second needed a stent for sealing the puncture site.
Results: Nevertheless, both patients developed a hemodynamic instability with severe hypovolemic
choc symptoms and were rapidly admitted to the ICU. Laboratory results revealed anaemia of 92 and
40 g/L, respectively. They presented a tenderness of the right abdomen with a palpable mass. Suspicion
of huge retroperitoneal hematoma with active bleeding at the puncture site was confirmed by
immediate CT-scan. Emergency surgical interventions were performed by evacuating the hematomas
and suturing the arterial lesions. Recovery was uneventful in both patients.
Conclusion: The incidence of potentially life threatening retroperitoneal hematomas is much higher
when the puncture site is located above the inguinal ligament. The arterial puncture site above the ligament
cannot be compressed adequately after these procedures and should therefore be avoided. During
the post procedural surveillance, hemodynamic parameters must been controlled regularly and
in short intervals. In any case of hypotension a CT scan or US should been undertaken immediately to
exclude active bleeding at the puncture site. Any detected active bleeding from the external iliac artery
has to be sutured immediately by an emergency intervention.
60.9
Multiterritorial ischemic lesions associated with internal carotid stenosis and persistent hypoglossal
artery
S. Stasakova, L. Giovannacci, J. C. Van den Berg, C. Staedler, R. Rosso (Lugano)
Objective: The persistent hypoglossal artery (PHA) is a rare vascular anomaly, the second most common
persistent embryological carotid-basilar communication, connecting anterior and posterior circulation.
We report the case of a 79-year old patient with multiple ischemic lesions in the territory of the
posterior cerebral and middle cerebral artery, with a stenosis of the left internal carotid artery that was
associated with PHA.
Methods: The patient was admitted to the emergency department with a history of memory difficulties,
headache, left – hemiparestesis and tiredness. Work up with CT and MR angiography, revealed leukoencephalopathy
compatible with chronic cerebral ischemia, and multiple ischemic lesions of embolic
origin in the territory of the posterior circulation and left middle cerebral artery. Moreover a stenosis
of the left internal carotid artery with persistent hypoglossal artery and hypoplasia of both vertebral
arteries was demonstrated.
Results: Two days after the initial presentation the patient developed motoric sensitive right hemisyndrome
with aphasia, left hemianopsia, and partial anosognosia. Considering the stenosis of the internal
carotid as symptomatic, the patient underwent a left carotid endarterectomy with an uneventfull
postoperative course and regression of the neurologic symptoms.
Conclusion: Carotid–basilar anastomosis represent persistent embryonic circulatory patterns that link
the carotid and vertebrobasilar system.It is important to know that a persistent carotid-basilar anastomosis
can be one of the causes bringing about ischemic lesions in both the anterior and posterior
vascular territories, mimicking cardioembolism Thus, PHA may present a challenge in diagnosis and
management of patients with carotid atherosclerosis and hemisperal and vertebrobasilar ischemia.
60.10
Revascularisation of the external carotid artery in a patient presenting jaw claudication
K. Galetti, P. A. Stalder, C. Staedler, L. Giovannacci, R. Rosso (Lugano)
Objective: Revascularisation of the external carotid artery is rarely performed. Accepted indications are
symptoms of cerebral ischemia in patients with (bilateral) internal carotid artery occlusion, ophtalmic
ischemia or jaw claudication. We present a case of jaw claudication treated with endarterectomy.
Methods: An 56 year-old woman with adrenogenital syndrome, presented with right jaw claudication.
Duplex Scan and MR Angiography demonstrated a severe external carotid stenosis on the right side and
a concurrent mild stenosis (50%) of the internal carotid with signs of hemispheral ischemic lesions.
Results: Considering the internal carotid stenosis as probably symptomatic and in order to treat the
stenosis of the external, an endarterectomy of the carotid bifurcation, the external and internal carotid
artery completed by a patch angioplasty was performed. The postoperative course was uneventfull,
and the jaw claudication disappeared completely.
Conclusion: In selected cases of jaw claudication, surgical revascularisation of the external carotid
artery may be indicated and can be performed safely with relief of symptoms.
60.11
Invalidisierende Kalziphylaxie (Calcific uraemic arteriolopathy)
V. Göber, A. Neumann, S. Schenker, J. Schmidli (Bern)
Objective: Fallbeschreibung.
Methods and Results: Ein 45jähriger Patient leidet seit seinem 11. Lebensjahr an Diabetes mellitus Typ
1. Dieser führte zu einer diabetischen Nephropathie, die im Alter von 35 Jahren dialysepflichtig wurde.
Im Verlauf wurde der Patient nierentransplantiert und es traten schmerzhafte Ulzerationen an den Fingerspitzen
beider Hände auf. Es kam zu bakteriellen Superinfektionen, Nekrosebildung und in der Folge
waren Amputationen, initial der Kleinfingerendglieder, notwendig. Anhand der Klinik wurde die Diagnose
einer Kalziphylaxie gestellt. Bei erhöhtem Parathormon-Spiegel, bedingt durch einen tertiären
Hyperparathyreoidismus, der medikamentös nicht zu senken war, wurde eine Parathyreoidektomie mit
Autotransplantation in die Tibialis anterior Loge rechts durchgeführt. Dennoch kam es immer wieder zu
Ulzerationen an beiden Händen und Füssen, die dem Patienten stärkste Schmerzen bereiteten. An den
Händen mussten die Finger teilamputiert werden, ebenso der rechte Unterschenkel und der Vorfuss
links. Weiterhin leidet der Patient an einer hypertensiven und koronaren Kardiopathie. Es erfolgten eine
PTCA mit Stentimplantation in die rechte Koronararterie und den Ramus interventricularis anterior.
