Stent-graft surface movement after endovascular aneurysm repair: baseline parameters for prediction, and association with migration and stent-graft-related endoleaks.

OBJECTIVES: To evaluate the influence of baseline parameters on the occurrence of stent-graft surface movement after endovascular aneurysm repair (EVAR) and to investigate its association with migration and stent-graft-related endoleaks (srEL). METHODS: In this retrospective, cross-sectional study, three-dimensional surface models of the stent-graft, delimited by landmarks using custom-built software, were derived from the pre-discharge and last follow-up computed tomography angiography (CTA). Stent-graft surface movement in the proximal anchoring zone between these examinations was considered significant at a threshold of 9 mm. The Cox proportional hazards model was used to determine baseline variables associated with the occurrence of stent-graft surface movement. The association between migration and srEL with stent-graft surface movement was tested with the chi-square and the Fisher exact test, respectively. RESULTS: Stent-graft surface movement was observed in 54 (28.9%) of 187 patients. Multivariate analysis revealed that age ([HR] 1.05; p = 0.017), proximal neck diameter ([HR] 5.07; p < 0.001), infrarenal aortic neck angulation ([HR] 1.02, p = 0.002), and proximal neck length ([HR] 0.62, p < 0.001) were significantly associated with the occurrence of stent-graft surface movement. Migration and srEL occurred in 17 (31.5%) and 5 (9.3%) patients, with and 11 (8.3%) and 2 (1.5%) without stent-graft surface movement (p < 0.001, p = 0.022). CONCLUSIONS: Age, neck diameter, infrarenal neck angulation, and proximal neck length were significantly associated with the occurrence of stent-graft surface movement. Apart from possible use of adjunctive sealing systems, concerned patients may benefit from regular CTA surveillance, enabling timely diagnosis of subtle changes of stent-graft position. KEY POINTS: • Stent-graft surface movement, demonstrating subtle, three-dimensional changes in stent-graft position in the proximal anchoring zone, can be derived from CTA examinations. • Age, proximal neck diameter, and infrarenal neck angulation were significantly associated with an increased incidence of stent-graft surface movement. Stent-graft surface movement is significantly more frequent in patients with stent-graft migration and stent-graft-related endoleaks. • Consideration of risk factors for stent-graft surface movement may help to identify patients who might benefit from regular CTA surveillance and timely diagnosis of subtle changes of stent-graft position, enabling re-interventions to prevent migration and srEL.

Melatonin attenuates thiocyanate-induced vasoconstriction in aortic rings.

Cigarette smoking not only has a carcinogenic effect but also leads to an increase in arterial blood pressure. Besides its main components, i.e. nicotine, tar, and carbon monoxide, cigarette smoke also contains thiocyanate. Thiocyanate anions (SCN-) arise from the detoxification of hydrogen cyanide and its plasma concentrations were found to correlate significantly with cigarette consumption. There is also evidence that atherosclerotic disease progression is much more rapid when serum SCN- levels are increased. Melatonin, a non-toxic indolamine with various physiologic functions, is believed to protect against inflammatory processes and oxidative stress. It has been demonstrated that melatonin serves as free radical scavenger and represents a potent antioxidant. Therefore, it is believed that melatonin with its atheroprotective effects may be useful either as a sole therapy or in conjunction with others. The aim of this study was to quantify the thiocyanate-induced vasomotor response in aortic tissue and further to examine the potential of melatonin in affecting the generated vasoreactivity. Aortic rings of adult male normotensive Wistar rats were cut into 4-mm rings. Following the administration of thiocyanate in various concentrations, vasomotor response of aortic vessel segments was measured. To assess the effect of melatonin on vasomotor activity, organ bath concentrations were modulated from 60 to 360 pM, which corresponds to physiologic plasma up to the levels of patients with regular oral intake of 3 mg of melatonin as a supplement. Thirty-six rat aortic rings were studied. When exposed to thiocyanate, vessel segments revealed vasoconstriction in a concentration-dependent manner. In rings which were preincubated with melatonin at a concentration of 360 pM, a 56.5% reduction of effect size could be achieved (4.09 ± 1.22 mN versus 9.41 ± 1.74 mN, P < 0.0001). Additionally, administration of 360 pM melatonin at a norepinephrine concentration of 80 mM resulted in a relaxation of 10.9 ± 2.2%. The vasodilatatory effect of melatonin was significantly reduced to 1.3 ± 0.5% when concentration of norepinephrine was doubled (P < 0.002). This study indicates that vessel segments that were exposed to thiocyanate responded with a dose-dependent vasoconstriction. The effect could be markedly attenuated in segments preincubated in melatonin.

