Spinal cord ischemia--use of spinal-evoked potentials for intraoperative monitoring in thoraco-abdominal aortic aneurysm (TAA) repair.
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Afferent Pathways↗
Biomedical subjects
W Sandmann
Publications and source records attributed to W Sandmann.
[Intraoperative quality control after vascular surgery reconstruction of kidney and visceral arteries: personal experiences with intraoperative angioscopy].
Angioscopy was applied as a way of intra-operative assessment after surgical reconstruction of renal and visceral arteries in 15 patients. Angioscopy resulted in relevant findings, which in part, demanded immediate intra-operative consequences. Angioscopy turned out to be a sensitive way of surveillance, the findings were easy to interpret.
Angioscopy↗
[Vascular surgery operations in tumor diseases].
In a retrospective analysis covering 10 years, we examined 53 patients with malignant tumors, who had undergone 74 vascular reconstructive operations. The rate of all complications was 40%. Thirty-two patients died within a period of 3.1 years because their tumor progression; the survival rate after an average of 6.9 years was 65.6%.
Aortic Aneurysm, Abdominal↗
[Abdominal aortic aneurysm--is surgical therapy in over 80-year-old patients justified?].
Abdominal aortic aneurysm repair in patients of 80 years and older has been performed in 51 patients over a period of ten years from 1985 to 1995; one-third of these patients underwent emergency operation for ruptures. The low mortality rate of 3.2% for the elective repair and the good long time survival expectancy, which does not differ very much from the life expectancy of the general population over 80 years, justify the elective abdominal aortic aneurysm repair in octogenarians. The high mortality rate of 69.2% in the case of rupture emphasizes the importance of elective aneurysm repair.
Aged↗
Surgical treatment of septic deep venous thrombosis.
BACKGROUND: Septic deep venous thrombosis (SDVT) is an uncommon but occasionally lethal disease caused by systemic complications. In most cases reported in the literature SDVT is caused by intravenous drug abuse or transvenous catheter lines. Conservative management with antibiotic drugs and systemic anticoagulation is usually successful, and the surgical approach is regarded as not indicated or unnecessary. Occasionally, however, conservative management fails, thrombosis progresses, and septic embolism develops. METHODS: In a 7-year period five patients (three male and two female; mean age, 21.2 years), three with severe systemic complications of SDVT (femoropopliteal, 1; iliofemoral, 1; iliofemoral+vena cava, 3), were treated by venous thrombectomy in addition to intravenous antibiotic administration. Simultaneous transabdominal caval thrombectomy was performed twice. RESULTS: Two patients suffered from respiratory failure caused by previous septic embolization. One patient had experienced multiorgan failure before thrombectomy was performed. Intensive care was necessary for all patients (mean, 28 days). All patients survived. CONCLUSIONS: In complicated cases of SDVT without improvement or even impairment after conservative management, venous thrombectomy is a lifesaving treatment.
Adolescent↗
New developments in vascular surgery: a young journal changes its title.
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Angioplasty↗
[Surgical treatment of thoraco-abdominal aneurysm. Indications and results].
Aortic replacement for thoraco-abdominal aneurysms remains a major challenge in vascular surgery. Related symptoms, maximal diameter > 6 cm, progression, aneurysm sac containing none or excentric thrombi and uncontrollable hypertension are factors in favour of surgery, if the general condition of the patient allows the operation. Patients with aneurysms < 5 cm maximal diameter, tube-size aneurysms, heavy calcification of the aortic wall, concentric thrombi within the aneurysmal sac and significant cardiopulmonary risks should be treated conservatively. Patients in good general condition with aneurysms around 5 cm maximal diameter should be controlled by computed tomography in 6 to 12 months intervals and in the case of progression surgery can be recommended despite missing symptoms. Crawford developed the 'graft-inclusion-technique', which combines the 'ingraft'-technique with reattachment of renal, visceral and segmental arteries. The 'clamp and repair' principle is used in patients with sufficient cardiac function. Otherwise shunt or left sided heart bypass are used to reduce cardiac afterload. According to the literature local cooling (flush perfusion), cytoprotective drugs and numerous methods to maintain or ameliorate distal aortic perfusion during clamping ischemia have been used in patients successfully for prevention of ischemic spinal complications. In physiological settings these methods may prove valuable, but under pathophysiological conditions of TAAA-repair one must doubt the efficacy, because the individual risk is difficult to assess. In our hands flush perfusion and cooling of the kidneys proved to be helpful. In animal experiments we have shown prolongation of ischemia tolerance time using eicosanoides to protect the kidneys and the spinal cord. If shunt or left-sided heart bypass can protect the spinal cord during clamping, is unknown, because the risk of paraplegia in the individual patient can be known only, if the function of the spinal cord is monitored. We have developed a spinal neuromonitoring system and found, that only one third of all TAAA-patients is at high risk to develop paraplegia during aortic clamping. The surgeon is guided by continuous recording of spinal evoked somatosensory potentials and can adapt the operative technique by early reimplantation and eventually subsequent separate reimplantation of segmental arteries supplying blood to the spinal cord, in order to reduce spinal ischemia time. Our results in 260 TAAA-patients are presented. In a high-risk population of patients with aneurysms type I-III (Crawford's classification) it was possible, to reduce the paraplegia rate from 7 to 3.5%, the risk of paraparesis from 15 to 6%, while the operative mortality was only reduced from 19 to 10%.
