R.I. Rückert

Thrombus in the non-aneurysmal, non-atherosclerotic descending thoracic aorta--an unusual source of arterial embolism.

INTRODUCTION Mural thrombus of the thoracic aorta is a rare clinical finding in the absence of aneurysm or atherosclerosis. METHODS The medical records of all patients diagnosed with a thrombus of a non-aneurysmatic and non-atherosclerotic descending thoracic aorta (NAADTA) and treated by the senior author between 04/1997 and 04/2010 were reviewed. RESULTS Eight patients with mural thrombus of the NAADTA were identified. Arterial embolism was the main clinical finding in all cases and involved the lower extremities (n = 6), mesenteric (n = 3) or renal arteries (n = 2). Hypercoagulable disorders were present in 3 cases and a concurrent malignancy in another 3. Two patients underwent open surgery while 4 patients were treated conservatively with anticoagulation. Of the remaining 2 patients, one was treated with a thoracic stent-graft and aorto-biiliac bypass and the other one with transfemoral thrombectomy. Technical success was achieved in all surgical cases and thrombus resolution or stable disease in the conservative management group. No thrombus recurrence was observed during a mean follow-up of 49 months. CONCLUSION The management of mural thrombus in NAADTA represents a challenge, especially in case of malignant disease or hypercoagulable disorder as a potential underlying pathology and should be individualized. Although no consensus exists in the literature, therapeutic anticoagulation is proposed as first-line therapy. The indication for surgical intervention results from contraindication to anticoagulation, mobile thrombus or recurrent embolism. Whenever possible, endovascular therapy should be preferred.

Correlation of Intimal Hyperplasia Development and Shear Stress Distribution at the Distal End-side-anastomosis, in vitro Study Using Particle Image Velocimetry

Low shear areas at the distal anastomosis of peripheral bypasses are thought to promote neointimal hyperplasia. In this study we evaluated the fluid dynamic environment at the distal anastomosis of peripheral bypasses by means of a new method for in vitro flow visualization and quantitative velocity field measurement. A silastic model of a distal end-side anastomosis was attached to a mock circulation loop driven by an artificial heart. High resolution velocity fields were measured by means of particle image velocimetry (PIV). The velocity vector data were used to calculate vorticity omega, strain rates ex, shear rates h and shear stresses tau. Two separations and a stagnation zone were identified by means of flow visualization. Measured velocities inside the three zones were significantly lower than in the high velocity mainstream. Calculated shear rates and shear stresses inside the zones were significantly lower than human wall shear rates. At the transition between the effective mainstream and the boundary layers high vorticity and compressive strain fields existed, indicating the presence of high shear forces. The locations of these areas corresponded to the well known zones of intimal hyperplasia. The high resolution shear stress analysis supports the low shear theory of intimal hyperplasia development. A wall diversion angle greater than 6 degrees leads to flow separation and presumed IH promotion until high shear transition areas are reached.

Robotic Thymectomy for Myasthenia Gravis

Robotic thymectomy with the da Vinci robotic system is the latest development in the surgery of thymic gland. Thymectomy for myasthenia gravis is best offered to patients with seropositive acetylcholine receptor antibodies and who are seronegative for muscle-specific kinase protein. The robotic operation technique is indicated in all patients with myasthenia gravis in association with a resectable thymoma, typically Masaoka-Koga stages I and II.

Effect of Preoperative Aneurysm Diameter on Long-Term Survival After Endovascular Aortic Aneurysm Repair

Objective: To investigate the effect of aneurysm size on long-term survival after endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). Methods: Retrospective study of all consecutive patients treated with EVAR for AAA at a single institution. Results: One hundred and nineteen patients (mean age 71, range 45-91) underwent EVAR during a 4-year period. The mean maximal aneurysm diameter was 58 mm (range 34-93 mm). Mean follow-up was 34 months (range 1-80). Cox regression analysis after controlling for age, renal function, coronary disease, and smoking showed a 4.9-fold higher risk of death for patients with preoperative aneurysm size ≥60 mm as compared to patients with aneurysm size <60 mm. No aneurysm-related deaths occurred during the follow-up. Conclusion: This present study provides evidence that aneurysm size ≥60 mm is independently associated with worse survival during follow-up.

