swissknife spezial 06 12.06.2006 13:39 Uhr Seite 32 Conclusion: Our experience shows that autologous composite vein grafting is an effective and safe alternative for the management of aorto-enteric fistula. In or<strong>der</strong> to reduce the operating time, two surgical teams should work simutaneously. Due to their high patency and low infection rates, this procedure remains our gold standard in fit patients. However, in situ Silver ® prosthetic graft reconstruction is a good alternative in ol<strong>der</strong> patients with severe co-morbidities. 16.02 J.T. Christenson 1 , C. Prins 2 , G. Salah 3 1 Cardiovascular Surgery, University Hospital of Geneva, 1211 Geneva/CH, 2 Dermatology, University Hospital of Geneva, 1211 Geneva/CH, 3 Angiology, University Hospital of Geneva, 1211 Geneva/CH In chronic venous insufficiency with therapy resistant ulcers does subcutaneous fasciotomy promote ulcer healing? Objective: In chronic venous insufficiency (CVI) leg ulcers frequently occur and many are therapy resistant. Transcutaneous oxygen tension (TcPO2) is often low near the ulcer edge. Increased subcutaneous (s.c.) and intramuscular (i.m.) tissue pressures have been reported. This study evaluates the impact of subcutaneous fasciotomy in patients with CVI. Methods: In 12 patients (15 limbs) with recurrent, therapy resistant venous leg ulcers, due to CVI s.c. fasciotomy was performed. I.m. and s.c tissue pressures and TcPO2 were measured pre- and postoperatively. Eight ulcers (67%) were previously skin grafted and of those 88% had received more than one failed skin graft. The mean age of the ulcers at the time of operation was 3.5 years (raging from 3 months to 15 years). Results: Patients with CVI and venous ulcers presented with significantly higher s.c. and i.m. tissue pressures and significantly lower TcPO2 values (p
swissknife spezial 06 12.06.2006 13:39 Uhr Seite 33 Conclusion: According the literature DTAB bypass is an alternative procedure for inferior limb revascularization with excellent overall long-term results. Patency rates and flow rates are comparable to conventional abdominal aorto- femoral bypass grafts. This technique should be evaluated as potential solution when intra-abdominal approach is not feasible or if heavy calcifications do not allow an anastomosis to the abdominal aorta. Our modest experience support these data. 16.08 K. Djebaili 1 , A. Kalangos 2 1 Cardiovascular Surgery Unit, Geneva University Hospital, 1211 Geneva/CH, 2 Cardiovascular Surgery, University Hospital of Geneva, 1211 Geneva/CH Endovascular treatement of floating thrombus in the thoracic aorta causing reccurent embolism Objective: Floating thrombus of the thoracic aorta is a rare entity that usually originates from an atherosclerotic aortic wall lesion, aneurysms, different forms of endothelial arterial disor<strong>der</strong>s or hypercoagulability and is a potential source of embolism. Systemic anticoagulation and open surgical procedures are the commonly used therapeutic modalities. We describe a successfull treatement of mobile thrombus by an endovascular approach. Methods: 67 year old women with a history of Hypertension and lower limb ischaemia, was admitted to hospital in emergency with acute pain in the upper right abdominal quadrant. A Ct scan performed showed a spleen infarct, she was treated by aspirin and coumadin to search for an emboligene source an angio Ct scan was done and reveled a huge aortic atherothrombotic plaque lying un<strong>der</strong>neath the left subclavian artery origin with new image of right renal infarction in the same day she presented an acute arterial bilateral leg ischemia and un<strong>der</strong>went an emergency surgery by hybrid procedure excluding the thrombus by introducing a thoracic aortic stent graft (Talent, Medtronic) and bilateral embolectomy of the right femoral artery and left popliteal artery. Results: The final angiogram showed a perfect stent graft position distal to the origin of the left subclavian artery. A postoperative CT scan confirmed exclusion of the thrombus without any more embolism image.Unfortunately the patient had critical right limb ischemia with unsuccessful femoro pedal bypass for limb salvage and was amputated below the knee. Conclusion: Floating thoracic aortic thrombus is a rare pathology which can be treated successfully by endovascular stent graft which is an effective minimally invasive method opening a new era of treatment. 