Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE

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swissknife spezial 06 12.06.2006 13:39 Uhr Seite 14 Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair – Influence on postoperative colon ischemia Objective: Replanting the inferior mesentery artery (IMA) in order to prevent ischemic colitis (IC) has been discussed for many years; yet, no prospective studies have been conducted to compare the incidence of histologically proven IC in patients with and without IMA revascularization. The aim of this prospective study with histological evaluation of the sigmoid colon mucosa was to asses the influence of replanting the IMA on IC and mortality. Methods: 160 consecutive patients with symptomatic (n = 21) and asymptomatic (n = 139) infrarenal aortic aneurysm operated from January 1999 to December 2003, were prospectively assessed and randomly assigned either to replanting or ligating the IMA. Sigmoidoscopy with biopsy was performed on day 4 or 5 after surgery; patients not surviving day 5 after surgery were autopsied. All patients gave written informed consent. Results: of the 160 randomized patients, 128 had a confirmed patent IMA and formed the basis of this study. Their age was 70 ± 8 years (men 70 ± 8 years; women 73 ± 7 years). 67 patients had the IMA replanted (52%) and 61 ligated (48%) intraoperatively. Six patients with a replanted IMA and 10 with a ligated IMA developed IC (RR = 0.55, CI95% =0.21 – 1.41; c2 = 1.62; P = 0.203). Blood loss in the two cohorts did not differ significantly (P = 0.788), however patients with IC had a significantly higher blood loss compared to the cohort without IC (P = 0.012) and were older (P=0.017). Age, sex distribution, clamping time, the use of tube or bifurcated grafts and intraoperative hypotension did not differ between patients with ligated or replanted IMA. Conclusion: Even though in this study replanting the IMA did not confer statistically significant reduction of perioperative morbidity or mortality, it appears that older patients and patients with increased intraoperative blood loss might benefit from IMA replantation, because this maneuver does not increase perioperative morbidity or substantially increase operation time. 4.02 D. Mayer 1 , T. Pfammatter 2 , J. Gauer 3 , M. Wilhelm 4 , M. Genoni 5 , M. Lachat 3 1 Clinic for Cardiovascular Surgery, Universitätsspital Zürich, 8091 Zürich/CH, 2 Institute for Diagnostic Radiology, University Hospital Zurich, Zurich/CH, 3 Department of Cardiovascular Surgery, University Hospital Zurich, Zurich/CH, 4 Department of Cardiovascular Surgery, University Hospital Zurich, 8091 Zurich/CH, 5 Herz Chirurgie, Stadtspital Triemli, 8063 Zürich/CH EVAR for mycotic aortic aneurysms and aorto-visceral fistulae – how to achieve more than a bridging procedure Objective: Endovascular aneurysm repair (EVAR) for mycotic aneurysms (MA) and aorto-visceral fistulae (AVF) is a controversial issue. Results are poor, especially if considered as a definitive solution. Therefore, EVAR for MA/AVF has been advocated as a bridging procedure during the past years, at the most. This paper presents an optimized treatment strategy to improve postoperative results. Methods: Retrospective analysis of 11 patients (mean age 69 years; range 55-89) with MA/AVF treated by EVAR from 1998 to 2006. The following pathologies were treated: 4 aortoduodenal fistulae, 2 aorto-bronchial fistulae, 4 mycotic thoracic aneurysms (1 with concomitant mycotic abdominal aneurysm) and 1 mycotic thoraco-abdominal aneurysm. 5 patients underwent a stepped procedure (4 EVAR first, then surgical fistula excision or infection debridement; 1 fistula repair first, then EVAR) and 6 patients a single step procedure (EVAR only). All but one patient received long-term antibiotic therapy. Results: Overall 30 day mortality was 9% (1/11), overall mid-term (15 months) mortality 27% (3/11). After a follow-up of 15 months all patients with MA (n=5) were alive, whereas 3/6 with AVF succumbed due to persistent infection with consecutive sepsis. All deaths occurred in patients treated by EVAR only (no fistula excision/infection debridement). There was no conversion to conventional open aneurysm repair. Conclusion: Our results suggest, that EVAR as an isolated treatment fails to achieve a good outcome in patients with MA/AVF. In comparison, EVAR combined with fistula excision and/or infection debridement seems to be a more appropriate treatment and heralds the potential to be more than a bridging procedure. 4.03 R. Seelos 1 , S. Ockert 2 , D. Böckler 2 , J.R. Allenberg 2 1 Gefässchirurgie, Kantonsspital Luzern, 6004 Luzern/CH, 2 Vascular and Endovascular Surgery, University Heidelberg, 69120 Heidelberg/DE Outcome after operation of inflammatory aortic aneurysms Objective: Inflammatory aneurysms (IA) are a rare subgroup among aortic aneurysms more difficult to treat surgically due to the inflammatory process involving the vessel wall and surrounding tissues. The morbidity and mortality rates reported are higher than in normal aneurysms. It is not known if the inflammatory wall process bears the risk of anstomotic tear and false aneurysm formation after exclusion of the aneurysm. In this paper we focus on the fate of the inflammatory process and anastomotic aneurysm formation as well as on perioperative morbidity and mortality. Methods: In a retrospective study all patients with IA surgery from 01/1995 to 11/2004 were in-cluded. Patients were operated either by open surgery or EVAR. All Patients had preoperative and 21 patients had follow up CT/MRI scans. Results: 45 patients were included in the study (open n=40, EVAR n=5). Median age was 67.3 years (range 51 86 years). 