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In PAOD, several vascular regions are usually affected, the pelvic axis in 35% of cases. Interventional-radiological/endovascular or hybrid interventions have been established for recanalization, so that bypass procedures are increasingly taking a back seat, but are not losing their importance.To study unilateral iliac artery occlusions (inclusion criterion) that were repaired either by implantation of an orthotopic or extraanatomic bypass (oBP/eaBP).Over a defined period of time, the rate of open vessel, complications (frequency, type, severity) to characterize morbidity and mortality as well as the extent of clinical improvement after BP implantation were analyzed in a clinical-systematic, single-center observational study (for vascular surgical quality assurance and contribution to vascular medical-clinical health care research). The study method was not explicitly based on the STROBE criteria, but essentially corresponds to them.Over 10 years, 122 PAOD patients (50% in stage IIb-stage III and IV equally distributed; mean age: 63 [range, 44-87] years; majority ASA III) were included with the same number of reconstructions: 71 patients received an eaBP ("crossover"), 51 patients an iliacofemoral (orthotopic - oBP) bypass (neither significant difference regarding frequency nor number of risk factors per patient).The oBP is not superior to eaBP with regard to the analysis parameters of openness, complication rate and mortality. Furthermore, extraanatomic revascularization does not have to be reserved for polymorbid patients only.
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Objectives: The Kasabach-Merritt syndrome (KMS) is characterized by the occurrence of hemangioendothelioma (giant hemangioma with thrombosis leading to thrombocytopenia), which can be associated with disseminated intravasal coagulation. Specific aim: Based on (i) selective references from the current scientific literature and derived recommendations as well as (ii) own experiences obtained in the diagnostic and perioperative management of a representative case from daily practice in abdominal surgery, the specific case undergoing elective cholecystectomy (CCE) in KMS is to be described by means of scientific case report. Case presentation: (Patient-, finding- and treatment-specific characteristics): - Medical history: 72-years old female patient with a known KMS of the left arm and upper thorax, recurrent thrombophlebitis of the left arm and thoracic veins, previous upper GI bleeding (Mallory-Weiss syndrome in 2006, chronic anemia in lack of vitamin B12, type-A gastritis, former bleeding complications after teeth extraction/open appendectomy 1962/Caesarean section 1968 with need of transfusion [60 red blood cell packages]), intraabdominal adhesions, hypothyreosis, initial liver cirrhosis. - Symptomatology: Characteristic for cholecystolithiasis (CCL). - Diagnostic: Abdominal ultrasound shows CCL, fibroscan does not confirm suspicious cirrhosis. Laboratory parameters showed: Activation of intravasal coagulation with elevated prothrombin fragments, D-dimers and reduced antiplasmin concentration. Accelerated fibrinolysis capacity; currently, no secondary thrombocytopenia or factor-13 decrease. In addition, fibrinogen concentration within normal range, no hint onto the manifestation of an aquired von-Willebrand's syndrome. - Diagnosis: Chronic fibrosing cholecystitis in CCL after former acute cholecystitis (3â¯months ago) with indication for surgical intervention. - Therapy: Laparoscopic CCE including careful exploration of upper abdominal cavity for KMS manifestation (with no revision of bile duct) and peritoneal adhesiolysis (histological finding, chronic fibrosing cholecystitis with thickening of the wall of the gall bladder but no hint of malignancy) under perioperative prophylaxis with antibiotics and temporary cessation of platelet medication for 7â¯d preoperatively, "bridging" with low molecular weight heparin (Clexane, 1 × 40â¯mgâ¯s.c.; Sanofi-Aventis, Frankfurt/Main, Germany); 1â¯h preoperatively, 15-20â¯mg/kg body weight Cyclocapron i.v. (once again 6-8â¯h postoperatively; thereafter, 500â¯mg of Cyclocapron 4×/d until the 3rd postoperative day). - Intraoperatively: Congestion of veins but not at the immediate surgical field (gall bladder, hepatic bed of the gall bladder, Calot's triangle). - Outcome: Uneventful, in particular, no (bleeding) complications. Conclusions: If surgical approach is indicated, the intervention should be thoroughly planned (in particular, under elective circumstances) with regard to hemangioma site and extension as well as distance to the surgical field and possible surgical alternative options (surgical access site, open/laparoscopic approach etc.) to prevent - at the best possible rate - bleeding complications intra-/postoperatively and, thus, to provide adequate patient safety.
