Special Clinical Focus
- Diabetic foot syndrome (DFS)
- Arterial occlusive disease (PAOD) of the leg arteries
- Surgery of the carotid arteries
- Aortic aneurysm
- Varicose vein surgery
- Chronic wounds
- Dialysis ports
- Foot surgery
In the twenty-two years that Prof. Gerhard Rümenapf has been heading the Upper Rhine Vascular Center Speyer, the institution has earned a high international reputation. In fact, there is no other place in the German-speaking world where as many patients with diabetic foot syndrome are treated as here. In other words: In one of the largest vascular centers in Germany, the highest number of amputations is avoided nationwide!
Most important goal: avoid amputations
As an experienced specialist in surgery and vascular surgery, Prof. Gerhard Rümenapf has turned the Upper Rhine Vascular Center Speyer into a recognized top address. The proven specialist has a wealth of experience in all aspects of vascular surgery.
With a highly competent and extremely committed team, he has achieved this outstanding position in vascular surgery. The Upper Rhine Vascular Center Speyer thus offers the entire spectrum of modern vascular surgery. Year after year, approximately 2500 vascular surgeries are performed here - hardly any other institution in Europe can keep up with this number either. Since November 2020, the Upper Rhine Vascular Center Speyer has been certified as an inpatient foot treatment unit by the German Diabetes Society (DDG).
It is therefore no wonder that the Upper Rhine Vascular Center attracts attention because of its particular success in preventing so-called major amputations (transfemoral, transtibial amputations): As a National Center for Amputation Prevention, the Vascular Center repeatedly sets standards in consistently preventing the need for amputations of the upper leg or even the lower leg. The team led by Prof. Gerhard Rümenapf has earned a great reputation for rapidly restoring arterial blood flow to the legs. The center is also frequently talked about internationally, as the almost legendary German "Amputation Prevention Center Speyer".
About 90% of all amputations can be prevented at the Upper Rhine Vascular Center in Speyer through the cooperation of many specialists. Patients often present themselves for a "second opinion before amputation" at the Upper Rhine Vascular Center in Speyer. Due to the current ruling of the joint federal committee, every patient who is faced with the prospect of an amputation now has the right to do so. The health insurance companies must allow the second opinion to be obtained and must also cover the costs.
Carotid artery surgery: local anesthesia
At the Upper Rhine Vascular Center in Speyer, about 200 surgeries on narrowed carotid arteries (so-called carotid endarterectomies) are performed every year. Thus, Prof. Rümenapf is able to prevent many strokes by timely detection and removal of carotid stenoses (see image gallery, picture 1). In contrast to most other vascular centers, Prof. Rümenapf performs almost all carotid artery surgeries under local anesthesia. Why? Because the patient is awake during the surgery and can move his hands and feet when asked. In this way, the surgeon has immediate proof that the cerebral blood flow is fine during the surgery. Strokes caused by the surgeon himself can thus be avoided.
Alternatively, dilatation and stenting of carotid stenoses is also offered, especially to patients for whom open surgery would be too dangerous, or to patients who have had previous surgery at the same site and have developed a new stenosis.
Abdominal aortic aneurysms are common, especially in older men (see image gallery, picture 2). If the diameter of the abdominal aorta exceeds 5 cm, the risk of the aneurysm rupturing increases. This is fatal in 80% of all cases.
Therefore, one should think about the elimination of the aneurysms in time. There are 2 methods for this:
The endoprostheses leak again after 5 years in 25% of all cases, so that follow-up surgeries are necessary. A patient after an endoprosthesis requires lifelong monitoring. After open surgery, the recovery period is longer and the surgery is slightly more dangerous than the endoprosthesis. On the other hand, the patient does not have to worry about complications for the rest of his life.
In Speyer, 50% of the aortic aneurysms are treated by EVAR. However, open aneurysm surgery is still performed. Prof. Rümenapf rejects the complete switch to endoprostheses. His department is one of the few where most of the team can still perform complicated open abdominal aortic surgeries.
Specialty Diabetic Foot
There are 8 million people with diabetes mellitus in Germany. Diabetes leads to occlusion of the arteries in the leg, in addition to sensory disorders in the feet (neuropathy). This often leads to painless ulcers on the foot or to tissue destruction, which can no longer heal due to poor blood circulation. Every year, 250,000 open wounds on the feet of people with diabetes have to be treated (see image gallery, picture 4).