Minimally invasive thymus surgery

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.ZusammenfassungFür die chirurgische Therapie mit dem Ziel der kompletten Entfernung der Thymusdrüse gibt es absolute und relative Indikationen. In der komplexen Therapie der autoimmun bedingten Myasthenia gravis nimmt die mit relativer Indikation durchgeführte Thymektomie eine zentrale Stellung ein. Besteht mit oder ohne Myasthenie ein Thymom, ist die Thymektomie absolut indiziert. Daneben ist eine Thymusresektion in Fällen ektoper intrathymischer Nebenschilddrüsen bei Hyperparathyreoidismus oder im Rahmen bestimmter Formen einer multiplen endokrinen Neoplasie notwendig. Traditionell war die transzervikale Operationstechnik Ausdruck des gut begründeten Strebens nach minimaler Invasivität der Thymektomie. Aber wegen der Forderung nach Radikalität erfolgten die meisten Eingriffe transsternal. Mit dem Einzug der therapeutischen Thorakoskopie in die Thoraxchirurgie haben sich mehrere streng oder erweitert minimal-invasive Operationstechniken für eine Thymektomie entwickelt. Es werden thorakoskopische ein- und beidseitige, subxiphoidale und modifiziert transzervikale Techniken einzeln oder in Kombinationen benutzt. Kürzlich ist eine neue Entwicklungsstufe der besonders präzisen thorakoskopischen Operationstechnik in Form der roboterassistierten Chirurgie begründet worden. Diese Technik ist insbesondere für die Thymektomie vorteilhaft. Die vorliegende Arbeit gibt einen Überblick über die Entwicklung und die bisherigen Erfahrungen der minimal-invasiven Thymektomie. Es werden bis dato publizierte Daten der größten Serien präsentiert.AbstractThere are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.

Midterm results of a precuffed expanded polytetrafluoroethylene graft for above knee femoropopliteal bypass in a multicenter study

INTRODUCTION Above knee (AK) femoropopliteal bypass remains a sufficient and durable therapy for long occlusions of the superficial femoral artery in the era of endovascular repair. A novel, precuffed expanded polytetrafluoroethylene (ePTFE) graft that was designed for AK femoropopliteal bypass (Dynaflo, Bard Peripheral Vascular Inc, Tempe, Ariz) has been available for clinical use since March 2005, promising better patency rates by optimizing the hemodynamic patterns within the distal anastomosis. METHODS A prospective, multicenter, nonrandomized study was performed to investigate the clinical results of the Dynaflo graft. Primary end points were patency rates, limb salvage, and complications. RESULTS Between March 2005 and August 2007, the Dynaflo graft was used in 135 AK bypasses in 134 patients (110 men) with a mean age of 66 years. Indication for revascularization was claudication in 99 (73%) and critical ischemia in 36 (27%). With a mean follow-up of 18 months the 6-, 12- and 24-month primary patency rates were 90%, 83% and 72.5% and the secondary patency rates were 93%, 88.6% and 82.2%, respectively. The cumulative limb salvage rate at 24 months was 95%. Complications were observed in 39 patients (29%), with bypass failure (29 cases) and significant thrombus accumulation at the distal anastomosis (4 cases) being the most severe. CONCLUSION This study presents the first clinical results of a novel ePTFE graft for supragenicular revascularization. The implantation of the Dynaflo graft seems to be safe and feasible for AK bypass, achieving acceptable medium-term patency rates. Nevertheless, long-term results have to be awaited, and prospective comparative studies are warranted.

Identification of HIV-1 Tat peptides for future therapeutic angiogenesis.

Abstract:  Therapeutic angiogenesis represents a novel approach to treat critical limb ischemia when revascularization is no more an option. The clinical use of the vascular endothelial growth factor is questioned, because of its side effects. This study was designed to identify and characterize human immunodeficiency virus type 1 (HIV‐1) Tat‐derived peptides based on their pro‐angiogenic properties. A series of Tat‐derived peptides were synthesized containing mutations in the basic domain. To minimize side effects Tat peptides were selected exerting no effects on the proteasome and on the viability of human umbilical vein endothelial cells (HUVEC). Tatpep5, 15, and 16 increased the endogenous levels of the pro‐angiogenic transcription factors c‐Jun and SP‐1 as well as the production of the plasminogen activator inhibitor‐1 (PAI‐1) by HUVEC. A significant induction of endothelial cell invasion was observed upon treatment of HUVEC with Tat peptides. In addition, selected Tat peptides induced tube formation by HUVEC as visualized and quantified in a Matrigel matrix. Our data demonstrate that the selected Tat peptides fulfill essential criteria for pro‐angiogenic substances. They represent the basis for the development of novel pro‐angiogenic drugs for future therapeutic angiogenesis, which might be applied for treatment of unreconstructible critical limb ischemia.

