Andreas Frech

Risk factors for mortality and failure of conservative treatment after aortic type B dissection.

BACKGROUND Despite medical treatment, one third of patients with uncomplicated type B aortic dissections experience severe late complications. The aim of this study was to identify patients at high risk of mortality during follow-up. METHODS A total of 183 patients with acute Stanford type B dissection were treated in one of the university hospitals (Aachen [Germany], Maastricht [The Netherlands], and Innsbruck [Austria]) between 1997 and 2010. Records indicated that 120 patients were treated conservatively. Of these patients, 16 were lost to follow-up. The maximum diameter, extent of the dissection, and patency of the side branches were determined from computed tomography angiography data. Survival and treatment failure were analyzed by univariate and multivariate Cox regression analysis. The univariate analysis investigated the influence of aortic diameter (≥41 vs <41 mm) on survival, and the multivariate analysis investigated the influence of aortic diameter, age, sex, and surgery on survival. RESULTS During the follow-up period, the initial treatment was converted to surgical treatment in 21 patients (20.2%). Sixteen of the 104 patients (15.4%) died after a mean of 845.5±805.9 days. The mean maximum aortic transversal diameter at admission was 41.2±8.7 mm. The multivariate analysis identified aortic diameter (P=.004; hazard ratio, 1.07) and age (P=.038; hazard ratio, 1.05) as risk factors that significantly reduce survival. CONCLUSIONS Our study revealed both early aortic dilatation and older age as risk factors for increased mortality after conservative treatment of type B dissection.

Elevated baseline hs-cTnT levels predict exercise-induced myocardial ischemia in patients with peripheral arterial disease

INTRODUCTION Due to the systemic nature of atherosclerosis, the prevalence of coronary artery disease (CAD) is high in patients with peripheral arterial disease (PAD). A biochemical assay for assessing cardiac risk might improve clinical evaluation of PAD patients. The aim of this study was to investigate whether a new high-sensitivity cardiac Troponin T (hs-cTnT) assay can predict exercise-induced myocardial ischemia in PAD patients without clinical signs of CAD. METHODS Sixty-eight ambulatory patients with Fontaine stage II PAD underwent treadmill stress testing to maximum walking distance. Myocardial ischemia was assessed using a 2-lead Holter ECG and ST-segment depression of ≥ 0.2 mV was considered significant. Hs-cTnT was measured from serum samples taken at baseline as well as 5, 10 and 30 min after exercise. RESULTS Hs-cTnT baseline levels were significantly higher (19.3 ng/L (5.0; 20.2 ng/L) vs. 6.6 ng/L (4.4; 9.4 ng/L); p=0.037) and increase of serum levels 5 min after cessation of exercise was more pronounced (1.09 ng/L (0.23; 1.80 ng/L) vs. 0.22 ng/L (-0.1; 0.65 ng/L), p=0.032) in ECG positive patients compared to individuals with normal ECG. Logistic regression analysis identified the baseline hs-cTnT serum level as an independent risk factor for developing significant exercise-induced ST-segment depression (odds ratio 1.2 per 1-unit increase, p=0.015). CONCLUSIONS In patients with PAD, exercise-induced myocardial ischemia is associated with elevated baseline levels and a significant early increase of hs-cTnT serum levels.

Periaortitis as a Rare Complication After Endovascular Aneurysm Repair

A 6.5-cm asymptomatic infrarenal aortic aneurysm was detected by contrast-enhanced computed tomography (CT) scan in a 70-year–old patient. Initially, there were no signs of aortic or periaortic inflammation (Figure 1), and complete blood cell count, renal function, and C-reactive protein levels were normal. Aneurysm repair was indicated, and the patient underwent endovascular aneurysm repair using an aorto-bi-ilac stent graft (Endurant II, Medtronic Inc, Minneapolis, MN). Routine follow-up contrast-enhanced CT scan was performed on the third postoperative day and showed correct stent graft position without evidence of abnormalities (Figure 2). At routine follow-up after 3 months, the patient …

Prognostic relevance of ischemia-modified albumin and NT-proBNP in patients with peripheral arterial occlusive disease

