G. Spillner

Endoluminal Stent–Grafts for Infrarenal Abdominal Aortic Aneurysms

BACKGROUND The treatment of aortic aneurysms with endovascular stents or stent-graft prostheses is receiving increasing attention as an alternative to major abdominal surgery. To define the clinical value of this technique, we prospectively studied the use of stent-graft endoprostheses made of nitinol and covered with polyester fabric for the treatment of infrarenal abdominal aortic aneurysms. METHODS We treated a total of 154 patients at three academic hospitals. Twenty-one patients with aortic aneurysms not involving the aortic bifurcation received straight stent-grafts, and 133 patients with aortic aneurysms involving the bifurcation and the common iliac arteries received bifurcated stent-grafts. After a unilateral surgical arteriotomy, the endoprostheses were advanced through the femoral arteries and placed under fluoroscopic guidance. Computed tomography and intraarterial angiography were performed during an average follow-up of 12.5 months. RESULTS The primary success rate, defined as complete exclusion of the abdominal aortic aneurysm from the circulation, was 86 percent in the group receiving straight grafts and 87 percent in the group receiving bifurcated grafts. In three patients the procedure had to be converted to an open surgical operation. Minor (n=13) or major (n=3) complications associated with the procedure (including 1 death) occurred in 10 percent of the patients. All patients had a postimplantation syndrome, with leukocytosis and elevated C-reactive protein levels. CONCLUSIONS Our results suggest that endovascular treatment of infrarenal abdominal aortic aneurysms is technically feasible and can effectively exclude abdominal aortic aneurysms from the circulation. With further refinement, endoluminal repair may emerge as an interventional strategy to treat infrarenal aortic aneurysms, especially in patients at high surgical risk.

A Comparison of Surgical and Medical Therapy for Atrial Septal Defect in Adults

BACKGROUND The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study. METHODS In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26). RESULTS Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different. CONCLUSIONS The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.

Two-Center German Experience with Aortic Endografting

Purpose: To report the results of a two-center study of endovascular abdominal aortic aneurysm (AAA) exclusion using a polyester-covered nitinol stent-graft. Methods: Candidates were evaluated with arteriography and computed tomography. Criteria for endovascular therapy were a proximal aortic neck > 10 mm in length and < 25 mm in diameter, no bilateral internal iliac artery involvement in the aneurysm, no markedly tortuous common iliac arteries (CIAs) or CIAs < 7 mm in diameter, and no superior mesenteric artery occlusive disease. Patients were treated with the Mialhe Stentor and Vanguard stent-grafts in either tube or bifurcated versions. Results: Between August 1994 and November 1996, 149 patients (mean age 67 years, range 49 to 90) were admitted to the study. Overall primary technical success (aneurysm exclusion without endoleak) was 87% (130 patients): 78% (7 patients) for tube grafts and 88% (123 patients) for bifurcated endografts. The rate of local, remote, or systemic complications was 10.8%, with a 30-day mortality rate of 0.7%. During an average 13.5-month follow-up, there were no late deaths. Four of 20 endoleaks sealed spontaneously, 14 were treated with endoluminal techniques, and 2 remain untreated by patient request. Three graft limb thromboses occurred; one was treated surgically, one with lytic therapy, and one was untreated. Secondary patency was 96%. Conclusions: Endoluminal repair of infrarenal AAAs using straight or bifurcated grafts is a feasible alternative to conventional surgical repair. Longer follow-up and more experience with refined endograft models will elucidate the durability of this endovascular approach to treating AAAs.

Determination of aortic valve orifice area in aortic valve stenosis by two-dimensional transesophageal echocardiography

Two-dimensional transesophageal echocardiography was used to measure aortic valve orifice area in 24 patients with aortic valve stenosis (AS) and 15 patients without aortic valve disease. Using transesophageal echocardiography, orifice area could be measured in 20 of 24 patients with AS. With transthoracic echocardiography, orifice area could be determined in only 2 of 24 patients. In patients with AS, orifice area determined by transesophageal echocardiography was 0.75 +/- 0.34 cm2 and that calculated with Gorlins formula was 0.75 +/- 0.32 cm2. In normal aortic valves, orifice area was 3.9 +/- 1.2 cm2 by transesophageal echocardiography. A good correlation was demonstrated between aortic valve orifice area determined using transesophageal echocardiography and calculated orifice area using Gorlins formula in patients with AS: r = 0.92, standard error of estimate = 0.14 cm2. The absolute difference between orifice area measured with both methods ranged from 0.0 to 0.4 cm2 (mean 0.09 +/- 0.1). In 4 patients orifice area could not be determined with transesophageal echocardiography. The orifice could not be identified in 2 patients because an appropriate cross-sectional view of the aortic valve could not be achieved and in 2 patients with pinhole stenosis (aortic valve orifice area 0.3 cm2). These data show that aortic valve orifice area can be measured reliably using 2-dimensional transesophageal echocardiography.

