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AIM: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations. METHOD: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options. RESULTS: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival. CONCLUSION: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.
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INTRODUCTION: Currently, there is an increase in severe stages of peripheral arterial occlusive disease (PAOD) with critical ischemia. This seems to correspond to the general demographic change as well as a consequence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic of the last 3 years. The now established and accepted interventional/endovascular approach for severe lower leg PAOD in experienced hands is still considered the first-line treatment but from the authors' perspective crural/pedal venous bypass is experiencing a renaissance. MATERIAL AND METHODS: Compact narrative review of the current state of crural/pedal bypass surgery in Germany and Saxony-Anhalt (SA) combined with selective references from the current scientific medical literature and own clinical experiences. RESULTS: The current statistics of case-related diagnosis-related groups (DRG) data show that, especially with the occurrence of the corona pandemic, a decrease in inpatient case numbers of patients with PAOD stage IIB can be observed nationwide and also in SA. The severe PAOD stages have remained approximately the same in case numbers but increased in SA. The risk stratification based on the wound, ischemia and foot infection (WIFI) classification offers the possibility to be able to make statements about the risk of amputation, benefits and type of revascularization measures. The length of the occlusion, occlusion site of the affected vessels and degree of calcification are taken into account in the global limb anatomic staging system (GLASS) to assess the prognosis. The evaluation of the case-based hospital statistics from 2015 to 2020 showed a constant use of femorocrural/femoropedal bypass surgery in Germany as well as a slight increase in reconstruction using femorocrural bypasses in SA, which seems to correlate with the tendency for an increase in the number of cases of severe PAOD. Parameter-based objectification of the severity of critical limb ischemia should be included in the indications for placement of a crural/pedal bypass. The WIFI classification and GLASS are suitable for this purpose as a relative prognosis of success is also possible. The treatment of critical limb ischemia by crural/pedal bypass surgery continues to find a constant application in Germany and SA.
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INTRODUCTION: An increasing shortage of specialists and training assistants is also being lamented in vascular surgery. Despite a continuous increase in the number of physicians and medical students in Germany in recent years, the need for specialists and training assistants in vascular surgery is enormous in a sustained manner. METHODS: Professional policy analysis from a medical vascular surgery perspective including currently available statistics, especially from the Federal Statistical Office, the Federal Medical Association, the Saxony-Anhalt (SA) State Medical Association and selective references from current medical scientific literature on epidemiological topics. RESULTS: In 2022, according to the basic data of the Federal Statistical Office 200 vascular surgery departments provided a total of 5706 beds for care. In 2021, 1574 physicians with the regional and specialist title in vascular surgery were registered by the medical associations. In the following years, there was an increase of 404 vascular surgeons. The recognition of the specialist title for vascular surgery fell from 166 in 2018 to 143 in 2021. There are 23 vascular surgery care units in Saxony-Anhalt (SA). At the SA Medical Association, there were 52 registered doctors with the specialist title in vascular surgery in the inpatient sector in 2021. In comparison, at the North Rhine Medical Association in 2021 there were 362 registered doctors with regional and specialist titles in vascular surgery overall and 292 in the inpatient sector. The age-standardized hospital incidence of peripheral arterial occlusive disease (PAOD) rose from approximately 190 to over 250 per 100,000 inhabitants in Germany between 2005 and 2016 and plateaued at this level. This corresponded to a relative increase of 33%. During the same observational period, the number of procedures performed doubled, mainly due to a strong increase in the number of endovascular interventions (approximately 140% increase) and interventions for arterial embolism/thrombosis (approximately +â¯80%). A research report commissioned by the German Hospital Society (DKG) in 2010 predicted a replacement requirement for physicians of approximately 108,000 by 2019 and an additional requirement of almost 31,000 physicians. While 14.6-27.2% of those employed in 2008 will have retired by 2020, between 45.6% and 68.5% will retire by 2030. Despite the statistically verifiable improvement in the staffing situation of specialists in vascular surgery in the inpatient and outpatient sectors in Germany, it can be assumed that there is a problem in recruiting young specialists. In order to target the recruitment of junior staff, it is first necessary to comprehensively record basic data on the staff situation and staff development in the area of residents in vascular surgery. In addition, further work should be done on implementing the recommendations for action already put forward years ago by scientific reports at state and federal levels.
