Jochen Hansmann

Endovascular aortic arch reconstruction with supra-aortic transposition for symptomatic contained rupture and dissection: early experience in 8 high-risk patients.

Purpose: To report our initial experience with total and subtotal endovascular aortic arch reconstruction combined with supra-aortic vessel transposition in high-risk patients and to present a new morphological classification of thoracic aortic lesions for patient and procedure selection. Methods: Among 80 patients treated with thoracic stent-grafts at our department between 1997 and 2003, 8 patients (6 men; mean age 71 years, range 45–81) unfit for open repair were not candidates for standard endovascular repair due to inadequate proximal landing zones on the aortic arch. Commercially available endografts (Excluder, Zenith, Endofit, Talent) were used to repair the arch after supra-aortic vessel transposition was performed. The endograft was implanted transfemorally or via an iliac Dacron conduit graft with standardized endovascular techniques and deployed during intravenous adenosine-induced asystole. The imaging data from all thoracic endograft patients was analyzed to classify thoracic and thoracoabdominal lesions according to a 4-level anatomical system. Results: Deployment success was 100% after staged supra-aortic vessel transposition, but 1 patient died of endograft-related rupture of the proximal aortic arch. There was no neurological complication. Mean follow-up was 16 months (range 1–36). Patency of all endografts and conventional bypasses was 100%, and no migration was observed. One minor type II endoleak was demonstrated. Conclusions: Initial results are encouraging for endovascular aortic arch repair in combination with supra-aortic transposition in selected high-risk patients with complex aortic pathologies.

Helical hydro-CT for diagnosis and staging of gastric carcinoma.

PURPOSE The purpose of this work was to define the accuracy of helical hydro-CT (HHCT) in the diagnosis and staging of gastric carcinoma. METHOD One hundred twelve patients with gastric carcinoma were preoperatively imaged by HHCT. Gastric distension was achieved by ingestion of up to 1,500 ml of water. Bolus tracking was performed, and peristalsis was minimized by intravenously administered spasmolytics. Contrast material was then injected, and helical scanning was performed at the time of peak enhancement of the liver. CT images were analyzed for tumor infiltration of the gastric wall, and TNM staging criteria were applied according to the International Union Against Cancer (UICC) classification. The results were correlated with histopathologic findings. RESULTS One hundred two of 115 (89%) gastric carcinomas were correctly diagnosed by HHCT. Small malignant ulcers (< or =2 cm) that corresponded to early gastric carcinoma were not visible on CT scans. T and N staging accuracies were 51% each; abdominal M staging was correct in 79% of all cases. The positive and negative predictive values of HHCT to foresee curative resection of gastric carcinoma were 75 and 84%, respectively. CONCLUSION Mural thickening as well as marked contrast enhancement of the gastric wall are firmly related to gastric carcinoma. The accuracy of HHCT is acceptable for M staging but inadequate for local staging of gastric carcinoma. Nonetheless, HHCT is a useful guide for choosing between tumor resection and nonoperative treatment of patients. We therefore recommend HHCT as the method of choice for preoperative imaging of gastric carcinoma.

Die Aortendissektion : Wann operieren, wann endoluminal therapieren?

