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

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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 disorders
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 underneath 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
underwent 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 undergoing 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 underwent 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 4.2%, 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 erforderte. Drei Jahre nach dem Eingriff wurde als Zufallsbefund im Rahmen
der Abklärung arthrotischer Kniegelenksbeschwerden klinisch (auskultatorisch) der Verdacht
auf eine AV-Fistel am Unterschenkel gestellt und duplexsonographisch die Diagnose einer
high-flow AV-Fistel der A. tibialis posterior bestätigt. Aufgrund des fehlenden
Spontanverschlusses, sowie des hohen Volumens stellten wir die Indikation zum Verschluss
der AV-Fistel unter Rekonstruktion der 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 Sonderform der traumatischen AV-Fistel dar. Verursachender
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 der Fistel oder einem hohen
Shuntvolumen gegeben um eine Dekompensation einerseits und eine Aneurysmabildung
andererseits zu verhindern. 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 underwent
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. Schneider 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.
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