Risk Stratification of Ruptured Abdominal Aortic Aneurysms in Patients Treated by Open Surgical Repair.

OBJECTIVE: The present study tested scoring models for ruptured abdominal aortic aneurysms (rAAAs) in patients treated by open surgical repair (OSR). Scores were tested in a European population to validate their applicability for predicting outcome. METHODS: Between 2002 and 2013, 92 patients with rAAAs underwent OSR and medical records were reviewed retrospectively. The Edinburgh Rupture Aneurysm Score (ERAS), Vascular Study Group of New England (VSGNE) rAAA risk score, Hardman Index, and Glasgow Aneurysm Score (GAS) were calculated and analyzed according to in hospital mortality. The discriminatory power and calibration of all models were assessed by applying the receiver operating characteristic and the Hosmer-Lemeshow test χ(2). RESULTS: An ERAS ≤ 1 (n = 55), 2 (n = 15) and 3 (n = 16) was associated with a mortality of 27%, 47%, and 69%, respectively. The calibration was the best of all tested scores (χ(2) = 0.44; p = .81) and the area under the curve (AUC) was 0.71 (95% CI 0.6-0.82; p = .001). A VSGNE rAAA risk score = 0 (n = 19), 1 (n = 15), 2 (n = 19), 3 (n = 25), and ≥ 4 (n = 9) was associated with a mortality of 11%, 20%, 32%, 72%, and 56%, and an AUC of 0.76 (95% CI 0.66-0.87; p = .001). The calibration was reduced (χ(2) = 6.9; p = .08). The GAS and Hardman Index increased stepwise with increasing in hospital mortality, but were inferior to ERAS and the VSGNE rAAA risk score. The Hardman Index showed the smallest AUC (0.68; 95% CI 0.56-0.80; p = .011) and demonstrated a lack of fit (χ(2) = 8.2; p = .04). The GAS showed good discrimination (AUC = 0.75; 95% CI 0.64-0.85; p < .001) and calibration (χ(2) = 0.85; p = .66); however, the parametric scale of GAS limits its use to classifying patients according to their risk. CONCLUSION: The present study revealed remarkable differences in survival between subgroups (10-70%) and underscores the need for risk stratification. The ERAS was favorable with striking ease of use and high accuracy in predicting outcome.

Invasive cardiac aspergillosis after orthotopic liver transplantation.

Invasive aspergillus infection occurs in 5 - 42 % of liver-transplanted recipients and is a dangerous complication, associated with high mortality if untreated. However, the early diagnosis of invasive aspergillosis can be elusive, as clinical signs are unspecific and the pathogenic agent is difficult to demonstrate. We here report about a 58-year-old man with acute liver failure caused by newly diagnosed chronic hepatitis B infection who underwent liver transplantation. The postoperative course was uneventful, and the patient was discharged after 30 days. After 105 days the patient was readmitted because of fever, recurrent chest and abdominal pain. Computed tomography revealed a cardiac lesion; other diagnostic steps including bone-marrow and endomycordial biopsy, virological and microbiological investigations gave no clear findings. To exclude a malignant process, thoracotomy with mass and simultaneous lower left lobe resection were performed. Histopathological findings revealed an invasive perimyocardial aspergillosis. Immediate intravenous therapy with voriconazole and caspofungin was initiated and monitoring of the mass was performed with transesophageal echocardiography and Cardio-MRI. Due to slightly increase of the lesion, medication was switched to posaconazole and caspofungin. Under this dual fungal treatment the lesion regressed and the patient could be discharged after two months in good clinical condition. Frequent Cardio-MRI scan after discharge showed further mass-regression. Therefore antifungal treatment was switched to oral posaconazole mono-therapy. After one year, complete reduction of the mass was achieved and antifungal therapy was discontinued. Recent diagnostic imaging follow-up showed no pathological finding.

[Early results after peripheral vascular replacement with biosynthetic collagen prosthesis in cases of graft infection]. / Frühergebnisse nach peripherem Gefäßersatz mit einer biosynthetischen Kollagenprothese bei Protheseninfektionen.

