[Treatment of the femoropopliteal arteries with a novel rotational atherectomy system: early single-center experience with the Pathway PVTM Atherectomy System]. / Behandlung von Läsionen der femoropoplitealen Arterien mittels eines neuartigen Rotationsatherektomiesystems: Erste single-center Erfahrungen mit dem Pathway PVTM Atherectomy System.

PURPOSE: The main problem when treating the superficial femoral and popliteal artery with PTA or stent implantation is the relatively high restenosis rate. Several ablative systems are available as an alternative. The purpose of this prospective study was to evaluate the safety and performance of a novel rotational and aspirating atherectomy system. MATERIALS AND METHODS: From June to December 2006, we treated 23 patients, median age 70.3 years (58-91), with the rotational atherectomy system. All patients had de-novo lesions of the SFA or PA with a minimum stenosis of 70%. According to the Rutherford classification, 39% of the patients were in category 2 and 61% in category 3. The median lesion length was 26.3 mm (5-100 mm). 26% of the patients had occlusions. RESULTS: The technical success rate was 100%. In 14 cases (61%) additional balloon dilatation was applied, in two cases stent implantation were performed. The median treatment duration with the device was 187.7 +/- 106.1 s (59-391 s). The aspirated volume was 116.5 +/- 72.0 ml. The ankle brachial index improved from preinterventional 0.60 +/- 0.16 to postinterventional 0.85 +/- 0.13 and after 6 month 0.80 +/- 0.13. During follow-up, two (8%) restenosis occurred. There were two complications, one dissection and one distal embolization. Follow-up could not be performed for two patients (8%). CONCLUSION: Atherectomy of femoropopliteal lesions with the Pathway PV Atherectomy System is very safe and effective. The low restenosis rate of 8% is promising, but there is still a lack of long-term results.

[Mechanical rotational thrombectomy for treatment thrombolysis in acute and subacute occlusion of femoropopliteal arteries: retrospective analysis of the results from 1999 to 2005]. / Mechanische Rotationsthrombektomie zur Behandlung von akuten und subakuten Okklusionen der femoropoplitealen Arterien: Retrospektive Auswertung der Ergebnisse von 1999 bis 2005.

PURPOSE: Direct intra-arterial thrombolysis is the standard of care over acute surgical intervention for acute infrainguinal occlusion. However, several mechanical thrombectomy devices can be utilized as a less invasive alternative to rapid reperfusion of the acutely threatened limb. MATERIALS AND METHODS: Retrospective analysis of 265 patients treated from 1999 to 2005, mean age 65+/-8.4 (range from 47 to 75) years, with acute (85 patients, 32.1 %, group 1) or subacute (180 patients, 67.9 %, group 2) occlusions of the femoropopliteal artery with a rotational thromboembolectomy system (Straub Rotarex). The mean occlusion length was 25 (range 2 - 40) cm. RESULTS: The technical success rate was 94.7 % (251 / 265). In the additional 14 patients, no complete clot removal (n = 9) or intraluminal guidewire passage was able to be achieved (n = 5). After a mean follow-up of 12 +/-3 months, the restenosis rate was 49 % in group 1 and 54 % in group 2. The ankle-brachial index improved in group 1 from 0.32 +/- 0.17 to 0.78+/- 0.24 at discharge and 0.71 +/- 0.23 after 12 months (p < or =0.001) and in group 2 from preinterventional 0.47+/- 0.24 to 0.81 +/- 0.19 at discharge and 0.74 +/- 0.24 after 12 months (p < or = 0.001). There were 16 (6 %) distal embolizations and 3 (1.2 %) perforations. There were no cases of amputation or death during follow-up. CONCLUSIONS: The mechanical rotational thrombectomy is a very safe and effective alternative to local lysis. The only limitation is that there is no treatment possible in the infrapopliteal artery.

[Treatment of acute femoropopliteal bypass graft occlusion: comparison of mechanical rotational thrombectomy with ultrasound-enhanced lysis]. / Behandlung akuter Okklusionen von femoropoplitealen Bypässen: Vergleich der mechanischen Rotationsthrombektomie mit der ultraschallgestützten Lyse.

