C Schlensak

Pulmonary artery banding with a novel percutaneously, bidirectionally adjustable device.

Pulmonary artery banding is commonly performed as a palliative procedure in complex congenital heart disease, when pulmonary blood flow is increased. However, the hemodynamics may change postoperatively requiring readjustment of the band, which may necessitate a second operation. We report a new system for pulmonary artery banding which allows precise placement of the band intraoperatively, as well as bidirectional percutaneous adjustment of the band postoperatively. Via left lateral thoracothomy the new device was implanted without complications into a neonate with congestive heart failure due to tricuspid atresia (IIc) and coarctation of the aorta. Although optimal placement of the band had been achieved intraoperatively the band had to be tightened 25 h after the operation and released 85 h after the operation in order to optimize hemodynamics. The bidirectionally adjustable device for banding of the pulmonary artery is superior to previously used devices with either no or unidirectional adjustability of the band because it is safe and easy to implant and has the potential to reduce the number of reoperations associated with this type of procedure.

Minimal-invasive, video-assisted vein harvesting for cardiac and vascular surgical procedures.

Harvesting of the saphenous vein is a routine procedure in coronary and peripheral vascular surgery. It is usually performed using a continuous long skin incision. Minor complications are reported in up to 24% (hematoma, wound dehiscence, infection, pain) and major problems necessitating surgical interventions (bleeding, abscess) in less than 1%. These complications lead to a prolonged hospital stay. To reduce these complications we have used a new endoscopic, video-assisted technique in 17 patients. Harvesting of the total length of the saphenous vein is possible with only one 2-3 cm long incision proximally the knee joint. We conclude that this technique is safe, may reduce the morbidity of saphenous vein harvesting and is associated with a perfect cosmetic result.

Clinical experience with the VentrAssist left ventricular assist device.

INTRODUCTION Left ventricular mechanical assist device (LVAD) support is well established as a bridge to transplantation and as an alternative to transplantation in patients with end-stage heart failure. There are currently various LVAD systems available based on different types of pump technology. We present the VentrAssist LVAD, a centrifugal pump, and focus on a surgical implantation technique that may help reduce the complications typically associated with VAD surgery. METHODS AND RESULTS 412 patients underwent VentrAssist LVAD implantation between June 2003 and January 2009 worldwide. The overall rate of success was 81 % (i.e., ongoing, HTX, or recovery). Interestingly hemolysis is greatly reduced with this intracorporeal centrifugal LVAD compared to other VAD systems with other pump designs. Our surgical implantation technique and strategy may contribute to reducing complications. CONCLUSION The VentrAssist is a powerful and effective LVAD; its use can considerably reduce hemolysis. Long-term follow-up is necessary to determine whether the VentrAssist is appropriate as a bridge to transplant as well as feasible for long-term application.

Diagnostic and surgical approach of innominate artery saddle embolus

Patients with an acute arterial occlusion of the right upper extremity and absent axillary pulse should have a Doppler scan examination before a balloon catheter embolectomy is performed. If there is no arterial pulse detectable, an angiography should be performed afterwards to localize the embolus. In the case of a proximal arterial occlusion of the right arm, the authors recommend this procedure to prevent an embolus dislocation by catheter embolectomy and subsequent cerebral embolization. For direct surgical embolectomy the authors recommend a supraclavicular incision.

Chirurgische Interventionen nach endoluminaler Therapie bei infrarenalem Bauchaortenaneurysma (BAA)

ZusammenfassungChirurgische Maßnahmen nach Implantationen von endovasculären Prothesen (Stent-Grafts) bei infrarenalem Bauchaortenaneurysma (BAA) sind bisher nur ausnahmsweise beschrieben worden. Zwischen September 1994 und Januar 1997 wurden in einer prospektiven Studie 70 Patienten (Altersdurchschnitt, 68±8 Jahre; 48–81 Jahre) mit einem endovasculären Stent-Graft versorgt. Alle Eingriffe wurden in Zusammenarbeit von Gefäßchirurgen und interventionellen Radiologen durchgeführt. Bei 67/70 Patienten (96%) konnte der Aortenstent erfolgreich plaziert werden. Bei 18/70 Patienten waren chirurgische Interventionen notwendig: Freilegung der kontralateralen Leiste (n=7), Rekonstruktion der Femoralgefäße (n=12), Thrombembolektomie (n=5), Leistenrevision (n=3), Konversion zur chirurgischen Therapie (n=2).Unter der Voraussetzung, daß die Intervention in Zusammenarbeit von Gefäßchirurgen und Radiologen durchgeführt wird, ist die endoluminale Therapie des BAA für ausgewählte Patienten eine Alternative zur konventionellen Operation.SummaryThere are little data about complications after exclusion of infrarenal aortic aneurysms (AAA) with endovascular stent-grafts. This study was undertaken in order to investigate complications requiring surgical procedures after transluminal repair of AAA.Between September 1996 and January 1997 we performed endoluminal repair for exclusion of AAA with use of polyester covered nitinol stents in 70 patients (mean age, 68±8 years; range, 48–81 years). All procedures were done under study conditions only and teamwork between interventional radiologists and vascular surgeons. Primary technical success with complete exclusion of the aneurysm was achieved in 67/70 patients (96%). Local complications requiring surgical interventions were: contralateral femoral cut down (n=7), repair of femoral artery (n=12), thrombectomy (n=5), revision of groin (n=3), amputation of the foot and lower limb (n=2), conversion to open procedure (n=2).Considering strict patient selection and account that implantation should be done as an cooperation of vascular surgeons and interventional radiologists, stent-graft implantation for AAA may be an alternative therapeutic option to conventional surgery.