ZusammenfassungZiel. Darstellung der Heidelberger Ergebnisse zur operativen und interventionellen Therapie der akuten Aortendissektion auf der Basis einer Analyse der Jahre 1999–2000. Material und Methode. 93 Patienten mit akuter Aortendissektion wurden im Untersuchungszeitraum durch Herzchirurgie, Gefäßchirurgie und Interventionelle Radiologie mit dem Ziel einer optimierten Stufentherapie behandelt. Entsprechend der klinischen und morphologischen Situation erfolgte die Therapie klassisch offen (Typ A) mit Herz-Lungen-Maschine und seit der Verfügbarkeit großlumiger Stentgrafts endoluminal (Typ B) oder dann konservativ, wenn weder klinisch noch morphologisch eine invasive Therapie erforderlich erschien. Ergebnisse. 36 Patienten hatten eine A- und 57 eine B-Dissektion. Fast alle A-Patienten wurden operiert (32), 3 der nichtoperierten verstarben kurz nach Aufnahme. 20 der Patienten mit B-Dissektion wurden therapiert, davon 12 endoluminal. Die Mortalität der A-Patienten lag insgesamt bei 35%, die der B-Patienten bei 15%, wobei allerdings die Mortalität in beiden Gruppen bei den unbehandelten am höchsten war. Die Mortalität der endoluminal behandelten Patienten war 0%. Der wichtigste Mortalitätsfaktor bei allen A-Patienten war die viszerale Ischämie, die trotz erfolgreicher Korrektur der Aorta ascendens durch symptomatischen ”True lumen collaps”, ggf. verschärft durch den Einsatz der Herz-Lungen-Maschine, in der unmittelbar postoperativen Periode entscheidend wurde. Paraplegische Kompliationen traten bei keinem Patient auf. Bei insgesamt 4 Patienten konnten erstmals Kombinationsverfahren aus offener Chirurgie und endoluminaler Korrektur der fortbestehenden (symptomatischen) B-Dissektion erfolgreich eingesetzt werden. Diskussion. Die Typ-A-Dissektion kann mit hoher technischer Erfolgsrate behandelt werden. Das Fortbestehen ungünstiger hämodynamischer Verhältnisse in der distalen Aorta begünstigt jedoch Organmalperfusionen. Die erfolgreiche Kombination mit endoluminalen Verfahren legt nahe, ein solches Konzept einer breiteren klinischen Erprobung zu unterziehen. Akute und klinisch symptomatische B-Dissektionen können mit hoher technischer Erfolgsrate endoluminal behandelt werden. Ungelöste Fragen betreffen allerdings noch das endgültige Prothesendesign.AbstractGoal. To demonstrate the Heidelberg results of the previous 2 years in patients referred for acute aortic dissection. Material and Methods. 93 patients referred for acute aortic dissection were treated by cardiac surgery, vascular surgery and interventional radiology according to a novel therapeutic algorithm including stent-grafts and combined open and interventional procedures and conservative medical therapy when no malperfusion syndrome was present or patients were considered prohibitive for even minor surgical procedures. Stent-graft placements were done assisted by short term cardiac arrest to facilitate correct device deployment. Results. 36 patients presented with type A and the other 57 with type B dissection. 32 of the A patients were operated and 20 of the B patients, respectively. 12 patients with B dissection were treated with stent-grafts. 3 required additional interventional therapy for organ malperfusion. The mortality was 0% in these 12 patients The overall mortality rate in the A group was close to 40% mainly as a result of postoperative organ malperfusion while it was 15% in the B group. In both groups mortality was highest in the respective untreated patient subgroup (3/4 and 8/37, respectively). The main mortality factor was visceral (mesenteric or liver) ischemia. Paraplegic complications occured in neither group. In 4 patients a combined approach applying cardiac surgery of the ascending aorta and endluminal stent-graft placement for the residual B dissection was successfully performed. In one patient this was done simultaneously. Discussion. Acute aortic dissection of type A with or without valve involvement, coronary artery ischemia can be treated with high technical success rates. However, remaining distal aortic dissection associated with true lumen collapse and organ malperfusion is the main causative factor for clinical failures. Successful combination of open proximal aortic surgery with endoluminal treatment of residual B dissection encourages further use of this novel approach. Acute B type dissection appears to be effectively and safely treated by endoluminal approach in selected cases. Unsolved questions of this less invasive therapeutic approach focus mainly on the design of the proximal anchoring part of the devices.

Bone involvement in patients with systemic AL amyloidosis mimics lytic myeloma bone disease

The definition of organ involvement in systemic AL amyloidosis has been recently published and a consensus conference has defined major criteria for 7 main organ systems.[1][1] However, bone disease was not included in the list of affected organs and has not yet been systematically studied. It has

