The aim of this study was to investigate the outcome of patients suffering from benign or malignant superior vena cava (SVC), brachiocephalic (BCV), and subclavian (SV) vein lesions treated with nitinol stents.

Summary Background Uncertainty surrounding the indication for treatment of post carotid-endarterectomy restenosis (pCEAR) exists. Conventional patch angioplasty (rCEA), carotid interposition graft (CIG), and stent-assisted angioplasty (CAS) have been studied; comparisons of these techniques have not been performed. Methods A time to event analysis of consecutive patients undergoing treatment for pCEAR was performed. Primary end-point was any cerebrovascular or myocardial event or death. Long-term results were expressed in Kaplan–Meier estimates. Results From 02/1997 to 03/2013, 93 procedures for severe pCEAR were performed in 89 consecutive patients. Group 1 consisted of 37 rCEA (40 %), group 2 included 33 CIG (35 %), and group 3 contained 23 CAS (25 %). Median time from primary CEA was significantly longer in group 2 compared with group 3 (118 vs. 54 months; p = 0.02). Groups were comparable with regard to degree of stenosis and cardiovascular risk factors. Five patients (6 %) underwent initial angiography with intention of CAS, but the procedures could not be completed (insufficient access n = 3, neurological symptoms n = 2) and open surgery was performed (rCEA: n = 4; CIG: n = 1). One perioperative death related to major stroke occurred in group 3 (3.6 %). There were no differences in 4-year estimated survival and event-free survival, whereas patients in group 3 were more likely to undergo a tertiary intervention (13 % at 4 years 95 % CI: 11–45 % p = 0.014). Conclusions All three groups presented with similar long-term outcome with regard to the predefined endpoints. Although associated with less perioperative complications, CAS required significantly more tertiary interventions. Carotid interposition graft was not superior to redo patch plasty.

Objectives: Surgical site infections (SSIs) after bypass procedures provoke major costs. The aim of this prospective randomised trial was to assess if preoperative duplex vein mapping (DVM) reduces costs generated by SSI.Materials/methods: Patients undergoing primary infrainguinal bypass were randomised to DVM of the ipsilateral greater saphenous vein (group A) or none (group B). Costs were calculated by the hospital's accounting department.Results: From December 2009 to April 2011, 130 patients (65 each group) were enrolled. Both cohorts were equal regarding demographics, risk factors and costs for primary bypass surgery, respectively. SSIs were classified minor (A: n = 13 vs. B: n = 13, P = n.s.) and major (A: n = 1 vs. B: n = 12, P = .0154). Preoperative DVM was the only significant factor to prevent major SSI (P = .011). Theatre costs for SSI: A: 537 (sic) versus B 6553 (sic) (P = .16). Recovery room/intensive care unit (ICU) costs for SSI: A: 0 (sic) versus B: 8016 (sic) (P = .22). Surgical ward costs for SSI: A: 2823 (sic) versus B: 22 386 (sic) (P = .011). Costs for outpatient visits due to SSI: A: 6265 (sic) versus B: 12 831 (sic) (P = .67). Total costs of patients without SSI: 8177 (sic) versus major SSE 10 963 (sic) (P < .001).Conclusion: DVM significantly reduces costs generated by re-admission in patients suffering from major SSI. (C) 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

ObjectivesManagement of proximal common carotid artery (pCCA) lesions is infrequently reported. We described open and endovascular treatment with regard to the neurological outcome and patency in patients suffering from atherosclerotic pCCA lesions.MethodsData were collected prospectively and analysed in a retrospective manner.ResultsFrom November 1991 to January 2010, 52 procedures, 24 surgical (11 bypasses, 12 transpositions and retrograde endarterectomy) and 28 endovascular (13 open transcervical and 15 transfemoral stent implantations) were performed (40.4% female, mean age 62.3 years, 65.4% left-sided). A total of 25 lesions (48.1%) were symptomatic (13 stenoses and 12 occlusions); 27 (51.9%) lesions were asymptomatic (22 stenoses and five occlusions). Two bypasses occluded within 30 days. Two early ipsilateral strokes were observed (3.8%). There was one perioperative death due to myocardial infarction after transcervical stent (1.9%). Mean follow-up was 61 months. In one transposition and two stent implantations, late redo interventions were performed. Fourteen of 48 patients died during follow-up.ConclusionpCCA repair for atherosclerotic lesions is associated with a substantial perioperative risk (combined stroke/death rate: 5.7%). Endovascular intervention is the preferred invasive treatment option in patients suffering from stenotic pCCA lesions. In cases of pCCA occlusion, open surgery is a valid alternative. Late survival in patients suffering from pCCA lesions is poor.

Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.

Le traitement de lésions de l'artère sous-clavière (ASC) est actuellement controversé. La transposition sous-clavio-carotidienne (TSCC) peut être difficile mais a des résultats à long terme sans égal. L'angioplastie transluminale percutanée (ATP) avec mise en place d'un stent est techniquement plus facile mais pas toujours faisable. Il n'a pas été publié de résultats et de comparaisons à long terme. Nous avons comparé les deux méthodes réalisées par des chirurgiens vasculaires. Les données ont été colligées de façon prospective avec une analyse rétrospective dans un centre de soins tertiaire. L'ATP a été réalisée par voie humérale rétrograde en utilisant des stents autoexpansibles en nitinol. La chirurgie conventionnelle s'est limitée à la TSCC. Les critères de publication de la Society for Vascular Surgery-International Society of Cardiovascular Surgery ont été appliqués. Soixante quatorze malades ont été traités entre Janvier 1995 et Août 2007 (âge médian 62,6 ans, 40 femmes, pathologie siègeant du côté gauche 60 (81,1%); facteur de risque: hypertension artérielle 45 (60,8%), dyslipidémie 47 (63,5%), diabète 21 (28,4%), tabagisme 43 (58,1%), occlusion de l'ASC 50 (67,6%). Quarante malades (54,1%) ont eu une ATP (62,5% d'occlusion) et 34 une TSCC (73,5% d'occlusion). Les deux groupes étaient comparables en ce qui concerne les facteurs de risque. Chez 12 malades (30%) des occlusions n'ont pas pu être recanalisées et chez deux malades (traités tous deux pour des sténoses) les stents ont été des échecs dans le mois. Tous sauf un ont eu par la suite une TSCC sans complication. Toutes les TSCC ont été réalisées avec succès. Aucun facteur de risque n'a pu être identifié comme étant à l'origine d'un échec du traitement sauf l'ATP (p = 0,002, test exact de Fisher). Le suivi médian a été de 50,1 mois pour les ATP et de 52,6 mois pour les TSCC. Aucune procédure n'a été un échec au cours du suivi dans aucun des groupes. L'ATP peut être réalisée avec succès par des chirurgiens. L'ATP a été un échec dans 48% des occlusions (30% de l'ensemble des ATP). La prédiction de l'échec n'est pas possible. D'après cette expérience, nous recommandons l'ATP pour les sténoses de l'ASC et la chirurgie pour les occlusions de l'ASC.