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INTRODUCTION: In vascular surgery too, more services and procedures will have to be shifted from the previous inpatient to the outpatient sector in the future. Therefore, the previous and new legal requirements as well as their implementation in vascular surgery will be explained and evaluated. MATERIAL AND METHODS: Professional policy analysis from a perspective of medical vascular surgery. RESULTS: The AOP catalog from 01.01.2023 was extended by 208 additional OPS codes. The inpatient performance of services which, according to the AOP contract, must be regularly performed on an outpatient basis, are now to be justified on the basis of context factors.A special sector-equivalent remuneration, which is independent of whether the remunerated service is performed on an outpatient or inpatient basis, is a prerequisite for a cost-covering expansion of outpatient operations and inpatient-replacing services. The rehabilitation of primary varicosis under outpatient conditions is undoubtedly the standard. The majority of AV shunt installations are performed as inpatient procedures. No new OPS codes were added to the 2023 AOP catalog for varicose vein, shunt and endovascular surgery. DISCUSSION: The shift of inpatient services to the outpatient sector can be a feasible path, based on the experience of other European countries. However, the structures, economic conditions and incentives should first be created to successfully promote transfer to outpatients. Integrated care offers the possibility for the health insurance funds to conclude contracts with the service providers named in § 140a of the Social Code, paragraph 3, for special care. The use of telemedicine in the sense of tele-premedication or tele-monitoring can be a way to expand outpatient surgery, especially in rural regions. In order to enable therapy concepts from one expert in vascular medicine, the outpatient service billing of interventional procedures must also be demanded by vascular surgeons and specialists. CONCLUSION: The potential to transform inpatient services into the outpatient setting of service provision is realisable in vascular surgery in the core areas of varicose vein surgery, shunt surgery and peripheral interventional procedures under specific conditions.
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Aim: The aim of this study was to investigate short-/long-term vascularsurgical patency and the outcome in chronic mesenteric ischemia (CMI) depending on the mesenteric revascularization technique and reflecting real-world data. Methods: This retrospective single-center observational study registered all patients who had undergone open vascularsurgical reconstruction because of CMI at a tertiary German university hospital comparing 1-versus (vs.) 2-vessel as well as antegrade versus retrograde reconstructions. Results: In total, 35 patients were enrolled (mean [± SD] age, 64 ± 13 [range, 45-83] years; sex ratio [m:f], 16:19 [46:54]) over 12 years. Three patients with symptoms of mesenteric ischemia because of rare causes (radiation-induced and median arcuate ligament syndrome) have been excluded. While 51% of patients underwent 1-vessel reconstruction, 49% underwent 2-vessel reconstruction. There was a trend of (i) more perioperative complications in the 2-vessel group (88.2% vs. 55.6%, p = 0.06) and (ii) higher morbidity at 1 year in the 2-vessel versus 1-vessel group (57.1% and 42.9%, respectively; p = 0.466), while the morbidity of the 2-vessel versus 1-vessel group at 5 years (100% vs. 33.3%) was significantly different (p = 0.009). The mortality was greater in the 2-vessel versus 1-vessel group as it was significantly different in the early postoperative period (31.3% vs. 0, p = 0.016) and at 1 year (50% vs. 0, p = 0.005) and 5 years (100% vs. 11%, p = 0.003). Regarding overall survival, the 1-vessel group showed a significant superiority above the 2-vessel group (p = 0.004). Actually, there was no significant difference of early postoperative morbidity comparing the retrograde and antegrade group (p = 0.285) as well as at 1 year and 5 years (p = 0.715 and p = 0.620, respectively). In addition, there was no significantly different postoperative mortality in antegrade versus retrograde group at each time. Specific and general complication rates were 62.9% and 57.1%, respectively, resulting in an overall morbidity of 77.1% (mortality, 20%). Conclusion: The vascular surgeon should be prepared to perform various procedures of mesenteric reconstruction to tailor the operative strategy to the specific needs of the individual patient.
