H. Diener

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.

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.

Antegrade In Situ Stent-Graft Fenestration for the Renal Artery Following Inadvertent Coverage During EVAR:

Purpose To report the use of antegrade in situ fenestration as a bailout technique to rescue a renal artery after inadvertent coverage during endovascular aneurysm repair (EVAR). Technique The technique is demonstrated in a patient with a 6-cm infrarenal abdominal aortic aneurysm (AAA) and a short, angulated proximal neck. A type I endoleak persisted on completion angiography after implantation of a bifurcated Zenith stent-graft despite dilation with a compliant balloon. A Giant Palmaz stent mounted on a large compliant balloon successfully resolved the endoleak. After placing the stent, the left renal artery was covered completely by the main aortic graft material, leading to only marginal opacification on angiography. To preserve flow to the renal artery, a transseptal sheath and transseptal needle were introduced from the right femoral artery and used to puncture the abdominal stent-graft antegrade at the site of the left renal artery. A 0.018-inch guidewire could then be introduced into the left renal artery; following a number of maneuvers, a balloon-expandable stent was placed through the fenestration into the target vessel. On computed tomographic angiography 4 days postoperatively, the AAA remained excluded and both renal arteries were patent, with all side branches fully preserved. Renal function was completely restored. Conclusion Antegrade in situ fenestration can facilitate immediate revascularization of inadvertently covered side branches in EVAR using a transseptal sheath and needle. If the anatomical features are supportive, antegrade in situ fenestration can be a useful bailout technique.

Outcome of Surgeon-Modified Fenestrated/Branched Stent-Grafts for Symptomatic Complex Aortic Pathologies or Contained Rupture

Purpose: To analyze the outcome of surgeon-modified fenestrated and branched stent-grafts (sm-FBSG) in high-risk patients with symptomatic complex aortic pathology or contained rupture. Methods: A single-center retrospective analysis was conducted of 21 consecutive patients (mean age 70 years, range 58–87; 16 men) treated with a sm-FBSG from April 2014 to September 2016. The indications included 11 thoracoabdominal and 10 pararenal aortic pathologies, which presented as symptomatic in 8 and as contained rupture in 13 patients. The mean aneurysm diameter was 7.4±2.3 cm. Results: Technical success was 100%. From 1 to 4 (mean 3) renovisceral branch vessels were targeted with fenestrations. The mean length of in-hospital stay was 19 days (range 1–78). There was 1 death within 30 days and 2 further in-hospital deaths. Two patients suffered permanent spinal cord injury, 2 developed respiratory failure, and 2 had renal failure requiring temporary or permanent dialysis. No myocardial infarction, stroke, or bowel ischemia occurred. Six early endoleaks (3 type II and 3 minor type III) were detected. Mean follow-up was 11.2 months (range 2–33) in 17 patients. One late aneurysm-related death occurred. All 13 follow-up imaging studies showed patent target renovisceral vessels, with 1 type I and 2 type II endoleaks. Conclusion: Sm-FBSG can be utilized for urgent treatment of complex abdominal and thoracoabdominal aortic pathologies in high-risk patients with anatomy unsuitable for commercially available stent-grafts.

Antegrade side branch access in branched aortic arch endografts: a porcine feasibility study

Purpose To describe the deployment technique for a single side branch arch endograft in a porcine model and prove the concept of transseptal or transapical antegrade access for catheterization and introduction of the mating stent-graft. Methods Six domestic pigs were operated with retrograde delivery of a single side branch arch endograft and antegrade introduction of a mating stent-graft using transseptal access (n=3) and transapical access (n=3). Technical feasibility, operating time, radiation parameters, and hemodynamic changes were studied. Results Transseptal and transapical access techniques were feasible in all animals. Catheterization and introduction of the mating stent-graft was feasible in 2 of 3 animals in the transseptal group and all animals in the transapical group. Technical feasibility was better in the transapical group, with shorter operating and fluoroscopy times and less hemodynamic impact during endograft deployment. Hemodynamic changes were short and reversible in all animals in both groups. Conclusion Antegrade transcardiac access to the aortic arch for implantation of mating stent-grafts in branched arch endografting is feasible in a porcine model with reversible impact on hemodynamic measures during deployment. Transapical access was technically easier, with shorter operating and fluoroscopy times.

