Search

Perioperative myocardial ischemia (PMI) after non-cardiac surgery remains a serious postoperative complication. This study analyzed the risk factors and outcomes of patients who suffered from PMI after elective aortic surgery.Data from 863 patients who underwent elective aortic surgery for aneurysms or Leriche syndrome were retrospectively analysed with regard to PMI. The diagnosis of PMI was based on a positive serum troponin diagnostic test. According to the clinical signs and symptoms, the patients with PMI were divided into two groups: symptomatic and asymptomatic patients. Comorbidities, preoperative medication, intraoperative parameters, postoperative complications, mortality, length of intensive care stay and hospitalisation, as well as the long-term follow-up, were compared in a matched-pair analysis (1:3) with patients without PMI. Logistic regression analyses were performed to identify independent risk factors for PMI.Thirty-two patients with PMI were identified. Cardiac comorbidities (previous myocardial ischemia, P = 0.0099; left ventricular systolic dysfunction, P = 0.0429), ASA score ≥III (P = 0.0114) and preoperative elevated creatinine (P = 0.0194) were more common in patients who suffered PMI. The regression analysis confirmed that peripheral artery disease and prolonged operative duration180 min are significant predictors of PMI. Surgical complications (wound healing deficit, P = 0.0027; rate of secondary interventions during primary admission, P = 0.0057) and medical complications (pneumonia, P = 0.0002; renal dysfunction, P = 0.0041) were more common in patients with PMI compared to the control group. Patients who suffered PMI remained in intensive care for a significantly longer period (P = 0.0001) and were also hospitalized for longer (P = 0.0001) than the control group. The long-term survival of patients who suffered PMI after aortic surgery was significantly worse than the control group (P0.0001, median 53 vs. 84 months), independent of clinical ischemia-associated symptoms.PMI after aortic surgery not only affects long-term survival, but also correlates with worsening of surgical outcome. Thus, meticulous preoperative risk stratification is required for high-risk patients, together with routine postoperative monitoring of troponin levels after aortic surgery.

Objective: The aim of this study was to report 10-year real-world single-center experience with the GORE TAG conformable thoracic aortic graft (CTAG), focusing on rupture-free survival, aortic-related reintervention, and device-related complications during midterm and long-term follow-up (FU). Methods: This retrospective study analyzes results of thoracic endovascular aortic repair (TEVAR) performed between January 2009 and December 2018. Out of 419 TEVAR procedures within this period, 194 patients (male 57.2%, 111/194), with a mean age of 65 ± 13 years, were treated with the CTAG device. Indication for TEVAR was a thoracic aortic aneurysm in 24.7% (48/194), type B aortic dissection in 32.5% (63/194), penetrating aortic ulcer 15.5% (30/194), and miscellaneous 27.3% (53/194). Emergently were operated 43.8% (85/194) patients. Median follow-up (FU) including computed tomography imaging was 43.5 months (Q1-Q3: 8.6–67.0) and was completed in 91.2% (177/194) of patients. Results: Overall survival rates were 75.8% (95% confidence interval [CI] = [0.76–0.70]) and 56.6% (95% CI = [0.57–0.50]) at 12 and 60 months, respectively. Cumulative incidence for aortic rupture was 11.9% (95% CI = [0.07–0.17]) at 60 and 90 months, respectively. Cumulative incidence for aortic-related reintervention was 27.5% (95% CI = [0.21–0.34]) at 60 and 90 months. Cumulative incidence for migration was 2.8% (95% CI = [0.004–0.05]) and 3.9% (95% CI = [0.007–0.07]) at 60 and 90 months, respectively. New endograft infections or material fatigue were not observed. Conclusions: The herein reported 10-year real-world single-center experience with the CTAG observed favorable long-term outcome. Thus, the device demonstrates appropriate persistent safety, efficacy, and clinical durability up to long-term FU in the treatment of diverse thoracic aortic pathologies.

In this study, we assessed the dynamic segmental anatomy of the entire ascending aorta (AA), enabling the determination of a favorable proximal landing zone and appropriate aortic sizing for the most proximal thoracic endovascular aortic repair (TEVAR). Methods: Patients with a non-operated AA (diameter < 40 mm) underwent electrocardiogram-gated computed tomography angiography (ECG-CTA) of the entire AA in the systolic and diastolic phases. For each plane of each segment, the maximum and minimum diameters in the systole and diastole phases were recorded. The Wilcoxon signed-rank test was used to compare aortic size values. Results: A total of 100 patients were enrolled (53% male; median age 82.1 years; age range 76.8–85.1). Analysis of the dynamic plane dimensions of the AA during the cardiac cycle showed significantly higher systolic values than diastolic values (p < 0.001). Analysis of the proximal AA segment showed greater distal plane values than proximal plane values (p < 0.001), showing a reversed funnel form. At the mid-ascending segment, the dynamic values did not notably differ between the distal plane and the proximal segmental plane, demonstrating a cylindrical form. At the distal segment of the AA, the proximal plane values were larger than the distal segmental plane values (p < 0.001), thus generating a funnel form. Conclusions: The entire AA showed greater systolic than diastolic aortic dimensions throughout the cardiac cycle. The mid-ascending and distal-ascending segments showed favorable forms for TEVAR using a regular cylindrical endograft design. The most proximal segment of the AA showed a pronounced conical form; therefore, a specific endograft design should be considered.

OBJECTIVES The aim of this study was to evaluate technical/clinical outcomes of the Gore TAG Conformable Thoracic Stent Graft with Active Control System (CTAG with ACS) in thoracic aortic disease since its introduction in Europe in 2017. METHODS Patients undergoing thoracic endovascular aortic repair (TEVAR) with the device between 2017 and 2020 were identified from a prospectively maintained single-centre database and retrospectively analysed. Predominant indications were aortic dissection (n = 46), thoracic/thoraco-abdominal aneurysm (n = 20/n = 7), penetrating ulcer (n = 14) and intramural haematoma (n = 12). Emergency procedures were performed in 47% (54/115). The primary outcome was technical success. Secondary outcomes were clinical success, serious adverse events and procedure-related reintervention. ACS was assessed regarding angulation, accuracy and apposition. The median follow-up was 8.46 months (interquartile range: 3.18–16.89 months). RESULTS A total of 115 consecutive patients (82 males, median age 63; interquartile range: 53–74 years) have been included. Technical success was achieved in 95.7% (110/115). Clinical success rate was 80.9% (93/115); mostly due to procedure-related death (n = 14). Overall mortality was 19.1% (22/115), with significant differences between elective/emergency procedures (log-rank: P CONCLUSIONS This single-centre study shows encouraging performance of the CTAG with ACS in an array of aortic pathologies. Although longer-term data must be awaited, ACS leads to overall favourable device placement. Despite ongoing advances in device technology, TEVAR remains challenging and is associated with significant burden inherent to the underlying disease.

Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery.This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients' discharge.Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure.PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.Die perioperative Myokardischämie (PMI) stellt eine schwerwiegende postoperative Komplikation dar. Insbesondere die Aortenchirurgie gehört zu den Hochrisikoeingriffen in Bezug auf das kardiale Operationsrisiko. Ziel dieser Arbeit ist es, die Krankheitsverläufe von Patienten mit PMI nach elektiven Aortenaneurysmen-Operationen zu untersuchen.Es handelt sich um eine retrospektive Datenanalyse von elektiv im Zeitraum Januar 2005 bis Januar 2012 in der Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie des Universitätsklinikums Heidelberg an der Aorta wegen Aneurysma operierten Patienten. Die Diagnose PMI wurde anhand einer Erhöhung des Serumtroponins gestellt. Es erfolgte eine Charakterisierung der PMI bezüglich des Zeitpunkt ihres perioperativen Auftretens, der klinischen Symptomatik sowie Besonderheiten der durchgeführten Diagnostik. Des Weiteren wurden Therapie-, Entlass- und Verlegungsmanagement analysiert.Insgesamt wurden im angegebenen Zeitraum 863 Patienten einem elektiven Aorteneingriff unterzogen. Eine PMI wurde bei 31 (3,6%) Patienten beobachtet, wobei in 21 von 31 (67,7%) Fällen eine konventionelle Operation erfolgt war. Bei 24 Patienten (77,4%) trat eine PMI während der ersten 3 postoperativen Tage auf. Mehr als die Hälfte der Patienten (16/31) waren klinisch asymptomatisch, in 77,4% der Fälle (24/31) war das Elektrokardiogramm unauffällig. In 25,8% der Patienten (8/31) lag der primäre Serumtroponinwert im Normbereich. Eine rein medikamentöse Therapie erfolgte in 17 Fällen (54,8%). Eine interventionelle Behandlung im Sinne einer Herzkatheteruntersuchung wurde in 12 Fällen (38,7%) durchgeführt, bei 2 (6,5%) Patienten wurde eine notfallmäßige aortokoronare Bypassanlage durchgeführt. Insgesamt 14 (45,1%) Patienten konnten direkt nach Hause entlassen werden, weitere 14 (45,1%) Patienten wurden zur Weiterbehandlung der PMI in ein Akutkrankenhaus (einschließlich hausinterne Verlegung) verlegt. Zwei Patienten verstarben während des Krankenhausaufenthalts an Multiorganversagen.Die PMI ist eine häufige Komplikation im Rahmen elektiver Aorteneingriffe. Die Diagnostik der PMI kann bei gering ausgeprägter/okkulter Klinik im Rahmen der Intensivtherapie erschwert sein. Aufgrund der potenziell schwerwiegenden Folgen sollte eine Herzenzymdiagnostik frühzeitig eingeleitet werden, um eine zeitnahe kardiologische Therapie zu ermöglichen.

Zusammenfassung Einleitung Die perioperative Myokardischämie (PMI) stellt eine schwerwiegende postoperative Komplikation dar. Insbesondere die Aortenchirurgie gehört zu den Hochrisikoeingriffen in Bezug auf das kardiale Operationsrisiko. Ziel dieser Arbeit ist es, die Krankheitsverläufe von Patienten mit PMI nach elektiven Aortenaneurysmen-Operationen zu untersuchen. Patienten und Methoden Es handelt sich um eine retrospektive Datenanalyse von elektiv im Zeitraum Januar 2005 bis Januar 2012 in der Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie des Universitätsklinikums Heidelberg an der Aorta wegen Aneurysma operierten Patienten. Die Diagnose PMI wurde anhand einer Erhöhung des Serumtroponins gestellt. Es erfolgte eine Charakterisierung der PMI bezüglich des Zeitpunkt ihres perioperativen Auftretens, der klinischen Symptomatik sowie Besonderheiten der durchgeführten Diagnostik. Des Weiteren wurden Therapie-, Entlass- und Verlegungsmanagement analysiert. Ergebnisse Insgesamt wurden im angegebenen Zeitraum 863 Patienten einem elektiven Aorteneingriff unterzogen. Eine PMI wurde bei 31 (3,6%) Patienten beobachtet, wobei in 21 von 31 (67,7%) Fällen eine konventionelle Operation erfolgt war. Bei 24 Patienten (77,4%) trat eine PMI während der ersten 3 postoperativen Tage auf. Mehr als die Hälfte der Patienten (16/31) waren klinisch asymptomatisch, in 77,4% der Fälle (24/31) war das Elektrokardiogramm unauffällig. In 25,8% der Patienten (8/31) lag der primäre Serumtroponinwert im Normbereich. Eine rein medikamentöse Therapie erfolgte in 17 Fällen (54,8%). Eine interventionelle Behandlung im Sinne einer Herzkatheteruntersuchung wurde in 12 Fällen (38,7%) durchgeführt, bei 2 (6,5%) Patienten wurde eine notfallmäßige aortokoronare Bypassanlage durchgeführt. Insgesamt 14 (45,1%) Patienten konnten direkt nach Hause entlassen werden, weitere 14 (45,1%) Patienten wurden zur Weiterbehandlung der PMI in ein Akutkrankenhaus (einschließlich hausinterne Verlegung) verlegt. Zwei Patienten verstarben während des Krankenhausaufenthalts an Multiorganversagen. Schlussfolgerung Die PMI ist eine häufige Komplikation im Rahmen elektiver Aorteneingriffe. Die Diagnostik der PMI kann bei gering ausgeprägter/okkulter Klinik im Rahmen der Intensivtherapie erschwert sein. Aufgrund der potenziell schwerwiegenden Folgen sollte eine Herzenzymdiagnostik frühzeitig eingeleitet werden, um eine zeitnahe kardiologische Therapie zu ermöglichen.

Purpose: The objective of this systematic review was to report the cumulative incidence of endograft migration (EM), as well as the morbidity, reintervention rates, and mortality related to EM. This study aimed to provide evidence-based data on patient-relevant sequelae of EM after thoracic endovascular aortic repair (TEVAR) performed using contemporary aortic endografts. Materials and Methods: A systematic electronic search of literature in MEDLINE (via PubMed), Web of Science, and Cochrane Central Register of Controlled Trials was performed. The pooled synthesis of outcomes was performed using the inverse variance method. Results: Seven prospective non-randomized and 4 retrospective studies, including a total of 1783 patients presenting 70 EMs, were considered for the quantitative analysis. The pooled rate of EM was 4% (95% CI, 2%–7%; range, 0.2%–11%; I2=82%); pooled morbidity rate was 31% (95% CI, 12%–59%; range, 0%–100%; I2=64%) and pooled reintervention rate was 32% (95% CI, 15%–56%; range, 0%–100%; I2=55%). The pooled mortality rate due to EM was 5% (95% CI, 1%–21%; range, 0%–40%; I2=24%). Conclusion: For the first time, this meta-analysis provides pooled reference estimates of EM after TEVAR. Thus, the results hold the potential to further characterize EM after TEVAR. The clinical relevance of EM is underlined by its association with high rates of endoleak-related morbidity, reintervention, and mortality. Close standardized surveillance after TEVAR for early detection of EM and prophylaxis of its sequelae is essential.

