K. Klemm

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections – A single center experience in 28 patients

OBJECTIVE We report our 6-year experience with the visceral hybrid procedure for high-risk patients with thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD). METHODS Hybrid procedure includes debranching of the visceral and renal arteries followed by endovascular exclusion of the aneurysm. A series of 28 patients (20 male, mean age 66 years) were treated between January 2001 and July 2007. Sixteen patients had TAAAs type I-III, one type IV, four thoracoabdominal placque ruptures, and seven patients CEAD. Patients were treated for asymptomatic, symptomatic, and ruptured aortic pathologies in 20, and 4 patients, respectively. Two patients had Marfans syndrome; 61% had previous infrarenal aortic surgery. The infrarenal aorta was the distal landing zone in 70%. In elective cases, simultaneous approach (n = 9, group I) and staged approach (n = 11, group II) were performed. Mean follow-up is 22 months (range 0.1-78). RESULTS Primary technical success was achieved in 89%. All stent grafts were implanted in the entire thoracoabdominal aorta. Additionally, three patients had previous complete arch vessel revascularization. Left subclavian artery was intentionally covered in three patients (11%). Thirty-day mortality rate was 14.3% (4/28). One patient had a rupture before the staged endovascular procedure and died. Overall survival rate at 3 years was 70%, in group I 80%, and in group II 60% (P = .234). Type I endoleak rate was 8%. Permanent paraplegia rate was 11%. Three patients required long-term dialysis (11%). Peripheral graft occlusion rate was 11% at 30 days. Gut infarction with consecutive bowel resection occurred in two patients. There was no significant difference between group I and II regarding paraplegia and complications. CONCLUSIONS Early results of visceral hybrid repair for high-risk patients with complex and extended TAAAs and CEADs are encouraging in a selected group of high risk patients in whom open repair is hazardous and branched endografts are not yet optional.

Emergency Carotid Endarterectomy

Objective: Evaluation of the therapeutical efficacy of emergency carotid endarterectomy (CEA) in neurologically unstable patients. Patients and Methods: Three groups of a consecutive series of 71 emergency CEAs performed from 1980 to July 1998 were classified: (1) acute onset of severe stroke (n = 16), (2) progressive stroke/stroke in evolution (n = 34), and (3) crescendo transient ischemic attacks (n = 21). Cerebral coma, cerebral haemorrhage, and major ischemic stroke established in cranial computed tomography scans were contraindications for surgery. The neurological outcome was assessed by the modified Rankin scale. Long-term survival and long-term stroke recurrences were analyzed. Results: The recovery/minor stroke rates (Rankin 0–3) in acute stroke, progressive stroke, and crescendo transient ischemic attacks were 56.3, 76.4 and 80.9%, respectively; the combined major stroke/mortality rates (Rankin 4–6) were 43.7, 23.6 and 19.1%, respectively. Intraoperative angiography in 39 patients detected early carotid reocclusions in 2 and intracranial embolism in 7 patients. Local application of thrombolytic agents (n = 5) may contribute to a better neurological outcome in emergency CEA. Life table probabilities of major strokefree survival were 74.5, 71.6, and 53.7% after 1, 2, and 5 years, respectively (including perioperative strokes). Life table probabilities to suffer no stroke recurrence during follow-up were 96.7, 96.7 and 85.3%, respectively (perioperative strokes excluded). Conclusions: Emergency CEA may be worthwhile in selected patients. Completion angiography is mandatory. Emergency CEA should be included in therapeutic strategies for ischemic stroke.