Air Embolism During TEVAR: Carbon Dioxide Flushing Decreases the Amount of Gas Released from Thoracic Stent-Grafts During Deployment

Purpose: To investigate the amount of gas released from Zenith thoracic stent-grafts using standard saline flushing vs the carbon dioxide flushing technique. Methods: In an experimental bench setting, 20 thoracic stent-grafts were separated into 2 groups of 10 endografts. One group of grafts was flushed with 60 mL saline and the other group was flushed with carbon dioxide for 5 minutes followed by 60 mL saline. All grafts were deployed into a water-filled container with a curved plastic pipe; the deployment was recorded and released gas was measured using a calibrated setup. Results: Gas was released from all grafts in both study groups during endograft deployment. The average amount of released gas per graft was significantly lower in the study group with carbon dioxide flushing (0.79 vs 0.51 mL, p=0.005). Conclusion: Thoracic endografts release significant amounts of air during deployment if flushed according to the instructions for use. Application of carbon dioxide for the flushing of thoracic stent-grafts prior to standard saline flush significantly reduces the amount of gas released during deployment. The additional use of carbon dioxide should be considered as a standard flush technique for aortic stent-grafts, especially in those implanted in proximal aortic segments, to reduce the risk of air embolism and stroke.

Diabetic foot syndrome

For patients with a diabetic foot wound the risk for amputation is high. The three main reasons for developing foot ulcers in diabetes are biomechanical factors, neurologic and vascular alterations. According to this the ulcers can be categorized in neuropathic (50%), ischemic (15%) and neuroischemic (35%). Sensomotoric polyneuropathy leads to the loss of perception of pain in the feet and in combination with extrinsic and intrinsic biomechanical factors, chronic wounds evolve (malum perforans). The therapy should take place within an interdisciplinary network and based on guidelines. Besides pressure off-loading debridement of the wound is mandatory. The arterial occlusions in diabetes mainly affect the cruropedal vessels and when ischemia occurs a reconstruction must be attempted. The risk of recurrence is high so that regular follow-up examinations, screening to detect high risk patients and education are necessary.ZusammenfassungDie Entwicklung einer Fußläsion beim Diabetiker geht mit einem erheblichen Risiko einer Amputation einher. Drei Ursachen sind wesentlich für die Ausbildung der Fußulzera: biomechanische Faktoren, neurologische und vaskuläre Veränderungen. Demnach werden die Ulzera in neuropathisch (50%), ischämisch (15%) oder neuroischämisch (35%) eingeteilt. Eine sensomotorische Polyneuropathie führt zu einem Verlust des Schmerzempfindens. Zusammen mit extrinsischen und intrinsischen biomechanischen Veränderungen am Fuß kommt es so zur Ausbildung chronischer Wunden (Malum perforans). Die Therapie sollte innerhalb eines leitlinienbasierten, interdisziplinären Netzwerkes erfolgen. Neben einer konsequenten Druckentlastung muss ein Débridement der Wunde erfolgen. Die Makroangiopathie beim Diabetes betrifft oft die kruropedale Ausstrombahn und bedarf einer aggressiven Indikation zur Revaskularisierung. Die Rezidivquote ist hoch, regelmäßige Nachuntersuchungen, Erkennung von Hochrisikopatienten und Schulungen sind notwendig.AbstractFor patients with a diabetic foot wound the risk for amputation is high. The three main reasons for developing foot ulcers in diabetes are biomechanical factors, neurologic and vascular alterations. According to this the ulcers can be categorized in neuropathic (50%), ischemic (15%) and neuroischemic (35%). Sensomotoric polyneuropathy leads to the loss of perception of pain in the feet and in combination with extrinsic and intrinsic biomechanical factors, chronic wounds evolve (malum perforans). The therapy should take place within an interdisciplinary network and based on guidelines. Besides pressure off-loading debridement of the wound is mandatory. The arterial occlusions in diabetes mainly affect the cruropedal vessels and when ischemia occurs a reconstruction must be attempted. The risk of recurrence is high so that regular follow-up examinations, screening to detect high risk patients and education are necessary.