Tension-Free Inlay Repair of Large Hiatal Hernias Using Dual-Sided Composite PTFE/ePTFE Meshes in Laparoscopic Surgery for Gastroesophageal Reflux Disease.

BACKGROUND: Patients with gastroesophageal reflux disease (GERD) also frequently suffer from concomitant hiatal hernia. It has been described that a preoperative hiatal hernia of ≥3 cm is associated with a more than threefold relative risk for reflux symptom recurrence after fundoplication without mesh reinforcement. In this report, we describe our experience with the implantation of dual-sided composite PTFE/ePTFE meshes in a tension-free fashion during laparoscopic antireflux surgery (LARS). METHODS: A prospective database containing data of all patients undergoing LARS and hiatal hernia repair with mesh implantation from January 2009 until December 2014 was interrogated. Ten patients with preoperative esophageal high resolution manometry and 24-hour pH impedance monitoring because of symptoms suggestive of GERD who received hiatal repair using dual-sided meshes in inlay technique were identified and included in this analysis. RESULTS: There were no conversions to open surgery in the study group. Median operative time was 138 minutes (interquartile range Q1-Q3: 119-151 minutes) and average length of postoperative stay was 3.5 days (interquartile range Q1-Q3: 2.3-4.0 days). During a median follow-up period of 43.3 months (interquartile range Q1-Q3: 18.9-47.1 months), no redo operations had to be performed. Noteworthy, 2 patients complained about dysphagia (20%) during follow-up, but symptoms resolved after endoscopic interventions. CONCLUSIONS: Tension-free inlay repair of large hiatal hernias using dual-sided composite PTFE/ePTFE meshes during LARS provides promising results. It provides satisfactory symptom relief and prolonged control of GERD. Further studies to validate its efficiency in a larger collective are needed.

Endovascular conversion into aorto-uniiliac configuration of acute failed endovascular aneurysm repair is associated with better one-year survival rates compared to open conversion.

BACKGROUND: Open conversions (OC) due to failed endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) are technically demanding because of preexisting prostheses and advanced aortic disease. This study evaluates the feasibility and outcomes of aorto-uniiliac endografting (AUI) as an alternative treatment option in acute failed EVAR. METHODS: From March 1995 through February 2012, 26 patients underwent acute conversion of failed EVAR at our tertiary care university center. All data were prospectively entered in our institutional database. Outcomes included 30-day or in-hospital mortality, postoperative complications, and mid-term survival. RESULTS: During the investigation period, a total of 692 patients received EVAR at our institution, while five of the 26 patients with acute conversion (19.2%) had an initial EVAR at an outlying institution and were referred for treatment. Therefore, our estimated institutional rate of acute conversions was 3% (21 of 692 EVAR). OC were performed in 14 patients (53.8%), while 12 patients underwent AUI (46.2%). An average time of 20.3 months (median: 18.6; interquartile range Q1-Q3: 0.0-38.6) elapsed between the initial EVAR and the acute conversion. All acute AUI conversion procedures were completed successfully. The 30-day mortality following acute conversions was 42.3% and since the use of AUI, it could be reduced to 33.3%. Kaplan-Meier estimates revealed a survival advantage for AUI at one year (p = 0.046), but the benefit was lost by mid-term follow-up (p = 0.103). CONCLUSIONS: AUI for the treatment of acute failed EVAR represents a feasible and less invasive alternative to OC, and is associated with better one-year survival rates.

Rates of adverse events and correction procedures after elective versus emergent aortouni-iliac endografting during mid-term follow-up: A prospective cohort study.