INTRODUCTION: Vascular graft infection in peripheral bypass surgery represents a highly significant risk with regard to limb loss and morbidity. In the absence of autologous superficial veins, finding a suitable replacement material can be difficult. Silver-coated polyester grafts, homografts, or use of deep veins can pose additional risks. Use of a biosynthetic collagen prosthesis on a Dacron matrix ("Omniflow-II®") was investigated as an alternative method, and the cost-effectiveness was evaluated. MATERIALS AND METHODS: From December 2010 to December 2011, eight patients with clinical symptoms of vascular graft infection, confirmed by imaging, were treated. Graft function or acute graft failure due to the infection was necessary for enrollment in the study. Infected material was removed, microbiological specimens taken and, in the absence of superficial veins, an "Omniflow-II®" prosthesis was implanted in an orthotopic position. Patients were followed up to evaluate their outcome, and the cost-effectiveness of the procedure was also analysed. RESULTS: The technical feasibility of the procedure was assessed in all cases. Pathogens were detected in five of eight cases. After a mean follow-up of 8 months, seven of eight patients showed that they were clinically cured of infection. Primary patency was 63%, secondary patency was 75%, and prevalence of limb salvage was 88%. One patient had to undergo limb amputation to avoid sepsis, and another unsuccessfully underwent thrombectomy after 12 months. Four PET-CT follow-up studies showed a reduction of uptake in the affected area. To generate adequate revenue by using this technique, specialised knowledge of the diagnosis-related group system is necessary. DISCUSSION: Treatment of vascular graft infections in peripheral bypass surgery in the absence of endogenous material necessitates the use of infection-resistant materials. The present study showed promising results using a collagen-biosynthetic prosthesis. Due to a lack of long-term results, the graft should be used only after detailed informed consent is obtained from the patient. The expenses incurred by using the biosynthetic graft should be covered adequately by revenues from these patients.

Stent Graft Placement by Pseudoaneurysm of the Hepatic Arteries: Efficacy and Patency Rate in Follow-up.

PURPOSE: To investigate efficacy and patency status of stent graft implantation in the treatment of hepatic artery pseudoaneurysm. MATERIALS AND METHODS: A retrospective analysis of patients who had undergone endovascular treatment of hepatic artery pseudoaneurysms between 2011 and 2020 was performed. Medical records were examined to obtain patients' surgical histories and to screen for active bleeding. Angiographic data on vascular access, target vessel, material used and technical success, defined as the exclusion of the pseudoaneurysm by means of a stent graft with sufficient control of bleeding, were collected. Vessel patency at follow-up CT was analyzed and classified as short-term (< 6 weeks), mid-term (between 6 weeks and 1 year), and long-term patency (> 1 year). In case of stent occlusion, collateralization and signs of hepatic hypoperfusion were examined. RESULTS: In total, 30 patients were included and of these, 25 and 5 had undergone stent graft implantation and coiling, respectively. In patients with implanted stent grafts, technical success was achieved in 23/25 patients (92%). Follow-up CT scans were available in 16 patients, showing stent graft patency in 9/16 patients (56%). Short-term, mid-term, and long-term short-term stent patency was found in 81% (13/16), 40% (4/10), and 50% (2/4). In patients with stent graft occlusion, 86% (6/7) exhibited maintenance of arterial liver perfusion via collaterals and 14% (1/7) exhibited liver abscess during follow-up. CONCLUSION: Stent graft provides an effective treatment for hepatic artery pseudoaneurysms. Even though patency rates decreased as a function of time, stent occlusion was mainly asymptomatic due to sufficient collateralization.

Validating New Software for Semiautomated Liver Volumetry--Better than Manual Measurement?