Minimal-invasive Chirurgie des Thymus

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.ZusammenfassungFür die chirurgische Therapie mit dem Ziel der kompletten Entfernung der Thymusdrüse gibt es absolute und relative Indikationen. In der komplexen Therapie der autoimmun bedingten Myasthenia gravis nimmt die mit relativer Indikation durchgeführte Thymektomie eine zentrale Stellung ein. Besteht mit oder ohne Myasthenie ein Thymom, ist die Thymektomie absolut indiziert. Daneben ist eine Thymusresektion in Fällen ektoper intrathymischer Nebenschilddrüsen bei Hyperparathyreoidismus oder im Rahmen bestimmter Formen einer multiplen endokrinen Neoplasie notwendig. Traditionell war die transzervikale Operationstechnik Ausdruck des gut begründeten Strebens nach minimaler Invasivität der Thymektomie. Aber wegen der Forderung nach Radikalität erfolgten die meisten Eingriffe transsternal. Mit dem Einzug der therapeutischen Thorakoskopie in die Thoraxchirurgie haben sich mehrere streng oder erweitert minimal-invasive Operationstechniken für eine Thymektomie entwickelt. Es werden thorakoskopische ein- und beidseitige, subxiphoidale und modifiziert transzervikale Techniken einzeln oder in Kombinationen benutzt. Kürzlich ist eine neue Entwicklungsstufe der besonders präzisen thorakoskopischen Operationstechnik in Form der roboterassistierten Chirurgie begründet worden. Diese Technik ist insbesondere für die Thymektomie vorteilhaft. Die vorliegende Arbeit gibt einen Überblick über die Entwicklung und die bisherigen Erfahrungen der minimal-invasiven Thymektomie. Es werden bis dato publizierte Daten der größten Serien präsentiert.AbstractThere are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.

Management von Komplikationen nach Revaskularisation wegen peripherer arterieller Verschlusskrankheit

ZusammenfassungHintergrundKomplikationen gefährden den Erfolg einer Revaskularisation zur Behandlung der peripheren arteriellen Verschlusskrankheit (paVK) und müssen daher primär vermieden oder bei Auftreten effektiv behandelt werden.Ziel der ArbeitEs soll eine Übersicht über die möglichen Komplikationen nach Revaskularisation bei paVK und deren Management erfolgen.Material und MethodenEine systematische Literaturrecherche wurde in PubMed und Medline unter besonderer Berücksichtigung von aktuellen Publikationen vorgenommen.ErgebnisseDie Revaskularisation zur Therapie der paVK kann prinzipiell offen, endovaskulär oder als Kombination beider Methoden (Hybridoperation) erfolgen. Das Spektrum möglicher Komplikationen unterscheidet sich dementsprechend. Es können Blutungs-, ischämische und systemische oder auch vaskuläre von nichtvaskulären Komplikationen unterschieden werden. Das optimale Komplikationsmanagement beginnt mit der primären Prophylaxe und beinhaltet weiter die zeitgerechte Diagnostik und Therapie von bereits eingetretenen Komplikationen. Die beste Prophylaxe besteht in einer hohen Qualität von Indikation und Durchführung der Revaskularisation.DiskussionFür den Erfolg der Revaskularisation zur Behandlung der paVK ist ein optimales Komplikationsmanagement von entscheidender Bedeutung.AbstractBackgroundComplications are a threat to successful revascularization for treatment of perpheral arterial occlusive disease (PAOD) and must, therefore, be either primarily prevented or effectively treated after having occurred.ObjectivesThe aim of this article is to give a survey of possible complications after revascularization for treatment of PAOD and their management.Material and methodsA systematic literature review was performed in PubMed and Medline. The analysis mainly considered recent publications with a higher level of evidence.ResultsRevascularization for treatment of PAOD can basically be performed by an open surgical approach, an endovascular approach or as a combination of both methods (hybrid operation). The spectrum of possible complications varies accordingly. A differentiation can be made between bleeding, ischemic and systemic complications as well as between vascular and non-vascular complications. Optimal management of complications begins with primary prophylaxis and further includes a timely diagnosis and treatment of established complications. The best prophylaxis consists of a high quality of indications and performance of revascularization.ConclusionOptimal management of complications is essential and of utmost importance for successful revascularization to treat PAOD.BACKGROUND Complications are a threat to successful revascularization for treatment of perpheral arterial occlusive disease (PAOD) and must, therefore, be either primarily prevented or effectively treated after having occurred. OBJECTIVES The aim of this article is to give a survey of possible complications after revascularization for treatment of PAOD and their management. MATERIAL AND METHODS A systematic literature review was performed in PubMed and Medline. The analysis mainly considered recent publications with a higher level of evidence. RESULTS Revascularization for treatment of PAOD can basically be performed by an open surgical approach, an endovascular approach or as a combination of both methods (hybrid operation). The spectrum of possible complications varies accordingly. A differentiation can be made between bleeding, ischemic and systemic complications as well as between vascular and non-vascular complications. Optimal management of complications begins with primary prophylaxis and further includes a timely diagnosis and treatment of established complications. The best prophylaxis consists of a high quality of indications and performance of revascularization. CONCLUSION Optimal management of complications is essential and of utmost importance for successful revascularization to treat PAOD.

