Volker Ruppert

Risk-adapted outcome after endovascular aortic aneurysm repair: analysis of anesthesia types based on EUROSTAR data.

Purpose: To compare anesthesia techniques in high-risk versus low-risk patients treated with endovascular aortic aneurysm repair (EVAR) with respect to outcomes. Methods: From July 1997 to August 2004, 5557 patients were enrolled in the EUROSTAR registry by 164 centers. Low-risk and high-risk patients were each divided into 3 groups according to anesthesia used during operation [general (GA), regional (RA), and local (LA)], resulting in 6 groups. Differences in preoperative and operative details among the 3 types of anesthesia were analyzed using a chi-square test for discrete variables and the Kruskal-Wallis test for continuous variables for each risk profile. Multivariate logistic regression analysis was performed on early complications. Results: Intensive care unit (ICU) admission was less frequent for high-LA (1.2% of patients) than high-RA (7.8%, p=0.0071) and high-GA (16.2%, p<0.0001), but high-RA still had a distinct advantage (p<0.0001) over high-GA. Systemic complications were lower both for high-LA (9.0%, p=0.0128) and for high-RA (10.7%, p<0.0001) than for high-GA (18.3%). Early death (≤30 days) was reduced in high-RA (3.0%) versus high-GA (4.3%, p=0.0286). Conclusion: On the basis of the EUROSTAR data, high-risk patients in particular attain important advantages from minimally invasive anesthetic techniques. Mortality, morbidity, hospital stay, and ICU admission are significantly lower for locoregional versus general anesthesia in the EUROSTAR registry. These results should encourage greater use of regional anesthesia in high-risk patients. Local anesthesia seems to be of similar benefit for EVAR in high-risk patients.

Serum S-100B Protein Levels during and after Successful Carotid Artery Stenting or Carotid Endarterectomy

Purpose: To characterize the course of S-100B serum levels, a reliable marker for cellular brain damage, in patients undergoing carotid artery stenting (CAS) or endarterectomy (CEA) for carotid artery stenosis compared to control groups undergoing hemithyroidectomy (HT) or coronary angiography (CA). Methods: Forty-six consecutive patients scheduled for revascularization of internal carotid artery (ICA) stenosis were included in the study. Fourteen patients (11 men; median age 70 years, interquartile range [IQR] 63–74) were selected for treatment with CAS, while CEA was performed in 31 patients (24 men; median age 68 years, IQR 54–78) during the same time period. Fourteen consecutive patients (8 men; median age 60 years, IQR 48–70) undergoing CA for suspected coronary heart disease and 14 patients (10 women; median age 36 years, IQR 26–54) undergoing HT for a single thyroid nodule served as controls. Results: All procedures were completed successfully. During ICA clamping in CEA patients without postoperative neurological deficits, median S-100B serum levels transiently increased from 0.04 to 0.26 ng/mL (p<0.01) and returned to baseline levels after declamping. Median S-100B serum levels of CAS patients without neurological impairment remained at baseline values. No increase in S-100B levels occurred in either control group. Three CEA patients who suffered from neurological deficits (1 transient ischemic attack and 1 major stroke) showed sustained elevation of S-100B serum levels 6 hours after extubation. Conclusion: In patients without neurological complications, CEA but not CAS was associated with a transient increase in the S-100B serum levels. Results indicate that the increase in S-100B does not originate from extracerebral sources, but rather appears to represent an impairment of the blood-brain barrier integrity or subtle brain cell damage probably due to hypoperfusion during clamping. Sustained elevation of S-100B serum levels corresponded to the development of postoperative neurological deficits.

