Richard Kellersmann

Bilateral patellar tendon rupture without predisposing systemic disease or steroid use: a case report and review of the literature

Simultaneous bilateral patella tendon ruptures are very rare injuries of the knee extensor complex often associated with systemic disorders such as lupus erythematosus or rheumatoid arthritis. We describe the case of a 34-year-old man without concomitant systemic disease or steroid use and provide the most comprehensive review of the German and English literature. Furthermore, we discuss the predisposing factors and causal mechanisms as well as current diagnostic procedures and treatment options. In the literature review, only a few patients without systemic disorder or steroid medication present with potential predisposing factors that may be responsible for degenerative changes of the patella tendon, weakening its stability. In addition, in most of these cases, it remains difficult to explain the bilateral and simultaneous nature of this injury.

Endovascular Treatment of Popliteal Artery Segments P1 and P2 in Patients With Critical Limb Ischemia: Initial Experience Using a Helical Nitinol Stent With Increased Radial Force

Purpose To evaluate efficacy, safety, and midterm patency of a helical, self-expanding nitinol stent after failed percutaneous transluminal angioplasty (PTA) of popliteal artery segments P1 and P2 in patients with chronic critical limb ischemia (CLI) or lifestyle-limiting claudication. Methods Between February 2009 and March 2011, 40 patients (23 men; mean age 77±10 years) classified as Rutherford category 3 (n = 10) or 4/5 (n = 30) underwent PTA of the proximal and mid popliteal artery followed by implantation of a SUPERA stent for elastic recoil, residual stenosis, or flow-limiting dissection. All patients had an elevated operative risk. Before and after the procedure and during the 12-month follow-up, a clinical investigation, ankle-brachial-index (ABI) measurement, and color-coded duplex sonography and/or digital subtraction angiography were performed. Primary endpoints were limb salvage and anatomical patency at 12 months. Results Stent implantation was successful in all patients. The major complication rate was 7.5% (an access-site pseudoaneurysm, 2 retroperitoneal hematomas, and 1 death from retroperitoneal bleeding). Mean follow-up was 15.9 months (range 0.5–27.9). The mean baseline ABI of 0.37 significantly increased to 0.91 at 12 months (p<0.01). Three (7.5%) patients underwent bypass surgery owing to lack of clinical improvement (<0.10 improvement in ABI). Primary and secondary patency rates at 12 months in the 34 patients eligible for follow-up were 68.4% and 79.8%, respectively. The major amputation rate was 5% at 1 year. Five (12.5%) in-stent stenoses and 1 of 2 (5.0%) in-stent occlusions were successfully recanalized (the second occlusion was asymptomatic). Conclusion Implantation of this helical stent into segments of the popliteal artery at the knee joint in CLI patients is a safe and clinically effective bailout method with acceptable intermediate patency.

Endovascular Treatment of Acute Limb Ischemia Secondary to Fracture of a Popliteal Artery Stent

The authors report the case of a patient with acute lower limb ischemia (category IIa) after occlusion of the popliteal artery due to fracture of a long indwelling stent. The patient refused surgical therapy for religious reasons, and an interventional revascularization was performed as acute rescue therapy. After reentry into the distal popliteal artery was achieved, the artery was dilated, and the fragmented stent was crushed, followed by implantation of two helical nitinol stents with high radial force and a third self-expandable nitinol stent. Sufficient primary technical success was achieved, and stent patency was present at midterm follow-up.

Heterogeneous histomorphology, yet homogeneous vascular smooth muscle cell dedifferentiation, characterize human aneurysm disease.

