[Vascular surgery in old people]

The age pyramid in Germany is upside down. According to the Federal Statistical Office this development will continue in the coming years, which presents a challenge for surgeons to surgically treat increasingly more and increasingly older people. Particularly in vascular surgery, which is a surgery of old people, this fact represents a special challenge. The frailty of old people is, among other things, due to a series of comorbidities, which must be taken into consideration within the framework of surgical treatment. They can have an important influence on the perioperative planning, the operation, the postoperative treatment and the outcome of the patient. This treatment planning becomes more and more challenging, because due to the progress in endovascular surgery there will soon be no limits to what is feasible; however, the question arises whether the feasible is also reasonable? Within the scope of this article the authors try to give answers to the treatment of old patients in vascular surgery and to find strategies for planning and to establish an individualized optimal treatment.

Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial

The reported incidence of incisional hernia following repair of abdominal aortic aneurysm (AAA) via midline laparotomy is up to 69%. This prospective, multicenter, double-blind, randomised controlled trial was conducted at eleven hospitals in Germany. Patients aged 18 years or older undergoing elective AAA-repair via midline incision were randomly assigned using a computer-generated randomisation sequence to one of three groups for fascial closure: with long-term absorbable suture (MonoPlus^®, group I), long-term absorbable suture and onlay mesh reinforcement (group II) or extra long-term absorbable suture (MonoMax^®, group III). The primary endpoint was the incidence of incisional hernia within 24 months of follow-up, analysed by intention to treat. Physicians conducting the postoperative visits and the patients were blinded. Between February 2011 and July 2013, 104 patients (69.8 ± 7.7 years) were randomised, 99 of them received a study intervention. The rate of incisional hernia within 24 months was not significantly reduced with onlay mesh augmentation compared to primary suture (p = 0.290). Furthermore, the rate of incisional hernia did not differ significantly between fascial closure with slow and extra long-term absorbable suture (p = 0.111). Serious adverse events related to study intervention occurred in five patients (5.1%) from treatment groups II and III. Wound healing disorders were more frequently seen after onlay mesh implantation on the day of discharge (p = 0.010) and three (p = 0.009) and six (p = 0.023) months postoperatively. The existing evidence on prophylactic mesh augmentation in patients undergoing AAA-repair via midline laparotomy probably needs critical review. As the implementation of new RCTs is considered difficult due to the increasing number of endovascular AAA treated, registry studies could help to collect and evaluate data in cases of open AAA-repair. Comparisons between prophylactic mesh implantation and the small bite technique are also required. Trial registration: ClinicalTrials.gov Identifier: NCT01353443. Funding Sources: Aesculap AG, Tuttlingen, Germany.

Complex endovascular treatment of intact aortic aneurysms: An analysis of health insurance claims data

Background

The complex endovascular repair of aortic aneurysms and dissections with fenestrated or branched stent grafts (FB-EVAR) remains challenging for interventional vascular surgery. To date, the evidence regarding treatment patterns and outcome measures consists of single center studies; however, it might be reasonable to validate results with multicenter real-world evidence.

Methods

Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, were used to determine outcomes following FB-EVAR of non-ruptured thoracic aorta (TA) or thoracoabdominal including pararenal abdominal (TAA) aorta. The study included patients operated between January 2008 and April 2017.

Results

Included were 984 patients (18.1% female) who underwent FB-EVAR. Patients with treatment of the TA were younger (71.7 vs. 73.2 years, p < 0.001) and more often female (38.5% vs. 17.0%, p < 0.001) as compared to patients with treatment of TAA. In the TA group peripheral arterial disease was less frequent compared to the TAA group (67.3% vs. 80.4%, p = 0.036). Mortality was significantly (p < 0.001) higher following repair of the TAA compared to the TA at discharge (17.3% vs. 4.6%), at 30 days (26.9% vs. 8.2%) and at 90 days (34.6% vs. 10.1%). Patients with treatment of the TAA suffered more often from stroke as compared to the TA group (7.7% vs. 1.2%, p = 0.002).

Conclusion

In this large-scale German analysis of claims data, multicenter real-world evidence was different from single center studies regarding patient risk-factors and outcome measures. Validated multicenter registry studies could help to further investigate this topic in times of increasing procedures.

