Juergen Falkensammer

Serum levels of ischemia-modified albumin in healthy volunteers after exercise-induced calf-muscle ischemia.

Abstract Background: Ischemia-modified albumin (IMA) is an emerging marker of ischemia. To investigate the applicability of IMA for the diagnosis of skeletal muscle ischemia, we examined IMA changes as measured by the albumin-cobalt binding test, in a group of healthy volunteers after standardized exercise-induced calf muscle ischemia. Methods: A total of 12 healthy volunteers underwent standardized exercise on a plantar flexion pedal. Ischemic conditions were achieved by inflating a femoral blood pressure cuff at incremental pressures of 0, 60, 90, 120 and 150 mm Hg. Calf muscle ischemia was identified by synchronous 31P magnetic resonance spectroscopy, measuring intracellular concentrations of phosphocreatine (PCr) and inorganic phosphate (Pi). In addition, IMA, serum albumin, lactate, troponin T (TnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were measured at baseline and at 5, 10, 30, 360 and 720 min after cuff release. Results: Magnetic resonance spectroscopy showed calf muscle ischemia in all participants upon exercise and cuff inflation. Circulating IMA concentrations increased significantly after cuff release (p=0.03) and returned to baseline within 30 min. While we found a significant negative correlation with albumin, there was no association of IMA levels with lactate or intracellular levels of PCr or Pi in samples obtained at baseline and post-ischemia. TnT and NT-proBNP remained within the normal range throughout the observation period in all participants. Conclusions: IMA may represent a clinical marker for skeletal muscle ischemia, although its lack of specificity requires careful clinical interpretation of data. The short period of IMA elevation after ischemic exercise requires standardized conditions for use as a diagnostic tool and hints at IMA applicability as a marker of prolonged or chronic ischemia. Clin Chem Lab Med 2007;45:535–40.

Repair of Arterial Injury after Blunt Trauma in the Upper Extremity–Immediate and Long-term Outcome

OBJECTIVE In contrast to upper extremity stab and gunshot wounds, data on management and outcome in blunt trauma (BT) are limited by small numbers and short follow-up periods. METHODS This study is a retrospective data analysis. All patients who had undergone arterial repair after upper-limb BT were included. Exclusion criteria were artery ligation and/or primary limb amputation. Endpoints included the following: peri-operative death, limb salvage, primary and secondary patency, vascular re-operation and/or intervention. RESULTS Eighty-nine patients (71 male; median age: 34.6 years, range: 2.5-81.7) underwent reconstruction of 96 arteries after BT since 1989: subclavian (n=16), axillary (n=22), brachial (n=48) and forearm (n=10). Concomitant arm vein lesions were present in 15 patients (17%) and accompanying nerve (n=38; 43%) and/or orthopaedic injuries (n=64; 72%) in 77 patients (87%). The 30-day mortality rate was 2% with the limb-salvage rate being 98%. Six reconstructions occluded during the first week (primary/secondary patency rate: 93%/99%). After a median follow-up time of 5.1 years, 67% of the patients were followed: There were no secondary amputations and no arterial re-interventions. CONCLUSIONS Arterial repair in upper extremity BT has excellent early and long-term outcome. In contrast to a significant risk of early occlusion, limb loss after repair, late vascular re-intervention and late arterial occlusion or stenosis are rare.

The influence of gender on patency rates after iliac artery stenting

OBJECTIVE The purpose of this study was to investigate the influence of gender on the long-term outcome after iliac artery stenting and to assess gender-specific differences of the influence of risk factors on treatment success and patency rates. METHODS Between January 2000 and December 2006, 404 percutaneous transluminal angioplasties with primary stent deployment for symptomatic iliac artery occlusive disease were performed at our center. These included 128 interventions in women and 276 interventions in men. RESULTS Whereas average age was significantly higher (65.9 ± 12.9 years; P = .007) and arterial hypertension more frequent (60.9% vs 49.3%; P = .032) in women, hyperuricemia (7.0% vs 14.1%; P = .047) and a positive smoking status (61.7% vs 74.3%; P = .014) were more frequently observed in men. Fontaine stage was more advanced (stages III and IV) in women than in men (P = .028; P < .001). Technical success was 97.7% in women and 99.3% in men. Overall complication rate was higher in women compared with men (P = .002), mostly caused by access site hematomas (4.7% vs 0.4%) and pseudoaneurysms (8.6% vs 2.5%). Patients were followed up for 45.0 ± 33.3 months. Restenosis developed in 16.8% of cases in women and in 14.6% of cases in men and was treated in 73.7% by an endovascular approach. Primary patency rates at 1, 3, 5, and 7 years were 90.3%, 77.2%, 60.2%, and 46.4% in women and 89.9%, 71.5%, 63.6%, and 59.7% in men, respectively (P = .524; log-rank, .406). Secondary patency rates were 97.2%, 91%, 81.5%, and 70.3% in women and 97.1%, 89.1%, 82.6%, and 78% in men, respectively (P = .959; log-rank, .003). Multivariate analysis identified lower age as the only independent risk factor for recurrent disease in both groups. Age-defined subgroup analysis showed a restenosis/reocclusion rate of 23.9% in men and 22.1% in women older than 63.5 years (P = .861) but 32.1% in men and 49.1% in women younger than that (P = .034). CONCLUSIONS Our data suggest that although women are older and present with a more advanced stage of peripheral arterial occlusive disease, endovascular therapy is equally effective irrespective of gender. Surprisingly, the subgroup of young female patients had a specifically poor outcome.

