Editor's Choice - Subsequent Results for Arch Aneurysm Repair with Inner Branched Endografts.

OBJECTIVES: The aim was to evaluate the current results of aortic arch aneurysm repair using inner branched endografts performed in three high volume aortic endovascular centers and to compare them to the pioneering global experience with this technology. METHODS: Included patients underwent repair of aortic arch aneurysms >55 mm in diameter using inner branched endograft technology between April 2013 and November 2014. All patients were deemed unfit for open surgery. Inner branches were designed to perfuse the brachiocephalic trunk and the left common carotid artery in all cases. A left subclavian artery (LSA) revascularization was performed prior to the arch endovascular repair. Data were collected retrospectively in an electronic database. Parameters included length of procedure, fluoroscopy time, contrast volume, technical success, presence of endoleaks, early and late complications, and mortality. RESULTS: Twenty-seven patients were included in the study. Technical success was achieved in all cases. No patients died during the 30 day post-operative period. Early neurologic events included two major strokes (7.4%) and one minor stroke (3.7%). Transient spinal cord ischemia with full recovery was observed in two patients (7.4%). Four patients (14.8%) underwent early (<30 day) re-interventions; these were for an access complication, an ischemic limb and exploration of the left ventricle through a sternotomy in two patients. During follow up (median 12 months), one patient (3.7%) died from a remote thoraco-abdominal aneurysm rupture. There were three Type 2 endoleaks (11.1%). Two re-interventions (7.4%) were performed, one to treat a Type 2 endoleak and one to treat a septic false aneurysm. A significant decrease in overall mortality was observed when comparing patients from the early experience with patients from the current report. CONCLUSIONS: The early outcomes associated with this technology are favorable. Branched endografting of aortic arch aneurysms should be considered in patients unfit for open surgery.

[Transcardiac Access Routes for Endovascular Treatment of Ascending Aortic Pathologies]. / Transkardiale Zugangswege zur endovaskulären Versorgung der Aorta ascendens.

Gold standard for treatment of pathologies of the ascending aorta is still open surgery with extracorporal circulation in moderate to deep hypothermia. These procedures are associated with high morbidity and mortality, especially if performed in older patients or after previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment option for thoracic aortic pathologies of the descending aorta even in high-risk patients with severe comorbidities resulting in reduced morbidity and mortality compared to open repair. Despite the continuous development of endograft technology an adequate arterial access still poses a relevant limitation of this treatment option accentuated in the proximal segments of the aorta. The transfemoral access may be limited due to severe kinking or arteriosclerotic plaque stenosis of femoral or iliac vessels. Furthermore, the long distance between femoral access vessels and the aortic lesion impairs device torsibility and exact deployment of the stent graft. To provide a practical alternative endovascular access to the ascending aorta, antegrade transcardiac access routes including transapical or transseptal techniques have recently gained increasing interest.

[Future vascular medicine: inauguration of a cardiovascular hybrid concept]. / Gefäßmedizin von morgen: Vorstellung eines kardiovaskulären Hybrid-Care-Konzepts.

The demographic developments will lead to an exponential increase of cardiovascular diseases. Additionally, technical developments of conservative and invasive treatment modalities will be added to distinguished, organ-orientated therapeutic concepts. This will also require a new orientation of vascular services. This concept implies that specific contents are referred to and contained in partner specialties. Since the heart and vascular system function as an anatomic and functional union, implementation of vascular medicine within cardiovascular centres represents a logical consequence.

[Treatment of abdominal aortic aneurysms]. / Therapie des abdominalen Aortenaneurysmas.

The treatment of abdominal aortic aneurysms (AAA) has changed significantly since the introduction of endovascular aortic repair (EVAR). In terms of perioperative morbidity and mortality, randomized multicenter trials revealed results in favour of EVAR compared to open reconstruction. However, EVAR is associated with possible late complications caused by endoleaks, stent migration, kinking and/or overstenting of side branches, making life-long follow-up necessary. Since the majority of patients requiring therapy are elderly and exhibit attendant comorbidities, EVAR has become the procedure of choice in those patients with favourable anatomy. Medicamentous and conservative treatment may be relevant in patients with small to medium-sized aneurysms. Since smoking is one of the major risk factors for the development of AAA, all patients should be advised to stop smoking. Studies on long-term statin therapy in patients following surgical AAA repair showed a reduction in both overall and cardiovascular mortality; AAA patients should therefore receive statins for secondary prevention.