Catheter-directed foam sclerotherapy of axial saphenous reflux: early results

Objectives: Foam sclerotherapy of the great saphenous vein is a relatively new and promising treatment option for patients with axial reflux. Its usefulness may be limited by low primary occlusion rates. We present a standard technique for catheter-directed foam sclerotherapy, which facilitates foam delivery precisely to its intended site of action and potentially improves occlusion rates.

Methods: A consecutive series of 53 patients were treated with foam sclerotherapy using a standard technique for foam delivery at Malmö University Hospital between September 2006 and April 2007. Patients were treated with 3% polidocanol foam through an introducer sheath, which was inserted percutaneously over a guidewire in the great saphenous vein (GSV). All successfully treated patients were examined by colour duplex one week after the procedure.

Results: Primary technical success with delivery of foam along the length of the GSV was achieved in 50 of 53 limbs (94%). All treated GSVs were occluded at one week duplex.

Conclusion: The use of an endovascular sheath inserted percutaneously over a guidewire under duplex ultrasound control is feasible in most patients and has resulted in high primary occlusion rates.

[Endovascular versus conventional vascular surgery - old-fashioned thinking? Part 1: interventions on the aorta]

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of complicated acute type B aortic dissection, descending thoracic aortic aneurysms, thoracoabdominal aortic aneurysms as well as asymptomatic and ruptured abdominal aortic aneurysms.

Modern diagnostics for type B aortic dissection

Background

Undifferentiated chest pain is one of the most common complaints in the acute care setting. Type B aortic dissection is an important cause of chest pain and a complex clinical entity, which carries significant morbidity and mortality and requires accurate clinical and radiological evaluation.

Methods

Imaging technologies have become an irreplaceable tool to establish the diagnosis of aortic dissection and to plan treatment strategies. Computed tomography is an important component in this process, replacing catheter-based angiography as the most commonly used preoperative and postoperative imaging modality for the thoracic aorta. The use of functional imaging methods, such as magnetic resonance imaging and echocardiography is evolving. These methods are able to provide the clinically relevant anatomical, hemodynamic and biomechanical information that is necessary for accurate diagnosis, risk stratification and patient selection for treatment.

Conclusion

Advanced image acquisition equipment and expertise are increasingly available in a growing number of institutions and as a consequence, existing strategies for the management of type B dissection are rapidly evolving.

Chronic type B aortic dissection: indications and strategies for treatment

Chronic type B aortic dissection is a distinctive condition that needs individual treatment strategies and different considerations than in therapy of acute or subacute type B aortic dissection. The most common indication for treatment of this complex disease is aneurysmal dilatation of the dissected aortic segment. While open repair of the enlarged dissected aorta remains the best option for good-risk patients and patients with connective tissue disorders in high-volume centers with respective expertise, endovascular management of chronic type B aortic dissection with postdissection aneurysms has significantly gained ground in the past years. But the concept of TEVAR with implantation of a tubular stent-graft into the thoracic aorta to seal the proximal entry tear and reroute the blood flow into the true lumen alone, is not associated with satisfactory results. This is mainly due to the sparse remodeling capacity of the aortic tissue compared to earlier stages of the disease as the aortic wall and the dissection membrane are thickened and more rigid. On the other hand, it is restricted by the most limiting factor for endovascular success in chronic type B aortic dissection: persistent false lumen perfusion. This problem also affects patients with residual dissection after surgical repair of a DeBakey type I aortic dissection or dissection after ascending aortic repair for other pathologies. Hence, it is evident that strategies to achieve endovascular false lumen occlusion are of increasing importance and novel techniques have been introduced to solve the problem of persisting false lumen flow. Thus, the evolution of a large variety of techniques to address the false lumen perfusion issue indicates that complicated chronic type B dissection involves a high diversity in clinical presentation and morphology. A large armamentarium of catheter skills as well as critical individualized treatment strategies are required to address the heterogenous morphological disease pattern for each individual patient. The rapid development in endovascular techniques gives new directions for treatment indications and strategies in chronic aortic dissection and enables new insights into this old disease.

