Decreased angiogenesis as a possible pathomechanism in cervical degenerative myelopathy.

Endogenous immune mediated reactions of inflammation and angiogenesis are components of the spinal cord injury in patients with degenerative cervical myelopathy (DCM). The aim of this study was to identify alteration of certain mediators participating in angiogenetic and inflammatory reactions in patients with DCM. A consecutive series of 42 patients with DCM and indication for surgical decompression were enrolled for the study. 28 DCM patients were included, as CSF samples were taken preoperatively. We enrolled 42 patients requiring surgery for a thoracic abdominal aortic aneurysm (TAAA) as neurologically healthy controls. In 38 TAAA patients, CSF samples were taken prior to surgery and thus included. We evaluated the neurological status of patients and controls prior to surgery including NDI and mJOA. Protein-concentrations of factors with a crucial role in inflammation and angiogenesis were measured in CSF via ELISA testing (pg/ml): Angiopoietin 2, VEGF-A and C, RANTES, IL 1 beta and IL 8. Additionally, evaluated the status of the blood-spinal cord barrier (BSCB) by Reibers´diagnostic in all participants. Groups evidently differed in their neurological status (mJOA: DCM 10.1 ± 3.3, TAAA 17.3 ± 1.2, p < .001; NDI: DCM 47.4 ± 19.7, TAAA 5.3 ± 8.6, p < .001). There were no particular differences in age and gender distribution. However, we detected statistically significant differences in concentrations of mediators between the groups: Angiopoietin 2 (DCM 267.1.4 ± 81.9, TAAA 408.6 ± 177.1, p < .001) and VEGF C (DCM 152.2 ± 96.1, TAAA 222.4 ± 140.3, p = .04). DCM patients presented a mild to moderate BSCB disruption, controls had no signs of impairment. In patients with DCM, we measured decreased concentrations of angiogenic mediators. These results correspond to findings of immune mediated secondary harm in acute spinal cord injury. Reduced angiogenic activity could be a relevant part of the pathogenesis of DCM and secondary harm to the spinal cord.

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.

[Thoracoabdominal aortic aneurysm]. / Thorakoabdominelles Aortenaneurysma.

Thoracoabdominal aortic aneurysms (TAAA) are rare events with an incidence of 5.9 cases per 100,000 persons per year. In Germany approximately 940 TAAA procedures are performed annually. The cause of TAAA is mostly degenerative but they can also occur on the basis of an aortic dissection or connective tissue disease (e. g. Marfan's syndrome). Patients often have severe comorbidities and suffer from hypertension, coronary heart disease or chronic obstructive pulmonary disease, mostly as a result of smoking. Operative treatment is indicated when the maximum aortic diameter has reached 6 cm (> 5 cm in patients with connective tissue disease) or the aortic diameter rapidly increases (> 5 mm/year). Treatment options are open surgical aortic repair with extracorporeal circulation, endovascular repair with branched/fenestrated endografts and parallel grafts (chimneys) or a combination of open and endovascular procedures (hybrid procedures). Mortality rates after both open and endovascular procedures are approximately 8 % depending on the extent of the repair. Furthermore, there are relevant risks of complications, such as paraplegia (up to 20 %) and the necessity for dialysis. In recent years several approaches to minimize these risks have been proposed. Besides cardiopulmonary risk evaluation, clinical assessment of patients by the physician with respect to the patient-specific anatomy influences the allocation of patients to one treatment option or another. Surgery of TAAA should ideally be performed in high-volume centers in order to achieve better results.

[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.

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.

Anatomic changes of target vessels after fenestrated and branched aortic aneurysm repair.

AIM: Objective of this study was to evaluate the anatomic changes of the stented target vessels after endovascular repair of complex aortic aneurysms. METHODS: Between July 2011 and December 2013, 53 aortic aneurysms were treated in our department with fenestrated and branched stent-graft devices. Forty-two of these patients were pre- and postoperatively scanned with a high resolution computer tomography (CT) (Cook Zenith® fenestrated or branched, Australia Pty. Ltd., Brisbane, Australia: N.=19; AnacondaTM fenestrated, Vascutek, Glasgow, Scotland, UK: N.=23). The other 11 out of the 53 patients did not receive a CT scan, because of a pre-existing renal failure. In the CT scans we retrospectively evaluated the anatomic vessel deviation at the origin of the target vessel and the vessel shift distal to the stent. For the first measurement the CT scans were loaded into OsiriX MD®, and the pre- and postoperative angles of the target vessels were measured and subtracted. For matching, the CT-scans were normalized at vertebral body lumbar 2. The second measured angle was the maximal measured angle distal to the target vessel stent-graft. RESULTS: Altogether, 113 target vessels were stented (celiac trunk [CT] 15, superior mesenteric arteries [SMA] 26, renal arteries [RA] 72), with 97 balloon-expandable PTFE stents: 90 Atrium V12 (Maquet Getinge group, Hudson, NH, USA), 7 BeGrafts (Bentley InnoMed, Hechingen, Germany) and 16 self-expandable fluency PTFE stents (Bard, Karlsruhe, Germany). The mean anatomic deviation at the target vessel origin was 28±17.3 and the mean vessel shift distal to the stent was 36.3±18.8. There were no significant differences between the main device and the target vessel stent types. CONCLUSION: Fenestrated and branched stent-graft solutions for aortic aneurysm repair induce changes of the target vessel anatomy. We did not observe significant differences between the several devices.