[Vascular surgery in old people]. / Gefäßchirurgie bei alten Menschen.

The age pyramid in Germany is upside down. According to the Federal Statistical Office this development will continue in the coming years, which presents a challenge for surgeons to surgically treat increasingly more and increasingly older people. Particularly in vascular surgery, which is a surgery of old people, this fact represents a special challenge. The frailty of old people is, among other things, due to a series of comorbidities, which must be taken into consideration within the framework of surgical treatment. They can have an important influence on the perioperative planning, the operation, the postoperative treatment and the outcome of the patient. This treatment planning becomes more and more challenging, because due to the progress in endovascular surgery there will soon be no limits to what is feasible; however, the question arises whether the feasible is also reasonable? Within the scope of this article the authors try to give answers to the treatment of old patients in vascular surgery and to find strategies for planning and to establish an individualized optimal treatment.

Abdominal incision defect following AAA-surgery (AIDA): 2-year results of prophylactic onlay-mesh augmentation in a multicentre, double-blind, randomised controlled trial.

The reported incidence of incisional hernia following repair of abdominal aortic aneurysm (AAA) via midline laparotomy is up to 69%. This prospective, multicenter, double-blind, randomised controlled trial was conducted at eleven hospitals in Germany. Patients aged 18 years or older undergoing elective AAA-repair via midline incision were randomly assigned using a computer-generated randomisation sequence to one of three groups for fascial closure: with long-term absorbable suture (MonoPlus®, group I), long-term absorbable suture and onlay mesh reinforcement (group II) or extra long-term absorbable suture (MonoMax®, group III). The primary endpoint was the incidence of incisional hernia within 24 months of follow-up, analysed by intention to treat. Physicians conducting the postoperative visits and the patients were blinded. Between February 2011 and July 2013, 104 patients (69.8 ± 7.7 years) were randomised, 99 of them received a study intervention. The rate of incisional hernia within 24 months was not significantly reduced with onlay mesh augmentation compared to primary suture (p = 0.290). Furthermore, the rate of incisional hernia did not differ significantly between fascial closure with slow and extra long-term absorbable suture (p = 0.111). Serious adverse events related to study intervention occurred in five patients (5.1%) from treatment groups II and III. Wound healing disorders were more frequently seen after onlay mesh implantation on the day of discharge (p = 0.010) and three (p = 0.009) and six (p = 0.023) months postoperatively. The existing evidence on prophylactic mesh augmentation in patients undergoing AAA-repair via midline laparotomy probably needs critical review. As the implementation of new RCTs is considered difficult due to the increasing number of endovascular AAA treated, registry studies could help to collect and evaluate data in cases of open AAA-repair. Comparisons between prophylactic mesh implantation and the small bite technique are also required. Trial registration: ClinicalTrials.gov Identifier: NCT01353443. Funding Sources: Aesculap AG, Tuttlingen, Germany.

Perioperative management and "Fast-Track" therapy in vascular medicine.

Perioperative risk in vascular medicine is particularly high due to the increased prevalence of cardiovascular comorbidity. Therefore, it is of the utmost importance that during periprocedural management the patient remains in good general condition and that the patient is mobilized as soon as possible. Along with implementation of minimally-invasive techniques and endovascular procedures, networking and cooperation between the surgeon, anesthesiologist, physiotherapist and the nursing team can lead to an optimization of perioperative mobilization. The Fast-Track concept represents uncharted territory in the field of vascular surgery and it can provide advantages, particularly in relation to multimorbidity in the field of vascular medicine. The Fast-Track concept was introduced by Danish surgeon Henrik Kehlet and was originally intended to be implemented in general surgery. When compared to conventional management, this method offers better medical results, lower costs and other advantages for the patient: besides a better perioperative condition a reduction of postoperative complications and reduction of overall in-hospital stay was achieved. Therefore, the next logical step was to introduce and adapt this concept to other fields of operative medicine. This paper represents a systematic review on the actual experience of the fast-track concept in vascular surgery.