Magnetic Resonance Angiography in the Follow-up of Distal Lower-Extremity Bypass Surgery: Comparison with Duplex Ultrasound and Digital Subtraction Angiography

PURPOSE The danger of limb loss as a consequence of acute occlusion of infrapopliteal bypasses underscores the requirement for careful patient follow-up. The objective of this study was to determine the agreement and accuracy of contrast material-enhanced moving-table magnetic resonance (MR) angiography and duplex ultrasonography (US) in the assessment of failing bypass grafts. In cases of discrepancy, digital subtraction angiography (DSA) served as the reference standard. MATERIALS AND METHODS MR angiography was performed in 24 consecutive patients with 26 femorotibial or femoropedal bypass grafts. Each revascularized limb was divided into five segments--(i) native arteries proximal to the graft; (ii) proximal anastomosis; (iii) graft course; (iv) distal anastomosis; and (v) native arteries distal to the graft-resulting in 130 vascular segments. Three readers evaluated all MR angiograms for image quality and the presence of failing grafts. The degree of stenosis was compared to the findings of duplex US, and in case of discrepancy, to DSA findings. Two separate analyses were performed with use of DSA only and a combined diagnostic endpoint as the reference standard. RESULTS Image quality was rated excellent or intermediate in 119 of 130 vascular segments (92%). Venous overlay was encountered in 26 of 130 segments (20%). In only two segments was evaluation of the outflow region not feasible. One hundred seventeen of 130 vascular segments were available for quantitative analysis. In 109 of 117 segments (93%), MR angiography and duplex US showed concordant findings. In the eight discordant segments in seven patients, duplex US overlooked four high-grade stenoses that were correctly identified by MR angiography and confirmed by DSA. Percutaneous transluminal angioplasty was performed in these cases. In no case did MR angiography miss an area of stenosis of sufficient severity to require treatment. Total accuracy for duplex US ranged from 0.90 to 0.97 depending on the reference standard used, whereas MR angiography was completely accurate (1.00) regardless of the standard definition. CONCLUSION Our data strongly suggest that the accuracy of MR angiography for identifying failing grafts in the infrapopliteal circulation is equal to that of duplex US and superior to that of duplex US in cases of complex revascularization. MR angiography should be included in routine follow-up of patients undergoing infrapopliteal bypass surgery.

Long-term Results After Primary Stenting of Distal Aortic Stenosis

Purpose: To review the long-term results of primary stent placement in the distal aorta above the bifurcation. Methods: Fourteen patients (8 men; mean age 62 years, range 46–82) underwent primary stent implantation performed by an interdisciplinary radiosurgical team. In 10 patients, a long-term follow-up examination consisting of patient history, clinical examination, and duplex sonography was performed. The ankle-brachial index (ABI) for the posterior tibial artery was calculated on the basis of Doppler pressure measurements. Results: The clinical success rate at the first follow-up examination (mean 2.9 months, range 2.1–4.4) was 100% (n=14). The mean baseline ABI of 0.64±0.12 had risen to 1.02±0.10 (p<0.0001). At midterm follow-up (mean 22.8 months, range 14–42) in 12 patients, the ABI was 0.96±0.12 (p<0.0001 versus baseline). At a mean 86 months (range 51–119) after stent treatment, the ABI in 10 patients was 0.90±0.20 (p<0.0001 versus baseline). Over the long term, the clinical success rate was 70%. Deterioration was due to the progression of atherosclerosis distal to the aorta; duplex sonography showed no aortic restenosis or occlusion. Conclusion: In view of the excellent long-term results in our small series, primary stent placement in focal abdominal aortic stenosis in properly selected patients is a durable treatment. In addition, the mortality and morbidity risks are markedly reduced compared with open surgery.

