[Varicose veins--surgical therapy].
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Humans↗
Biomedical subjects
H Loeprecht
Publications and source records attributed to H Loeprecht.
[Diabetic foot--uncontrollable infections despite successful revascularization].
We treated foot ulcerations in diabetics with limb-threatening ischemia using percutaneous balloon dilatation (44) and popliteodistal vein grafts (94). After revascularization, we observed in 12% an increase in the infection which necessitated major amputation despite open bypass or successful dilatation. A diabetic local immunodeficiency leads to cellular and humoral alterations which may cause severe tissue damage although the perfusion has been improved.
Aged↗
Superior mesenteric venous aneurysm.
The case of a 50-year-old woman with an extremely rare venous malformation of the portal venous system is reported. The patient presented with a true aneurysm of the superior mesenteric vein, which has thus far been reported in no more than eight cases worldwide. This malformation may be congenital or acquired. Secondary aneurysms are thought to be due to liver disease, portal hypertension, trauma, or inflammation. Aneurysms of the portomesenteric venous system may be asymptomatic or give rise to severe, often dramatic conditions such as crampy abdominal pain, jaundice, and upper gastrointestinal hemorrhage secondary to portal hypertension. The diagnosis is usually made by ultrasound (B-mode or color flow Doppler), CT scan, and MRI. Invasive procedures such as venous phase mesenteric arteriography or splenoportography may be helpful in confirming it. In our opinion aneurysms of the portal venous system, even if they are congenital and (still) asymptomatic, require early surgical control because the prognosis for patients with these aneurysms is unpredictable and potential complications (e.g., portal hypertension, fistula, contained perforation, or rupture) may be fatal. In the case presented the mesenteric venous aneurysm was resected and the confluent veins were reconstructed.
Aneurysm↗
[Percutaneous transluminal hydrodynamic thrombectomy--the initial results].
PURPOSE: First clinical applications in the femoro-popliteal vessels of a new system for percutaneous, transluminal hydrodynamic thrombectomy are presented. MATERIAL AND METHOD: Three patients suffering from femoro-popliteal thromboembolic obstruction were treated. A new hydrodynamic 8-F catheter with two lumina was used. The jet leaving at the tip of the catheter shredded the thrombotic material. Using the Venturi effect the thrombus was collected. The shredded material was transported outside through the second channel of the catheter. RESULTS: All obstructions could be removed. Underlying degenerative vessel disease and older thromboemboli needed additional therapy like PTA or aspiration thrombectomy (PAT). CONCLUSIONS: The new catheter is helpful in removing arterial femoro-popliteal thromboembolic obstructions. Additional interventions may be necessary. More clinical experience is needed.
Aged↗
[Percutaneous transluminal angioplasty (PTA) of isolated crural arterial stenoses in critical arterial occlusive disease].
PURPOSE: Retrospective analysis of the results after infrapopliteal PTA of isolated crural limb artery stenoses in patients with critical crural limb ischaemia. PATIENTS AND METHODS: Between 1989 and 1994 70 infrapopliteal dilatations of isolated crural limb artery stenoses in 44 patients (47 PTA procedures) were done with small diameter balloon catheters. 45 patients were stage IV according to Fontaine's classification, two patients were stage III. No patient had a relevant obstruction up to the popliteal artery. Follow up ranged from 1-50 months (mean 13.3 months). RESULTS: A technical success with a residual stenosis below 30% compared to the original vessel diameter was achieved in 80% of patients (n = 56). The cumulative limb-salvage rate was 76.6% after 6 to 36 months after PTA. RESULTS: In patients with chronical critical crural limb ischaemia PTA of isolated crural limb artery stenoses is an efficient therapy modality for limb-salvage. In many cases PTA is the last alternative method to amputation surgery if there is no sufficient distal vessel for a bypass.
Aged↗
[Reconstruction of isolated lower leg arteriovenous occlusions in the critical foot ischemia stage--assessment of current status].
