[Perioperative antibiotic prophylaxis in dermatosurgery-2019 status quo]. / Perioperative Antibiose in der Dermatochirurgie ­ Stand 2019.

Perioperative antibiotic prophylaxis (PAP) is determined as a short-term, in general single-shot administration of an antibiotic prior to a surgical intervention. The main goal of PAP is to reduce postoperative surgical site infections. In addition, PAP is administered to avoid development of bacterial endocarditis in patients who are at high risk. Regarding the increasing prescription of antibiotics by dermatologists and the rising emergence of resistant bacterial strains, a rational use of PAP in dermatosurgery has to be demanded. Thus, identification of risk factors being determined either by the patient, the type of surgery or the location will help to identify those patients requiring PAP. Moreover, utilizing established criteria will avoid the unnecessary administration of PAP-which only creates a false sense of safety.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.

OBJECTIVES: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Aortomonoiliac endografting after failed endovascular aneurysm repair: indications and long-term results.

OBJECTIVES: To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. DESIGN: Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. MATERIALS AND METHODS: From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: -1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. RESULTS: Technical success rate of AMI endografting was 95.65% (n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1-Q3: 1.3-9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1-Q3: 17-69 months). CONCLUSIONS: Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.

Acute dissection of the descending thoracic aorta carries a 30-day mortality of around 10% with best medical treatment (BMT). In addition, about 25% will develop an aneurysm during the following 4-5 years. This is the first ever randomised trial on acute dissections comparing BMT with BMT and stent grafting of the proximal tear in patients having an uncomplicated acute dissection of the descending aorta. The commonly used temporal definition of acute dissection being within 14 days of onset of symptoms is applied. A total of 61 patients will be randomised and followed at regular intervals (1, 3, 6, 12, 18, 24, 30 and 36 months) after acute dissection. Thrombosis of the false lumen, aortic enlargement and rupture are the primary end points. The study will examine whether aortic remodelling occurs after stent grafting in acute type B dissections, and its effect on aneurysm formation, rupture and re-intervention.

Diabetic foot and PAD: the endovascular approach.

Diabetic foot ulceration (DFU) is recognized as one of the most serious complications of diabetes. Active revascularisation plays a crucial role in achieving ulcer healing. Non-surgical, minimally invasive, revascularisation options for DFU have expanded over the last decade and have become a prominent tool to prevent amputation. Endovascular treatment of arterial DFU lesions is mainly concentrated in the below-the-knee arteries. The outcome of both open surgery and endovascular treatment is broadly spoken the same for the endpoints ulcer healing and limb salvage and is between 78% and 85%. The choice between endovascular treatment and open surgery should always be the outcome of a team discussion. Local expertise plays an important role in these discussions. In many institutions, the endovascular approach has currently become the first choice treatment option. The revascularisation of below-the-knee vessels needs experienced hands, team discussion and the right set of devices. Centralisation in DFU centres is therefore probably the best guaranty for the best outcome.

A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease.

In several large recent observational studies, peripheral arterial disease (PAD) was present in up to 50% of the patients with a diabetic foot ulcer and was an independent risk factor for amputation. The International Working Group on the Diabetic Foot therefore established a multidisciplinary working group to evaluate the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. A systematic search was performed for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980-June 2010. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 49 papers were eligible for full text review. There were no randomized controlled trials, but there were three nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70.5-85.5%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular revascularization. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of medically treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot.

The International Working Group on the Diabetic Foot (IWDGF) has produced in 2011 a guideline on the diagnosis and treatment of peripheral arterial disease in patients with diabetes and a foot ulcer. This document, together with a systematic review that provided the background information on management, was produced by a multidisciplinary working group of experts in the field and was endorsed by the IWDGF. This progress report is based on these two documents and earlier consensus texts of the IWDGF on the diagnosis and management of diabetic foot ulcers. Its aim is to give the clinician clear guidance on when and how to diagnose peripheral arterial disease in patients with diabetes and a foot ulcer and when and which treatment modalities should be considered, taking both risks and benefits into account.