BACKGROUND: Due to preferential implantation of bifurcated devices during endovascular repair of infrarenal abdominal aortic aneurysms (AAA), longer-term results following aortouni-iliac (AUI) endografting are scarce. The aim of this study was to determine the rate of endoleaks as well as frequency of secondary correction procedures after elective and emergent AUI endografting. METHODS: A prospectively gathered database at a tertiary care university hospital was retrospectively reviewed from January 2000 until January 2012. This interrogation identified 61 patients who had undergone AUI endografting to treat their AAA. Data retrieval obtained 47 patients with elective AAA repairs while 14 patients received emergent AUI endografting in case of rupture. Procedural outcomes, endoleaks, complications, and secondary interventions during mid-term follow-up were recorded for analysis. RESULTS: Fifty-five patients of the study cohort were male (90.2%) and mean age was 76.5 years (median: 77.2, Q1-Q3: 72.1-81.6). Patient demographics, comorbidities, procedural characteristics, as well as median follow-up length (39.8 months versus 34.9 months) were similar between groups. Endoleaks, complications, and rate of secondary correction procedures were not increased following emergent AUI endografting. The majority of these interventions comprised catheter-based or less invasive surgical procedures. All patients requiring major surgery (three open surgical conversions with endograft explantation and one open aortic banding) survived, while one patient sustained fatal myocardial infarction after a transluminal correction procedure. CONCLUSION: Emergent AUI endografting was not associated with higher rates of adverse events or correction procedures during mid-term follow-up. Secondary interventions to maintain aneurysm exclusion could be carried out with low mortality.

Secondary modification into aortouniiliac configuration to salvage failed endovascular aneurysm repair is safe and effective but not associated with higher intervention rates during long-term follow-up.

BACKGROUND: Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE). METHODS: A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done. RESULTS: Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan-Meier estimates for long-term survival between groups were comparable (P = .36). CONCLUSIONS: Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

Aortouni-iliac endografting as an alternative salvage procedure to open conversion in failed endovascular aneurysm repair.

PURPOSE: To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration. METHODS: A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion. RESULTS: An average time of 52.2 months (median 46.9, IQR 0.0-92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done >30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0-17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero. CONCLUSION: Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Endovascular treatment of delayed rupture following prior abdominal aortic aneurysm repair achieves better survival rates.

PURPOSE: To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion. METHODS: All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3-4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality. RESULTS: The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011). CONCLUSION: Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Liver failure after major liver resection: risk assessment by using preoperative Gadoxetic acid-enhanced 3-T MR imaging.

PURPOSE: To determine if gadoxetic acid-enhanced magnetic resonance (MR) imaging with measurement of relative liver enhancement (RLE) on hepatobiliary phase images can allow preoperative assessment of the risk of liver failure after major liver resection. MATERIALS AND METHODS: The local institutional review committee approved this retrospective analysis and waived written informed consent. The study included 73 patients (39 men; median age, 64.4 years) who underwent gadoxetic acid-enhanced 3-T MR imaging before resection of three or more liver segments. RLE was calculated as the ratio of signal intensity measurements of the liver parenchyma before and 20 minutes after intravenous administration of gadoxetic acid. RLE was assessed in each liver segment and the mean value of all segments was used for analysis. Posthepatectomy liver failure was defined according to the "50-50 criteria" (ie, prothrombin time <50% and serum bilirubin >50 µmol/L on postoperative day 5) and the International Study Group of Liver Surgery (ISGLS) classification. The association of RLE and liver failure was tested with univariate and multivariate logistic regression analysis. In addition to RLE, the latter also included demographic, clinical, operative, and histologic variables. RESULTS: Patients with liver failure according to the 50-50 criteria (n = 3) had significantly lower RLE (54.5%) than those without (125.6%) (P = .009). According to ISGLS criteria, RLE was 112.5% in patients with grade A liver failure (n = 20), 88.4% in patients with grade B (n = 7), 41.7% (n = 2) in patients with grade C, and 136.5% (P < .001) in those without liver failure. In a logistic regression analysis, RLE was inversely related to the probability of liver failure according to the 50-50 (P = .02) and ISGLS (P < .001) criteria. In a multivariate analysis, RLE was independently associated with a higher probability of liver failure according to ISGLS classification (P = .003). CONCLUSION: Gadoxetic acid-enhanced MR imaging can help with the assessment of the risk for liver failure after major liver resection.