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Especialidades Quirúrgicas , Cirujanos , Humanos , Alemania , Recursos Humanos , Procedimientos Quirúrgicos VascularesRESUMEN
INTRODUCTION: Intravascular leiomyoma is a rare type of myoma. It was firstly described by Birch-Hirschfeld in 1896, however, its intracardiac subtype was firstly reported by Durck in 1907. Most patients are asymptomatic. The tumor invades mostly the tributaries of the inferior vena cava (IVC) with upward extension that may approach the intracardiac space. AIM: By means of a scientific case report, a patient with the very rare diagnosis of an endocaval leiomyoma thrombus post-hysterectomy is described based on the clinical experiences obtained in the specific case management and selective references from the literature. CASE PRESENTATION: A 48-years old female was diagnosed with intravascular tumor growth within the IVC with intracardiac extension using chest and abdominal CT scan, ECG and echocardiography which was approached by an interdisciplinary (vascular and cardiothoracic) surgical intervention (278 min) including heart-lung machine (99 min) with favorable postoperative result (R0 resection status with mid-term outcome, no recurrent tumor growth). Histopathological investigation diagnosed leiomyoma origin already from ovarian vein most likely in context to the former hysterectomy (3 years ago). DISCUSSION AND CONCLUSION: Intravascular leiomyoma is a benign tumor with invasive tendency, which can be considered a diagnostic and therapeutic challenge. It should be thoroughly investigated to be planned for a radical surgical removal. By possible adherence to the intraabdominal or -thoracic organs, an interdisciplinary and eventually step-wise surgical approach (combining vascular, abdominal, thoracic and heart surgery as well as gynecology and urology), which can be demanding, is recommended to be seriously considered to i) reliably achieve R0 resection status and, thus, ii) provide best outcome, quality of life and prognosis.
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Histerectomía/efectos adversos , Leiomioma/patología , Células Neoplásicas Circulantes/patología , Neoplasias Uterinas/patología , Vena Cava Inferior/patología , Carcinoma de Células Renales/patología , Femenino , Humanos , Neoplasias Renales/patología , Persona de Mediana Edad , Neoplasias Primarias Múltiples/patología , Nefrectomía , Neoplasias Uterinas/cirugíaRESUMEN
BACKGROUND: Neck tumors are challenging regarding the diagnostic and therapeutic management particularly in cases of malignant growth near relevant vessels to achieve R0 resection status and the best prognosis. AIM: The aim of this case report on a patient with a rare malignant tumor of the glomus caroticum (paraganglioma) is to present the successful outcome of a demanding interdisciplinary surgical approach (otorhinolaryngology and vascular surgery). Surgical re-intervention was necessary due to malignant tumor growth (detected in the histopathological investigation of the first specimen) including vascular resection using a hybrid graft for vascular reconstruction of the internal carotid artery near the skull base. CASE REPORT: A 38-year-old male patient underwent magnetic resonance angiography and digital subtraction angiography to clarify the diagnosis of a tumor in the right neck. This was preoperatively embolized and subsequently resected including vascular reconstruction using a prosthetic interposition graft (7â¯cm; W.L. Gore, Putzbrunn, Germany) between the common and internal carotid arteries. HISTOLOGY: malignant paraganglioma 40â¯mm in diameter with haemangiosis et lymphangiosis carcinomatosa demonstrating lymph node metastasis and prompting re-operation (neck dissection levels II, III, IV, V). This was followed by a novel vascular reconstruction using a GORE® hybrid vascular graft prosthetic stent (W.L. Gore) as interposition graft because of the short extracranial stump of the distal internal carotid artery near the skull base and to limit clamping time. Early postoperative outcome revealed no complications and after 24 months there were no signs or symptoms of recurrent tumor growth. CONCLUSION: Extended resections, if necessary including vascular (arterial) segments, aim at achieving R0 classification as shown in this extremely rare and usually challenging malignant tumor. Hybrid vascular prostheses are suitable for time-saving vascular reconstruction (>50%) to provide sufficient blood supply.
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Tumor del Cuerpo Carotídeo , Cuerpo Carotídeo , Paraganglioma , Adulto , Arteria Carótida Interna/cirugía , Tumor del Cuerpo Carotídeo/cirugía , Alemania , Humanos , Masculino , Paraganglioma/cirugía , Base del CráneoRESUMEN
AIM: To investigate the perioperative management and outcome of patients undergoing abdominal surgery with additional vascular (comorbid) alterations for internal quality assurance of the clinical results. METHODS: Over a defined study period all consecutive cases of the aforementioned profile were documented and retrospectively analyzed as part of an ongoing prospective monocentric observational study to reflect the daily surgical practice. RESULTS: Over 10 years (from January 1999 to December 2008), a total of 113 cases were registered. Pancreas resection including vascular reconstruction showed the highest percentage (30.1%). Within the target patient groups, similar outcome data were found compared with international reports. An exception was in the case of mesenteric ischemia, where open surgery was more frequently used in comparison to the study situation (included together were patients treated by surgery and interventions). The majority of vascular alterations during the postoperative course and iatrogenic lesions occurred following pancreas resection. In the therapeutic profile there are two particularly important measures, namely open surgery on one hand and image-guided radiology as well as endoscopy on the other hand. The majority of patients with a rare visceral artery aneurysm (considerable potential for rupture or erosion) were more frequently treated with image-guided interventional radiology versus open surgery. This conforms to the current well-established sequential patient (individual), results, and, in particular, risk-adapted staged treatment approach. CONCLUSION: Additional vascular surgical treatment of problematic situations during abdominal surgery or in emergency cases is not daily routine; however, it is a challenging field including a considerable potential for complications (morbidity) and definitely mortality. This requires an experienced surgeon with high expertise, if possible in a center for vascular medicine.