El tratamiento actual de las lesiones de la arteria subclavia (AS) es controvertido. Su transposición a la arteria carótida común (TSC) presenta mayor complejidad técnica a cambio de ofrecer mejores resultados a largo plazo. La angioplastia transluminal percutánea con stent (ATPs) resulta técnicamente más sencilla, pero no siempre es factible. No se han publicado resultados ni comparaciones a largo plazo. Nosotros comparamos ambos métodos realizados por cirujanos vasculares. Los datos se obtuvieron de forma prospectiva mediante un análisis retrospectivo en un centro terciario. La ATPs se realizó a través de un abordaje humeral retrógrado utilizando stents de nitinol autoexpansibles. La cirugía abierta fue siempre mediante TSC. Se aplicaron los estándares de registro de la Society for Vascular Surgery/International Society of Cardiovascular Surgery. Setenta y cuatro pacientes fueron sometidos a tratamiento desde enero de 1995 hasta agosto de 2007 (media de edad: 62,6 años, 40 mujeres; patología de lado izquierdo: 60 [81,1%]; factores de riesgo: hipertensión arterial 45 [60,8%], dislipidemia 47 [63,5%], diabetes 21 [28,4%], tabaquismo 43 [58,1%], oclusión de AS 50 [67,6%]). Cuarenta pacientes (54,1%) fueron sometidos a ATPs primaria (62,5% por oclusiones) y 34 a TSC (73,5% por oclusiones). Ambos grupos fueron comparables en cuanto a los factores de riesgo. En 12 pacientes no se pudieron recanalizar las oclusiones (30%), y en 2 fracasaron los stents al mes de la intervención (ambos por estenosis). Todos excepto uno fueron sometidos posteriormente a una TSC sin más problemas. Todas las TSC fueron satisfactorias. No se pudo identificar ningún factor de riesgo para el fracaso del tratamiento a excepción de la ATPs (p = 0,002, test exacto de Fisher). La media del seguimiento fue de 50,1 meses para la ATPs y de 52,6 meses para la TSC. Ninguna intervención fracasó durante el seguimiento en ninguno de los grupos. Los cirujanos pueden realizar ATPs de forma satisfactoria. La ATPs primaria fracasó en el 48% de las oclusiones (30% de todas las ATPs). No es posible predecir el fracaso. Según nuestra experiencia, recomendamos realizar una ATPs primaria en casos de estenosis de AS y cirugía en caso de oclusiones de AS.

BACKGROUND: Postoperative oral antithrombotic therapy in patients after femoro-popliteal saphenous vein bypass still remains a matter of debate. Aim of this study was to evaluate bypass patency, morbidity and mortality in patients treated by primary saphenous femoro-popliteal vein bypasses with either postoperative oral antiaggregation or oral anticoagulation. METHODS: Retrospective analysis of prospectively maintained database in a university tertiary care hospital. Patients underwent surgery for peripheral vascular disease. The only procedure investigated was primary reversed femoro-popliteal saphenous vein bypass. RESULTS: Between January 2000 and December 2003 two-hundred-and-thirty-four patients received 243 primary femoro-popliteal saphenous vein bypass procedures. Postoperatively either oral antiaggegants (Aspirin® 100 mg/day) or oral anticoagulants (phenprocoumon or acenocoumarol, INR: 2–4) were prescribed. There was no significant difference in patency rates between the antiaggregation group (AGG) and the oral anticoagulation group (AC) at all time intervals studied. After 1 year, the primary patency rate of femoro-popliteal vein bypasses in the AGG was 90% as compared to 91% in the AC, and after 6 years it was 86 and 91%, respectively (p = 0.26). There were 69 deaths of 195 patients in the AGG and 17 deaths of 39 patients in the AC (risk ratio 80%; confidence interval 0.5–1.2; p > 0.05). Major hemorrhagic events with fatal outcome occurred in 3 patients (all of them in the AGG, p = 0.59). Limb salvage was achieved in 97% in the AGG and in 93% in the AC. CONCLUSIONS: We could not show a significant difference between patients who received postoperative aspirin or oral anticoagulation in terms of bypass graft patency, morbidity and mortality after femoro-popliteal saphenous vein bypass procedures.