Management von Komplikationen nach Revaskularisation wegen peripherer arterieller Verschlusskrankheit@@@Management of complications after revascularization due to peripheral arterial occlusive disease: Prophylaxe und konsequente adäquate Therapie nach zeitgerechter Diagnostik@@@Prophylaxis and consistent adequate therapy after timely diagnostics

ZusammenfassungHintergrundKomplikationen gefährden den Erfolg einer Revaskularisation zur Behandlung der peripheren arteriellen Verschlusskrankheit (paVK) und müssen daher primär vermieden oder bei Auftreten effektiv behandelt werden.Ziel der ArbeitEs soll eine Übersicht über die möglichen Komplikationen nach Revaskularisation bei paVK und deren Management erfolgen.Material und MethodenEine systematische Literaturrecherche wurde in PubMed und Medline unter besonderer Berücksichtigung von aktuellen Publikationen vorgenommen.ErgebnisseDie Revaskularisation zur Therapie der paVK kann prinzipiell offen, endovaskulär oder als Kombination beider Methoden (Hybridoperation) erfolgen. Das Spektrum möglicher Komplikationen unterscheidet sich dementsprechend. Es können Blutungs-, ischämische und systemische oder auch vaskuläre von nichtvaskulären Komplikationen unterschieden werden. Das optimale Komplikationsmanagement beginnt mit der primären Prophylaxe und beinhaltet weiter die zeitgerechte Diagnostik und Therapie von bereits eingetretenen Komplikationen. Die beste Prophylaxe besteht in einer hohen Qualität von Indikation und Durchführung der Revaskularisation.DiskussionFür den Erfolg der Revaskularisation zur Behandlung der paVK ist ein optimales Komplikationsmanagement von entscheidender Bedeutung.AbstractBackgroundComplications are a threat to successful revascularization for treatment of perpheral arterial occlusive disease (PAOD) and must, therefore, be either primarily prevented or effectively treated after having occurred.ObjectivesThe aim of this article is to give a survey of possible complications after revascularization for treatment of PAOD and their management.Material and methodsA systematic literature review was performed in PubMed and Medline. The analysis mainly considered recent publications with a higher level of evidence.ResultsRevascularization for treatment of PAOD can basically be performed by an open surgical approach, an endovascular approach or as a combination of both methods (hybrid operation). The spectrum of possible complications varies accordingly. A differentiation can be made between bleeding, ischemic and systemic complications as well as between vascular and non-vascular complications. Optimal management of complications begins with primary prophylaxis and further includes a timely diagnosis and treatment of established complications. The best prophylaxis consists of a high quality of indications and performance of revascularization.ConclusionOptimal management of complications is essential and of utmost importance for successful revascularization to treat PAOD.BACKGROUND Complications are a threat to successful revascularization for treatment of perpheral arterial occlusive disease (PAOD) and must, therefore, be either primarily prevented or effectively treated after having occurred. OBJECTIVES The aim of this article is to give a survey of possible complications after revascularization for treatment of PAOD and their management. MATERIAL AND METHODS A systematic literature review was performed in PubMed and Medline. The analysis mainly considered recent publications with a higher level of evidence. RESULTS Revascularization for treatment of PAOD can basically be performed by an open surgical approach, an endovascular approach or as a combination of both methods (hybrid operation). The spectrum of possible complications varies accordingly. A differentiation can be made between bleeding, ischemic and systemic complications as well as between vascular and non-vascular complications. Optimal management of complications begins with primary prophylaxis and further includes a timely diagnosis and treatment of established complications. The best prophylaxis consists of a high quality of indications and performance of revascularization. CONCLUSION Optimal management of complications is essential and of utmost importance for successful revascularization to treat PAOD.