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AIM: To illustrate incidence, aetiopathogenesis, symptomatology, diagnostic testing, peri-interventional/-surgical management and outcome of SA based on selective references from the scientific medical literature and our own clinical experiences in diagnostic and therapeutic care. METHODS: Narrative overview RESULTS: CONCLUSION: SA as relevant quantity of care has become a substantial part of basic vascular surgical or image-guided radiology treatment. The vascular surgeon or radiologist (for image-guided interventions) needs to be adequately focused on the demanding diagnostic and therapeutic management, demanding her/his complete competence and expertise.
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Aneurisma , Aneurisma/cirurgia , Feminino , Humanos , Radiografia , Radiologia Intervencionista , Suturas , Procedimentos Cirúrgicos VascularesRESUMO
OBJECTIVE: The complex changes in vascular surgical teaching and commonalities are to be outlined and discussed, in particular, similarities/differences to general surgery, specifics of teaching/teaching content and its university requirements. METHOD: Compact narrative overview RESULTS: Vascular surgical teaching component at Magdeburg University Hospital comprises 10 academic teaching hours and includes the following topics: PAD, embolism/thrombosis, vascular injury, compartment syndrome, mesenteric ischemia, aortic aneurysm and venous surgery. This puts vascularsurgical teaching here well above the average of 6.1 academic teaching hours in Germany. The strength of (vascular)surgical training lies in the fact that the knowledge gained at the bedside can be linked to visual impressions and simultaneous explanations in the operating theatre. Close integration of the student into the team is the high art of promoting acceptance of surgery as a profession and vocation. The prerequisites for successful teaching are a didactically competent teacher with specialist expertise, a proactive teaching attitude, knowledge of the specific learning objectives, the curriculum, modern teaching methods and awareness of the special role model function for students. Classical teaching by means of lecture, seminar, practical course and textbook is justified and should be strengthened but it is increasingly supplemented by the use of internet-based learning platforms, libraries and video portals. CONCLUSION: In the coming years, vascular surgical teaching will (have to) shift to a (rather) multimodal/-media approach with more practice-oriented components and intensive integration of students into everyday clinical practice.
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Competência Clínica , Especialidades Cirúrgicas , Currículo , Alemanha , Humanos , Procedimentos Cirúrgicos VascularesRESUMO
OBJECTIVE: To assess the incidence of post-operative non-ischaemic cerebral complications as a pivotal outcome parameter with respect to size of cerebral infarction, timing of surgery, and peri-operative management in patients with symptomatic carotid stenosis who underwent carotid endarterectomy (CEA). METHODS: Retrospective analysis of prospectively collected single centre CEA registry data. Consecutive patients with symptomatic carotid stenosis were subjected to standard patch endarterectomy. Brain infarct size was measured from the axial slice of pre-operative computed tomography/magnetic resonance imaging demonstrating the largest infarct dimension and was categorised as large (> 4 cm2), small (≤ 4 cm2), or absent. CEA was performed early (within 14 days) or delayed (15 - 180 days) after the ischaemic event. Peri-operative antiplatelet regimen (none, single, dual) and mean arterial blood pressure during surgery and at post-operative stroke unit monitoring were registered. Non-ischaemic post-operative cerebral complications were recorded comprising haemorrhagic stroke and encephalopathy, i.e., prolonged unconsciousness, delirium, epileptic seizure, or headache. RESULTS: 646 symptomatic patients were enrolled of whom 340 (52.6%) underwent early CEA; 367 patients (56.8%) demonstrated brain infarction corresponding to stenosis induced symptoms which was small in 266 (41.2%) and large in 101 (15.6%). Post-operative non-ischaemic cerebral complications occurred in 12 patients (1.9%; 10 encephalopathies, two haemorrhagic strokes) and were independently associated with large infarcts (adjusted odds ratio [OR] 6.839; 95% confidence interval [CI] 1.699 - 27.534) and median intra-operative mean arterial blood pressure in the upper quartile, i.e., above 120 mmHg (adjusted OR 13.318; 95% CI 2.749 - 64.519). Timing of CEA after the ischaemic event, pre-operative antiplatelet regimen, and post-operative blood pressure were not associated with non-ischaemic cerebral complications. CONCLUSION: Infarct size and unintended high peri-operative blood pressure may increase the risk of non-ischaemic complications at CEA independently of whether performed early or delayed.