Adult↗
[Angioscopy as intraoperative outcome control after reconstructive surgery of the renal arteries: presentation of a new method].
Main reasons for obstruction of renal arteries are atherosclerosis and fibromuscular dysplasia. In our clinic transaortic renal endarterectomy and interposition of a vein segment are preferred for arterial reconstruction. The surveillance of the distal intimal ridge after blind transaortic endarterectomy is still an unsolved problem, and the distal anastomosis of a vein graft must be checked, as it is performed under difficult conditions, if the suture is done in situ. We introduce angioscopy as a means of intraoperative surveillance.
Anastomosis, Surgical↗
[Open indications for endovascular surgery].
Endovascular techniques are becoming a part of minimally invasive surgery. The AIM is either preservation or reconstruction of the vascular lumen without the risk involved in conventional reconstructive procedures. The therapeutic success is often only palliative and not durable, because only the local cause of the disease is excluded and not removed definitively. Despite improvement in the technical equipment the indication for endovascular surgical treatment remains questionable and is the subject of experimental vascular research. Like other innovative procedures, the place for endovascular procedures will emerge in relation to the individual patient risk patient concerning age, concomitant diseases and cardiorespiratory conditions. In comparison to conventional reconstructive procedures endovascular techniques are being strongly pushed by specialists and industry because the risks of treatment are believed to be significantly lower. However, the risks of conventional vascular reconstruction are often overestimated and, as a rule, the failure rate in endovascular reconstructive surgery is often underestimated.
Angioplasty, Balloon↗
[Surgical therapy of occlusions of the brachiocephalic trunk: long-term follow-up after transthoracic reconstruction].
Hemodynamically relevant lesions of the innominate artery can be treated either by extraanatomic bypass or by intrathoracic repair. 32 patients were retrospectively evaluated after ascending aorta to innominate artery interposition graft. In all except 6 cases additional bypass-procedures to extracranial vessels were necessary for complete revascularisation. The patency rate was 100% after a mean follow up period of 871 days. Only one patient suffered from a perioperative stroke with upper extremity paresis which resolved after 2 weeks. There were 3 wound complications which required reoperation. In conclusion we believe that direct intrathoracic repair for innominate artery occlusion can be recommended as a treatment of choice with a high long-term patency rate.
Adult↗
[Chronic mesenteric ischemia].
Thirty-four patients (twelve men, 22 women, mean age 53[16-71] years) with chronic mesenteric ischaemia were operated upon between 1979 and 1992. The most frequent symptom was loss of weight (50%) and postprandial pain (44%). The mean interval between onset of symptoms and diagnosis was 35 months. Angiography revealed disease of the coeliac trunk (CT) or the superior mesenteric artery (SMA) in 16 patients, of only the SMA in ten, and of only the CT in eight. Revascularisation was obtained with an autologous vein graft in 21 patients (on the TC in 12, AMS in nine), while transaortic endarterectomy was performed in 15 (on the CT in seven, the AMS in nine). There was one perioperative death. 20 patients were symptom-free 1-126 months after the operation, while five still had residual symptoms even though improved in three. Seven patients had a recurrence of symptoms, three immediately after operation and four after an initial symptom-free period. These results show that freedom from symptoms can be achieved even in advanced stages of chronic mesenteric ischaemia by reconstructive surgery of the intestinal and visceral arteries. However, residual symptoms that are possibly not of a vascular nature may persist after successful vascular reconstruction. Patients with recurrent obstruction may become symptom-free by repeat surgery even many years later.
Adolescent↗
Complications following caval interruption.