Between May 1, 1986 and November 1, 1994 94 distal reconstructions were performed in diabetics with isolated tibioperoneal vessel occlusive disease. Mostly the below knee popliteal artery was used as inflow site and most grafts were anastomosed distally to a malleolar artery. Autologous vein was implanted throughout. Mortality at 30 days was 1.06%. Primary and secondary cumulative patency rates were 78% and 82% at 1 year, 65% and 78% at 5 years. Limb salvage rates were 76% at 1 year and 72% at 5 years. Major amputations became inevitable in 12 cases of uncontrollable foot infections despite patent grafts. This is probably due to the diabetic immunopathy. The experience we have gained suggests that distal bypasses in patients with peripheral vascular occlusive disease and critical foot ischemia are excellently suited to attain limb salvage.
Adult↗
[Development of an illness-specific instrument for assessment of quality of life in patients with arterial occlusive disease (Peripheral Arterial Occlusive Disease 86 Questionnaire)].
Impairment in health-related quality of life in patients with peripheral arterial occlusive disease (PAOD) are well-known to clinicians, but due to the lack of disease specific assessment instruments, have not been systematically investigated. We describe the development and psychometric testing of a 86-items patient-based questionnaire for the assessment of the quality of life in PAOD containing 7 dimensions: functional status, pain, symptoms, mood, disease related anxiety, social life and treatment evaluation. The questionnaire was included along with standard questionnaires in a prospective study with 308 patients suffering from PAOD in Fontaine stages I to IV before and one week into treatment. Psychometric testing pertained to reliability (internal consistency, retest), validity (convergent, discriminant) and sensitivity (treatment-related change over time). In addition patient acceptance of the questionnaire was assessed. Psychometric testing yield exellent results regarding scale structure and reliability of the newly developed questionnaire. Validity was reflected in high correlations with standard generic questionnaires and in discriminating in quality of life between patients according to disease severity. The sensitivity was reflected in improved quality of life ratings in patients with improved treadmill performance. Patients needed 20 minutes for responding and rated the questionnaire to be easily understandable and not exhausting. These results show that the newly developed PAVK-86 questionnaire is a reliable, valid and sensitive instrument for the assessment of quality of life in patients with arterial occlusive disease which can be used in clinical studies, epidemiological research and quality assurance programs.
Activities of Daily Living↗
[Infrarenal aortic aneurysm].
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Aortic Aneurysm, Abdominal↗
[Quality of life in peripheral arterial occlusive disease. Multicenter study of quality of life characteristics with a newly developed disease-specific questionnaire].
AIM: Owing to a lack of disease-specific measuring instruments, no systematic investigations of the impairment of the quality of life in patients with peripheral arterial occlusive disease (PAOD) have so far been possible. The aim of the present study, therefore, was to develop an appropriate questionnaire and to submit it to a psychometric test in a sufficiently large number of patients. PATIENTS AND METHOD: A disease-specific questionnaire comprising 86 individual items was developed (PAVK 86) and was tested in a longitudinal study involving 308 patients with confirmed peripheral arterial occlusive disease, Fontaines's stages I to IV. At the same time, three established generic questionnaires were also employed (SF 36, NHP, Every Day Life). RESULTS: Analysis showed that, in comparison with a normal population, the quality of life in patients with PAOD is considerably impaired, in particular by pain, anxiety, general complaints and reduced physical mobility and performance, and is comparable with that of patients suffering from renal carcinoma. In Fontaine's stage III and IV, the quality of life is significantly more greatly impaired than in patients with stage II disease. No differences in quality of life were to be found between Fontaine's stages III and IV. The psychometric test revealed that the PAVK 86 questionnaire is a sensitive, reliable, valid and practicable measuring instrument. CONCLUSION: The PAVK 86 questionnaire is suitable for determining the course and outcome of therapeutic measures on the quality of life of PAOD patients, and can therefore be included in clinical studies. In addition, its use in combination with established generic questionnaires also permits a comparison with age-matched healthy control groups, and is thus also of importance for the assessment of aspects of health economics.
Activities of Daily Living↗
[Postoperative digital subtraction angiography after infrainguinal bypass operation].