PURPOSE: This prospective study compared a manual program for liver volumetry with semiautomated software. The hypothesis was that the semiautomated software would be faster, more accurate and less dependent on the evaluator's experience. MATERIALS AND METHODS: Ten patients undergoing hemihepatectomy were included in this IRB approved study after written informed consent. All patients underwent a preoperative abdominal 3-phase CT scan, which was used for whole liver volumetry and volume prediction for the liver part to be resected. Two different types of software were used: 1) manual method: borders of the liver had to be defined per slice by the user; 2) semiautomated software: automatic identification of liver volume with manual assistance for definition of Couinaud segments. Measurements were done by six observers with different experience levels. Water displacement volumetry immediately after partial liver resection served as the gold standard. The resected part was examined with a CT scan after displacement volumetry. RESULTS: Volumetry of the resected liver scan showed excellent correlation to water displacement volumetry (manual: ρ = 0.997; semiautomated software: ρ = 0.995). The difference between the predicted volume and the real volume was significantly smaller with the semiautomated software than with the manual method (33% vs. 57%, p = 0.002). The semiautomated software was almost four times faster for volumetry of the whole liver (manual: 6:59 ± 3:04 min; semiautomated: 1:47 ± 1:11 min). CONCLUSION: Both methods for liver volumetry give an estimated liver volume close to the real one. The tested semiautomated software is faster, more accurate in predicting the volume of the resected liver part, gives more reproducible results and is less dependent on the user's experience. KEY POINTS: Both tested types of software allow exact volumetry of resected liver parts. Preoperative prediction can be performed more accurately with the semiautomated software. The semiautomated software is nearly four times faster than the tested manual program and less dependent on the user's experience.

Mid- and long-term results after replacement of infected peripheral vascular prosthetic grafts with biosynthetic collagen prosthesis.

AIM: We assess mid- and long-term outcome after prosthetic graft replacement with biosynthetic collagen prosthesis (Omniflow II®) in the presence of graft infection. METHODS: Between December 2010 and January 2012, an analysis of 9 consecutive patients was performed, who underwent replacement of an infected peripheral graft with a biosynthetic prosthesis. Morbidity, in-hospital mortality, primary and secondary patency were analyzed. FDG-PET was performed to diagnose graft infection, and exclude reinfection at long-term follow-up. RESULTS: Graft infection occurred after a median of 12 (range 3-97) months after the initial procedure. Replacement surgery was performed successfully in all 9 patients without intraoperative complications. Microbiological cultures revealed pathogenic infection in 7 cases. In 2 patients, no pathogen was isolated. The morbidity rate was 55.5% with no in-hospital deaths. Early and late bypass occlusion occurred in 2 patients. One high above-knee amputation was performed due to patient deterioration. The median length of stay was 23 (range 12-122) days and after graft replacement 13 (range 10-62) days. The median time of follow up was 23 (range 8-25) months. Primary and secondary patency rates were 66.6% and 78% at 19 months, respectively. FDG-PET was performed in 6 (85.5%) patients after a median follow up period of 19 (range 3-23) months, and excluded graft reinfection in all patients. CONCLUSION: Replacement of infected peripheral prosthetic grafts with the prosthesis (Omniflow II®) has encouraging results. The collagen prosthesis appears to be a promising alternative with a low reocclusion rate and no reinfection.

Management of urologic complications in renal transplantation: a single-center experience.

INTRODUCTION: Ureterovesical complications subsequent to renal transplantation are associated with a high morbidity leading to graft loss or even death. In the present study, the management of these complications by using interventional and surgical procedures (native pyeloureterostomy [NPUS]/ureteroureterostomy [NUU] vs ureteroneocystostomy [UNC]) was evaluated retrospectively. PATIENTS AND METHODS: Between 1994 and 2012, a total of 780 kidney transplantations (690 deceased and 90 living donors) were performed at our institution. Demographic, clinical, and laboratory data from patients with urologic complications were analyzed and compared. RESULTS: Fifty patients (6.4%) exhibited ureterovesical complications, and 18 patients (36%) were operated on immediately. In 32 (64%) of 50 patients, an interventional procedure was initially performed, with 21 patients (66%) undergoing operation due to therapy failure. NPUS/NUU and UNC were performed in 26 (66.6%) and 13 (33.3%) patients, respectively. Indications for an operation were ureteral stenosis in 12 patients (30.8%), ureteral necrosis and urine leakage in 19 patients (48.7%), and symptomatic vesicoureteral reflux in 8 patients (20.5%). Long-term results were comparable between all groups. CONCLUSIONS: Surgical revision of ureteral complications should be the standard therapy. NPUS/NUU, UNC, and the successful interventional procedures did not differ significantly in terms of long-term results.