Caval interruption is widely regarded as the treatment of choice for the prevention of recurrent pulmonary embolism (PE). The safety, ease of insertion and "convenience" of the devices are the main arguments for filter placement. Today many filters are placed for prophylactic reasons, sometimes without an established diagnosis of pulmonary embolism or underlying deep venous thrombosis. Early and late complications have been published but the rate is reported to be low, although only limited numbers of patients have been followed. In an 18-year period 11 patients with problems following caval interruption were treated, 10 with acute complications, one with chronic caval occlusion. Six were treated conservatively, five underwent venous thrombectomy and a.v.-fistula. The device was removed in four. During the same period only three permanent filters were placed in our hospital (two with complications). Caval interruption is useful in selected high-risk patients and is the least invasive but not necessarily the best treatment. Provided stringent criteria are applied, the early and late complications can be accepted in order to prevent sudden death in patients with threatening massive PE. Extended or more liberal indications for caval interruption are neither necessary nor justified.
Adult↗
[Fresh homologous arterial transplant as aorto-iliac-femoral vascular replacement in prosthesis infection].
A patient with late graft infection in the groin following aorto-bifemoral-Dacron-bypass and recurrent infection of extra-anatomic bypasses is presented. Despite the evidence or graft infection (by preoperative imaging studies and intraoperative perigraft purulence) cultures did not identify the infective organism. Retrospectively a graft infection with Staphylococcus epidermidis is supposed as the most likely cause. A graft replacement with freshly harvested, not cryopreserved arterial homograft was performed. The perfusion of the extremities was excellent, the wounds healed perfectly. In special indications freshly harvested cadaveric arterial homografts are an acceptable substitute for infected aorto-femoral grafts.
Aorta, Abdominal↗
[Subclavian-carotid transposition--experience in the treatment of arteriosclerotic lesions of the carotid artery near its origin].
Symptomatic atherosclerotic lesions of the subclavian artery are rare. A special treatment is necessary and consists today of various extrathoracic bypass procedures or a subclavian-carotid-transposition. The latter is our preferred kind of therapy. 116 patients (57 female, 59 male, mean age 59.1 years, 116 operations) underwent subclavian-carotid-transposition for symptomatic subclavian artery lesion of the first segment. In 33.6% a thrombendarterectomy of the ipsilateral carotid bifurcation and in 19% an open or eversion thrombendarterectomy of the second segment of the subclavian artery and/or the vertebral artery had to be performed. 3 patients (2.6%) died perioperatively (myocardial infarction 2, cerebral infarction 1). In 3 out of 4 early postop, thrombosed transpositions patency was restored successfully. 70 patients (74.5% of the patients alive) were followed for in the mean 58.6 +/- 41.5 months. The transposition was found to be patent in 67 (95.7%) patients, a mild stenosis presented 2, an occlusion 1 (occluded perioperatively). The cumulative patency rate (126 months) was 95%. Subclavian-carotid transposition is in contrast to bypass procedures a more difficile treatment for symptomatic subclavian lesions with various advantages. Besides an orthograde inflow to subclavian and vertebral artery and the construction of simply one anastomosis with wall segments of identical compliance the main advantage is the avoidance of any autogenous or artificial bypass material. Excellent long-term results underline that this therapy is the more elegant and better concept treating subclavian artery lesions of the first segment.
Adult↗
Thrombectomy with arteriovenous fistula for embolizing deep venous thrombosis: an alternative therapy for prevention of recurrent pulmonary embolism.
Thrombectomy with arteriovenous fistula was performed between 1977 and 1988 in 103 patients (41 females, 62 males, mean age 46.7 years, 114 involved extremities) with embolizing deep-vein thrombosis (DVT). The sole aim of the surgical procedure was prevention of recurrent embolization. On the basis of the proximal extent of the thrombosis the source of embolization was identified as the iliac veins or inferior vena cava in 63% of the patients; 48% presented with a post-phlebitic vein and/or an older thrombosis, and 46% had already had recurrent pulmonary emboli. Unsuccessful aggressive procedures had been carried out previously in 11%. The rate of intraoperative pulmonary embolism (PE) was 3% (one fatal case). The perioperative mortality was 6.8%, but only one death was related to the surgical treatment itself. During follow-up (8-140 months postoperatively, mean 55 +/- 34 months) late recurrent PE was confirmed in two patients (antithrombin III deficiency, contralateral DVT) and was reported as the suspected cause of death in a third (3.6%). Venous thrombectomy with arteriovenous fistula is a reliable and effective procedure for management of embolizing DVT and is indicated especially in young patients. The rates of early- and late-recurrent PE are low, introduction of artificial material into the vein can be avoided, and long-term preservation of valve function is occasionally possible.