Right heart dilatation in adult congenital heart disease: imaging appearance on cardiac magnetic resonance.

Imaging morphology and function of the right heart is of paramount importance in patients with adult congenital heart disease, since right ventricular dysfunction is associated with adverse cardiac events. Cardiac MRI has been shown to be a powerful tool for the non-invasive precise assessment of right ventricular and valvular dysfunction. Differential diagnoses of congenital heart disease characterised by, or combined with, right heart dilatation are diverse and necessitate a systematic approach.

Endovascular aortic arch repair: hopes and certainties.

For aneurysms and dissections involving the aortic arch, the traditional treatment is open surgical repair requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. Reported mortality rates range from 7% to 17% and neurologic injury rates range from 4% to 12%. Since the first clinical applications of endovascular repair in the early 1990s, this less-invasive treatment modality has evolved steadily. For the treatment of aortic arch pathologies, combined open and endovascular strategies (hybrid procedures) have gained a widespread implementation. Evidence to date proves the feasibility of open surgical branch re-vascularisation followed by endovascular repair into the proximal arch. For hybrid procedures, mortality and stroke rates are given as 0-20%, and 0-8%, respectively. Alternative approaches using fenestrated and branched stent grafts have been considered. Although this technique is challenging and devices are not available widely, it is anticipated that this new technique will expand the range of aortic arch pathologies that can be treated by endovascular means.

Bail-out visceral bypass grafting for acute intestinal ischemia after endovascular stent-graft placement in a complicated type B dissection.

We report on the case of a 35-year-old male who underwent emergency stent-graft placement in March 2007 due to a complicated type B dissection. One week after this procedure the patient developed critical visceral malperfusion. Subsequently, autologous iliaco-mesenteric as well as iliaco-hepatic bypass grafting was performed. At 6-month follow-up, aortic remodelling has occurred and visceral perfusion is regular.

AMS INSIGHT--absorbable metal stent implantation for treatment of below-the-knee critical limb ischemia: 6-month analysis.

Endoluminal treatment of infrapopliteal artery lesions is a matter of controversy. Bioabsorbable stents are discussed as a means to combine mechanical prevention of vessel recoil with the advantages of long-term perspectives. The possibility of not having a permanent metallic implant could permit the occurrence of positive remodeling with lumen enlargement to compensate for the development of new lesions. The present study was designed to investigate the safety of absorbable metal stents (AMSs) in the infrapopliteal arteries based on 1- and 6-month clinical follow-up and efficacy based on 6-month angiographic patency. One hundred seventeen patients with 149 lesions with chronic limb ischemia (CLI) were randomized to implantation of an AMS (60 patients, 74 lesions) or stand-alone percutaneous transluminal angioplasty (PTA; 57 patients, 75 lesions). Seven PTA-group patients "crossed over" to AMS stenting. The study population consisted of patients with symptomatic CLI (Rutherford categories 4 and 5) and de novo stenotic (>50%) or occlusive atherosclerotic disease of the infrapopliteal arteries who presented with a reference diameter of between 3.0 and 3.5 mm and a lesion length of <15 mm. The primary safety endpoint was defined as absence of major amputation and/or death within 30 days after index intervention and the primary efficacy endpoint was the 6-month angiographic patency rate as confirmed by core-lab quantitative vessel analysis. The 30-day complication rate was 5.3% (3/57) and 5.0% (3/60) in patients randomized for PTA alone and PTA followed by AMS implantation, respectively. On an intention-to-treat basis, the 6-month angiographic patency rate for lesions treated with AMS (31.8%) was significantly lower (p = 0.013) than the rate for those treated with PTA (58.0%). Although the present study indicates that the AMS technology can be safely applied, it did not demonstrate efficacy in long-term patency over standard PTA in the infrapopliteal vessels.

Elective abdominal aortic aneurysm repair: does the aneurysm diameter influence long-term survival?

