[Certification of vascular centers. Influence on quality and healthcare structures]. / Zertifizierung von Gefäßzentren. Auswirkungen auf Qualität und medizinische Versorgungsstrukturen.

Diagnosis and therapy of vascular diseases are increasingly being performed following a multimodal, interdisciplinary and less invasive approach. The introduction of specialized, organ-related centers is a logical consequence in view of a better treatment quality and a more effective use of resources. The German societies of radiology, vascular surgery and angiology jointly developed a process of certification, which has been successfully applied to more than 100 units in Germany. In this article the terms and results of the process are described and possible effects on the quality and structures of the healthcare system are discussed.

[Diminishing boundaries between vascular surgery and interventional radiology from the view of a radiologist]. / Schwindende Fachgrenzen zwischen Gefässchirurgie und interventioneller Radiologie aus Sicht des Radiologen.

Vascular surgeons increasingly claim that percutaneous interventional treatment of peripheral arterial disease belongs to their discipline.In further medical training interventional radiology is exclusively bound to the discipline of radiology and necessitates a minimum of 250 procedures for valid qualification. Training in vascular surgery requires 25 endovascular procedures which do not, however, fulfill the criteria of percutaneous interventional procedures for a number of reasons.The desired expansion of vascular surgery to include the complete field of vascular medicine is not based on adequate specific training, is functionally unnecessary and not achievable for practical reasons. However, this desired expansion endangers the consensus of an interdisciplinary concept of treatment as represented by interdisciplinary vascular centers which offer a high level of competence.

[Treatment guidelines for aneurisms of the aorta]. / Behandlungsrichtlinien bei Aortenaneurysmen.

Aneurysmatic diseases of the aorta usually have a bad prognosis in the case of acute rupture. Guidelines exist for surgical treatment but are relatively old and have not yet been brought up to date. By introducing new techniques, thoracic aneurysms are predominantly treated by endoluminal means, for asymptomatic type B dissections, however, a stent graft insertion cannot be principally recommended. For thoracoabdominal aneurysms, a combined endoluminal and open surgical approach is still under evaluation. For the relatively frequent problem of infrarenal abdominal aortic aneurysms, an endoluminal approach is more and more taken although randomized trials have not yet shown an improvement concerning long-term mortality in favor of endografts. Interdisciplinary guidelines do not yet exist.

[Follow-up in uterine fibroid embolization]. / Nachsorge bei Myomembolisation.

Follow-up controls in patients after uterine fibroid embolization (UFE) should monitor clinical improvement of symptoms, document shrinkage of the fibroids, exclude malignancies and detect and treat potential complications of the intervention.A close cooperation with the referring gynecologist, sufficiently and carefully informing the patient about the routine follow-up procedure, potential complications and their clinical signs are necessary to fulfill this goal.Imaging is usually based on ultrasound imaging but may be supplemented by MRI. There are different complications in the early phase after UFE and in the later postembolization phase.

[Guidelines of the German Radiological Society for percutaneous vertebroplasty]. / Leitlinien der Deutschen Röntgengesellschaft zur Vertebroplastie.

In many countries, percutaneous vertebroplasty became a widely accepted therapeutic option in osteoporotic and neoplastic fractures of the vertebral bodies which is employed in more and more patients. Under image guidance the method can be safely performed and provides a high success rate regarding stabilization of vertebral fractures and pain relief. Due to the increasing interest in vertebroplasty in Germany the German Radiological Society-Working Group on Interventional Radiology decided to produce guidelines for percutaneous vertebroplasty. This guidelines are based on the recent standard of knowledge and represent a guide for practical performance of this procedure. Based on the technical development of the method, indications and implementation of the method in multimodal therapy regimens may change over the next years. Therefore, this guidelines are not a rigid body of rules but a basis for an ongoing development adjusted to the scientific progress and the interdisciplinary discussion.

[Transbrachial selective carotid DSA in outpatients: safety and efficacy]. / Diagnostische Sicherheit und Effizienz ambulanter transbrachialer selektiver Karotisangiographien.

