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Conclusion: In our patient cohort, CAS was significantly more often associated with the postinterventional
MRI finding of fresh – and therefore likely intervention-associated - cerebral ischemias than CEA.
This result warrants further investigations with regard to its clinical relevance and a possible association
with patient symptoms.
34.3
Novel biodegradable vascular prosthesis: short-term results after carotid artery replacement in the pig
D. Mugnai, W. Mrowczynski, S. de Valence, J.-C. Tille, E. Khabiri, R. Gurny, A. Kalangos, M. Moeller,
B. H. Walpoth (Geneva)
Objective: There is a continuous search for shelf-ready small-caliber vascular prostheses. Biodegradable
scaffolds, repopulated by recipient’s cells regenerating a neo-vessel, can be a suitable option for
both adult and pediatric, urgent and elective cardiovascular procedures. We assessed a new biodegradable
vascular prosthesis for arterial replacement in the pig.
Methods: Ten anesthetized pigs underwent bilateral carotid artery replacement with biodegradable
electrospun Poly(e-caprolactone) (PCL) nanofibre prostheses (4mm-ID; 5cm-long); or expandedpolytetrafluoroethylene
(ePTFE) prostheses serving as control. Peri-operative anticoagulation was
achieved with intravenous heparin (double baseline ACT). Post-operatively, until conclusion of the
study at 1-month, animals received aspirin daily. Transit Time Flow (TTF) was measured intra-operatively
and at sacrifice. Doppler ultrasound follow-up was performed at 1 and 4 weeks when a selective
carotid angiography assessed patency. Graft examination consisted of histology with special stainings,
planimetry and SEM.
Results: Surgical handling and haemostasis of the new prostheses were excellent. Patency rate was
78% (7/9) for PCL grafts, compared to 70% (7/10) for ePTFE grafts. TTF and Doppler ultrasound
showed no significant changes in flow and velocity or diameter over time in both groups. Both prostheses
showed minimal in vivo compliance as compared to native carotid artery. Neoendothelialisation
was 79% for PCL and 80% for ePTFE grafts. Neointima formation was limited in both grafts. The PCL
graft was partially infiltrated from the adventitia by macrophages, myofibroblasts and capilleries with
a mild foreign-body reaction and focal thrombus formation.
Conclusion: Biodegradable, electrospun PCL grafts showed good surgical properties, no aneurysm
formation and similar short-term patency compared to ePTFE grafts. Rapid, good endothelialisation
and cell ingrowth confirms the hypothesis of in vivo vascular tissue engineering. Despite good early
results long-term follow-up is required before clinical application.
34.4
Treatment of iliofemoral venous thrombosis (IFVT) is a surgical entity – review of 13 surgical
thrombectomies and catheter-directed thrombolysis
C. Geppert 1,2 , R. Marti 1 , P. Hess 3 , L. Gürke 2 , P. Stierli 1,2 ( 1 Aarau, 2 Basel, 3 Luzern)
Objective: The incidence of IFVT in Middle Europe is 0,1-0,3% per year. Those affected are often treated
by physicians & are only referred to surgeons when severe pain &/or swelling of the limb persist. Postthrombotic
syndrome & chronic venous insufficiency (CVI) are early & late sequelae of IFVTs which
need to be avoided at all cost. Surgical thrombectomy combined with catheter-directed thrombolysis
are the most efficient methods to desobliterate the affected veins. To aid patency & improve blood flow
there are recommendations to create a temporary arteriovenous fistula (AVF).
Methods: The study reviewed all surgical thrombectomies performed for IFVT in the past 6 years (electronical
data). End points were postoperative patency & venous competence, complications, mortality
& efficacy of AVF.
Results: There were 11 patients with 7:4 female:male ratio of median age of 38 (range 19-69) years.
All but 1 patient had left-sided IFVT. In total 13 limbs were operated on (1 patient bilateral IFVTs & 1
patient with re-thrombectomy due to early rethrombosis). 4 women were on oral contraceptive therapy,
1 woman developed a IFVT post partum, 1 woman with a hip ganglion & 1 woman with a large metastasis
causing iliac compression. 1 man with prolonged immobilization after pelvic fracture without
prophylactic antithrombotic therapy developed bilateral IFVTs & 1 man was diagnosed with aplasia of
the common iliac vein. All patients underwent surgical thrombectomy & catheter-directed thrombolysis.
In 3 cases a cavotomy due to the extent of the thrombosis was performed. All but 2 patients had
AVF, of which 3 closed spontaneously, 2 thrombosed & 5 were closed surgically after a median of 8
(range 2-14) months. All patients were followed up for a median of 15 (range 2-27) months. In 9 limbs
there was normal venous competence & no CVI. In 2 cases (1 had no AVF; 1 rethrombosed AVF) a
thrombosed external iliac vein remained with good collateral circulation & symptomatic swelling of
the affected limb. 1-yr mortality was 0%, there was 30% complication rate (4 of 13: 1 central venous
catheter-sepsis, 1 seroma, 1 lymphocoele, 1 remaining stenosis due to overriding right iliac artery).
Conclusion: Surgical thrombectomy & catheter-directed thrombolysis prevent early & late sequelae of
IFVT. Controversy remains whether the formation of an AVF is beneficial. The results of our review support
the creation of a temporary AVF.
34.5
Complex surgical treatment of aortic arch complications after stenting of the descending aorta
F. Rüter, B. Winkler, P. Matt, M. T. Grapow, O. Reuthebuch, F. Eckstein (Basel)
Objective: Stenting has become the method of choice in treatment of uncomplicated chronic or acute
dissections and traumatic lesions of the descending aorta. However the advantage of avoiding open
surgery is adherent to possible serious complications. A New Entity of ascending or aortic arch lesions
after stenting of the descending aorta is described on the basis of two clinical cases.
