Urine neutrophil gelatinase-associated lipocalin predicts outcome and renal failure in open and endovascular thoracic abdominal aortic aneurysm surgery.

Urine neutrophil gelatinase-associated lipocalin (uNGAL) has been evaluated as a biomarker for AKI detection and adverse outcome in open and endovascular thoracoabdominal aortic aneurysm surgery. This observational, retrospective study included 52 patients. UNGAL was measured peri-operatively (48 h) and correlated with AKI requiring dialysis, tracheotomy and adverse outcome. Mean patients' age was 64.5 years. A total of 26.9% (n = 14) developed AKI, and 21.1% (n = 11) required dialysis, tracheotomy rate was 19.2% (n = 10) and in-hospital mortality rate was 7.6% (n = 4). uNGAL levels were related to AKI requiring dialysis at ICU (p = 0.0002), need for tracheotomy at baseline and admission on ICU (p = 0.0222, p = 0.0028, respectively), as well as adverse discharge modality (p = 0.0051, p = 0.0048, respectively). Diagnostic quality was good for uNGAL levels at admission to ICU regarding AKI requiring dialysis (sensitivity: 81.8% [48.2-97.7]; specificity: 87.8% [73.8-95.9]; area under the curve (AUC): 0.874 [0.752-0.949]). The diagnostic quality of uNGAL was favorable for the prediction of tracheotomy (sensitivity: 70.0% [34.8-93.3]; specificity: 83.3% [68.6-93.0]; AUC: 0.807 [0.674-0.903]) and adverse discharge (sensitivity: 77.8% [40.0-97.2]; specificity: 83.7% [69.3-93.2]; AUC: 0.817 [0.685-0.910]). uNGAL may be valuable as an post-operative predictor of AKI and adverse outcome after open and endovascular TAAA repair.

Surgical sutures: coincidence or experience?

BACKGROUND: Knotting sutures by hand is still important in daily surgical routine, especially laparotomy closure. The expectation is that hand suturing relies on the experience and subjective estimation of the surgeon. The aim of this study was to investigate whether hand suturing tension is reproducible and if surgical experience influences reproducibility. METHODS: At the annual Congress of the German Association of Surgery, 118 surgeons performed repetitive sutures on a standardized and certified measuring device simulating the final knot of a fascial closure. Each surgeon was asked to perform five identical single knots in a row using the suture tension that each considered ideal. Tension during knotting was measured in Newtons. The surgeons were divided into five subgroups based on surgical experience: group 1, <1 year; group 2, 2-5 years; group 3, 6-10 years; group 4, 11-20 years; and group 5, >30 years. RESULTS: The tension measured at the end of knotting ranged from 0.19 to 10 N. The mean suture tension at endpoint was 3.88 N for group 1 and slightly higher in the other groups, but not significantly different. The overall mean suture tension was 5.43 N and did not correlate with surgical experience. Suture tension was not reproducible. CONCLUSION: Sequential suture tension varied, even among experienced surgeons. The ideal tissue-dependent suture tension has not been defined. Measured values appear to be intuitive, relying on individual feeling rather than the level of experience.

Interventional treatment of postthrombotic syndrome.

BACKGROUND: Postthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT) and has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is related more to venous obstruction than it is to venous reflux. The use of interventional techniques for the treatment of venous obstruction and/or venous occlusion has rapidly increased in recent years. OBJECTIVE: This article summarizes the current concept of endovenous and hybrid interventions and presents the optimized treatment of choice in patients with chronic symptomatic venous obstruction. METHODS: We performed a systematic literature search in the Medline database to identify relevant studies on the treatment of patients with PTS. RESULTS: A meta-analysis of the relevant studies showed that this minimally invasive procedure is an effective treatment option with low morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good mid-term patency rates and a significant decrease in related symptoms. CONCLUSION: Interventional therapy for the treatment of symptomatic chronic venous obstruction has become the method of choice in recent years. More studies are needed to evaluate the long-term success rate of dedicated venous stents.

Effect of a new incision management system (PREVENA®) on wound healing after endophlebectomy of the common femoral vein: a case series.