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Aneurisma , Procedimientos Quirúrgicos Vasculares , Aneurisma/cirugía , Humanos , Estudios Prospectivos , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
INTRODUCTION: Abnormal links between the arterial system and other luminal systems are a challenge to those in charge of their adequate diagnostic and therapeutic management. OBJECTIVE: Scientific case report on an individual who underwent successful treatment combining vascular-surgical and interventional radiology techniques for a rare right uretero-iliac artery fistula based on personal clinical experience, a selective literature research and a detailed discussion of current recommendations for diagnostic workup and subsequent treatment. CASE CHARACTERISTICS: A 79-year-old patient was admitted with haematuria : and bladder tamponade : in the presence of bilateral actinic ureteral strictures secondary to neoadjuvant radiochemotherapy followed by abdominoperineal rectum exstirpation due to suprasphincteric rectal cancer (ypT3ypN0M0). Laboratory tests revealed anaemia; transabdominal ultrasound demonstrated bilateral urinary retention. A complementary CT scan did not reveal any manifest bleeding resulting from intermittent haemorrhage. SURGICAL PROCEDURE: Initially, the bladder haematoma was removed and ureteral catheters were changed. Due to endoluminal bleeding in the right ureter, a combined procedure was initiated, involving a vascular-surgical approach (access to the right femoral artery, ultimate disobliteration and intimal refixation in the right superficial femoral artery due to dissection) and an interventional radiology approach (insertion of an Amplatzer [AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, USA] into the right internal iliac artery and iliac stenting by a cross-over manoeuvre from the left femoral access site) although no acute bleeding was detected in the CT scan (but acute haemorrhage from the right ureteric ostium was confirmed during cystoscopy). CLINICAL COURSE: The patient stabilised in due time in response to periinterventional treatment in the ICU. He was discharged on the 15th day after surgery without evidence of recurrent haemorrhage. SUMMARY: In the presented case, this promptly initiated (vascular-surgical and interventional radiology) hybrid operation was absolutely indicated, being the approach with the best prospects for recurrent arterial bleeding with clinical manifestation of haematuria and haemorrhage within the urinary bladder due to a uretero-iliac artery fistula. CONCLUSION: Today, a minimally invasive approach with stenting is the method of choice in the sequential, urgent management of a potentially life-threatening uretero-iliac fistula in the presence of arterial endoluminal bleeding and an imminent haemorrhagic shock.
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Enfermedades Ureterales/etiología , Fístula Urinaria/etiología , Fístula Vascular/etiología , Anciano , Hematuria/etiología , Humanos , Arteria Ilíaca , Masculino , Radioterapia/efectos adversos , Enfermedades Ureterales/terapia , Obstrucción Ureteral/etiología , Fístula Urinaria/terapia , Fístula Vascular/terapiaRESUMEN
AIM, PATIENTS AND METHODS: Through a defined time period, all consecutive vascular surgical patients with indicated and initiated medication with cilostazol (PAOD, stage IIâb) were registered and controlled clinically within 3-month time intervals to investigate the therapeutic effect in a representative, specifically vascular surgical group of patients using a systematic prospective, unicentre clinical observational study. In particular, maximum walking distance, subjective (semiquantitative) assessment of the quality of life, impact of accompanying diseases as well as the occurrence of adverse effects and their impact onto the treatment were studied. RESULTS: Out of the 146 registered patients with initiated medication of cilostazol, 93 subjects were finally evaluated. Three months after initiation of cilostazol medication, maximum walking distance increased by 108 m (159.7â%) based on the initial 181 m. After 6 and 9 months, walking distance increased by 181 m (200â%) and 168 m (192.8â%), respectively. After 12 months, there was no further increase of the walking distance by 126 m (169.6â%) compared with months 6 and 9 but still with a significant difference to the initial distance. There was a trend of an improved walking distance from the 3rd to the 6th month (p = 0.1055) and a significant difference between the 3rd and the 9th month (p = 0.0094; no further significant differences between the time points 3rd/12th, 6th/9th, 6th/12th and 9th/12th month). While an improved quality of life was reported in 80.7â% of patients after 3 months, the rate varied between 82.6, 72.9 and 80.9â% at 6, 9 and 12 months, respectively, i.e., always in the majority of cases. There were no hints for safety concerns with regard to severe adverse effects, in particular, bleeding episodes. Subgroup analyses on accompanying diseases such as diabetes, hyperlipidemia or nicotine abuse did not reveal any impact on the improved walking distance (ABI - no feasible parameter). CONCLUSION: Medication with cilostazol led to a significant increase of the maximum walking distance (p < 0.0001) compared to the initial distance, which was further increased through one year (however, the effect became weaker) accompanied by a dominating improvement of the quality of life. The effects can be observed longer than 3-6 months.