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Infarto Encefálico/epidemiologia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Encéfalo/diagnóstico por imagem , Infarto Encefálico/diagnóstico , Infarto Encefálico/etiologia , Infarto Encefálico/cirurgia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Razão de Chances , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Hypothesis: Post-exercise measurements better discriminate PAOD-patients from healthy persons and they more sensitively detect hemodynamic improvements after treatment procedures than resting measurements. METHODS: A total of 19 healthy volunteers and 23 consecutive PAOD-patients underwent measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV), minimal diastolic velocity (MDV), time-averaged maximum velocities (TAMAX), resistance index (RI) and pulsatility index (PI) before and after a standard exercise test (at 1, 2, 3, 4 and 5 min) before and after treatment (incl. epidemiological data, PAOD risk factors and comorbidities). RESULTS: In resting values, healthy persons and PAOD-patients did not differ significantly in any of the hemodynamic parameters. PSV increased after treatment in PAOD-patients by 5 cm/s (paired ttest, p: 0.025); however, when the amplitude of autoregulatory changes related to the resting values were calculated, PAOD-patients showed clearly less hemodynamic changes after exercise than healthy persons (p: 0.04; 0.002; <0.001 for PSV, TAMAX and PI, resp.). The time course after exercise was compared by repeated measures of ANOVA. Healthy persons differed significantly in PI, RI and PSV from PAOD patients before and after treatment (p<0.001 each). The PAOD-patients revealed a significantly improved PI after treatment (p: 0.042). The only factor contributing significantly to PI independently from grouping was direct arterial vascularization as compared to discontinuous effects by an obstructed arterial tree. CONCLUSION: Healthy persons cannot be well differentiated from PAOD-patients solely by hemodynamics at rest but by characteristic changes after standard exercise. Treatment effects are reflected by higher PI-values after exercise.
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Arteriopatias Oclusivas , Hemodinâmica , Velocidade do Fluxo Sanguíneo , HumanosRESUMO
AIM: To investigate the value of intraoperative angiography and its ad hoc evaluation with respect to cases of surgical technical inaccessibility. METHODS: Overall, 523 consecutive carotid artery thrombendarterectomy (TEA) patients with intraoperative control angiography, postoperative color-coded duplex sonography and retrospective re-evaluation of documented angiographic images were included in the evaluation. RESULTS: In the retrospective angiographic re-evaluation 23 (4.4%) occlusions or high-grade stenoses of the common carotid artery (CCA) or internal carotid artery (ICA) in the surgical field (12, 2.3%) or of downstream ICA or middle cerebral artery (MCA, 11, 2.1%) were detected. The detection rate was significantly lower in the intraoperative ad hoc evaluation with overall only 13 (2.5%) detected pathologies (7, 1.3% in the surgical field, 6, 1.1% in large downstream arteries, p=0.002). Postoperative duplex sonography performed in 505 patients detected 50 cases (10.1%) of local surgical technical inaccessibility, which was significantly more than in the angiography (p<0.001). In most cases these were nonocclusive, low-grade stenosing detachments of the intima media (n=19), 13 suture contractions, and 14 kinking/abrupt diameter changes at the distal end of the patch. Suture contractions and kinking/diameter changes were associated with a left-sided TEA (adjusted odds ratio, OR 2.4, 95% confidence interval, CI 1.1-5.1), an operation without a patch (adjusted OR, 16.6, 95% CI 1.3-215.0), and using Dacron patches in contrast to PTFE patches (adjusted OR 3.0, 95% CI 1.4-6.6). CONCLUSION: The ad hoc evaluation of intraoperative completion angiography by surgeons missed a substantial number also of occluding and severely stenosing pathologies. Angiography is not suitable for the detection of nonocclusive and low-grade stenosing cases of operative inaccessibility. Postoperative color-coded duplex sonography is an adequate tool for surgical quality control.