22 patients (48.9 %) were symptomatic at time of operation, 4 had a rupture. Perioperative mortality was 4.9 % without rupture, 2/4 patients with rupture died. Morbidity was 15.6 %. In the EVAR group there was no mortality. At time of follow up examination (mean 4.1 years, range 3 months 10 years) 33 patients were alive (73.3 %). No anastomotic aneurysm could be detected postoperatively. Complete remission of the inflammation on CT/MRI scan was seen in 10/21 (47.6%), partial remission (>50 % of inflammatory wall thickening) was seen in 9/21 (42.9 %) and 2/21 remained unchanged. Conclusion: Postoperatively 90.5 % of patients had a complete or more than 50 % reduction of the inflammatory vessel wall thickening. The inflammatory process does not seem to enhance the risk of anastomotic aneurysm formation. Perioperative mortality and morbidity was in the upper range expected for open repair of non-inflammatory infrarenal aortic aneurysms. 4.04 J. Schmidli 1 , L. Englberger 2 , H.O. Savolainen 3 , P. Jandus1, D. Do 4 , A. Haeberli 5 , M.K. Widmer 5 , I. Bau mgartner 4 , T. Carrel 2 14 swiss knife 2006; special edition 1 Cardiovascular Surgery, University Hospital, 3010 Bern/CH, 2 Department of Cardiovascular Sur-gery, University of Berne, Bern/CH, 3 Vascular Surgery, Swiss Cardiovascular Center, 3010 Bern/CH, 4 Division of Angiology, University Hospital, 3010 Bern/CH, 5 Clinical Research, University Hospital, 3010 Bern/CH Activated coagulation during open and endovascular abdominal aortic aneurysm repair Objective: Biological responses to surgical trauma and ischemia/reperfusion injury include complex inflammatory response and activation of coagulation and fibrinolysis. This study was conducted to determine activation of coagulation in patients undergoing open (OAR) and endovascular infrarenal abdominal aortic aneurysm repair (EVAR). Methods: In a prospective, non-randomized, comparative study 30 consecutive patients undergoing OAR (n = 15) or EVAR (n = 15) were investigated. Blood samples to determine fibrinopeptide A (FPA), fibrin monomer (FM), thrombin-antithrombin complex (TAT), and Ddimer were taken up to five days postoperatively. Routine hematologic and hematochemical parameters as well as clinical data were collected. Results: No statistically significant demographic differences were seen between the groups with respect to mean age, gender, history of concomitant disease, cardiovascular risk profile, aneurysm diameter or involvement of the iliac vessels. No mortality and no major complications occured. Operating time was longer in OAR (249 ± 77 min. versus 186 ± 69 min., p
swissknife spezial 06 12.06.2006 13:39 Uhr Seite 15 4.07 T. Wolff 1 , T. Eugster 2 , P. Stierli 3 , L. Gürke 4 1 Zentrum für Gefässchirurgie Aarau-Basel, Universitätsspital Basel, 4031 Basel/CH, 2 Gefässchirurgie, Universitätsspital Basel, 4031 Basel/CH, 3 Gefässchirurgie, Kantonsspital Aarau, Aarau/CH, 4 Allgemeinchirurgische Klinik, Universitätsspital Basel, Basel/CH Paraplegia after aortobifemoral bypass full recovery after emergency revascularization of one internal iliac artery and CSF drainage Objective: Paraplegia after surgery of the abdominal aorta is very rare and commonly irreversible. We report a case of paraplegia after elective aortobifemoral bypass. After emergency surgery to revascularize one internal iliac artery the patient made a full recovery from the neurological deficit. Methods: Case report Results: A 58y old woman with distal ulcerations due to occlusion of the left common and left external iliac artery and occlusion of the left femoropopliteal artery underwent aortobifemoral bypass and femorocrural vein bypass. Because of extreme calcification of the infrarenal aorta nearly up to the level of the renal arteries, the proximal anastomosis could not be performed end-to-side and was performed end-to-end with suprarenal clamping. The distal anastomoses were performed end-to-side to both common femoral arteries. Intraoperatively the right external iliac artery unexpectedly proved to be occluded too. Since we had relied on the right external iliac artery to retrogradely perfuse the right internal iliac artery, this meant that there was no pulsatile blood flow to the pelvis. As there was no sign of colon ischemia at termination of the aortobifemoral bypass, no measures were taken. After waking up from anaesthesia, paraplegia with only minor movements of the toes was noted. The patient was immediately reoperated and a short bypass between one limb of the aortobifemoral bypass and the right common iliac artery was performed, thereby re-establishing pulsatile flow to the right internal iliac artery. At the same time CSF was drained for 24h. Postoperatively the patient made a full recovery from the paraplegia. Conclusion: Spinal cord ischemia is predominately a complication of thoracoabdominal aortic surgery. With surgery to the abdominal aorta it has an incidence of
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