Measurements After Image Post-processing Are More Precise in the Morphometric Assessment of Thoracic Aortic Aneurysms: An Intermodal and Intra-observer Evaluation.

OBJECTIVES: Precise pre-procedural anatomical analysis of aneurysmal anatomy is essential for successful thoracic endovascular aortic repair (TEVAR). Since surgeons and radiologists have to perform multiple measurements in the same patient, high intra-observer reliability of any imaging method is mandatory. Commercially available three dimensional (3D) post-processing techniques are expected to be superior to conventional two dimensional multiplanar reconstructions (MPRs) derived from computed tomography angiograms (CTAs). However, few data exist to support this view. This study aims to evaluate the intermodal and intra-observer differences using 3D software (3surgery) in descending thoracic aortic aneurysms (dTAAs). METHODS: Pre-operative CTAs (performed between 2004 and 2010) of 30 dTAAs (mean maximum diameter 61.4 ± 13 mm) were assessed by three independent investigators with different experience in the measurement of aortic pathologies. Intra-observer reliability and intermodal differences (3D vs. 2D) were investigated using pre-specified measurement points (distances of total length, maximum diameter, proximal and distal landing zones). Statistical analyses were performed using the Bland-Altman method and a mixed regression model. RESULTS: Intermodal comparison showed that 2D measurements significantly underestimate the measured distances (maximum diameter 3.7 mm [95% CI -5.3 to -2.1] and landing zone maximum 1.4 mm [95% CI -2.0 to -0.2] shorter with 2D, p < .05). In almost all 3D measurements, all investigators showed lower variability comparing the intra-observer differences, most notably in the measuring point total length (reduction of the SD up to 7.9 mm). CONCLUSIONS: These data show that both techniques led to significant measurement disparity. This occurs especially at the point of indication (maximum diameter) and the total length of the aneurysm (important for correct stent graft selection). But overall the variability is reduced with the 3D technique, which also tends to measure greater distances. The use of post-processing software therefore leads to more precise device selection for TEVAR in TAA.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.

OBJECTIVES: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

[Traumatic rupture of the aorta: origin, diagnosis, and therapy of a life-threatening aortic injury]. / Traumatische Aortenruptur. Pathomechanismus, Diagnostik und Therapie einer lebensbedrohlichen aortalen Verletzung.

In polytraumatized patients, traumatic rupture of the thoracic aorta is usually caused by blunt vascular injuries due to deceleration. The aortic injury is generally located distal to the left subclavian artery. Even without further thoracic lesions, a computer tomography should be performed in the emergency room, because a rupture can exist even in the absence of symptoms. The traditional therapeutic option is open, left thoracotomy followed by direct aortic reconstruction. Alternatively, endovascular implantation of a thoracic stent graft can be performed immediately in urgent situations or, with delayed priority, under systematically management of the blood pressure. In this article, not only the mechanisms of injury but also diagnostic and therapeutic options of traumatic rupture of the thoracic aorta are described. As depicted by two case histories, potential symptoms and prognosis of patients with this life-threatening vascular lesion depend on accompanying injuries. With rapid diagnosis and treatment, there is the possibility of good recovery from traumatic aortic rupture.

[The diabetic foot]. / Der diabetische Fuss.

In the last 20 years the prevalence of diabetes in Germany has increased by approximately 50%. Associated with this is a distinct rise of diabetes-induced comorbidities and long-term consequences. One of the most frequent consequences is the diabetic foot or the diabetic foot syndrome. This is an ulceration of neuropathic and angiopathic origin, which often reaches a chronic stadium due to a poor healing tendency. Despite the disease management program for diabetes in Germany which mainly concentrates on the prophylaxis and multidisciplinary treatment of chronic diseases, there are approximately 250,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years. To achieve a reduction of the amputation rate identification of the main reasons is necessary. In addition a professional therapy of the vascular disorders and a stage-adjusted wound therapy have to take place in an interdisciplinary collaboration in a centre for wound care. Last but not least this aim can only be achieved by a preventive education of diabetics.

[Prospective DRG coding : Improvement in cost-effectiveness and documentation quality of in-patient hospital care]. / Fallbegleitende DRG-Kodierung : Verbesserung von Wirtschaftlichkeit und Dokumentationsqualität in der stationären Versorgung.