PURPOSE: Mechanical thrombectomy has become a viable alternative to intra-arterial thrombolysis for the treatment of acute infrainguinal occlusion. The aim of this prospective study was to evaluate the safety and effectiveness of a mechanical thrombectomy system in comparison with ultrasound-enhanced thrombolysis. MATERIALS AND METHODS: From April 2005 to March 2007, 20 patients, mean age 67.4+/-13.6, with acute occlusions of the femoropopliteal bypass graft were treated with either a rotational thrombectomy system (Straub Rotarex, n=10) or with 1.0 mg/h Actilyse using an ultrasound-enhanced lysis system (EKOS Lysus Peripheral Catheter System, n=10). The mean occlusion length was 33.1 cm (range 28-40 cm) in the thrombectomy group and 33.7 cm (11-50 cm) in the lysis group. RESULTS: The technical success rate was 100% in the thrombectomy group and 90 % in the lysis group. The mean treatment time was significantly lower with 64.5 min (45-90 min) in the thrombectomy group in comparison with 904.0 min (120-1350 min) in the lysis group. The ankle brachial index (ABI) improved in the thrombectomy group from 0.41+/-0.09 to 0.86+/-0.10 at discharge and 0.85+/-0.07 after 1 month (p<0.05) and in the lysis group from preinterventional 0.37+/-0.15 to 0.82+/-0.16 at discharge and 0.80+/-0.24 after 1 month (p<0.05). In one case lysis had to be stopped after two hours because of dislocation of the introducer sheath which was then treated by open surgery. CONCLUSION: Mechanical-rotational thrombectomy with the Rotarex system and lysis with the ultrasound-enhanced catheter from Ekos were very safe and effective treatment options for acute occlusion. Blood flow is restored much faster with mechanical thrombectomy.

Treatment of long superficial femoral artery occlusions with excimer laser angioplasty: long-term results after 48 months.

PURPOSE: To evaluate clinical and hemodynamical long-term results after laser angioplasty of long occlusions of the superficial femoral artery (SFA). MATERIAL AND METHODS: In a prospective trial of 452 patients with long occlusions of the SFA, excimer percutaneous transluminal laser angioplasty (PTLA) for recanalization was applied. The average occlusion length of the SFA was 25.5 cm (range 16-38 cm). The recanalization attempt was done with the crossover technique in 398 patients, in 36 patients with the antegrade technique and in another 18 patients with the transpopliteal technique. RESULTS: The application of laser angioplasty demonstrated a successful recanalization of the SFA in 386/452 patients (85.5%). Recanalization with PTLA was not possible in 66 patients (14.5%). The main reason for the unsuccessful PTLAs was obstructing calcified material (n = 28) resistant to PTLA application. After a follow-up period of 48 months there was a primary, primary-assisted, and secondary patency rate of 22.3%, 40.9%, and 43.2%, respectively. CONCLUSION: Laser angioplasty of long occlusions of the SFA is a feasible procedure with a low failure rate. Long-term results are promising, but additional interventions are required in most patients if a patency rate of 43.2% is to be achieved after 4 years.

[Extracapsular spread of cervical lymph node metastases: diagnostic relevance of ultrasound examinations]. / Kapseldurchbrüche zervikaler Lymphknotenmetastasen: Diagnostischer Stellenwert der Sonographie.

OBJECTIVE: Assessment of the value of ultrasound examination in the determination of extracapsular neoplastic infiltration and soft tissue infiltration of cervical lymph nodes. MATERIAL AND METHODS: In a prospective study the results of ultrasound studies in 110 patients with squamous cell carcinoma in the head-neck region were compared with the findings of the histologic examination after neck dissection. RESULTS: Ultrasound examination showed a specificity of 81.8 % in the determination of extracapsular neoplastic infiltration. The sensitivity was only 78.6 % - this was mainly caused by microscopic extracapsular growth, which gave false-negative results. Infiltration of blood vessels were identified in all patients. There was only one false negative diagnosis of muscle infiltration. CONCLUSION: The specificity (81.8 %) and sensitivity (78.6 %) of ultrasound examinations in the diagnosis of extracapsular infiltration in patients with lymph nodes metastasis is promising. But the examiner has to keep in mind that especially microscopic extracapsular neoplastic infiltration cannot be seen in ultrasound.

