[An unusual foreign body in the upper gastrointestinal tract causing nonspecific abdominal pain]. / Ungewöhnlicher Fremdkörper im oberen Gastrointestinaltrakt als Ursache eines unklaren Abdomens.

The risk of penetration of vena cava filters through the wall of the vena cava is estimated to be as high as 25%, although clinical symptoms are observed far less frequently in patients with this complication. Due to the close relationship between vena cava and duodenum, the latter can be injured by dislocated filters. We describe the presentation, evaluation, and treatment of a patient with a cava filter protruding into the duodenum, and we review the literature.

Endovascular stenting in patients with Iliac compression syndrome. Experience in three cases.

The authors report their experience in the percutaneous treatment of the iliac compression syndrome in three women (20-53 years old) with acute iliofemoral deep venous thrombosis; in one case, there was an additional thrombus in the inferior caval vein. They were treated by percutaneous implantation of Palmaz stents in the left common iliac vein 1 day after surgical thrombectomy and construction of an arterial venous fistula. All patients showed marked improvement, as determined from venograms obtained immediately after stent implantation. The arteriovenous fistulae were closed 3 months later. At 6 months follow-up, the median clinical and color-coded duplex ultrasound indicates that all stents are patent and all patients are free of symptoms.

Endovascular stent-graft placement versus conventional open surgery in infrarenal aortic aneurysm: a prospective study on acute phase response and clinical outcome.

BACKGROUND: For the treatment of aortic aneurysm, stent-graft implantation is an alternative method to open surgery. There is no study comparing both methods with regard to endotoxaemia, the acute phase cascade, and clinical outcome. METHODS: In this prospective study, we enrolled 40 patients (34 males, 6 females; mean age 72.1+/-7.5 [58-92] years) with infrarenal abdominal aortic aneurysm who underwent aortic surgery. Comparable groups of patients were treated with open (n=20) or endovascular (n=20) stent-graft implantation. To characterize the inflammatory response, plasma levels of endotoxin, endotoxin-neutralizing capacity (ENC), interleukin-6 (IL-6), C-reactive protein (CRP), and white blood cell count were determined. In all patients, measurements were performed on admission, skin suture, 4 h and from the first to fifth postoperative day. As parameters for the clinical outcome, we assessed daily temperature, lung function, pain, duration of postoperative hospital stay, and morbidity. Wilcoxon rank test was used for statistical analysis. RESULTS: In both groups, a significant increase of endotoxin plasma levels and a decrease of ENC was found already after skin incision. IL-6 levels peaked 4 h postoperatively in both groups, whereas CRP rose at the first postoperative day, reaching a maximum at day 2. Conventionally operated patients had significantly higher plasma levels of endotoxin, IL-6, and CRP and lower ENC during and after surgery than patients with stent-graft implantation. Moreover, patients with endovascular stent grafting had significant less postoperative pain, less restriction of total vital capacity, a shorter hospital stay, and a lower morbidity. CONCLUSIONS: Endovascular stent grafting of infrarenal aortic aneurysm seems to be superior not only in terms of the inflammatory response but also in overall clinical outcome.

Mechanical thrombectomy of embolic occlusion in both the profunda femoris and superficial femoral arteries in critical limb ischaemia.

We report our preliminary experience using the Amplatz device for percutaneous thromboembolectomy in acute occlusion in both the profunda femoris artery (PFA) and superficial femoral artery (SFA) in four patients (mean age 78.5 years). All patients suffered from acute lower limb ischaemia, Fontaine Grade 3, due to cardiac embolization. Estimated occlusion times range from 3 h to 3 days. All four patients were treated successfully. Device activation time for both the PFA and the SFA was 85 s +/- 15 s. Total procedure time was 25 min +/- 10 min. There was no need for adjunctive procedures or intensive care monitoring. We conclude that the Amplatz device is a very effective and safe procedure for the quick restoration of vascular patency in cases of simultaneous embolically occluded PFA and SFA.

[Therapy of acute traumatic vascular injuries using covered stents]. / Therapie akuter, traumatischer Gefässläsionen mittels ummantelter Stents.

