T.J. van der Steenhoven

Spiral Vein Reconstruction of the Infected Abdominal Aorta Using the Greater Saphenous Vein: Preliminary Results of the Tilburg Experience

OBJECTIVES The aim of this study was to evaluate patients, who underwent spiral vein reconstruction of the abdominal aorta to repair infected aneurysms or replace infected aortic grafts. METHODS All spiral vein reconstructions between March 2005 and May 2010 because of vascular infections of the abdominal aorta were retrospectively included. Diagnosis was determined by clinical examination, laboratory results, computed tomography (CT) and positron emission tomography (PET) scan, and microbiological tests. Spiral vein reconstruction consisted of harvesting the greater saphenous vein (GSV) and construction into a spiral graft, aortic reconstruction and a transmesenteric omentumplasty. Primary outcomes were survival and limb salvage. Secondary outcomes included technical, clinical and ongoing success, re-infection, ongoing infection and patency. RESULTS All five patients survived surgery, and there were no in-hospital deaths. Survival and limb salvage were 100% after median follow-up of 13 months (6-67 months). Further, technical, clinical and continuing success was 100%. There were no re-infections or ongoing infections. CONCLUSIONS Spiral vein reconstruction using the GSV showed good short-term survival and limb salvage. It, therefore, might be considered as an attractive treatment method for vascular infections of the abdominal aorta. Still, more follow-up is needed to evaluate long-term results.

Zinc chloride–mediated reduction of apoptosis as an adjunct immunosuppressive modality in cardiac transplantation ☆

BACKGROUND Zinc (Zn) blocks caspase-3 activation in cardiac allografts and therefore may synergistically decrease apoptosis along with cyclosporine (CsA), which inhibits mitochondrial release of cytochrome c. Simultaneous treatment of rat recipients of heterotopic heart transplants with zinc chloride (ZnCl(2)) thus may allow lower doses of CsA for immunosuppression. METHODS PVG (RT1(c)) rat hearts were transplanted heterotopically into the abdomen of ACI (RT1(a)) rats. Group 1 (n = 15) rats received no treatment. Group 2 rats (n = 8) received 2 mg/kg/day CsA (sub-therapeutic dose) by oral gavage. Group 3 rats (n = 9) received 2 mg/kg/day oral CsA in addition to 1 mg/kg/day sub-cutaneous ZnCl(2) delivered by osmotic pump. All rats were imaged using Annexin V-bound (99m)Technetium ((99m)Tc-Annexin V) on post-operative Day 4 and subsequently killed. Annexin V avidly binds apoptotic cells in vivo. Region of interest per whole body (WB) data were calculated using the images. The allograft survival study was conducted with n = 11, 6, and 5 in control, CsA, and CsA+Zn groups, respectively. Finally, percentages of allografts that reached tolerance were measured in both CsA-only and CsA+Zn groups (n = 8 each). RESULTS Zinc chloride had an additive effect with CsA on apoptotic blockade and graft survival. The regions of interest per WB uptake of (99m)Tc-Annexin V were 2.43% +/- 0.37%, 2.08% +/- 0.52%, and 1.49% +/- 0.29%*, and acute survivals were 6.4 +/- 1.7, 7.2 +/- 2.1, and 11.2 +/- 2.5* days for control, CsA, and CsA+Zn groups, respectively (*p < 0.001 vs controls). In addition, 87.5% of allografts became tolerant and survived for 90 days in the CsA+Zn group compared with only 37.5% in the CsA-only group (p = 0.049). CONCLUSION Zinc-mediated reduction of apoptosis served as an effective adjunct immunosuppressive therapy to CsA in a rat model of cardiac transplantation.

Aortic Customize: An In Vivo Feasibility Study of a Percutaneous Technique for the Repair of Aortic Aneurysms Using Injectable Elastomer

OBJECTIVE This study aimed to test a percutaneous technique for aneurysm-sac filling by means of in situ polymerisation in an in vivo model. DESIGN Aortic Customize is a new endovascular treatment concept for aortic aneurysms: a non-cross-linked liquid elastomer is injected to fill the aneurysm sac around a balloon-catheter. With this method, a compliant elastomer mould with a patent lumen is created. MATERIAL The formulation used in the experiments consisted of a two-component addition-cure liquid-silicone formulation, based on vinyl-terminated polydimethylsiloxane (PDMS). METHODS The concept of aneurysm-sac filling was tested in vivo in porcine experiments (n = 3). RESULTS In vivo porcine experiments with the sac-filling application showed successful exclusion of the created aneurysms with patent lumens and absence of endoleaks. The aneurysms were excluded successfully in the in vivo model, injecting elastomer through a 7-French catheter, filling up the entire aneurysm sac. CONCLUSIONS These in vivo experiments demonstrate that the principle of aneurysm-sac filling by means of in situ curing is feasible, excluding the aneurysm and creating a new lumen. Further long-term animal experiments must be done prior to consideration of clinical application.