Intentional Overstenting of the Celiac Trunk During Thoracic Endovascular Aortic Repair: Preoperative Role of Multislice CT Angiography

Purpose: To report initial experience with intentional coverage of the celiac trunk to expand the distal landing zone in thoracic endovascular aortic repair (TEVAR) and to analyze preprocedural visualization of collateral blood flow by noninvasive computed tomographic angiography (CTA). Methods: Between January 1997 and April 2008, 202 patients with thoracic aortic pathologies were treated by TEVAR. In 5 high-risk patients (3 women; mean age 73 years, range 62–88), intentional overstenting of the celiac trunk was performed when treating 2 ruptured aneurysms, 1 penetrating aortic ulcer, 1 type B dissection, and 1 distal type I endoleak. Multislice CTA (MSCTA) with multiplanar reconstruction was used to visualize the visceral collaterals; no angiography was performed. Results: MSCTA was able to visualize the patent pancreaticoduodenal artery and other collaterals and to verify sufficient collateral blood flow. All celiac arteries were patent preoperatively; only 1 severe stenosis was demonstrated. After successful TEVAR in all cases, 1 of the 5 patients developed visceral malperfusion and died of multiorgan failure 1 day after TEVAR of a ruptured thoracic aneurysm. A second patient died 6 weeks postoperatively due to cardiopulmonary failure (non-procedure-related). There were no late complications or reinterventions. Conclusion: Overstenting of the celiac trunk is feasible, with acceptable risk in emergency cases and high-risk patients if MSCTA documents collateral blood flow. Noninvasive MSCTA is sufficient and may obviate pre- and intraoperative selective angiography with or without a balloon occlusion test.

Klinische Anforderungen an die Bildgebung der Aorta

ZusammenfassungDie moderne Bildgebung, insbesondere die nichtinvasive Schnittbildgebung, hat sich in den letzten Jahren dramatisch weiterentwickelt und stellt mittlerweile die Basis für die prä- und postoperative Diagnostik aortaler Pathologien dar. Insbesondere die Planung, aber auch die Nachsorge endovaskulärer Aortenrekonstruktionen stellen sehr hohe Anforderungen an den Diagnostiker und Therapeuten. Aus der Vielzahl der bestehenden diagnostischen Modalitäten gilt es, die für die jeweilige Pathologie geeignete Untersuchungsmethode auszuwählen und für den Patienten individuell anzuwenden. Die Sonographie ist für das Screening und die Nachsorge infrarenaler Aneurysmen die Untersuchung der Wahl. Die transösophageale Echokardiographie und MR-Angiographie (MRA) werden mit hoher Sensitivität und Spezifität bei der Diagnostik, der intraoperativen Navigation von Endografts und im follow-up konservativ behandelter Patienten mit Aortenbogenaneurysmen und Aortendissektionen eingesetzt. Die Verwendung der MRA ist jedoch durch lange Untersuchungszeiten, Metallartefakte und limitierte Verfügbarkeit begrenzt. Die digitale Subtraktionsangiographie (DSA) hat ihre Rolle in der Diagnostik der Aorthenpathologien gegenüber der CTA eingebüßt, behält aber derzeit ihre Domäne bei der intraoperativen Darstellung der Verankerungszonen von Endoprothesen. Der selektive Nachweis postoperativer Endoleckagen mit anschließender therapeutischer Embolisation ist ein weiteres Einsatzgebiet der DSA. Die CT-Angiographie (CTA) inklusive der sog. Bildnachverarbeitung („image postprocessing“) haben die Führungsrolle bei der Bildgebung der Aorta übernommen. Krankheitsspezifische diagnostische Algorithmen sind im klinischen Alltag sinnvoll und notwendig.AbstractModern imaging modalities, especially noninvasive cross-sectional imaging techniques, have advanced dramatically in recent years and are now the backbone of pre- and postoperative evaluation of aortic pathologies. The planning in particular, but also the aftercare following endovascular aortic reconstructions, make heavy demands on physicians. It is necessary to select the method of examination that is best suited to the pathology concerned and to apply it to the patient in an individual manner. Ultrasound is the examination of choice for screening and follow-up of infrarenal aneurysms. Transesophageal echocardiography and magnetic resonance angiography are used in diagnosis, in intraoperative navigation during the implantation of endografts and in follow-up of patients with thoracic aortic aneurysms and aortic dissections who have undergone conservative treatment, with very high sensitivity and specificity. The use of MRA is restricted by the long time needed for an examination, metal artifacts and limited availability. DSA has been largely superseded in the diagnosis of aortic pathologies by CTA, but as yet retains its role in intraoperative imaging of the anchorage regions of endoprostheses. Selective demonstration of postoperative internal leaks with subsequent therapeutic embolization is a further area of use for DSA. CTA, including so-called image postprocessing, has taken over the prime role in imaging of the aorta. Disease-specific diagnostic algorithms are useful and necessary in day-to-day clinical practice.Modern imaging modalities, especially noninvasive cross-sectional imaging techniques, have advanced dramatically in recent years and are now the backbone of pre- and postoperative evaluation of aortic pathologies. The planning in particular, but also the aftercare following endovascular aortic reconstructions, make heavy demands on physicians. It is necessary to select the method of examination that is best suited to the pathology concerned and to apply it to the patient in an individual manner. Ultrasound is the examination of choice for screening and follow-up of infrarenal aneurysms. Transesophageal echocardiography and magnetic resonance angiography are used in diagnosis, in intraoperative navigation during the implantation of endografts and in follow-up of patients with thoracic aortic aneurysms and aortic dissections who have undergone conservative treatment, with very high sensitivity and specificity. The use of MRA is restricted by the long time needed for an examination, metal artifacts and limited availability. DSA has been largely superseded in the diagnosis of aortic pathologies by CTA, but as yet retains its role in intraoperative imaging of the anchorage regions of endoprostheses. Selective demonstration of postoperative internal leaks with subsequent therapeutic embolization is a further area of use for DSA. CTA, including so-called image postprocessing, has taken over the prime role in imaging of the aorta. Disease-specific diagnostic algorithms are useful and necessary in day-to-day clinical practice.