16.09 H. Probst 1 , A. Kayoumi1, N. Ducrey 2 , M. Depairon 2 , C. Haller 3 , J. Corpataux 4 1 Service De Chirurgie Thoracique et Vasculaire, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne/CH, 2 Service D'angiologie, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne/CH, 3 Thoracic and Vascular Surgery, CHUV, 1011 Lausanne/CH, 4 Vascular and Thoracic Surgery, CHUV, 1011 Lausanne/CH Quality of life and functional outcomes after stripping of lower limb varicose veins Objective: Superficial venous incompetence is a very frequent disease. The stripping of the great saphenous vein (GSV) and/or the small saphenous vein (SSV) is a well-known and effective treatment. As this surgical procedure lowers the risk of recurrence, it is often associated with significant morbidity. The purpose of this study is to assess the outcomes of the venous stripping on quality of life, correlated with functional venous haemodynamic results. Methods: This prospective study comprises 45 consecutive patients un<strong>der</strong>going stripping of the GSV and/or SSV. All patients were assessed by the VEINES-Quality of Life questionnaire, measurements of leg circumferences and strain-gauge plethysmography performed pre-operatively, at 3 and 12 months postoperatively. Duplex ultrasound was systematically performed to detect left incompetent venous segments and/or early recurrence. Results: Forty five patients un<strong>der</strong>went venous stripping on 60 lower limbs. Surgical intervention consisted of 57 GSV long stripping and 7 SSV stripping. The quality of life questionnaire showed disappearance of initial symptoms, associated with reduction of daily inconvenience and psychological adverse effects. No significant change of leg circumferences was observed. Venous outflow (VO) was measured at 151.1%/min preoperatively and 116.7 %/min at 1 year postoperatively and venous volume (VV) at 10.45% and <strong>4.</strong>2%, respectively. Conclusion: Stripping of lower limb varicose veins significantly improves patient’s quality of life. This observation was also correlated with significant haemodynamic modifications regarding VO and VV. 16.10 A.E. Münch 1 , I. Schwegler 2 , L. Gürke 3 , P. Stierli 4 1 Chirurgie, Kantonsspital Aarau, 5001 Aarau/CH, 2 Gefässchirurgie, Kantonsspital Aarau, 5000 Aarau/CH, 3 Gefässchirurgie, Universitätsspital Basel, Basel/CH, 4 Gefässchirurgie, Kantonsspital Aarau, Aarau/CH Iatrogene AV-Fistel nach Varizenstripping Objective: Iatrogene AV-Fisteln sind seltene Komplikationen, die am häufigsten postinterventionell nach inguinaler Gefässpunktion, z.B. nach Angiographien auftreten. Im Gegensatz zu traumatischen AV-Fisteln verschliessen sie sich unter konservativer Therapie meist spontan. Methods: Fallbericht: Wir beschreiben eine ungewöhnliche Ursache einer iatrogenen AV-Fistel um für die Erfassung einer solchen Komplikation zu sensibilisieren. Nach einer Varizenoperation mit V. saphena magna-Stripping und Perforansligaturen entwickelte die 71jährige Patientin im Verlauf von drei Wochen postoperativ ein ausgedehntes Hämatom am medialen Unterschenkel, welches eine operative Revision mit offener Wundbehandlung und Sekundärnaht erfor<strong>der</strong>te. Drei Jahre nach dem Eingriff wurde als Zufallsbefund im Rahmen <strong>der</strong> Abklärung arthrotischer Kniegelenksbeschwerden klinisch (auskultatorisch) <strong>der</strong> Verdacht auf eine AV-Fistel am Unterschenkel gestellt und duplexsonographisch die Diagnose einer high-flow AV-Fistel <strong>der</strong> A. tibialis posterior bestätigt. Aufgrund des fehlenden Spontanverschlusses, sowie des hohen Volumens stellten wir die Indikation zum Verschluss <strong>der</strong> AV-Fistel unter Rekonstruktion <strong>der</strong> A. tibialis posterior durch Direktnaht. Results: Obwohl die Literatur bislang keine AV-Fisteln als Folge von Varizenoperationen beschreibt, sind iatrogene AV-Fisteln nach Varizenstripping wahrscheinlich häufiger als angenommen und stellen eine Son<strong>der</strong>form <strong>der</strong> traumatischen AV-Fistel dar. Verursachen<strong>der</strong> Pathomechanismus ist das operativ bedingte Trauma bei enger anatomischer Beziehung von Venen und Arterien in Kombination mit einer sparsamen Präparation. Conclusion: Vermutlich bleiben die meisten iatrogenen AV-Fisteln asymtomatisch und verschliessen sich abgesehen von high-flow Fisteln i.d.R spontan, so dass kein Inter- ventionsbedarf besteht. Ausgeprägte Hämatome, eine persistierende Schwellneigung, sowie Schwirren sollten an AV-Fisteln denken lassen und weitere Abklärungen nach sich ziehen. Die Indikation zur Operation ist unseres Erachtens nur bei Persistenz <strong>der</strong> Fistel o<strong>der</strong> einem hohen Shuntvolumen gegeben um eine Dekompensation einerseits und eine Aneurysmabildung an<strong>der</strong>erseits zu verhin<strong>der</strong>n. Operativ bevorzugen wir die Rekonstruktion. 16.11 T. Wolff 1 , A.L. Jacob 2 , P. Stierli 3 , W. Brett 4 1 Zentrum für Gefässchirurgie Aarau-Basel, Universitätsspital Basel, 4031 Basel/CH, 2 Interventional Radiology, University Hospital Basel, 4056 Basel/CH, 3 Gefässchirurgie, Kantonsspital Aarau, Aarau/CH, 4Klinik für Herz- Und Thoraxchirurgie, Universitätsspital Basel, Basel/CH „Reverse axillo-femoral bypass“ as a salvage procedure in a patient with progressive neurological deficits after accidental overstenting of the supraaortic vessels Objective: Placing a stentgraft in the vicinity of the supraaortic vessels is associated with the risk of overstenting the origin of the left carotid artery or brachiocephalic artery. We describe the unconventional „reverse“ use of an axillo-femoral bypass as a salvage procedure to temporarily improve the cerebral circulation. Methods: Case report Results: A 67 year old patient with an asymptomatic aneurysm in the distal aortic arch un<strong>der</strong>went stentgraft treatment. As