Comprehensive Wound Center am Universitätsklinikum Hamburg-Eppendorf

ZusammenfassungDie umfassende Versorgung chronischer Wunden erfordert ein breites Spektrum verschiedener Berufsgruppen und Fachdisziplinen. Am Universitätsklinikum Hamburg-Eppendorf wurde zum Januar 2010 das Comprehensive Wound Center gegründet. Ziel dieses Konzepts ist die kompetente, fachübergreifende und patientengerechte Diagnostik und Therapie komplizierter, chronischer Wunden auf universitärem Niveau. Neben der interdisziplinären Zusammenarbeit verschiedener ärztlicher und pflegerischer Fachdisziplinen im ambulanten und stationären Bereich erfolgt eine sektorenübergreifende Wundversorgung durch die enge Kooperation mit niedergelassenen Ärzten und Pflegediensten innerhalb des Wundnetzes. Das Comprehensive Wound Center hat neben der Patientenbetreuung einen Schwerpunkt in der grundlagenwissenschaftlichen, klinischen und versorgungswissenschaftlichen Forschung. Der ganzheitliche Ansatz der Wundbehandlung hat zum Ziel, eine kompetente, patientengerechte Wundtherapie anbieten zu können, die die neuesten wissenschaftlichen Erkenntnisse berücksichtigt und zur Erlangung neuer wissenschaftlicher Erkenntnisse beiträgt.AbstractComprehensive treatment of patients with chronic wounds requires a multidisciplinary team of healthcare professionals. In January 2010 the Comprehensive Wound Center was established at the University Clinic of Hamburg-Eppendorf. The main objective is an interdisciplinary healthcare provision for patients with chronic wounds taking patient needs into consideration. In addition to a close collaboration of different healthcare professionals, the department offers inpatient as well as outpatient evidence-based care. Given the excellent cooperation between the outpatient care providers and the nursing services, a multidiscipline wound care management can be guaranteed at any time. In addition the Comprehensive Wound Center focuses on clinical research, basic research and health services research. This holistic approach of wound care management aims at competent, patient-oriented wound treatment and contributes to new research results and insights into evidence-based medicine.

Infektionen chronischer Wunden unter besonderer Berücksichtigung des diabetischen Fußes: Systemische und lokale Therapieansätze

Chronic wounds are results of various diseases. Evaluation and therapy of underlying disorders of chronic wounds must be the first step of successful wound healing. Bacterial colonization and infection of ischemic wounds and diabetic foot ulcers are limb-threatening factors. Therefore, a special therapy concept is necessary. The therapy is based on a sufficient wound bed preparation, moist wound dressings and vacuum-assisted closure (VAC) therapy and infection control with systemic antibiotics in case of clinical infection. Another major point is the possibility of revascularization. This comprehensive wound care protocol can reduce the rate of major amputations.