PURPOSE: Evaluation of percutaneously implanted covered stents in acute vascular bleeding as therapeutic alternative to conventional surgical treatment. MATERIALS AND METHODS: 8 patients aged 26 to 83 years with acute vascular lesions caused by traumas, and subsequent haemorrhage, were transferred to our department. Because of general inoperability or difficult surgical access, interdisciplinary evaluation favoured an interventional treatment. In 6 patients stents could be placed percutaneously to the aorta, subclavian and iliac arteries. In one case we had to implant three stents into the thoracic aorta. RESULTS: In 7 interventionally treated patients the stents could be placed exactly on the lesions (88%). The bleeding could be stopped immediately in 6 cases (75%). In one patient we had to implant successfully two more stents in reintervention (12%). In another patient the available prosthesis was too short, so that the patient had to be referred to the OR for surgical treatment (12%). There were no complications during the treatment. CONCLUSION: First results in the use of covered stents as interventional treatment of acute vascular lesions are encouraging and may represent a possible alternative to surgical therapy in locally limited bleedings, presupposing that all different types and sizes of industrially produced covered stents are available. Further investigations to compare surgical and interventional techniques are warranted.

Treatment of thoracoabdominal aortic aneurysms with a combined endovascular and surgical approach.

AIM: The conventional approach for the repair of thoracoabdominal aneurysms remains complex and demanding and is associated with substantial morbidity and mortality. Moreover, in cases of reoperation the impact can be dramatic either in survival or in quality of life of the patients, albeit the use of adjuncts. A combined endovascular and surgical approach with retrograde perfusion of visceral and renal vessels has been realized in order to minimize intraoperative and postoperative complications. METHODS: Within an experience of 231 aortic stent-grafts between 1995-2000, 4 of the patients with thoracoabdominal aneurysms were treated with a combined endovascular and surgical approach. Three procedures were electively conducted and 1 on emergency basis. Two women, 59 and 68 years old, and 2 men, 68 and 73 years old (maximum aneurysm's diameter was 10, 6, 8 and 9 cm, respectively) were operated with the combined method (the first 2 patients had a previous open repair of a thoracoabdominal aneurysm). The surgical approach was executed in all patients without thoracotomy or re-do retroperitoneal exposure. Revascularization of renal, superior mesenteric (and celiac in 2 cases) arteries was accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was performed by stent-graft deployment. RESULTS: The entire procedure was technically successful in all patients. The 1(st) patient was discharged 6 weeks after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of leak or secondary rupture of the aneurysm; the patient died 3 months after the repair, due to rupture of an aneurysm of the ascending aorta. In the 2(nd) patient, 30 months after the operation, spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularized vessels. The 3(rd) patient died on the 6th postoperative day due to multiorgan failure after having developed ischemic-related pancreatitis, albeit the successful combined repair. The 4(th) patient followed an uneventful course. No patient experienced any temporary or permanent neurological deficit. CONCLUSION: The combined endovascular and surgical approach is feasible, without cross-clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems the appropriate strategy for high risk and previously operated, with a thoracoabdominal trans-diaphragmatic approach, patients.

[Endoluminal stent-assisted management of acute traumatic aortic rupture]. / Endoluminale stentgestützte Versorgung der akuten traumatischen Aortenruptur.

INTRODUCTION: Open repair of traumatic descending aortic rupture in trauma patients is associated with a mortality rate of 15-20% and a risk of paraplegia of 5-10%. Stent grafts may decrease the morbidity and mortality of these procedures by reducing blood loss and aortic occlusion time. MATERIAL AND METHODS: Within an experience of 52 thoracic stent grafts between 1995 and 2000, eight men with acute traumatic descending aortic rupture were conducted as emergencies without delay. All patients had severe coinjuries and presented with acute onset of mediastinal hematoma due to periaortic bleeding. Successful stent deployment was performed in all eight patients, seven of them required one single stent and one required two stents; within the aortic arch all stents covered the origin of the left subclavian artery. RESULTS: All acute aortic ruptures were sealed successfully. One death occurred in hospital from multiorgan failure. There was no conversion to open repair. Not one patient's condition resulted in temporary or permanent paraplegia. One endoleak required treatment by overstenting. Two patients required secondary surgical procedures (iliac access complication and revascularisation of left subclavian artery). Mean follow-up was 11 months (1-21 months). Mid-term freedom from endoleak was monitored in all patients. CONCLUSION: The treatment of acute traumatic descending aortic rupture with an endovascular approach is feasible and safe and may offer the best means of therapy. The mortality rate and risk of paraplegia are low compared with the risks associated with open operations. Continued surveillance is essential.

[Prophylactic indications in thoracic aortic aneurysm]. / Prophylaktische Indikation beim thorakalen Aortenaneurysma.