BACKGROUND: New endovascular techniques facilitate treatment of complex deep vein obstructions in cases of post-thrombotic syndrome. In a relevant number of these patients, endophlebectomy including the implantation of an arteriovenous fistula between the common femoral artery and the femoral vein is indispensable in order to establish a good inflow. These procedures display a high risk of wound complications. Despite conservative efforts to prevent these postoperative complications, wound healing problems occur in more than 20 % of cases. The present case report is the first description of wound dressing using a PREVENA® incision management system in cases of endophlebectomy. CASE PRESENTATION: A single center's experience with the incision management system PREVENA®, which was used after endophlebectomy and venous stenting in complex hybrid procedures in three white men aged 46 years, 53 years, and 61 years is the subject of this case report. Although the surgical procedures were performed under therapeutical anticoagulation and took a couple of hours, no wound complications occurred. CONCLUSIONS: These encouraging results underline a potential benefit of the incision management system PREVENA® in cases of complex venous recanalization including endophlebectomy of the femoral vein as well as the implantation of an arteriovenous fistula.

[The Compression Syndrome of Lumbar Arteries - Case Report of a Rare Disease Pattern]. / Das Kompressionssyndrom der Lumbalarterien - Kasuistik eines seltenen Krankheitsbilds.

STUDY DESIGN: We present a monocentric analysis of the lumbar artery compression syndrome (LACS) in the form of a case report. OBJECTIVES: Literature information was collected about the symptoms, diagnosis and treatment of this rare disorder in the context of the existing data. METHODS: The current medical literature includes only one report about three cases of LACS, collected over 20 years in France and Germany. We compared these cases with the experience of the European Vascular Center Aachen-Maastricht. RESULTS: The symptoms of this rare disorder are dominated by reversible, motion-dependent paralysis of the legs. Compression of the right lumbar arteries by muscular fibres or connective tissue is a fundamental cause. CONCLUSION: Surgical treatment, which means decompression of the lumbar arteries via a thoracolaparotomy, is an appropriate therapy with few complications and good long-term results.

[Popliteal artery aneurysma as an important differential diagnosis]. / Das Poplitealarterienaneurysma als wichtige Differenzialdiagnose.

A common reason for painful lesions of the popliteal fossa are baker's cysts. An important differential diagnosis is the popliteal artery aneurysm, which is rare, but is associated with severe complications. The preferred method of diagnosis is the colour-coded duplex ultrasound. By showing the case of a 58-year-old man, who experienced life-threatening complications caused by an insufficient diagnosis before the operation of a Baker's cyst, we want to underline the importance of preoperative duplex ultrasound diagnosis in this context.

[Pro and contra: aggressive or conservative thrombosis therapy? - Pro aggressive thrombosis therapy]. / Pro und Kontra: Aggressive oder konservative Thrombosetherapie? - Pro aggressive Therapie.

The post-thrombotic syndrome (PTS), long-term sequelae of a deep vein thrombosis (DVT), reduces quality of life and is of great socio-economic importance. Despite conservative treatment which does not directly facilitate recanalization more than 25% of patients develop PTS. Early thrombus removal may decrease the incidence and severity of PTS. Although the evidence for surgical thrombectomy is weak which allows an early and rapid recanalization, this therapy appears to reduce the risk of PTS and iliofemoral thrombosis. Systemic thrombolysis can reduce the incidence of PTS but it is no longer recommended due to serious bleeding complications. Previous studies with new endovascular catheter-guided procedures allowing local application of thrombolysis and thrombus aspiration displayed promising results. However, so far one prospective randomised study (CaVent study) with long-term results has revealed a significant reduction of PTS. The current evidence recommends early thrombus removal for patients at high risk for PTS. New endovascular procedures such as catheter-guided thrombolysis allow rapid thrombus removal but more prospective randomised studies are necessary to ensure the long-term success of this therapy.

Treatment of symptomatic aberrant subclavian arteries.

OBJECTIVE: The aim of this study is to present experience with 10 patients with symptomatic aberrant subclavian artery (ASA) and aneurysm of ASA who underwent surgical treatment. METHODS: From 2008 to 2011 10 patients with symptomatic aberrant subclavian artery (mean age 60 years [range 24-90 years]) were studied. Symptoms were dysphagia (n = 7), dyspnea (n = 4), acute chest pain (n = 1), respiratory distress syndrome (n = 1), superior cava syndrome, and shock (n = 1). Six patients had aneurysm formation of the ASA (mean diameter of 7.1 cm [range 3.0-12.4 cm]; rupture [n = 1], dissection [n = 1]). All data were analyzed retrospectively. RESULTS: Treatment was performed as a hybrid procedure in eight patients. This included thoracic endoluminal graft exclusion with revascularization of the ASA, a pure endovascular procedure with two occluders in one patient, and an open procedure in one patient with ligation of the aberrant artery through a thoracotomy. Three patients died during the early postoperative period owing to pulmonary complications. All three suffered from a symptomatic aneurysm, and two were treated as an emergency procedure. Median follow-up was 20 months (range 12-49 months). CONCLUSION: A symptomatic ASA and its associated aneurysmal formation should be excluded after diagnosis. In most cases, a hybrid procedure consisting of thoracic endografting and revascularization of the ASA is feasible.

