Alexander Oberhuber

Fast track management reduces the systemic inflammatory response and organ failure following elective infrarenal aortic aneurysm repair.

OBJECTIVES Systemic inflammatory response syndrome (SIRS) is common after abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the impact of a multimodal fast track (FT) regimen on incidence rates of SIRS after elective infrarenal AAA repair. METHODS Post hoc analysis of a randomized controlled trial including 99 patients after either traditional (TC) or FT care. Basic FT elements were no bowel preparation, reduced preoperative fasting, patient controlled epidural analgesia, enhanced postoperative feeding and mobilization. The presence of SIRS, organ failure and mortality, length of stay (LOS) on intensive care unit (ICU) were analyzed during the postoperative course. RESULTS The incidence of SIRS in the FT treatment arm was significantly lower as compared to TC: 28% vs. 50%, P = 0.04. The rate of any organ failure (AOF) and multiple organ failure (MOF) was lower in the FT group: AOF: 16% vs. 36%, P = 0.039; MOF: 2% vs. 12%; P = 0.112. LOS on ICU showed a slight advantage for FT care: 20 hours vs. 32 hours (P = 0.183). CONCLUSION An optimized patient care program in elective open AAA repair significantly decreases the postoperative incidence of SIRS as well as rates of organ failure.

Plasmin Triggers Chemotaxis of Monocyte-Derived Dendritic Cells Through an Akt2-Dependent Pathway and Promotes a T-Helper Type-1 Response

Objective—Dendritic cells (DC) accumulate in atherosclerotic arteries where they can modulate atherogenesis. We investigated whether plasmin might alter the function of human DC. Methods and Results—Stimulation of monocyte-derived DC with plasmin elicited a time-dependent actin polymerization and chemotaxis comparable to that triggered by the standard chemoattractant formyl-methionyl-leucyl-phenylalanine. Plasmin triggered rapid activation of Akt and mitogen-activated protein kinases, followed by phosphorylation of the regulatory myosin light chain and chemotaxis. For the chemotactic DC migration, the activation of Akt and p38 and extracellular signal-regulated kinase 1/2 mitogen-activated protein kinases were indispensable, as shown by pharmacological inhibitors. DC express Akt1 and Akt2, but not Akt3. However, in DC, plasmin activates exclusively Akt2 via a p38 mitogen-activated protein kinase-dependent pathway. Accordingly, knockdown of Akt2 with short-hairpin RNA, but not of Akt1, blocked the plasmin-induced extracellular signal-regulated kinase 1/2 activation and the chemotactic response. Moreover, plasmin-stimulated DC induced polarization of CD4+ T cells toward the interferon-&ggr;–producing, proinflammatory Th1 phenotype. Consistent with a role for DC and adaptive immune response in atherogenesis, we demonstrate DC in human atherosclerotic vessels and show that plasmin is abundant in human atherosclerotic lesions, where it colocalizes with DC. Conclusion—Plasmin generation in the atherosclerotic vessel wall might contribute to accumulation of DC, activation of the adaptive immune response, and aggravation of atherosclerosis.

Technical and clinical success after endovascular therapy for chronic type B aortic dissections.

OBJECTIVE To analyze early technical success and late clinical success after endovascular entry sealing for chronic type B dissection with special emphasis on reintervention, false lumen thrombosis, and aortic remodeling. METHODS Retrospective analysis of a prospective database. From September 1999 to January 2011, 19 patients with chronic type B dissections were treated by endovascular entry sealing. Median age was 60 years. Median time between onset of acute dissection and surgical intervention was 36 (1 to 60) months. Median follow-up was 13 months (1 to 124). RESULTS The endografts used were: Medtronic Captivia (5), Medtronic Valiant (5), Gore TAG (6), Gore C-TAG (2), and Cook Zenith (1). In four patients, revascularization of the left subclavian artery was performed prior to entry sealing. Primary technical success rate (entry sealing, absence of type I leak) was 18/19 (94.7%). In-hospital mortality was 0%. Spinal cord injury with persistent paraplegia occurred in 1/19 (5.2%) patients. After a maximal follow-up of 124 months, reinterventions in 9/19 (47.3%) were necessary: distal/proximal extension of stent graft (8), replacement of the aortic arch due to retrograde dissection (1), and open infrarenal aneurysm repair (1). During follow-up, none of the patients died due to stent-related complications. CONCLUSION Endovascular treatment (EVT) in chronic type B dissections has a high technical success rate and low mortality/morbidity. However reintervention rates are not negligible which might reduce the clinical success of EVT. Future investigations should aim at identifying patients who benefit from EVT at better defining the timing of EVT and at determining if entry sealing alone is sufficient.

Comparison of aortic neck dilatation after open and endovascular repair of abdominal aortic aneurysm.