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Arteriopatías Oclusivas/clasificación , Arteriopatías Oclusivas/tratamiento farmacológico , Evaluación de la Discapacidad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Calidad de Vida , Tetrazoles/uso terapéutico , Caminata , Adulto , Anciano , Anciano de 80 o más Años , Cilostazol , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
AIM, PATIENTS AND METHODS: By means of a systematic single-centre prospective observational study, spectrum (symptomatology, frequency) and diagnostics of the different visceral artery aneurysm sites as well as the postinterventional course of the various therapeutic options used according to local finding and patient's clinical status as well as risk factors were analysed to contrast the different procedures (conservative, image-guided radiological intervention, open vascular surgery) in consideration of their decision-making criteria and their early postinterventional outcome (on the basis of complication rate, peri-interventional morbidity and hospital lethality) including relevant references from the literature. RESULTS: During a time period of 14 years, 22 patients (sex ratio: 12 males/10 females; mean age: 54.3 [range: 22-76] years) were registered. Most frequently, visceral artery aneurysms occurred in the splenic artery (50â%). The gastroduodenal artery, the hepatic artery and the right renal artery were affected in each with 13.6â% (n = 3/22), the superior mesenteric artery in 9.1â% (n = 2/22). The majority of patients (54.5â%) were treated with image-guided radiological intervention, whereas in 31.8â%, the patient underwent open vascular surgery and 13.6â% of cases were managed with "watchful waiting". While morbidity was 21.1â% (n = 4/19), overall lethality was 9.1â% (n = 2/22). CONCLUSION: Decision-making for a specific therapeutic approach should be made (i) after adequate diagnostic measures (transabdominal ultrasound, MR angiography, duplex ultrasonography, CT-A/DSA if required), (ii) on an individual case-adapted base, (iii) in a vascular surgical centre, (iv) case-associated to the specific local finding (in particular, according to size/specific probability of rupture [cave: gravidity]) and (v) according to the individual risk profile using the whole spectrum of therapeutic options (conservative vs. interventional; image-guided radiological intervention [endovascular repair such as embolisation, stent or stent graft] vs. open vascular surgery [according to a step-up approach]; open vascular ligation vs. reconstruction after exclusion of the aneurysm) including sufficient quality assurance of the treatment results as well as control investigations (duplex ultrasonography; MR-A if required) in a specialised vascular surgical out-patient centre within appropriate time intervals.
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Aneurisma/cirugía , Vísceras/irrigación sanguínea , Adulto , Anciano , Aneurisma/diagnóstico , Angiografía de Substracción Digital , Implantación de Prótesis Vascular , Estudios de Cohortes , Sistemas de Apoyo a Decisiones Clínicas , Diagnóstico Diferencial , Embolización Terapéutica , Procedimientos Endovasculares , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Estudios Prospectivos , Factores de Riesgo , Stents , Cirugía Asistida por Computador , Adulto JovenRESUMEN
PURPOSE: This study was designed to identify parameters on CT angiography (CTA) of type II endoleaks following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), which can be used to predict the subsequent need for reinterventions. METHODS: We retrospectively identified 62 patients with type II endoleak who underwent early CTA in mean 3.7 ± 1.9 days after EVAR. On the basis of follow-up examinations (mean follow-up period 911 days; range, 373-1,987 days), patients were stratified into two groups: those who did (n = 18) and those who did not (n = 44) require reintervention. CTA characteristics, such as AAA, endoleak, as well as nidus dimensions, patency of the inferior mesenteric artery, number of aortic branch vessels, and the pattern of endoleak appearance, were recorded and correlated with the clinical outcome. RESULTS: Univariate and receiver operating characteristic curve regression analyses revealed significant differences between the two groups for the endoleak volume (surveillance group: 1391.6 ± 1427.9 mm(3); reintervention group: 3227.7 ± 2693.8 mm(3); cutoff value of 2,386 mm(3); p = 0.002), the endoleak diameter (13.6 ± 4.3 mm compared with 25.9 ± 9.6 mm; cutoff value of 19 mm; p < 0.0001), the number of aortic branch vessels (2.9 ± 1.2 compared with 4.2 ± 1.4 vessels; p = 0.001), as well as a "complex type" endoleak pattern (13.6 %, n = 6 compared with 44.4 %, n = 8; p = 0.02). CONCLUSIONS: Early CTA can predict the future need for reintervention in patients with type II endoleak. Therefore, treatment decision should be based not only on aneurysm enlargement alone but also on other imaging characteristics.