Low-level-laser irradiation induces photorelaxation in coronary arteries and overcomes vasospasm of internal thoracic arteries.

BACKGROUND AND OBJECTIVE: As low-level laser irradiation (LLLI) seems to induce vasodilation besides many other known biological effects, LLLI has been increasingly used in therapy of medical conditions with various irradiation parameters. The aim of this study was to investigate the effect of LLLI on photorelaxation of human coronary and internal thoracic arteries (ITA). MATERIALS AND METHODS: Thirty vessel segments of ITA used for routine coronary artery bypass grafting as well as left anterior descending coronary arteries (LAD) of patients undergoing cardiac transplantation were cut into 4-mm rings stored in a modified Krebs-Henseleit solution and evaluated in a myograph. Both types of vessel segments were irradiated by a semiconductor non-thermal GaAs diode laser operating at a wavelength of 680 nm. After precontraction with thromboxane agonist U44619, respective relaxation responses were evaluated and compared to pharmacological dilatation induced by substance P. RESULTS: Mean pharmacological vasodilation by substance P was 22.6 ± 3.3%, 12.8 ± 1.4%, and 20.4 ± 3.2% in macroscopic healthy LAD, LAD with atheromatous plaque, and ITA, respectively. Average photorelaxation induced by LLLI was 16.5 ± 2.0%, 1.9 ± 1.7%, and 6.8 ± 4.7%, accordingly. Vasodilatatory responses induced either by substance P or administration of LLLI were significantly decreased in LAD with atheromatous plaque (P < 0.0001). Vasospasms of ITA segments occurring during experiments could be abandoned when LLLI was administered. CONCLUSION: Macroscopic healthy LAD exposed to LLLI revealed significant photorelaxation. With the administration of LLLI, 73% of the maximal obtainable effect by an endothelium-dependent vasodilator could be reached. Furthermore, LLLI has the potential to overcome vasospasms of ITA.

Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up.

PURPOSE: To evaluate the frequency of type II endoleaks after endovascular aneurysm repair (EVAR) and to compare sac diameter and neck changes in patients with type II endoleak to endoleak-free patients with at least 3-year imaging follow-up. METHODS: Among 407 consecutive EVAR patients, 109 patients (101 men; mean age 72.1 years, range 55-86) had at least 3-year computed tomography (CT) data and no type I or III endoleak. In this cohort, 49 patients presented with a type II endoleak at some time and 60 patients had no endoleak. Patients with type II endoleaks were further divided into subgroups based on the vessel origin and the perfusion status (persistent or transient). The course of the perfusion status of type II endoleaks and changes in the aneurysm sac diameters, neck diameters, and renal to stent-graft distances (RSD) were evaluated in the defined groups. Reintervention and death rates were also reported. RESULTS: The mean follow-up was 68.1 ± 23.8 months. Compared to the no endoleak group, overall sac diameter increased significantly in the type II endoleak group (p = 0.007), but vessel origin did not have any influence. With regard to the perfusion status of type II endoleaks, aneurysm sac changes were significantly higher (p = 0.002) in the persistent endoleak group. During the study period, the increase in the proximal neck diameter was significantly higher in the no endoleak group compared to the type II endoleak group (p = 0.025). No significant difference was found in RSD changes between the defined groups. Reinterventions were performed in 20 (18.3%) patients (13 for type II endoleak); 2 (1.8%) patients without type II endoleak died of ruptured aneurysm. CONCLUSION: Persistent type II endoleaks led to significant aneurysm sac enlargement, but without increased mortality or rupture rates.

Light-induced vasodilation of coronary arteries and its possible clinical implication.