Prophylactic operations of aneurysms of the descending thoracic aorta have to take into consideration the expansion rate, probability of rupture and individual life expectancy of patients > 70 years of age as well as the individual risk of operation. Candidates for elective surgery are those with large aneurysms and low operative risk from low comorbidity who are expected to experience death from acute rupture unless operated on in a prophylactic way. Endoluminal stent grafts--though very attractive in this aortic segment--are still in statu nascendi and not recommended for general use.

Endograft treatment of anastomotic aneurysms following conventional open surgery for infrarenal aortic aneurysms.

OBJECTIVE: to evaluate the use of endograft therapy for treating anastomotic aneurysm following open surgical repair of infrarenal aneurysms of the abdominal aorta. METHODS: four male patients (age 47-75 years) at high surgical risk (ASA IV n=3, ASA III n=1) developed secondary aneurysms at the site of the central (four aneurysms) and additional peripheral (two aneurysms) anastomosis of their tube or bifurcation prosthesis an average of 13 years (range 1-23 years) after conventional open surgical correction of infrarenal aneurysm of the abdominal aorta. In two patients, there was covered rupture of the aneurysm sac. The aneurysm diameter was 4.8 cm, 8.0 cm, 7.4 cm, 7.0 cm, respectively (mean 6.8 cm). Follow-up included helical CT imaging at 1 week, 3 months and 6 months postoperatively. RESULTS: anastomotic aneurysm was successfully treated in all four cases. No evidence of endoleak was observed during the follow-up period. Two patients died 14 and 18 days after surgery due to myocardial infarction and cerebrovascular accident. The endovascular repair of the two patients who died was intact. CONCLUSION: although no long-term results are available, the use of a graft-in-graft method to repair anastomotic aneurysms following conventional implantation of tube or bifurcation prostheses appears to be effective, particularly in patients at high surgical risk.

Influence of treatment of type II leaks on the aneurysm surface area.

OBJECTIVE: to determine whether interventional treatment of type II endoleaks leads to a decrease in aneurysm surface area. MATERIAL AND METHOD: type II endoleaks were detected in a group of 14 male patients (median age: 70.2 years) following endovascular repair of a total number of 160 infrarenal aneurysms of the abdominal aorta. The surface area of the aneurysm was determined by computed tomography (CT) pre- and postoperatively and at subsequent follow-up examinations. If type II endoleaks were documented at CT, patients underwent treatment by means of coil embolisation. RESULTS: interventional treatment resulted in successful occlusion of type II endoleaks in eight patients. One of the cases exhibited spontaneous occlusion. Occlusion was associated with an average decrease in aneurysm surface area of 3.3 cm(2)( p =0.01). In one of these patients, treatment resulted in a temporary occlusion of the endoleak, also with associated decrease in aneurysm size. After recurrence of the type II endoleak, however, the patient experienced an increase in aneurysm surface area. In the remaining four patients the type II endoleaks persisted, resulting in a non significant increase in aneurysm surface area. CONCLUSION: only complete occlusion of endoleaks results in decrease in the size of the aneurysm sac. Because of endotension and the risk of rupture we favour an early interventional treatment of type II endoleaks.

Endoluminal grafting of infrarenal aortic aneurysms.

BACKGROUND: The department policy regarding therapy fo infrarenal aortic aneurysms is reviewed, based on the treatment results of a 12-months period. METHODS: From October 1996 to August 1997, 60 patients with infrarenal aortic aneurysms were admitted to our department. Of these 31 (52%) were found to be anatomically or pathomorphologically suitable for endovascular treatment, based on the premises that: 1. Whenever the anatomy is suitable and confirmed with CT or angiography, repair is by means of stent placement. 2. In emergencies and in cases where the anatomical relationships are unfavourable, patients undergo conventional open surgery. RESULTS: In all 31 patients treated endovascularly, stent placement was technically successful. Procedure-associated mortality was zero. The following stenting complications occurred: seven endoleaks, one thrombotic iliac occlusion, one femoral arterial dissection, two puncture-related inguinal hematomas. Elective open surgery was performed in the other 29 patients. One of these died from the effects of renal failure. CONCLUSIONS: This comparison shows that endovascular treatment of infrarenal aortic aneuryms is possible in a large proportion of patients and is not associated with an unfavourable rate of complications. Endovascular treatment can significantly reduce patients' postoperative hospitalization (three days) and time spent in intensive care.

