Eike Sebastian Debus

Cost-of-illness of chronic leg ulcers in Germany

Chronic wounds are important because of their frequency, their chronicity and high costs of treatment. However, there are few primary data on the cost‐of‐illness in Germany. The aim was to determine the cost‐of‐illness of venous leg ulcers (VLU) in Germany. Prospective cost‐of‐illness study was performed in 23 specialised wound centres throughout Germany. Direct, medical, non medical and indirect costs to the patient, statutory health insurers and society were documented. Thereover, health‐related quality of life (QoL) was recorded as intangible costs using the Freiburg quality of life assessment for wounds (FLQA‐w, Augustin). A total of 218 patients (62.1% female) were recruited consecutively. Mean age was 69.8 ± 12.0 years. The mean total cost of the ulcer per year and patient was €9569, [€8658.10 (92%) direct and €911.20 (8%) indirect costs]. Of the direct costs, €7630.70 was accounted for by the statutory health insurance and €1027.40 by the patient. Major cost factors were inpatient costs, outpatient care and non drug treatments. QoL was strikingly reduced in most patients. In Germany, VLU are associated with high direct and indirect costs. As a consequence, there is a need for early and qualified disease management. Deeper‐going cost‐of‐illness‐studies and cost‐benefit analyses are necessary if management of chronic wounds is to be improved.

Editor's Choice – Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

Editors Choice - Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).

Distal False Lumen Occlusion in Aortic Dissection With a Homemade Extra-Large Vascular Plug: The Candy-Plug Technique

Purpose To report a technique to create an extra-large vascular plug for occlusion of a large distal false lumen in chronic aortic dissection. Technique The “candy-plug” technique is demonstrated in a 58-year-old multimorbid man with a history of complicated acute type B aortic dissection and a 9-cm chronic thoracic false lumen aneurysm. The patient underwent a staged repair with a cervical debranching procedure as a first step and a thoracic endovascular aortic repair from the innominate artery to the celiac artery as a second step. To occlude the large false lumen from a distal route, a stent-graft was modified on-table with a diameter-restricting suture, giving it a wrapped candy–like shape. This plug was deployed into the false lumen, and the remaining opening was occluded with a standard vascular plug. On 3-month follow-up imaging, the thoracic false lumen aneurysm remained completely thrombosed. Conclusion The candy-plug technique can facilitate complete occlusion of chronic thoracic false lumen aneurysm by prohibiting distal false lumen backflow.

The “Wound‐QoL”: A short questionnaire measuring quality of life in patients with chronic wounds based on three established disease‐specific instruments

The aim of this study was to develop a short questionnaire measuring health‐related quality of life (HRQoL) in chronic wounds. Three validated instruments assessing HRQoL in chronic wounds—the Freiburg Life Quality Assessment for wounds, the Cardiff Wound Impact Schedule, and the Würzburg Wound Score—were completed by 154 German leg ulcer patients in a longitudinal study. For implementation in the new, shorter questionnaire Wound‐QoL, all of those 92 items that covered the core content of the three questionnaires and showed good psychometric properties were selected. Internal consistency, convergent validity, and responsiveness were analyzed using the study data on the selected items (a new approach called virtual validation). Subscales were determined with factor analysis. Item, instruction, and response scale wording were harmonized. Seventeen items were included in the Wound‐QoL, which could be attributed to three subscales on everyday life, body, and psyche. Both global score and subscale scores were internally consistent with Cronbachs alpha between 0.71 and 0.91. The global score showed significant convergent validity (r = 0.48 to 0.69) and responsiveness (r = 0.18 to 0.52); the same was true for the subscale scores. The Wound‐QoL for measurement of HRQoL in chronic wounds proved to be internally consistent, valid, and responsive in German leg ulcer patients. The findings of this virtual validation study need to be confirmed in a longitudinal validation study on the final Wound‐QoL, which is currently being conducted.

Customized Transapical Thoracic Endovascular Repair for Acute Type A Dissection

A 67-year-old patient with severe comorbidities and acute type A aortic dissection with pericardial tamponade was treated with an endograft introduced through a mini-thoracotomy and puncture of the left ventricular apex. Final angiography showed complete coverage of the dissection. Early and 6-month follow-up computed tomography showed full apposition of the endograft without residual dissection. Transapical thoracic endovascular repair of acute type A aortic dissection appears to be feasible and is associated with minimal physiologic compromise. It may provide a less invasive alternative for patients with increased operative mortality.

Carbon Dioxide Flushing Technique to Prevent Cerebral Arterial Air Embolism and Stroke During TEVAR.