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Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/métodos , Tomografía Computarizada por Rayos X/métodos , Anciano , Anciano de 80 o más Años , Implantación de Prótesis Vascular , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
PURPOSE: An extensive analysis of the value of computed tomography (CT) parameters as potential predictors of the clinical outcome of type 2 endoleaks after endovascular aortic aneurysm repair (EVAR). MATERIALS AND METHODS: Initial CT scans of 130 patients with abdominal aortic aneurysms (AAAs) were retrospectively reviewed. On the basis of postoperative CT scans and angiographies, patients were stratified into a low-risk group (LRG; without or transient type 2 endoleak; nâ=â80) and a high-risk group (HRG, persistent type 2 endoleak or need for reintervention; nâ=â50). Statistical analysis comprised a univariate and multivariate analysis. RESULTS: Anatomical, thrombus-specific, as well as aortic side branch parameters were assessed on the initial CT scan. Of all anatomical parameters, the diameter of the immediate infrarenal aorta was significantly different in the univariate analysis (LRG 22.4â±â3.8âmm; HRG 23.6â±â2.5âmm; pâ=â0.03). The investigation of the thrombus-specific parameters showed a trend towards statistical significance for the relative thrombus load (LRG 31.7â±â18.0%; HRG 25.3â±â17.5%; pâ=â0.09). Assessment of aortic side branches revealed only for the univariate analysis significant differences in the patency of the inferior mesenteric artery (LRG 71.3%; HRG 92.0%; pâ=â0.003) and their diameter (LRG 3.3â±â0.7âmm; HRG 3.8â±â0.9âmm; pâ=â0.004). In contrast, the number of lumbar arteries (LAs; LRG 2.7â±â1.4; HRG 3.6â±â1.2; univariate: pâ=â0.01; multivariate: pâ=â0.006) as well as their diameter (LRG 2.1â±â0.4âmm; HRG 2.4â±â0.4âmm; univariate: pâ<â0.001; multivariate: pâ=â0.006) were highly significantly associated with the development of type 2 endoleaks of the HRG. CONCLUSION: The most important predictive factors for the development of high-risk type 2 endoleaks were mainly the number and the diameter of the LAs which perfused the AAA. KEY POINTS: ⢠This study is a very detailed and comprehensive analysis of the value of various CT parameters as potential predictors of the clinical outcome of type 2 endoleaks after EVAR. ⢠Anatomical as well as thrombus-specific parameters were unsuitable as predictors. ⢠The most important predictive factors were mainly the number and the diameter of the LAs which perfused the AAA.
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Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/métodos , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares , Tomografía Computarizada por Rayos X/métodos , Anciano , Anciano de 80 o más Años , Medios de Contraste , Femenino , Humanos , Aumento de la Imagen/métodos , Interpretación de Imagen Asistida por Computador , Yopamidol/análogos & derivados , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
AIM: Peripheral artery disease results in impaired blood flow to the extremities, most often as a consequence of atherosclerotic disease. The hallmark of atherosclerosis is chronic inflammation in the vessel wall. The renin-angiotensin and endothelin systems are considered important pathophysiological effectors. Midkine, a multifunctional cytokine, fulfils different roles in inflammation and promotion of neoangiogenesis. The aim of this study was to assess whether circulating midkine serum levels in patients with peripheral artery disease correlate with established atherosclerosis risk factors, as well as titers of functional autoantibodies directed against receptors of the renin-angiotensin and endothelin system. METHODS: Clinical data, laboratory values and serum samples from 118 patients operated on for severe peripheral artery disease, and from 100 healthy blood donors were collected. Serum samples were analysed for midkine concentrations as well as autoantibody titers against angiotensin II type 1 and endothelin-1 type A receptors. RESULTS: Midkine values were significantly higher in the study population than in healthy controls (P<0.001). Circulating midkine levels did not correlate with neither of the traditional risk factors age, sex, obesity, smoking, hypertension, high cholesterol levels, or diabetes mellitus. An unexpected inverse correlation was found with the autoantibodies against angiotensin II type 1 receptor (P<0.05) and endothelin-1 type A receptor (P<0.01). CONCLUSION: The high levels of midkine in severe peripheral artery disease patients introduce this cytokine as a possible novel effector in the advanced atherosclerotic process. These results also suggest a functional link between vascular receptor autoantibody formation and down-regulated midkine serum levels, that may be relevant in the pathogenesis of clinically relevant peripheral artery occlusive disease.
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Aterosclerosis/inmunología , Autoanticuerpos/sangre , Factores de Crecimiento Nervioso/sangre , Enfermedad Arterial Periférica/inmunología , Receptor de Angiotensina Tipo 1/inmunología , Receptor de Endotelina A/inmunología , Adulto , Anciano , Anciano de 80 o más Años , Aterosclerosis/sangre , Aterosclerosis/diagnóstico , Biomarcadores/sangre , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Midkina , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Valor Predictivo de las Pruebas , Factores de Riesgo , Índice de Severidad de la Enfermedad , Regulación hacia ArribaRESUMEN
INTRODUCTION: Vascular alterations such as arterial lesions themselves or caused by injuries (external site) occur only rarely in children and adolescents. By means of a narrative review including our own clinical experience and a representative case report, vascular alterations in children and adolescents are discussed. Complex Patient- & clinical Finding-associated Aspects: - Dissections of vertebrocerebral arterial branches: usually, the aetiopathogenesis reveals external factors or primary alterations of the vascular wall. The therapeutic approach comprises anticoagulation or surgical, sometimes endovascular intervention in cases of recurrent ischaemic symptoms. - Aneurysm of the carotid artery: the therapeutic approach is characterised by surgical and interventional treatment according to the individual case-specific finding, alternatives in vascular reconstruction can be derived from the classification by de Jong et al. Representative Case Report: An 11 year old boy was diagnosed with intracranial dissection of the left vertebral artery initially treated with anticoagulation (6 months) and a consecutive neurosurgical approach (trepanation and coverage of the dissecting aneurysm) and, subsequently (within the 16th year of age), he underwent interventional treatment (coil embolisation) because of an expansion of the aneurysm. In addition, an aneurysm of the right internal carotid artery was found, which was approached surgically with interposition of a vena-saphena-magna segment. CONCLUSION: Vascular alterations such as dissections and aneurysms of vertebrocerebral arterial branches in children and adolescents are challenging. Dissections should be treated with anticoagulation. In the case of recurrent ischaemic symptoms or in cases of pressure phenomenon including neurological alterations, interventional or surgical treatment is indicated. In the case of an aneurysm of the carotid artery, there is an indication for surgical treatment: In children and teenagers, venous segments for interposition and single-stitch sutures are usually used. Competent decision-making for treatment and periinterventional management require appropriate interdisciplinary expertise.