What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?

In this review we evaluated the effect of different suggested factors associate with the outcome after recanalization of chronic venous obstruction (CVO). HEMODYNAMIC FACTORS: Based upon literature no clear suggestions can be made to identify the risk of stent occlusion in association with the hemodynamic effects. However it is evident that ensuring optimal in- and outflow of the stented tract is key in maintaining the patency. PATIENT SELECTION: Noninvasive imaging modalities are used to divide patients in three subgroups based on the place and extension of post-thrombotic changes. Moreover it should be noted that AV fistula in selected patients can reduce the risk of thrombosis or re-occlusion. GEOMETRY: Excessive oversizing of the stent and stent compression from outside are considered to be associated with stent occlusion. Additionally, overlapping rigid stents, unnatural angel between stents and in-stent kinking are other geometrical factors related to worse outcome after venous recanalization. ANTICOAGULATION: Adequate peri-and postoperative anticoagulation has a crutial role in stent patency. There is no data regarding the duration of anticoagulation therapy and recommendations vary between 6 weeks to 6 months. RESULT: impaired inflow or outflow, presence of a hypercoagulability, total number of treated segments and use of stents designed for implantation in arterial system are associated with decreased stent patency.

Catheter-directed thrombolysis in deep vein thrombosis: Which procedural measurement predicts outcome?

The post-thrombotic syndrome (PTS) as a long-term consequence of deep vein thrombosis (DVT) is caused by a venous obstruction and/or chronic insufficiency of the deep venous system. New endovascular therapies enable early recanalization of the deep veins aiming reduced incidence and severity of PTS. Extended CDT is associated with an increased risk of bleeding and stenting of residual venous obstruction is indispensable to avoid early rethrombosis. Therefore, this article focuses on measurements during or after thrombolysis indicating post procedural outcome.

Thoracoabdominal aneurysms and changes in adjacent vertebral bodies.

AIM: The aim of this study was to assess if chronic intermittent pressure of a thoracoabdominal aortic aneurysm (TAAA) induces structural changes in vertebral bodies and if eroded vertebral bones can still be found after the extermination of syphilis. METHODS: A retrospective analysis of computed tomography (CT) scans of patients with TAAA was performed. In the anatomical regions were the TAAA was in close contact with the vertebral bodies, the vertebral body alteration was distinguished into 4 categories. Category 0: no changes; 1: discrete changes, minimal asymmetry; 2: obvious asymmetry of the vertebral body with sustained cortical layer; 3: severe destruction of the vertebral body with loss of the cortical layer. RESULTS: Eighty-six CT scans of patients (mean age 63; range 25-82 years) with TAAA pathology were examined (24 female, 62 male). The mean aneurysm diameter was 6.5 cm (4.3-14 cm). The results for scoring were: category 0: 33 patients; category 1: 46 patients; category 2: 5 patients and category 3: 2 patients. One of the category 3 patients suffered from acute spinal cord compression with complete paraplegia. In total, 62% of patients showed some degree of changes at vertebral bodies adjacent to the TAAA. CONCLUSION: Intermittent pressure by either dissecting or non-dissecting TAAAs may induce structural changes in the vertebral bodies of the spine. Severe destruction of the bone is a rare, but existing complication.

Carbon dioxide-contrasted computed tomography angiography: high pitch protocols and adapted injection parameters improve imaging quality.