Intermittent claudication secondary to a traumatic arteriovenous fistula

Arteriovenous fistula (AVF) formation is a recognized complication of arterial trauma. A 63-year-old man with no known risk factors for atheroma and a history of a 20-year delay in the diagnosis and treatment of a traumatic AVF presented with right calf claudication (maximal walking distance = 150 m). A duplex ultrasound scan and a magnetic resonance angiography showed an aneurysmatic dilatation and partial thrombosis of the infrarenal aorta and the right leg feeding arteries. Selective angiography revealed a complete occlusion of the right popliteal artery in the segment 2 and the infrapopliteal arteries with good collateral formation in the lower leg. At this time, there is no indication for infragenual arterial revascularisation in this patient. Instead, therapy consists of exercise training and antiplatelet therapy. We concluded, that peripheral microembolism from the aneurysmatic aorta, iliac or femoral arteries is most probably the reason for the popliteal occlusion in this patient, representing a rare, nonatherosclerotic cause of claudication.

Modular training in vascular and endovascular surgery exemplified by the Vascular International Foundation and School

ZusammenfassungDer zumindest partielle „shift“ vom Patienten zum Modell ist für die Chirurgie ein sinnvoller und notwendigen Paradigmenwechsel, um die Patientensicherheit zu erhöhen und den verkürzten Weiterbildungszeiten in den Kliniken und den gestiegenen Qualitätsansprüchen gerecht zu werden. Seit 1991 wurden von der Vascular International Foundation & School zahlreiche Trainingskurse mit mehr als 2500 Kursteilnehmern durchgeführt. Das modular aufgebaute Trainingssystem ermöglicht das Erlernen einer Vielzahl offen-gefäßchirurgischer und endovaskulärer Operationstechniken an lebensechten, pulsatil durchströmten Modellen. Die Simulationskurse können das Training im OP zwar nicht ersetzen, sie sind aber geeignet, die kognitive und die assoziative Stufe des Erreichens motorischer Fähigkeiten zu unterstützen. Die wissenschaftliche Evaluation der Kurse zeigt durchgehend, dass das seit 1991 etablierte Trainingsprinzip zu signifikanten Lernerfolgen führen kann. Sie sind nicht nur für Anfänger sinnvoll, sondern auch für erfahrene Gefäßchirurgen. Sie können in allen Stadien der professionellen Entwicklung helfen, die Lernkurve abzukürzen, neue Techniken zu erlernen oder bereits angewandte Operationstechniken zu verfeinern.AbstractThe partial shift from patient to model is a reasonable and necessary paradigm shift in surgery in order to increase patient safety and to adapt to the reduced training time periods in hospitals and increased quality demands. Since 1991 the Vascular International Foundation and School has carried out many training courses with more than 2,500 participants. The modular build training system allows to teach many open vascular and endovascular surgical techniques on lifelike models with a pulsatile circulation. The simulation courses cannot replace training in operating rooms but are suitable for supporting the cognitive and associative stages for achieving motor skills. Scientific evaluation of the courses has continually shown that the training principle established since 1991 can lead to significant learning success. They are extremely useful not only for beginners but also for experienced vascular surgeons. They can help to shorten the learning curve, to learn new techniques or to refine previously used techniques in all stages of professional development.