BACKGROUND Cardiovascular morbidity is high among patients with peripheral arterial occlusive disease (PAOD). The aim of this study was to evaluate the ability of ischemia-modified albumin (IMA), N-terminal proBNP (NT-proBNP), and high-sensitive cardiac Troponin T (hs-cTnT) to predict cardiovascular complications in male patients with Fontaine stage II PAOD. METHODS 68 men with stage II PAOD underwent treadmill testing. NT-proBNP, IMA and hs-cTnT were measured before and after exercise. Patients were followed up prospectively and complete follow-up data were available for 66 individuals. RESULTS Median follow-up time was 43.0months. 12 (18.2%) patients had suffered from a major adverse cardiac event (MACE). IMA and NT-proBNP baseline concentrations were significantly higher in patients who developed MACE during follow-up: IMA: 110.6±2.4kU/L vs. 102.5±0.9kU/L (p<0.001); NT-proBNP: 270.5±295.9ng/L vs. 84.6±15.4ng/L (p=0.007). In multivariable regression models only IMA was significantly associated with the primary endpoint (HR=1.07, CI 1.01-1.13; p=0.029). CONCLUSION In the present study, a serum concentration of >103.9kU/L of IMA was a better independent predictor of MACE than NT-proBNP or hs-cTnT. IMA might be a valuable tool for risk stratification in PAOD patients.

Compared to 123I-MIBG SPECT/CT, 18F-DOPA PET/CT provides accurate tumor extent in patients with extra-adrenal paraganglioma

AimThe aim of this study was to compare the accuracy of 123I-MIBG SPECT/CT with that of 18F-DOPA PET/CT for staging extra-adrenal paragangliomas (PGLs) using both functional and anatomical images (i.e., combined cross-sectional imaging) as the reference standards.MethodsThree men and seven women (age range 26–73 years) with anatomical and/or histologically proven disease were included in this study. Three patients had either metastatic head-and-neck paragangliomas (HNPGLs) or multifocal PGL, and seven patients had nonmetastatic disease. Comparative evaluation included morphological imaging with CT, functional imaging with 18F-DOPA PET, and 123I-MIBG imaging including SPECT/CT. Imaging results were analyzed on a per-patient and per-lesion basis.ResultsOn a per-patient basis, 18F-DOPA PET’s detection rate for both nonmetastatic and metastatic/multifocal disease was 100%, whereas that of planar 123I-MIBG imaging alone was 10.0% and that of 123I-MIBG SPECT/CT was 20.0%. Overall, on a per-lesion basis, 18F-DOPA PET showed a sensitivity of 69.2% (McNemar p < 0.001) compared with anatomical imaging. Sensitivity of planar 123I-MIBG scintigraphy was 5.6%, and that of SPECT/CT was 11.1% (McNemar p < 0.0001). Overall, 18F-DOPA PET identified 18 lesions, and anatomical imaging identified 26 lesions; planar 123IMIBG imaging identified only 1 lesion, and SPECT/CT, 2 lesions.Conclusion18F-DOPA PET is more sensitive than is 123I-MIBG imaging, including SPECT/CT, for staging HNPGL. Combined functional and anatomical imaging (PET/CT) is indicated to exclude metastatic disease in extra-adrenal PGL.

Abdominal Aortic Aneurysms An Overview of Screening and Management in Primary Care

Abdominal aortic aneurysms represent both an individual risk of mortality and a socioeconomic burden for health care systems worldwide, but screening is not performed in all countries. Here, the authors summarize the pros and cons of screening to reduce abdominal aortic aneurysm–related mortality.

Subclavian artery rupture in a young man during excessive weight lifting

We report a 19-year-old man with rupture of the right subclavian artery after an excessive exercise of weight lifting. Imaging showed a hematothorax and hematomediastinum, a pseudoaneurysm with a maximum diameter of 4 cm, and a dissection of the right vertebral artery. As an emergency procedure an interposition graft was performed for reconstruction of the right subclavian artery. The patients postoperative course was uneventful, and he was symptom free except for regressive hoarseness due to a paresis of the right recurrent laryngeal nerve.

Response to Letter Regarding Article, “Periaortitis as a Rare Complication After Endovascular Aneurysm Repair”

We thank Kakkos et al for their interest in our case report entitled “Periaortitis as a Rare Complication After Endovascular Aneurysm Repair.”1 Information concerning secondary periaortitis after stent graft implantation in humans is indeed rare, and only 6 cases have been published so far,2–5 although a huge number of endovascular aneurysm repair procedures are performed worldwide. Interestingly, there are similarities in all reported …