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Estenose das Carótidas , Angiografia , Artérias Carótidas , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Humanos , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
INTRODUCTION: The mobilization of patients with diabetic foot syndrome after surgical treatment by debridement or partial amputation is usually difficult in daily practice and in inpatient care. AIM AND METHOD: A case report - with a representative case showing the innovative possibilities of an alternative mobilization option by means of a new orthesis ("iWALK 2.0®"; IWALKFree® Inc., Mansfield, Ontario, Canada) after surgical therapy of diabetic gangrene, exemplified by the successful clinical course. RESULTS: The inpatient admission of a 59-year-old male patient revealed septic gangrene of the right foot in insulin-dependent diabetes mellitus. After admission and initial diagnosis, the calculated antibiotics therapy and initial surgical rehabilitation of the right foot took place. After stabilization and control of the infection, the minor amputation was performed at the Bona-Jäger line without primary wound closure, wound care was provided by vacuum sealing. Complicated by pre-existing peroneal paralysis of the contralateral leg following herniated disc, mobilization could be accomplished out of the wheelchair using a novel "free-hand" orthesis "iWALK 2.0" and a walker with physiotherapeutic support. Thus, while simultaneously relieving the operated foot, self-sufficient mobilization at a later time was possible. This gave the patient a positive attitude to life in addition to more independence. CONCLUSION: The successful application of the "free-hand" site "iWALK 2.0" under the listed clinical constellation thus suggests that it is a clear alternative of "postoperative rehabilitation" in the diagnosis of a surgically treated diabetic foot gangrene after minor amputation with a consolidated wound while ultimately serving to achieve a more comprehensive level of experience for targeted use with a clearly defined indication.
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Amputação Cirúrgica , Pé Diabético , Canadá , Desbridamento , Humanos , Masculino , Pessoa de Meia-Idade , CicatrizaçãoRESUMO
Background: To assess the vascular and clinical course of acute symptomatic extracranial internal carotid artery (ICA) occlusion. Patients and methods: Patients with an acute ischemic event in the anterior circulation and corresponding extracranial ICA occlusion at CT angiography and/or color-coded duplex sonography underwent recurrent duplex follow-up for detection of spontaneous recanalization. Stroke recurrence and functional outcome 4.5 months after the ischemic index event assessed by modified Rankin scale served as secondary outcome parameters. Results: 133 patients (91 men, mean age 62.3 years, SD 10.8) demonstrated symptomatic occlusion of the extracranial ICA with open intracranial ICA and open middle cerebral artery and were followed-up for spontaneous recanalization. Twenty-eight recanalized spontaneously, 25 to high-grade focal stenosis within 12 days, revealing an early cumulative recanalization rate of 23 %. Detection of recanalization was independently associated with de novo dual anti-platelet therapy (adjusted odds ratio [OR], 3.24; 95 % confidence interval [CI], 1.34 to 7.80). Ischemic recurrence occurred in 16 patients, of which 10 deemed to be embolic and 5 hemodynamic. Spontaneous ICA recanalization and an exhausted cerebrovascular reserve in the hemisphere distal to the occluded ICA were both independently associated with the occurrence of a recurrent ischemic event at Cox regression. An increasing NIHSS score at admission, a decreasing middle cerebral artery flow velocity and an ischemic recurrence independently predicted poor outcome (modified Rankin scale 3 to 6) in multivariate analysis. Conclusions: Acute symptomatic extracranial ICA occlusion is an unstable condition with frequent spontaneous recanalization to severe stenosis and early embolic stroke recurrence, demanding appropriate prevention especially in those patients with only mild deficit.