Double Tube Stent-Grafts for Infrarenal Aortic Aneurysm: A New Concept

Purpose: To present the concept of double tube stent-grafts and examine the indications for and results achieved with these devices. Methods: From January 1, 2000, to December 31, 2005, 759 patients who underwent endovascular repair of infrarenal aortic aneurysms at 2 centers. Of these, 45 (5.9%) patients received a double tube stent-graft; complete operative and follow-up data were available for retrospective analysis in 41 patients (33 men; mean age 73.1±8.9 years). Diameters measured before stent-graft implantation and at follow-up (12, 24, 36, and 48 months) with clinical examination, 2-phase computed tomographic angiography, duplex sonography, and biplanar abdominal radiography were tested for significant changes using ANOVA with the Bonferroni-Dunn correction. Late outcomes (clinical success and endoleak) were analyzed by the Kaplan-Meier method. Results: The postoperative complication rate was 12.2%, with 2.4% systemic complications (1 patient with angina pectoris); the early mortality rate was 0%. Mean follow-up was 21.9±12.8 months (range 12–61) for the 41 patients. Four (9.8%) patients died during follow-up of cardiac causes (n=2), lung cancer (n=1), and bowel ischemia (n=1). Four (9.8%) endoleaks were observed during follow-up: 1 distal type I, 2 type II, and 1 type III. Maximum aneurysm diameters shrank from 52.0±9.5 mm preoperatively to 44.0±10.8 mm (p<0.0001) postoperatively at the latest available follow-up. Conclusion: Our study supports the use of this double tube technique for repair of appropriate saccular infrarenal aortic aneurysms. The double tube stent-graft method appears safe in terms of endoleaks and migration, so we recommend that it be considered an option of endovascular aortic aneurysm therapy.

Weiterbildung in endovaskulären Techniken mit der privaten Akademie der DGG

ZusammenfassungDie endovaskulären Techniken sind integraler Bestandteil gefäßchirurgischer Tätigkeit. Sie sind in diesem Fachgebiet tief verwurzelt, aber noch nicht flächendeckend gleichmäßig verbreitet. Die Sektion „Endovaskuläre Techniken“ der Akademie für Forschung und Weiterbildung der DGG hat deshalb das Konzept einer strukturierten Weiterbildung in diesen Techniken entwickelt und mit einem Kurssystem hinterlegt, dass Gefäßchirurgen die komplette diesbezügliche Weiterbildung ermöglicht. Der Nachweis der erreichten Kompetenz kann durch die Zertifizierung zum „Endovaskulären Chirurgen“ oder „Endovaskulären Spezialisten“ geführt werden. Konzept, Kurssystem und der Weg zur Zertifizierung werden dargelegt.AbstractEndovascular techniques are integrated into vascular surgery. Vascular surgeons are deeply involved in using these techniques, but the techniques are not being spread everywhere. Therefore, members of the section for endovascular techniques of the private Academy for Research and Education of the German Society for Vascular Surgery developed a concept for structured education concerning endovascular activities. A system of workshops was developed to render this education feasible. To prove full endovascular competence, a vascular surgeon can achieve certification as an endovascular surgeon or endovascular specialist. The concept, workshops, and method of achieving certification are herein explained.

Die chronische kritische Unterschenkelischämie: prätherapeutische Diagnostik, Methoden der Revaskularisation

ZusammenfassungJährlich entwickeln 1–2% der Patienten mit peripherer arterieller Verschlusskrankheit (pAVK) eine chronisch-kritische Ischämie (chronic limb ischemia, CLI) der unteren Extremität, die durch Ruheschmerzen und/oder periphere Ulzerationen bzw. Gangräne charakterisiert ist. Sie bedeutet einen Zusammenbruch der Mikrozirkulation und ist mit einem Anstieg der Einjahresmortalitätsrate auf 25% und einem hohen Amputationsrisiko vergesellschaftet. Zur Behandlung der CLI stehen konservative, endovaskuläre und operative Behandlungsmaßnahmen zur Verfügung, wobei klare Therapieempfehlungen bislang nur für Läsionen der suprapoplitealen Strombahn existieren. Oft und gerade bei Diabetikern liegt die Ursache jedoch infrapopliteal.Die endovaskulären Therapieverfahren haben in den letzten Jahren eine massive Weiterentwicklung erfahren. Grund genug, um unter Berücksichtigung neuester Erkenntnisse die Alternativen zur Revaskularisierung infrapoplitealer Gefäßveränderungen bei der CLI neu zu diskutieren.AbstractEach year 1–2% of patients with peripheral arterial occlusive disease (pAOD) develop critical limb ischemia (CLI), characterized by rest pain and peripheral ulcer or gangrene. This aggravation of the disease is accompanied by an increase of the 1-year mortality rate up to 25% and a similarly increased frequency of major amputation. We can choose between conservative, endovascular, and surgical procedures for an adequate therapy of the underlying vascular stenoses or occlusions. Yet, clear therapeutic recommendations only exist for suprapopliteal lesions. However, in a number of cases, especially in diabetics, target lesions have an infrapopliteal location. Since endovascular procedures have undergone significant improvement in the last few years, the following review discusses methods for infrapopliteal revascularization taking into consideration the newest publications on this topic.

