Florian Liewald

Endovascular repair of traumatic descending aortic transection.

PURPOSE To present the results of endovascular repair of acute traumatic descending aortic transection. METHODS Among 66 thoracic stent-graft repairs performed between 1995 and 2001, 11 patients (9 men; mean age 34 years, range 12-73) underwent emergent endovascular repair of acute traumatic descending aortic transection following traffic accidents. Immediate treatment of aortic rupture was indicated in all patients because of a marked fresh hematoma with hemothorax; the spiral computed tomographic (CT) scans showed circular or semicircular descending thoracic aortic injuries. The devices used included 11 thoracic Excluders and 1 Talent stent-graft. RESULTS No patient required conversion to an open transthoracic operation. No patient developed temporary or permanent neurological deficit after endovascular treatment. Two type I endoleaks required periprocedural treatment: a second stent-graft was deployed in one and the existing stent-graft was balloon dilated in the other. Two patients underwent secondary procedures (iliac access complication and revascularization of the left subclavian artery). One patient died 22 days postoperatively secondary to injuries unrelated to the aortic repair. Over a mean 14-month follow-up (range 1-26), the surveillance CT scans have shown the stent-graft to be correctly positioned in all patients. CONCLUSIONS The treatment of acute traumatic descending aortic transection with an endovascular approach is feasible and safe and may offer the best means of therapy. Mortality and the risk of neurological deficit are low compared with open operations.

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture.

Abstract  Purpose: The purpose is to present results of endovascular exclusion (stent‐graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies. Methods: Indications for stent‐graft treatment were dependent on multislice angio‐CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio‐CT. Long‐term follow‐up consisted of evaluation with angio‐CT after 6 and 12 months, and from there on once a year and with plain chest X‐rays. Follow‐up was achieved in all patients. Results: Mean follow‐up is 21 months (1–66); 30‐day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left‐hand ischemia or subclavian steal syndrome. Conclusion: Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well‐defined morphologies. Mid‐term results are promising but it has to be observed whether these will translate into long‐term durability. (J Card Surg 2003; 18:367‐374)

Diffusion-weighted MRI: Detection of cerebral ischemia before and after carotid thromboendarterectomy

Purpose Conventional postoperative evaluation of patients following carotid thromboendarterectomy (TEA) consists of a clinical neurologic examination to assess neurologic deficits, color duplex ultrasound to document the surgically reestablished patency of the carotid artery, and CT for exclusion of postoperative ischemic infarctions. Recent studies prove that diffusion-weighted MRI is more sensitive in the detection of fresh insults than conventional MRI and CT. The objective of the study was to ascertain the incidence of clinically asymptomatic peri-and postoperative ischemic infarctions visualized at MRI. Method We included 52 patients in the study. Fifty-one patients (31 men, 20 women; average age 68 years) underwent cranial MR examination including a diffusion-weighted sequence at 24 h prior to carotid TEA and again 24 h following the procedure. One patient did not agree to participate. Results In 29 of 51 patients (56%), neither the pre-nor the postoperative MR scans showed any diffusion abnormalities. In 16 patients (31%), however, preoperative MRI detected fresh ischemic insults. In nine patients (17.6%), the size of the insult resulted in surgery being postponed for 4 weeks. In six patients (11.8%), postoperative MRI returned findings of fresh disturbances of diffusion suggestive of ischemia that were not visualized on preoperative scans. Discrete neurologic deficits were observed in only two (3.9%) of these patients. Deficits were transient and disappeared within 72 h. Conclusion Our findings underscore MRIs capacity for visualizing perioperative ischemic events. Moreover, MRI provides evidence of clinically asymptomatic embolisms that occur perioperatively.