OBJECTIVES: The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. DESIGN: Retrospective analysis of database. MATERIAL AND METHODS: Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. RESULTS: Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p<0.0016). CONCLUSIONS: Patients with small aneurysms (< or =5.5cm) have an improved long-term survival than patients with larger aneurysms.

Multidetector CT angiography in the assessment of peripheral arterial occlusive disease: accuracy in detecting the severity, number, and length of stenoses.

The purpose was to evaluate the accuracy of multidetector CT angiography (MD-CTA) in the morphologic assessment of peripheral arterial occlusive disease (PAOD) compared to digital subtraction angiography (DSA). Fifty consecutive patients referred for DSA of the peripheral arteries due to PAOD were prospectively included in this study and underwent 16-row MD-CTA prior to DSA. Maximum intensity projections and multipath curved planar reformations were created with a semi-automated toolbox. Twenty-one vascular segments were defined in each leg and compared to DSA findings with regard to gradation, length, and number of lesions. Mean sensitivity and specificity in the detection of significant stenoses (over 70%) were 100% and 99.5% in the iliac arteries, 97.4% and 99.0% in the femoro-popliteal arteries, and 98.3% and 99.8% in the infrapopliteal arteries, respectively. High kappa values for exact stenoses gradation (0.74-1), lesion length (0.74-1), and number of lesions (0.71-1) were reached by MD-CTA, indicating high agreement with DSA. Non-invasive MD-CTA is an accurate tool for the assessment of all treatment-relevant morphologic information of PAOD (gradation, length, and number of stenoses) compared to DSA.

Endovascular versus open surgical AAA exclusion techniques the importance of individual patient selection criteria.

Abdominal aortic aneurysms (AAA) are managed by two different treatment options, i.e. open graft replacement (OGR) as open surgical technique or endovascular aneurysm repair (EVAR) as minimally invasive procedure, to avoid fatal rupture. The intention of this review was to show how by offering electively either OGR or EVAR - adjusted to the patient's individual risk profile--a benefit for the individual patient could be obtained and overall mortality rates of elective AAA repair could be significantly reduced. A comparative evaluation of both treatment regimes is offered, latest literature as well as own research is presented. Our own risk adjusted patient selection regime is described as well as its statistically significant impact on overall mortality rates in elective AAA exclusion. As conclusion, the benefit of offering both EVAR and OGR is the capability to select and recommend the optimal AAA management for the individual patient with respect to the individual risk profile. The result is a decrease in the overall mortality rate while simultaneously the number of treated patients increases. Furthermore EVAR offers a treatment option for otherwise incurable high risk patients.

Plaque imaging of the internal carotid artery - correlation of B-flow imaging with histopathology.

BACKGROUND AND PURPOSE: The noninvasive identification of plaque types prone to cause symptomatic disease is of great interest to improve the effectiveness of surgical or interventional management. The purpose of the present prospective pilot study was to evaluate the association between the results of imaging-the novel sonography technique B-flow imaging (BFI), B-mode, and color Doppler imaging (CDI)-and histopathologic examination in the characterization of internal carotid artery (ICA) plaques. METHODS: Twenty-eight consecutive patients with high-grade internal carotid artery stenosis scheduled for carotid endarterectomy were included. BFI, B-mode, and CDI images were used to classify the plaques applying the standardized scores of Beletsky et al and the American Heart Association (AHA), to calculate the gray-scale median (GSM) and to detect potential ulcerations; histopathologic examination results of explanted plaques served as the "gold standard." RESULTS: Based on the classification of Beletsky et al, BFI and histopathologic examination results agreed in 21 (75%, kappa = 0.61, P < .001) patients, and the corresponding results for B-mode were 19 (68%, kappa = 0.52, P < .001) patients, respectively. Corresponding results for the AHA classification revealed inferior agreements for BFI (19 patients/68%, kappa = 0.38, P = .003) and B-mode (17 patients/61%, kappa = 0.25, P = .045). The median GSM for BFI and B-mode correlated significantly (r = 0.95, P < .001). The sensitivity of BFI for the detection of ulcerated plaques was 100% and the specificity was 95.8%; corresponding values for CDI were 100% and 92.7%, respectively. CONCLUSION: BFI and the combination of B-mode and CDI exhibit comparable results in the assessment of ICA plaque components and plaque ulceration as well as in the determination of GSM levels.