BACKGROUND: Low-level laser therapy and light-emitting diodes (LED) are increasingly used in phototherapy. Their therapeutic effects are at least partly mediated by light-induced vasodilation. The aim of this study was to determine the effect of different light sources on coronary arteries. METHODS: Porcine left coronary arteries were cut into 4-mm rings that were irradiated either by a semiconductor nonthermal gallium-arsenide diode laser or a noncoherent athermic red light source both with the same energy density up to 16 J/cm(2). After precontraction with 9, 11-dideoxy-11α, 9α-epoxymethano-prostaglandin F(2)α, respective relaxation responses were evaluated. The role of endothelium as well as intracellular pathways was investigated. RESULTS: Maximum vasodilation after exposure to laser was observed at 10 J/cm(2) (56.8% ± 1.2%) and decreased to 43.9% ± 2.8% at 16 J/cm(2) (p < 0.003). After adjusting exposure time to achieve equivalent energy densities in the LED group, vessel segments revealed photorelaxation of 52.9% ± 6.5% and 47.5% ± 0.6%, respectively. Vasodilations achieved by either light source were comparable at 10 J/cm(2) (p < 0.574) and 16 J/cm(2) (p < 0.322). Furthermore, vasodilation could be inhibited by administration of 2-(4-carboxyphenyl)-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide (nitric oxide scavenger) and 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (guanocyclase inhibitor) but not with L-nitro-arginine methyl ester or deendothelialization. CONCLUSIONS: Vessels exposed to either light source showed a remarkable as well as comparable photorelaxation at definite energy densities. This effect is mediated by an intracellular nitric oxide-dependent mechanism. As LED sources are of small size, simple, and inexpensive build-up, they may be used during routine coronary artery bypass surgery to ease suturing of anastomosis by target vessel vasodilation.

Complete ten-year follow-up after endovascular abdominal aortic aneurysm repair: survival and causes of death.

PURPOSE: To analyze the hazard and causes of death after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms during a complete ten year follow-up. METHODS: This is a retrospective clinical study of 130 consecutive patients undergoing EVAR between 1995 and 1998. One-hundred twenty-one patients (93.1%) were treated with first-generation stentgrafts and nine patients (6.9%) received second-generation devices. All patients completed a follow-up of at least 10 years, unless death occurred before then. Time and causes of death were provided by the Austrian central register of deaths. RESULTS: The median follow-up was 7.6 years, and the 130 patients had 968.5 person-years of follow-up. The ten-year mortality rate was 62.3%. Cardiovascular events were the most frequent causes of death, with a 3.9 incidence rate per 100 person-years. Cancer death and death due to other causes occurred in 2.1 and 1.8 cases per 100 person-years, respectively. Lethal late aneurysm rupture happened in 4.6% (n=6), which corresponds to an annual incidence rate of 0.6 per 100 person-years. All of those patients had been treated with first-generation devices. CONCLUSIONS: Cardiovascular events were the most frequent cause of death after EVAR, followed by malignancy and other diseases. The risk of dying from secondary rupture was clearly lower than that of death due to other reasons during ten years after EVAR, even in patients with first-generation stentgrafts.

The influence of comorbidities and etiologies on the success of extracorporeal shock wave therapy for chronic soft tissue wounds: midterm results.

Possible effects of comorbidities and of different wound etiologies on the success of extracorporeal shock wave therapy (ESWT) of chronic soft tissue wounds were investigated. From September 2003 until February 2007, 282 patients, being previously treated unsuccessfully were enrolled. Treatment consisted of ESWT occurring at defined intervals. At each treatment session a wound bed score was recorded, also at initial presentation a detailed patient history and wound etiology. Observed comorbidities were pooled according to the chapters of the ICD-10 system. Two hunderd fifty-eight patients were analyzed (91.49%) and underwent follow-up for a median of 31.8 months. Wound closure occurred in 191 patients (74.03%) by a median of two treatment sessions. No wound reappeared at the same location. A multivariate logistic regression model showed that pooled comorbidities and wound etiologies did not have a significant influence on success. Comorbidities and wound etiologies have surprisingly no significant influence on the success of ESWT.

Effect of blower-mister devices on vasoreactivity of coronary artery bypass grafts.