The aim of this prospective study conducted at a tertiary referral center was to evaluate the efficacy of high-frequency duplex scanning in the preoperative evaluation of potential pedal target vessels. Material and methods The study population consisted of thirty-three consecutive diabetics suffering critical limb ischemia, with indications of infra-popliteal occlusive disease. Duplex ultrasound was performed by an angiologist unaware of any prior imaging procedures. The pedal vessels were divided into four segments. The inner diameter-, the grade of calcification (on a scale from 1-to-3), the maximal systolic velocity, and the resistance index ([V.max syst-V min syst]/V max syst), were assessed by using a 13-MHz probe, and the pedal target vessel best suited for surgery was identified. Results of duplex scanning were compared to (1) the results of selective digital subtraction angiography (DSA) and contrast-enhanced magnetic resonance angiography (CE-MRA) studies interpreted by two radiologists, (2) the site of distal anastomosis predicted by a vascular surgeon according to DSA and CE-MRA studies, (3) the definitive site of distal anastomosis, and (4) early postoperative results (patency at three months).Duplex scanning depicted significantly more pedal vascular segments than selective DSA- (P =.004, McNemar test). Agreement in predicting the site of distal anastomosis expressed as kappa value as follows: duplex versus DSA/CE-MRA, kappa 0.71;-DSA/CE-MRA versus definitive anastomosis, kappa 0.67; -and duplex versus definitive anastomosis kappa 0.82. Two patients were excluded from surgery as all three imaging modalities failed to demonstrate a pedal target vessel. Two patients had exploratory dissection of a pedal vessel (according to CE-MRA findings) that turned out to be occluded (as predicted by duplex scanning). In one patient the operation had to be terminated due to lack of autologous bypass material. In 31 patients who underwent pedal artery bypass, the resistance index could not be correlated to the run-off as assessed by intra-operative angiography.High-frequency duplex focusing on the vacular-morphology is a worthwhile diagnostic tool to evaluate-potential pedal target vessels and extremely helpful when contrast-related methods (selective DSA, CE-MRA) do not sufficiently depict the pedal vasculature.

Purpose: To describe the occurrence of a false aneurysm after percutaneous transluminal angioplasty of a severely calcified, high-grade stenosis of the brachiocephalic trunk.Case Report: A 68-year-old patient was admitted with cerebrovascular insufficiency, right upper extremity ischemia, and recurrent amaurosis fugax. Magnetic resonance arteriography (MRA) and duplex ultrasound revealed a severely calcified, high-grade stenosis of the innominate artery. Balloon dilation of this lesion was performed with minimal morphological success. After dilation, the patient suffered a reversible ischemic neurological deficit, from which he recovered completely. The patient's symptoms improved, but after 3 weeks he was re-admitted with palsy of the recurrent laryngeal nerve. An MRA showed a false aneurysm at the dilation site. Open surgery was performed, and the patient received a bifurcated aorto-subclavian-carotid bypass graft. He was discharged free of his preoperative symptoms.Conclusions: This case illustrates the potential hazards of angioplasty of severely calcified stenoses of the supra-aortic vessels.

Purpose: Superficial vein thrombosis (SVT), which can be managed sufficiently with compressive bandage and locally applied or systemic nonsteroidal antiphlogistics, is generally considered as being rela- tively harmless. However, the SVT can spread into the deep vein system necessitating other more aggressive surgical and/or systemic treatment. In this randomis- ed, controlled, open, multicentre, comparative study, the efficacy and tolerability of a new galenic formula- tion of liposomal heparin-spraygel was compared with subcutaneously administered low molecular weight heparin. Methods: 42 patients (31 female, 11 male), diagnosed with superficial vein thrombosis confirmed by duplex sonography, were entered. All patients got a compressive therapy and were permitted to use paracetamol (1000 mg per day) as pain rescue medication. The treatment results were assessed after seven or fourteen days of therapy. The primary end points were reduction of pain (VAS, VRS), ery- thema (planimetry) and swelling (ordinal scale). At each visit the length of thrombus (mm) was measured by duplex sonography. Results: None of the 42 patients developed a deep ve- nous thrombosis. The results of the pain evaluation (VAS evaluation) showed a comparable pain reduction in both groups. The consumption of rescue medication was also comparable. Erythema and thrombus size showed a con- tinuous decrease in both groups without any significant difference. Conclusion: The topical application of liposomal heparin-spraygel in combination with compressive therapy showed a comparable efficacy profile to the sub- cutaneously applied low molecular weight heparin in the treatment of superficial vein thrombosis. Kurzfassung: Liposomales Heparin-Spraygel im Vergleich zu subkutanem niedermolekularem Heparin bei Patienten mit oberflachlicher Venen- thrombose. Eine randomisierte, kontrollierte, offene Multicenter-Studie. Ziel: Die oberflachliche Venenthrombose (superficial vein thrombosis, SVT), die durch Kompressionsbehandlung sowie lokal ange- wandte oder systemische nichtsteroidale Antiphlo- gistika hinreichend behandelt werden kann, wird ge- nerell als relativ harmlos eingestuft. Allerdings kann eine SVT auch tiefer gehen, was eine aggressivere chirurgische und/oder systemische Behandlung notig macht. In der vorliegenden randomisierten, kontrollier- ten, offenen, multizentrischen Vergleichsstudie wur- den Wirkung und Toleranz des neuen galenischen liposomalen Heparin-Spraygels mit subkutan verab- reichtem niedermolekularem Heparin verglichen. Methodik: 42 Patienten (31 Frauen, 11 Manner) mit diagnostizierter SVT, mittels Duplex-Sonographie besta- tigt, wurden eingeschlossen. Alle Patienten erhielten eine Kompressionstherapie, daruber hinaus war es ihnen er- laubt, Paracetamol (1000 mg/Tag) als Schmerzhemmer einzunehmen. Die Behandlungsergebnisse wurden nach 7 oder 14 Tagen uberpruft. Die primaren Endpunkte um- fasten Schmerzreduktion (VAS, VRS), Erythema (Planime- trie) und Schwellung (ordinale Skala). Bei jeder Visite wur- de die Lange des Thrombus (mm) mittels Duplex-Sono- graphie gemessen. Ergebnisse: Keiner der 42 Patienten entwickelte eine tiefe Venenthrombose. Das Ergebnis der Schmerz- evaluierung (VAS-Evaluation) zeigte eine vergleichbare Schmerzreduktion in beiden Gruppen. Der Medikamen- tenkonsum war ebenfalls vergleichbar. Erythema und Thrombengrose zeigten einen kontinuierlichen Anstieg in beiden Gruppen, ohne signifikante Unterschiede. Schlusfolgerung: Die topische Anwendung von liposo- malem Heparin-Spraygel mit Kompressionstherapie zeig- te in der Behandlung oberflachlicher Venenthrombosen eine vergleichbare Wirkung zum subkutan verabreichten niedermolekularen Heparin. J Kardiol 2003; 10: 375-8.