Complications and institutionalization are almost doubled after second hip fracture surgery in the elderly patient.

Purpose: To determine patient and hip fracture characteristics, early postoperative complication rate, and need for institutionalization at the time of discharge from the hospital in patients treated for a second contralateral hip fracture. Methods: During a 6-year period (2003–2009), 71 patients (60 women and 11 men; age range, 54–94 years) underwent first hip fracture surgery and subsequent contralateral hip fracture surgery at our hospital. Variables, including age, gender, American Society of Anesthesiologists classification (ASA), AO fracture classification, time between both hip fractures, rate and severity of early postoperative complications, and destination of discharge were obtained from the electronic medical records. Data from both hospitalization periods were compared. Results: Forty-six percent of second hip fractures occurred within 2 years after the first hip fracture. After the first hip fracture surgery, 13 patients had 1 or multiple complications compared with 23 patients after a second hip fracture surgery (P = 0.02). The mean time (±SD) between the first and second hip fractures in patients without complications after the second injury was 4.3 (±4.2) years, compared with 2.6 (±2.1) years in patients with complications after the second injury (P = 0.03). The mean ASA classification of patients without complications after the second hip fracture surgery was 2.6 (±0.6) versus 3.0 (±0.6) in patients with complications (P = 0.04). After the first hip fracture surgery, 27 patients (38%) were discharged to an institutional care facility, whereas 72% of patients resided at an institutional care facility after a second hip fracture. Conclusions: Early complication rate in patients sustaining a second contralateral hip fracture was almost twice that documented after the first hip fracture. After the second hip fracture surgery, most patients resided in an institutional care facility. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Cyclic loading of fractured cadaveric femurs after elastomer femoroplasty: An in vitro biomechanical study

BACKGROUND Elastomer femoroplasty is a novel and experimental approach in the prevention of hip fracture surgery. Previously, we published the results of an in vitro cadaveric experiment in which we showed a significant reduction of fracture displacement in treated femurs. The aim of the present study was to establish the failure loads and inter-fragmentary movement of fractured, elastomer femoroplasty treated femurs during cyclic loading. METHODS 16 cadaveric femurs were treated with elastomer femoroplasty and fractured in a simulated fall configuration. Each specimen underwent 10 cycles with a preload of 50 N, starting with a peak load of 250 N followed by 10 cycles of 500 N and continued with 500 N increments. The crosshead speed was 2 mm/s. The failure load, the number of completed cycles, and crosshead extensions were recorded. FINDINGS The mean failure load was 2709 N (SD 1094). The number of completed cycles until failure was 60 (SD 22). The mean translation during maximum loading was 5.25 mm (SD 0.9). At 1500 N (two times the bodyweight of a 75 kg individual) the extension was 3.16 mm. INTERPRETATION Preventive elastomer femoroplasty leads to the stabilization of the proximal femur after fracture. In a single leg stance configuration, cyclic loading with mean failure loads that well exceed the peak loads during normal gait is feasible.

Elastomer femoroplasty prevents hip fracture displacement In vitro biomechanical study comparing two minimal invasive femoroplasty techniques.

UNLABELLED The purpose of this study was to test femur strength and the ability to prevent fracture displacement of two minimal invasive Elastomer femoroplasty techniques. METHODS A total of sixteen fixed human cadaveric femur pairs were used. From each pair one femur was randomly assigned for Elastomer femoroplasty. In these femora we drilled a 3.5mm entrance in the lateral cortex. Cavities for the Elastomer were created by: group A, balloon and group B an excentric drill. All femora were fractured by simulating a fall on the greater trochanter. Neck-shaft-angles on plain anterior posterior radiographs were measured to determine fracture displacement. FINDINGS There was no significant difference in fracture load between controls and treated femora for group A, 2904N (SD 1091) versus 2803N (SD 627) and group B, 2773N (SD 747) versus 2597N (SD 834). In group A the mean displacement was 35° (SD 14) for the control femora and 3° (SD 2) for the treated femora (P<0.001). In group B the mean displacement was 38° (SD 10) for the controls and 8° (SD 13) for the treated femora (P<0.001). INTERPRETATION The results of this study show that minimal invasive Elastomer femoroplasty prevents fracture displacement of the proximal femur. We found no significant compromise in load-to-fracture after minimal invasive balloon or excentric drill femoroplasty.