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Aneurisma/diagnóstico , Aneurisma/terapia , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/terapia , Disección de la Arteria Vertebral/diagnóstico , Disección de la Arteria Vertebral/terapia , Adolescente , Aneurisma/epidemiología , Aneurisma/etiología , Angiografía de Substracción Digital , Enfermedades de las Arterias Carótidas/epidemiología , Enfermedades de las Arterias Carótidas/etiología , Disección de la Arteria Carótida Interna/diagnóstico , Disección de la Arteria Carótida Interna/epidemiología , Disección de la Arteria Carótida Interna/etiología , Disección de la Arteria Carótida Interna/terapia , Angiografía Cerebral , Niño , Estudios Transversales , Embolización Terapéutica , Humanos , Aneurisma Intracraneal/diagnóstico , Aneurisma Intracraneal/epidemiología , Aneurisma Intracraneal/etiología , Aneurisma Intracraneal/terapia , Factores de Riesgo , Venas/trasplante , Disección de la Arteria Vertebral/epidemiología , Disección de la Arteria Vertebral/etiologíaRESUMEN
BACKGROUND: Isolated aneurysms of the iliac artery are rare but in case of rupture potentially life-threatening. AIM, PATIENTS AND METHODS: The aim of this systematic, clinical, prospective observational study was to retrospectively evaluate prospectively collected perioperative data obtained in consecutive patients with an isolated iliac artery aneurysm with regard to the diagnostic and therapeutic management including the outcome characterised by periinterventional morbidity, lethality, and overall survival over an intermediate time course of the follow-up. RESULTS: From 01/01/2002 to 03/31/2013, overall 35 patients with an isolated iliac artery aneurysm were diagnosed (females, n = 3 [8.6 %]; mean age, 70 [46-83] years). The mean hospital stay was 13 days. There were 24 aneurysms at the common iliac artery (AIC; 69 %), 8 at the internal iliac artery (AII; 23 %) and 3 at the external iliac artery (AIE; 9 %). Three patients (9 %) with an aneurysmatic rupture were admitted. The therapeutic options comprised: 12 patients underwent open resection and subsequent implantation of a prosthesis (34 %), 17 individuals were treated with an endovascular repair (49 %); 5 cases were managed with a "wait and see" policy (14 %). There was no lethality among the elective interventions whereas the lethality of emergency cases was 33 % (n = 1). Subdividing the patients treated with open surgery versus endovascular repair indicates significant differences of the preoperative characteristics, e.g., of the proportions of AIC in the distribution of aneurysmatic sites (75 % vs. 59 %; p = 0.007) reflecting the differential indication. CONCLUSIONS: Isolated iliac artery aneurysms can be approached with open surgery or with an endovascular repair depending on elective or emergency circumstances. In addition, clinical status of the patient and personal experience need to be taken into account. Depending on aneurysmatic site, extension, combination with accompanying findings and implantation sites at the proximal and distal sites of the aneurysm, the less invasive and less traumatic image-guided radiological approach can provide acceptable therapeutic success with regard to the sufficient exclusion of the aneurysm and can be increasingly used according to the individual patient and his/her findings.
