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suffered visceral ischemia 30d postoperatively with repetitive bowel resection although an aorto-mesenteric
bypass was performed. Preoperative neurological symptoms disappeared.
Conclusion: Revascularization of both carotid arteries has several problems. First of all the site of the
inflow has to be evaluated. Further on neurological problems due to clamping or embolism have to be
prevented. Simultaneous revascularization of both carotid arteries bears a high risk of postoperative
hyperperfusion syndrome according to the literature. In our cases inflow from the ascending aorta and
staged carotid revascularization were chosen. Postoperative problems are frequent due the multivascular
disease in these patients as presented by the second patient.
62.2
Palma procedure to re-establish venous outflow in a case of common Iliac vein aplasia
C. Geppert 1 , R. Marti 1 , L. Gürke 2 , P. Stierli 1,2 ( 1 Aarau, 2 Basel)
Objective: A 45yr old man presented with an acutely swollen left leg & phlegmasia coerulea dolens. No
previous history of deep venous thrombosis, pulmonary embolism (PE) or thrombophilia. There were
clinical signs of chronic venous insufficiency in both legs. The diagnosis of an acute iliofemoral vein
thrombosis (IFVT) was confirmed by duplex sonography & CT scan with additional bilateral peripheral
PEs. There was a high suspicion of an aplasia of the left common iliac vein (CIV) with well-established
collateral circulation from the left internal iliac & testicular vein.
Methods: Surgical thrombectomy at the level of the common femoral vein (CFV) & local thrombolysis
with 300’000 IE urokinase over the posterior tibial vein. Successful Fogarty manoeuvre distally
& proximally with 10mmHg PEEP. Intra-operative phlebography confirmed the suspected aplasia of
the CIV with effortless intubation of the left testicular and renal vein. Almost all collateral veins were
thrombosed. Imperative decision to establish outflow via a crossover procedure. The contralateral
great saphenous vein (GSV) measured less than 4mm diameter, too small to be employed as an autologous
spiral graft. Decision to perform an adapted femoro-iliac Palma Procedure with a 10mm,
externally supported ePTFE graft.
Results: Oblique, retroperitoneal incision & exposition of the right external iliac vein (EIV). End-to-side
graft-anastomosis with left CFV, retropubic tunnelling of the graft under the inguinal ligaments & endto-side-anastomosis
with the right EIV. Due to diffident venous drainage & to improve flow & patency,
we created an AV-fistula. We used the contralateral GSV as interpositional graft between the superficial
femoral artery & GSV. Evident improvement of ingraft flow & immediate decrease in leg swelling.
Conclusion: Compression of the left CIV by an overriding right iliac artery (May-Thurner-Syndrome)
is an infrequent cause for left IFVT. Congenital anomalies are very rare. There are very few reports
of hypo- or aplasia of iliac veins, mostly associated with Klippel-Trenaunay-Syndrome. Occasionally,
membranous occlusion of the suprahepatic IVC with/without hepatic vein thrombosis (Budd-Chiari-
Syndrome) can lead to IFVT. To our knowledge, primary aplasia of the CIV is extremely rare. Salvage
of the leg by establishing venous drainage is performed by cross-pubic bypass (Palma Procedure),
ideally with autologous GSV.
62.3
Synchrotron micro-computed tomography (SR-micro-CT) to quantify neovascularisation of a porous
vascular graft material on the capillary level
C. Schmidt 1,2 , L. Brülhart 2 , N. Lindenblatt 2 , L. Nebuloni 2 , G. Kuhn 2 , D. Bezuidenhout 3 , K. Marquart 2 ,
S. Hoerstrup 2 ( 1 Schaffhausen, 2 Zurich, 3 Cape Town/ZA)
Objective: Vascularisation of scaffold materials is regarded as a prerequisite for the adequate integration
of tissue engineered constructs. However, quantification of neovascularisation of a porous vascular
graft material aiming at autologous transmural endothelialisation by histological methods is time
consuming and often restricted to a limited number of sections. Recently, micro-computed tomography
has been shown to allow the evaluation of three dimensional vascular networks within biomaterials.