Purpose: To examine the need for completion angiography after endovascular femoropopliteal brachytherapy using a centering catheter. Methods: Nine consecutive patients (7 men; mean age 68 years, range 53–79) were enrolled in a double-blinded multicenter randomized trial of endovascular brachytherapy after femoropopliteal balloon angioplasty. All patients underwent postdilation angiography, after which the centering catheter was placed in the dilated segment. The patients were randomized and transferred to the radiotherapy unit; the centering catheter was inflated only in patients randomized to receive brachytherapy (18 Gy of γ radiation delivered to the target site 2 mm from an iridium-192 source axis). Because the local ethics committee required angiography after any interventional procedure (not stipulated in the study protocol), our patients were taken back to the angiosuite for angiography. Results: There were no complications of angioplasty or centering catheter introduction. In the 5 patients randomized to brachytherapy, the median inflation time of the centering catheter was 12.1 minutes (range 9.1–13.3). The completion angiogram following brachytherapy showed peripheral embolization in 2 patients and lesion recoil that required redilation in another; all the complications were confined to the treatment group. Conclusions: Three of 5 patients who received brachytherapy via a centering catheter demonstrated sequelae on postradiation angiography. Therefore, as in any other peripheral vascular intervention, completion angiography after brachytherapy seems to be essential in preventing delayed diagnosis of procedural complications.

OBJECTIVE to evaluate selective digital subtraction angiography (DSA), contrast-enhanced magnetic resonance angiography (CE-MRA) and duplex ultrasound (duplex) in preoperative pedal artery imaging. MATERIAL AND METHODS DSA, CE-MRA and duplex were studied prospectively in 37 patients suffering from critical leg ischaemia. Two radiologists independently reviewed both the CE-MRA and DSA images. The pedal vessels were scored on a scale from 0 to III (0=vessel not visualised, I=vessel faintly visualised, II=stenosis >50%, III=vessel without relevant stenosis). Duplex ultrasound was performed by an angiologist blind to both the DSA and MRA findings and the pedal arteries were scored 0-III according to their diameter. Each examiner named the pedal artery best suitable for bypass surgery. Agreement in artery assessment was expressed as kappa values. Patency of the bypass at 30 days was used as validation of the artery's suitability as the run-off vessel. RESULTS interobserver agreement for DSA (weighted Kappa 0.63, CI 0.53-0.73 and CE-MRA (weighted kappa 0.60, CI 0.5-0.7) was moderate to substantial. CE-MRA depicted significantly more vascular segments than DSA (p congruent with 0.0001).In the prediction of the distal outflow vessel duplex and CE-MRA proved to be superior to DSA. CONCLUSION because of the moderate inter-observer agreement it may be questionable to regard selective DSA as gold standard imaging procedure in preoperative pedal artery imaging. CE-MRA and duplex are very helpful in assessing the pedal artery morphology and should be used if selective DSA does not sufficiently depict the pedal vasculature.