Angiographie und interventionelle Radiologie der Nieren

ZusammenfassungIn der Diagnostik von pathologischen Veränderungen der Nieren konkurrieren die Katheterangiographie, der Ultraschall, die Computertomographie und die Kernspintomographie. In der Abklärung renaler Raumforderungen stehen die Schnittbildverfahren heute im Vordergrund. In der Diagnostik von Nierenarterienstenosen ist die Angiographie bis heute der Goldstandard. Die weniger invasiven angiographischen Techniken der CT und der MRT sind in aufwendigen Studien der Angiographie der Nierenarterien ebenbürtig, es mangelt jedoch insbesondere für die immer häufiger zum Einsatz kommende MR-Angiographie an verbindlichen Qualitätskriterien. In der interventionellen Radiologie der Nieren sind die angiographischen Techniken der Nierenarterienangioplastie inklusive der Stentimplantation und die Embolisationstechniken ausgereift. Die klinischen Ergebnisse können gut gegen die der operativen Verfahren bestehen. Die interventionellen Verfahren haben somit ihren festen Platz im Spektrum der modernen minimal invasiven Medizin.SummaryFor imaging of renal pathology a broad spectrum of radiologic diagnostic procedures are available which are, sometimes and particularly more recently, competing among each other in their diagnostic yield and relevance. For tumorous lesions ultrasound, computed tomography and magnetic reso-nance imaging are performed predominantly. Angiography is no longer required with the exception of highly selected cases and in some specific preoperative workup requirements. Until recently, catheter based digital subtraction angiography has been consid- ered as gold standard. However, non-invasive techniques such as CT-angiography and MR-angiography are evolving parallel to their quantum leap of resolutions and readiness to use. Nevertheless, well accepted criteria for quality assessement of these new modalities are still lacking. More comparison studies are urgently warranted. Despite the availability of ultrashort pulse sequences applying the T1 relaxation reduction effect of gadolinium enhanced MR techniques overestimation of renal artery stenosis still po-ses a substantial problem. Renal intervention implies a variety of procedures such as plain angioplasty, stent placement, embolization of traumatic and both benign and malignant tumors. These methods have emerged over the last two decades from a more experimental nature to a fully accepted treatment option. When renal artery angioplasty is embedded in an aggressive approach including stenting as an adjunct for more complex cases, renal ostial lesions and a well organized follow-up regimen its therapeutic potential for treatment of renal insufficiency, malignant hypertension, for organ preservation bears a very high potential. Provided adequat periinterventional drug regimen restenosis rates may be as low as 10%. In highly selected cases capillary embolization might be used as an alternative to nephrectomy with a similar clinical outcome. Particularly the development of superselective small caliber embolization catheters parallel to further refinement of embolization material has aided to use superselective occlusion techniques in benign vascular lesions and renal trauma.

Die Venenverschlusskrankheit der Leber nach infradiaphragmaler total lymphatischer Bestrahlung: Eine seltene Nebenwirkung