Results from the First in Man German Pilot Study of the Silver Graft, a Vascular Graft Impregnated with Metallic Silver

The purpose of this study was to assess the safety of a novel vascular prosthesis in 50 patients who underwent inguinal and infrainguinal vascular reconstructions. The safety data were based on ultrasound Doppler data at 2 and 18 months to quantify the graft-tissue integration in this patient cohort. Between August 9, 2005, and January 25, 2006, 50 patients underwent inguinal or infrainguinal reconstructions with the Silver Graft (SG; B. Braun Melsungen AG, B. Braun Aesculap AG, Tuttlingen, Germany) in six vascular centers. All participating centers received the metallic silver-coated polyester graft (SG) with a diameter of 8 mm and a total length of 60 cm, which was length adjusted to fit the patients anatomy and the planned vascular reconstruction. The mean patient age was 69.1 ± 9.0 years, the male inclusion rate was 72.0%, and the Fontaine classifications were stage IV (16%), stage III (14%), stage IIb (66%), and stage IIa (4%), whereas aneurysm repairs amounted to 4%. In-hospital results revealed the presence of minimal perigraft fluid in 14.0% of all cases (7 of 50). At the 2-month follow-up, perigraft fluid was detected in one patient (1 of 50). At 18 months, a single case of minimal perigraft fluid was detected in an asymptomatic patient. Wound healing was accomplished at discharge in 96% of all patients, whereas at the 2-month follow-up, no signs of wound infection or irritation could be detected. The accumulated primary patency rates were 94% at 2 months and 88% at 18 months. The available clinical data on perigraft fluid as a marker for graft-tissue incorporation at 2 and 18 months, patency, and wound healing are comparable to those of other relevant clinical results with polyester grafts and support the safety of the metallic SG in the studied patient population with inguinal and infrainguinal reconstructions. However, it cannot be guaranteed that all graft infections can be avoided with the SGs.

Effect of felodipine on regional blood supply and collateral vascular resistance in patients with peripheral arterial occlusive disease.

This double-blinded, randomized, placebo-controlled study was designed to investigate the acute effect of felodipine on regional blood supply and collateral vascular resistance in patients with peripheral arterial occlusive disease (PAOD). Thirty men with PAOD were treated with a single dose of 5 mg felodipine or placebo. Systolic blood pressure (SBP), Doppler ankle pressure (DAP), calf blood flow (CBF) by venous occlusion plethysmography and calf transcutaneous oxygen tension (tcpO2) were measured during a cycle ergometry. Felodipine reduced SBP significantly (from 149 to 136 mmHg, p < 0.05), while placebo did not. DAP increased slightly but not significantly in both groups. The pressure gradient between SBP and DAP fell significantly in the felodipine group (60 vs 39 mmHg, p < 0.01) but not in the placebo group (59 vs 56 mmHg). There was a trend for lower velocity in tcpO2 decrease during the stress test and higher velocity of tcpO2 increase during recovery from exercise in the felodipine group although the differences between both groups were not significant. In the felodipine group, CBF increased by 35.6% (p < 0.05) whereas it did not change in the placebo group. In conclusion, while lowering SBP, felodipine increased slightly, or at least maintained, the blood supply to the calves in PAOD patients, which probably results from reducing collateral vascular resistance.

Das Pleuramesotheliom — Probleme in der Diagnostik und klinischer Verlauf bei 25 Patienten

SummaryPatients with benign pleurafibromas should undergo surgery as suspect thoracic tumors have the potential to become malignant. In benign cases diagnosis can easily be made during the operation. In such a case the prognosis is good and it is seldom necessary to undergo repeated surgery due to recurrence. In the case of malignant pleuramesothelioma the preoperative diagnosis with an exact staging of the tumor is very important to determine an adequate therapeutic regimen. X-ray, CT-scanning, tapping of the pleura fluid and biopsy of the pleura are together insufficient to diagnose a pleuramesothelioma correctly. Since it is not always possible to diagnose a malignant pleuramesothelioma even at thoracoscopy, one should not hesitate to perform an open lung biopsy in order to obtain enough material under adequate vision.ZusammenfassungDas benigne Pleurafibrom sollte wie jeder unklare pleuraständige Rundherd wegen der potentiellen Entartungsmöglichkeit operativ entfernt werden. Die Diagnosesicherung kann bei den gutartigen Formen problemlos und während der Operation erfolgen. Die Langzeitprognose ist günstig, und es treten bei vollständiger Entfernung des Tumors nur sehr selten Rezidive auf. Beim malignen Pleuramesotheliom erscheint vor dem Hintergrund einer stadienabhängigen Therapie die gesicherte präoperative Diagnose mit einem genauen Staging von besonderer Bedeutung. Neben den bildgebenden Verfahren stellen die Punktion des Pleuraergusses, sowie die FNP der Pleura unzureichende Techniken der, um ein Pleuramesotheliom sicher zu diagnostizieren. Kann nach einer Thoracoskopie ein Pleuramesotheliom nicht sicher ausgeschlossen werden, sollte nicht gezögert werden, eine frühzeitige diagnostische Thoracotomie mit ausgiebiger Gewebeentnahme unter guter Sicht vorzunehmen.Patients with benign pleurafibromas should undergo surgery as suspect thoracic tumors have the potential to become malignant. In benign cases diagnosis can easily be made during the operation. In such a case the prognosis is good and it is seldom necessary to undergo repeated surgery due to recurrence. In the case of malignant pleuramesothelioma the preoperative diagnosis with an exact staging of the tumor is very important to determine an adequate therapeutic regimen. X-ray, CT-scanning, tapping of the pleura fluid and biopsy of the pleura are together insufficient to diagnose a pleuramesothelioma correctly. Since it is not always possible to diagnose a malignant pleuramesothelioma even at thoracoscopy, one should not hesitate to perform an open lung biopsy in order to obtain enough material under adequate vision.