Modulares Training in vaskulärer und endovaskulärer Chirurgie am Beispiel der Stiftung und Schule Vascular International

ZusammenfassungDer zumindest partielle „shift“ vom Patienten zum Modell ist für die Chirurgie ein sinnvoller und notwendigen Paradigmenwechsel, um die Patientensicherheit zu erhöhen und den verkürzten Weiterbildungszeiten in den Kliniken und den gestiegenen Qualitätsansprüchen gerecht zu werden. Seit 1991 wurden von der Vascular International Foundation & School zahlreiche Trainingskurse mit mehr als 2500 Kursteilnehmern durchgeführt. Das modular aufgebaute Trainingssystem ermöglicht das Erlernen einer Vielzahl offen-gefäßchirurgischer und endovaskulärer Operationstechniken an lebensechten, pulsatil durchströmten Modellen. Die Simulationskurse können das Training im OP zwar nicht ersetzen, sie sind aber geeignet, die kognitive und die assoziative Stufe des Erreichens motorischer Fähigkeiten zu unterstützen. Die wissenschaftliche Evaluation der Kurse zeigt durchgehend, dass das seit 1991 etablierte Trainingsprinzip zu signifikanten Lernerfolgen führen kann. Sie sind nicht nur für Anfänger sinnvoll, sondern auch für erfahrene Gefäßchirurgen. Sie können in allen Stadien der professionellen Entwicklung helfen, die Lernkurve abzukürzen, neue Techniken zu erlernen oder bereits angewandte Operationstechniken zu verfeinern.AbstractThe partial shift from patient to model is a reasonable and necessary paradigm shift in surgery in order to increase patient safety and to adapt to the reduced training time periods in hospitals and increased quality demands. Since 1991 the Vascular International Foundation and School has carried out many training courses with more than 2,500 participants. The modular build training system allows to teach many open vascular and endovascular surgical techniques on lifelike models with a pulsatile circulation. The simulation courses cannot replace training in operating rooms but are suitable for supporting the cognitive and associative stages for achieving motor skills. Scientific evaluation of the courses has continually shown that the training principle established since 1991 can lead to significant learning success. They are extremely useful not only for beginners but also for experienced vascular surgeons. They can help to shorten the learning curve, to learn new techniques or to refine previously used techniques in all stages of professional development.

Klinische Anforderungen an die Bildgebung der Aorta@@@Clinical requirements of aortic imaging