Every year, 12,000 people with diabetes lose a leg because of this. Speyer's vascular surgery specializes in restoring arterial blood flow to the feet. The wounds are then able to heal and amputations are avoided by 90%. The improvement of the blood flow is achieved either by open surgery using removal grafting or bypasses, or with dilatation balloons and stents. Both procedures are offered in Speyer, and their use depends on the extent of vascular damage, the distribution pattern, and the age and overall condition of the patient. Thus, the optimal solution can be found for each patient. As a rule, short-stretch constrictions are dilated, while long-stretch constrictions are bridged by a bypass. The latter bypasses can reach down to the foot. Speyer performs the largest number of such bypass surgeries in all of Germany, so patients come from far and wide. Patients with diabetic foot syndrome need intensive aftercare to prevent re-injury to the foot. The risk is high, mainly due to neuropathy, i.e. the patient's lack of pain sensation. The Vascular Center in Speyer therefore offers wound treatment by wound specialists, and special shoes, insoles and orthoses are made by an orthopedic technician to relieve pressure. All patients are closely monitored by a diabetologist.
Diabetic foot syndrome is one of the most feared diseases among people with diabetes mellitus (see image gallery, picture 5). Whether wounds, tissue destruction or even calluses, the total loss of the foot as a result of diabetes mellitus is always a possibility. This is why this topic occupies a particularly important position in the range of services offered by Prof. Gerhard Rümenapf. The Upper Rhine Vascular Center Speyer-Mannheim treats the largest number of patients with diabetic foot syndrome in Germany - around eighty percent of all patients in Speyer are diabetics.
So it's a good thing that the Upper Rhine Vascular Center in Speyer is headed by a specialist who, in addition to his vascular surgery expertise, is also certified as a foot surgeon - by the Society for Foot and Ankle Surgery (GFFC).
So when it comes to avoiding amputation through customized therapy, the vascular center with its high success rate is exactly the right address for patients on both sides of the Rhine - and this has also been sufficiently documented: For the "Speyer Model," which was developed in the vascular surgery department there, the readmission rate of DFS patients was significantly reduced. For this, Prof. Rümenapf's team received the Innovation Award of the German Society for Care and Case Management in 2013, and also the "Diabetic Foot" prize of 20,000 euros from the Fondation Urgo in 2015 for the publication of the discharge model.
Specialist for peripheral artery occlusive disease
Another focus of the established facility is the treatment of peripheral arterial occlusive disease (PAOD). Narrowing of the iliac and leg arteries (see image gallery, picture 6) is common. They are caused by vascular calcification (plaque). Cigarette smokers and patients with high cholesterol, high blood pressure and diabetes mellitus are at the greatest risk. Narrowing of the arteries leads to reduced blood flow to the leg muscles.This can lead to pain in the calves, forcing the patient to stand until the pain goes away. As the occlusive disease progresses, pain occurs even at rest. Patients can only sleep by letting their legs hang down. In the final stage, the toes die and amputations become necessary (so-called "smoker's leg").
The treatment of peripheral arterial occlusive disease is similar to the treatment of diabetic feet. Narrowing and occlusion of the leg artery can be removed or bridged with a bypass, or they can be dilated with a balloon and, if necessary, held in place with a stent. The decision on the respective form of treatment is based on experience. Long-stretch occlusions are bypassed, short-stretch occlusions are dilated. No procedure is superior to the other, each has its field of application. Approximately 400 bypass surgeries are performed every year in Speyer, mainly on patients with diabetic foot syndrome, but also on many smokers. Well over 1000 dilatations and stents of the pelvic, upper and lower leg arteries are performed annually.
This refers to a combination of small surgical interventions with simultaneous dilatations, i.e. a combination of endovascular and open surgical techniques. This has the advantage that the patient has fewer incisions on the leg, because several vascular layers can be repaired via only one surgical access. This significantly reduces the burden on the patient, and the clinical results are almost as good as with complete open surgical treatment. In Speyer, several hundred such hybrid interventions are performed each year.
Hybrid opeating room
This is a highly sterile operating room with a high-performance angiography unit. In this operating room, open surgery can be performed under highly sterile conditions, while at the same time dilatations or endoprostheses can be implanted under X-ray control. Such hybrid operating rooms are extremely costly. For the past 5 years, the Upper Rhine Vascular Center in Speyer has been home to an exceptionally comfortable hybrid operating room (see picture gallery, picture 7), one of the largest in Germany. By means of an industrial robot, the X-ray tube can be controlled by the surgeon with millimeter precision.