Verschluss der A. iliaca interna bei stentgestützter Ausschaltung infrarenaler Aortenaneurysmen

ZusammenfassungZielsetzung. Ziel dieser retrospektiven Studie war es, die Morbidität der Patienten zu erfassen, bei denen uni- oder bilateral ein Verschluss der A. iliaca interna herbeigeführt wurde, um ein Aortenaneurysma mit Hilfe des Endograftverfahrens auszuschalten. Patienten und Methoden. Bei 27 von 174 Patienten, die im Zeitraum von 7/1995—1/2001 wegen eines Aortenaneurysmas mit Hilfe des Endograftverfahren operiert worden waren, wurden 31 Aa. iliacae internae verschlossen (4 Patienten mit beidseitigem A.-iliaca-interna-Verschluss). Ergebnisse. 8 der 27 Patienten (31%) gaben keine Beschwerden an. 13 Patienten (48%) wiesen Symptome von motorischen und sensiblen Defiziten der unteren Extremität sowie Claudicatio glutealis, Gutealatrophie und neu aufgetretene sexuelle Dysfunktion auf.Lebensbedrohliche Komplikationen, wie z. B. Nekrosen des kleinen Beckens und Kolonischämie, traten auch bei beidseitigem Verschluss der A. iliaca interna nicht auf. Zusammenfassung. Die häufigsten Beschwerden, die bereits bei Verschluss einer A. iliaca interna auftreten, sind die Claudicatio glutaealis bzw. motorisch sensible Defizite der unteren Extremität. Lebensbedrohliche Komplikationen im Sinne von Beckennekrosen traten nicht auf, sodass die endovaskuläre Aufgabe einer bzw. beider Aa. iliacae internae bei Risikopatienten von uns in Kauf genommen wurde.AbstractObjective. Objective of this retrospective study was to evaluate morbidity in patients experiencing either uni- or bilateral occlusion of the internal iliac artery secondary to endograft treatment of infrarenal aneurysms of the abdominal aorta. Patients and Methods. In a group of 174 patients undergoing endograft treatment for infrarenal aneurysms of the abdominal aorta between July 1995 and January 2001, occlusion of a total of 31 internal iliac arteries occurred in 27 patients (unilateral occlusion in 23 patients and bilateral occlusion in four patients). Results. Eight of 27 patients (31%) reported no complaints. Thirteen patients (48%) exhibited motor and sensory deficits of the lower extremity, gluteal claudication, gluteal atrophy and new onset of sexual dysfunction.Life-threatening complications, such as necroses of the lesser pelvis and colon ischemia, did not occur, even in patients with bilateral occlusion of the internal iliac arteries. Discussion. The most common complaints in patients with only unilateral occlusion of an internal iliac artery included gluteal claudication, and motor and sensory deficits of the lower extremity. Life-threatening complications such as pelvic necroses did not occur. Hence, the benefits of endovascular treatment of aneurysms in high-risk patients outweigh the detrimental effects of potential occlusion of one or both internal iliac arteries.