Objective Abdominal aortic aneurysm (AAA) is a frequent, potentially life‐threatening, disease that can only be treated by surgical means such as open surgery or endovascular repair. No alternative treatment is currently available, and despite expanding knowledge about the pathomechanism, clinical trials on medical aneurysm abrogation have led to inconclusive results. The heterogeneity of human AAA based on histologic examination is thereby generally neglected. In this study we aimed to further elucidate the role of these differences in aneurysm disease. Methods Tissue samples from AAA and popliteal artery aneurysm patients were examined by histomorphologic analysis, immunohistochemistry, Western blot, and polymerase chain reaction. The results were correlated with clinical data such as aneurysm diameter and laboratory results. Results The morphology of human AAA vessel wall probes varies tremendously based on the grade of inflammation. This correlates with increasing intima/media thickness and upregulation of the vascular endothelial growth factor cascade but not with any clinical parameter or the aneurysm diameter. The phenotypic switch of vascular smooth muscle cells occurred regardless of the inflammatory state and expressional changes of the transcription factors Kruppel‐like factor‐4 and transforming growth factor‐&bgr; lead to differential protein localization in aneurysmal compared with control arteries. These changes were in similar manner also observed in samples from popliteal artery aneurysms, which, however, showed a more homogenous phenotype. Conclusions Heterogeneity of AAA vessel walls based on inflammatory morphology does not correlate with AAA diameter yet harbors specific implications for basic research and possible aneurysm detection. Clinical Relevance Basic research is crucial for the elucidation of abdominal aortic aneurysm pathology and progress in detection, prediction, and possible nonsurgical treatment. Heterogeneity of aneurysms, as seen on histologic analysis, is thereby most often not referred to in clinical and basic research studies but might help to identify core mechanisms of aneurysm development. Implication on the clinical course is only about to be unraveled. Superordinate transcription factors, such as Kruppel‐like factor 4 or transforming growth factor‐&bgr;, were identified as being involved in aneurysm development, not only in aortic but also popliteal artery aneurysm, and are thus important targets.

Extra- and Intraluminal Elastase Induce Morphologically Distinct Abdominal Aortic Aneurysms in Mice and Thus Represent Specific Subtypes of Human Disease.

Topical application of elastase to induce arterial aneurysm formation is an emerging murine model of vascular disease. In the context of aortic abdominal aneurysm (AAA), angiotensin II infusion and porcine pancreatic elastase perfusion models are commonly used today. This study, therefore, compares matrix remodeling, inflammation, and angiogenesis as distinct features of aneurysms in two models treated with intra-/extraluminal elastase. C57BL/6 mice underwent intra-/extraluminal elastase application via laparotomy and were followed up for 4 weeks. Basic histology and immunohistochemistry were performed at different time points along with transmission electron microscopy, PCR analysis, TUNEL assays, and blood analysis. Both models did not differ in aneurysm growth rate, but they showed distinct features and results depending on the way of elastase application. Extraluminal aneurysm induction preserved endothelial cell function and elastic fibers but showed ongoing acute inflammation, mainly in the adventitia. The destruction of elastic layers followed by chronic inflammation was a characteristic of intraluminal elastase perfusion, as well as medial angiogenesis, a key feature in human AAA. Different animal models harbor different features of human AAA and must, therefore, be chosen wisely. External elastase application mimics an acute inflammatory aneurysm, whereas intraluminal elastase perfusion shows chronic inflammation with angiogenesis and endothelial destruction, thus better mimicking human disease.

Femoral vein obturator bypass revascularization in groin infectious bleeding: two case reports and review of the literature

IntroductionGroin infections resulting in arterial bleeding due to bacterial vessel destruction are a severe challenge in vascular surgery. Patients with them most often present as emergencies and therefore need individualized reconstruction solutions.Case presentationCase 1 is a 67-year-old man with infectious bleeding after an autologous reconstruction of the femoral bifurcation with greater saphenous vein due to infection of a bovine pericard patch after thrombendarterectomy. Case 2 is a 35-year-old male drug addict and had severe femoral bleeding and infection after repeated intravenous and intra-arterial substance abuse. Both patients were treated with an autologous obturator bypass of the superficial femoral vein. We review the current literature and highlight our therapeutic concept of this clinical entity.ConclusionsTreatment should include systemic antibiotic medication, surgical control of the infectious site, revascularization and soft tissue repair. An extra-anatomical obturator bypass with autologous superficial femoral vein should be considered as the safest revascularization procedure in infections caused by highly pathogenic bacteria.