Methods: Report of two serious complications and their complex surgical management.
Results: Case 1: Due to endoleak after primary stenting in acute Type B dissection in a 60 year old
patient, a 2 nd stent with overstenting of the left sublavian artery was implanted succesfully. Routine CT-
scan 3 month later showed retrograde Type A dissection with a large haematoma at the inner curvature
of the aortic arch beginning at the proximal end of the covered stent. Supracoronary replacement
of the ascending aorta and the aortic arch with replantation of brachiocephalic trunk and left carotid
artery with distal anastomosis in “elephant trunk technique” under deep hypothermic circulatory arrest
(DHCA) was performed. Postoperative subclavian steal syndrome was treated with left carotid
to left subclavian artery bypass. Case 2: A 37-year-old patient received urgent stenting of traumatic
descending aortic rupture in the context of multiple trauma after high speed motorcycle accident. CT
scan after rehabilitation showed proximal stent fracture with partial occlusion of the aortic arch due to
inversion into lumen documented by transesophageal echocardiography. Open stent explantation was
performed under DHCA without any complications.
Conclusion: Stenting of descending aortic lesions is associated with possible complications in ascending
and aortic arch. Diagnosis is difficult due to variable occurrence, surgical treatment is complex.
Frequent observation of these patients is mandatory.
34.6
A rare cardiac complication of vascular access steal syndrome
A. Lakomski, S. Mantziari, O. De Rougemont, P. Meier, C. Sierro, C. Haller (Sion)
Objective: The vascular access steal syndrome is a complication occuring after the creation of vascular
access for hemodialysis. We report the case of a man known for terminal renal failure who presented
a myocardial infarction with cardiorespiratory arrest, one year after the creation of a vascular
access.
Methods: A 63-years-old man known for ischemic heart disease with CABG in January 2008, and a
terminal renal failure with a brachio-cephalic native arterio-venous fistula of the left arm created in April
2008, presented a ventricular fibrillation and cardio-respiratory arrest on December 2009. ECG and
cardiac enzymes showed a NSTEMI in the infero-lateral territory. The coronarography two weeks later
showed permeable internal mammary bypass and no significant stenosis, but a fall of pressure in the
left subclavian artery, which led us to suspect a steal syndrome due to the arterio-venous fistula. Left
internal mammary artery is the choice of vascular structure for myocardial revascularizations. An inversion
on this artery’s flow, secondary to pressure drop in proximal subclavian artery is rare, but more
and more often diagnosed. This phenomenon is known as «coronaro-subclavian steal syndrome». This
pathology is more frequent in patients with a subclavian artery stenosis.
Results: In our patient, the pressure drop in the left subclavian artery, due to the arterio-venous fistula
on the same side with a coronary perfusion only due to the left internal mammary artery, could lead
to the myocardial infarction (type 2 by hypoperfusion of the left internal mammary artery). This could
explain the ventricular fibrillation and successive cardiorespiratory arrest with infarction of the inferolateral
territory. A closer of the arterio-venous fistula was made, with recovery of the angina pectoralis
immediately after the procedure. The patient is now dialysed by a left jugular catheter and a new fistula
is scheduled on the right arm.
Conclusion: Heart implication of steal syndrome has not been reported so far. The physiopathology of
this condition is still poorly known. An adequate patient selection for surgery and early management
are both essential to avoid the potentially fatal consequences of this condition.
34.7
Remote external iliac artery endarterectomy – how to pimp an old technique
T. Lattmann, I. Schwegler (Zürich)
Objective: Treatment of chronic external iliac artery (EIA) occlusive disease often requires a considerable
surgical effort by lumbotomy or blind ring stripper endarterectomy. We describe step-by-step a
minimally invasive technique, using fluorosopy, a guide-wire, and an over-the wire fogarthy catheter to
desobliterate the EIA with a classical ring stripper.
Methods: Supine position on the carbon fibre table. Preparation of the femoral vessels through a longitudinal
groin incision. After inspection of the grade of calcification, the CFA is punctured and a 0.35 mm
guide wire is inserted under fluoroscopic guidance followed by placement of an 8 french sheath. Control
of the position under fluoroscopy using a pigtail catheter. The guide wire is changed to a 0.25mm
wire and an arteriotomy of the CFA directly over the sheath is performed. Open endarterctomy is started
in the CFA and a LeMaitre ® over-the-wire fogarthy-catheter (LeMaitre Vascular GmbH, Sulzbach, Germany)
as well as a ring stripper according to the vessel‘s diameter is inserted. The fogarthy catheter
is blocked in the unaffected part of the CIA. The ring stripper is advanced under rotating movements
under fluoroscopic control up to the balloon of the fogarthy catheter. The catheter and the entire intima
core are carefully retracted while the guidewire is left in position until the result is documented by fluoroscopy.
If nessessary the distal intima in the SFA and the profound femoral artery are anchored with
tacking sutures. The arteriotomy is closed with a patch.
Results: Fourteen patients with iliac artery occlusive disease were treated by the two authors using
this technique. Median age was 62.5 (50-86) years, (m:f 6:1 ). Postoperative ankle-brachial index at
discharge significantly improved when compared with the preoperative situation. The intervention was
successful in all cases. Two patients needed conversion to open surgery by a lumbotomy with open
endarterectomy due to an unretractable intima core.
Conclusion: Remote endarterectomy under fluoroscopic guidance using a guide wire and an overthe-wire
fogarthy catheter is a minimaly invasive, elegant and safe technique to desobliterate chronic
external iliac artery occlusions. Using this technique, the risk of vessel peforation is minimized, transsection
of the intima core is controled and a residual stenosis can be treated using a stent in the same
session if nessessary.
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