Adolescent↗
Spinal evoked potential in patients undergoing thoracoabdominal aortic reconstruction: a prognostic indicator of postoperative motor deficit.
We studied 76 patients who had thoracoabdominal aortic reconstruction between January 1981 and March 1991. Evoked potential monitoring of the spinal cord (peridural bipolar catheter stimulation at level L4-L5, recording via a second bipolar catheter at level Th4) was used to predict intraoperatively a possible motor deficit. There was a close linear correlation of r = 0.892 between postoperative motor deficit (normal, paraparesis, paraplegia) and the time from declamping to reappearance of the potential. Forty-three of 76 patients received prostaglandin E1 (5 ng/kg/min) for pharmacologic protection of the spinal cord 15 minutes before onset of clamping and through the entire clamping period. Patients with protection had a loss of their potential significantly later (20.2 min; p < 0.05) than those patients who had not received any pharmacologic treatment (15.2 min). Pharmacologic protection also resulted in a reduced incidence of postoperative neurologic deficit and paraplegia when compared with patients receiving no treatment (25% vs 5%). These data suggest that spinal evoked potentials may be very useful for monitoring during these hazardous cases. They also suggest that pharmacologic protection before clamping may help preserve the function of the spinal cord during aortic clamping.
Aged↗
Somatosensory evoked potential, a prognostic tool for the recovery of motor function following malperfusion of the spinal cord: studies in dogs.
The potential usefulness of somatosensory evoked potential monitoring during aortic cross-clamping is slowly being realized. In addition, the protection of endangered spinal nervous tissue during aortic cross-clamping has not been sufficiently evaluated. To test the pharmacologic protective efficacy of various agents, we recorded spinal evoked somatosensory potentials (bipolar epidural catheter) in dogs under controlled conditions (N2O/O2-enflurane anesthesia) following clamping of the aorta for 1 hour. There were 5 groups of animals: those treated with different medications, such as prostaglandin E1 (PGE1), prostacyclin (PGI2), superoxide dismutase (SOD), and PGE1 plus SOD for pharmacologic protection during ischemia, and the controls. The time to recovery of evoked potentials during the reperfusion period was 36 minutes in the controls, 15.9 minutes in the SOD group (p < 0.01), 12.5 minutes in the PGE1 group (p < 0.001), 10.8 minutes in the PGI2 group (p < 0.001), and 3.8 minutes in the combination group (p < 0.001). In addition, treatment resulted in a better neurologic outcome on the seventh postoperative day when compared with the control group. While in the control group only 1 animal could walk (9%), 7 of 12 in the PGE1 group (58%), 4 of 12 in the SOD group (33.8%), 8 of 12 in the PGI2 group (66.7%), and all animals in the combination group (100%) could walk. We computed an exponential correlation that related the mean time of potential recovery during reperfusion with Tarlov scoring (grade 0 = paraplegia; grade 1 = paraplegia with little movements; grade 2 = paraparesis; grade 3 = paraparesis with some problems; grade 4 = normal motor function) in the various groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Alprostadil↗
In situ replacement of infected vascular prostheses with rifampin-soaked vascular grafts: early results.
Based on the excellent results of experimental studies with antibiotic-bonded vascular prostheses for prevention of graft infection, gelatin-sealed grafts soaked with rifampin were implanted in situ in five patients with vascular infection. All patients were at risk for limb loss or death and could not be treated by standard techniques such as graft excision and extra-anatomic bypass. In one patient an infected aortic stump aneurysm with involvement of both renal and visceral arteries was found. He was treated by implantation of a bifurcation rifampin-soaked graft between the subdiaphragmal aorta and both renal arteries and reimplantation of celiac and superior mesenteric artery into the graft. In four patients with in-flow or runoff problems on angiography, an antibiotic-soaked graft was used for replacement of a partially or totally infected graft. Cultures were positive for Staphylococcus aureus in three and coagulase-negative staphylococci in two patients. Wound healing was uncomplicated; there was no need for amputation. After a follow-up of at least 6 months, all grafts were patent without any evidence of reinfection on computed tomographic scan. We conclude that infected vascular prostheses can be replaced in situ by rifampin-soaked grafts in patients at high risk for death or major amputation.
Aged↗