Endovascular Management of Inadvertent Subclavian Artery Catheterization during Subclavian Vein Cannulation

PURPOSE To retrospectively review a 9-year experience with endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation. MATERIALS AND METHODS From June 2000 through July 2009 (109 months), 13 patients underwent endovascular management of inadvertent subclavian artery catheterization. All catheters were still in situ, including one 7-F catheter, six 8-F catheters, and six large-bore 10-11-F catheters. Treatment was performed with an Angio-Seal device (n = 6) or balloon catheters (n = 7) and by additional stent-graft placement (n = 4). RESULTS Mean follow-up was 27.3 months (range, 0.4-78 months). The 30-day mortality rate was 7.7% and the late mortality rate was 46.1%. Primary technical success was achieved in nine patients (69.2%), in four with the use of a compliant balloon catheter and in the other five with an Angio-Seal device. Complications required additional stent-graft placement in four patients (30.8%), one because of stenosis after Angio-Seal device deployment and three as a result of insufficient closure of the puncture site by balloon tamponade. Stent-graft repair was successful in all four patients, for a primary assisted technical success rate of 100%. CONCLUSIONS Endovascular techniques offer a less invasive alternative to surgery. The present limited experience shows that the use of the Angio-Seal device is not without risks, whereas balloon tamponade is not always reliable in closing the puncture site. Stent-graft placement may be required in patients in whom balloon tamponade fails or in whom the use of the Angio-Seal device is contraindicated.

Antiphospholipid Antibodies Predict Progression of Abdominal Aortic Aneurysms

Antiphospholipid antibodies (aPLs) frequently occur in autoimmune and cardiovascular diseases and correlate with a worse clinical outcome. In the present study, we evaluated the association between antiphospholipid antibodies (aPLs), markers of inflammation, disease progression and the presence of an intra-aneurysmal thrombus in abdominal aortic aneurysm (AAA) patients. APLs ELISAs were performed in frozen serum samples of 96 consecutive AAA patients and 48 healthy controls yielding positive test results in 13 patients (13.5%) and 3 controls (6.3%; n.s.). Nine of the 13 aPL-positive AAA patients underwent a second antibody testing >12 weeks apart revealing a positive result in 6 cases. APL-positive patients had increased levels of inflammatory markers compared to aPL-negative patients. Disease progression was defined as an increase of the AAA diameter >0.5 cm/year measured by sonography. Follow-up was performed in 69 patients identifying 41 (59.4%) patients with progressive disease. Performing multipredictor logistic regression analysis adjusting for classical AAA risk factors as confounders, the presence of aPLs at baseline revealed an odds ratio of 9.4 (95% CI 1.0–86.8, p = 0.049) to predict AAA progression. Fifty-five patients underwent a computed tomography in addition to ultrasound assessment indicating intra-aneurysmal thrombus formation in 82.3%. Median thrombus volume was 46.7 cm3 (1.9–377.5). AAA diameter correlated with the size of the intra-aneurysmal thrombus (corrcoeff = 0.721, p<0.001), however neither the presence nor the size of the intra-aneurysmal thrombus were related to the presence of aPLs. In conclusion, the presence of aPLs is associated with elevated levels of inflammatory markers and is an independent predictor of progressive disease in AAA patients.

Pararenal Aortic Ulcer Repair

OBJECTIVE/BACKGROUND In order to investigate techniques and outcomes of pararenal penetrating aortic ulcer (PAU) repair, a retrospective cohort study was performed. METHODS Over the 6 year study period, 12 patients treated for a pararenal PAU were included. Outcome measures included technical success, survival, and peri-operative complications, as well as stent patency. RESULTS Treatment modalities included hybrid procedures with endovascular aneurysm repair (EVAR) and bypass grafting, chimney EVAR (Ch-EVAR), and fenestrated EVAR (FEVAR). Four of the 12 patients were symptomatic, and eight patients underwent elective surgery. The technical success rate was 100%. Symptom resolution was recorded in all symptomatic patients immediately post-operatively. Complications encountered included one type I endoleak in a patient who underwent Ch-EVAR, and one case of post-operative stroke, paralysis, and death in a patient who underwent FEVAR. No adverse events were recorded in the remaining 10 patients. The PAU protrusion distance was significantly greater in symptomatic patients. Perforation and leakage were more prevalent in patients with pre-operative abdominal or back pain. CONCLUSION Encouraging results of endovascular treatment of pararenal PAUs were observed. One major and fatal complication was encountered, which underlines the complexity and risks of the techniques. Another patient required re-intervention owing to an endoleak following off label use of covered stents for Ch-EVAR. FEVAR, which generally requires a custom made graft, was increasingly applied over the study period, potentially because of an increased awareness of this distinct pathology allowing for elective procedure planning. Ch-EVAR and hybrid procedures were predominantly used in symptomatic patients, whereas FEVAR was the preferred elective treatment option.

Abdominal Aortic Aneurysms An Overview of Screening and Management in Primary Care

Abdominal aortic aneurysms represent both an individual risk of mortality and a socioeconomic burden for health care systems worldwide, but screening is not performed in all countries. Here, the authors summarize the pros and cons of screening to reduce abdominal aortic aneurysm–related mortality.