BACKGROUND: In prospective reimbursement schemes a diagnosis-related group (DRG) is assigned to each case according to all coded diagnoses and procedures. This process can be conducted retrospectively after (DC) or prospectively during the hospitalization (PC). The use of PC offers advantages in terms of cost-effectiveness and documentation quality without impairing patient safety. MATERIAL AND METHODS: A retrospective analysis including all DRG records and billing data from 2012 to 2015 of a surgical department was carried out. The use of PC was introduced into the vascular surgery unit (VS) in September 2013, while the remaining surgical units (RS) stayed with DC. Analysis focused on differences between VS and RS before and after introduction of PC. Characteristics of cost-effectiveness were earnings (EBIT-DA), length of stay (LOS), the case mix index (CMI) and the productivity in relation to the DRG benchmark (productivity index, PI). The number of recorded diagnoses/procedures (ND/NP) was an indicator for documentation quality. RESULTS: A total of 1703 cases with VS and 27,679 cases with RS were analyzed. After introduction of PC the EBIT-DA per case increased in VS but not in RS (+3342 Swiss francs vs. +84, respectively, p < 0.001). The CMI increased slightly in both groups (+0.10 VS vs. +0.08 RS, p > 0.05) and the LOS was more reduced in VS than in RS (-0.36 days vs. -0.03 days, p > 0.005). The PI increased in VS but decreased in RS (+0.131 vs. -0.032, p < 0.001), ND increased more in VS (+1.29 VS vs. +0.26 RS, p < 0.001) and NP remained stable in both groups. CONCLUSION: The use of PC helps to significantly improve cost-effectiveness and documentation quality of in-patient hospital care, essentially by optimizing LOS and cost weight in relation to the DRG benchmark, i. e. increasing the PI. The increasing ND indicates an improvement in documentation quality.

An unusual cause of peripheral artery embolism: floating thrombus of the thoracic aorta surgically removed.

Intraluminal mobile thrombus of the descending aorta are rare disorders. They are at high risk for peripheral embolism and therefore indication for treatment is mandatory. We report on a 54-year-old patient with peripheral arterial embolization who was treated by surgical thrombus removement by thoracotomy and staged peripheral bypass grafting. New diagnostic tools are presented, therapy and prognosis are discussed.

Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections.

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.

[Early transfer from intensive care does not influence clinical results of carotid endarterectomy]. / Limitierte Uberwachung nach Karotisthrombendarteriektomie. Frühverlegung aus der Uberwachungseinheit beeinflusst nicht das klinische Ergebnis.

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

[Intraluminal mass lesions of the thoracic aorta]. / Intravasale Raumforderungen der thorakalen Aorta. Differenzialdiagnosen und risikoadapiertes Management der embolisierenden Läsionen.

Aortic intraluminal mass lesions of the thoracic aorta are rare disorders with a wide range of differential diagnoses. Generalized hypercoagulation or vascular endothelial disorders have been proposed as the main etiological factor. The risk of catheter-related thrombus development or embolization after interventional procedures is as high as 17%. Malignancies of the aorta are somewhat rare. In some cases, the specific source of the thrombus could not be determined. Mainly, intraluminal tumors of the thoracic aorta become evident through peripheral embolization. Modern diagnostic tools are able to identify the structure and location of intravascular formations. Therapy options are influenced, due to the heterogenic entity, by the individual risk to the patient and the pathology of the thrombus.

[Surgical management of isolated iliac aneurysms]. / Chirurgisches Management des isolierten Beckenarterienaneurysmas.

Isolated iliac aneurysms (IIA) are uncommon lesions that require surgical repair to prevent rupture. The aim of this article is to give an update on the current surgical management of IIA. This report also evaluates the application of endovascular repair in IIA, based on a recent Pubmed search and on our own experience in the interventional field: Open reconstruction achieves good longterm results and still represents the golden standard in surgical treatment of IIA. Transluminally placed endovascular stent grafts can be successfully used to exclude isolated iliac aneurysms in selected high risk patients with suitable anatomy. A classification based on aneurysm morphology is useful for patient selection. The value of endovascular therapy has yet to be determined.

[Vascular injuries after extremity trauma]. / Gefässverletzungen nach Extremitätentrauma.

The aim of the present examination was to analyse extremity trauma with additional vascular injuries. Between 1973-2000 78 patients with traumatic peripheral vascular injuries have been treated at the Surgical Department of the University Hospital of Mannheim. In addition to clinical examination Doppler-Duplex ultrasonography (cw-Doppler) was routinely performed. In selected cases either conventional or magnetic resonance angiography completed the diagnostic procedure. Vascular injuries to the upper extremities were found in 46.2 % (n = 36) whereas 53.8 % (n = 42) of the patients suffered from trauma of the lower extremities. The popliteal artery was affected in 28.2 % followed by the brachial artery with 23.1 %. 52.6 % of the patients had interposition of autologous vein for reconstruction. Only 7.7 % of the cases needed interposition of alloplastic material. In general the injured extremity was immobilised by external fixation, followed by secondary vascular reconstruction. An efficient trauma management reduced amputation rate as low as 2.6 %.