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Doenças das Artérias Carótidas , Estenose das Carótidas , Embolia , Acidente Vascular Cerebral , Idoso , Artéria Carótida Interna , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
INTRODUCTION: Circuits of abdominal arteries to adjoining lumenal organs, especially in triggering circumstances, are rare diseases that are increasingly evident in endovascular therapies and complex viscero-/tumor-surgical procedures with subsequent lengthy adjuvant therapies. Their care is a challenge and involves frequent complications and mortality. METHOD: Narrative overview on the basis of current scientific references and our clinical and surgical experience. RESULTS: Uretero-arterial fistulas are usually associated with recurrent and intermittent gross haematuria. The diagnostic test of choice continues to be angiography with the potential for endovascular therapy, which has displaced open surgical procedures due to minimal invasiveness, low morbidity and mortality. Aorto-oesophageal fistulas may result from underlying infectious and malignant diseases as well as open and endovascular therapies of the aorta. Multi-line contrast CT of the thorax/abdomen and gastroscopy have priority in diagnostic testing. Endovascular procedures can only be understood as bridging procedures, and only the removal of prostheses with aortic and gastrointestinal reconstruction are curative. Aorto-enteric fistulas are secondary complications of open and endovascular aortic surgery. Contrast enhanced multi-line CT has high sensitivity and specificity. In contrast, open surgical therapy involves in-situ reconstruction of extra-anatomical reconstructions with aortic ligature. Endovascular therapy is reserved for exceptional cases. Inflammatory aneurysms of visceral arteries may be associated with adjacent inflammatory processes, most commonly pseudoaneurysms. The most suitable diagnostic procedure is contrast-enhanced thin-film CT angiography. The treatment of choice is endovascular ablation using covered stents or embolisation. CONCLUSION: Arterio-visceral/arterio-lumenal fistulas are similar in pathogenesis, predisposing factors and clinical symptoms. An interdisciplinary consultation is employed to identify individualised therapy. Endovascular/interventional procedures are safe and effective, and open surgical rehabilitation is mostly curative.
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Falso Aneurisma , Doenças da Aorta , Implante de Prótese Vascular , Procedimentos Endovasculares , Fístula Vascular , Doenças da Aorta/terapia , Humanos , Stents , Resultado do Tratamento , Fístula Vascular/cirurgiaRESUMO
INTRODUCTION: Interdisciplinary cooperation between surgeons can help to optimise outcome in the management of complex surgical diseases. The indication for surgical intervention has gradually expanded in advanced multivisceral tumour growth, with iatrogenic vascular injuries in the field of abdominal and oncological surgery and mesenteric ischemia. Appropriate expertise in vascular surgery is then essential, although this is not always available or in all hospitals. AIM: Narrative review based on current scientific references in the relevant literature and our own clinical and surgical experiences in decision making, the approach in clinical management and various options of vascular reconstruction in abdominal surgery. RESULTS: Prognosis is still limited in pancreatic cancer. R0 resection is the only curative therapeutic option - thus, the surgeon has to provide specific intraoperative expertise. Arterial reconstruction is still controversial, due to increased postoperative morbidity and limited evidence. But in specific cases, venous reconstruction has been established in clinical practice. In addition, in retroperitoneal sarcoma with advanced/extended tumour growth, reconstruction of the infiltrated inferior V. cava or common iliac artery by means of patch plasty or autologous bypass/segmental vascular prosthesis can become necessary as part of multivisceral resections. During inflammatory processes or with tumour adhesions/infiltrations to surrounding anatomical structures, intraoperative vascular injuries or postoperative vascular alterations can occur, further complicated by anatomical variants. The extremely strict demands on the abdominal surgeons, in particular in mesenteric ischemia, are influenced by i) a competent assessment of the mesenteric vessels based on ii) adequate imaging as well as iii) appropriate time management. Prompt recanalisation can play a decisive role for the prognosis. CONCLUSION: Vascular reconstructions in abdominal surgery, in particular, in oncological surgery, require great expertise of the surgeon. In this context, competent preoperative diagnostic testing, extensive specific experience in vascular surgery/interventions, appropriate interdisciplinary case management, adequate surgical tactic and technique are all important.