PURPOSE: To describe safety and efficacy of transbrachial selective carotid digital subtraction angiography (DSA) in outpatients. MATERIALS AND METHODS: From July 1999 to November 2001, selective carotid angiography was performed in 141 outpatients preferably using a left brachial arterial approach. The average age of the patients was 68 years (range: 39 - 89 years). After flush aortography through a 4F-pigtail catheter, bilateral selective common carotid artery (CCA) catheterization was performed with 4F-Sidewinder-1 or Sidewinder-2 catheters. In 49 patients, Doppler-sonography was performed before or after arteriography. A total of 41 patients underwent carotid surgery. RESULTS: Selective catheterization of the CCA was successful in 96 % of the cases. The diagnostic quality of the opacified aorta and CCA images was good to excellent. The overall complication rate did not exceed 2.1 %, and severe complications were not observed. One patient showed transient neurological symptoms and another mild nausea and agitation, probably as toxic reaction to the contrast medium. A single local hematoma developed after unsuccessful puncture of the brachial artery. CONCLUSION: Transbrachial selective carotid DSA is safe, reliable and well-tolerated in outpatients and achieves a superimposition-free CCA visualization.

[Evolution of inflammatory parameters after fibroid embolization]. / Entwicklung der Entzündungsparameter nach Myomembolisation.

PURPOSE: To describe the rise of classical laboratory tests for inflammation following transarterial uterine fibroid embolization (UFE) in order to monitor the normal course following UFE. MATERIALS AND METHODS: In 20 females, white blood cell (WBC) count and C-reactive protein (CRP) were determined before and up to 5 days after UFE. With the exception of one noninflammatory complication, the post-procedure course was uneventful in all patients. The measured values were correlated with both the total uterine volume and the amount of instilled embolizing agent. RESULTS: Following UFE, an increase in the WBC count to an average maximum of 10.8 +/- 3.5/wL (range 5.9 - 18.6/wL) was found. In 13 of 20 patients, the WBC count was above normal on at least one day following UFE. The increase reached the maximum on the third post-interventional day and subsided within 5 days after the UFE. The CRP values increased significantly to an average maximum of 41.9 +/- 28.8 mg/l. The maximum was found on the 2nd post-interventional day in 8 patients, on the 3rd day in 11 patients and on the 4th day in one patient. No correlation to the total uterine volume or to the amount of the instilled embolizing agents was detected. CONCLUSION: Following uncomplicated UFE, a steep increase in CRP occurs with no or only a mild increase in the WBC count, which does not indicate an infected fibroid. The maximum is reached on the 3rd or 4th post-interventional day, followed by a decline in CRP and normalization of the WBC count.

Results of a European multicentre iliac stent trial with a flexible balloon expandable stent.

PURPOSE: to determine the 12 months success rate with a balloon expandable, flexible stainless steel stent in iliac artery obstructions. MATERIALS AND METHODS: one-hundred and twenty-six consecutive patients with iliac obstructive disease and who demonstrated an unsatisfactory angioplasty result with a post-dilatation gradient of at least 10 mmHg, or a primary occluded lesion were included in the study. Follow-up was by Doppler sonography, ankle pressures with and without exercise and clinical parameters. RESULTS: after stent placement, the mean percentage diameter stenosis decreased from 79 to 4%, with a mean intra-arterial pressure gradient of 3 mmHg. Primary stent patency was 94% at 6 months and 89% at 12 months. Primary clinical result at 6 months was 88% and at 12 months 81%. Primary assisted clinical result (after re-pta) at 6 and 12 months was 89 and 86%, respectively. The Ankle Brachial Index (ABI) after exercise at 1 month follow-up was reduced from 0.88 to 0.75, with minor deterioration at 6 months to 0.72, and at 12 months to 0.68. The 1, 6, and 12 months follow-up Piek Systolic Velocity (PSV) ratios across the stented lesions remained stable at a mean of 1.4, 1.6, and 1.6, respectively. However, respectively 44, 39 and 34% of the patients still experienced symptoms of claudication. CONCLUSIONS: the results presented here support the suggestion stenting to be an effective device in the treatment of iliac artery obstructive disease. This study also, confirms other study results concerning haemodynamic patency after iliac stenting on the indication of a 10 mmHg pressure gradient after pta and the discrepancy between good haemodynamic patency and clinical result.