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Aneurisma/cirugía , Procedimientos Endovasculares/métodos , Arteria Ilíaca/cirugía , Planificación de Atención al Paciente , Cirugía Asistida por Computador/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico por imagen , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugía , Angiografía , Embolización Terapéutica , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Stents , Tomografía Computarizada por Rayos XRESUMEN
UNLABELLED: â¼HISTORY AND ADMISSION FI NDINGS: A 61-year-old woman presented with a 2-month-history of progressive deterioration, increasing exertional dyspnoea and pain in the right upper abdomen (past medical history: bronchial asthma and hypertension). The physical examination showed mild generalized weakness, tenderness in the right upper abdomen, and ascites. INVESTIGATIONS: Laboratory studies did not reveal any hormonal abnormalities. A CT angiogram revealed a mass of the right adrenal gland with distinct invasion into the inferior vena cava, and tumour thrombosis that extended proximally into the right atrium. Distally, the tumour ended at the caudate lobe of the liver with an extensive peripherally engulfed thrombus from the inferior vena cava down to the common iliac -veins. TREATMENT AND COURSE: An open right adrenalectomy with resection of the periadrenal tissue and exstirpation of the intracaval tumour thrombus (by cavotomy under digital occlusion of the blood flow from the vena cava into the right atrium - cardiac surgeon) was carried out with no significant postoperative complications. Subsequently, the patient underwent adjuvant mitotane therapy for 3 years. So far, no recurrence has occurred during a course of 7 years. CONCLUSION: Tumour induced thrombotic occlusion of the inferior vena cava and other veins is rare, especially with right atrium involvement. In the absence of other effective treatment options, the combination of radical resection and adjuvant mitotane therapy remains the only successful curative treatment for primary invasive pararenal gland carcinoma.
Asunto(s)
Neoplasias de la Corteza Suprarrenal/patología , Neoplasias de la Corteza Suprarrenal/cirugía , Conducta Cooperativa , Comunicación Interdisciplinaria , Células Neoplásicas Circulantes/patología , Vena Cava Inferior/patología , Vena Cava Inferior/cirugía , Neoplasias de la Corteza Suprarrenal/irrigación sanguínea , Neoplasias de la Corteza Suprarrenal/tratamiento farmacológico , Adrenalectomía/métodos , Angiografía , Quimioterapia Adyuvante , Terapia Combinada , Diagnóstico Diferencial , Embolectomía/métodos , Femenino , Humanos , Escisión del Ganglio Linfático , Persona de Mediana Edad , Mitotano/efectos adversos , Mitotano/uso terapéutico , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Pronóstico , Arteria Renal/patología , Arteria Renal/cirugía , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Tumor lesions of the inferior vena cava are extremely challenging with regard to adequate therapeutic management also in advanced malignant urological tumor lesions which can be caused by malignant adhesion, impression and tumor infiltration from the surrounding tissue. This can be the case with metastases from a seminoma or testicular carcinoma (differential diagnosis: primary vena cava leiomyosarcoma), tumor-associated growth into and within the inferior vena cava originating from renal cell carcinoma or carcinoma of the pararenal gland. The aim of this overview was to summarize current clinical and operative experiences in the treatment of inferior vena cava-associated urological tumor lesions, perioperative management, individual-specific and finding-adapted surgical technique and possible outcome, including prognostic considerations from clinical daily practice and representative data found in the literature. BASIC STATEMENTS: The primary aim of the surgical approach is to achieve R0 resection with reconstruction of the inferior vena cava lumen providing a reasonable risk-benefit ratio, which comprises i) complete resection and substitution of the inferior vena cava by a prosthesis along the previous extent of tumor growth, ii) partial resection of the vena cava wall with subsequent patch-plasty or tangential resection with primary suture or iii) removal of the vena cava thrombus after cavotomy. Particular attention should be paid to tumor thrombi reaching the right atrium which need to be extracted after sternotomy and atriotomy using an extracorporeal circulation (cardiac surgeon). For surgical planning, subdivision of the inferior vena cava into three segments, infracardiac, infrahepatic and infrarenal third, has been proven and tested. CONCLUSIONS: The current development status and advances in surgical approaches as well as advances in medical technology allow the successful approach to such advanced stage urological tumor manifestations. A deciding factor is the abdominal and cardiovascular surgical expertise of each surgeon after formation of a team of surgical specialists (including urologists) and only then prognostic advantages can be achieved.
Asunto(s)
Procedimientos de Cirugía Plástica/métodos , Neoplasias Urológicas/cirugía , Procedimientos Quirúrgicos Urológicos/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Vena Cava Inferior/cirugía , Trombosis de la Vena/cirugía , Medicina Basada en la Evidencia , Humanos , Resultado del Tratamiento , Neoplasias Urológicas/complicaciones , Trombosis de la Vena/etiologíaRESUMEN
HISTORY AND ADMISSION FINDINGS: A 61-year-old woman presented with a 2-month-history of progressive deterioration, increasing exertional dyspnoea and pain in the right upper abdomen (past medical history: bronchial asthma and hypertension). The physical examination showed mild generalized weakness, tenderness in the right upper abdomen, and ascites. INVESTIGATIONS: Laboratory studies did not reveal any hormonal abnormalities. A CT angiogram revealed a mass of the right adrenal gland with distinct invasion into the inferior vena cava, and tumour thrombosis that extended proximally into the right atrium. Distally, the tumour ended at the caudate lobe of the liver with an extensive peripherally engulfed thrombus from the inferior vena cava down to the common iliac veins. TREATMENT AND COURSE: An open right adrenalectomy with resection of the periadrenal tissue and extirpation of the intracaval tumour thrombus (by cavotomy under digital occlusion of the blood flow from the vena cava into the right atrium) was carried out with no significant postoperative complications. Subsequently, the patient underwent adjuvant mitotane therapy for three years. So far, no recurrence has occurred during a course of 7 years. CONCLUSION: Tumour induced thrombotic occlusion of the inferior vena cava and other veins is rare, especially with right atrium involvement. In the absence of other effective treatment options, the combination of radical resection and adjuvant mitotane therapy remains the only successful curative treatment for primary invasive adrenal gland carcinoma.
