Karl Heinz Orend

Endovascular repair of traumatic descending aortic transection.

PURPOSE To present the results of endovascular repair of acute traumatic descending aortic transection. METHODS Among 66 thoracic stent-graft repairs performed between 1995 and 2001, 11 patients (9 men; mean age 34 years, range 12-73) underwent emergent endovascular repair of acute traumatic descending aortic transection following traffic accidents. Immediate treatment of aortic rupture was indicated in all patients because of a marked fresh hematoma with hemothorax; the spiral computed tomographic (CT) scans showed circular or semicircular descending thoracic aortic injuries. The devices used included 11 thoracic Excluders and 1 Talent stent-graft. RESULTS No patient required conversion to an open transthoracic operation. No patient developed temporary or permanent neurological deficit after endovascular treatment. Two type I endoleaks required periprocedural treatment: a second stent-graft was deployed in one and the existing stent-graft was balloon dilated in the other. Two patients underwent secondary procedures (iliac access complication and revascularization of the left subclavian artery). One patient died 22 days postoperatively secondary to injuries unrelated to the aortic repair. Over a mean 14-month follow-up (range 1-26), the surveillance CT scans have shown the stent-graft to be correctly positioned in all patients. CONCLUSIONS The treatment of acute traumatic descending aortic transection with an endovascular approach is feasible and safe and may offer the best means of therapy. Mortality and the risk of neurological deficit are low compared with open operations.

Fast track management reduces the systemic inflammatory response and organ failure following elective infrarenal aortic aneurysm repair.

OBJECTIVES Systemic inflammatory response syndrome (SIRS) is common after abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the impact of a multimodal fast track (FT) regimen on incidence rates of SIRS after elective infrarenal AAA repair. METHODS Post hoc analysis of a randomized controlled trial including 99 patients after either traditional (TC) or FT care. Basic FT elements were no bowel preparation, reduced preoperative fasting, patient controlled epidural analgesia, enhanced postoperative feeding and mobilization. The presence of SIRS, organ failure and mortality, length of stay (LOS) on intensive care unit (ICU) were analyzed during the postoperative course. RESULTS The incidence of SIRS in the FT treatment arm was significantly lower as compared to TC: 28% vs. 50%, P = 0.04. The rate of any organ failure (AOF) and multiple organ failure (MOF) was lower in the FT group: AOF: 16% vs. 36%, P = 0.039; MOF: 2% vs. 12%; P = 0.112. LOS on ICU showed a slight advantage for FT care: 20 hours vs. 32 hours (P = 0.183). CONCLUSION An optimized patient care program in elective open AAA repair significantly decreases the postoperative incidence of SIRS as well as rates of organ failure.

Valiant Thoracic Stent-Graft Deployed With the New Captivia Delivery System: Procedural and 30-Day Results of the Valiant Captivia Registry

Purpose To evaluate procedural and 30-day outcomes of thoracic endovascular aortic repair (TEVAR) employing the Valiant Thoracic Stent Graft with the Captivia Delivery System. Methods Enrollment in the study (www.ClinicalTrials.com identifier NCT01181947) included all eligible patients implanted with the Valiant Captivia System retrospectively and prospectively at 15 sites in Europe and Turkey between October 2009 and June 2010. In the 100 treated patients (81 men; mean age 64.6±12.0 years, range 25–87), indications included descending thoracic aortic aneurysm (TAA, 49.0%) and aortic dissection (42.0%). Results Technical success was 100.0%, with no misaligned deployments or aortic perforations. Mean follow-up was 68.9±34.9 days (range 20–147, median 61). The 30-day rate of all-cause mortality was 4.0% (all 4 cases procedure-related, 3 device-related). Retrograde type A dissection occurred in 2 patients. The only conversion to open surgery was successful in a patient experiencing intraoperative aneurysm rupture. Stroke occurred in 4 (4.0%) patients and paraplegia in 1 (1.0%). Among 66 patients with 30-day imaging studies evaluable for endoleak, 4 (6.1%) had type I and 7 (10.6%) had type II endoleak; there were no types III or IV. Within 30 days, no secondary endovascular procedures were required due to endoleak. One patient with type II endoleak died 3 weeks postimplantation before scheduled embolization. Conclusion In this analysis of procedural and 30-day results, the high technical success and clinical outcome rates showed that the Valiant Thoracic Stent Graft with the new Captivia Delivery System has promising capacity to treat a variety of thoracic aortic conditions in a range of anatomies.

