Hyperhomocysteinemia and recurrent carotid stenosis.

BACKGROUND: Hyperhomocysteinemia has been identified as a potential risk for atherosclerotic disease in epidemiologic studies. This study investigates the impact of elevated serum homocysteine on restenosis after carotid endarterectomy (CEA). METHODS: In a retrospective study, we compared fasting plasma homocysteine levels of 51 patients who developed restenosis during an eight year period after CEA with 45 patients who did not develop restenosis. Restenosis was defined as at least 50% stenosis and was assessed by applying a routine duplex scan follow up investigation. Patients with restenosis were divided into a group with early restenosis (between 3 and 18 months postoperative, a total of 39 patients) and late restenosis (19 and more months; a total of 12 patients). RESULTS: The groups were controlled for age, sex, and risk factors such as diabetes, nicotine abuse, weight, hypertension, and hyperlipidemia. Patients with restenosis had a significant lower mean homocysteine level (9.11 micromol/L; range: 3.23 micromol/L to 26.49 micromol/L) compared to patients without restenosis (11.01 miccromol/L; range: 5.09 micromol/L to 23.29 micromol/L; p = 0.03). Mean homocysteine level in patients with early restenosis was 8.88 micromol/L (range: 3.23-26.49 micromol/L) and 9.86 micromol/L (range 4.44-19.06 micromol/L) in late restenosis (p = 0.50). CONCLUSION: The finding suggests that high plasma homocysteine concentrations do not play a significant role in the development of restenosis following CEA.

3-deoxy-3-[(18)F]fluorothymidine-positron emission tomography for noninvasive assessment of proliferation in pulmonary nodules.

We investigated whether uptake of the thymidine analogue 3-deoxy-3-[(18)F]fluorothymidine ([(18)F]FLT) reflects proliferation in solitary pulmonary nodules (SPNs). Thirty patients with SPNs were prospectively examined with positron emission tomography. Standardized uptake values were calculated for quantification of FLT uptake. Histopathology revealed 22 malignant and 8 benign lesions. Proliferation was evaluated by Ki-67 immunostaining and showed a mean proliferation fraction of 30.9% (range, 1-65%) in malignant SPNs and <5% in benign lesions. Linear regression analysis indicated a significant correlation between FLT-standardized uptake values and proliferative activity (P < 0.0001; r = 0.87). FLT uptake was specific for malignant lesions and may be used for differential diagnosis of SPNs, assessment of proliferation, and estimation of prognosis.

Thoracic surgery in children.

OBJECTIVE: Children rarely undergo thoracic surgery. When they do, the procedures fall into five main groups: oncologic indications, immune defects, malformations, infections and trauma. In addition to considerations associated with the underlying indication, the different proportions of the anatomical structures in children require special modifications in both diagnostics and surgical technique compared to corresponding procedures in adults. METHODS: Of a total 2137 thoracic surgical procedures performed between 1992 and 2001, 49 were performed in children (n = 37; age: 3 months-15 years; median age: 8 years). Indications for surgery included underlying oncologic disease (n = 20), immunodeficiency (n = 5), thoracic or pulmonary malformation (n = 6) and trauma (n = 3). Patients' postoperative clinical course was analyzed retrospectively for all 49 procedures. Pre- and postoperative pulmonary function test results are available for 16 children. Data regarding quality of life were documented in 24 children. RESULTS: The following procedures were performed: 27 atypical resections, seven lobectomies, one pneumonectomy, three decortications, four mediastinotomies or mediastinoscopies and seven other procedures. Six procedures represented second or third procedures in the same patient. Two of six patients with immune defects died during the perioperative period. Eleven of 20 oncologic patients (55%) have remained free of recurrent disease. Quality of life, as assessed by the Karnowski index in 24 children, was at least 80%. CONCLUSIONS: Thoracic surgical procedures in children with underlying benign disease are associated with a good prognosis and high quality of life scores. Surgical treatment of pulmonary metastases is a feasible component of the overall oncologic therapy concept and can offer the only opportunity for curation for a selected group of patients. Because of high postoperative mortality, however, the indication for diagnostic thoracotomies in children with immunodeficiencies and poor general health should be weighed critically.

Results from the first in man german pilot study of the silver graft, a vascular graft impregnated with metallic silver.