Endovaskuläre Ausschaltung thorakaler Aortenaneurysmen, Dissektionen und Rupturen

ZusammenfassungIm Rahmen einer prospektiven, nicht randomisierten Studie wurde die funktionelle stentgestützte Ausschaltung von Aneurysmen, Dissektionen und traumatischen Rupturen im Bereich der Aorta descendens untersucht. Im Zeitraum von 1995 bis 2000 erwiesen sich 52 (46,4%) von 112 Patienten mit thorakalen Aortenläsionen und hohem Risiko für einen offenen chirurgischen Eingriff anatomisch und pathomorphologisch geeignet für eine stentgestützte Rekonstruktion. 16 (30,8%) Patienten wurden notfallmäßig im Stadium der Ruptur versorgt, bei 36 (69,2%) Patienten erfolgte der Eingriff elektiv.Die 30-Tage-Letalität betrug 5,7%. In 2 Fallen musste eine Konversion zur konventionell offenen Operation erfolgen. Zwei Patienten entwickelten postoperativ eine beinbetonte passagere Parese. Ein permanentes neurologisches Defizit fand sich bei keinem der 52 Patienten. Die primäre Endoleakrate betrug 9,6% (5 Patienten). Bei insgesamt 10 (19,2%) Patienten war ein zusätzlicher chirurgischer Eingriff erforderlich, in 7 Fällen im Bereich der Zugangsgefäße. In 3 Fällen war eine Revaskularisation der linksseitigen A. subclavia bzw. linksseitigen A. carotis communis erforderlich. Renale, kardiale und pulmonale Komplikationen traten bei 12 (23,0%) Patienten auf.Die mittlere Nachbeobachtungszeit betrug 19 Monate (1–66 Monate). 4 Patienten verstarben im Nachbeobachtungszeitraum an kardiopulmonalen Ereignissen. Ein Patient starb an den Folgen eines chronischen Pleuraempyems nach sekundärer Ausräumung eines Hämatothorax. Eine sekundäre Konversion musste in einem Fall bei Rezidiv einer aortobronchialen Fistel erfolgen; ein sekundäres Endoleak trat bei einem (1,9%) Patienten auf.Unsere Ergebnisse zeigen, dass eine stentgestützte Rekonstruktion im thorakalen Aortenabschnitt technisch durchführbar und mit einer ausreichenden Sicherheit begleitet ist. Das Verfahren eignet sich für elektive und Notfallpatienten ebenso wie für Hochrisikopatienten mit schwerwiegenden kardiopulmonalen Begleiterkrankungen. Als Ergebnis resultiert im Vergleich zum offenen Verfahren eine niedrigere Sterblichkeit und Paraplegierate, insbesondere wenn der Eingriff bei rupturierten Aortenerkrankungen durchgeführt werden muss.AbstractIn a prospective nonrandomized study, endovascular repair was evaluated for the treatment of descending aortic aneurysms, dissections, and ruptures.Over a 5-year period (1995–2000), endografts were placed into 52 patients at high risk for conventional surgical repair: 16 (30.8%) procedures were conducted as emergencies and 36 (69.2%) electively.The overall 30-day mortality rate was 5.7%. There were two conversions to open repair. Temporary neurologic deficits developed in two patients; no patient suffered permanent paraplegia. Five (9.6%) endoleaks required treatment. Ten (19.2%) cases required secondary surgical procedures (femoral and iliac access complications in seven patients and revascularization of the left subclavian artery and left carotid artery in three cases). Median follow-up was 19 months (1–66 months).In the follow-up period, four patients died due to cardiopulmonary complications, one single patient due to a fatal pleura empyema. A secondary conversion to open repair was necessary in one (1.9%) patient due to a recurrent aortobronchial fistula. Conclusion. The treatment of descending thoracic aortic aneurysms, dissections, and ruptures with an endovascular approach is feasible and safe and may offer the best means of therapy in high-risk patients and in emergencies.Thoracic endografting is followed by a low rate of mortality and paraplegia; procedure-related complications can be reduced best by precise patient selection.