Behandlungsstrategien bei therapierefraktärer Angina pectoris: Transmyokardiale Laserrevaskularisation

Hintergrund: Vermag die Transmyokardiale Laserrevaskularisation (TMLR) als eine neue chirurgische Methode zur Behandlung der schweren Angina pectoris die myokardiale Perfusion und Kontraktilität zu verbessern?¶Methoden: Siebenundsechzig Patienten, die zur TMLR überwiesen worden waren, wurden mittels klinischer Untersuchung, Ergometrie, Echokardio-, Ventrikulographie und hybrid PET präoperativ und Patienten, die mit TMLR behandelt wurden, nach 6 und 12 Monaten follow up evaluiert. Hämodynamische Messungen und klinische Untersuchung wurden perioperativ durchgeführt.¶Ergebnisse: In 28 von 67 Patienten (42%) ACVB, in 9 von 67 Patienten (13%) ACVB in Kombination mit TMLR (kombinierte Gruppe) und in 30 von 67 Patienten (45%) nur TMLR (isolierte Gruppe) wurden durchgeführt. Die perioperative Letalität in der isolierten Gruppe lag bei 13%, in der kombinierten Gruppe bei null und in der ACVB Gruppe bei 11%. In jeder Gruppe wurde ein signifikant verbesserter klinischer Status (p≤0,01) 1 Woche postoperativ und in den TMLR-Gruppen auch nach 6 und 12 Monaten beobachtet. In den TMLR-Gruppen verbesserte sich ebenfalls die Belastbarkeit in der Ergometrie (p<0,05), obgleich Funktion, Perfusion und Metabolismus sich nach 6 und 12 Monaten follow up nicht signifikant veränderten.¶Zusammenfassung: TMLR verbessert signifikant den klinischen Status und die Belastbarkeit in der Ergometrie, aber verändert nicht die Perfusion, Funktion und den Metabolismus. Background: Does transmyocardial laser revascularization (TMLR) as a new surgical technique for treating patients with otherwise intractable angina pectoris improve myocardial perfusion or contractility? Methods: Sixty-seven patients transferred for TMLR were evaluated by clinical evaluation, treadmill stress testing, echocardiography, ventriculography, and hybrid positron emission tomography preoperatively and in patients treated with TMLR at 6 and 12 month follow up. Hemodynamic assessment and clinical evaluation were performed perioperatively. Results: In 28/67 cases (42%) CABG, in 9/67 patients (13%) CABG in combination with TMLR (combined group), and in 30/67 patients (45%) only TMLR (sole group) were performed. Perioperative mortality in the sole group was 13%, in the combined group zero, and in the CABG group 11%. In all groups a significantly improved clinical status (p≤0.01) 1 week postoperatively and in TMLR groups also at 6 and 12 months was observed. In the TMLR groups treadmill tolerance (p<0.05) improved, although function, perfusion and metabolism did not change significantly at the 6 and 12 month follow up. Conclusion: TMLR significantly improves clinical status and treadmill stress tolerance, but does not change function, perfusion, and metabolism.

Atrioventricular septal defect with double-outlet right atrium

SummaryA rare type of primum atrial septal defect is described in which the atrial septum deviated to the left, resulting in a double-outlet right atrium. The obstruction at the site of the small atrial septum defect led to an elevation of the left atrial mean pressure and to pulmonary arterial hypertension. The presence of mixed blood in the right atrium caused systemic arterial desaturation. A cleft in the septal leaflet of the left atrioventricular (AV) valve caused a left ventricular-right atrial shunt, which—added to the left-to-right atrial shunt—totaled 60% of the pulmonary circulating volume. Preoperative knowledge of the anatomic features facilitated surgical repair, which consisted in resection of the abnormal septum, construction of a new septum with a Dacron patch, and closure of the septal commissure of the left-sided AV valve.