Late rupture after EVAR: a new trend?

AIM: Endovascular aortic repair (EVAR) is an adequate therapy for abdominal aortic aneurysms (AAA). Late aortic ruptures caused by endoleaks after EVAR still remain a critical issue. The aim of this study was to assess the causes of ruptured aortic aneurysms after EVAR in a single center study. METHODS: All patients, who were treated in our University hospital with a ruptured juxtra- or infrarenal AAA between January 2011 and October 2013, were included in this retrospective analysis. RESULTS: Thirty patients with ruptured infra- or juxtrarenal aneurysms were treated in this time frame. Six out of these 30 patients had previous EVAR repair. The median maximal aneurysm diameter of these post-EVAR patients was 82 (75-95) mm. The median time between primary EVAR and rupture was 42.5 (14-99) months. Three patients with type Ia endoleaks were treated by stent removal and conventional aortic reconstruction. In two patients with type II endoleak the bleeding was controlled by occluding the back bleeding lumbar arteries. One type III endoleak was sealed by an additional stent-graft implantation into the right iliac artery. CONCLUSION: We observed a considerable number of patients with a ruptured AAA after EVAR. Surprisingly, we observed two ruptured aneurysms due to type II endoleaks.

Optimizing the pharmacotherapy of vascular surgery patients by medication reconciliation.

AIM: Medication errors may occur at any stage during the medication process and can lead to preventable adverse drug events and patients' harm. Pharmacists' support for reconcilable medication has been shown to be effective, rectifying errors and inaccuracies of the drug treatment and in the increase of medication safety. However, none of the previous studies focused on vascular patients. We investigated the nature and frequency of drug-related problems (DRPs) including the amount of potentially inappropriate medication (PIM) prescribed for elderly patients suffering from vascular diseases and the influence of pharmacists in the improvement of cardiovascular medication. METHODS: After the patients' routine admission process, medication reconciliation was performed. Therefore, a pharmacist obtained an accurate medication use history. The patients' drug therapy was critically screened for DRPs and referring to this, intervention was made by the pharmacist and communicated to the physician if necessary. Potentially inappropriate medication in the elderly was reviewed through a retrospective analysis using the Priscus-List. DRPs were documented anonymously and classified. RESULTS: We identified 138 DRPs among 105 patients. Sixty-five patients experienced at least 1 DRP, accordingly 1.3 DRPs per patient. In total, 43 unintended discrepancies between current medication and admission medication were detected with an overall rate of 0.41 per patient; 100 interventions were made of which 56 resulted in explicit recommendations for prescription changes. Drug classes frequently affected by DRPs were antihypertensive in 23.9%, antithrombotic agents in 19.3% and lipid lowering agents in 12.1%. In a retrospective analysis of the home medication, 12 definite PIM were identified in 49 elderly patients. CONCLUSION: DRPs are common in the medication of vascular surgery patients and may be improved by pharmacists.

A new shunting concept to prevent lower limb ischemia/reperfusion injury in prolonged fenestrated stent-graft procedures.

AIM: Complex endovascular procedures to treat thoracoabdominal aortic aneurysms (TAAA) can be time consuming and therefore comprise the risk of lower limb ischemia with subsequent reperfusion injury and compartment syndrome. Aim of this study was to evaluate a new protective method to prevent these postoperative problems. METHODS: In order to maintain blood perfusion to both legs during prolonged endovascular aortic procedures we developed a shunting technique with two additional 7 French (Fr) sheaths in both superficial femoral arteries. We evaluated the perfusion technique in 5 patients with fenestrated endovascular aortic aneurysms repair (FEVAR). First, we measured the flow in the 7 Fr sheaths; second, we clinically controlled the lower limb for developing compartment syndrome. Third we measured creatinine kinase (CK) as marker for postoperative muscular damage. RESULTS: In 5 male patients (median age 77, range 59-80 years) undergoing endovascular TAAA repair, the perfusion technique was feasible. The median flow per catheter was 102 mL/min (range 61-156.5 mL/min) and monophasic with a mean arterial blood pressure of 71 mmHg (range 56-82 mmHg). No patient developed a compartment syndrome. The CK levels were only lightly elevated. CONCLUSION: This simple perfusion technique allows adequate lower limb perfusion during prolonged complex endovascular aortic procedures.

Intentional left subclavian artery coverage without revascularization during TEVAR.