Management intraoperativer Komplikationen bei der Applikation stentgestützter Aortenprothesen

Zusammenfassung Intraoperative Komplikationen können je nach Zeitpunkt des Ereignisses in 3 Gruppen definiert werden: Gruppe I – Zugangsprobleme, Gruppe II – Einbringen des endovaskulären Stents (a: Absetzen des Hauptteils, b: Andocken des 2. Schenkels), Gruppe III – Inzidenz primärer Endoleaks.Zielsetzung dieser retrospektiven Studie war es, das Management zur Behebung dieser Komplikationen darzustellen. Von 130 Patienten mit endovaskulärer Ausschaltung eines Aortenaneurysmas traten bei 26 Patienten 31 intraoperative Komplikationen auf (20,0%).Die führenden Komplikationen in jeder Gruppe sowie das daraus resultierende Management waren: Gruppe I: Die Korrektur erfolgte durch Dilatation, retroperitoneale Streckung, Kürzungsoperation der A. iliaca externa und Interponat. Gruppe II a: Bei Überstentung der Nierenarterien erfolgte die Konversion oder Zug am Endograft. Gruppe II b: Führungsdraht oder Andocksystem können nicht platziert werden. Die Behebung erfolgte durch Konversion und Anwendung neuer Systeme. Gruppe III: Hier wurden erneute Stentplazierungen, postoperativer Coil-Embolisationen und Konversionen durchgeführt.Die endovaskuläre Therapie aortaler Aneurysmen birgt eine Rate intraoperativer Schwierigkeiten von 20%. In 3,8% der Fälle musste eine Konversion durchgeführt werden. Durch adäquates Management konnten die Letalität (1/26) und Morbidität jedoch gering gehalten werden.Abstract Intraoperative complications can be divided into three categories on the basis of the time of their occurrence: Group I – Problems associated with access; group II: introduction of the endovascular stent (a: release of the main segment, b: anchoring the second limb); and group III: incidence of primary endoleaks.The objective of the present study was to describe the management of these complications. In a group of 130 patients undergoing endovascular treatment of aneurysms of the abdominal aorta, a total of 31 complications occurred in 26 patients (20.0%).The most frequently encountered complication in each group and its respective management was as follows: Group I: Correction was performed using dilatation and retroperitoneal stretching as well as surgical shortening of the external iliac artery with interposition; group IIa: overstenting the renal arteries was corrected either by conversion or tugging at the endograft; group IIb: the guide wire or docking system could not be placed. Such cases were managed either through conversion or use of fresh systems; group III: such complications were treated with repeated stent placement, postoperative coil embolizations, or conversion.The endovascular therapy of aortic aneurysms is associated with intraoperative complications in 20% of cases. Adequate management helps to keep both morbidity and mortality rates low.

Thermische Verfahren in der Bronchologie

ZusammenfassungDie Hauptindikation für die Anwendung thermischer Verfahren in der Bronchologie ist die Rekanalisation der zentralen Atemwegsstenose oder des zentralen Atemwegsverschlusses. Bei Stenosen, die durch exophytisches Tumorwachstum und durch Kompression von außen verursacht sind, können die thermischen Rekanalisationsverfahren mit einer anschließenden Stentimplantation kombiniert zur Anwendung kommen. Die am häufigsten in der Bronchologie zur Anwendung kommenden thermischen Verfahren sind die Lasertherapie und die Argon-Plasma-Koagulation. In der klinischen Routine sind die Verfügbarkeit, die Erfahrung des Anwenderteams mit einem Verfahren und methodenspezifische Eigenschaften die Kriterien für die Auswahl eines Rekanalisationsverfahrens. Mit der Anwendung von Kältesonden zur bronchialen und transbronchialen Biopsie ist ein thermisches Verfahren erstmals als diagnostische Methode in der Bronchologie beschrieben worden.AbstractThe main indication for the use of thermal procedures in bronchology is the recanalization of a central airway stenosis or central airway occlusion. In stenoses caused by exophytic tumour growth and external compression, the thermal recanalization procedures can be combined with subsequent stent implantation. The thermal procedures most commonly used in bronchology are laser therapy and argon plasma coagulation. In routine clinical practice, availability, experience of the team of users with a particular method, and method-specific features are the criteria used to select a recanalization procedure. The use of cryoprobes for bronchial and transbronchial biopsy is the first thermal procedure to be described as a diagnostic method in bronchology.