Die hier aufgefuhrten „Choosing-wisely“-Empfehlungen zur Behandlung der akuten und chronischen Typ-Stanford-B-Dissektion basieren auf den Leitlinien und Konsensusempfehlungen in der publizierten Literatur der letzten 10 Jahre. Es existieren neben ADSORB und INSTEAD keine randomisierten Studien zum Therapievergleich „best medical treatment“ (BMT) versus „TEVAR“ („thoracic endovascular aortic repair“). Die Literatur zur offenen Chirurgie der Aortendissektion ist mittlerweile historisch, da im Falle der Indikation zur invasiven Therapie TEVAR seit mehr als einem Jahrzehnt die Methode der Wahl ist. Die Positivempfehlungen adressieren insbesondere Differenzialdiagnose, Diagnostik und Indikationsstellung sowie TEVAR und Nachsorge. Die Negativempfehlungen fokussieren auf das State-of-the-Art-Management der konservativen Therapie, dem sog. „best medical treatment“, die Pravention der schwerwiegenden Komplikation der Paraplegie und die elektive Indikationsstellung der chronisch expandierenden Typ-B-Dissektion. Der Artikel stellt die Komplexitat der Therapieentscheidungen mit der anspruchsvollen Diagnosestellung und der komplikationsreichen invasiven Therapie am Beispiel der Aortendissektion Typ Stanford B ab. Ein Risiko der endovaskularen Uberversorgung besteht bei Patienten mit unkomplizierter Typ-B-Dissektion. Eine Gefahr der Unterversorgung besteht sowohl im Hinblick auf die primare Diagnosestellung und Diagnosesicherung als auch hinsichtlich der Nachsorge und Uberwachung wahrend des Follow-ups.

Die Claudicatio beim jungen Menschen ist eine seltene Entitat. In Abwesenheit bekannter Risikofaktoren der Atherosklerose ist die klassische periphere arterielle Verschlusskrankheit (pAVK) als Ursache eher unwahrscheinlich. An Differenzialdiagnosen kommen vaskulitische Erkrankungen wie M. Winiwarter-Burger und M. Behcet in Frage. Als vaskulare Ursache ist die venose Claudicatio als Teil des postthrombotischen Syndroms zu beachten. An arteriellen Ursachen sind die zystische Adventitiadegeneration und die fibromuskulare Dysplasie zu nennen. Bei anamnestisch intensiver sportlicher Belastung ist an vaskulare Kompressionssyndrome der unteren Extremitat zu denken (popliteales Entrapment-Syndrom, Adduktorenkanalsyndrom, iliakale Endofibrose). Die Untersuchungen sind an die pAVK-Diagnostik angelehnt. Allerdings sollten diese auch nach Belastung bzw. in entsprechender Funktionsstellung durchgefuhrt werden. Der therapeutische Ansatz ist primar konservativ. Bei operativer Notwendigkeit sind die offen-operativen Verfahren fuhrend.

Purpose Colonic ischaemia (CI) represents a serious complication after aortic surgery. This study aimed to analyse risk factors and outcome of patients suffering from postoperative CI. Methods Data of 1404 patients who underwent aortic surgery were retrospectively analysed regarding CI occurrence. Co-morbidities, procedural parameters, colon blood supply, procedure-related morbidity and mortality as well as survival during follow-up (FU) were compared with patients without CI using matched-pair analysis (1:3). Results Thirty-five patients (2.4%) with CI were identified. Cardiovascular, pulmonary and renal comorbidity were more common in CI patients. Operation time was longer (283 ± 22 vs. 188 ± 7 min, p < 0.0001) and blood loss was higher (2174 ± 396 vs. 1319 ± 108 ml, p = 0.0049) in the CI group. Patients with ruptured abdominal aortic aneurysm (AAA) showed a higher rate of CI compared to patients with intact AAA (5.4 vs. 1.9%, p = 0.0177). CI was predominantly diagnosed by endoscopy (26/35), generally within the first 4 postoperative days (20/35). Twenty-eight patients underwent surgery, all finalised with stoma creation. Postoperative bilateral occlusion and/or relevant stenosis of hypogastric arteries were more frequent in CI patients (57.8 vs. 20.8%, p = 0.0273). In-hospital mortality was increased in the CI group (26.7 vs. 2.9%, p < 0.0001). Survival was significantly reduced in CI patients (median: 28.2 months vs. 104.1 months, p < 0.0001). Conclusion CI after aortic surgery is associated with considerable perioperative sequelae and reduced survival. Especially in patients at risk, such as those with rAAA, complicated intraoperative course, severe cardiovascular morbidity and/or perioperative deterioration of the hypogastric perfusion, vigilant postoperative multimodal monitoring is required in order to initiate diagnosis and treatment.

OBJECTIVES Optimal treatment for patients with diseased proximal landing zones in acute/subacute Stanford type B dissection and intramural haematoma remains unclear. This study describes the preliminary outcomes of a localized endovascular treatment [spot-stent grafting (SSG)] of main entries/intramural blood pooling located downstream (aortic zones 4 and 5) using one single short device comprising diseased landing zones, looking particularly at the technical and morphological outcomes. METHODS Patients undergoing thoracic endovascular aortic repair (TEVAR) for acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B between 1997 and 2018 were identified from a prospectively maintained institutional database. In a total of 183 cases, 22 patients (7 women; median age 62 years; range 35–79 years) received SSG. The primary study end point was technical success. The primary morphological end point was false lumen thrombosis/aortic remodelling. Secondary end points were TEVAR-related mortality/morbidity and reinterventions. The median follow-up was 28.5 months (5 days–15.6 years). RESULTS The primary technical success rate was 100% (22/22). During follow-up, false lumen thrombosis was seen in 21 patients (95.5%) at a median of 6 days (0 days to 2.7 years) after the index procedure (limited/extended false lumen thrombosis: n = 9 vs 12). Aortic remodelling was achieved in 15 of 22 patients (68.2%) at a median of 360 days (3 days to 7.2 years). Limited/extended remodelling was observed in 8/15 and 7/15, respectively. Retrograde dissection or stent graft-induced new entry was not observed. No stroke or spinal cord injury occurred. Reinterventions were performed in 4/22 cases. The in-hospital mortality and 30-day mortality were 0%. Overall mortality during the follow-up period was 22.7% (5/22). CONCLUSIONS This study shows favourable technical and morphological results for SSG in selected patients with acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B. Patient allocation to SSG remains individual. Prospective large-scale long-term data may allow refinement of the application.

Zusammenfassung Hintergrund Mausmodelle zur Erforschung der Pathogenese von Aortenerkrankungen sind seit Jahren in der vaskulären Forschung etabliert. Aufgrund der komplexen multifaktoriellen Prozesse der Entstehung von Aortenaneurysmen, die bis heute noch nicht vollständig verstanden sind, wurden verschiedene Mausmodelle entwickelt. Der vorliegende Artikel stellt eine Übersicht der verfügbaren Modelle sowie der Vor- und Nachteile des jeweiligen Modells vor dem Hintergrund spezifischer Fragestellungen dar. Methodik Es erfolgte eine selektive Literaturrecherche zum Thema. Ergebnisse Die verfügbaren Mausmodelle lassen sich in drei Kategorien einteilen: genetisch induzierte, chemisch-topisch induzierte und medikamentös-systemisch induzierte Modelle. Die einzelnen Mausmodelle bieten jeweils spezifische Vor- und Nachteile, sodass die Auswahl des Modelles anhand der zugrunde liegenden Fragestellung erfolgen muss. Idealerweise werden mehrere Modelle kombiniert, um auszuschließen, dass den Ergebnissen modellspezifische Effekte zugrunde liegen. Medikamentös-systemisch induzierte Modelle mittels Angiotensin II und chemisch-topisch induzierte Modelle mittels Kalziumchlorid oder Elastase stellen dabei aufgrund ihrer Flexibilität die am häufigsten verwendeten Mausmodelle dar. Sie erlauben die Untersuchung einer Vielzahl verschiedener Einflussfaktoren oder medikamentöser Therapieansätze. Schlussfolgerung Mausmodelle liefern grundlegende Erkenntnisse zur bislang noch unzureichend verstandenen komplexen und multifaktoriellen Pathophysiologie der Entstehung und Progression von Aortenaneurysmen. Tiermodellbasierte Forschungsansätze stellen dabei eine ideale Grundlage für translationale Forschungsprojekte dar, welche prospektiv für die Entwicklung konservativer medikamentöser Therapieansätze für Aortenaneurysmen wesentliche Erkenntnisse beitragen können.