Die chronische kritische Unterschenkelischämie: prätherapeutische Diagnostik, Methoden der Revaskularisation@@@Chronic critical ischemia of the lower leg: pretherapeutic imaging and methods for revascularization

ZusammenfassungJährlich entwickeln 1–2% der Patienten mit peripherer arterieller Verschlusskrankheit (pAVK) eine chronisch-kritische Ischämie (chronic limb ischemia, CLI) der unteren Extremität, die durch Ruheschmerzen und/oder periphere Ulzerationen bzw. Gangräne charakterisiert ist. Sie bedeutet einen Zusammenbruch der Mikrozirkulation und ist mit einem Anstieg der Einjahresmortalitätsrate auf 25% und einem hohen Amputationsrisiko vergesellschaftet. Zur Behandlung der CLI stehen konservative, endovaskuläre und operative Behandlungsmaßnahmen zur Verfügung, wobei klare Therapieempfehlungen bislang nur für Läsionen der suprapoplitealen Strombahn existieren. Oft und gerade bei Diabetikern liegt die Ursache jedoch infrapopliteal.Die endovaskulären Therapieverfahren haben in den letzten Jahren eine massive Weiterentwicklung erfahren. Grund genug, um unter Berücksichtigung neuester Erkenntnisse die Alternativen zur Revaskularisierung infrapoplitealer Gefäßveränderungen bei der CLI neu zu diskutieren.AbstractEach year 1–2% of patients with peripheral arterial occlusive disease (pAOD) develop critical limb ischemia (CLI), characterized by rest pain and peripheral ulcer or gangrene. This aggravation of the disease is accompanied by an increase of the 1-year mortality rate up to 25% and a similarly increased frequency of major amputation. We can choose between conservative, endovascular, and surgical procedures for an adequate therapy of the underlying vascular stenoses or occlusions. Yet, clear therapeutic recommendations only exist for suprapopliteal lesions. However, in a number of cases, especially in diabetics, target lesions have an infrapopliteal location. Since endovascular procedures have undergone significant improvement in the last few years, the following review discusses methods for infrapopliteal revascularization taking into consideration the newest publications on this topic.

Endovaskuläre Optische Kohärenztomographie (OCT) zur Evaluation der Gewebsalteration nach endovenöser Radiofrequenz- und Lasertherapie

Die endovenose OCT ermoglicht eine reproduzierbare Darstellung der Gefaswandschichten und deren thermische Alteration mit einer hohen Auflosung und guten Korrelation zu korrespondierenden histologischen Schnittbildern. Durch den kontinuierlichen spiralformigen Untersuchungsgang unter Akquisition einer Vielzahl von Schnittbildern kann ein definiertes Gefassegment luckenlos beurteilt werden. OCT erscheint damit insbesondere zur Evaluation experimenteller diskontinuierlicher endovenoser thermischer Lasionen als Erganzung zu histologischen Untersuchungen, die nur stichprobenartig durchgefuhrt werden konnen, geeignet.

Indikationen, Methoden und Ergebnisse der Kombinationsbehandlung in der aortoiliakalen Etage

Arteriosklerotische Prozesse im aortoiliakalen Bereich resultieren meist nicht in der extremitatenbedrohenden Ischamie, sind aber verantwortlich fur Behinderungen durch Gesas-, Oberschenkel- und Unterschenkelclaudicatio sowie fur Impotenz. Zur Behandlung dieser Erkrankungen kommen mehrere Behandlungsregime in Betracht. Neben der alleinigen konservativen Therapie mit vasoaktiven Medikamenten und Gehtraining mussen bei starkeren Beschwerden invasive Masnahmen eingesetzt werden. Dies sind insbesondere gefaschirurgische und katheterassistierte Verfahren, die alleine oder in Kombination einzeitig oder zweizeitig im Intervall eingesetzt werden konnen.