Current status of power Doppler and color Doppler sonography in the differential diagnosis of lymph node lesions.

The use of Power Doppler sonography in nodal diseases provides an improvement of early and noninvasive diagnosis of regional metastatic involvement. By using Power Doppler sonography it is possible to characterize lymph nodes as reactively enlarged, metastases, malignant lymphoma, tuberculosis and to study cervical cysts. The high diagnostic accuracy is based on perfusion-characteristics of these lymph nodes. Reactive lymph nodes show increased central perfusion of the hilum, whereas metastases tend to show increased peripheral perfusion. Affected lymph nodes in patients with by malignant lymphoma are highly perfused in the center but also peripheral. Power Doppler sonography is still not able to discriminate small (<8 mm) nonnecrotic metastasis or micrometastases from reactive lymph nodes. The purpose of this paper is to provide a summary of the current status of power Doppler and Doppler sonography in the differential diagnosis of lymph nodes.

Short (1-10 cm) superficial femoral artery occlusions: results of treatment with excimer laser angioplasty.

PURPOSE: To evaluate the safety and long-term results after laser angioplasty of short occlusions of the superficial femoral artery (SFA). METHODS: In a prospective trial in 312 patients with short occlusions of the SFA excimer laser angioplasty for recanalization was applied. The average occlusion length of the SFA was 7.5 cm (range 1-10 cm). The recanalization attempt was done using either a cross-over technique from the contralateral femoral artery (278 patients), antegrade technique (16 patients) or transpopliteal technique (18 patients). RESULTS: Percutaneous transluminal laser angioplasty (PTLA) produced successful recanalization of the SFA in 286 of 312 patients (91.7%). In 26 patients (8.3%) recanalization was not possible. The reason for the unsuccessful PTLAs was obstructing calcified materialn = 8) which was resistant to laser application. In nine cases obstructing calcifications resulted in positioning of the laser catheter in subintimal tissue or perforation of the SFA. In another four patients there was an aberrant anatomy of the SFA which resulted in a direct vessel injury after advancing the laser catheter. In five patients subintimal recanalization failed. After a follow-up period of 36 months there was a primary, primary assisted and secondary patency rate of 49.2%, 76.5% and 86.3%. CONCLUSION: Excimer laser angioplasty of short occlusions of the SFA is a feasible procedure with a low failure rate. Long-term results are promising but additional interventions are required in most patients to achieve a patency rate of 86.3% after 3 years. Further studies are needed to compare the clinical outcome of PTLA and PTA in short occlusions of the SFA.

[Extracapsular spread of cervical lymph node metastases: Diagnostic value of magnetic resonance imaging]. / Kapseldurchbrüche zervikaler Lymphknotenmetastasen: Diagnostischer Stellenwert der Magnetresonanztomographie.

OBJECTIVE: Assessment of the value of magnetic resonance tomography in the determination of extracapsular neoplastic spread and soft tissue infiltration of cervical lymph nodes. MATERIALS AND METHODS: The results of magnetic resonance tomographies of 110 patients with squamous cell carcinoma in the head-neck region were prospectively compared with the findings of the histologic examination after neck dissection. RESULTS: Magnetic resonance tomography reaches a specificity of 72.2 % in the detection of extracapsular neoplastic spread. The sensitivity of the method is 74.4 %. Mainly small (less than 1 cm; n = 11) extracapsular growth was not detected and was diagnosed false-negative in the MRI examinations. CONCLUSION: The specificity (72.2 %) and sensitivity (74.4 %) of MRI examinations to detect extracapsular spread of lymph nodes is only partially satisfying.