Die Kolonischamie gehort trotz erfolgreicher Etablierung der endovaskularen Techniken weiterhin zu den schwerwiegenden Komplikationen der Aortenchirurgie. Zu den Risikofaktoren zahlen neben der Aortenaneurysmaruptur die Aortenabklemmzeit, die perioperative Hypotonie, der Bedarf an kreislaufunterstutzenden Medikamenten, der Verschluss der hypogastrischen Arterien sowie die Niereninsuffizienz. Die Klinik einer postoperativen Kolonischamie ist oft unspezifisch. Zu den klassischen Symptomen gehoren abdominelle Schmerzen, Diarrhoen, rektaler Blutabgang und ein Anstieg der Entzundungsparameter. Ein spezifischer Laborparameter fur eine Kolonischamie existiert nicht. Der diagnostische Goldstandard besteht in der Endoskopie; bildgebende Methoden wie Sonographie oder Computertomographie spielen eine untergeordnete Rolle. Die transmurale Ischamie mit Darmwandnekrose stellt eine strenge Indikation zur notfallmasigen Operation dar, uberwiegend im Sinne einer Darmresektion ohne primare Anastomosierung.

Journal of Clinical Medicine 11(3), (2022). doi:10.3390/jcm11030498 special issue: "Topical Collection "Peripheral Artery Disease: Epidemiology and Global Perspectives" / Editors: Dr. Christian-Alexander Behrendt, Collection Editor; Dr. Frederik Peters, Collection Editor; Dr. Ulrich Rother, Collection Editor", Published by MDPI, Basel

Genetic variation in LRP1 (low-density lipoprotein receptor-related protein 1) was reported to be associated with thoracic aortic dissections and aneurysms. The aims of this study were to confirm this association in a prospective single-center patient cohort of patients with acute Stanford type B aortic dissections (STBAD) and to assess the impact of LRP1 variation on clinical outcome. The single nucleotide variation (SNV) rs11172113 within the LRP1 gene was genotyped in 113 STBAD patients and 768 healthy control subjects from the same population. The T-allele of rs11172113 was more common in STBAD patients as compared to the reference group (72.6% vs. 59.6%) and confirmed to be an independent risk factor for STBAD (p = 0.002) after sex and age adjustment in a logistic regression model analyzing diabetes, smoking and hypertension as additional risk factors. Analysis of clinical follow-up (median follow-up 2.0 years) revealed that patients with the T-allele were more likely to suffer aorta-related complications (T-allele 75.6% vs. 63.8%; p = 0.022). In this study sample of STBAD patients, variation in LRP1 was an independent risk factor for STBAD and affected clinical outcome.

Zusammenfassung Hintergrund Interdisziplinäre Aortenkolloquien (iAK) gelten als wertvolle Instrumente in der Konzepterstellung für die Therapie aortaler Pathologien im Bereich der Krankenhausmaximalversorgung. Ziel der Arbeit ist die Evaluation eines universitären iAK (Universitätsklinikum Heidelberg; beteiligte Kliniken: Gefäßchirurgie und Endovaskuläre Chirurgie [GCH]/Kardiochirurgie [KCH]/Radiologie) unter den Gesichtspunkten Gesamtpatientenvolumen, fachspezifische Vorstellungen, konservativer/operativer Therapieentscheid und interdisziplinäre fachrichtungswechselnde Therapieallokation (GCK nach KCH und vice versa). Methodik Es erfolgte eine retrospektive monozentrische Datenerfassung aller im iAK vorgestellten Patienten im Zeitraum 01/2014 – 12/2018. Ergebnisse Insgesamt wurden in 5 Jahren 344 Patienten (Median: 71 Patienten/Jahr) im iAK evaluiert. Davon wurden 262 von der GCH (76%), 63 von der KCH (18%) und 19 (6%) von anderen Disziplinen vorgestellt. Bei 153 von 344 Patienten (45%) wurde eine OP-Indikation gestellt. Entsprechend erfolgte eine konservative Therapieempfehlung in 191 von 344 Fällen (55%). In den Fällen mit gestellter OP-Indikation handelte es sich in 117 von 153 (76%) um originär GCH-geführte, in 29 von 153 (19%) um originär KCH-geführte und in 7/153 (5%) um anderweitig geführte Patienten. Eingriffe aus dem Fachbereich GCH wurden in 85/153 Fällen (55%) indiziert, davon entfielen 25% (22/85) auf fachfremde Patienten. Eingriffe aus dem Fachbereich KCH wurden in 68/153 Fällen (45%) indiziert. Der Anteil der fachrichtungswechselnden Therapieallokation betrug hier 84% (57/68). In 59 von 153 Fällen (39%) erfolgte die im iAK indizierte Therapie nicht. Schlussfolgerung Die Frequentierung des iAK zeigt sich über die Jahre konstant. Nicht zuletzt aufgrund der ambulanten Präsenz des Faches stellt die GCH den größten Teil der evaluierten Patienten. Die hohe Rate an konservativen Therapieentscheiden unterstreicht die Verantwortung/Selektionsaufgabe eines iAK. In Bezug auf die gestellten OP-Indikationen zeigt die vergleichbare relative Verteilung auf GCH/KCH eine gute Interdisziplinarität. Die hohe Rate fachfremder Fälle im Indikationsvolumen der KCH spiegelt den nach wie vor hohen Stellenwert des Faches wider. Kritisch zu hinterfragen ist die Effizienz des iAK in Bezug auf die tatsächliche Umsetzung der gestellten OP-Indikationen.

Hintergrund. Vor dem Hintergrund eines steigenden Nachwuchsmangels in chirurgischen Fachern kommt der zeitgemasen Nachwuchsforderung in der Aus- und Weiterbildung eine zunehmende Rolle zu. Hierzu ist eine Anpassung der Lehrstrukturen an die Anforderungen einer technisierten und spezialisierten Medizin essenziell. Der vorliegende Ubersichtsartikel widmet sich den Hintergrunden von Simulation in der Chirurgie, stellt Simulation in den Kontext von Nachwuchsmangel und eruiert simulationsbasierte Strategien in der gefaschirurgischen Aus- und Weiterbildung. Methodik. Es erfolgte eine selektive Literaturrecherche zum Thema. Ergebnisse. Simulationsbasiertes Lernen hat in der medizinischen Aus- und Weiterbildung einen hohen Stellenwert. Trotz guter Datenlage und bereits zunehmender Anwendung von Skills-Trainings in der Weiterbildung ist die Anwendung in der Pragraduiertenausbildung bisher marginal. Schlussfolgerung. Die Implementierung simulationsbasierter Lehreinheit in die Ausbildung ist nicht nur im Sinne der Nachwuchsforderung des eigenen Fachbereichs sinnvoll. Skills-Trainings bieten die Moglichkeit, Chirurgie und die damit assoziierten Aspekte in einem angemessenen Umfeld zu lehren und den jungen und motivierten Nachfolgegenerationen naher zu bringen. Unterstutzung finden Konzepte simulationsbasierter Lehreinheiten ganz aktuell durch die im Masterplan Medizinstudium 2020 geforderte Verschiebung der traditionellen Curriculumsinhalte zugunsten von Kompetenzen und klinisch-praktischen Fertigkeiten. Dies ist insbesondere in der klinikinternen Curriculumsplanung zu beachten. Prospektiv denkbare Ansatze fur die Weiterbildung waren auserdem eine verpflichtende Aufnahme von Simulationstrainings als Facharztstandard.