Human papillomavirus (HPV) infection, HIV infection and cervical cancer in Tanzania, east Africa.

The presence of HPV-DNA was determined in tumor biopsies of cervical-cancer patients and in cervical swabs of non-cancer patients from Tanzania, East Africa, by Southern blot hybridization and/or PCR. HPV types 16 and 18 were detected in 38% and 32%, respectively, of 50 cervical-carcinoma biopsies. A consensus primer PCR capable of detecting a broad spectrum of HPV types revealed the presence of HPV-DNA in 59% of 359 cervical swabs of non-cancer patients. Type-specific PCR showed that types 16 and 18 accounted for 13.2% and 17.5%, respectively, of all HPV infections. Therefore we concluded that HPV 18 is more prevalent in Tanzania than in any other geographical location so far reported. The strongest risk factors for the presence of any HPV-DNA in the 359 female non-cancer patients were young age and HIV infection. The epidemiology of HPV types 16 and 18 was found to differ from that of other HPV types, being associated in univariate analysis with trichomonas vaginalis infection, martial status (single/divorced), age at first intercourse, and young age at menarche. However, young age at menarche accounted for most of the effects of all other, variables in multivariate analysis. Of the non-cancer patients, 12.8% had antibodies against HIV I (no patient being severely symptomatic), and HIV infection was highly correlated with the presence of HPV-DNA, especially types 16 and 18. While HPV-DNA of any type was detectable 1.4-fold more often in HIV-positive patients than in HIV-negative patients, evidence of an infection with HPV types 16 or 18 was found 2.2-fold more often in the HIV-positive patients. The HIV-positive women did not show an increased rate of cervical cytological abnormalities as assessed by PAP staining of a single cervical smear, the overall rate of abnormalities being 2.8%. Furthermore, the age-adjusted prevalence of HIV antibodies was found to be considerably lower in 270 cervical-carcinoma patients (3% HIV-positive) in comparison with non-cancer patients. Thus there was no association observable between the prevalence of HIV infections and the frequency of cervical cytological abnormalities or cervical cancer in the setting of this cross-sectional study.

PIP: Southern blot hybridization and/or PCR was used to examine tumor biopsies of 53 women with cervical or vaginal cancer at Ocean Road Hospital in Dar es Salaam, Tanzania, and the cervical swabs of 359 women with no cancer at the gynecologic clinic at Muhimbili University College of Health Sciences in Dar es Salaam. Tanzanian and German scientists wanted to determine whether an association existed between human papillomavirus (HPV) infections and HIV, and whether the high prevalence of HIV infection was matched by a high prevalence of HPV infections, cervical dysplasias, and cervical cancer in HIV-positive cases. 59% of the noncancerous women had HPV-DNA. Young age and HIV infection were the greatest risk factors for HPV-DNA in these women (p .0001 for age and HPV-16/18; p = .08 for other HPVs; and p = .03 for HIV). 13.2% and 17.5% of all HPV infections were HPV types 16 and 18, respectively. Tanzania had the highest prevalence of HPV 18 ever reported. HPV-16/18 risk factors included: Trichomonas vaginalis infection (odds ratio [OR] = 2.23; p = .04), single status (OR = 2.55; p = .01), 16 years old or less at first intercourse (OR = 2.1; p = .03), and young age at menarche (OR = 6 for or=12 years old; p = .02 and OR = 3.25 for or=13 years old and or=16 years old; p = .05). Yet, the multivariate analysis revealed young age at menarche had the greatest effect (OR = 6.2 for or= 12 years old, p = .03; OR = 3.73 for or=16 years old, p = .08). 12.8% of noncancerous women tested positive for HIV-1, but none of them were obviously symptomatic. These HIV-positive women had a higher OR if they had HPV-16/18 than if they had other HPV types (4.25 vs. 2.02). Further, they did not have more cervical cytological abnormalities than did the HIV-negative women (overall cervical cytological abnormality rate - 2.8%). The HIV-positive rate for cancerous patients was only 3%. In conclusion, no association existed between HIV infection and cervical cytological abnormalities or cervical cancer.