Dittmar Böckler

Universität Heidelberg, Heidelburg, Baden-Württemberg, Germany

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Publications (284)516.02 Total impact

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    ABSTRACT: To identify morphologic factors affecting aortic expansion in patients with uncomplicated type B aortic dissections. Computed tomography data of 24 patients (18 male; median age: 61 years), diagnosed with acute uncomplicated type B aortic dissections between 2002 and 2013, were retrospectively reviewed. All patients had at least two computed tomography angiography scans and six months of uneventful follow-up. Computed tomography scans were assessed by two independent readers with regard to presence and number of entry tears. Thoracic and abdominal aortic diameters were derived using image processing software. Twenty-two of 24 patients showed aortic expansion over a median computed tomography angiographic follow-up of 33.2 months. Annual rates showed an increase of 1.7 mm for total aortic diameter, 2.1 mm for the false and a decrease of -0.4 mm for the true lumen. In three patients (12.5%), aortic diameter exceeded 60 mm during follow-up, and all three patients underwent thoracic endovascular aortic repair. Patients with a maximum aortic diameter <4 cm at baseline showed a significantly higher expansion rate compared to cases with an initial maximum aortic diameter of ≥4 cm (p=0.0471). A median of two entries (range: 1-5) was recognized per patient. Presence of more than two entry tears (n = 13) was associated with faster overall diameter expansion (mean annual rates: 2.18 mm vs. 1.16 mm; p = 0.4556), and decrease of the cross-sectional surface of the true lumen over time (annual rate for > 2 entries vs. ≤2 entries: -7.8 mm(2) vs. +37.5 mm(2); p = 0.0369). Median size of entry tears was 12 mm (range: 2-53 mm). The results presented herein suggest that uncomplicated type B aortic dissection patients with more than two entry tears and/or an initial maximum aortic diameter of<4 cm are at risk for aortic dilatation and, therefore, may require stricter follow-up including the possible need for early intervention. © The Author(s) 2015.
    Vascular 06/2015; DOI:10.1177/1708538115591941
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    ABSTRACT: Somatic DNA-alterations are known to occur in atherosclerotic carotid artery lesions; however their significance is unknown. The accumulation of microsatellite mutations in coding DNA regions may reflect a deficiency of the DNA mismatch repair (MMR) system. Alternatively, accumulation of these coding microsatellite mutations may indicate that they contribute to the pathology. To discriminate between these two possibilities, we compared the mutation frequencies in coding microsatellites (likely functionally relevant) with that in non-coding microsatellites (likely neutral). Genomic DNA was isolated from carotid endarterectomy (CEA) specimens of 26 patients undergoing carotid surgery, and from 15 non-atherosclerotic control arteries. Samples were analyzed by DNA fragment analysis for instability at three non-coding (BAT25, BAT26, CAT25) and five coding (AIM2, ACVR2, BAX, CASP5, TGFBR2) microsatellite loci with proven validity for detection of microsatellite instability in neoplasms.We found an increased frequency of coding microsatellite mutations in CEA specimens, compared with control specimens (34.6% versus 0%; p= 0.0013). Five CEA specimens exhibited more than one frameshift mutation, and ACVR2 and CASP5 were affected most frequently (5/26 and 6/26). Moreover, the rate of coding microsatellite alterations (15/130) differed significantly from that of non-coding alterations (0/78) in CEA specimens (p= 0.0013). In control arteries, no microsatellite alterations were observed, neither in coding nor in non-coding microsatellite loci. In conclusion, the specific accumulation of coding mutations suggests that these mutations play a role in the pathogenesis of atherosclerotic carotid lesions, since the absence of mutations in non-coding microsatellites argues against general microsatellite instability, reflecting MMR deficiency.
    Molecular Medicine 06/2015; DOI:10.2119/molmed.2014.00258
  • Journal of Vascular Surgery 06/2015; 61(6). DOI:10.1016/j.jvs.2015.04.008