Bypass occlusions in infrainguinal arterial reconstructions occur in up to 20% within the first postoperative month and are caused by technical defects in most cases. In a prospective study to evaluate the importance of imaging techniques in infrainguinal bypass grafting 81 of 103 bypasses were examined by intraarterial DSA 10 days postoperatively. The findings of early postoperative DSA were compared with the results of intraoperative angioscopy and completion angiography. In 11 cases (13.6%) there were additional pathological findings. In 6 patients stenoses were localized at the proximal anastomosis, which could not be visualized intraoperatively due to technical reasons. In 2 more patients postoperative DSA revealed an occlusion of the distal segment of the recipient artery with a retrograde blood flow in the proximal segment. Further pathological findings were one perianastomotic stenosis caused by a thrombus at a venous valve site and one arteriovenous fistula in an in-situ-bypass. In one more patient angiography showed a stenosis in the outflow tract. The duplex-derived PSV, however, was normal and no revision was made. At present, examination of the proximal anastomosis is possible by intraoperative DSA, but initially unrecognized and secondary bypass defects can only be identified by early postoperative DSA in asymptomatic patients. A final scrutiny of the arterial reconstruction can be achieved by postoperative DSA without any recognizable morbidity before subsequent bypass function is monitored by non invasive methods like duplex sonography.
Adult↗
[The diagnostic value of angioscopy in venous thrombectomy].
Since 1983 angioscopy was applied as a control method in 187 venous thrombectomies to improve the treatment of acute iliofemoral thrombosis. In a retrospective study we tried to show the impact of angioscopy intraoperatively and the influence on long-term results. Thrombectomy was performed in 97 patients affected at three levels, in 50 cases with pelvic-femoral, in 35 with pelvic and in 43 with femoro-tibial thrombosis. The average clinical age of the thrombosis was 5 days, 66% of the patients (age 39 years) were female. The endoscopic findings were compared with phlebological results after one year using a phleboscore between 0 points (occlusion) and 5 points (normal). The phlebographies were analyzed so that the functional status of the vein was represented. After venous thrombectomy 42.8% of the cases were endoscopically classified complete but in 57.2% residual clots were observed. It was possible to completely (24.6%) or partly (18.7%) remove these clots by further thrombectomy maneuvers, non removable remnants were found in 7.5% and a venous spur in 6.4%. The statistical analysis with Kruskal-Wallace test showed significant differences in venous morphology between the endoscopically complete thrombectomies and those with residual clots. After a follow-up period of 30 months (12-64) the clinical results were very good. In 58% we observed normal findings, a cvi grade I in 35%, grade II in 4%. Crural ulcers had developed in only 3%. From our data we conclude that endoscopy is an excellent method for intraoperative quality-control in venous thrombectomy.
Adolescent↗
Intraoperative imaging techniques in infrainguinal arterial bypass grafting: completion angiography versus vascular endoscopy.
This prospective study was designed to establish whether vascular endoscopy would provide more information on the graft lumen than standard completion angiography during infrainguinal bypass surgery. Ninety-nine patients with 102 infragenicular bypass grafts who underwent both angiography and angioscopy intraoperatively were evaluated. In 99 of the 102 patients the indication was critical limb ischaemia. Of the 102 bypass grafts, 81 were autogenous vein. Distally, 24 grafts were anastomosed to the below-knee popliteal segment, 64 extended to the crural and 14 to the pedal arteries. On completion of the distal anastomosis, grafts were first evaluated by angiography and then by angioscopy. The images obtained with the two monitoring modalities were compared by the operating surgeon and re-explorations were performed immediately if necessary. Completion angiography and angioscopy produced images of good quality in 96 and 97 cases, respectively. In 12 cases completion angiography showed abnormalities. Of these, five were located below the distal anastomosis and were not accessible to angioscopic examination. Conduit defects were found in seven instances. In one of them angioscopy showed the angiogram to be false-positive. Of the 90 grafts with normal completion angiograms, seven were found to show significant pathology on angioscopy. Compared to angioscopy, the sensitivity and specificity of angiography to detect abnormalities within the graft was 46% and 98%, respectively. Our results suggest that vascular endoscopy is superior to angiography for disclosing conduit defects, but that it does not provide adequate information about the distal arterial anatomy.