Objective The influence of vascular morphology and metabolic parameters including lipoprotein(a) (Lp(a)) on restenosis after peripheral angioplasty has been compared in Type 2 diabetes (DM) vs. non-diabetic patients (ND).Research design and methods The clinical course and risk profile of 132 (54 DM vs. 78 ND) patients with peripheral arterial occlusive disease (PAD) were observed prospectively following femoropopliteal angioplasty (PTA). Clinical examination, oscillometry, ankle brachial blood pressure index (ABI) and the toe systolic blood pressure index (TSPI) were used during follow-up. Duplex sonography and reangiography were also used to verify suspected restenosis or reocclusion.Results At the time of intervention patients with DM had a lower median Lp(a) of 9 vs. 15 mg/dl (P<0.01) in patients without diabetes. Recurrence within I year after PTA occurred in 25 diabetic (=46%, Lp(a) 12 mg/dl) and 30 non-diabetic (=38%, Lp(a) 48 mg/dl) patients. DM patients with 1 year's patency had a median Lp(a) of 7 vs. 11 mg/dl in non-diabetic patients (P<0.05). However, 12 months after angioplasty Lp(a) correlated negatively with the ABI (r = -0.44, P<0.01) in diabetic and in non-diabetic patients (r = -0.20, P<0.05). The probability of recurrence after PTA continuously increased with higher levels of Lp(a) in each subgroup of patients.Conclusions Our data indicate that Lp(a) is generally lower in those with peripheral arterial occlusive disease and Type 2 diabetes than in non-diabetic individuals. The increased risk for restenosis with rising levels of Lp(a) is set at a lower Lp(a) in diabetes and may be more harmful for diabetic patients.

PURPOSE:To evaluate initial technical success, procedural complications, and 12-month patency of duplex-guided angioplasty compared to conventional fluoroscopically-guided procedures.METHODS:One hundred four patients (65 men; mean age 69 years) who underwent duplex-guided femoropopliteal angioplasty were compared to 104 patients undergoing fluoroscopically-guide procedures who were matched for age, sex, baseline ankle-brachial index (ABI), and length and grade of lesion. Patients were followed for 12 months, and restenosis was assessed by ABI and duplex sonography.RESULTS:Technical success was achieved in 88 (84.6%) patients from the duplex-guided group and in 102 (98.1%) control patients (p=0.001). Periprocedural complications occurred in 12.5% (n=13) and 18.3% (n=19), respectively (p=0.4). Contrast-induced transient renal impairment was observed in 7 (6.7%) patients in the fluoroscopic group. One hundred (96.1%) patients in the duplex and 102 (98.1%) patients in the fluoroscopic group completed the 12-month follow-up. Restenosis was found in 35 (39.8%) patients of the duplex group and in 38 (37.2%) patients of the fluoroscopic group (p=0.8).CONCLUSIONS:Technical success of duplex-guided procedures was significantly lower compared to fluoroscopic angioplasty; complications and 12-month patency were similar with both techniques. Duplex-guided angioplasty may be a feasible alternative, particularly for patients at high risk for contrast-induced complications.