Intra-aneurysm sac pressure in patients with unchanged AAA diameter after EVAR.

OBJECTIVE: To study intra-aneurysm sac pressure and subsequent abdominal aortic aneurysm (AAA) diameter changes in patients without endoleaks that remain unchanged in AAA diameter more than 1 year after endovascular aneurysm repair (EVAR). METHODS: A total of 23 patients underwent direct intra-aneurysm sac pressure (DISP) measurements 16 months (IQR: 14-35 months) after EVAR. Tip-pressure sensors were used through translumbar AAA puncture. Mean pressure index (MPI) was calculated as the percentage of mean intra-aneurysm pressure relative to the simultaneous mean intra-aortic pressure. Aneurysm expansion or shrinkage was assumed whenever the diameter change was > or =5mm. Values are presented as median and interquartile range. RESULTS: In 18 patients, no fluid was obtained upon AAA puncture (group A). In five patients, fluid was obtained (group B). In group A, follow-up continued for 29 months (IQR: 15-35 months) after DISP; five AAAs shrank, 10 remained unchanged and three expanded (MPIs of 26% (IQR: 18-42%), 28% (IQR: 20-48%) and 63% (IQR: 47-83%) and intra-sac pulse pressures of 3 mmHg (IQR: 0-5 mmHg), 4 mmHg (IQR: 2-8mm Hg) and 12 mmHg (IQR: 6-20 mmHg), respectively, for the three subgroups). MPI and intra-sac pulse pressures were higher in AAAs that subsequently expanded (P=0.073 and 0.017, respectively). MPI and pulse pressure correlated with total diameter change (r=0.49, P=0.039 and r =0.39, P=0.109, respectively). Pulse pressure had a greater influence than MPI on diameter change (R(2)=0.346, P=0.041, beta standardised coefficient of 0.121 for MPI and 0.502 for pulse pressure). Similar results with stronger, and significant correlation to pulse pressure were obtained when relative diameter changes were used (r=0.55, P=0.017). In group B, MPI and AAA pulse pressure were 32% (IQR: 18-37%) and 1 mmHg (IQR: 0-6 mmHg), respectively. After 36 months (IQR: 21-38 months), one AAA shrank, three continued unchanged while one expanded. CONCLUSIONS: AAAs without endoleak and unchanged diameter more than 1 year after EVAR will often continue unchanged. Expansion can eventually occur in the absence of intra-sac fluid accumulation and is associated with higher and more pulsatile intra-sac pressure. However, in patients with intra-sac fluid, expansion can occur with low intra-sac pressures.

Management of inadvertent arterial catheterisation associated with central venous access procedures.

OBJECTIVE: This study aims to describe the clinical management of inadvertent arterial catheterisation after attempted central venous catheterisation. METHODS: Patients referred for surgical or endovascular management for inadvertent arterial catheterisation during a 5-year period were identified from an endovascular database, providing prospective information on techniques and outcome. The corresponding patient records and radiographic reports were analysed retrospectively. RESULTS: Eleven inadvertent arterial (four common carotid, six subclavian and one femoral) catheterisations had been carried out in 10 patients. Risk factors were obesity (n=2), short neck (n=1) and emergency procedure (n=4). All central venous access procedures but one had been made using external landmark techniques. The techniques used were stent-graft placement (n=6), percutaneous suture device (n=2), external compression after angiography (n=1), balloon occlusion and open repair (n=1) and open repair after failure of percutaneous suture device (n=1). There were no procedure-related complications within a median follow-up period of 16 months. CONCLUSIONS: Inadvertent arterial catheterisation during central venous cannulation is associated with obesity, emergency puncture and lack of ultrasonic guidance and should be suspected on retrograde/pulsatile catheter flow or local haematoma. If arterial catheterisation is recognised, the catheter should be left in place and the patient be referred for percutaneous/endovascular or surgical management.

Predictors for outcome after vacuum assisted closure therapy of peri-vascular surgical site infections in the groin.