[Transcardiac Access Routes for Endovascular Treatment of Ascending Aortic Pathologies]

Gold standard for treatment of pathologies of the ascending aorta is still open surgery with extracorporal circulation in moderate to deep hypothermia. These procedures are associated with high morbidity and mortality, especially if performed in older patients or after previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment option for thoracic aortic pathologies of the descending aorta even in high-risk patients with severe comorbidities resulting in reduced morbidity and mortality compared to open repair. Despite the continuous development of endograft technology an adequate arterial access still poses a relevant limitation of this treatment option accentuated in the proximal segments of the aorta. The transfemoral access may be limited due to severe kinking or arteriosclerotic plaque stenosis of femoral or iliac vessels. Furthermore, the long distance between femoral access vessels and the aortic lesion impairs device torsibility and exact deployment of the stent graft. To provide a practical alternative endovascular access to the ascending aorta, antegrade transcardiac access routes including transapical or transseptal techniques have recently gained increasing interest.

[Future vascular medicine: inauguration of a cardiovascular hybrid concept]

The demographic developments will lead to an exponential increase of cardiovascular diseases. Additionally, technical developments of conservative and invasive treatment modalities will be added to distinguished, organ-orientated therapeutic concepts. This will also require a new orientation of vascular services. This concept implies that specific contents are referred to and contained in partner specialties. Since the heart and vascular system function as an anatomic and functional union, implementation of vascular medicine within cardiovascular centres represents a logical consequence.

TEVAR for chronic aortic dissection - is covering the primary entry tear enough?

Treatment-strategies for type B aortic dissection (TBAD) are rapidly developing towards endovascular treatment strategies. While TEVAR for acute TBAD shows favourable results, TEVAR in chronic TBAD following the same interventional strategies as in acute TBAD by covering the proximal entry-tear alone has shown unsatisfactory results with one third of the patients developing further false-lumen growth and mortality of 36% at 3 years. This review article describes endovascular strategies and adjunctive techniques to prevent distal false-lumen back-flow in patients with chronic TBAD, as covering the proximal entry tear has proven insufficient.

Acute aortic syndromes: definition, prognosis and treatment options

Acute aortic syndromes (AAS) are life-threatening vascular conditions of the thoracic aorta presenting with acute pain as the leading symptom in most cases. The incidence is approximately 3-5/100,000 in western countries with increase during the past decades. Clinical suspicion for AAS requires immediate confirmation with advanced imaging modalities. Initial management of AAS addresses avoidance of progression by immediate medical therapy to reduce aortic shear stress. Proximal symptomatic lesions with involvement of the ascending aorta are surgically treated in the acute setting, whereas acute uncomplicated distal dissection should be treated by medical therapy in the acute period, followed by surveillance and repeated imaging studies. Acute complicated distal dissection requires urgent invasive treatment and thoracic endovascular aortic repair has become the treatment modality of choice because of favorable outcomes compared to open surgical repair. Intramural hematoma, penetrating aortic ulcers, and traumatic aortic injuries of the descending aorta harbor specific challenges compared to aortic dissection and treatment strategies are not as uniformly defined as in aortic dissection. Moreover these lesions have a different prognosis. Once the acute period of aortic syndrome has been survived, a lifelong medical treatment and close surveillance with repeated imaging studies is essential to detect impending complications which might need invasive treatment within the short-, mid- or long-term.

Acute ischemia and bypass occlusion: current options

AIM

Acute limb ischemia (ALI) and bypass occlusion are vascular emergencies and require immediate decisions and therapy. There are a lot of options, and the vascular therapist should be able to provide multiple alternatives. In this article we give on overview over the actual therapeutic options and present the data of a retrospective analysis of bypass occlusions.

METHODS

Therapeutic options of ALI are discussed according to the current literature. For the retrospective study, patients with acute or subacute occlusion of below knee alloplastic bypass were included. Endpoints of the study were secondary patency and limb salvage rate. A prognostic index was calculated to estimate the specific risk.

RESULTS

We analyzed 262 bypass occlusions; 161 patients were male. The majority of patients (N.=249) presented with threatened limb at readmission. After one year, 2/3 of the bypasses showed a reocclusion. Introducing the therapy with bypass thrombolysis enhanced the prognosis significantly. Of the factors examined, cardiac and renal insufficiency had a significant poor influence, whereas therapy with Coumadin enhanced the prognosis in terms of patency. The prognostic index was calculated using the factors identified as relevant in the multivariate analysis.