Asunto(s)
Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/patología , Conducta Cooperativa , Atrios Cardíacos/patología , Comunicación Interdisciplinaria , Células Neoplásicas Circulantes/patología , Trombosis/diagnóstico , Trombosis/patología , Vena Cava Inferior/patología , Neoplasias de las Glándulas Suprarrenales/tratamiento farmacológico , Neoplasias de las Glándulas Suprarrenales/cirugía , Quimioterapia Adyuvante , Terapia Combinada , Femenino , Estudios de Seguimiento , Venas Hepáticas/patología , Humanos , Vena Ilíaca/patología , Persona de Mediana Edad , Invasividad Neoplásica , Estadificación de Neoplasias , Trombosis/cirugía , Tomografía Computarizada por Rayos X , Vena Cava Inferior/cirugíaRESUMEN
Cilostazol (Pletal(®), UCB Pharma, Monheim, Deutschland) has been successfully established since its inauguration on the German market in 2007, which is associated with a considerable distribution, in particular, in angiologic patients. However, vascularsurgical specifics in the use of Cilostazol are still lacking. The aim of this very compact short overview is (based on a selective literature search and own clinical experiences over the years) to characterize mechanism of action, use and expectable therapeutic effect of Cilostazol in the challenging management of exclusively vascularsurgcial patients with peripheral arterial occlusion disease (PAOD). Cilostazol inhibits phosphodiesterase 3 and platelet aggregation in a reversible manner with a dose-effect association, has vasodilating potential and a positive inotropic effect but provides a selective effect on the platelets, muscle and endothelial cells of the vascular wall via an intracellular increase of cAMP; in addition, there is an antiproliferative effect, it promotes neoangiogenesis, inhibits apoptosis and generation of endothelial adhesion molecules - taken together, it can be considered antiatherogenic ("anti-arterioscleroticum"). From a clinical point of view, Cilostazol is indicated in stage IIb of PAOD (Fontaine); its recommended dosage is 2x100 (reduced in case of moderate side effects, 2x50) mg with detectable prolongation of subjective (reported by the patient) and objective walking distance (but not in smokers [!]; ABI-based measurement of the effect not suitable) and partially with an improval of the quality of life (associated with a prolonged but steadily improving therapeutic effect from the 4th to the 6th week until the 6th to the 12th month). The profile of side effects is broad but mostly short-term and dominated by headache [~ 30 %] and diarrhoea [~ 15 %]). While Cilostazol not only plays a beneficial role in the setting to be used in the primary arteriosclerotic course of PAOD (called sequential therapeutic preoperative course), it appears also to provide great effect in case of a re-manifestation of claudication (approaching stage IIb according to Fontaine's classification) after previous image-guided interventional or vascularsurgical treatment (suitable conservative mid-term intermediate therapy), i) resulting in a flexible physician's tool of the angiologic and vascularsurgical setting of an outpatient clinic, and ii) which reduces significantly the number of re-interventions or prolonges the time interval(s) in between. This might finally be relevant in the perspective for an amputation-free survival.
Asunto(s)
Arteriopatías Oclusivas/tratamiento farmacológico , Enfermedad Arterial Periférica/tratamiento farmacológico , Tetrazoles/administración & dosificación , Cilostazol , Relación Dosis-Respuesta a Droga , Alemania , Humanos , Inhibidores de Fosfodiesterasa 3/administración & dosificación , Resultado del TratamientoRESUMEN
The necessity of haemangioma treatment in infants has been controversially discussed for years. One reason is the favoured clinical observation of a potential spontaneous involution without any therapeutic approach or medical treatment, thus avoiding their specific risks. On the other hand, there are several reports on serious cases with -rapidly growing haemangiomas including severe consequences. There are potential complications such as loss of visus in cases of periorbital manifestation. A basic problem is the lack of a unique systematic classification, on the basis of which -diagnostic measures, therapeutic indications and modes could be compared. Such a classification would be much more competent including a sufficient comparison of treatment results. The basic aim in management is to achieve control of the haemangioma growth and induction of its sub-sequent involution back to only a cosmetic detraction. Each threatening functional loss can be classified as an urgent indication for treatment. There is a need to consider the treatment options and their values; in particular, cryotherapy or laser therapy in localised manifestations are mostly -favoured because of the convincing evidence from available data. In the case of a more disseminated haemangioma manifestation, the initiation of propranol medication is possible, a novel drug for this indication. However, there are no follow-up data on the mid-term or long-term outcome available at this time. Further studies on the subject are therefore required.