BACKGROUND Radiotherapy is potentially curative in early stages of follicle center lymphoma. Frequent side effects are pancytopenia, nausea and abdominal discomfort. A radiation-induced liver injury with serious clinical symptoms and changes in liver function is a rare complication. CASE REPORT Whole abdomen was irradiated in a 49-year-old patient with a centrocytic-centroblastic lymphoma, stage IA (localization: left inguinal region). A total dose of 30 Gy was delivered in a weekly fractionation of five times 1.5 Gy. Kidneys were protected by shielding after a dose of 13.5 Gy, liver blocks were positioned after 25 Gy. During the last 2 days of therapy the patient presented with weight gain, ascites, dyspnoea and elevated liver enzymes. Diagnostics revealed hepatosplenomegaly, ascites and an increased portosystemic pressure gradient. Liver biopsy specimen showed a veno-occlusive disease. Complete relief of symptomatology was achieved within 7 days following placement of a transjugular intrahepatic portosystemic stent-shunt (TIPSS), heparinization and diuretics. Liver enzymes are in the normal range. CONCLUSION Veno-occlusive disease of the liver (VOD) is a very rare side effect of primary abdominal irradiation of follicle center lymphoma. This complication should be taken into consideration if a patient presents with upper right quadrant pain, ascites and elevation of liver enzymes especially within 4 months following radiotherapy. Genesis of veno-occlusive disease, diagnostics, therapy and a review of the literature are presented.Hintergrund: Die Strahlentherapie spielt bei der kurativen Behandlung der Frühstadien follikulärer Keimzentrumslymphome die entscheidende Rolle. Therapiebegleitende Nebenwirkungen sind häufig Panzytopenie, Nausea und abdominelle Beschwerden. Eine radiogen induzierte Leberschädigung mit klinisch manifester Symptomatik und schwerer Leberfunktionsstörung ist dagegen äußerst selten. Fallbeschreibung: Bei einem 49-jährigen Patienten mit einem zentrozytisch-zentroblastischen Non-Hodgkin-Lymphom, Stadium IA (Lokalisation: linke Leiste) wurde die gesamte Abdomen- und Beckenregion (“abdominelles Bad”) bestrahlt. Bei einer wöchentlichen Fraktionierung von fünfmal 1,5 Gy wurde eine Gesamtdosis von 30 Gy appliziert. Zum Schutz der Risikoorgane wurden Nierenblöcke nach 13,5 Gy und Leberblöcke nach 25 Gy eingesetzt. Während der letzten beiden Therapietage kam es zur Verschlechterung des Allgemeinzustandes des Patienten mit Gewichtszunahme, Vergrößerung des Bauchumfangs, Dyspnoe und einem Anstieg der Leberwerte. Die weiterführende Diagnostik ergab eine Hepatosplenomegalie mit ausgeprägter Aszitesbildung und einen erhöhten portosystemischen Druckgradienten. Im Leberbiopsat wurde eine Venenverschlusskrankheit gefunden. Innerhalb 1 Woche nach Anlage eines transjugulären intrahepatischen portosystemischen Stent-Shunts (TIPPS), Vollheparinisierung und unter Diuretikagabe war der Patient beschwerdefrei. Die Leberwerte sind im Normbereich. Schlussfolgerung: Die Venenverschlusskrankheit der Leber (VOD) ist eine sehr seltene Nebenwirkung bei der abdominellen Bestrahlung nicht vorbehandelter follikulärer Keimzentrumslymphome. Bei Oberbauchbeschwerden, Anstieg der Leberenzyme sowie Aszitesbildung, insbesondere in einem Zeitraum von bis zu 4 Monaten nach Therapieabschluss, muss an diese Komplikation gedacht werden. Genese, Diagnostik und Therapie der Venenverschlusskrankheit der Leber werden im Literaturüberblick präsentiert.Background: Radiotherapy is potentially curative in early stages of follicle center lymphoma. Frequent side effects are pancytopenia, nausea and abdominal discomfort. A radiation-induced liver injury with serious clinical symptoms and changes in liver function is a rare complication. Case Report: Whole abdomen was irradiated in a 49-year-old patient with a centrocytic-centroblastic lymphoma, stage IA (localization: left inguinal region). A total dose of 30 Gy was delivered in a weekly frationation of five times 1.5 Gy. Kidneys were protected by shielding after a dose of 13.5 Gy, liver blocks were positioned after 25 Gy. During the last 2 days of therapy the patient presented with weight gain, ascites, dyspnoea and elevated liver enzymes. Diagnostics revealed hepatosplenomegaly, ascites and an increased portosystemic pressure gradient. Liver biopsy specimen showed a veno-occlusive disease. Complete relief of symptomatology was achieved within 7 days following placement of a transjugular intrahepatic portosystemic stent-shunt (TIPPS), heparinization and diuretics. Liver enzymes are in the normal range. Conclusion: Veno-occlusive disease of the liver (VOD) is a very rare side effect of primary abdominal irradiation of follicle center lymphoma. This complication should be taken into consideration if a patient presents with upper right quadrant pain, ascites and elevation of liver enzymes especially within 4 months following radiotherapy. Genesis of veno-occlusive disease, diagnostics, therapy and a review of the literature are presented.

Restoration of Liver Function and Portosystemic Pressure Gradient After TIPSS and Late TIPSS Occlusion

TIPSS (transjugular intrahepatic portosystemic shunt) may be indicated to control bleeding from esophageal and gastric varicose veins, to reduce ascites, and to treat patients with Budd-Chiari syndrome and veno-occlusive disease. Numerous measures to improve the safety and methodology of the procedure have helped to increase the technical and clinical success. Follow-up of TIPSS patients has revealed shunt stenosis to occur more often in patients with preserved liver function (Child A, Child B). In addition, the extent of liver cirrhosis is the main factor that determines prognosis in the long term. Little is known about the effects of TIPSS with respect to portosystemic hemodynamics. This report deals with a cirrhotic patient who stopped drinking 7 months prior to admission. He received TIPSS to control ascites and recurrent esophageal bleeding. Two years later remarkable hypertrophy of the left liver lobe and shunt occlusion was observed. The portosystemic pressure gradient dropped from 24 mmHg before TIPSS to 11 mmHg and remained stable after shunt occlusion. The Child’s B cirrhosis prior to TIPSS turned into Child’s A cirrhosis and remained stable during the follow-up period of 32 months. This indicates that liver function of TIPSS patients may recover due to hypertrophy of the remaining non-cirrhotic liver tissue. In addition the hepatic hemodynamics may return to normal. In conclusion, TIPSS cannot cure cirrhosis but its progress may be halted if the cause can be removed. This may result in a normal portosystemic gradient, leading consequently to shunt occlusion.