Moreover, synchrotron micro-CT (SR-micro-CT) provides the high resolution necessary to visualize
complete vascular networks including capillaries. Here we present the visualization and morphometric
analysis of neovascularisation of Polyurethane scaffolds by SR-micro-CT.
Methods: Porous Polyurethane (PU) discs (diameter 5.4mm, thickness 400μm, pore size 150μm)
were implanted in dorsal skinfold chambers of C57BL/6J mice for 10 days (n=7). After sacrifice, the
circulatory system of the mice was perfused with a leadchromate containing silicone rubber (Microfil_).
SR-micro-CT scanning (nominal resolution 1.48μm, energy 23KeV, exposure time 360ms) was
performed at the TOMCAT beamline at the Swiss Light Source, Paul Scherrer Institute, Villigen, Switzerland,
on 6 volumes of interest per chamber (3 inside and 3 outside the PU disc). Vascular parameters
such as vessel diameter, vessel density, vessel length and junction number density were evaluated
using the method described by Heinzer et al. 2007.
Results: Neovascularisation within PU discs appeared to be evenly distributed and could be quantified
in a three dimensional fashion between 5.3μm and 146μm diameter. Mean vessel diameter was
18.05±5.9μm, vessel length 55.29±7.54μm, vessel density 3.86±3.22% and junction number density
607.33±333.10 [1/mm^3]. There was no difference between vessels inside PU discs and outside
in the parameters evaluated.
Conclusion: The use of SR-micro-CT allows a detailed visualization and quantification of capillaries
inside the porous biomaterial Polyurethane in a three dimensional fashion. Since the micro vascular
network inside the PU shows a physiologic architecture, transmural neovascularisation of porous PU
appears to be a promising concept for the spontaneous endothelialisation of a synthetic vascular graft
material.
52 swiss knife 2010; 7: special edition
62.4
A special deal to heal a patient on hemodialysis with steal
D. Danzer, M. Czerny, M. K. Widmer (Berne)
Objective: Clinical relevant steal syndrome after vascular access surgery has a prevalence of 1- 4%
and is far less common when the radial artery is used compared with the brachial artery.
Methods: A 51year old man on dialysis presented a critical hand ischemia with rest pain and a non
healing ulcer two years after proximalisation of a previous distal radio-cephalic av fistula. The flow
rate of the shunt was 450 ml/ min. The angiogram showed a distally thrombosed ulnar artery and
an occluded radial artery between the first and second anastomoses. The vein of initial radio-cephalic
fistula was still patent. In order to correct the hand ischemia we performed a valvulotomy of this vein
and made a cubital anastomosis between the brachial artery and the vein to improve direct flow to
the hand.
Results: After surgery the patient showed a palpable radial pulse with normalisation of the skin temperature.
After 4 months the clinical status was significantly improved with restored sensibility, no pain
at rest or exertion and a healed ulcer.
Conclusion: Due to the anatomical finding and creative planning it was possible to perform a distal
revascularisation operation without interval ligation to heal a patient with a critical ischemia of the
hand originating from steal whilst at the same time preserving his well functioning av fistula.
62.5
Verschluss der A. iliaca externa beidseits induziert durch Extremradsport
M. Koeppel, R. Kuster, W. Nagel (St. Gallen)
Objective: Anhand der Krankengeschichte eines 46-jährigen Patienten mit bilateralem Verschluss der
A. iliaca externa induziert durch langjähriges, intensives Fahrradfahren, werden die operativen Möglichkeiten
und der Heilungsverlauf dargestellt.
Methods: Case report.