EMERGENT ENDOLUMINAL REPAIR OF DELAYED ABDOMINAL AORTIC RUPTURE AFTER BLUNT TRAUMA

PURPOSE To report the emergency repair of a traumatic abdominal aortic rupture using endoluminal techniques. METHODS AND RESULTS A 25-year-old female sustained multiple head, chest, and abdominal injuries in a motorcycle accident. Six days after emergency treatment (including splenectomy and repair of a superficial hepatic rupture and lacerations to the stomach, small bowel, and colon), she became hemodynamically unstable. A massive retroperitoneal hematoma had evolved from a distal aortic rupture. Owing to a hostile abdomen and possibility of bacterial contamination, a self-expanding stent-graft was inserted transfemorally to repair the aortic injury. The patient recovered uneventfully and continues in good health with a patent endograft repair 2 years after treatment. CONCLUSIONS This experience would support the efficacy of endograft implantation for emergent repair of trauma aortic injuries; however, proper facilities, an experienced interventional team, and an assortment of endografts and stents must be available.

Comparison of Clinical and Surgical-Pathological Staging in IIIA Non-Small Cell Lung Cancer Patients

BackgroundThe heterogeneous group of IIIA NSCLC patients requires careful preoperative clinical staging as tumor size and lymph node involvement guide treatment. The purpose of our study was to analyze the correctness of clinical staging in IIIA patients.MethodsRetrospective analysis of all patients resected due to lung cancer that had been staged IIIA either clinically using invasive and noninvasive techniques or surgical-pathologically after surgical resection. Correctness, sensitivity, specificity, and positive and negative predictive values of clinical staging were calculated.ResultsFrom our tumor database, 49 patients who met the inclusion criteria were identified. The histology of the primary tumor included adenocarcinoma (53%), squamous cell carcinoma (41%), and other (6%). Preoperative clinical staging consisted of computed tomography (CT), integrated positron emission tomography–CT (PET–CT), bronchoscopy, and mediastinoscopy. The predominant surgical procedures performed were lobectomies (57%) and pneumonectomies (29%). Clinical staging for UICC, T and N stage was correct in 36.7, 38.7, and 40.8%, respectively. In terms of T4 stage, sensitivity was 28.5%, specificity was 80.9%, positive predictive value was 20%, and negative predictive value was 87.1%. As for N2 involvement, we found a sensitivity of 66.6% and a specificity of 35.7%. Positive and negative predictive values for N2 involvement were 43.7 and 58.8% in that order.ConclusionsDespite multimodal preoperative invasive and noninvasive staging techniques, the correctness of clinical staging in IIIA NSCLC patients is low. Hence, in doubt more invasive staging or probatory thoracotomy should be performed not to deny potentially curative surgery in those patients.

Fast Track in der Thoraxchirurgie

Patients undergoing thoracic surgery are threatened by pulmonary complications such as pneumonia and atelectasis. Age, preoperative FEV(1), operative time and extent of resection are predictors for adverse outcome. Reported morbidity after lung resection is as high as 42% and mortality up to 7%. Fast track in thoracic surgery aims at reducing morbidity and mortality rates after lung resection by introducing specific measures into the pre-, intra- and postoperative periods. Basic fast track elements in thoracic surgery are smoking cessation, preoperative physiotherapy, micronutrient supplementation, high thoracic epidural anesthesia, fluid restriction, early mobilization and enteral feeding. The effectiveness of these individual measures has been proven of value in perioperative care, however, evidence on multimodal therapy regimens in thoracic surgery is limited. In particular it remains to be elucidated which patients should be fast tracked in order to improve outcomes.ZusammenfassungPatienten, die sich thoraxchirurgischen Eingriffen unterziehen, sind v.a. durch pulmonale Komplikationen wie Pneumonie und Atelektase gefährdet. Je nach Alter, präoperativer FEV1 (forcierte exspiratorische Ein-Sekunden-Kapazität), Operationsdauer und Resektionsausmaß wird in der Literatur die Morbidität mit bis zu 42%, die Mortalität mit bis zu 7% angegeben. Fast Track in der Thoraxchirurgie zielt auf Reduktion der pulmonalen Komplikationsrate und der Mortalität nach resezierenden Lungeneingriffen, speziell bei Patienten mit präoperativ reduzierter FEV1. Dies soll durch spezifische Maßnahmen im prä-, intra- und postoperativen Bereich geschehen. Wesentliche Fast-Track-Elemente in der Thoraxchirurgie sind Nikotinverzicht, Atemtherapie, Nahrungsergänzung, hohe thorakale Periduralanästhesie, Flüssigkeitsrestriktion, frühe Mobilisation und früher Kostaufbau. Die Wirksamkeit dieser Einzelmaßnahmen wurde bereits dokumentiert, allerdings gibt es noch wenig Evidenz, welchen Vorteil die Kombination dieser Maßnahmen im Sinne eines multimodalen Fast-Track-Konzeptes bietet; insbesondere sollte noch genauer charakterisiert werden, welche Patienten von solchen Konzepten profitieren.AbstractPatients undergoing thoracic surgery are threatened by pulmonary complications such as pneumonia and atelectasis. Age, preoperative FEV1, operative time and extent of resection are predictors for adverse outcome. Reported morbidity after lung resection is as high as 42% and mortality up to 7%. Fast track in thoracic surgery aims at reducing morbidity and mortality rates after lung resection by introducing specific measures into the pre-, intra- and postoperative periods. Basic fast track elements in thoracic surgery are smoking cessation, preoperative physiotherapy, micronutrient supplementation, high thoracic epidural anesthesia, fluid restriction, early mobilization and enteral feeding. The effectiveness of these individual measures has been proven of value in perioperative care, however, evidence on multimodal therapy regimens in thoracic surgery is limited. In particular it remains to be elucidated which patients should be fast tracked in order to improve outcomes.