Nifedipine inhibits granulocyte activation during cardiopulmonary bypass.

Two groups of patients were investigated. Group 1 consisted of 6 patients (4 female, 2 male) with a mean age of 36.8_+9.1 years and group II of 7 male patients (56.3 _+ 1.7 years). Patients of group II received a continuous infusion of nifedipine (5.91 ±0.53 gg/kg of body weight/h) 15 min before the begin of the extracorporeal circulation till the end. Patients of group I acted as controls. Heparinized blood samples were taken as indicated. Plasma levels of C3a and granulocyte elastase in complex with cq-proteinase inhibitor (E-cq PI) were determined as previously described [31.

Cavoatrial bypass for occlusion of the inferior caval vein in a patient with Budd-Chiari syndrome

We report the case of a young man with Budd-Chiari syndrome and occlusion of the inferior caval vein. Peripheral edema was his predominant complaint. Symptoms of portal hypertension were lacking, indicating membranotomy and not portosystemic shunting as the treatment of choice. At operation, membranotomy was not feasible, and a cavoatrial bypass using a 22 mm Gore-Tex graft was placed instead. Shortly after the operation the peripheral edema vanished, diuretic treatment could be withdrawn, and liver function improved. Eighteen months later the bypass remains patent, edema is absent, and liver function is stable. We conclude that cavoatrial bypass is a therapeutic option in patients with occlusion of the inferior vena cava with no clinical symptoms of portal hypertension if transcardiac membranotomy is not feasible.

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.

Myxoma-Syndrom : eine benigne Erkrankung mit malignem Krankheitsverlauf

Zwischen 1986 und 1995 erkrankte eine heute 36jährige Frau wiederholt an Vorhofmyxomen, die zweimal typischerweise im linken und einmal im rechten Vorhof lokalisiert waren. 1986 stellte sich die Patientin erstmalig mit den Zeichen einer zerebralen Ischämie in der neurologischen Kinik vor. Nachdem das erste symptomlose Tumorrezidiv bei einer Routinekontrolle diagnostiziert werden konnte, erlitt sie neun Jahre später im Rahmen des dritten Myxomwachstums eine Lungenembolie. Die zusätzlich positive Familienanamnese für Herztumoren, eine auffällige Hautpigmentierung und ein Schilddrüsenadenom vervollständigten das Krankheitsbild eines “Myxoma-Syndroms”. Im Vergleich zu Patienten mit einer “sporadischen Myxomerkrankung” sind die Patienten mit “Myxoma-Syndrom” jünger (mittleres Alter 56 vs 25 Jahre), haben eine Lentiginosis (68%) und haben häufig eine positive Familienanamnese für Herztumoren (25%). Die Myxome weisen atypische Lokalisationen auf (85% Atrium, 15% Ventrikel, je 50% solitär und multilokulär) und haben in den ersten fünf Jabren eine hohe Rezidivrate (18%). Da die klinischen Zeichen kardialer Tumoren häufig sehr unspezifisch sind, bleibt es häufig den bildgebenden Verfahren vorbehalten, die Diagnose eines Herztumors zu stellen. Hierbei spielt die transösophageale Echokardiographie eine besondere Rolle, die in diesem Fallbericht hervorgehoben wird. We are reporting on a 36 year-old woman who presented with recurrent cardiac myxomas over a period of nine years. Two of the tumors typically originated in the left atrium and one in the right atrium. Tumor embolization was the presenting symptom twice, leading to reversible cerebral ischemia and minor pulmonary embolism, respectively. The third tumor remained asymptomatic and was detected during routine echocardiographic examination. Based on a positive family history of cardiac tumors, a facially pronounced hyperpigmentation of the skin and the presence of a thyroid adenoma, the diagnosis of a “myxoma syndrome” was established. Patients with “myxoma syndrome” are generally younger than their counterparts with “sporadic myxoma” (mean age at diagnosis 25 vs. 56 years) and have a high frequency of unusual skin freckling (68%). Familial clustering of cardiac myxomas is also frequent (25%). The tumors may be located in any of the cardiac chambers (87% in the atrias, 13% in the ventricles, 50% at multiple sites simultaneously) and have relatively high (18%) 5-year recurrence rate after surgical excision. Since the clinical signs of cardiac tumors are non-specific, diagnosis essentially relies on cardiac imaging by echocardiography, computer tomography, or angiography. The superiority of transesophageal echocardiography is emphasized in this report.