Excimer laser-assisted recanalisation of femoral arterial stenosis or occlusion caused by the use of Angio-Seal.

The aim of this study was to demonstrate the effect of excimer laser and balloon angioplasty of femoral artery stenosis and occlusion after use of a haemostatic puncture closure device. A haemostatic puncture closure device (Angio-Seal) was used in 6000 patients after diagnostic or therapeutic artery catheterisation. In 34 of those patients symptoms of peripheral artery disease occurred. Sixteen of those 34 cases were transferred to our clinic for excimer laser angioplasty. All 16 patients presented with symptoms of acute peripheral artery disease within 1-14 days: superficial femoral artery (SFA) occlusions (4 cases); superficial femoral artery stenosis (3 cases); high-grade stenosis of the common femoral artery (CFA; 3 cases); high-grade stenosis of CFA; SFA and profund femoral artery (PFA; 3 cases); and occlusions of CFA, SFA and PFA (3 cases). Before any procedure was performed, informed consent was given by the patient, which included the use of the Angio-Seal closure device. Every patient who had to undergo recanalisation procedures gave additional informed consent which especially included the usage of the excimer laser for recanalisation. A measurement of the walking distance, ankle-brachial systolic pressure index (ABI) and diagnostic angiography was performed in 13 cases before and immediate after as well as 3 and 6 months after therapeutic percutaneous transluminal laser angioplasty followed by balloon angioplasty (PTLA/PTA). In 3 patients the risks of PTLA/PTA was considered too high; those patients underwent surgical repair. Angiographic and clinical improvement was achieved in 13 of 13 patients. The mean walking distance increased from 81 to > 400 m. The average ankle-brachial systolic pressure index (ABI) increased from 0.47 to 0.84. One patient developed a dissection of the SFA, and in 1 case a peripheral embolisation was seen. The PTLA/PTA technique is a successful therapeutic option for patients with femoral artery occlusion or high-grade stenosis after Angio-Seal application.

[Treatment of arterial traumas by the Wallgraft endoprosthesis]. / Behandlung von iliakalen Gefässverletzungen mittels der Wallgraft-Endoprothese.

PURPOSE: Percutaneous peripheral interventional procedures as well as coronary interventions can be complicated by dissections and traumatic lesions of peripheral arteries. The aim of this study was to evaluate the efficacy of treatment for traumatic peripheral arterial lesions. MATERIAL AND METHODS: In this study we used the Wallgraft-Endoprothesis (Boston Scientific, USA), which is a self-expanding covered stent. In 17 patients a total number of 24 endoprostheses (mean length 6.4 cm) were implanted in iliac arteries. Indications for stenting were large dissections (n = 9), arterial perforations (n = 4), aneurysms (n = 3), and stent in stent implantation (n = 2). RESULTS: An immediate exclusion of the lesion could be achieved in all cases. There were no major procedural complications. The primary patency after a mean follow-up of 18 months was 82.4% (14/17). Early reocclusion was seen in two cases, one stent in stent reocclusion and one reocclusion after acute stent thrombosis. In one other case the angiography revealed relevant restenosis (> 75%). The patency could be restored in one of these three cases leading to a secondary patency rate of 94.1%. CONCLUSIONS: The Wallgraft-Endoprotheses seems to be safe and effective to seal large dissections and traumatic lesions of peripheral arteries, showing a high long-term patency rate.

Treatment of catheter-induced iliac artery injuries with self-expanding endografts.