Results: Anamnestisch Ausüben von langjährigem, wettkampfmässigem Mountainbike-Sport. Bereits
vor 16 Jahren wurde, bei einem Verschluss der A. iliaca externa rechts, eine Thrombendarterektomie
mit Venenpatchplastik durchgeführt. Es zeigte sich eine vollständige Remission der Beschwerden nach
der Operation. Nun seit ca. 9 Jahren progrediente Claudicatiobeschwerden kontralateral bei genanntem
exzessivem Radsport ohne kardiovaskuläre Risikofaktoren. Eine MR-Angiographie bestätigt den
Verdacht auf einen Verschluss der linken A. iliaca externa über eine Länge von ca. 3,5 cm, distal der
Iliakalbifurkation beginnend. Perfusion der Beinachse durch Kollateralisierung über die A. circumflexa
iliaca profunda der A. iliaca interna bis auf Höhe des Leistenbandes. Starke Beeinträchtigung des
Patienten beim Sport in Form von Kribbeln im linken Fuss, rsp. Schmerzen im dorsalen Oberschenkel
während körperlicher Höchstleistungen. Stellen der Indikation zur Thrombendarterektomie der linken A.
iliaca externa. Komplikationsloses Durchführen der retroperitonealen Thrombendarterektomie mit Einnähen
eines Dacron-Silber-Patches und intraoperativer Embolektomie mit gutem Backflow. Postoperative
Normalisierung der Verschlussdruckwerte. Medikamentöse Versorgung mit Plavix und Umstellung
auf ASS lebenslang nach 6 Wochen. Vollständige Regredienz der Symptomatik linksseitig im Verlauf.
Conclusion: In der Literatur finden sich gut dokumentierte Fälle von Beckenarterienstenosen bei Langstreckenläufern
oder Radrennfahrern. Als Pathomechanismen werden fibromuskuläre Dysplasien der
Media, sowie Dissektionen durch Intimaläsionen unter massiver Steigerung des Herzminutenvolumens
bei Belastung diskutiert. Eine Thrombozyten-aggregationshemmung in der sportlichen Leistungsphase
könnte prophylaktisch eingesetzt werden. Die operative Therapie zeigt in unserem Fall, sowie in
der Literatur gute Resultate bei einem kardiovaskulär ansonsten risikofreiem Patientengut.
62.6
Reversed axillofemoral („femoro-axillary“) bypass to improve the cerebral perfusion
T. Wolff 1 , T. Eugster 1 , C. Rouden 1 , L. Gürke 1 , P. Stierli 1,2 ( 1 Basel, 2 Aarau)
Objective: Bypass grafting from the ascending aorta to the supraaortic vessels via a sternotomy for
the treatment of atherosclerotic occlusions in elderly, polymorbid patients is associated with significant
morbidity. We describe an unusual technique to improve the cerebral circulation in selected situations.
Methods: A 77 year old woman was admitted with worsening symptoms of orthostatic dizziness and
recurring falls. Shortly before admission, the spells had increased in frequency, occurring several times
per day, leading to brief periods of loss of consciousness and had altogether incapacitated the patient.
Duplex scan followed by MR and CT angiography revealed complex supraaortic occlusive disease with
complete occlusion of the left common and internal carotid, occlusion of the left subclavian and tight,
heavily calcified stenosis of the brachio-cephalic artery. The distal brachio-cephalic artery, the right
subclavian and the right common carotid artery were unstenosed. Balloon dilatation and stenting of
the brachio-cephalic artery stenosis was declined because of tortuous vessel anatomy and the risk of
cerebral ischemia during stent placement. Aorto-carotid bypass was considered only as a second line
treatment, primarily because of the patient‘s age and comorbidities and because it was not altogether
certain that the neurological symptoms were due to cerebral hypoperfusion. We revascularized the
right subclavian artery from the groin with a reversed axillofemoral („femoro-axillary“) bypass using
a 8mm PTFE graft.
Results: Since the operation the bouts of dizziness and loss of consciousness have altogether disappeared
and the patient leads a very active life again. Postoperative duplex scans and MR angiography
revealed an improved flow in the right carotid and vertebral artery and an unstenosed bypass.
Conclusion: This is only the third report in the literature of the use of an axillofemoral bypass to improve
the cerebral circulation. The procedure should be kept in mind when discussing the treatment of proximal
lesions of the brachiocephalic artery not amenable to endovascular techniques, since it avoids
the morbidity of aorto-carotid byass due to the sternotomy, the clamping of the ascending aorta and
carotid arteries and intraoperative cerebral ischemia. Although no long term experience is available it
can be assumed that patency is inferior to aorto-carotid bypass.