Purpose: To describe the technique of carbon dioxide (CO2) flushing of thoracic stent-grafts to reduce the risk of cerebral air embolism. Technique: To remove room air, thoracic stent-grafts were preoperatively flushed 2 minutes with carbon dioxide from a cylinder connected to the flushing chamber of the captor valves of Zenith custom-made endografts; this was followed by the standard saline flush. Thirty-six patients undergoing thoracic endovascular aortic repairs (TEVAR) involving the ascending aorta and the aortic arch received CO2-flushed Zenith endografts. One patient with a highly calcified arch experienced a minor stroke. Conclusion: Arterial air embolism is a potentially underappreciated problem of aortic endografting, especially in the proximal segments of the aorta. CO2 flushing may have the potential to reduce air embolization during TEVAR.

Operative und interventionelle Gefäßmedizin

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Cyber medicine enables remote neuromonitoring during aortic surgery

OBJECTIVE This study assessed the feasibility and effectiveness of remote neuromonitoring as an adjunct to spinal cord protection during surgical repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. METHODS Four aortic centers in three European countries participated in this prospective observational study. A similar surgical protocol was used in all centers, including assessment of spinal cord function by means of monitoring motor-evoked potentials (MEPs). MEP information was evaluated at one central neurophysiologic department in Maastricht, The Netherlands. Transfer of MEP data from all operating rooms to Maastricht was arranged by Internet connections. In all patients, the protective and surgical strategies to prevent paraplegia were based on MEPs. The on-site surgeons reacted in real time to the interpretation and feedback of the neurophysiologist. RESULTS Between March 2009 and May 2011, 130 patients (85 men) were treated by open surgical repair. Extent of aneurysms was equally distributed among the centers. Neuromonitoring was technically stabile and successful in all patients. The transfer of data from the operating room in the different vascular centers was undisturbed and without any technical problems. By maintaining a mean distal aortic pressure of 60 mm Hg, MEPs were undisturbed in 65 patients (50%). In another 65 patients (50%), significant changes in MEPs prompted the surgical teams to initiate additional protective and surgical strategies to restore spinal cord perfusion. These measures were not effective in five patients (3.8%), and acute paraplegia resulted. Delayed paraplegia occurred in 10 patients (7.7%) but improved in three and recovered completely in another three. No false-negative or false-positive MEP recordings were experienced. CONCLUSIONS Remote neuromonitoring of spinal cord function during open repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms as a telemedicine technique is feasible and effective. It allows centralization of expertise and saves individual centers from investing in complex technology. The value of monitoring MEPs was confirmed in different aortic centers, resulting in adequate neurologic outcome after extensive aortic surgical procedures.

Transapical access for thoracic endograft delivery.

The purpose of this paper is to describe the technique of transapical deployment of a thoracic endograft and to discuss the specifics of this access. The technique of endograft deployment through a transapical access is demonstrated in a patient with a symptomatic 14-cm aortic arch aneurysm. The 73-year-old patient, with concomitant chronic obstructive airway disease and cardiovascular disease, had been denied open surgery. Femoral artery access was deemed contraindicated because of a more distal concomitant type III thoracoabdominal aneurysm, borderline renal failure and heavily calcified iliac arteries. Bilateral iliac–subclavian debranching and thoracic endografting via a combined transapical and left subclavian access successfully excluded the thoracic aortic aneurysm. The patient died within 24 hours postoperatively due to a massive myocardial infarction. In conclusion, transapical access for thoracic endograft delivery is feasible. Combined with complex debranching procedures in a challenging aneurysmal anatomy, it carries a high risk for periprocedural complications.

Maximizing therapeutic success: The key concepts of individualized medical strategy (IMS)

Abstract Individualised medical strategy (IMS) seeks therapeutic success in the following three dimensions: (1) biology, (2) sociology, and (3) psychology. IMS addresses these dimensions of success (1) as efficiency by achieving biological goals such as medication that normalizes blood pressure or surgery that completely eradicates cancer; (2) as effectiveness by achieving social goals such as satisfying guidelines, patients’ purposes, and ethical demands; and (3) as motivation by achieving psychological goals such emotional support and identification of patients with therapy. IMS designs patients as principals of care, with utility-driven action style, physicians as agents of medical rationality with duty-driven action style, and strategy as primer for cooperation between patients and physicians. Dialog is central to maximize success through (1) informing patients about their pathologic conditions, options, and risks of treatment, (2) negotiating patients’ needs, and (3) motivating patients to support therapy. IMS understands therapy as open-ended process where one-sided views of what is to be considered as “best medicine” is not appropriate, and where physicians integrate normative and emotional dimensions of patients into therapy. In conclusion, we suggest IMS as a highly useful concept of medical action, where physicians integrate patients’ individual utilities, ethical principles, and emotions to maximize therapeutic success.