Endoluminale stentgestützte Versorgung der akuten traumatischen Aortenruptur

AbstractIntroduction. Open repair of traumatic descending aortic rupture in trauma patients is associated with a mortality rate of 15–20% and a risk of paraplegia of 5–10%. Stent grafts may decrease the morbidity and mortality of these procedures by reducing blood loss and aortic occlusion time. Material and Methods. Within an experience of 52 thoracic stent grafts between 1995 and 2000, eight men with acute traumatic descending aortic rupture were conducted as emergencies without delay. All patients had severe coinjuries and presented with acute onset of mediastinal hematoma due to periaortic bleeding. Successful stent deployment was performed in all eight patients, seven of them required one single stent and one required two stents; within the aortic arch all stents covered the origin of the left subclavian artery. Results. All acute aortic ruptures were sealed successfully. One death occurred in hospital from multiorgan failure. There was no conversion to open repair. Not one patients condition resulted in temporary or permanent paraplegia. One endoleak required treatment by overstenting. Two patients required secondery surgical procedures (iliac access complication and revascularisation of left subclavian artery). Mean follow-up was 11 months (1–21 months). Mid-term freedom from endoleak was monitored in all patients. Conclusion. The treatment of acute traumatic descending aortic rupture with an endovascular approach is feasible and safe and may offer the best means of therapy. The mortality rate and risk of paraplegia are low compared with the risks associated with open operations. Continued surveillance is essential.ZusammenfassungHintergrund. Die Gesamtletalität der Verletzten mit traumatischer thorakaler Aortenruptur, die nach Unfall zur Klinikaufnahme kommen, beträgt etwa 30%. Nach offener chirurgischer Versorgung resultiert eine Sterblichkeit von 15–20%, die Paraplegierate variiert zwischen 5 und 10%. Eine endovaskuläre Versorgung erscheint äußerst viel versprechend, da dieser Eingriff auch bei polytraumatisierten Patienten im Sinne einer Sofortkorrektur durchgeführt werden kann. Zudem ist die stentgestützte Versorgung unter hämodynamisch stabilen Bedingungen und ohne aortale Klemmphase durchführbar. Patienten und Methode. Bei 8 von 52 Patienten, die im Zeitraum 1995–2000 endovaskulär im thorakalen Aortenabschnitt therapiert wurden, handelte es sich um polytraumatisierte Patienten mit akuter traumatischer Aortenruptur typico loco mit großem Mediastinalhämatom und periaortaler Blutung. In 7 Fällen wurde die Rupturstelle mit 1 Stent, in 1 Fall mit 2 Stents versorgt. Ergebnisse. Die Rupturstelle konnte bei allen 8 Patienten endovaskulär und ohne Konversion zur offenen Operation ausgeschaltet werden. Ein Patient verstarb an den Folgen schwerer Begleitverletzungen. Ein zentrales Endoleak wurde durch Platzierung eines zweiten Stentgrafts suffizient verschlossen. Kein Patient entwickelte ein passageres oder permanentes neurologisches Defizit. In 2 Fällen war ein zusätzlicher chirurgischer Eingriff erforderlich. Die mittlere Nachbeobachtungszeit betrug 11 Monate. Schlussfolgerungen. Die stentgestützte Versorgung traumatischer thorakaler Aortenrupturen im Isthmusbereich ist technisch durchführbar und mit einer ausreichenden Sicherheit verbunden. Im Vergleich zum offenen Verfahren können mit dieser Technik die Letalität und Paraplegierate gesenkt werden.

Effect of statin therapy on serum activity of proteinases and cytokines in patients with abdominal aortic aneurysm.