ZusammenfassungDie moderne Bildgebung, insbesondere die nichtinvasive Schnittbildgebung, hat sich in den letzten Jahren dramatisch weiterentwickelt und stellt mittlerweile die Basis für die prä- und postoperative Diagnostik aortaler Pathologien dar. Insbesondere die Planung, aber auch die Nachsorge endovaskulärer Aortenrekonstruktionen stellen sehr hohe Anforderungen an den Diagnostiker und Therapeuten. Aus der Vielzahl der bestehenden diagnostischen Modalitäten gilt es, die für die jeweilige Pathologie geeignete Untersuchungsmethode auszuwählen und für den Patienten individuell anzuwenden. Die Sonographie ist für das Screening und die Nachsorge infrarenaler Aneurysmen die Untersuchung der Wahl. Die transösophageale Echokardiographie und MR-Angiographie (MRA) werden mit hoher Sensitivität und Spezifität bei der Diagnostik, der intraoperativen Navigation von Endografts und im follow-up konservativ behandelter Patienten mit Aortenbogenaneurysmen und Aortendissektionen eingesetzt. Die Verwendung der MRA ist jedoch durch lange Untersuchungszeiten, Metallartefakte und limitierte Verfügbarkeit begrenzt. Die digitale Subtraktionsangiographie (DSA) hat ihre Rolle in der Diagnostik der Aorthenpathologien gegenüber der CTA eingebüßt, behält aber derzeit ihre Domäne bei der intraoperativen Darstellung der Verankerungszonen von Endoprothesen. Der selektive Nachweis postoperativer Endoleckagen mit anschließender therapeutischer Embolisation ist ein weiteres Einsatzgebiet der DSA. Die CT-Angiographie (CTA) inklusive der sog. Bildnachverarbeitung („image postprocessing“) haben die Führungsrolle bei der Bildgebung der Aorta übernommen. Krankheitsspezifische diagnostische Algorithmen sind im klinischen Alltag sinnvoll und notwendig.AbstractModern imaging modalities, especially noninvasive cross-sectional imaging techniques, have advanced dramatically in recent years and are now the backbone of pre- and postoperative evaluation of aortic pathologies. The planning in particular, but also the aftercare following endovascular aortic reconstructions, make heavy demands on physicians. It is necessary to select the method of examination that is best suited to the pathology concerned and to apply it to the patient in an individual manner. Ultrasound is the examination of choice for screening and follow-up of infrarenal aneurysms. Transesophageal echocardiography and magnetic resonance angiography are used in diagnosis, in intraoperative navigation during the implantation of endografts and in follow-up of patients with thoracic aortic aneurysms and aortic dissections who have undergone conservative treatment, with very high sensitivity and specificity. The use of MRA is restricted by the long time needed for an examination, metal artifacts and limited availability. DSA has been largely superseded in the diagnosis of aortic pathologies by CTA, but as yet retains its role in intraoperative imaging of the anchorage regions of endoprostheses. Selective demonstration of postoperative internal leaks with subsequent therapeutic embolization is a further area of use for DSA. CTA, including so-called image postprocessing, has taken over the prime role in imaging of the aorta. Disease-specific diagnostic algorithms are useful and necessary in day-to-day clinical practice.Modern imaging modalities, especially noninvasive cross-sectional imaging techniques, have advanced dramatically in recent years and are now the backbone of pre- and postoperative evaluation of aortic pathologies. The planning in particular, but also the aftercare following endovascular aortic reconstructions, make heavy demands on physicians. It is necessary to select the method of examination that is best suited to the pathology concerned and to apply it to the patient in an individual manner. Ultrasound is the examination of choice for screening and follow-up of infrarenal aneurysms. Transesophageal echocardiography and magnetic resonance angiography are used in diagnosis, in intraoperative navigation during the implantation of endografts and in follow-up of patients with thoracic aortic aneurysms and aortic dissections who have undergone conservative treatment, with very high sensitivity and specificity. The use of MRA is restricted by the long time needed for an examination, metal artifacts and limited availability. DSA has been largely superseded in the diagnosis of aortic pathologies by CTA, but as yet retains its role in intraoperative imaging of the anchorage regions of endoprostheses. Selective demonstration of postoperative internal leaks with subsequent therapeutic embolization is a further area of use for DSA. CTA, including so-called image postprocessing, has taken over the prime role in imaging of the aorta. Disease-specific diagnostic algorithms are useful and necessary in day-to-day clinical practice.

Limitierte Überwachung nach Karotisthrombendarteriektomie

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

Early transfer from intensive care does not influence clinical results of carotid endarterectomy

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.