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Neoplasias Pancreáticas , Procedimentos Cirúrgicos Vasculares , Humanos , Artéria Ilíaca , Neoplasias Pancreáticas/cirurgia , Assistência Perioperatória , Veia Cava InferiorRESUMO
Impaired activated protein C (aPC) generation is associated with atherosclerosis and diabetes mellitus. Diabetes-associated atherosclerosis is characterized by the hyperglycaemic memory, e.g., failure of disease improvement despite attenuation of hyperglycaemia. Therapies reversing the hyperglycaemic memory are lacking. Here we demonstrate that hyperglycaemia, but not hyperlipidaemia, induces the redox-regulator p66Shc and reactive oxygen species (ROS) in macrophages. p66Shc expression, ROS generation, and a pro-atherogenic phenotype are sustained despite restoring normoglycemic conditions. Inhibition of p66Shc abolishes this sustained pro-atherogenic phenotype, identifying p66Shc-dependent ROS in macrophages as a key mechanism conveying the hyperglycaemic memory. The p66Shc-associated hyperglycaemic memory can be reversed by aPC via protease-activated receptor-1 signalling. aPC reverses glucose-induced CpG hypomethylation within the p66Shc promoter by induction of the DNA methyltransferase-1 (DNMT1). Thus, epigenetically sustained p66Shc expression in plaque macrophages drives the hyperglycaemic memory, which-however-can be reversed by aPC. This establishes that reversal of the hyperglycaemic memory in diabetic atherosclerosis is feasible.
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PURPOSE: The previously reported 6-month angiographic and 12-month clinical outcomes of the CONSEQUENT trial demonstrated the safety and efficacy of a novel paclitaxel-resveratrol-coated balloon for the treatment of lesions in the femoropopliteal segment. The purpose of this report is to present the 2-year results including a cost-benefit analysis for Germany. MATERIALS AND METHODS: Patients with symptomatic peripheral artery occlusive disease in femoropopliteal lesions were randomized either to drug-coated balloon (DCB, n = 78) or plain old balloon angioplasty (POBA, n = 75). As secondary endpoints, the 2-year clinical results consisting of target lesion revascularization (TLR), patency and increase in walking distance were recorded. Based on the Kaplan-Meier analyses for TLR and other adverse events, a cost-benefit analysis was conducted for the German DRG system. RESULTS: There were no additional TLRs in both groups between 14 and 24 months so that the corresponding rates remained significantly different between the treatment groups (DCB: 19.1 vs. POBA 40.6%, p = 0.007). At 2 years, the patency rate was significantly higher in the DCB group (72.3 vs. 48.4%, p = 0.006). The walking distance increase was also significantly higher after DCB angioplasty (172 ± 103 vs. 52 ± 136 m, p = 0.001). We estimated 2-year cost savings of 1111.97 per patient treated with DCB instead of POBA. CONCLUSIONS: The use of paclitaxel-resveratrol matrix-coated peripheral balloons compared to POBA was associated with a significantly reduced TLR rate, superior patency and substantial cost savings at 2 years. ClinicalTrials.gov Identifier NCT01970579.