OBJECTIVE: Potential disadvantages, such as lower graft patency rates, that could lead to the need for more subsequent revascularization after off-pump coronary artery bypass grafting are discussed. One mechanism may involve endothelial damage originating from tools to facilitate a bloodless surgical field during anastomosis. We investigated the effect of the use of a blower-mister device on in vitro endothelial and contractile functions of human internal thoracic arteries and greater saphenous veins. METHODS: The distal ends of both bypass graft types were exposed to the air and water stream of the device for 10 minutes, representing the usual time needed for completion of an anastomosis using the off-pump technique. Vessel segments of both groups were cut into 4-mm rings and stored in a modified Krebs-Henseleit solution. Contraction responses to U44619 and relaxation responses to acetylcholine, substance P, papaverine, and nitroprusside were evaluated. RESULTS: Forty-eight artery ring segments from 8 patients were studied. Absolute maximum contraction to U44619 was significantly less in rings subjected to the blower-mister device than in controls (internal thoracic artery: 17.17 ± 2.57 mN vs 8.67 ± 4.54 mN, P < .048; greater saphenous vein: 28.33 ± 9.71 mN vs 11.42 ± 7.97 mN, P < .026). Control rings had significantly greater endothelium-dependent relaxation response to acetylcholine (mean difference 29.2% ± 3.4%, P < .001), whereas those subjected to the blower-mister device had reduced responses. Endothelium-independent relaxation to nitroprusside was not significantly different among the groups. CONCLUSIONS: Vessels exposed to the air and water stream of a blower-mister device showed a reduced vasoreactivity. This effect should be studied further, especially if it contributes to lower graft patency rates in off-pump surgery.

Improved survival after abdominal aortic aneurysm rupture by offering both open and endovascular repair.

BACKGROUND: In the treatment of ruptured abdominal aortic aneurysm (rAAA), the results of open graft replacement (OGR) have remained constant but discouraging for the last 4 decades. Provided suitable anatomy, elective endovascular abdominal aortic aneurysm repair (EVAR) is less invasive and leads to improved perioperative mortality. Thus, it is reasonable to assume that endovascular treatment should improve the results of rAAA therapy. OBJECTIVE: To determine whether the use of both endovascular and open repair of rAAA leads to improved results. DESIGN: A single-center, retrospective analysis of 89 patients suffering from rAAA treated either by EVAR or OGR. PATIENTS: From October 1999 until July 2006, a consecutive series of patients with rAAA were analyzed. Time was divided into 2 periods of 41 months. During the first period, 42 patients were treated by OGR exclusively. Period 2 started with the availability of an EVAR protocol to treat rAAA; 31 patients received open repair while 16 patients underwent EVAR. MAIN OUTCOME MEASURES: Kaplan-Meier survival estimates were calculated and compared. RESULTS: Survival estimates showed a statistically significant reduction in overall postoperative mortality following the introduction of EVAR (P < .03). The 90-day overall mortality rate was reduced from 54.8% to 27.7% during the second period (P < .01). Survival of patients older than 75.5 years was especially improved (75% vs 28.6%; P < .01). There was a parallel pattern of significant reduction of the mortality rate after OGR to 29% (P < .03). CONCLUSION: Offering both EVAR and OGR to patients with rAAA leads to significant improvements in postoperative survival.

Effect of body armor on simulated landmine blasts to cadaveric legs.

BACKGROUND: Antipersonnel landmine protective footwear relies on blast deflection or on exaggerated standoff between the foot and the explosive. Neither design has been tested for clinical effectiveness. METHODS: 4 cadaveric lower extremities--3 fitted with a Koflach boot incorporating TABRE (Technology for Attenuating Blast Related Energy) were subjected to controlled blast with charges of up to 100 g trinitrotoluene (TNT). The blasts were recorded by a digital recording system. All legs were X-rayed and underwent computed tomography scanning before and after testing. RESULTS: TABRE-protected limbs directly subjected to the blast hyperextended at the knee during firing. Injuries showed a pattern of open tibial fractures (Gustilo grade I, II), of multiple calcaneal (Sanders Type III, IV), and fibular fractures and of the tibial plateau, but showed no traumatic amputation. CONCLUSIONS: Development of protective footwear against landmine blast is feasible. From medium mines up to charges of 100 g TNT limb salvage may be possible.