Reducing the ischemic time of donor hearts will decrease morbidity and costs of cardiac transplantations

With liberalization of donor eligibility criteria, donor hearts are being harvested from remote locations, increasing ischemic times. The aim of this study was to examine the effect of total ischemic time (TIT) on length of stay in the intensive care unit (LOS in ICU) and its economic consequences. The study population included recipients without prior mechanical support undergoing heart transplantation between 1998 and 2008 at a single institution. The mean age of the 72 recipients (56 men, 16 women) was 50.6 years (range 15–68 years) and the mean donor age was 41.5 years (range 11–61 years). The median TIT was 181.2 min (range 107–243) and median LOS in ICU was 11.5 days (range 3–107 days). There was a statistically significant linear relationship between TIT and LOS in ICU r(72)s0.317, Ps0.004. Each 5 min and 38 s of TIT equated to one more day in ICU. An ischemic time )180 min was associated with higher LOS in ICU, renal failure, and a more frequent use of nitric oxide in our cohort. For longer distance harvesting, the reduction of TIT by the fastest possible transport (learjet, helicopter) would have economic advantages with regards to the high cost of treatment in ICU. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Explantation von Bauchaortenstents - Ursachen, OP-Technik, Ergebnisse -

Background: Endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms (AAA) has gained widespread acceptance because it is associated with lower perinterventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. Methods and Results: Between 9/94 and 12/98, 150 patients (age = 69.6 ′ 8.5 y; m = 142, f = 8) with AAA were treated by placing an intravascular nitinol stent graft (Stentor, n = 55; Vanguard-System, n = 95; 8 tubular grafts, 142 bifurcated grafts). Initial placement of the stent graft was successful in 144 patients. In 12% of stent graft placements we encountered one of the following complications (n, days after stent placement): migration or dislocation of the prosthesis (4, 914′220d), rupture of the aorta (2, 452d/802d), recurrent thrombosis of the stent graft (3, 478′359d), endoleak (3, 955′472d), infection of the prosthesis (5, 798 ′495 d). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a dacron graft. Conclusions: 1. The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. 2. Explantation of the prosthesis and surgical repair is feasible but bears additional risks. 3. Since the onset of reperfusion of the excluded aneurysm can not be predicted, all patients with infrarenal aortic stent grafts require frequent computer tomographic follow up. 4. Lastly, the results call for further improvements in the design of the stent graft.

[Explantation of aortic stent-grafts].

Background: Endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms (AAA) has gained widespread acceptance because it is associated with lower perinterventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. Methods and Results: Between 9/94 and 12/98, 150 patients (age = 69.6 ′ 8.5 y; m = 142, f = 8) with AAA were treated by placing an intravascular nitinol stent graft (Stentor, n = 55; Vanguard-System, n = 95; 8 tubular grafts, 142 bifurcated grafts). Initial placement of the stent graft was successful in 144 patients. In 12% of stent graft placements we encountered one of the following complications (n, days after stent placement): migration or dislocation of the prosthesis (4, 914′220d), rupture of the aorta (2, 452d/802d), recurrent thrombosis of the stent graft (3, 478′359d), endoleak (3, 955′472d), infection of the prosthesis (5, 798 ′495 d). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a dacron graft. Conclusions: 1. The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. 2. Explantation of the prosthesis and surgical repair is feasible but bears additional risks. 3. Since the onset of reperfusion of the excluded aneurysm can not be predicted, all patients with infrarenal aortic stent grafts require frequent computer tomographic follow up. 4. Lastly, the results call for further improvements in the design of the stent graft.

Explantation von Bauchaortenstents

Background: Endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms (AAA) has gained widespread acceptance because it is associated with lower perinterventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. Methods and Results: Between 9/94 and 12/98, 150 patients (age = 69.6 ′ 8.5 y; m = 142, f = 8) with AAA were treated by placing an intravascular nitinol stent graft (Stentor, n = 55; Vanguard-System, n = 95; 8 tubular grafts, 142 bifurcated grafts). Initial placement of the stent graft was successful in 144 patients. In 12% of stent graft placements we encountered one of the following complications (n, days after stent placement): migration or dislocation of the prosthesis (4, 914′220d), rupture of the aorta (2, 452d/802d), recurrent thrombosis of the stent graft (3, 478′359d), endoleak (3, 955′472d), infection of the prosthesis (5, 798 ′495 d). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a dacron graft. Conclusions: 1. The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. 2. Explantation of the prosthesis and surgical repair is feasible but bears additional risks. 3. Since the onset of reperfusion of the excluded aneurysm can not be predicted, all patients with infrarenal aortic stent grafts require frequent computer tomographic follow up. 4. Lastly, the results call for further improvements in the design of the stent graft.

Surgical treatment of acute pulmonary embolism

Pulmonary embolism is a common event in hospitalized patients. In most cases, pulmonary embolism is asymptomatic and undergoes spontaneous resolution. Pulmonary embolectomy is required when refractory hypotension persists, despite all resuscitative efforts, and a thrombus has clearly been documented by angiography, computed tomography or magnetic resonance angiography. Embolectomy for massive embolism is performed through median sternotomy with the use of cardiopulmonary bypass. Usually the common pulmonary artery is incised and the emboli are extracted using forceps, suction or Fogarty catheters. For chronic embolisation or if no cardiopulmonary bypass is available, a lateral thoracotomy may be performed. The embolus may be removed after proximal occlusion of the pulmonary artery while normal circulation continues in the opposite lung. In patients with high risk of recurrence, the vena cava inferior may be interrupted or a vena cava filter may be implanted. Postoperatively, systemic anticoagulation should be administered for 3 months or longer depending on the patient’s risk profile. Interventional approaches for the treatment of pulmonary embolism are currently under investigation. Their benefit over surgical embolectomy remains to be established.