Background and aims: Metalloproteinases (MMPs) are considered to be key enzymes in the pathogenesis of abdominal aortic aneurysms (AAA), with elevated levels in diseased aorta and in patient sera. Statins seem to exert an inhibitory effect on MMP activity in the aortic wall. No data exist on the effect of statins on serum activity of MMPs and inflammatory cytokines (interleukins, IL). Methods: The serum activities of MMP2 and MMP9, osteoprotegerin (OPG), and IL6 and IL10 in 63 patients undergoing elective infrarenal aneurysm repair were measured on the day before surgery. Levels were correlated to statin therapy and aneurysm diameter. Results: There was no significant difference between the two groups in the activity of circulating levels of MMP2/9, OPG, and IL6/10 in patients with infrarenal aortic aneurysm. IL6 levels in patients with AAA larger than 6 cm were significantly elevated; differences in serum activities of MMP2/9, OPG, and IL10 were not related to AAA diameter. Conclusion: Serum activities of MMP2/9, OPG, and IL6/10 are not correlated to statin therapy; IL6 levels are higher in patients with large aneurysms. Hence the effect of statin therapy in the treatment of aneurismal disease remains to be elucidated.

Fast track in thoracic surgery

Patients undergoing thoracic surgery are threatened by pulmonary complications such as pneumonia and atelectasis. Age, preoperative FEV(1), operative time and extent of resection are predictors for adverse outcome. Reported morbidity after lung resection is as high as 42% and mortality up to 7%. Fast track in thoracic surgery aims at reducing morbidity and mortality rates after lung resection by introducing specific measures into the pre-, intra- and postoperative periods. Basic fast track elements in thoracic surgery are smoking cessation, preoperative physiotherapy, micronutrient supplementation, high thoracic epidural anesthesia, fluid restriction, early mobilization and enteral feeding. The effectiveness of these individual measures has been proven of value in perioperative care, however, evidence on multimodal therapy regimens in thoracic surgery is limited. In particular it remains to be elucidated which patients should be fast tracked in order to improve outcomes.ZusammenfassungPatienten, die sich thoraxchirurgischen Eingriffen unterziehen, sind v.a. durch pulmonale Komplikationen wie Pneumonie und Atelektase gefährdet. Je nach Alter, präoperativer FEV1 (forcierte exspiratorische Ein-Sekunden-Kapazität), Operationsdauer und Resektionsausmaß wird in der Literatur die Morbidität mit bis zu 42%, die Mortalität mit bis zu 7% angegeben. Fast Track in der Thoraxchirurgie zielt auf Reduktion der pulmonalen Komplikationsrate und der Mortalität nach resezierenden Lungeneingriffen, speziell bei Patienten mit präoperativ reduzierter FEV1. Dies soll durch spezifische Maßnahmen im prä-, intra- und postoperativen Bereich geschehen. Wesentliche Fast-Track-Elemente in der Thoraxchirurgie sind Nikotinverzicht, Atemtherapie, Nahrungsergänzung, hohe thorakale Periduralanästhesie, Flüssigkeitsrestriktion, frühe Mobilisation und früher Kostaufbau. Die Wirksamkeit dieser Einzelmaßnahmen wurde bereits dokumentiert, allerdings gibt es noch wenig Evidenz, welchen Vorteil die Kombination dieser Maßnahmen im Sinne eines multimodalen Fast-Track-Konzeptes bietet; insbesondere sollte noch genauer charakterisiert werden, welche Patienten von solchen Konzepten profitieren.AbstractPatients undergoing thoracic surgery are threatened by pulmonary complications such as pneumonia and atelectasis. Age, preoperative FEV1, operative time and extent of resection are predictors for adverse outcome. Reported morbidity after lung resection is as high as 42% and mortality up to 7%. Fast track in thoracic surgery aims at reducing morbidity and mortality rates after lung resection by introducing specific measures into the pre-, intra- and postoperative periods. Basic fast track elements in thoracic surgery are smoking cessation, preoperative physiotherapy, micronutrient supplementation, high thoracic epidural anesthesia, fluid restriction, early mobilization and enteral feeding. The effectiveness of these individual measures has been proven of value in perioperative care, however, evidence on multimodal therapy regimens in thoracic surgery is limited. In particular it remains to be elucidated which patients should be fast tracked in order to improve outcomes.

In vivo study on the expression pattern of resistin in patients with abdominal aortic aneurysm.

Objective: To study the expression pattern of resistin in abdominal aortic aneurysms and to correlate its plasma levels to aneurysm size and statin therapy. Patients and Methods: From 25 patients on regular and 38 patients without statin therapy tissue specimen and plasma samples were obtained for analysis. Results: Demographic data, past medical history, and body mass index showed no significant differences between the statin and no statin group. Immunohistochemistry showed positive stainings for resistin in all sections and in part colocalization to CD 68 positive cells. Patients with large aneurysms showed significant correlation of C-reactive protein (CRP) and interleukin 10 (IL-10) levels; patients on statin medication had significantly lower plasma levels of resistin and CRP. Conclusion: In contrast to IL-10 and CRP plasma levels of resistin are not correlated to aneurysm diameter; yet statin therapy results in decrease of resistin and CRP, suggesting an anti-inflammatory action in patients with abdominal aortic aneurysms (AAAs).