Zusammenfassung Bei kritischer Vorfußischämie auf Basis einer distal betonten arteriellen Verschlusskrankheit kann durch die Anlage eines pedalen Bypasses ein pulsatiler Aflux und somit die Voraussetzung für eine Heilung hergestellt werden. In dieser Übersichtsarbeit werden die intraarterielle digitale Subtraktionsangiographie, die kontrastverstärkte 3D-MR-Angiographie und die hochauflösende Duplexsonographie in ihrer Wertigkeit für die präoperative Diagnostik miteinander verglichen. Es werden die Untersuchungstechniken und die durch sie bedingte Aussagekraft über die Anschlussfähigkeit der Pedalgefäße dargestellt. Die selektive DSA mit Kontrastmittelinjektion in die A. femoralis ist derzeit das Standardverfahren. Die KM-MRA könnte als nicht-invasives Verfahren in Zukunft die DSA abzulösen. Die hochauflösende Duplexsonographie ist eine wertvolle Ergänzung und als einzige in der Lage direkt anhand der Doppleruntersuchung die Flussverhältnisse im pedalen Anschlussgefäß zu evaluieren.

BACKGROUND:To evaluate colour duplex sonographic guidance of local lysis of occlusions in the femoropopliteal region.METHODS:Thirteen consecutive patients (8 female, mean age 67) with peripheral artery disease with acute and subacute occlusions in the superficial femoral or popliteal artery were included in this study. The lesions were identified by colour duplex ultrasound (Acuson 128 XP/10) After anterograde puncture the guidewire was advanced through the arterial lesions under B-mode image control. The Mewissen Infusion Catheter and a Katzen infusion wire were then accurately positioned within the lesion under B-mode image control. The fibrinolytic drugs were then inserted into the occlusions, initially 2.5 mg rt-PA as a bolus followed by Urokinase (50,000 IU/h) for 24 hours. After control duplex sonography (over 24 hours) the additional angioplasty was performed either under fluoroscopic or exclusively under ultrasound guidance.RESULTS:Eleven of 13 patients with occlusions in the femoro-popliteal region were partially recanalised after ultrasound guided local lysis and after the additional angioplasties (nine under fluoroscopic and three under ultrasound guidance) the arteries were completely recanalised.CONCLUSIONS:Our data show that not only is the positioning of the catheter and the guidewire for local lysis exclusively under colour duplex guidance possible, but also the surveillance of the local lysis and the additional angioplasty. In the case of any complications, however, easy access to angiography should be possible.

We report the first case of a successful stent placement under color coded ultrasound guidance alone in the superficial femoral artery of a 73-year-old woman suffering from intermittent calf claudication following restenosis after an uncomplicated angioplasty five months previously. Because of a hemodynamically residual stenosis after three attempts at dilatation, a percutaneous transluminal angioplasty and stent insertion were performed under the sole guidance of color coded ultrasound. The intervention was performed without complication and at the six-month follow-up examination, the patient was symptom-free and the stent was morphologically intact and hemodynamically functional. This case shows that successful stent placement under ultrasonic guidance alone, without fluoroscopic control is possible, provided that there is adequate sonographic visualization.

Hemodialysis through an arteriovenous (AV-) fistula remains the most frequent treatment of terminal renal insufficiency until renal transplantation. In case of malfunction of the shunt colour coded duplex sonography or angiography are used for investigation.We tried to evaluate the technical feasability of infrared thermography for control of hemodialysis shunts.27 consecutive patients who were planned for duplex sonographic control of their AV-shunts had temperature measurements by infrared thermography before dialysis. All investigations were done under standardized ambient conditions with an Infrared Thermo Tracer TH1100. Morphological and functional aspects of AV-fistulas have been compared with their digitized infrared thermograms.The maximal shunt flow velocity (m/sec) correlated best with the highest temperature difference between arms (p < 0.001). The shunt-volume proved to be significantly correlated with the mean temperature difference to the contralateral upper extremity (p < 0.05). Patients suffering a complete thrombosis of their shunt (n=4) presented statistically lower maximum temperatures on the surface of their shunt regions (33.9 +/- 1.0 C) than AV-fistulas without occlusion (36.3 +/- 0.6 C), p < 0.01.Our data seem promising that infrared thermography might deliver additional fast and non-invasive global information of function of hemodialysis shunts.