DISCUSSION

Despite all new technical tools, ALI and bypass occlusion is still associated with a significant risk for limb loss and mortality. Endovascular procedures are excellent options. The prognostic index may be a helpful tool in estimating the patency or risk of limb loss.

How to calculate the main aortic graft-diameter for a chimney-graft

Aim: The aim of this paper was to present a mathematical model to calculate the required main aortic graft-diameter for parallel chimney-grafts. Methods: Geometric approximation model, developed to allow for a standardized calculation of the main aortic graft-diameter determined by the aortic diameter and the diameter of the chimney-graft. Results: We propose a mathematical formula using circular segments of the aorta and the chimney-graft and provide a table with recommended main aortic graft-diameters for single chimney-grafts of 6 and 8 mm. Conclusion: Geometric approximation can be used to calculate the required main aortic graft-diameter. For parallel running chimney-grafts a significant degree of oversizing is necessary to allow the main aortic body to surround the chimney and to prevent the occurrence of gutters, which may cause type-1 endoleaks.

Risk-adjusted strategies in the prevention of early arterial thrombosis following lower extremity arterial reconstruction: a comparison of unfractionated versus low molecular weight heparin

AIM

In vascular surgery postoperative thrombosis prophylaxis must sufficiently prevent arterial thrombosis. This cohort study examines different therapeutic approaches of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) after vascular reconstruction.

METHODS

Four hundred seventy-five patients entered the study between 2005 and 2008. Our clinical routine made a differentiation between low-risk patients (N.=375) and patients with peripheral bypass, which were grouped as high-risk (N.=148). We changed our postoperative anticoagulation management after 24 months in the low-risk and after each 16 months in the high-risk group. The anticoagulation of low-risk patients consisted of either two applications of 7.500 IU UFH subcutaneously (N.=158) or one daily application of 40 mg LMWH each up to discharge (N.=169). High-risk patients received either 25.000 IU UFH i.v. over 24 hours and 4 days (N.=48), 2-times (N.=51) or one-time weight-adjusted LMWH (N.=49) up to discharge (1 mg/kg body weight). Minor complications (bleedings) were differentiated from major early graft occlusion during the postoperative course. Further follow-up was not done for this study.

RESULTS

Low risk: under LMWH, complications could be significantly reduced (P=0.001). Under LMWH significantly fewer occlusion complications occurred (P=0.01) and operation-induced hemorrhages were less frequently observed (P=0.05), this was significant in the complete low-risk group. High-risk: the one-time weight-adjusted LMWH group similarly exhibited many occlusions, like the unfractionated group (NS). The two-time LMWH treatment was significantly superior to the one-time application with respect to occlusion followed by amputations (P=0.03). Minor complications could be minimized overall by administration of LMWH and its dose reduction (NS).

CONCLUSION

The differentiation between patients with high and low risk seems reasonable. An improvement could be achieved by differentiated LMWH application. Synthetic specific antifactor Xa substances (fondaparinux) or other medications could lead in future to other changes in the management of vascular surgery patients and should be further evaluated.

Advanced endovascular techniques for thoracic and abdominal aortic dissections

Endovascular treatment of aortic dissection is still in its infancy and consists usually of implantation of thoracic tubular stent-grafts to cover the proximal entry tear and redirect flow into the true lumen. Large registries comparing endovascular treatment by thoracic endovascular aortic repair (TEVAR) with open surgery for aortic dissection of the descending aorta have demonstrated a clear benefit for endovascular treatment with lower mortality and morbidity rates turning TEVAR into the standard treatment for complicated type B aortic dissection. With this momentum of success endovascular techniques continue to challenge open surgical techniques also in the aortic arch and the ascending aorta. TEVAR for aortic dissection has become more complex requiring an individualized treatment strategy as endovascular techniques have developed with the advent of new devices and increased experience of the operators. In many cases straight implantation of a thoracic tubular stent-graft is sufficient. But as rerouting of the blood flow can also change perfusion of vital side-branches the endovascular operator needs to have a large armamentarium of techniques and adjunctive procedures in order to sufficiently address the individual patient morphology. This chapter reviews a variety of endovascular techniques including access techniques, proximal sealing, the Petticoat-technique, false lumen deployment, fenestration techniques, branch vessel stenting and false lumen obstruction by various techniques.