PURPOSE: To systematically investigate the impact of image acquisition and contrast injection parameters for CO2-enhanced CT angiography (CTA) of the aorto-iliac and peripheral arteries in a pig model using commercially available equipment. The aim was to establish an imaging protocol that is ready for use in human subjects. MATERIALS AND METHODS: Three domestic swine underwent CO2-CTA with varying injection parameters: pitch (1.0, 3.0), injection pressure (0.7 bar, 1.0 bar, 1.3 bar) and scan delay (2 s, 4 s, 6 s). Objective (vessel diameter) and subjective (image quality) parameters and applied radiation doses were systematically evaluated. To ensure clinical applicability of the setting, only approved catheters/injectors and standard injection parameters were evaluated. RESULTS: The image quality scores were superior and the vessel diameter was larger with high pitch in comparison to standard pitch (diameters: 4.7 ± 2.0 mm vs. 3.6 ± 2.1 mm, p = 0.0040, scores: 2.6 ± 1.1 vs. 2.0 ± 1.1, p = 0.0038). High injection pressure (1.3 bar) improved the image quality as assessed by subjective and objective ratings (diameters: 3.6 ± 2.0 mm, 4.0 ± 2.1 mm and 4.6 ± 2.1 mm, for 0.7, 1.0 and 1.3 bar, p-values ≤ 0.0052, scores: 1.9 ± 1.1, 2.3 ± 1.1 and 2.7 ± 1.2, p-values ≤ 0.0017), the same was observed for a shorter injection delay (diameters: 3.5 ± 2.0 mm, 4.2 ± 2.1 mm and 4.8 ± 2.1 mm, for 6 s, 4 s, and 2 s, p ≤ 0.0022, scores: 1.9 ± 1.1, 2.3 ± 1.1 and 2.7 ± 1.1, p-values ≤ 0.0013). The dose length products were 239 ± 47 mGycm (high pitch) and 565 ± 63 mGycm (standard pitch, p-values < 0.0001). CONCLUSION: A higher pitch, shorter delay and higher injection pressure improve image quality in CO2-enhanced CTA. Since commercially available, clinically approved equipment was used. The protocol is now ready for use in human subjects.

[A false aneurysm as a rare complication of knee arthroscopy]. / Aneurysma spurium als seltene Komplikation einer Kniegelenksarthroskopie.

We present the rare case of a false aneurysm of the genus lat which occurred after knee arthroscopy. Apart from a pulse-synchronic swelling in close proximity to the former anterolateral portal there were no complaints and no pain. The diagnostic and therapeutic strategies - in this case performed with coiling of the involved vessel - are presented and discussed.

Safety and feasibility of ultrasound-accelerated catheter-directed thrombolysis in deep vein thrombosis.

OBJECTIVE: One in four patients with primary iliofemoral deep vein thrombosis (DVT) develops post-thrombotic syndrome (PTS) within 1 year despite optimal standard anticoagulant therapy. Removal of thrombus by thrombolytic drugs may prevent PTS. The aim of this study was to assess the short-term safety and efficacy of ultrasound-accelerated catheter-directed thrombolysis (US-accelerated CDT). DESIGN: This was a prospective non-randomised interventional study with US-accelerated CDT for DVT. PATIENTS AND METHODS: Twelve patients with DVT (seven caval-iliofemoropopliteal, three iliofemoropopliteal, one femoropopliteal and one superior caval vein thrombosis) receiving standard anticoagulant and compression therapy, were treated with additional US-accelerated CDT (13 procedures) using the EKOS Endowave(®) system (EKOS Corporation, Bothell, WA, USA) between October 2008 and January 2010. RESULTS: Thrombolysis was successful in 85% (11/13), with complete clot lysis (>90% restored patency) and in one case with partial clot lysis (50-90% restored patency). No pulmonary embolism and one bleeding at the catheter-insertion site were observed. In three patients, underlying lesions were successfully treated with balloon angioplasty and stent insertion. Four patients developed early recurrent thrombosis due to untreated residual venous obstruction. CONCLUSION: US-accelerated CDT is a safe and promising treatment in patients with DVT. Residual venous obstruction should be treated by angioplasty and stent insertion to avoid early re-thrombosis.

Serum analyses for protein, albumin and IL-1-RA serve as reliable predictors for seroma formation after incisional hernia repair.