Der erste Teil dieser Ubersichtsarbeit „Intraoperatives Monitoring in der konventionellen und endovaskularen Aortenchirurgie“ befasst sich mit drei etablierten Monitoringverfahren, welche im Rahmen der konventionell-offenen Aortenchirurgie selektiv Anwendung finden. Diese sind (1) die transosophageale Echokardiographie (TEE), (2) die Ableitung motorisch-evozierter Potenziale (MEP) und (3) die zerebrospinale Liquordrainage (CSFD). Jedes Verfahren wird einzeln hinsichtlich seiner Methodik und Evidenz diskutiert. Abschliesend erfolgt eine zusammenfassende Bewertung.

Limb occlusion following endovascular aortic repair (EVAR) is one of the most common complications requiring secondary interventions and is associated with a relevant morbidity and mortality. This review article describes the risk factors for limb occlusion, highlights strategies for prevention and provides a treatment algorithm involving current open and endovascular modalities. A selective literature search for risk factors and treatment modalities of limb occlusion after EVAR was carried out. A total of five risk factors for limb occlusion after EVAR were identified: (1) iliac angulations >60°/high iliac tortuosity (odds ratio, OR 5.76), (2) severe iliac calcification (OR 5.8), (3) excessive oversizing >15% (OR 5.54), (4) graft placement in the external iliac artery (EIA) with (5) EIA diameter

BACKGROUND The worldwide prevalence of peripheral artery disease (PAD) is increasing and endovascular revascularisation (ER) has become the primary invasive treatment option. This study aims to illuminate gender disparities in ER of PAD. METHODS This is a retrospective, cross sectional study design. All inpatient invasive, percutaneous endovascular treatments of PAD conducted in the metropolitan area of Hamburg (Germany) were collected consecutively between 01/2004 and 12/2015. Relevant socio-demographic risk factors, technical assessments, procedural details, and in hospital outcomes were collected and subsequently analysed. RESULTS A total of 23,715 ERs were identified (39.7% females). Female patients were older (74 vs. 70 years, p

Der Fallbericht beschreibt die erfolgreiche endovaskulare Therapie einer intraoperativen Verletzung der Ao. thoracica descendens im Rahmen einer Re-Spondylodese in einem malignombedingt schwierigen Operationssitus. Die Intervention erfolgte im Sinne der aortalen Blutungskontrolle und verdeutlicht die Notwendigkeit und Moglichkeiten eines interdisziplinaren operativen Netzwerks.

BACKGROUND The aim of this study was to evaluate the impact of extended postoperative intensive care on short- and long-term patient outcome after elective abdominal aortic surgery and to assess the risk factors for patient survival after extended intensive care unit (ICU) treatment. METHODS The data of 231 patients that underwent open or endovascular abdominal aortic surgery were retrospectively analysed with regard to extended postoperative intensive care, defined as ICU treatment for more than 24 consecutive hours. Pre- and intraoperative factors were evaluated. The endpoints of the study were postoperative complications, mortality, and long-term follow-up. Univariate and multivariate Cox proportional regression analyses were performed to identify risk factors of worse overall survival. RESULTS Extended postoperative intensive care was needed in 84 patients (63 after open and 21 after endovascular surgery). The period of ICU treatment was similar in both groups. Only the wound complications (31.8% vs. 9.5%, p=.0498; OR 4.42 (0.94-20.84)) and the rate of acute kidney injury (82.5% vs. 57.1%, p=.0352; OR 3.55 (1.20-0.46)) were more frequent after open surgery, whereas brief reactive psychosis (38.1% vs. 14.3%, p=.0281; OR 0.27 (0.09- 0.84)) was more frequent after endovascular surgery. ICU stay of ≥8 days correlated with significantly lower survival rates compared to a shorter ICU stay (p=.0034), independent of open or endovascular techniques. Other multivariate risk factors for worse survival were the absence of preoperative aspirin medication, a body mass index (BMI) of

Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a “TEVAR-first” policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32–82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.

Summary: Background: Isolated femoral artery revascularisation (iFAR) represents a well-established surgical method in the treatment of peripheral arterial disease (PAD) involving common femoral artery disease. Data for iFAR in multilevel PAD are inconsistent, particularly in patients with critical limb ischemia (CLI). The aim of the study was to evaluate the outcome of iFAR in CLI regarding major amputation and reintervention and to identify associated risk factors for this outcome. Patients and methods: The data used have been derived from the German Registry of Firstline Treatment in Critical Limb Ischemia (CRITISCH). A total of 1200 patients were enrolled in 27 vascular centres. This sub-analysis included patients, which were treated with iFAR with/without concomitant iliac intervention. For detection of risk factors for the combined endpoint of major amputation and/or reintervention, selection of variables for multiple regression was conducted using stepwise forward/backward selection by Akaike’s information criterion. Results: 95 patients were included (mean age: 72 years ± 10.82; 64.2% male). Of those, 32 (33.7%) participants reached the combined endpoint. Risk factor analysis revealed continued tobacco use (odds ratio [OR] 2.316, confidence interval [CI] 0.832–6.674), TASC D-lesion (OR: 2.293, CI: 0.869–6.261) and previous vascular intervention in the trial leg (OR: 2.720, CI: 1.037–7.381) to be associated with reaching the combined endpoint. Conclusions: iFAR provides a reasonable, surgical option to treat CLI. Lesion length (TASC D) seems to have a negative impact on outcome. Further research is required to better define the future role of iFAR for combined femoro-popliteal lesions in CLI – best in terms of a randomised controlled trial.

The SARS-CoV‑2 pandemic represents a great challenge worldwide not only under the aspect of treatment but also of prevention. The infection curve could be flattened by the rapid implementation of simple distance and hygiene measures. In order to ensure current and future patient care in conjunction with protection of medical personnel working in the healthcare system during this pandemic, adequate protective equipment is essential. Routine care can only be resumed if there is sufficient and adequate personal protective equipment (PPE). If recommended hygiene protective measures including the necessary PPE are seriously taken into account both elective interventions and emergency care can be carried out without an increased risk of infection. This is very important in vascular surgery with a high proportion of urgent and emergency disease management.