Aged↗
[Follow-up of infra-inguinal bypass operations: value of the peak systolic velocity and arm-ankle index for evaluation of femorodistal reconstructions].
In a prospective study, the efficacy of noninvasive surveillance techniques including measurement of ABI and duplex-derived velocity parameters was studied after 74 infrainguinal arterial reconstructions. A decrease of ABI > or = 0.2 compared with prior examinations was considered abnormal. Results of the duplex scan were interpreted as abnormal when PSV was less than 45 cm/sec or greater than 200 cm/sec or when an interval decrease of greater than 30 cm/sec occurred. All patients meeting any of these criteria during the follow-up examinations were subjected to i.a. DSA. The combination of all duplex velocity criteria was significantly more sensitive to identify a failing graft than was measurement of ABI (90% vs. 18%; p = 0.00004). When independent variables (ABI- and PSV criteria, monophasic curve configuration) were entered into a logistic regression multivariate analysis, the model proved to be effective (F-value 5.551; df 4.8; R2 = 0.735; significance 98.03%; p < 0.02) in predicting angiogram findings (dependent variable). ABI measurements (significance 4.75%; p > 0.95) and the presence of a monophasic curve configuration (significance 89.58%; p > 0.1) failed to reach significance in the multivariate analysis. By excluding these latter parameters, the statistical power for the model could be improved (F-value 1036.57; df 2.1; R2 = 0.999; significance 97.69%; p = 0.0231): As a result normal PSV criteria indicated normal and abnormal angiographic findings in 83 and 17%, respectively. A PSV less than 45 cm/sec or greater than 200 cm/sec was suggestive of an abnormal angiogram in 80% and of a normal angiogram in 20%. The corresponding figures for a PSV interval decrease > 30 cm/sec were 71% and 29%. In conclusion, PSV parameters were found to be measurably more accurate to identify a failing graft than was measurement of ABI.
Aged↗
[Percutaneous balloon dilatation of isolated lesions of the calf arteries in critical ischemia of the leg].
Between 1990 and 1993 we performed 42 percutaneous transluminal balloon angioplasties (PTA) in 30 patients with isolated lesions of crural arteries and limb threatening ischaemia. The average age of the patients was 70.5 years, 90% were diabetics. With low-profile balloon catheters between 2 and 4 mm we dilatated 15 tibioperoneal trunks, 12 anterior tibial arteries, 3 posterior tibial arteries and 12 peroneal arteries. Initial success was achieved in 83% of the dilatations with an average increase of ankle-brachial index of 0.18. After PTA two groin haematomes as the only complications were observed. In 22 cases healing of the acral lesions under local surgical treatment was seen. Two of the clinical unsuccessful patients required popliteopedal bypass surgery and 5 below-knee amputation because of lacking reconstructive possibilities. The follow-up period varied from 1 to 35 months (mean 10.3 months). Life table analysis showed a cumulative limb salvage rate of 82% after one and two years. The PTA of infrapopliteal artery stenoses and occlusions is considered as an effective and safe therapy modality to avoid below-knee amputation in patients with limb threatening ischaemia.
Aged↗
[Value of interventional procedures in treatment of stenotic and occluded infra-inguinal vascular bypasses].