OBJECTIVES: To assess outcomes (wound healing, amputation and mortality) after vacuum assisted closure (VAC) therapy of peri-vascular surgical site infections in the groin after arterial surgery. DESIGN: Retrospective study. MATERIALS: Thirty-three groins received VAC therapy between August 2004 and December 2006 at Vascular Centre, Malmö University Hospital. METHODS: Following surgical revision, VAC therapy was applied in the groin at a continuous topical negative pressure of 125 mmHg. The median follow up time was 16 months. RESULTS: Median age was 75 years. Twenty-three (70%) cases underwent surgery for lower limb ischaemia. Intestinal flora was present in 88% of the wound cultures. Median duration of VAC therapy was 20 days and 27 (82%) wounds healed within 55 days. One serious VAC associated bleeding and three late false femoral artery aneurysms were reported. The median cost of VAC treatment was 2.7% of the in-hospital costs. Synthetic vascular graft infection (n=21) was associated with adverse infection-related events (n=9; p=0.012). Non-healing wounds were associated with amputation (p=0.005) and death (p<0.001). CONCLUSIONS: VAC treated synthetic vascular graft infections in the groin were at a greater risk of developing infection-related complications. Non-healing surgical site infections after VAC therapy were associated with amputation and death.

What to do when evidence is lacking--implications on treatment of aortic ulcers, pseudoaneurysms and aorto-enteric fistulae.

UNLABELLED: Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available. MATERIAL: From our centre we collected 65 patients treated with open (n = 15) or endovascular reconstruction (n= 50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment. RESULTS: Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended. CONCLUSION: Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.

Staged procedures for prevention of spinal cord ischemia in endovascular aortic surgery.

BACKGROUND: Spinal cord ischemia with development of paraplegia is the most relevant complication of thoracoabdominal aortic surgery caused by compromising the segmental arteries. To prevent this devastating complication in endovascular aortic surgery, staging procedures have been developed to reinforce collateral blood flood to the spinal cord. RESULTS: In patients with a medium to high risk for spinal cord ischemia, staged aortic repair is recommended. The classical staged repair is the two-step repair with delayed implantation of the aortic stent grafts. Additionally, more recent methods for short-term salvage of segmental artery perfusion by leaving an endoleak have been developed. Perfusion branches, delayed bridging stents as well as the open branch technique are among these methods. The latest option of staged repair is minimally invasive segmental artery embolization. CONCLUSION: Besides the nonsurgical options for monitoring and therapy of spinal cord ischemia, various staging procedures are available, which can be implemented depending on the patient and the aortic anatomy. Evidence that underlines staged repair for endovascular treatment of thoracoabdominal aortic pathologies is mostly based on retrospective studies.

Complex endovascular treatment of intact aortic aneurysms: An analysis of health insurance claims data.

BACKGROUND: The complex endovascular repair of aortic aneurysms and dissections with fenestrated or branched stent grafts (FB-EVAR) remains challenging for interventional vascular surgery. To date, the evidence regarding treatment patterns and outcome measures consists of single center studies; however, it might be reasonable to validate results with multicenter real-world evidence. METHODS: Health insurance claims data from Germany's third largest insurance provider, DAK-Gesundheit, were used to determine outcomes following FB-EVAR of non-ruptured thoracic aorta (TA) or thoracoabdominal including pararenal abdominal (TAA) aorta. The study included patients operated between January 2008 and April 2017. RESULTS: Included were 984 patients (18.1% female) who underwent FB-EVAR. Patients with treatment of the TA were younger (71.7 vs. 73.2 years, p < 0.001) and more often female (38.5% vs. 17.0%, p < 0.001) as compared to patients with treatment of TAA. In the TA group peripheral arterial disease was less frequent compared to the TAA group (67.3% vs. 80.4%, p = 0.036). Mortality was significantly (p < 0.001) higher following repair of the TAA compared to the TA at discharge (17.3% vs. 4.6%), at 30 days (26.9% vs. 8.2%) and at 90 days (34.6% vs. 10.1%). Patients with treatment of the TAA suffered more often from stroke as compared to the TA group (7.7% vs. 1.2%, p = 0.002). CONCLUSION: In this large-scale German analysis of claims data, multicenter real-world evidence was different from single center studies regarding patient risk-factors and outcome measures. Validated multicenter registry studies could help to further investigate this topic in times of increasing procedures.