To evaluate the significance of perioperative changes in ankle-brachial index (ABI) with regard to extremity-related outcome in non-diabetic patients with critical limb ischemia (CLI) following revascularization. The study represents a subanalysis of the multicentric Registry of First-line Treatment in Patients with CLI (CRITISCH). After exclusion of diabetic patients, conservative cases, and primary major amputation, 563 of 1200 CRITISCH patients (mean age 74 ± 10.7 years) were analyzed. This population was divided into two groups regarding perioperative ABI changes ∆ + 0.15 (Group 1) or ∆ − 0.15 (Group 2). Study endpoints were reintervention and major amputation during a mean follow-up of 14.6 ± 9 months. Logistic regression was performed in order to identify factors for ABI group affiliation. There were 279 patients in Group 1 (49.5%) and 284 in Group 2 (51.5%). ABI sensitivity and specificity regarding vessel patency were calculated to be 54 and 87%. A preoperative ABI ≤ 0.4 [odds ratio (OR) 7.7], patent vessels at discharge (OR 12.2), and secondary interventions (OR 2.4) were identified as factors for Group 1 affiliation. Contrariwise, previous revascularization (OR 0.6), a glomerular filtration rate ≤ 15 ml/min/1.73 m2 (OR 0.3), and TASC A lesions (OR 0.2) were associated with Group 2 affiliation. No statistical difference was found with regard to the need of reintervention. However, time to reintervention was significantly shorter in Group 2 compared to that in Group 1 (10.0 ± 9.5 months vs 12.1 ± 9.1 months; p = 0.005). Amputation rate in Group 2 was 14.4%, significantly higher compared to that in Group 1 (6.0%; p

Multidisciplinary aortic boards (mAB) are a valuable tool for decision making in patients with aortic pathologies. The aim of this study was to evaluate the mAB of a maximum care hospital with regards to total patient volume and discipline-specific presentations. Furthermore, the indications for conservative/surgical treatment and the patients' allocation were reviewed.A retrospective analysis was performed of all patients discussed in the mAB of Heidelberg University Hospital (Department of Vascular and Endovascular Surgery [VS]/Department of Cardiac Surgery [CS]/Department of Radiology), between 01/2014 and 12/2018.Within a five-year period, 344 patients (median of 71 patients/year) were discussed. Of those, 262 (76%) were presented by VS, mostly recruited from the outpatient sector. Another 63 cases (18%), originated from CS and 19 patients (6%) from other disciplines. An indication for surgical treatment was defined in 153 of 344 patients (45%), whereas 191 of 344 cases (55%) were treated in a conservative fashion. Procedures performed by VS were indicated in 85/153 (55%) cases, including 25% (22/85) of non-VS-patients. Procedures performed by CS were indicated in 68/153 (45%) cases containing 84% (57/68) of non-CS-patients. Despite a dedicated indication for surgery, 59/153 patients (39%) did not receive the recommended therapy.mAB maintenance is highly dependent on the outpatient sector. With respect to patient selection, the mAB has an important filter function towards conservative treatment. The nearly balanced distribution between VS and CS underlines the importance of a multidisciplinary approach to aortic surgery. Given the relevant number of untreated patients, a central management office with an in-hospital registry seems crucial in order to improve mAB performance.Interdisziplinäre Aortenkolloquien (iAK) gelten als wertvolle Instrumente in der Konzepterstellung für die Therapie aortaler Pathologien im Bereich der Krankenhausmaximalversorgung. Ziel der Arbeit ist die Evaluation eines universitären iAK (Universitätsklinikum Heidelberg; beteiligte Kliniken: Gefäßchirurgie und Endovaskuläre Chirurgie [GCH]/Kardiochirurgie [KCH]/Radiologie) unter den Gesichtspunkten Gesamtpatientenvolumen, fachspezifische Vorstellungen, konservativer/operativer Therapieentscheid und interdisziplinäre fachrichtungswechselnde Therapieallokation (GCK nach KCH und vice versa).Es erfolgte eine retrospektive monozentrische Datenerfassung aller im iAK vorgestellten Patienten im Zeitraum 01/2014 – 12/2018.Insgesamt wurden in 5 Jahren 344 Patienten (Median: 71 Patienten/Jahr) im iAK evaluiert. Davon wurden 262 von der GCH (76%), 63 von der KCH (18%) und 19 (6%) von anderen Disziplinen vorgestellt. Bei 153 von 344 Patienten (45%) wurde eine OP-Indikation gestellt. Entsprechend erfolgte eine konservative Therapieempfehlung in 191 von 344 Fällen (55%). In den Fällen mit gestellter OP-Indikation handelte es sich in 117 von 153 (76%) um originär GCH-geführte, in 29 von 153 (19%) um originär KCH-geführte und in 7/153 (5%) um anderweitig geführte Patienten. Eingriffe aus dem Fachbereich GCH wurden in 85/153 Fällen (55%) indiziert, davon entfielen 25% (22/85) auf fachfremde Patienten. Eingriffe aus dem Fachbereich KCH wurden in 68/153 Fällen (45%) indiziert. Der Anteil der fachrichtungswechselnden Therapieallokation betrug hier 84% (57/68). In 59 von 153 Fällen (39%) erfolgte die im iAK indizierte Therapie nicht.Die Frequentierung des iAK zeigt sich über die Jahre konstant. Nicht zuletzt aufgrund der ambulanten Präsenz des Faches stellt die GCH den größten Teil der evaluierten Patienten. Die hohe Rate an konservativen Therapieentscheiden unterstreicht die Verantwortung/Selektionsaufgabe eines iAK. In Bezug auf die gestellten OP-Indikationen zeigt die vergleichbare relative Verteilung auf GCH/KCH eine gute Interdisziplinarität. Die hohe Rate fachfremder Fälle im Indikationsvolumen der KCH spiegelt den nach wie vor hohen Stellenwert des Faches wider. Kritisch zu hinterfragen ist die Effizienz des iAK in Bezug auf die tatsächliche Umsetzung der gestellten OP-Indikationen.

Despite the successful establishment of endovascular techniques, colonic ischemia continues to be a serious complication of aortic surgery.The risk factors for colonic ischemia include aortic aneurysm rupture, prolonged aortic clamping, perioperative hypotension, the need for catecholamine therapy, occlusion of the hypogastric arteries and renal insufficiency.The clinical presentation of postoperative colonic ischemia is often unspecific. Classic symptoms include abdominal pain, diarrhea, peranal bleeding and rise of inflammatory parameters. A specific laboratory parameter for colonic ischemia does not exist. The diagnostic gold standard is endoscopy. Imaging methods such as sonography or computer tomography play only a supportive role. Transmural ischemia resulting in bowel wall necrosis is an indication for emergency surgery, predominantly colonic resection with creation of artificial anus.

Objective To report procedural results and mid-term follow-up outcomes of patients treated with endovascular aneurysm sealing (EVAS) for abdominal aortic disease. Methods In this retrospective observational study, all patients treated with EVAS between March 2013 and January 2018 for abdominal aortic aneurysm (AAA) or abdominal penetrating aortic ulcer were included. The datasets included demographics, aneurysm morphology, and procedural and clinical surveillance outcomes. Furthermore, patients treated within the original instructions for use (IFU-group) were compared with patients treated outside the IFU (non-IFU-group) with regard to survival, reintervention-free survival, freedom from type I endoleak, and freedom from stent graft migration. Results Seventy patients were included (67 male; median age, 72.5 years). Sixty-five patients were treated for AAA and 5 patients for abdominal penetrating aortic ulcer. Sixty-nine cases were treated electively (98.6%). Technical success was achieved in 68 cases (97.1%). The median clinical follow-up was 50.5 months (interquartile range, 29.3-62.7 months) with a median computed tomography angiographic follow-up of 38.5 months (interquartile range, 17.1-60.2 months). There were five deaths during the study period (7.1%), four of which were aneurysm related (5.7%). Five secondary AAA ruptures were detected (7.1%). Overall, 25 of 70 patients (35.7%) underwent 35 reinterventions, mostly owing to thrombotic complications (18.6%), stent graft migration (17.1%), and type I endoleak (12.9%). Fifteen patients were treated outside of the IFU (non-IFU-group) (21.4%). The estimated reintervention-free survival for the entire cohort at 30 days and 1, 3, and 5 years was 94.3%, 88.5%, 72%, and 56.9%, respectively. Freedom from stent graft migration at 1, 3, and 5 years was 98.6%, 82.0%, and 47.3%, respectively. The estimated freedom from type I endoleak at 30 days and 1, 3, and 5 years in the IFU-group was 100%, 100%, 94.9% and, 91.1% and significantly different when compared with the non-IFU-group with 79.5%, 72.2%, 72.2%, and 72.2% (P = .012). Conclusions Although the technical and initial results were satisfying, the mid-term results were disappointing. The enforcement of a close follow-up protocol for all patients treated with EVAS, especially vigilant for stent graft migration to prevent secondary type I endoleak and rupture, is strongly recommended.

Acute occlusion of the descending thoracic aorta (DTA) is rare and associated with high morbidity and mortality. In the case described here, rescue thoracic endovascular aortic repair (TEVAR) was successful in a 59-year-old man with acute occlusion of the DTA accompanied by lower body hypoperfusion after two previous open repairs for aortic coarctation.

The most important structural proteins of the vascular wall are collagen and elastin. Genetically linked connective tissue diseases lead to degeneration, aneurysm formation and spontaneous dissection or rupture of arteries. The most well-known are Marfan syndrome, vascular Ehlers-Danlos syndrome (type IV), Loeys-Dietz syndrome and familial aortic aneurysms and dissections.This review article addresses the current status of endovascular treatment options for important connective tissue diseases.Evaluation of currently available randomized studies and registry data.The treatment of choice for patients that are mostly affected at a young age is primarily conservative or open repair. There is only limited evidence for endovascular aortic repair (EVAR) of abdominal aneurysms or thoracic endovascular aortic repair (TEVAR).The progression of the disease with dilatation leads to secondary endoleaks and high reintervention rates with uncertain long-term results. For this reason, there is currently consensus that EVAR and TEVAR should be limited to justified exceptional cases and emergency situations in patients with genetically linked aortic diseases.Die wichtigsten Strukturproteine der Gefäßwand sind Kollagen und Elastin. Genetisch bedingte Bindegewebserkrankungen führen zu Degeneration und Aneurysmabildung, spontanen Dissektionen oder Rupturen von Arterien. Am bekanntesten sind das Marfan-Syndrom, das Ehlers-Danlos-Syndrom vom vaskulären Typ, das Loeys-Dietz-Syndrom sowie familiäre Aortenaneurysmen und Dissektionen.Welchen Stellenwert haben endovaskuläre Behandlungsoptionen in der Therapie aortaler Pathologien auf dem Boden von Bindegewebserkrankungen?Auswertung aktueller randomisierter Untersuchungen und Registerstudien.Die Therapie der Wahl der meist bereits in jungem Alter betroffenen Patienten ist primär konservativ bzw. offen chirurgisch. Zur endovaskulären Therapie abdomineller Aneurysmen (EVAR) oder thorakalen Aortenpathologien (TEVAR) gibt es nur wenig Evidenz.Die Progression der genetisch bedingten Grunderkrankung mit konsekutiver Aortendilatation führt zu sekundären Endoleckagen und vermehrten Reinterventionen mit unsicherem Langzeitergebnis. Deshalb besteht derzeit Konsensus, dass EVAR und TEVAR bei genetisch bedingten Aortenerkrankungen auf begründete Ausnahmefälle und Notfallsituationen begrenzt sein sollten.

Die Kasuistik beschreibt die erfolgreiche endovaskulare Therapie einer Pelottierung der A. thoracica descendens durch einen Knochenzementsporn bei Zustand nach Kyphoplastie. Die Intervention erfolgte im Sinne der Ruptur-/Embolieprophylaxe und verdeutlicht den Stellenwert der Gefaschirurgie im interdisziplinaren Netzwerk der Orthopadie.

Welchen Stellenwert haben endovaskulare Behandlungsoptionen in der Therapie aortaler Pathologien auf dem Boden von Bindegewebserkrankungen. Auswertung aktueller randomisierter Untersuchungen und Registerstudien. Die Therapie der Wahl der meist bereits in jungem Alter betroffenen Patienten ist primar konservativ bzw. offen-chirurgisch. Zur endovaskularen Therapie abdomineller Aneurysmen (EVAR) oder thorakalen Aortenpathologien (TEVAR) gibt es nur wenig Evidenz. Die Progression der genetisch bedingten Grunderkrankung mit konsekutiver Aortendilatation fuhrt zu sekundaren Endoleckagen und vermehrten Reinterventionen mit unsicherem Langzeitergebnis. Deshalb besteht derzeit Konsensus, dass EVAR und TEVAR bei genetisch bedingten Aortenerkrankungen auf begrundete Ausnahmefalle und Notfallsituationen begrenzt sein sollten.

Glyoxalase 1 (GLO1) is ubiquitously expressed in the cytosol of the cell and is the major opponent against the reactive metabolite methylglyoxal, which is involved in the development of atherosclerosis. Nondiabetic individuals with an increased hemoglobin A1c (HbA1c) level are at higher risk for development of cardiovascular diseases. As such, this study investigated whether there was an association between reduced GLO1 activity in atherosclerotic lesions of nondiabetic patients with an increased HbA1c level.HbA1c level was determined in venous blood of patients with carotid artery disease. Protein level of GLO1 was measured in endarterectomy-derived carotid artery plaques by Western blotting. Activity was measured by spectrophotometric assay in the plaques as well as in the erythrocytes; GLO1 activity in erythrocytes was compared with that in a cohort of healthy individuals (n = 15; 33% men; average age, 60 years).There were 36 patients with carotid artery disease (69% men; average age, 69 years) included in this study and divided into two equal groups: group I, HbA1c 5.7% (39 mmol/mol); and group II, 5.7% ≤ HbA1c 6.5% (39 mmol/mol ≤ HbA1c 48 mmol/mol). GLO1 activity in carotid plaques was reduced by 29% in group II compared with group I (P = .048), whereas protein expression was unchanged (P = .25). Analysis of GLO1 activity in erythrocytes revealed no difference between the groups (P = .36) or in comparison to healthy controls (P = .15). Examination of clinical parameters showed an increased amount of patients with concomitant peripheral arterial disease in group II (44% vs 10%; P = .020).Reduction of GLO1 activity in atherosclerotic lesions of nondiabetic patients with increased HbA1c is associated with a functional involvement of this protective enzyme in atherogenesis. Systemic GLO1 activity seems to be independent of both HbA1c and localized atherosclerosis as it was unchanged between group I and group II as well as compared with healthy controls, respectively.

Die Versorgung von Aortenpathologien mit Beteiligung des Bogens wird an spezialisierten Zentren mittlerweile vornehmlich endovaskular durchgefuhrt. Gemas der Literatur stellt die offene Rekonstruktion zwar noch den Goldstandard dar, allerdings gilt dies lediglich fur ein hochselektioniertes Patientenkollektiv. Dementsprechend ist der Anteil von Versorgungen in Notfallsituationen und bei alteren bzw. vorerkrankten Patienten im TEVAR-Kollektiv besonders hoch. Insgesamt liegt die technische Erfolgsrate der TEVAR im Aortenbogen unabhangig von der Landungszone bei ca. 90 % mit einer Mortalitat von 0–14 % und einer Morbiditat von bis zu 55 %. Durch die anatomische Beziehung zu den supraaortalen Asten und den diversen Atiologien mit oft komplexen morphologischen Konfigurationen ist neben der kritischen Indikationsstellung die technische Herangehensweise anspruchsvoll und fur den Erfolg masgebend. Die angemessene Apposition des Stentgrafts im Bereich der proximalen Landungszone ist der wesentliche Aspekt fur das klinische Ergebnis. Ein thrombogener Aortenbogen bzw. die Positionierung in Landungszone 1 gehen mit erhohter neurologischer Morbiditat einher. Wird eine Proximalisierung in die Zonen 2–0 notwendig, erfordert dies eine Uberstentung der linken A. subclavia bzw. ein Debranching der supraaortalen Gefase. Durch sog. „Chimney“-Techniken und seit Kurzem eingesetzten fenestrierten bzw. verzweigten („gebranchten“) TEVAR-Stentgraftprothesen speziell fur den Bogen erweitert sich das rein endovaskulare Repertoire. TEVAR im Aortenbogen ist ein etabliertes Verfahren auch fur komplexe Pathologien. Aufgrund schwieriger Indikationsstellung und technischer Komplexitat ist aber fur die erfolgreiche Umsetzung ein spezialisiertes und zudem erfahrenes Team mit entsprechender Infrastruktur notwendig.

Ruptured abdominal aortic aneurysm (rAAA) represents one of the most challenging emergencies in surgery. Open repair (OR) is associated with relevant morbidity and mortality and has not been reduced significantly over the last decade. The introduction of endovascular aneurysm repair (EVAR) and its meanwhile common use in the treatment of rAAA has raised the demand for randomised controlled trials (RCTs) in order to resolve a potential superiority of either OR or EVAR.This review discusses the current treatment strategies in rAAA repair including diagnostics, peri-operative management and results of OR and EVAR, focussing on RCTs comparing both modalities.Thirty-day mortality after OR and EVAR shows no significant difference in published RCTs. In particular with respect to OR, 30-day mortality was much lower than anticipated throughout all RCTs ranging from 18 to 37 %. EVAR for rAAA resulted in reduced in-hospital stay. Limitations of all except one RCT are low patient recruitment and exclusion of haemodynamically unstable patients.OR and EVAR need to be provided for rAAA. Despite lacking evidence, EVAR is the first choice treatment in experienced high-volume vascular centres. Low mortality rates in all RCTs raise the question if aortic surgery should be centralised.

BACKGROUND Due to recent advances in endograft design and percutaneous access, technical success could be increased during endovascular aneurysm repair (EVAR). Beside EVAR, endovascular aneurysm sealing (EVAS) provides an alternative procedure to treat aneurysms. To compare the two methods, additional benchmark criteria should be evaluated: Screening time, dose area product (DAP), procedure time and contrast use. In this study these technical variables are analyzed for EVAS vs. EVAR in comparable patient cohorts. METHODS It is a retrospective, single-center study. Only elective cases of infrarenal aortic aneurysms were included, all treated by the same surgeon (D.B.). Procedures were performed within the instructions for use without additional procedures. All operations were undertaken in a hybrid operating theatre. For EVAR, only the Medtronic Endurant® and the Gore C3 Excluder® were included. For EVAS the Nellix® from Endologix was used. RESULTS Between 2012 and 2016, 67 patients were treated with EVAS and 40 with EVAR; of these 20 and 16 could be introduced into the study respectively. Median age was 73 and 72 years respectively (only men). The two groups were comparable in terms of BMI, GFR and ASA-status. Screening time was reduced for EVAS (10.6 vs. 14.5 min., P

OBJECTIVES: To analyse early and long-term results of thoracic endovascular aortic repair (TEVAR) in patients with pseudoaneurysms after open aortic coarctation (CoA) repair. METHODS: A total of 11 patients of 418 patients who had been treated with TEVAR during the period from January 1998 to April 2015 (8 males; median age 53 years) were retrospectively analysed. Dacron patch aortoplasty was primarily performed in 9 patients and subclavian flap aortoplasty in 2 patients. Seven of the 11 patients had asymptomatic pseudoaneurysms (median diameter 56 mm, range 20–65 mm) diagnosed by routine screening. Symptomatic patients presented with haemoptysis, lower limb ischaemia, haemodynamic collapse and back pain and underwent emergency repair (4/11). Adjunctive procedures at the proximal landing zone were required in 7/11 patients. The median number of implanted endoprostheses per patient was 1 (range: 1–5). The median follow-up was 60 months (range 6–161 months). RESULTS: Technical success was achieved in 91% (10/11; 1 secondary elective open conversion). The 30-day mortality was 0%. The stroke rate was 18% (2 non-disabling strokes). In 2 patients (20%), stent-graft displacement during deployment was observed. The reintervention rate was 33% (Type Ib endoleak, left arm claudication, partial coverage of the left common carotid artery). Clinical success during follow-up was achieved in 10/11 patients. In 9/10 patients, aneurysm sac shrinkage was observed. The Type II endoleak rate was 10% (1/10; intercostal artery). The overall mortality ratewas 9% (1 patient died of amyotrophic lateral sclerosis). CONCLUSIONS: Endovascular treatment of post-coarctation pseudoaneurysms is feasible in elective and emergency cases, yielding durable results in the long term. Due to anatomical specifics, implantation may be challenging and requires careful procedural planning. On-site cardiothoracic surgery backup is essential in case open conversion is required.

Purpose: To report initial experience with automatic pressure-controlled cerebrospinal fluid drainage (CSFD) during thoracic endovascular aortic repair (TEVAR). Methods: A prospective nonrandomized study enrolled 30 consecutive patients (median age 68 years, range 42–89; 18 men) who underwent TEVAR between March 2012 and July 2013 and were considered to be at high risk for postoperative spinal cord ischemia (SCI), fulfilling 2 of the following criteria: stent-graft length >20 cm, left subclavian artery coverage, and previous infrarenal aortic repair. All patients received perioperative CSFD via the LiquoGuard system. The protocol aimed for a CSF pressure of 10 mm Hg and duration of CSFD of 3 or 7 days in asymptomatic or symptomatic patients, respectively. Muscle strength of the lower extremities was assessed with the Oxford muscle strength grading scale. Results: Completion of the CSFD protocol was achieved in 26 (87%) of 30 patients. CSFD was prematurely stopped due to catheter dislocation in 1 patient and bloody spinal fluid in 3 patients. CSFD was performed for a median of 3 days (range 1–7). Median total CSFD volume was 714 mL (range 13–2369), with a median 192 mL drained per 24 hours. The SCI rate was 3% (1/30). CSFD-related complications were observed in 33% of the patients: 1 fatal intracranial hemorrhage, 3 bloody spinal fluid episodes, 3 persistent CSF leaks requiring epidural blood patch, and 3 post lumbar puncture headaches. Mortality during a median follow-up of 16 months (range 10–25) was 3% (1/30). Conclusion: Prophylactic CSFD was associated with a low SCI rate in a high-risk patient collective undergoing TEVAR. Monitoring and drainage by an automatic modus was feasible, reproducible, and reliable but associated with relevant drainage-associated complications.