Conclusion: Die Kalziphylaxie ist ein seltenes Krankheitsbild, das überwiegend niereninsuffiziente,
dialysepflichtige Patienten befällt aber auch im Rahmen anderer Grunderkrankungen beschrieben
wird. Die Krankheit manifestiert sich mit kutanen, therapierefraktären Hautläsionen. Histologisch findet
man eine Intimaproliferation und eine Mediakalzifizierung der kleinen Gefässe, die zu einer Okklusion
des Gefässlumens führt. Auf dem Boden der Ulzerationen entwickeln sich häufig therapierefraktäre
Superinfektionen, die bis zur Sepsis führen können und die hohe Letalität von 80% erklären. Die Diagnosestellung
erfolgt anhand der Klinik und des dermato-histopathologischen Bildes. Empfohlen
wird die Entnahme einer Biopsie an den betroffenen Stellen. Jedoch wird vor Stichprobenfehlern und
Initiierung oder Verschlechterung ulzeröser Läsionen gewarnt. Ätiologisch werden sowohl Störungen
im Kalzium-Phosphat-Haushalt als auch ein vermindertes Vorhandensein homoeostatischer Mechanismen
diskutiert. Es existiert keine kausale Therapie. Empfohlen werden supportive Massnahmen wie
ein adäquates Wundmanagement und eine optimale Kalzium- und Phosphat-Kontrolle.
60.12
Acute renal failure and lower extremity ischemia - a rare case report
R. Bühlmann, R. Marti, L. Gürke, P. Stierli (Aarau/Basel)
Objective: Acute occlusion of the distal aorta (Leriche’s syndrome) is a well known entity with a relevant
morbidity and mortality rate. So far, the combination of an embolic Leriche syndrome in a patient
with a renal transplant hasn’t been described in literature yet. We report on a patient with cardioembolic
occlusion of the renal transplant artery and the aortic bifurcation, which was treated by a combined
open and interventional procedure.
Methods: Case report
Results: A 50 years old woman was hospitalised since 2 month due to miliar tuberculosis. She had a
perfectly functioning renal transplant in the right iliac fossa since 6 years and a known lumboradicular
pain syndrome with hyposensibility in the dermatome S1 on the right side. Therapeutic low molecular
weight heparin was given due to a newly diagnosed atrial thrombus. 24 hours before angiologic and
surgical consultation, she suffered of strong lower extremity pain on both sides with hyposensibility
and paresis mainly on the right side. Concurrently, she developed anuria with a rise in creatinine level
from 78 to 341 µmol/l. Femoral and peripheral pulses were not palpable. Toe oscillography showed a
flat line. Duplex sonography revealed aortoiliac as well as renal transplant artery occlusion. The operative
procedure consisted in inguinal approaches on both sides with conventional aortoiliac embolectomy.
The occluded renal transplant artery was cannulated with a guide wire with following over the wire
embolectomy under fluoroscopic control. The follow up was uneventful except necessary transient
dialysis during 15 days. The creatinine level slowly lowered to 212 µmol/l two month later. Duplex
sonography showed an open renal transplant artery without residual embolus.
Conclusion: Acute renal failure and bilateral leg ischemia are the typical symptoms of the Leriche’s
syndrome in patients with a renal transplant. Combined fluoroscopic guided over the wire and conventional
embolectomy prevents an open aorto-renal procedure. In embolic renal ischemia, a minimal rest
perfusion often exists. This results in better chance of renal recovery even after late embolectomy.
60.13
Cold finger: embolization from a chronically thrombosed Cimino-Brescia-fistula
T. Wyss, R. Von Allmen, J. Schmidli, I. Baumgartner, M. K. Widmer (Bern)
Objective: Embolizations from thrombosed dialysis shunts have been rarely described for arterio-venous
grafts, not for native fistulas. We report the case of digital embolization from a thrombosed arterio-venous
fistula leading to a complete thumb ischemia.
Methods: A 47-year-old man was admitted to the hospital with an acute ischemia of his right thumb. He
presented with a painful, cold and pale thumb with reduced sensibility but intact motor function. Radial
and ulnar pulses were strong but recapillarisation of the thumb was nearly absent. There was no history
of trauma or recent arterial puncture. In March 2003 he had undergone successful cadaveric renal
transplantation because of a chronic renal failure due to a glomerulonephritis of unknown etiology.
swiss knife 2009; special edition 41