New surgical and hybrid techniques for crural and pedal anastomoses

Although there is currently a trend using endovascular methods to treat long and/or complex distal lesions, there are some interesting new approaches, technical modifications and simplifications in open surgery. Some of these are new, and some are older, but their effectiveness is now starting to be recognized. 1) Anatomical concepts: the lower leg/foot consists of 6 angiosomes, which are supplied by the 3 main arteries. It has been shown that the revascularization of the correct angiosome could lead to a higher rate of success when compared to the connection of an indirect artery. Other anatomical concepts describe the use of a flow-thru flap, and the advances in the use of homografts in peripheral bypass surgery. 2) New materials for implantation: while biological graft materials (tissue engineering) are still under development, no fundamental changes in clinical use have taken place. If autologous vein is missing, alloplastic materials made from polyester or polytetrafluorethylene (PTFE) are the available alternatives. On the basis of studies published so far, heparin coating does appear to offer advantages. 3) New aids for operative treatment: in contrast to rather slow (clinical) advancement with regard to bypass materials, there have been some interesting developments with regard to ancillary products. There are clips for stapled anastomoses, small shunts or thermosensitive polymers to avoid clamping. Furthermore some techniques perform anastomoses without sewing, like intraluminal protein tubes or ring anastomoses. The Viabahn Padova Sutureless (ViPS) technique anastomoses a stent-graft to the artery by placing it openly into the vessel and then releasing a stent by a simple pulling mechanism. In summary, peripheral bypass surgery remains a very standardized operation. Although not spectacular, there are some interesting new approaches, technical modifications and simplifications.

Perioperative management and "Fast-Track" therapy in vascular medicine

Perioperative risk in vascular medicine is particularly high due to the increased prevalence of cardiovascular comorbidity. Therefore, it is of the utmost importance that during periprocedural management the patient remains in good general condition and that the patient is mobilized as soon as possible. Along with implementation of minimally-invasive techniques and endovascular procedures, networking and cooperation between the surgeon, anesthesiologist, physiotherapist and the nursing team can lead to an optimization of perioperative mobilization. The Fast-Track concept represents uncharted territory in the field of vascular surgery and it can provide advantages, particularly in relation to multimorbidity in the field of vascular medicine. The Fast-Track concept was introduced by Danish surgeon Henrik Kehlet and was originally intended to be implemented in general surgery. When compared to conventional management, this method offers better medical results, lower costs and other advantages for the patient: besides a better perioperative condition a reduction of postoperative complications and reduction of overall in-hospital stay was achieved. Therefore, the next logical step was to introduce and adapt this concept to other fields of operative medicine. This paper represents a systematic review on the actual experience of the fast-track concept in vascular surgery.

Role of endovascular intervention in patients with diabetic foot ulcer and concomitant peripheral arterial disease

AIM

The aim of this study was to evaluate wound healing, major amputation and mortality in patients with diabetic foot ulcer and peripheral arterial disease (PAD), and to compare the group decided to have an endovascular intervention with groups referred to conservative treatment or to those judged as unreconstructable.

METHODS

A retrospective two-year review of all patients with diabetic foot ulcers and PAD presented at an interdisciplinary diabetic foot round 2006-2007 at Malmö University Hospital, Sweden, was performed. Independent predictive factors of insufficient ulcer healing, amputation and mortality during follow-up were analysed according to treatment decisions at the diabetic foot round.

RESULTS

A total of 135 limbs in 115 consecutive diabetic patients with foot ulcers were included. Median age was 73 years and 41% were women. During a median follow-up time of 17 months, 44% of the ulcers did not heal, 15% of the limbs underwent major amputation and 42% died. Ulcer depth with a Wagner grade ≥3 (hazard ratio [HR] 5.8; 95% confidence interval [CI] 2.6-12.9), CRP (HR 1.007; 95% CI 1.002-1.012, and impaired run-off (HR 3.0; 95% CI 1.03-8.9) were independent risk factors for incomplete wound healing. The three treatment decision groups: attempt for endovascular leg revascularization (N.=75), conservative (N.=42) and unreconstructable (N.=18) showed no significant difference in terms of wound healing, major amputation or death.

CONCLUSION

Patients with diabetic foot ulcers and concomitant PAD are at high risk for limb loss and premature death. Ulcer depth, CRP and impaired run-off are independent risk factors for incomplete wound healing. There is an apparent need for prospective controlled studies to better define the role of endovascular therapy in this subset of diabetic foot ulcer patients.

Hemodynamics and jugular venous oxygen saturation during carotid endarterectomy: a comparison between general and locoregional anesthesia

AIM

To study hemodynamic and blood oxygenation changes in patients undergoing carotid endarterectomy (CEA) under general (GA) or locoregional (LRA) anesthesia.

METHODS

Prospective non-randomized study including 50 patients undergoing CEA (31 men, mean age 72 (range 50-84) years-old under GA (N.=23) or LRA (N.=27). Systemic blood pressure, ECG, venous oxygen saturation in the ipsilateral jugular bulb and pulse-oximetry were monitored. Blood-gas analysis was done from blood obtained from the radial artery and ipsilateral jugular vein.

RESULTS

Pulse rate and systemic systolic blood pressure were higher in LRA compared to the GA before, during and after cross clamping (P<0.05). Seven GA patients required dopamine-infusion to maintain systolic blood pressure >120 mmHg. Jugular venous saturation was initially identical in both groups, but decreased significantly upon cross clamping in LRA compared to GA (P<0.05). This difference remained at least 3 minutes after cross clamp release (P<0.05).

CONCLUSION

Patients under LRA seem to have increased sympathetic activity compared to patients under GA, as expressed by higher pulse rates and systolic blood pressures. Jugular venous saturation was lower during clamping of LRA patients. The differences were small and concur with the near-equality findings in studies analysing the clinical outcome.

Management of inadvertent arterial catheterisation associated with central venous access procedures

OBJECTIVE

This study aims to describe the clinical management of inadvertent arterial catheterisation after attempted central venous catheterisation.

METHODS

Patients referred for surgical or endovascular management for inadvertent arterial catheterisation during a 5-year period were identified from an endovascular database, providing prospective information on techniques and outcome. The corresponding patient records and radiographic reports were analysed retrospectively.

RESULTS

Eleven inadvertent arterial (four common carotid, six subclavian and one femoral) catheterisations had been carried out in 10 patients. Risk factors were obesity (n=2), short neck (n=1) and emergency procedure (n=4). All central venous access procedures but one had been made using external landmark techniques. The techniques used were stent-graft placement (n=6), percutaneous suture device (n=2), external compression after angiography (n=1), balloon occlusion and open repair (n=1) and open repair after failure of percutaneous suture device (n=1). There were no procedure-related complications within a median follow-up period of 16 months.

CONCLUSIONS

Inadvertent arterial catheterisation during central venous cannulation is associated with obesity, emergency puncture and lack of ultrasonic guidance and should be suspected on retrograde/pulsatile catheter flow or local haematoma. If arterial catheterisation is recognised, the catheter should be left in place and the patient be referred for percutaneous/endovascular or surgical management.

What to Do When Evidence is Lacking — Implications on Treatment of Aortic Ulcers, Pseudoaneurysms and Aorto-Enteric Fistulae

Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available.

Material:

From our centre we collected 65 patients treated with open (n=15) or endovascular reconstruction (n=50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment.

Results:

Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.

Conclusion:

Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.

The complex between activated protein C and protein C inhibitor: A clinically useful indicator of aortic aneurysms?

The concentration of the complex between activated protein C and the protein C inhibitor reflects the degree of activation of blood coagulation. A sandwich method has been devised that measures the complex concentration in blood plasma. A key feature of the method is that the catching monoclonal antibody recognizes a complex-dependent neoepitope in PCI, which is a prerequisite, since the concentration of uncomplexed PCI is approximately 10(4)-fold higher than that of the complex. In patients with atherosclerotic disease, those with aortic aneurysms exhibit a three-fold increase in complex concentration compared to that of normal subjects.