PURPOSE: The aim of this study was to identify potential parameters as predictors for seroma formation after incisional hernia mesh repair. METHODS: The incidence of postoperative seroma was determined prospectively in 37 patients who underwent incisional hernia repair with lightweight polypropylene-polyglactin composite mesh (Vypro-II®). Postoperative seroma manifestation was related to patient characteristics (gender, age, BMI, comorbidity, nicotine abuse) and to preoperative serum concentration of total protein, albumin, interleukin-1-receptor-antagonist (IL-1-RA), propeptid-III-procollagen, hyaluronan and fibronectin. Ultrasound investigation was performed on postoperative days 1, 2, 3, 8 and 10. RESULTS: Ten patients (27%) developed seroma with a mean volume of 77 ± 88 ml. Higher BMI correlated with increased seroma formation (P = 0.038). In patients with seroma, total protein (67 ± 7 vs 72 ± 4 g/l; P = 0.037), albumin (42 ± 3 vs 40 ± 4 g/l; P = 0.018) and IL-1-RA (1.4 ± 1 vs 0.8 ± 0.6 U/ml; P = 0.048) exhibited significantly altered serum concentrations in comparison to patients without seroma formation. No significant differences were seen in any other parameters. CONCLUSIONS: High BMI, lowered preoperative serum concentration of total protein and albumin, and high serum concentration of IL-1-RA are related to an elevated risk for postoperative seroma formation.

Marfan Syndrome: when to operate TAA(A)s?

Marfan Syndrome is a heritable disorder of connective tissue leading to aortic aneurysms and other cardiovascular complications associated with reduced life expectancy. Marfan patients with thoracic aortic aneurysms (TAAs) or with thoracoabdominal aortic aneurysms (TAAAs) should be treated by means of open surgery, requiring an extensive protocol, including extracorporeal circulation, neuromonitoring and adjunctive modalities to provide organ protection. Then, open surgical repair of TAA(A)s are associated with excellent results. However, in the last time a gradual change to endovascular treatment in Marfan patients is observable. Particularly in patients with an increased surgical risk due to redo sternotomy or thoracotomy, endovascular treatment might be an alternative due to its less invasive approach. Consequently, thoracic endovascular aortic repair comprises a therapeutic alternative in individual situations even in Marfan patients, when the landing zones are safe and appropriate. In cases of failed endovascular therapy, however, conversion to open surgery remains still an option with acceptable results, although the distal and proximal clamping positions change inappropriate with larger extensions due to the aortic stent.

Different methods of mesh fixation in open retromuscular incisional hernia repair: a comparative study in pigs.

PURPOSE: Reinforcement of the abdominal wall with alloplastic mesh material in incisional hernia repair is well established. To avoid dislocation and migration of the prostheses, mesh fixation is recommended. However, there seems to be a correlation between postoperative pain and mesh fixation. Furthermore, it remains unclear whether mesh fixation is necessary at all. METHODS: A retromuscular mesh implantation was performed in 36 pigs using a polypropylene-polyglecaprone 25 composite mesh (Ultrapro(®), 12 × 18 cm). In group 1, the mesh was fixed to the posterior rectus sheet with non absorbable single sutures (Prolene(®) 2-0), in group 2 fixation was with absorbable sutures (Vicryl(®) 2-0), in group 3 mesh fixation was with 5 ml fibrin sealant (Quixil(®)), and, as a control, there was no fixation in group 4. The abdominal wall was explanted on postoperative day 7, 14 and 56. Mesh size and position was measured, and pull-out force of the mesh was analysed mechanically by tensiometry. The ratio of collagen type I/III was analysed to determine the quality of mesh integration. RESULTS: Neither mesh dislocation nor mesh migration was detected. Mesh size showed no significant differences, whether comparing time points or groups. No significant differences in the tensile strength of mesh integration were found when comparing the groups (group 1: 155 ± 17 mmHg; group 2: 175 ± 9 mmHg; group 3: 166 ± 24 mmHg; group 4: 172 ± 28 mmHg). Though the type I/III collagen ratio increased over time, no significant differences according to the type of fixation used were detected. CONCLUSION: Mesh fixation in open incisional hernia repair with retromuscular mesh augmentation to avoid mesh dislocation or migration in the early postoperative period appears to be unnecessary.

[The value of postoperative ultrasonography]. / Stellenwert der Sonographie in der postoperativen Phase.

In the early period following surgery, it is very important to reveal any complications. In this article the role of ultrasound in recognizing postoperative complications is demonstrated. Ultrasound findings in typical complications of abdominal surgery such as bleeding, abscess formation, acute cholecystitis, pancreatitis, and postoperative ileus are described. The diagnosis of postoperative bleeding, acute cholecystitis, and ileus is very reliable by ultrasound (sensitivity and specificity >95%). Ultrasonography is inferior to computed tomography in detecting pancreatitis and abscess formation. The guiding of interventions by ultrasound offers additional therapeutic options.