Vessel wall morphology is equivalent for different artery types and localizations of advanced human aneurysms

Aneurysm formation occurs most frequently as abdominal aortic aneurysm (AAA), but is also seen in other localizations like thoracic or peripheral aneurysm. While initial mechanisms for aneurysm induction remain elusive, observations from AAA samples show transmural inflammation with proteolytic imbalance and repair mechanisms triggered by the innate immune system. However, limited knowledge exists about aneurysm pathology, especially for others than AAA. We compared 42 AAA, 15 popliteal, 3 ascending aortic, five iliac, two femoral, two brachial, one visceral and two secondary aneurysms to non-aneurysmatic controls by histologic analysis, immunohistochemistry and cytokine expression. Muscular and elastic type arteries show a uniform way of aneurysm formation. All samples show similar morphology. The changes compared to controls are distinct and include matrix remodeling with smooth muscle cell phenotype switch and angiogenesis, adventitial lymphoid cell accumulation and M1 macrophage homing together with neutrophil inflammation. Inflammatory cytokines are up-regulated accordingly. Comparative analysis of different disease entities can identify characteristic pathomechanisms. The phenotype of human advanced aneurysm disease is observed for elastic and muscular type arteries, does not differ between disease localizations and might, thus, be a unique response of the vasculature to the still unknown trigger of aneurysm formation.

Failure of Minimally Invasive Arm Port Retrieval Caused by Post-Thrombotic Adhesions of the Port Catheter

Peripherally placed venous arm ports are used for patients who need temporary central venous access, e.g., chemotherapy or artificial nourishment [1]. Complications during or after port implantation include accidental arterial puncture, seroma, hematoma, infection, sepsis, thrombosis, cardiac arrhythmia, and catheter dislocation, disconnection, occlusion, rupture, and dysfunction [2–5]. If the device is no longer needed, it can be relatively easily removed with the patient under local anaesthesia. However, the clinical literature on port retrieval failure is largely incomplete, with only one recent study in which reasons for and complications during removal of pectorally placed port devices were evaluated [6]. We recently experienced the uncommon case of interventional port-removal failure 4 years after implantation because of post-thrombotic adhesions. This rare case therefore highlights the problems encountered during an attempt at minimally invasive retrieval and the necessity for a surgical approach.

Proximal occlusion of unaffected internal iliac artery versus distal occlusion of aneurysmatic internal iliac artery prior to EVAR: a comparative evaluation of efficacy and clinical outcome

OBJECTIVE Occlusion of the internal iliac artery (IIA) may be necessary prior to endovascular aneurysm repair (EVAR) to prevent endoleak Type II. We compared efficacy and clinical outcome after proximal occlusion of an unaffected IIA (ProxEmbx) using an Amplatzer vascular plug (AVP) I vs distal occlusion of aneurysmatic IIA with coils and plugs (DistEmbx). METHODS Between 2009 and 2012, 22 patients underwent EVAR. In 9 patients with unaffected IIA, occlusion was performed by a single AVP. In 13 patients with aneurysmatic IIA, more distal embolization (DistEmbX) was conducted by using several coils and additional AVPs. Retrospectively, technical success, clinical outcome and complications were evaluated. RESULTS Embolization of the IIA was successful in all patients. Three patients with more DistEmbX of aneurysmatic IIAs suffered from new onset of sexual dysfunction after occlusion without statistically significant difference (p > 0.05). Transient buttock claudication was observed in three patients in each group. Bowel ischaemia did not occur. The procedure time (p = 0.013) and fluoroscopy time (p = 0.038) was significantly lower in the ProxEmbx group than in the DistEmbx group. CONCLUSION Proximal occlusion of an unaffected IIA and more distal occlusion of an aneurysmatic IIA prior to EVAR had the same technical and clinical outcome. However, proximal plug embolization of an unaffected IIA prior to EVAR was associated with shorter procedure and fluoroscopy time in comparison with more DistEmbX of aneurysmatic IIAs. Advances in knowledge: Proximal embolization of unaffected IIA and DistEmbX of aneurysmatic IIA before EVAR are both effective in preventing Type II endoleaks and have the same technical and clinical outcome.