The purpose of this study was to assess the safety of a novel vascular prosthesis in 50 patients who underwent inguinal and infrainguinal vascular reconstructions. The safety data were based on ultrasound Doppler data at 2 and 18 months to quantify the graft-tissue integration in this patient cohort. Between August 9, 2005, and January 25, 2006, 50 patients underwent inguinal or infrainguinal reconstructions with the Silver Graft (SG; B. Braun Melsungen AG, B. Braun Aesculap AG, Tuttlingen, Germany) in six vascular centers. All participating centers received the metallic silver-coated polyester graft (SG) with a diameter of 8 mm and a total length of 60 cm, which was length adjusted to fit the patient's anatomy and the planned vascular reconstruction. The mean patient age was 69.1 +/- 9.0 years, the male inclusion rate was 72.0%, and the Fontaine classifications were stage IV (16%), stage III (14%), stage IIb (66%), and stage IIa (4%), whereas aneurysm repairs amounted to 4%. In-hospital results revealed the presence of minimal perigraft fluid in 14.0% of all cases (7 of 50). At the 2-month follow-up, perigraft fluid was detected in one patient (1 of 50). At 18 months, a single case of minimal perigraft fluid was detected in an asymptomatic patient. Wound healing was accomplished at discharge in 96% of all patients, whereas at the 2-month follow-up, no signs of wound infection or irritation could be detected. The accumulated primary patency rates were 94% at 2 months and 88% at 18 months. The available clinical data on perigraft fluid as a marker for graft-tissue incorporation at 2 and 18 months, patency, and wound healing are comparable to those of other relevant clinical results with polyester grafts and support the safety of the metallic SG in the studied patient population with inguinal and infrainguinal reconstructions. However, it cannot be guaranteed that all graft infections can be avoided with the SGs.

Endovascular repair of traumatic descending aortic transection.

PURPOSE: To present the results of endovascular repair of acute traumatic descending aortic transection. METHODS: Among 66 thoracic stent-graft repairs performed between 1995 and 2001, 11 patients (9 men; mean age 34 years, range 12-73) underwent emergent endovascular repair of acute traumatic descending aortic transection following traffic accidents. Immediate treatment of aortic rupture was indicated in all patients because of a marked fresh hematoma with hemothorax; the spiral computed tomographic (CT) scans showed circular or semicircular descending thoracic aortic injuries. The devices used included 11 thoracic Excluders and 1 Talent stent-graft. RESULTS: No patient required conversion to an open transthoracic operation. No patient developed temporary or permanent neurological deficit after endovascular treatment. Two type I endoleaks required periprocedural treatment: a second stent-graft was deployed in one and the existing stent-graft was balloon dilated in the other. Two patients underwent secondary procedures (iliac access complication and revascularization of the left subclavian artery). One patient died 22 days postoperatively secondary to injuries unrelated to the aortic repair. Over a mean 14-month follow-up (range 1-26), the surveillance CT scans have shown the stent-graft to be correctly positioned in all patients. CONCLUSIONS: The treatment of acute traumatic descending aortic transection with an endovascular approach is feasible and safe and may offer the best means of therapy. Mortality and the risk of neurological deficit are low compared with open operations.

Thoracoscopy versus thoracotomy: a prospective comparison of trauma and quality of life.

BACKGROUND: Reliable comparisons of thoracoscopy (TCC) and anterolateral thoracotomy (ATT) with regard to trauma and post-operative quality of life are rare. This study was conducted to quantify the results of TCC, which was expected to show an advantage. METHODS: Using a matched-pair design (matching criteria: comparable intracavitary procedure, benign/malignant disease and sex), 22 patients were compared who underwent either TCC or ATT (Wilcoxon matched-pairs signed-ranks test, P<0.05). RESULTS: Incision and operation time were shorter for TCC (TCC 5.3 vs ATT 23.7 cm, P=0.003; TCC 64 vs ATT 87 min, P=0.029). Differences in favor of TCC were detected for interleukin 6 (IL6) (TCC 17.2 vs ATT 105.6 pg/ml, P=0.036) in the immediate postoperative period, C-reactive protein (CRP) (TCC 28.2 vs ATT 86.6 mg/l; P=0.010) on the day 1 after the operation, forced vital capacity (FVC) (TCC 2.5 vs ATT 1.5 l, P=0.0173), elevation of the arm (EA) (TCC 143 vs ATT 109; P=0,026), pain on coughing (CP) (TCC 2.5 vs ATT 6.9 patients; P=0.009) and Spitzer Index (SI) (TCC 9.2 vs ATT 7,1 patients; P=0.009), as well as CP (TCC 1.4 vs ATT 4.4 patients; P=0,005) on day 4 after the operation. Forced expiratory volume in the first second, pain, creatin kinase, blood glucose and neopterin showed no differences. CONCLUSIONS: In terms of surgical trauma and quality of life ICC is superior to ATT in the immediate postoperative period. With the exception of pain and coughing, there were no differences after postoperative day 4.