Abdominal aortic aneurysms and concomitant diseases requiring surgical intervention: simultaneous operation vs staged treatment using endoluminal stent grafting.

HYPOTHESIS: To investigate whether staged or synchronous treatment of infrarenal abdominal aortic aneurysms (AAAs) and concomitant diseases (CDs) requiring surgical repair plays a clinical role. We considered endovascular aneurysm repair (EVAR) in particular. DESIGN: Review of a prospectively gathered database. SETTING: Tertiary care university teaching hospital. PATIENTS: We reviewed a total of 946 patients receiving elective AAA exclusion from 1980 through 2002. We divided the period into 2 observation intervals: 1980-1994, when only open graft replacement was available (n = 331), and 1995-2002, with 615 patients (326 who had open graft replacement and 289 who had EVAR). With regard to the physical status, expressed by the score from the American Society of Anesthesiologists (Park Ridge, Ill), we recorded in-hospital mortality rates and checked possible differences. MAIN OUTCOME MEASURES: Indications for therapy and mortality rates before and after the availability of EVAR. RESULTS: During the first interval, 14 simultaneous operations were carried out. During the second period, 19 patients received simultaneous operations while 49 underwent staged treatment using EVAR. The overall mortality rate was 3.7%. Irrespective of the American Society of Anesthesiologists classification, the mortality rate for patients who had EVAR was 0% in comparison with 13.6% for patients in American Society of Anesthesiologists class 3 or 4 after open graft replacement (P<.03). CONCLUSIONS: The coincidence of a patient having both an AAA and a CD is rare but should not be neglected. Staged treatment of AAAs using EVAR followed by surgical therapy for CDs can be an effective causal therapy with an acceptable mortality rate provided that suitable aneurysm anatomy exists.

Endografting increases total volume of AAA repairs but not at the expense of open surgery: experience in more than 1000 patients.

PURPOSE: To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. METHODS: A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeon's discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001-2002 after the introduction of "high-risk" screening criteria (age > or = 72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. RESULTS: While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p > 0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p = 0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p = 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p > 0.05) and fell still further to 1.2% in the most recent period (p = 0.021 versus pre EVAR). CONCLUSIONS: The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.

[Ruptured abdominal aortic aneurysms: status quo after a quarter century of treatment experience]. / Rupturierte abdominelle Aortenaneurysmen: Status quo nach einem Vierteljahrhundert Behandlungserfahrung.

BACKGROUND: Postoperative mortality rates between 40% and 50% have been invariably reported for the treatment of ruptured abdominal aortic aneurysms (rAAA) over the last 50 years. The aim of this analysis was to investigate which patient subgroups benefit from open surgery and in which subgroups a change of treatment strategies should be considered due to lack of improvement despite optimal patient management. PATIENTS AND METHODS: From 1980 to 2002 a total of 230 patients underwent surgery because of a ruptured AAA. The observation period was divided into 3 intervals to achieve an approximately equal distribution of patients. The effect of the observation period and of baseline parameters on mortality rates were investigated. RESULTS: Between 1980 and 1990, 72 patients were operated with a mortality rate of 38.9% (n = 28). During the second period (1991-1996) surgery was performed in 72 patients with a mortality rate of 40.3% (n = 29). In the third observation interval (1997-2002) 86 patients underwent surgery with an unvaried high mortality rate of 40.7% (n = 35). By applying a logistic regression model including age, gender, modality of rupture, location of cross-clamping and type of operation, only the modality of rupture and the patient's age, which are uncontrollable by the surgeon, could be shown to have a significant impact. CONCLUSION: Summing up these findings, open surgical repair of rAAA only leads to acceptable results when performed in younger patients without supposed comorbidities. Survival appears to be accidental in patients with advanced age and increased prevalence of relevant comorbidities/underlying diseases. Minimally invasive techniques may offer promising treatment options to those patients, as they do in elective interventions.