At present, endovascular therapy is a well-established treatment for different types of thoracic aortic pathologies. There is growing evidence, that thoracic endovascular aortic repair (TEVAR) has advantages over open repair with regard to perioperative morbidity and mortality in the treatment of thoracic aortic aneurysms. However, in up to 50% of TEVAR procedures the proximal end of the stent-graft will (partly) cover the origin of the left subclavian artery (LSA) in order to achieve a save sealing zone. Intracranial stroke and paraplegia are feared complications and might be associated with LSA exclusion from the circulation. Unfortunately, no reliable technique is available to assess the individual risk of stroke and paraplegia in case of LSA coverage, so that the indication for LSA revascularization continues to be matter of assuming and guessing. The quality of available evidence on necessity or superfluity to revascularize the LSA is very low and studies report, to some extent, controversial outcome after intentional LSA coverage. In the light of the devastating consequences for patients in case of neurological complications due to LSA coverage the question of prophylactic LSA revascularization remains a significant problem which is elucidated and discussed in this manuscript.

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.

Technical challenges and anatomic anomalies encountered during aortic surgery.

Since the introduction of endovascular techniques for the treatment of aortic pathologies, clinical application of these lesser invasive procedures has increased exponentially during the last two decades and changed daily vascular practice completely. Starting in the infra-renal aorta, the indications for endovascular repair have gradually extended to the suprarenal aorta, aortic arch, descending and thoracoabdominal aorta. In addition, other pathologies than aneurysms have been treated by endovascular means, including dissection, traumatic injuries, penetrating aortic ulcer, intramural hematoma and aorto bronchial fistula. With increased application, short-term and longer-term technical failures have developed, in the majority of cases managed by repeat endovascular techniques. However, these complications cannot always be solved by endotechniques, requiring conversion to open surgery. At present there are additional reasons why open surgical repair remains a mainstay in the treatment of complex aortic diseases. Younger patients might choose for traditional surgery because of the unknown durability of complex endovascular reconstructions. Patients with connective tissue disease suffer from vulnerable aortic tissue in which endografts might behave different as compared to degenerative aneurysms. Therefore, the modern vascular surgeon should not only be trained in endovascular procedures but also master the wide spectrum of open surgical techniques. Besides anatomical knowledge and standard vascular handling, the surgeon must be familiar with unusual variations and unexpected situations.

[Intraoperative neuromonitoring for prevention of neurological complications in aortic surgery]. / Intraoperatives Neuromonitoring zur Prävention neurologischer Komplikationen bei Aortenbogen- und thorakoabdomineller Aortenchirurgie.

AIM: Stroke and paraplegia are devastating complications of thoracic and thoracoabdominal aortic surgery. The aim of this study was to analyse the value of transcranial Doppler ultrasound (TCD), electroencephalogram (EEG) and motor-evoked potentials (MEP) in preventing neurological complications. Moreover, the principles, technology and surgical protocols are described. PATIENTS AND METHODS: In 2009, 22 patients (4 females, 18 males) underwent thoracic or thoracoabdominal open aortic repair. We performed 2 arches with descending aortic replacement, 5 arches with TAAA repair, 2 type II, 9 type III, 3 type IV and one type V TAAA aortic repair. In 6 patients, the neuromonitoring included TCD, EEG and MEPs. In 15 patients only MEP monitoring was necessary. In one patient who was operated on in an emergency setting, neuromonitoring was not performed. The surgical approach was a left thoracotomy in 3 and a left thoracolaparotomy in 19 patients. The surgical protocol included cerebrospinal fluid drainage (n=22), moderate (n=19) or deep hypothermia (n=2), and extracorporeal circulation (n=21) with retrograde aortic perfusion and selective cerebral and/or viscerorenal perfusion. RESULTS: In 21 patients, the neuromonitoring could be established successfully. Using TCD and EEG, a relevant cerebral ischaemia during supraaortic clamping was excluded. With a mean distal arterial pressure of 60 mmHg, the MEPs remained adequate in 15 patients (68.2%). Increasing of the blood pressure restored the MEPs in one patient. In 5 patients (22.7%), a reimplantation of segmental arteries (n=4) or of the left subclavian artery (n=1) re-established spinal cord perfusion, as indicated by restored MEPs. We had no absent MEPs at the end of the procedures. Delayed paraparesis developed in 2 patients with a haemodynamic instability during the postoperative course. Paraplegia was not observed. CONCLUSION: TCD, EEG and MEPs are reliable techniques to unmask cerebral or spinal cord ischaemia during aortic surgery. Immediate operative strategies based on neuromonitoring information prevent neurological complications in aortic surgery.

Gastro-pericardial fistula as an early complication after surgery for combined paraesophageal and hiatal hernia.

Open surgery is still used to treat massive combined paraesophageal and hiatal hernias. The operative principles include repositioning of the stomach in the abdomen, resection of the hernia sac, narrowing of the hiatus, and gastropexy. We report on a case in which a life-threatening, gastro-pericardial fistula was an early complication after open surgical treatment.