PURPOSE: To evaluate the efficacy of fabric-covered endoprostheses for percutaneous repair of traumatic iliac artery lesions. METHODS: Among 47 patients treated for catheter-induced iliac artery injuries, 20 (42%) patients (13 men; mean age 58 +/- 10 years, range 41-76) presented with acute (n = 7) or subacute (n = 13) lesions considered inappropriate for bare stent implantation (17 dissecting aneurysms, 2 perforations, and 1 traumatic arteriovenous fistula). The self-expanding Cragg EndoPro System I or Passager devices were deployed percutaneously to exclude the defects. RESULTS: Immediate exclusion of the lesion was achieved in all 20 cases; there were no major procedural complications. However, within 24 hours after implantation, fever (n = 11, 55%) and elevations in white blood cell count (n = 10, 50%) and C-reactive protein (n = 13, 65%) were seen in the majority of patients, which prolonged hospitalization in this group (8.4 versus 4.2 days). During a median 21-month follow-up (range 5-31), 2 angiographically documented restenoses at the outlet of the endografts were treated successfully with balloon angioplasty, achieving primary and secondary patency rates of 87% and 100%, respectively. CONCLUSIONS: Early model stent-grafts provided a safe and effective endovascular treatment for iliac perforations and large arterial dissections, showing a high mid-term patency rate. However, postimplantation syndrome appears to occur frequently with this type of Dacron-covered nitinol device.

Treatment of postinterventional pseudoaneurysms by ultrasound-guided compression.

RATIONALE AND OBJECTIVES: This 3-year study was performed to evaluate the effectiveness and safety of ultrasound-guided compression (UGC) in the treatment of postinterventional pseudoaneurysms (PAs). METHODS: One hundred ten PAs were sonographically diagnosed after peripheral or cardiac interventions. In 98 patients (65 men and 33 women; age range, 44-79 years), UGC was performed. The PAs were related to the common femoral artery (n = 78), the superficial femoral artery (n = 26), the profound femoral artery (n = 2), and the distal external iliac artery (n = 4). The PAs showed diameters ranging from 0.8 to 9.86 cm (mean, 4.8 cm) and volumes between 0.6 and 109 mL (mean, 15.6 mL). Follow-up examinations including color Doppler-coded ultrasound and peripheral Doppler were performed after 18 hours +/-6 and 28 days +/-4. RESULTS: Complete closure of the PA and its neck was achieved by UGC in 96 of 98 cases (98%). In 86 of 98 cases (87.8%), UGC was successful during the first session; a second treatment was needed in 10 cases. The compression time varied from 12 to 85 minutes (mean, 35.6 minutes). Except for medically controllable vagal reactions in 4 of 98 cases (4.1%) and 1 easily controlled PA rupture, no treatment-related complications were observed. CONCLUSIONS: According to the effectiveness and safety results, we conclude that UCG is the method of choice in the treatment of postinterventional PAs. Diagnosis and UGC treatment should be performed as early as possible to minimize symptoms and hospitalization time.

Laser angioplasty of peripheral arteries after unsuccessful recanalization of the superficial femoral artery.

AIM: To demonstrate the range of applying laser angioplasty after unsuccessful recanalization of the superficial femoral artery (SFA) with conventional interventional techniques. MATERIALS AND METHODS: In a prospective trial in 94 cases with occlusion of the SFA and formerly unsuccessful conventional percutaneous transluminal angioplasty, laser angioplasty for recanalization was applied. The average occlusion length of the SFA was 17.5 cm (range 4-36 cm). The recanalization attempt was made using the crossover technique in 78 patients, in eight patients with the antegrade technique and in another eight patients using the transpopliteal technique. The primary recanalization attempt was performed with Terumo wires (curved and straight) as well as different catheters (Multipurpose/Vertebralis/Cobra). After the unsuccessful recanalization attempt the laser catheter was applied. RESULTS: The application of laser angioplasty demonstrated a successful recanalization of the SFA in 76/94 patients (80.9%). In 18 patients (19.1%) the recanalization was not possible even with percutaneous transluminal laser angioplasty (PTLA). The reason for the unsuccessful PTLA was in 10 cases due to obstructing calcified material, which was resistant to PTLA application. In four cases obstructing calcifications caused the laser catheter to be positioned in subintimal tissue, resulting in perforation of the SFA. In another four patients there was an aberrant anatomy of the SFA which resulted in a direct vessel injury after advancing the laser catheter. After a follow-up period of 12 months primary, primary-assisted and secondary patency rates were 50.0%, 65.8% and 73.7%, respectively. DISCUSSION: In primarily unsuccessful recanalization of the SFA, PTLA allows in 80% of cases a successful recanalization of the SFA. The technical success rate and the patency rate support the application of PTLA.