Emergent endoluminal repair of delayed abdominal aortic rupture after blunt trauma.

PURPOSE: To report the emergency repair of a traumatic abdominal aortic rupture using endoluminal techniques. METHODS AND RESULTS: A 25-year-old female sustained multiple head, chest, and abdominal injuries in a motorcycle accident. Six days after emergency treatment (including splenectomy and repair of a superficial hepatic rupture and lacerations to the stomach, small bowel, and colon), she became hemodynamically unstable. A massive retroperitoneal hematoma had evolved from a distal aortic rupture. Owing to a hostile abdomen and possibility of bacterial contamination, a self-expanding stent-graft was inserted transfemorally to repair the aortic injury. The patient recovered uneventfully and continues in good health with a patent endograft repair 2 years after treatment. CONCLUSIONS: This experience would support the efficacy of endograft implantation for emergent repair of trauma aortic injuries; however, proper facilities, an experienced interventional team, and an assortment of endografts and stents must be available.

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture.

PURPOSE: The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies. METHODS: Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients. RESULTS: Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome. CONCLUSION: Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability.

Thrombus formation in aortic endografts.

PURPOSE: To examine the incidence of intraprosthetic thrombotic deposits in aortic endografts. METHODS: Transfemoral implantation of tube or bifurcated stent-grafts was performed in 82 patients (75 men; average age 67.7 years, range 25-88) for treatment of aneurysms of the abdominal (n = 73) or thoracic (n = 9) aorta in a 3.5-year period. Patients underwent 3-phase helical computed tomographic (CT) examinations at 3-month intervals. The length and cross-sectional area of any thrombotic deposits were measured from axial and 3-dimensional CT images. RESULTS: Over a 12.1-month mean follow-up, intraluminal deposits of thrombotic material were observed in 19 (23.2%) patients, all with infrarenal endografts that were predominately of a bifurcated design. The first signs of thrombus formation occurred on average 7 months postoperatively (range 1 week to 20 months). In 16 patients, nonocclusive deposits of thrombotic material were seen in the aortic segment of the endograft; a graft limb was involved in 5 patients. Three graft limbs occluded owing to kinking; no thrombus was seen on CT scans taken prior to occlusion. In 3 cases the thrombotic deposits disappeared completely from the prosthesis lumen during follow-up. CONCLUSIONS: Based on this small experience, nearly 1 in 5 patients may experience some degree of intraluminal thrombus following endovascular treatment of aortic aneurysms. Whether the deposition of thrombus is influenced by the geometry of the aortic stent-graft or by flow conditions within the prosthetic lumen must be determined in future studies.

Intraoperative, perioperative and late complications with endovascular therapy of aortic aneurysm.

PURPOSE: To describe the incidence and management of the intraoperative, perioperative and late complications of endovascular aortic aneurysm repair. METHODS: Endovascular aneurysm repair was attempted in 130 patients between October, 1995 and January, 2000. Follow-up including computed tomography (CT) was performed in the immediate postoperative period and then at 3, 6, 9 and 12 months and biannually thereafter. The median follow-up period was 20 months. RESULTS: Intra- and perioperative problems occurred in 26 patients (20%). Conversion to open surgery was required in five cases (4%). The primary technical success rate was 86%. Three patients (2%) died within the first 30 postoperative days. Late problems occurred in 28 patients (26%). These included: endoleaks (type I: 5%; type II: 10%; type III: 1%) and limb occlusion (3%). The cumulative rate of freedom from secondary intervention was in the first 65 patients treated: 86% and 65% after 1 and 3 years, respectively, and in the last 65 patients: 90% at 1 year. CONCLUSIONS: Endovascular aneurysm repair is associated with a higher complication rate than open surgery.

Does a postimplantation syndrome following endovascular treatment of aortic aneurysms exist?