Thrombogenicity of a New Injectable Biocompatible Elastomer for Aneurysm Exclusion, Compared to Expanded Polytetrafluoroethylene in a Human Ex Vivo Model

OBJECTIVES Customized aortic repair (CAR) is a new concept for endovascular aortic aneurysm repair in which a non-polymerised elastomer is injected to fill the aneurysm sac around a balloon catheter. Amongst other variables, the thrombogenicity of the elastomer should be tested, before further clinical experiments can take place. The aim of this human ex vivo study was to measure the thrombogenicity of the elastomer and to compare it to expanded polytetrafluoroethylene (ePTFE). DESIGN AND MATERIALS In a validated ex vivo model, non-anticoagulated blood was drawn from the antecubital veins of 10 healthy donors with a 19-gauge needle. It was drawn through elastomer tubes and through ePTFE Gore-Tex vascular grafts, both 60 cm long and with an inner diameter of 3 mm. METHODS Fibrinopeptide A (FPA) and P-selectin expression was measured in blood samples, collected at the end of the grafts. After the experiments, the deposition of platelets and fibrin onto the grafts was visualised by scanning electron microscopy. RESULTS For these graft types, a progressive increase in FPA production was observed in time. No significant difference was observed between the elastomer and ePTFE grafts (p > 0.05). No increase in P-selectin expression, and thereby no platelet activation, was observed in the perfusate of either grafts (p > 0.05). By scanning electron microscopy, numerous platelet aggregates were observed on the ePTFE grafts, whereas just a few adhered platelets and no aggregates were observed in the elastomer grafts. CONCLUSIONS The elastomer in its current formulation has a low thrombogenicity, comparable to ePTFE, making it an ideal substance for endovascular aneurysm sac filling. Further research should clarify the feasibility of CAR in vivo.

Feasibility of osteosynthesis of fractured cadaveric hips following preventive elastomer femoroplasty.

BACKGROUND In vitro cadaveric studies showed that elastomer femoroplasty prevents displacement of fracture parts after proximal hip fracture allowing for conservative treatment. In the event that secondary displacement does occur, the purpose of this present study was to determine the feasibility of performing osteosynthesis of a fractured hip after preventive treatment with elastomer femoroplasty. METHODS Ten pairs of human cadaveric femurs were fractured in a simulated fall configuration. From each pair, one femur was randomly selected for elastomer femoroplasty prior to fracture generation and the contralateral femur was used as control. Following hip fracture generation, osteosynthesis was performed in all femurs. The operative time per case, technical difficulties during the procedure, and postoperative energy-to-failure load were recorded. RESULTS The mean (SD) time to perform osteosynthesis was 20 (6) minutes in the control-group and 19 (5) minutes in the elastomer femoroplasty-group (P=0.69). During osteosynthesis of the fractured hip in the elastomer femoroplasty-group, no difficulties including the need for additional instruments to remove elastomer from the proximal femur were recorded. Postoperative energy-to-failure load was similar in the control-group and the elastomer femoroplasty-group. CONCLUSION Fixation with routine osteosynthesis of displaced cadaveric hip fractures is not hindered by the presence of previously injected elastomer.

Influence of aneurysm wall stiffness and the presence of intraluminal thrombus on the wall movement of an aneurysm - an in vitro study.

The purpose of this in vitro study was to investigate the influence of aneurysm wall stiffness and of the presence of intraluminal thrombus (ILT) on aneurysm wall movement. Three latex aneurysms were used with different wall stiffness. The aneurysms, equipped with 20 tantalum markers, were attached to an in vitro circulation model. Fluoroscopic roentgenographic stereo photogrammetric analysis was used to measure marker movement during six cardiac cycles at three different systemic pressures. To investigate the influence of ILT on wall movement, we repeated the same experiment with one of the aneurysms. The aneurysm sac was then filled with one of two E-moduli differing thrombus analogues (Novalyse 8 and 20) or with perfusate as a control. It was noted that the amplitude of the wall movement (mm) increased significantly (P < 0.05) as the compliance of the wall increased. The mean amplitude of the wall movement decreased (P < 0.05) as the stiffness (E-modulus) of the ILT increased. In conclusion, ILT has a ‘cushioning effect’. Wall movement (and theoretically wall stress) diminishes when the stiffness of the ILT increases. Compliance of the aneurysm wall influences wall movement. When the stiffness of the wall increases, the wall movement diminishes.