Differential diagnosis of lymph node lesions. A semiquantitative approach with power Doppler sonography.

RATIONALE AND OBJECTIVES: To assess the value of power Doppler for distinguishing reactive from malignant lymph node disease. METHODS: In a prospective study, 48 untreated patients with palpable cervical lymph node enlargement (n = 211) underwent examination with power Doppler sonography. The perfusion sites were subdivided into three groups: central, peripheral, and hilar perfusion. In addition, the authors qualified the intensity of perfusion using a semiquantitative scale from 0 (no perfusion) to III (high perfusion). Finally, the overall perfused lymph node area was measured and the percentage of perfused nodal area was calculated. RESULTS: Power Doppler sonography showed perfusion in 183 of 211 lymph nodes. Histologic examination revealed 67 reactively enlarged lymph nodes, 72 metastases, and 44 lymphomas. Reactively enlarged lymph nodes showed characteristically intense hilar perfusion (82.1%), whereas nodal metastases exhibited mainly peripherally located flow (84.7%) of grade intensity I to III. Lymph nodes invaded by malignant lymphoma were highly perfused, displaying color signals in the center as well as in the nodal periphery (90.9%). CONCLUSIONS: The perfusion patterns of lymph nodes provide useful additional information in the differential diagnosis of cervical lymphadenopathy.

[The extracapsular spread of cervical lymph node metastases: the diagnostic value of computed tomography]. / Kapseldurchbrüche zervikaler Lymphknotenmetastasen: diagnostischer Stellenwert der Computertomographie.

OBJECTIVE: To assess the value of computed tomography in the determination of extracapsular neoplastic spread and soft tissue infiltration of cervical lymph nodes. MATERIALS AND METHODS: Prospectively 165 CT reports of patients with squamous cell carcinoma in the head-neck region were compared with the histologic specimens after neck dissection. RESULTS: CT reached a sensitivity of 80.9% in the determination of extra-capsular neoplastic spread. The infiltration of cervical muscles and the jugular vein was always determined but-often diagnosed false-positive. Therefore, the overall specificity in determining extracapsular neoplastic spread was low with 72.7%. CONCLUSIONS: The accuracy of computed tomography (76.3%) in the determination of extracapsular neoplastic spread, infiltration of cervical muscles and the jugular vein is only partially satisfying.

[Results of "cross-over implantation of Palmaz-stents" with cross-over sheaths]. / Ergebnisse der "Cross-over Implantation von Palmaz-Stents" mit Cross-Over Schleuse.

PURPOSE: Presentation of technique of cross-over stent implantation of Palmaz stents using a cross-over sheath. MATERIAL AND METHODS: Between 1996 and March 1997 72 patients presenting symptoms of peripheral artery disease received 136 Palmaz stents, which were implanted in a cross-over technique with the aid of a cross-over sheath. RESULTS: As indications for stent implantation occurred: occlusion (n = 14), recoil (n = 11), distinctive calcification (n = 32), recurring stenosis/occlusion (n = 32), perforation (n = 3), dissection (n = 31), and aneurysms (n = 2). The cross-over technique with the aid of a cross-over sheath was successful in all 136 cases. Within the first 24 hours 3 acute reocclusions occurred (all femoral). For stents placed in the iliac artery the primary patency rate was 93.3% at 12 months and for stents placed in the femoral artery 72.0%. Furthermore, this techniques allows for simultaneous stenting of pelvic, femoral or lower leg arteries (n = 17). By using this technique, stenting of the distal external iliacal artery, common femoral artery (CFA) and proximal superficial femoral artery becomes either possible for the first time or easier. CONCLUSION: If Palmaz stents with a length of 2-7.8 cm should be implanted in the cross-over technique, the use of a cross-over sheath is recommended.