[Simple localization of peripheral pulmonary nodules - CT-guided percutaneous hook-wire localization]. / Einfache Lokalisation von intrapulmonalen Rundherden - CT-gesteuerte perkutane Hakenmarkierung.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is an alternative approach to small intrapulmonary nodules, if transbronchial or percutaneous biopsy have failed. We investigated the feasibility and effectiveness of the percutaneous CT-guided placement of hook-wires to localize such nodules before video-assisted thoracoscopy. SUBJECTS AND METHODS: 19 patients with new by diagnosed intrapulmonary nodules underwent CT-guided hook-wire localization by application of a X-Reidy -Set (Cook, Inc., Bjaeverskov, Denmark). The average age of the patient was 63 years (range: 19 - 80 years), the mean distance between the nodule and the pleura visceral was 7.58 mm (range: 0 - 25 mm) and the mean diameter was 11.58 mm (range: 5 - 25 mm). After localization, the patients underwent a VATS resection of the lesion within a mean time of 30 min (range 10 - 48 min). RESULTS: In all cases, resection of the nodules was successful. In 4 older patients the marking was complicated by poor cooperability. At the end of manipulation the end of the hook was distanced from the nodule. But also in these cases, resection was successfully performed. 8 patients developed an asymptomatic pneumothorax: 5 of them in a minor (max. 1.5 cm rim), three of them in a moderate (max. 3 cm rim) dimension. In 4 patients, in whom the tumor was hit directly by the needle, local bleeding occurred. In one case, haemoptoe was present. In no patient did a dislocation of the hookwire-system occur. CONCLUSION: CT-guided placement of a hook-wire system is a simple and reasonable procedure which facilitates safe VATS resection of small pulmonary nodules.

Percutaneous interventions for treatment of iliac artery stenoses and occlusions.

Balloon angioplasty is still the main workhorse for percutaneous interventions in the iliac arteries. It is simple to perform, cost-effective, and remarkably safe. If an adequate hemodynamic result has been achieved, patency is acceptable. To monitor the quality of success, intraarterial pressure monitoring is an important tool. Balloon angioplasty may be followed by stent insertion in case of insufficient luminal gain after inadequate balloon angioplasty or occurrence of significant dissection. Percutaneous treatment of chronic iliac occlusions is technically challenging. For chronic occlusions (duration exceeding 3 months), balloon angioplasty alone, thrombolysis with subsequent balloon angioplasty, and elective stenting or mechanical passage of the occlusion followed by primary stent implantation have been described as alternative techniques. In case of in-stent stenosis, directional atherectomy or balloon dilatation is recommended. Stent grafts allow percutaneous exclusion of isolated iliac aneurysms, iatrogenic perforation, rupture, and arteriovenous fistulas, but these cases are rare. Some authors increasingly favor the use of endoluminal graft systems for treating atherosclerotic disease in iliac arteries, but insufficient data are available to prove the benefit of stent grafts in patients with atherosclerotic disease.

Suramin inhibits proliferation of human arterial smooth muscle cells in vitro: potential drug for prevention of restenosis by local drug delivery.

PURPOSE: Suramin is known to inhibit proliferation of various tumor cells. This study was performed to investigate the effect of suramin on proliferating human arterial smooth muscle cells (HASMC) and thus to examine its suitability for the prevention of restenosis. METHOD: Proliferation of HASMC was stimulated with human whole blood serum (HWBS), as well as with platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF). Proliferation was assessed by measuring DNA synthesis and cell viability was assessed by measuring mitochondrial activity. RESULTS: Suramin exerted a strong attenuating effect on the proliferation stimulators HWBS, PDGF, and bFGF. A suramin concentration of 0.5 mmol/L, which is approximately twice the dosage used for systemic application, was sufficient for complete neutralization of proliferation stimulation by 10% HWBS added to the cell culture medium. CONCLUSION: The authors' data demonstrate a strong proliferation inhibiting effect of suramin on HASMC in vitro. Because it is known to interact not only with one but with a multitude of relevant growth factors, these results make suramin a most interesting substance for local application for prevention of hyperplastic neointima formation.

Improvement of haemocompatibility of metallic stents by polymer coating.