Erratum to: Complex endovascular treatment of intact aortic aneurysms. An analysis of health insurance claims data.

[This corrects the article DOI: 10.1007/s00772-018-0387-7.].

I-SWOT as instrument to individually optimize therapy of thoracoabdominal aortic aneurysms: Effective, norm-compliant and meeting the needs.

BACKGROUND: Guidelines summarize medical evidence, they identify the most efficient therapy under study conditions and recommend this therapy for use. The physician now has the challenge to translate a therapy that is efficient under laboratory conditions to a patient who is an individual person. To accomplish this task the physician has to make sure that (I) the ideal typical therapy is applicable and effective in this individual patient taking the special features into consideration, that (II) therapy is compliant with the norm including guidelines, laws and ethical requirements (conformity) and that (III) the therapy meets the patient's needs. OBJECTIVE: How can physicians together with the patients translate the medical evidence into an individually optimized therapy? MATERIAL AND METHODS: At the German Aortic Center in Hamburg we use I­SWOT as an instrument to identify such individually optimized therapy. With I­SWOT, we present an instrument with which we have developed an (I) efficient, (II) conform and (III) needs-oriented therapeutic strategy for individual patients. RESULTS: I-SWOT cross-tabulates strengths (S) and weaknesses (W) related to therapy with opportunities (O) and threats (T) related to individual patients. This I­SWOT matrix identifies four fundamental types of strategy, which comprise "SO" maximizing strengths and opportunities, "WT" minimizing weaknesses and threats, "WO" minimizing weaknesses and maximizing opportunities and "ST" maximizing strengths and minimizing threats. We discuss the case of a patient with asymptomatic thoracoabdominal aneurysm to show how I­SWOT is used to identify an individually optimized therapy strategy.

[Endovascular versus conventional vascular surgery - old-fashioned thinking? Part 1: interventions on the aorta]. / Endovaskuläre vs. konventionelle Gefäßchirurgie - antiquiertes Denken? Teil 1: Eingriffe an der Aorta.

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of complicated acute type B aortic dissection, descending thoracic aortic aneurysms, thoracoabdominal aortic aneurysms as well as asymptomatic and ruptured abdominal aortic aneurysms.

Modern diagnostics for type B aortic dissection.

BACKGROUND: Undifferentiated chest pain is one of the most common complaints in the acute care setting. Type B aortic dissection is an important cause of chest pain and a complex clinical entity, which carries significant morbidity and mortality and requires accurate clinical and radiological evaluation. METHODS: Imaging technologies have become an irreplaceable tool to establish the diagnosis of aortic dissection and to plan treatment strategies. Computed tomography is an important component in this process, replacing catheter-based angiography as the most commonly used preoperative and postoperative imaging modality for the thoracic aorta. The use of functional imaging methods, such as magnetic resonance imaging and echocardiography is evolving. These methods are able to provide the clinically relevant anatomical, hemodynamic and biomechanical information that is necessary for accurate diagnosis, risk stratification and patient selection for treatment. CONCLUSION: Advanced image acquisition equipment and expertise are increasingly available in a growing number of institutions and as a consequence, existing strategies for the management of type B dissection are rapidly evolving.

[Complications following aortic reconstruction surgery]. / Komplikationen nach Rekonstruktion der Aorta.

BACKGROUND: The potential complications following aortic reconstruction surgery are diverse and potentially life-threatening. Besides the well known complications of open aortic repair (OAR) the spectrum of complications has been extended and shifted by the growing use of endovascular aortic repair (EVAR). AIM: The most common complications of open as well as endovascular aortic surgery are presented in a summarizing review. The focus is placed on the presentation of cardiovascular and nephrological complications, colonic ischemia, as well as aortic graft infections and graft fistulas. Spinal ischemia and endoleaks after EVAR are also discussed. Additionally epidemiological data, risk factors and basic therapeutic principles are outlined. CONCLUSION: Aortic reconstruction surgery can be associated with severe complications, the main features of which should be known by all surgical specialties.