The postimplantation syndrome (PIS) is a weakly defined condition that has been observed following endovascular treatment of aortic aneurysms; the postulated criteria include significant leukocytosis, fever, and/or coagulation disturbances. Among the factors that are supposed to contribute to this syndrome are contact activation by the stent covering with consecutive endothelial activation. Associated clinical parameters of a PIS were perioperatively monitored in the postoperative phase in a total of 69 patients with infrarenal aortic aneurysms treated with Y-stent grafts. C-reactive protein (CRP)-levels, leukocyte concentrations, and body temperature curves were directly compared to those of 50 patients undergoing conventional transperitoneal aneurysm resection. A subgroup of 10 patients of the endovascular group was compared with 13 operated-on patients with regard to an ischemia-reperfusion syndrome of the lower extremities. The mediator determinations were performed on venous (femoral vein) as well as in systemic (arterial) blood samples. The incidence of temperature values above 38 degrees C was higher in patients following endovascular treatment (72%) compared to conventionally operated-on patients (28%). CRP levels were not significantly different within the first 8 post-operative days. During open surgery, significantly higher values for lactate and lower pH levels were observed (p<0.01), as well as higher 6 keto prostaglandin F1alpha (PGF1alpha) levels. There was a short peak of PGF1alpha during eventeration of the intestine during the operative procedure that could not be detected during endovascular manipulations. The clinical and biochemical parameters do not prove the presence of a PIS following endovascular treatment of aortic aneurysms. In contrast, during open surgery the unspecific inflammatory reaction is higher, but not long-lasting. In the future, the suggested phenomenon of a decreased antiinflammatory cytokine response during endovascular surgery needs to be further examined.

Endovascular repair of aortic rupture due to trauma and aneurysm.

OBJECTIVES: to report a single centre experience with endovascular repair of the ruptured descending thoracic and abdominal aorta. DESIGN: prospective non-randomised study in a university hospital. MATERIAL AND METHODS: between 1995 and 2000, endovascular treatment was utilised for 231 aortic repairs; in 37 cases (16%) endografting was conducted on an emergency basis for 21 ruptured infrarenal aortic aneurysms, 15 ruptured descending thoracic aortic lesions, and 1 ruptured thoracoabdominal aortic aneurysm. The feasibility of endovascular treatment and the prostheses' size were determined, based on preoperative spiral CT and intraoperative angiography, both obtained in each patient. RESULTS: endografting was successfully completed in 35 patients (95%). Primary conversion to open repair was necessary in 2 patients (5%). Postoperative 30-day mortality rate was 11% (4 deaths). No patient developed postoperative temporary or permanent paraplegia. In 2 patients (5%) primary endoleaks required overstenting and in 6 patients (16%) secondary surgical interventions were required. Mean follow-up was 19 months (1-70 months); three deaths occurred within three months postoperatively (1-year survival rate 81+/-6%). In one case, secondary conversion to open repair was necessary 14 months postoperatively. CONCLUSION: the feasibility of endoluminal repair of the ruptured aorta has been demonstrated. Endoluminal treatment may reduce morbidity and mortality, and may in time become the procedure of choice in certain centres. However, further follow-up is required to determine the long-term efficacy.

Percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease using a transluminal endatherectomy catheter (TEC): initial results and angiographic follow-Up.

PURPOSE: To evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease. METHODS: Rotational atherectomy was performed in 39 patients aged 39-87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2-14 months). RESULTS: There was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%-50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p << 0.001) from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%. CONCLUSION: Percutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach.

Endovascular treatment in diseases of the descending thoracic aorta: 6-year results of a single center.

OBJECTIVE: The purpose of this study was to evaluate endovascular treatment in diseases of the descending thoracic aorta. MATERIAL AND METHODS: This study was designed as a single center's (university hospital) experience. Over a 6-year period (1995 to 2001), thoracic endografts were placed in 74 patients with a diseased descending thoracic aorta who were at high risk for conventional open surgical repair: 34 had atherosclerotic aneurysms, six had posttraumatic aneurysms, 14 had type B dissection with aneurysmal dilatation of the false lumen, 12 had isthmic transections from blunt trauma, five had thoracoabdominal aneurysms (treated with a combined procedure), two had aortic coarctation, and one had an aortobronchial fistula. Twenty-six procedures (35.1%) were conducted as emergencies, and 48 (64.9%) were elective. The feasibility of endovascular treatment and sizing of stent grafts were determined with preoperative spiral computed tomography and intraoperative angiography. RESULTS: Endovascular operations were completed successfully in all 74 patients; postprocedural conversion to open repair was necessary in three cases. The overall 30-day mortality rate was 9.5% (seven deaths). Temporary neurologic deficits developed in two patients; not one patient had permanent paraplegia. The primary endoleak rate was 20.3% (15 patients). The mean follow-up period was 22 months (range, 3 to 72 months). Five deaths occurred in the follow-up period, and three patients needed secondary conversion to open repair 2, 3, and 14 months after initial endografting. CONCLUSION: Endoluminal treatment in diseases of the thoracic descending aorta is feasible and may offer results as good as the open method.