Wundnetze in Deutschland

ZusammenfassungHintergrundWundnetze sind strukturierte Kooperationen zwischen verschiedenen Berufsgruppen und ärztlichen Disziplinen im Bereich der Versorgung von Patienten mit chronischen Wunden. Angesichts der komplexen chronischen Verläufe dieser Patienten mit einer Vielzahl potenziell relevanter Komorbiditäten und einer Vielfalt möglicher Therapieoptionen kommt der evidenzbasierten, strukturierten Versorgung von Patienten mit chronischen Wunden eine besondere Bedeutung zu. Diese Versorgung ist jedoch sehr heterogen und vielfach unkoordiniert.ZielsetzungBestandsaufnahme der in Deutschland aktiven regionalen Wundnetze und Charakterisierung ihrer Struktur, Aktivitäten und Zielsetzungen.MethodenBundesweite Untersuchung, gerichtet an Wundexperten und Wundfachgesellschaften sowie zuvor kartierte Wundnetze. In den bereits bekannten Wundnetzen wurde eine aktualisierende Erhebung durchgeführt. Alle identifizierten Netze wurden mit einem standardisierten strukturierten Fragebogen zur Größe der Netze, zum regionalen Umfang, beteiligten ärztlichen Disziplinen und Berufsgruppen sowie deren Aktivitäten erhoben. Über die vorstrukturierten Antworten hinaus wurden Freitextangaben aufgenommen.ErgebnisseDie Anzahl der identifizierbaren Wundnetze betrug n = 35. In einem Großteil der Netze waren sowohl Ärzte und Pflegende aus Kliniken wie auch niedergelassene Ärzte und ambulante Pflegende vertreten.Die häufigsten ärztlichen Disziplinen waren Gefäßchirurgen (74 %) vor Allgemeinmedizinern (63 %), Diabetologen (60 %), Allgemeinchirurgen (60 %) und Dermatologen (57 %). Die häufigsten Aktivitäten waren informelle Zusammenkünfte zu Fortbildungen (77%), Austausch von Erfahrungen und Zweitmeinungen (je 71%) und Absprachen über Patientenversorgung (69%). Nur in wenigen Fällen wurden im Rahmen der Kooperation Selektivverträge umgesetzt.SchlussfolgerungDie in Deutschland durch Eigeninitiative von Wundexperten gegründeten Wundnetze stellen stark interdisziplinär und interprofessionell ausgerichtete Expertenplattformen mit hohem Potenzial für eine strukturierte, effiziente Versorgung dar. Wünschenswert sind Anreize zur systematischen Nutzung dieser Strukturen im Zuge einer qualitätsverbesserten und vergüteten Versorgung von Patienten mit chronischen Wunden.AbstractBackgroundWound networks are structured collaborations between various professions and medical disciplines in the field of treatment of patients with chronic wounds. In view of the complex chronic courses of such wounds with many relevant underlying diseases, comorbidities and a multitude of possible therapy options, the evidence-based structured treatment of patients with wound problems is of particular importance. However, this treatment is very heterogeneous and often uncoordinated.ObjectiveThis article describes a stocktaking of the active regional wound networks in Germany with characterization of their structures, activities and objectives.MethodsA nationwide survey was carried out targeting wound specialists and wound societies as well as already established wound networks for which an updating was carried out. All identified networks were issued with a standardized questionnaire about the size of the network, extent of regional coverage, participating medical disciplines and professional groups and activities. In addition to the preformulated questions, free text information was also encouraged.ResultsA total of 35 wound networks could be identified. The majority of networks consisted of representatives of hospitals as well as physicians in private practice and nursing personnel. The most frequently represented medical disciplines were vascular surgeons (74 %), general physicians (63 %), diabetologists (60 %), general surgeons (60 %) and dermatologists (57 %). The most frequent activities were informal meetings on further education (77 %), exchange of experiences and second opinions (both 71 %) and consultation on patient treatment (69 %). Selective contracts were only implemented in very few cases.ConclusionThe wound networks established in Germany on self-initiatives represent strong interdisciplinary and interprofessional-oriented specialist platforms with a high potential for structured and efficient treatment. Incentives for systematic utilization of these structures in the course of improvements in quality and remuneration of treatment of patients with chronic wounds would be desirable.BACKGROUND Wound networks are structured collaborations between various professions and medical disciplines in the field of treatment of patients with chronic wounds. In view of the complex chronic courses of such wounds with many relevant underlying diseases, comorbidities and a multitude of possible therapy options, the evidence-based structured treatment of patients with wound problems is of particular importance. However, this treatment is very heterogeneous and often uncoordinated. OBJECTIVE This article describes a stocktaking of the active regional wound networks in Germany with characterization of their structures, activities and objectives. METHODS A nationwide survey was carried out targeting wound specialists and wound societies as well as already established wound networks for which an updating was carried out. All identified networks were issued with a standardized questionnaire about the size of the network, extent of regional coverage, participating medical disciplines and professional groups and activities. In addition to the preformulated questions, free text information was also encouraged. RESULTS A total of 35 wound networks could be identified. The majority of networks consisted of representatives of hospitals as well as physicians in private practice and nursing personnel. The most frequently represented medical disciplines were vascular surgeons (74%), general physicians (63%), diabetologists (60%), general surgeons (60%) and dermatologists (57%). The most frequent activities were informal meetings on further education (77%), exchange of experiences and second opinions (both 71%) and consultation on patient treatment (69%). Selective contracts were only implemented in very few cases. CONCLUSION The wound networks established in Germany on self-initiatives represent strong interdisciplinary and interprofessional-oriented specialist platforms with a high potential for structured and efficient treatment. Incentives for systematic utilization of these structures in the course of improvements in quality and remuneration of treatment of patients with chronic wounds would be desirable.