Long-term remission of paraprotein-induced immunotactoid glomerulopathy after high-dose therapy and autologous blood stem cell transplantation

Dear Editor, Immunotactoid glomerulopathy (ITGN) is a complication of plasma cell disorders like monoclonal gammopathy and multiple myeloma as defined by Durie and Salmon [1] or the international staging system (ISS) [2] criteria, which is characterized by the deposition of paraprotein in the glomerulus. The deposition of immunoglobulins leads to a glomerular pattern of kidney dysfunction with proteinuria as initial clinical finding that progresses to nephrotic syndrome if the underlying disease is not effectively treated. In the further course of the disease, renal function further deteriorates and patients can develop end stage renal disease (ESRD) requiring dialysis. ITGN belongs to a group of immunoglobulin deposition disorders that can affect the kidney as AL-amyloidosis, monoclonal immunodeposition disease (MIDD), and proliferative glomerulonephritis with monoclonal IgG deposits [3] and cryoglobulinemia. The common denominator of these entities is that they all affect the glomerulus, and the extent of the underlying malignant plasma cell and tumor burden is the major factor for organ dysfunction. Paraprotein-induced glomerulopathies have to be separated from cast nephropathy that can also be a reason for paraprotein-induced renal failure but is based on the precipitation of paraprotein, in most cases Bence–Jones proteins, in the ascending henle loop and is in most cases coupled to a substantial increase in tumor burden [4]. Typical ultrastructural characteristics of ITGN are glomerular deposits of extracellular, elongated, nonbranching microfibrils/microtubules, which show neither periodicity nor substructure. They colocalize with immune deposits identified by fluorescence microscopy, implying that they contain immunoglobulins and complement as principal components [4]. Other ultrastructural findings are nonspecific. In most cases, deposits are described throughout the glomerulus. Isolated mesangial involvement is seen in approximately 25% of cases. Deposits associated with the basal lamina have a predilection for the lamina densa and the lamina rara externa, appear to diffusely infiltrate and replace the basal lamina in some instances, and may form prominent subepithelial and subendothelial deposits [5]. The reported therapeutical experience for ITGNs limited and anecdotal, but therapeutic trials with steroids alone, steroids with cytotoxic agents, and steroids with plasmapheresis have been associated with clinical remission of proteinuria in fewer than 10% of the cases. If there is no other systemic disease, their prognosis, independent of renal survival, is quite good. Therefore, renal transplantation has been performed in IT glomerulopathy patients with Ann Hematol (2007) 86:927–930 DOI 10.1007/s00277-007-0330-6

Radiodiagnostik der Transplantatniere

ZusammenfassungDie bildgebende Diagnostik nach Nierentransplantation hat einen hohen Stellenwert in der Differentialdiagnostik peri- und postoperativer Komplikationen. Die Sonographie mit Doppler- und Farbduplexsonographie ist die Methode der ersten Wahl in der Diagnostik der akuten Transplantatabstoßung. Die MRT kann als zusätzliche Methode in der Diagnostik der akuten Transplantatdysfunktion und insbesondere bei unklarer perirenaler Flüssigkeitsansammlungen nach Transplantation eingesetzt werden. MR-Angiographie und MR-Urographie sind ergänzende nichtinvasive Methoden, welche die Angiographie (DSA) und Pyelographie zunehmend ersetzen können. Die Angiographie, ergänzt durch die CO2-Angiographie, ist weiterhin der Goldstandard in der Diagnostik von Transplantatarterienstenosen.SummaryDiagnostic imaging after renal transplantation is of high importance in the differential diagnosis of peri-and postoperative complications. Sonography with color duplex imaging is the method of choice in the diagnosis of acute transplant rejection. MRI is an additional method in the diagnosis of transplant dysfunction especially in diagnosis of perirenal fluid collections. MR angiography and MR urography are noninvasive diagnostic modalities with the potential to replace angiography and pyelography. Angiography, complemented by carbon dioxide angiography, still is the gold standard in the diagnosis of transplant artery stenosis.

Late Aneurysm Rupture after Repressurization of a Thrombosed Stent-Graft

PURPOSE To report late abdominal aortic aneurysm (AAA) rupture after endovascular stent-graft repair despite complete thrombotic stent-graft occlusion. CASE REPORT A 65-year-old man underwent successful endovascular aneurysm repair (EVAR) with a Stentor device in 1995. In the interim course, the patient developed complete thrombotic stent-graft occlusion, which was treated with an axillobifemoral bypass. After 8 years, the patient presented with a reperfused and ruptured infrarenal AAA. Open repair was performed, with a good clinical result and exclusion of the AAA. CONCLUSION Thrombosed stent-grafts and aneurysms can transmit systemic arterial pressure and cause late rupture. Lifelong surveillance is mandatory in EVAR patients.