An alternative to open heart surgery in treating arterial diseases causing restricted blood flow is the implantation of intracoronary metallic stents. In spite of the advances in implantation and in spite of the excellent mechanical properties of metallic stents, there are still limitations because of the thrombogenicity of the metal. We have, hence, directed our attention to the coating of metallic stents with an ultrathin polymer layer by chemical vapor deposition (CVD) polymerization of 2-chloroparacyclophan. In a second step of surface modification the poly(2-chloroparaxylylene) layer is modified by treatment with a sulfur dioxide plasma in order to obtain a more hydrophilic surface with new functional groups. The results demonstrate the stable polymer coating of the stents and the improvement of haemocompatibility after treatment with sulfur dioxide plasma. Platelet adhesion is decreased from 85% for the metal surface to 20% for the CVD-coated and sulfur-dioxide-plasma treated surface.

[New TIPS placement in pregnancy in recurrent esophageal varices hemorrhage--assessment of fetal radiation exposure]. / TIPS-Neuanlage in der Schwangerschaft bei rezidivierender Osophagusvarizenblutung--Abschätzung der fetalen Strahlenexposition.

Recurrent variceal bleeding due to liver cirrhosis led to treatment with a transjugular intrahepatic portosystemic shunt (TIPS) in a pregnant woman at 20 weeks' gestation. Fetal radiation exposure was estimated to be less than 10 mSv. The use of a graduated catheter allowed measurement of field size and reliable determination of the patient's entrance dose. Radiation exposure of an approximated fetal dosage of 5.2 mSv did not justify abortion for medical reasons. Therefore, TIPS procedure is not generally contraindicated during pregnancy itself. TIPS placement may be a therapeutic option related to the severity of the underlying maternal disease, after radiation exposure of the fetus has been estimated.

Spondylodiskitic abscesses: CT-guided percutaneous catheter drainage.

PURPOSE: To determine whether computed tomographically (CT) guided percutaneous catheter drainage of spondylodiskitic abscesses is an appropriate and effective alternative to surgery. MATERIALS AND METHODS: CT-guided percutaneous catheter drainage was performed in 21 patients (16 men, five women; age range, 24-81 years) with 33 spondylodiskitic abscesses. Nine intradiskal, 12 paravertebral, and 12 psoas abscesses were drained with 5.6-14.0-F catheters. In 29 cases, the catheter was inserted by using the Seldinger technique in four cases, a trocar technique was used. All patients underwent follow-up CT or magnetic resonance imaging examinations for 6 months. RESULTS: Successful placement of the drainage catheter was achieved in each patient without procedural complications. The duration of drainage was 4-56 days (average duration, 26.8 days). Three of 33 catheters were changed because of insufficient drainage; one of the 33 catheters had to be reinserted because of dislocation. Two patients underwent surgery for stabilization of the spine with the drainage catheter in place. In 16 of the 21 patients, specific organisms were isolated; thus, definitive medical therapy was possible. Complete evacuation of all abscesses was achieved initially, with no evidence of recurrence during the follow-up. CONCLUSION: CT-guided percutaneous catheter drainage is an efficient and safe procedure in the management of spondylodiskitic abscesses.

Interventional magnetic resonance. Initial clinical experience with a 1.5-tesla magnetic resonance system combined with c-arm fluoroscopy.

RATIONALE AND OBJECTIVES: The authors evaluate the feasibility of performing magnetic resonance (MR) procedures on a 1.5-tesla (T) system combined with conventional c-arm fluoroscopy. METHODS: A 1.5-T MR imaging system was combined with a conventional c-arm fluoroscopy unit in one room. The two systems were connected via a floating table top. Twenty-six interventional procedures (biopsies, MR-portography, percutaneous alcohol injection, laser ablation, fluid aspiration, and breast marking) were performed in 22 patients under MR, fluoroscopic control, or both. For MR guidance, fast gradient echo sequences were used, initiated from a panel at the front of the magnet. Images were displayed on an liquid crystal display screen positioned on the magnet. RESULTS: All MR-guided procedures were performed successfully without complications. The addition of c-arm fluoroscopy was useful for bone interventions and MR-portography. All diagnostic biopsies yielded sufficient amounts of tissue for histologic diagnosis. In breast lesions, the target identified on dynamic MR imaging was marked correctly in each case. In interstitial laser thermotherapy the laser effect could be visualized, and in percutaneous ethanol injection the distribution of the alcohol could be seen. Both imaging systems worked without image distortions and high-quality MR images were obtained. CONCLUSIONS: The combination of a 1.5-T MR imager with a c-arm fluoroscopy system seems to be a promising technical solution for performing interventional MR procedures.