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Angioplastia com Balão/economia , Angioplastia com Balão/métodos , Artéria Femoral/diagnóstico por imagem , Doença Arterial Periférica/economia , Doença Arterial Periférica/terapia , Artéria Poplítea/diagnóstico por imagem , Idoso , Angiografia , Angioplastia com Balão/instrumentação , Materiais Revestidos Biocompatíveis/economia , Feminino , Artéria Femoral/patologia , Alemanha , Humanos , Estimativa de Kaplan-Meier , Masculino , Artéria Poplítea/patologia , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: Based on a novel paclitaxel-resveratrol drug matrix, the safety and efficacy to inhibit intimal hyperplasia were studied in symptomatic claudicants with morphologically challenging lesions. BACKGROUND: The treatment of peripheral artery occlusive disease (PAOD) with percutaneous transluminal angioplasty is limited by occurrence of vessel recoil and neointimal hyperplasia. Drug-coated balloons (DCB) deliver drugs to the arterial wall to potentially reduce the restenosis rate. A number of paclitaxel-coated balloon technologies are available to treat peripheral lesions. METHODS: In this randomized controlled trial, a total of 153 patients with symptomatic PAOD in femoro-popliteal lesions were randomized either to DCB or plain old balloon angioplasty (POBA). RESULTS: The mean lesion length was 13.2 ± 10.4 cm with target lesion total occlusions in 26.1% of all patients (40/153). The primary endpoint of in-lesion late lumen loss (LLL) at 6 months was significantly reduced in the DCB group as compared to the POBA group (0.35 mm CI [0.19; 0.79 mm] vs. 0.72 mm CI [0.68; 1.22 mm], p = 0.006). At 12 months, the TLR rate in the DCB group was significantly lower as compared to the POBA group (17.8 vs. 37.7% p = 0.008). The censored walking distance increase suggests a benefit for patients who underwent DCB angioplasty as compared to the standard POBA treatment (12 months 165 ± 105 vs. 94 ± 136 m, p = 0.012). CONCLUSION: The use of paclitaxel-resveratrol-matrix-coated peripheral balloon angioplasty as compared to POBA was associated with significantly reduced in-lesion LLL and reduced TLR rates. ClinicalTrials.gov identifier NCT01970579.
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Angioplastia com Balão/métodos , Artéria Femoral/fisiopatologia , Paclitaxel/administração & dosagem , Doença Arterial Periférica/terapia , Artéria Poplítea/fisiopatologia , Idoso , Angiografia/métodos , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/efeitos dos fármacos , Alemanha , Humanos , Masculino , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/efeitos dos fármacos , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Moduladores de Tubulina/administração & dosagemAssuntos
Coartação Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Ponte de Artéria Coronária/métodos , Insuficiência de Múltiplos Órgãos/diagnóstico por imagem , Insuficiência de Múltiplos Órgãos/cirurgia , Adulto , Coartação Aórtica/diagnóstico por imagem , Humanos , Masculino , RadiografiaRESUMO
OBJECTIVE: To evaluate the predicting factors for the development of endoleak type II, its frequency and influencing factors after elective endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA). METHODS: Data were prospectively collected in a unicenter observational study (tertiary center of [endo-] vascular surgery) and retrospectively evaluated in patients who had undergone elective EVAR of AAA. Vascular (lumbar arteries (LA) and inferior mesenteric artery, aneurysm) and general patient (habits, medication, basic diseases) as well as procedural characteristics, were analyzed for their association with the development of endoleak type II. Pre and postinterventional computed tomography (CT) scans were evaluated for aneurysm anatomy, in particular, postinterventional growth or shrinkage as well detection of an endoleak of each type. RESULTS: The study cohort included 82 patients (mean age, 72 (52-87) years; 77 men, 93.9%) throughout 36 months. The median follow-up period was 29.5 months (range, 1-57). Overall, 51 endoleaks type II (62.2%) were identified at any time during the postinterventional follow-up period. In the Cox regression, AAA length was the only significant predictor (P = 0.024; hazard ratio (HR), 1.07; 95% confidence interval (CI), 1.01-1.14). Thirteen patients (15.8%) underwent at least one secondary intervention. Aneurysm growth was observed in four patients because of an endoleak type II (4.9%). No AAA rupture occurred in association with an isolated endoleak type II. CONCLUSION: The preoperative AAA length (correlating with the number of LA) can be considered a risk factor for postinterventional occurrence of endoleak type II prompting to greater attention and possible preemptive therapy.