In a prospective study, the results following PTA of 30 short stenoses > 70% in 17 infrainguinal arterial bypass grafts were examined. The stenoses were detected after a mean follow-up of 7.2 months by Duplex-ultrasound. The initial success rate after PTA was 100%. After an average time of 4.6 months recurrent graft stenoses were identified in 8 bypasses and 1 patient experienced graft thrombosis. Overall 8 of the 17 patients with stenotic grafts were treated by PTA alone during a mean follow-up of 11.7 months. Using life-table analysis, primary and assisted primary patency rates were each 100% at 1 month and 41 and 86% at 2 years. The efficacy of thrombolysis in 36 occluded grafts (graft age > 30 days) with clinical symptoms of incomplete ischaemia was analyzed retrospectively. After successful lysis in 61% (22/36), 15 grafts underwent additional procedures including PTA (10), vein patch angioplasty (4) and distal graft extension (1). Following successful initial graft salvage, primary cumulative patency and limb salvage rates were 45 and 72% at 1 month and 16 and 51% at 3 years. PTA of primary graft stenoses may be regarded as an acceptable initial therapeutic option, but has some limitations in providing sustained patency. Grafts initially salvaged with lysis do not have favourable short and long-term patency.
Aged↗
Distal vein graft reconstruction for isolated tibioperoneal vessel occlusive disease in diabetics with critical foot ischaemia--does it work?
Since 1986, 75 distal vein bypass procedures have been performed in 72 diabetics with isolated tibioperoneal vessel occlusive disease for limb salvage. Fifty-six grafts were anastomosed proximally to the below-knee popliteal artery and 19 to the anterior tibial artery. Autologous vein was used in all patients. One patient died within the first postoperative month. Of the occluded grafts, only two which failed during hospitalisation were salvaged. In six patients progressive plantar gangrene necessitated below-knee amputation in spite of graft patency. Using life-table analysis, primary and secondary patency rates were 84 and 86% at 1 year and 71 and 76% at 5 years. One- and five-year limb salvage rates were 81 and 72%, respectively. Distal vein graft reconstruction for limb threatening ischaemia produces excellent patency rates and contributes significantly to limb salvage in these patients.
Aged↗
In situ saphenous vein grafts for femorodistal bypass: evaluation of endoscopically monitored valvulotomy on graft patency.
An overview of a total of 135 in situ femorocrural bypass operations is given. In the operations all grafts were anastomosed distally to the infrapopliteal arteries: to the proximal half of the crural vessels 52 times and to the distal half 83 times. The indication for surgery was critical limb ischaemia. In addition to routine intraoperative angiography, orthograde angioscopy of the graft was carried out to assess the completeness of valvulotomy in 96 patients (group A). In 39 patients (group B) for whom an endoscope was not available, completion angiography was conducted to ensure graft integrity. The two groups were comparable with respect to their composition. On the basis of the endoscopic findings, revisions were performed in 17 patients with incomplete valve ablation in group A, whereas in group B there were no interventions (P < 0.01, chi 2 test). Using life-table analysis, cumulative primary patency rates for groups A and B were 76% and 76% at 30 days, 62% and 44% at 1 year and 43% and 27% at 4 years, respectively. By comparison with the log rank test, a significant difference in patency among both groups could not be established (P = 0.18).
Aged↗
Technique and results of vascular endoscopy in arterial and venous reconstructions.
In an effort to maximize results, vascular endoscopy was used in our institution to monitor arterial and venous reconstructions. Since 1982, angioscopy was applied as a control method in 182 venous thrombectomies to treat iliofemoral thrombosis and 114 aortoiliac thromboendarterectomies. Of the cases with venous thrombectomy reviewed, 50% were incomplete by endoscopic evidence; of these, in 80% the remaining clots could be partly or completely removed. Additionally, in six patients a venous spur was found. Of 114 attempted aortoiliac thromboendarterectomies, only 91 could be completed. In the remainder, endoscopic evidence of persistent intimal flaps forced us to bypass the affected segments. With further miniaturization of the angioscopes, the method was also applied to check vessel repair on small-caliber arteries. In an initial study with 220 femorodistal bypasses we were unable to find a statistically significant difference of primary patency in grafts that were endoscopically controlled or not. In the learning phase with the in situ technique, we identified competent valve remnants in 40%, but this rate could be reduced to 12.7% with growing experience in valvulotomy. We conclude from our data that angioscopy is very helpful in assessing the morphological integrity of aortoiliac thromboendarterectomies and venous thrombectomies. The actual value in infrainguinal arterial reconstructions still remains to be proven.
Angioscopy↗