Treatment of an acute type B dissection with an intramural haematoma in the ascending aorta by percutaneous endovascular stent-graft placement.

Acute type B dissections accompanied by an intramural haematoma in the ascending aorta are rare. However, progression of the intramural haematoma in the ascending aorta poses risks for the patients, which are similar to those of type A dissections, including pericardial effusions and consecutive tamponade. To date, no clear treatment guidelines exist for these patients. We report on successful percutaneous endovascular stent-graft treatment of an acute type B dissection accompanied by an intramural haematoma in the ascending aorta as primary and sole form of treatment.

The role of multi-slice spiral CT angiography in patient management after endovascular therapy.

OBJECTIVES: To bring out the role of multi-slice spiral CT angiography (MS-CTA) in patient management after endovascular therapy of subclavian artery stenosis. METHODS: Twenty-one consecutive patients with clinically suspected restenosis after endovascular treatment of subclavian artery stenosis or occlusion were included in the study. Eleven patients had been treated with percutaneous transluminal angioplasty (PTA) alone and 10 with PTA and stenting. The mean follow-up period after PTA or stenting was 57 (+/-27 SD) months. CTA was performed using a bolus-triggered high-resolution protocol with biphasic intravenous contrast medium injection. Axial images and curved planar reformations (CPRs) were rated by three readers with regard to patency of supra-aortic vessels. Imaging findings were correlated with a standardized clinical assessment. RESULTS: All examinations were of diagnostic quality. Of 21 referred patients, 7 had significant reobstruction of the treated subclavian artery. Six of the 7 patients with significant restenosis on CTA were treated conservatively (antiplatelet agents), despite 2 of them being symptomatic on the standardized clinical assessment, which showed a sensitivity and specificity of 86% in predicting stenosis. One patient was treated with PTA and stent deployment because of strong subjective suffering. CONCLUSION: MS-CTA is useful for exclusion or quantification of clinically suspected restenosis in carefully selected patients after endovascular therapy where ultrasound is inconclusive and/or contrast-enhanced magnetic resonance angiography is contraindicated.

PTA versus carbofilm-coated stents in infrapopliteal arteries: pilot study.

PURPOSE: To determine the primary success and short-term patency of stent application as a primary treatment modality for high-grade lesions of the infrapopliteal arteries compared with treatment with percutaneous transluminal angioplasty (PTA) in critical limb ischemia in a randomized prospective study. METHODS: Endovascular therapy was performed on 95 lesions in 51 patients (mean age 72.0 years, range 47-80 years) who presented clinically with Fontaine stages III and IV. One patient underwent treatment in both limbs. After angiographic lesion identification, patients were randomized for treatment by PTA (53 lesions in 27 patients) or stent application (42 lesions in 24 patients). Follow-up by clinical investigation and conventional angiography or spiral CT angiography was performed in 37 patients (57 lesions) 6 to 12 months after the procedure, or when clinically indicated. Evaluation was performed by two observers, double-blinded, with thresholds for lesion restenosis of 50% and 70%. Statistical evaluation was performed on a lesion basis by Kaplan-Meier estimated probability rates, and log-rank and Wilcoxon tests. The primary endpoint was the angiographic patency rate of treated lesions. RESULTS: The inter-reader agreement was high (kappa = 0.82). For the stent group the cumulative primary patency at 6 months was 83.7% at the 70% restenosis threshold, and 79.7% at the 50% restenosis threshold. For PTA, the primary patency at 6 months was 61.1% at the 70% restenosis threshold and 45.6% at the 50% restenosis threshold. Both results were statistically significant (p < 0.05). CONCLUSION: Infrapopliteal stent application is an effective treatment modality for high-grade lesions in chronic critical limb ischemia. Compared with PTA, higher patency rates can be expected after 6 months.