OBJECTIVE This study evaluated the changes of the aortic diameter at the suprarenal and infrarenal segment after open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS This was a retrospective analysis of all patients undergoing AAA repair between 1997 and 2008. Inclusion criteria were at least 3 months of follow-up at our institution, elective aneurysm repair, and absence of false, mycotic, or inflammatory aneurysms. For EVAR, standard computed tomography (CT) scans from follow-up were used; in the OR group, CT scans performed for unrelated nonvascular indications were used. Diameters of the aorta were measured at the first slice below the lowest renal artery and at the first slice above the highest renal artery. A 2-mm change was defined as measurable aortic neck dilatation. RESULTS Inclusion criteria were met by 46 patients in the OR group and 103 in the EVAR group. After a follow-up of 34.1 months (range, 5.5-131.7 months) in the OR group and 39.4 months (range, 3-108.9 months) in the EVAR group, the mean changes were 1.75 ± 3.50 mm (OR) and 0.9 ± 2.3 mm (EVAR; P = .305) in the suprarenal diameters and 0.8 ± 2.9 mm (OR) and 1.2 ± 2.5 mm (EVAR; P = .311) in the infrarenal diameters. The absolute suprarenal vs infrarenal sizes were 29.7 ± 7.1 and 28.7 ± 6.8 mm in the OR group and 28.7 ± 3.2 and 28.5 ± 3.6 mm, respectively, in the EVAR group (suprarenal, P = .749; infrarenal, P = .273). Increase of the aortic diameter >2 mm, defined as aortic neck dilatation, was found in 23 of 103 EVAR patients (22.3% ± 0.862%), and in nine of 46 OR patients (19.57% ± 0.484%; P = .870). Increase in the suprarenal change >2 mm occurred in 21 of 103 EVAR patients (20.39% ± 1.04%) and in 14 of 46 OR patients (30.4% ± 0.446%; P = .260). Reintervention rate of patients with an increase >2 mm was 31% (seven of 23) in EVAR and 11.1% (one of nine) in the OR group (P = .386). CONCLUSIONS The AAA groups treated with EVAR or OR demonstrated similar increases of aneurysmal neck diameters. This suggests that aortic neck dilatation may be caused by a natural progression of the disease rather than by deviating therapeutic strategies.

Comparison of Clinical and Surgical-Pathological Staging in IIIA Non-Small Cell Lung Cancer Patients

BackgroundThe heterogeneous group of IIIA NSCLC patients requires careful preoperative clinical staging as tumor size and lymph node involvement guide treatment. The purpose of our study was to analyze the correctness of clinical staging in IIIA patients.MethodsRetrospective analysis of all patients resected due to lung cancer that had been staged IIIA either clinically using invasive and noninvasive techniques or surgical-pathologically after surgical resection. Correctness, sensitivity, specificity, and positive and negative predictive values of clinical staging were calculated.ResultsFrom our tumor database, 49 patients who met the inclusion criteria were identified. The histology of the primary tumor included adenocarcinoma (53%), squamous cell carcinoma (41%), and other (6%). Preoperative clinical staging consisted of computed tomography (CT), integrated positron emission tomography–CT (PET–CT), bronchoscopy, and mediastinoscopy. The predominant surgical procedures performed were lobectomies (57%) and pneumonectomies (29%). Clinical staging for UICC, T and N stage was correct in 36.7, 38.7, and 40.8%, respectively. In terms of T4 stage, sensitivity was 28.5%, specificity was 80.9%, positive predictive value was 20%, and negative predictive value was 87.1%. As for N2 involvement, we found a sensitivity of 66.6% and a specificity of 35.7%. Positive and negative predictive values for N2 involvement were 43.7 and 58.8% in that order.ConclusionsDespite multimodal preoperative invasive and noninvasive staging techniques, the correctness of clinical staging in IIIA NSCLC patients is low. Hence, in doubt more invasive staging or probatory thoracotomy should be performed not to deny potentially curative surgery in those patients.

Endovascular Repair of Aortic Isthmus Coarctation With a Self-Expanding Covered Stent

BACKGROUND Coarctation is one of the most often seen congenital aortal defects. In the majority, diagnosis will be made in newborns. Endovascular repair is critical in children owing to their growth, but in adult patients, it is an interesting alternative. METHODS A 31-year-old man presenting with hypertension of upper extremities and pulseless lower extremities was admitted to our hospital. Systolic blood pressure was 190 mm Hg, although a triple antihypertensive medication was administered. Computed tomographic angiography showed a nearly total occlusion of the aortic isthmus. Coarctation was treated by an endovascular approach with a self-expanding covered stent-graft (Medtronic Talent; Medtronic World Medical, Sunrise, FL) after predilatation with a Reliant balloon (Medtronic World Medical, Sunrise, FL). RESULTS After a follow-up of 40 months, the patient is normotensive and antihypertensive medication could be reduced. Lower extremities showed normal pulses and normal ankle-brachial index. Computed tomographic scans showed unchanged stent-graft position, with constant slight waist. DISCUSSION Endovascular repair of atresia or coarctation of the thoracic aorta is a minimal invasive debatable option. Not only reduction of blood pressure but also reduction of left ventricular mass and prolongation of life expectancy can be achieved by endovascular treatment.