In endovascular surgery, direct treatment within the vessels often prevents open surgery - Prof. Rümenapf then expands the vascular constriction internally with a balloon and inserts a stent, for example. The specialist has long been familiar with this particularly gentle method, and he is also considered an absolute expert in the hybrid interventions mentioned above. This is also matched by the technically perfect equipment: the Vascular Center has a state-of-the-art hybrid operating room that combines the advantages of the sterile operating room with a high-performance angiography system (see below).
The CHIVA method, which is also new, is used primarily for diabetic varicose vein patients with circulatory disorders.
Prof. Rümenapf and his great team of senior physicians, functional senior physicians, residents, assistants and nursing staff all contribute to the renowned vascular center further expanding its high international reputation. The vascular surgery background service also provides fast, uncomplicated emergency care for vascular patients. Two vascular surgery specialists are on call around the clock. In this area, too, the facility has a nationwide coverage area due to its extraordinary reputation.
Varicose veins (varices)
Diseases of the leg veins manifest themselves primarily through a disturbance in the flow of blood in the superficial or deep leg veins. Depending on the severity, there are cosmetically unattractive varicose veins, swelling of the lower legs due to blood stagnation, skin changes (see image gallery, picture 8), and finally the so-called "open leg", i.e. non-healing painful wounds on the lower legs. The cause can be varicose veins, but also occlusions of the deep leg veins (thrombosis).
Varicose vein surgery is usually performed on an outpatient basis. Prof. Rümenapf and his team specialize in complicated cases, i.e. patients with varicose veins who can no longer be operated on reasonably under outpatient conditions because they have too many concomitant diseases or because the varicose veins are too extensive. Patients with fresh occlusions of the deep leg and pelvic veins are also operated on in Speyer, by means of so-called venous thrombectomy. These are complicated and dangerous surgeries for which a vascular surgeon needs a great deal of experience, as is the case in vascular surgery in Speyer.
Of course, patients with "normal", i.e. uncomplicated varicose veins are also operated on in Speyer. Accordingly, you can rely on a good surgical result. It is crucial to understand the flow conditions in the deep and superficial venous system, as a prerequisite for sensible surgical planning. With high-resolution color duplex sonography, the distribution pattern and flow dynamics in the varicose veins can be precisely determined before surgery, so that the surgery is economical, precise and cosmetically perfect.
Varicose vein surgery is problematic in patients who also suffer from diabetes mellitus and have arterial circulatory disorders of the legs (see diabetic foot). It should be performed only by surgeons who recognize all these problematic cases, i.e. varicose vein disease, diabetes, arterial circulatory disorder. People with diabetes mellitus and varicose veins should not be operated according to the classical surgical principles, namely removal of all diseased leg veins. They need gentler surgical procedures, such as the innovative CHIVA method.
With appropriate ultrasound examination, only blood column underbands and divisions are performed, without stripping, sclerosing or destroying the veins by heat. This protects the leg veins and preserves them for possible later bypass surgeries on the arterial system. This is of great importance at the Upper Rhine Vascular Center in Speyer, because about 400 of the approximately 2,500 surgeries performed each year are bypass surgeries on the legs, and they are mostly performed on patients with diabetes mellitus using the leg veins.
Shunt surgery for dialysis
Dialysis patients usually need "blood cleansing" 3 times a week for about 4 to 6 hours (see image gallery, picture 9). This replaces the extinguished kidney function. Blood purification (hemodialysis) requires that about ½ liter of blood per minute be removed from the human body, purified outside the body, and returned to the body. In order for this to work at all, a short-circuit connection must be made between a vein in the arm and an artery in the arm (dialysis shunt) so that enough blood can flow in the vein for dialysis. This is called a dialysis shunt. Prof. Rümenapf's team specializes in shunt surgery, and Prof. Rümenapf also offers shunts made of plastic material as well as dialysis catheters (Demers catheters), which are implanted via a minor surgical procedure. Every year, about 200 dialysis accesses are surgically placed in Speyer. Dialysis patients in the vascular surgery department have the option of dialysis at any time in the dialysis practice of Dr. Schmitt and colleagues, which is affiliated with the hospital.
In the patient's room:
In the bathroom: