[Vascular injury-An underestimated entity?] / Die Gefäßverletzung ­ eine unterschätzte Entität?: Einfluss auf Prognose und Ergebnis in der Schwerverletztenversorgung.

Background: Vessels are not frequently affected in traumatology and isolated vascular trauma (VT) is rare; therefore, there is a lack of reliable and current data on the incidence and mortality. Objective: This article reports on the status of VT in trauma care of the severely injured in Germany based on selected references and data from our own published analyses and current studies from the data of the TraumaRegister DGU® (TR-DGU). Material and methods: Selected review of the literature and report on 2 retrospective assessments of datasets of the TR-DGU. Records with moderate to severe VT in the injury pattern were compared to records of cases without VT (non-VT) with the same injury severity. Target parameters were morbidity, mortality and parameters of the clinical course and prognosis. Results: The 2002-2012 database evaluation (TR-DGU Project-ID 2013-011) revealed an impact of allocation and level of care of the trauma centers on expected mortality (EM) and observed mortality (OM) in 2961 cases with VT among 42,326 severely injured patients (7%). The difference between OM and EM in VT was + 3.4% vs. ±â€¯0.1% in non-VT. Due to an OM in severe VT of 33.8% vs. 16.4% in non-VT with identical injury severity, the subsequent analysis of 2008-2017 (TR-DGU Project-ID 2018-045) was initiated. The sub-stratification of isolated, main and concomitant VT could show a significant effect of the treatment level, allocation and transport on the OM in the treatment reality. A relevant mismatch of OM to EM could only be shown in VT, on average ca. + 2% and in high-risk constellations with VT up to + 29% as a measure for the relevance of VT in trauma care. Conclusion: These results indicate a substantial need for further optimization of emergency care of severely injured patients with VT, where VT vigilance, allocation, transportation and a low threshold early re-allocation can be derived as starting points.

[Aortic Aneurysm: Fenestrated/Branched Endovascular Aortic Repair (EVAR) and Fenestrated/Branched Thoracic Endovascular Aortic Repair (TEVAR). Is Total Endovascular Repair Already Here?] / Aortenaneurysma: fenestrierte/gebranchte abdominale EVAR (fbEVAR) und fenestrierte/gebranchte thorakale EVAR (fbTEVAR). Ist die komplette endovaskuläre Therapie schon da?

Five years after the first endovascular aortic repair (EVAR), Park et al. reported the first implantation of a fenestrated endoprosthesis. In the meantime, advanced generations of new fenestrated and branched endografts evolved. Endografts for complex pathologies are either so-called "off-the-shelf" grafts with predetermined length, width, diameter and clock position of the branches and fenestrations, predetermined by the manufacturer, "custom-made" grafts which need to be sized and planned individually for patients with specific thoracoabdominal anatomy. Open aortic repair in the treatment of thoracoabdominal aortic aneurysm (TAAA) still remains challenging and is associated with high morbidity and mortality, even in the elective setting. The ongoing development of endovascular treatment modalities, such as fenestrated and branched endovascular aneurysm repair (F-EVAR, B-EVAR), enables less invasive procedures for more challenging aortic pathologies. In recent years, extensive endovascular treatment of the aortic arch to the thoracoabdominal segment has become more and more important, but its outcomes have not been completely evaluated. The aim of this is article is to provide an overview of the currently available endovascular treatment options for complex aortic aneurysms requiring extensive coverage from the aortic arch to the infrarenal aorta.

Systematic review and meta-analysis of published studies on endovascular repair of thoracoabdominal aortic aneurysms with the t-Branch off-the-shelf multibranched endograft.

BACKGROUND: Endovascular treatment of thoracoabdominal aortic aneurysms is becoming increasingly popular in clinical practice, mainly because of its reduced perioperative mortality and morbidity. However, the custom-made stent graft platform that companies offer requires detailed preoperative planning and production time that can take up to 12 weeks. This may delay surgery in elective patients and is not an option for urgent or emergent cases. To surpass this limitation, the t-Branch (Cook Medical, Bloomington, Ind) was launched in 2012 in Europe as the first off-the-shelf standardized multibranched endograft for the endovascular treatment of thoracoabdominal aneurysms. Our aim was to systematically evaluate all published experience with this commercially available off-the-shelf thoracoabdominal stent graft. METHODS: We performed a systematic inquiry of the medical databases to identify all published studies that reported on the outcomes of patients treated with the t-Branch stent graft and then conducted a qualitative synthesis and meta-analysis of the results. The main end points studied were technical success, mortality, major stroke, spinal cord ischemia, primary branch patency, and renal insufficiency during the first 30 days along with midterm mortality and reintervention rate. We estimated pooled proportions and 95% confidence intervals (CIs). RESULTS: We identified seven retrospective studies published between 2014 and 2018, with a total of 197 patients (mean age, 72.3 ± 7 years; 70% male). Among 165 patients, 45% were symptomatic and 19% were treated for a ruptured aortic aneurysm. In 197 patients, pooled technical success was 92.75% (95% CI, 83.9%-98.7%), and in 10% of the cases, an early endoleak was detected (95% CI, 0%-43.7%). Early mortality was 5.8% (95% CI, 2.5%-10%), and major stroke was observed in 4% of the patients (95% CI, 0.96%-8.40%). The rate of spinal cord ischemia was 12.2% (95% CI, 4.1%-23.2%), with the rate of permanent paraplegia at 1.3% (95% CI, 0%-8.7%). Acute renal failure was 18.7% (95% CI, 9.1%-30.4%), whereas primary branch patency was calculated at 98.2% (95% CI, 96.7%-99.2%). Mean follow-up was 15 ± 7 months. During this time, midterm mortality (after 30 days) was 6.9% (95% CI, 2.44%-12.8%) and pooled reintervention rate was 5.7% (95% CI, 1.70%-11.4%). CONCLUSIONS: This pooled analysis indicated good technical success rate after t-Branch endograft implantation, with acceptable mortality and neurologic complications despite a high rate of urgent procedures. Thoracoabdominal endovascular repair with the t-Branch endograft is a feasible and safe therapeutic option for elective and urgent patients.

Extension of Iliac Branch Device Repair Into the Superior Gluteal Artery Is a Safe and Effective Maneuver.

BACKGROUND: In some cases of complex aortoiliac endovascular repair, the hypogastric landing zone is suboptimal or even insufficient. This study aimed at the technical feasibility and at the outcome of iliac branch device (IBD) deployment with extension of the IBD into the superior gluteal artery (SGA). MATERIALS AND METHODS: This study involves a retrospective analysis of a prospectively maintained single-center cohort of patients with implantation of IBD for aortoiliac and postdissection aneurysms. The IBD cohort with landing zones in the hypogastric main trunk (IIA IBD) was compared with the IBD cohort with landing zones in the SGA (SGA IBD). The main outcome parameters were primary technical success, patency of the hypogastric branch, and freedom from IBD-specific secondary interventions within 30 days. Other outcomes of interest were long-term patency and freedom from buttock claudication, as well as the incidence of endoleaks. Group comparisons were made by univariate significance tests, and freedom from reintervention was analyzed with the Kaplan-Meier-method. RESULTS: From January 2015 to October 2017, a total of 46 IBDs were implanted in 40 patients (39 male; mean age, 71.9 ± 9.1 years). Nineteen of 46 (41.3%) IBDs were extended with at least one bridging stent graft into the SGA because of aneurysmal or short internal iliac artery (IIA). Technical success was achieved in 97.8% (96.3% for IIA IBD vs. 100% for SGA IBD, P = 0.163), and the primary ipsilateral limb patency rate was 100% within 30 days after the procedure. During a mean follow-up period of 19.8 ± 10.0 months (24.7 ± 10.8 for IIA IBD vs. 25.1 ± 9.8 for SGA IBD, P = 0.461), 11.1% IBDs in the IIA IBD group and 15.8% IBDs in the SGA IBD group needed secondary interventions (P = 0.33). Follow-up revealed no patients suffering from persistent buttock claudication or erectile dysfunction. One patient in the SGA IBD group died at late follow-up from a non-aneurysm-related cause. CONCLUSIONS: Extension of IBD into the SGA is a technically feasible and safe maneuver in the treatment of aortoiliac aneurysms with outcomes comparable to those when IBDs extend to the main trunk of the hypogastric artery.

[Thoracic Aortic Aneurysms - Diagnosis and Treatment Strategies]. / Das thorakale Aortenaneurysma ­ Diagnostik und Behandlungsstrategien.

Thoracic aortic aneurysms are a relatively uncommon disease, with an incidence of 10.4/100 000, with an increase in the last decades, due to the increased quality of vascular screening. Several imaging techniques like thoracic radiography, echocardiography, magnetic resonance (MRI) or positron emission tomography (PET) can be used for the diagnosis of such condition, whose first diagnosis is usually incidental. The gold standard for aneurysm evaluation is computed tomography angiography (CTA), which allows precise diameter assessment and accurate preoperative planning. Advancements in imaging techniques, through electrocardiography (ECG)-gated CTA, permit to avoid movement artifacts and have a more precise definition of proximal aortic segments (aortic arch, ascending aorta).The urgent or emergent treatment of thoracic aneurysms is indicated in symptomatic patients and in case of rupture, respectively. The current European Society for Vascular Surgery guidelines recommend the elective treatment of thoracic aneurysms with a diameter > 55 mm, since diameters of 55 - 60 mm are associated with a rupture risk of 10 %/year. Lower perioperative morbidity and mortality rates have been demonstrated for endovascular repair in comparison with open surgery. According to the current guidelines, the treatment of choice is endovascular, through the implantation of an aortic stent graft (thoracic endovascular aortic repair, TEVAR), while open surgery is reserved to young patients, fit for open surgery. Hybrid procedures, introduced in 2000, include the debranching of supra aortic vessels and TEVAR and are a well established procedure for the treatment of aneurysms involving the aortic arch. The increasing research and expertise in endovascular surgery lead to the development of complex procedures, like chimney TEVAR, fenestrated and branched TEVAR which allowed to reach proximal landing zone to the ascending aorta.

Current evidence on aortic remodeling after endovascular repair.

Anatomical changes after endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) are thoroughly studied as they could affect the long-term postoperative outcome. The aim of the present study was to review the literature and summarize the recent data regarding the aortic remodeling and its clinical significance. A continuous aortic neck expansion is observed after EVAR and is more rapid at the first month and during the third postoperative year. This aortic neck dilation is not influenced by the type of proximal stent-graft fixation, is comparable to open surgical aneurysm repair and is most probably related with the natural progression of aneurismal disease. Aortic neck angulation reduces significantly immediately after EVAR and then continues to reduce slowly and gradually. Neck angulations ≥60° have a greater reduction compared to neck angulations <60°. An expansion of the common iliac arteries at the distal landing zone is also observed after EVAR and is more prominent in the first six postoperative months. A postoperative increase of the distance between superior mesenteric artery and iliac bifurcations (aortoiliac elongation) is described and is associated with increased type I endoleaks and reinterventions. The aneurysm sac diameter most frequently reduces after EVAR in absence of an endoleak and this aneurysm sac regression has been associated with the stent-graft type.

Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery.

BACKGROUND: Our study aim was to evaluate the impact of left subclavian artery (LSA) flow preservation during thoracic endovascular aortic repair (TEVAR) on outcome. METHODS: Between August 2001 and October 2016, 176 patients (mean age, 61.3 ± 15.8 years) underwent TEVAR with complete LSA coverage. Fifty-five of those patients (31.3%) also underwent LSA revascularization, whereas 121 patients (68.7%) did not. Perioperative data were acquired retrospectively for statistical analysis at the three study institutions. RESULTS: Overall in-hospital and follow-up mortality was 8.5% (n = 15) and 9.1% (n = 16), respectively, including 88 urgent and emergent cases (50%). Stroke (independent of location) and permanent paraplegia rates were 6.8% and 6.3%, respectively, for the entire cohort. Isolated upper-left extremity malperfusion exclusively occurred in 12 (9.9%) of the 121 patients without LSA revascularization. Left-hemispheric stroke was observed four times more often in patients without LSA revascularization and left arm malperfusion (16.7% versus 3.7%, p = 0.095). Multivariate analysis identified no LSA revascularization (odds ratio [OR] 3.779, 95% confidence interval [CI]: 1.096 to 13.029, p = 0.035), two or more endografts (OR 3.814, 95% CI: 1.557 to 9.343, p = 0.003), and coronary artery disease (OR 3.276, 95% CI: 1.262 to 8.507, p = 0.015) as independent risk factors for procedure-related adverse events (left-hemispheric stroke, left arm malperfusion, and permanent paraplegia) after TEVAR with complete LSA overstenting. CONCLUSIONS: Every 10th patient with LSA overstenting and no revascularization experienced left arm malperfusion. No LSA revascularization, extensive aortic coverage with two or more endografts, and coronary artery disease increased the risk of permanent paraplegia, left-hemispheric stroke, and left arm malperfusion. Patients should undergo LSA revascularization to prevent left vertebral artery-associated central neurologic complications and to maintain upper-left extremity perfusion.

Effect of endoleaks on changes in aortoiliac volume after endovascular repair for abdominal aortic aneurysm.

PURPOSE: To evaluate changes in aortoiliac volume after endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) in patients with and without endoleaks. MATERIALS AND METHODS: We retrospectively analyzed 137 patients who underwent EVAR for AAA. We manually measured the aortoiliac volume on pre-procedural baseline CT angiograms (CTAs) and post-procedural follow-up CTAs. All post-procedural CTAs were evaluated for the presence of endoleaks. Follow-up examinations were grouped into five time points relative to the date of the EVAR procedure and mean aortoiliac volume changes from the baseline were calculated. RESULTS: In 51 patients (37.2%), endoleaks were detected during follow-up. In patients without any endoleaks, mean aortoiliac volume decreased by 21.1% from the pre-interventional baseline examination to the last follow-up examination. In patients with any endoleak during follow-up aortoiliac volume increased by 12.2% and in patients with only transient, post-procedural endoleaks (n = 18), aortoiliac volume decreased by 13.4% over the same time period. CONCLUSION: After EVAR for AAA, aortoiliac volume on CT angiography decreases by approximately 20% over time in the absence of endoleaks and increases in the presence of endoleaks. Transient post-procedural endoleaks, however, do not influence long-term volume regression.