an anatomic variant he had a „bovine trunc“, a single supraaortic vessel giving rise to the right subclavian and both carotid arteries. The stentgraft was accidentally advanced too far and led to subtotal occlusion of the bovine trunc. Interventional methods to move the stentgraft further distally were not successful. Balloon dilatation of the remaining lumen of the bovine trunc appeared to lead to a satisfactory result, so the procedure was terminated. Postoperatively progressive neurological deficits developed and Duplex sonography showed severely impaired blood flow in both carotid arteries. The patient was urgently reoperated. Primarily a temporary extracorporeal axillo-femoral bypass was placed for immediate restoration of cerebral blood flow. Then the supraaortic vessels were revascularized from the ascending aorta via sternotomy. The patient made a near full recovery. Follow up showed a correctly perfused bypass from the ascending aorta to the bovine trunc and no endoleak. Conclusion: This is the first description of a successful use of an axillo-femoral bypass in the „reverse direction” for temporary improvement of the cerebral circulation. Our case illustrates the challenge of correct stentgraft deployment in the aortic arch and illustrates that emergency surgery for progressive neurological symptoms due to severely impaired cerebral perfusion can be successful. 16.12 A. Stellmes 1 , U. Schnei<strong>der</strong> 2 , P. Knüsel 3 , C. Zollikofer 3 , T. Kocher 2 1 Departement of Surgery, Hospital of Baden, 5404 Baden/CH, 2 Department of Surgery, Hospital of Baden, 5404 Baden/CH, 3 Department of Radiology, Hospital of Baden, 5404 Baden/CH AV-malformations in both lungs in Osler’s disease as explanation for cerebral ischaemic attacks Objective: We present the case of a sporty 29 year old male with a history of transient ischaemic attack with left sided paresis and signs of a non symptomatic PICA-infarction in a MRI 5 years ago. No pathophysiologic explanation could be found at that time. Methods: We now found evidence of av-malformations in both lungs, incidentally diagnosed after a bike accident. These av-malformation could be verified by CT-scan. In the context of a personal and family history of recurrent epistaxis this is very suspicious for Osler`s disease. Results: The av-malformations were treated by angiographic embolisation. The postinterventional course was uneventful. Conclusion: According to several reports, Osler`s disease represents a possible explanation for the ischaemic events in this young man. 16.13 T. Wolff 1 , T. Eugster 2 , A.L. Jacob 3 , R. Hügli 4 , P. Stierli 5 , L. Gürke 6 1 Zentrum für Gefässchirurgie Aarau-Basel, Universitätsspital Basel, 4031 Basel/CH, 2 Gefässchirurgie, Universitätsspital Basel, 4031 Basel/CH, 3 Interventional Radiology, University Hospital Basel, 4056 Basel/CH, 4 Radiology, Universitätsspital, Basel/CH, 5 Gefässchirurgie, Kantonsspital Aarau, Aarau/CH, 6 Gefässchirurgie, Universitätsspital Basel, Basel/CH Paraplegia caused by aortic intramural haematoma with total obstruction of the descending aorta full recovery after CSF drainage and emergency stentgraft placement Objective: We describe the case of a patient where intramural haematoma in the descending aorta led to sudden complete aortic obstruction causing paraplegia and life-threatening hypoperfusion of the visceral organs and lower extremities. Methods: Case report Results: A 62 year old patient presented with pulmonary edema and extremely high blood pressure. On lowering her blood pressure she developed paraplegia and acute renal failure. CT revealed complete obstruction of the descending aorta caused by an intramural haematoma. There was no false lumen or other sign of aortic dissection. Treatment consisted of immediate cerebrospinal fluid drainage and reopening the aortic lumen by placing a TAG stentgraft. Reperfusion was established 5 hours after the onset of neurological symptoms. Postoperatively the patient made a full recovery from paraplegia and renal function returned to normal. The patient developed an occlusion of the origin of the left subclavian artery 6 months postoperatively. The occluding material removed from the vessel lumen consisted of cells from an intimal sarcoma. In retrospect the intramural haematoma had probably formed at the site of the primary tumor and was caused by tumor hemorrhage. The connection between the intramural haematoma and the intimal sarcoma remains unclear because on the CT 6 months after initial treatment there is no clear evidence of tumor and the original haematoma at the site of aortic obstruction is not visible anymore. Conclusion: Both, intramural haematoma leading to complete obstruction of the aorta and full recovery from paraplegia after endovascular treatment of aortic occlusion have not been described before. We believe that the salient features of our case acute complete obstruction of the descending aorta and full recovery from paraplegia after rapid endovascular treatment are not specific to the intramural haematoma being caused by a tumor. swiss knife 2006; special edition 33
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