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    ABSTRACT: Despite improvements in endograft devices, operator technique, and patient selection, endovascular repair has not achieved the long-term durability of open surgical aneurysm repair. Persistent or recurrent aneurysm sac flow from failed proximal sealing, component failure, or branch vessel flow underpins a significant rate of reintervention after endovascular repair. The Nellix device (Endologix, Irvine, Calif) employs a unique design with deployment of polymer-filled EndoBags surrounding the endograft flow lumens, sealing the aneurysm sac space and potentially reducing complications from persistent sac flow. This retrospective analysis represents the initial experience in consecutive patients treated with the device in real-world practice. This study was performed at six clinical centers in Europe and one in New Zealand during the initial period after commercialization of the Nellix device. Patients underwent evaluation with computed tomography and other imaging modalities following local standards of care. Patients were selected for treatment with Nellix and treated by each institution according to its endovascular repair protocol. Clinical and imaging end points included technical success (successful device deployment and absence of any endoleak at completion angiography), freedom from all-cause and aneurysm-related mortality, endoleak by type, limb occlusion, aneurysm rupture, and reintervention. During a 17-month period, 171 patients with abdominal aortic aneurysms were treated with the Nellix device and observed for a median of 5 months (range, 0-14 months). The 153 male and 18 female patients with mean age of 74 ± 7 years had aneurysms 61 ± 9 mm in diameter with an average infrarenal neck length of 28 ± 15 mm and infrarenal angulation of 37 ± 22 degrees. Technical success was achieved in all but two patients (99%); one patient had a type Ib endoleak and another had a type II endoleak. Through the last available follow-up, type Ia endoleak was observed in five patients (3%), type Ib endoleak in four patients (2%), and type II endoleak in four patients (2%). There were eight limb occlusions (5%), among which seven were evident at the 1-month follow-up visit. Aneurysm-related reinterventions were performed in 15 patients (9%). There were no aneurysm ruptures or open surgical conversions. This first multicenter postmarket report of the Nellix device for infrarenal abdominal aortic aneurysm repair demonstrates satisfactory results during the initial learning phase of this new technology. The rate of aneurysm exclusion was high, and frequency of complications was low. More definitive conclusions on the value of this novel device await the results of the ongoing Nellix EVAS FORWARD Global Registry and the EVAS FORWARD investigational device exemption trial. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2015; DOI:10.1016/j.jvs.2015.03.031
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    ABSTRACT: To report initial experience with automatic pressure-controlled cerebrospinal fluid drainage (CSFD) during thoracic endovascular aortic repair (TEVAR). A prospective nonrandomized study enrolled 30 consecutive patients (median age 68 years, range 42-89; 18 men) who underwent TEVAR between March 2012 and July 2013 and were considered to be at high risk for postoperative spinal cord ischemia (SCI), fulfilling 2 of the following criteria: stent-graft length >20 cm, left subclavian artery coverage, and previous infrarenal aortic repair. All patients received perioperative CSFD via the LiquoGuard system. The protocol aimed for a CSF pressure of 10 mm Hg and duration of CSFD of 3 or 7 days in asymptomatic or symptomatic patients, respectively. Muscle strength of the lower extremities was assessed with the Oxford muscle strength grading scale. Completion of the CSFD protocol was achieved in 26 (87%) of 30 patients. CSFD was prematurely stopped due to catheter dislocation in 1 patient and bloody spinal fluid in 3 patients. CSFD was performed for a median of 3 days (range 1-7). Median total CSFD volume was 714 mL (range 13-2369), with a median 192 mL drained per 24 hours. The SCI rate was 3% (1/30). CSFD-related complications were observed in 33% of the patients: 1 fatal intracranial hemorrhage, 3 bloody spinal fluid episodes, 3 persistent CSF leaks requiring epidural blood patch, and 3 post lumbar puncture headaches. Mortality during a median follow-up of 16 months (range 10-25) was 3% (1/30). Prophylactic CSFD was associated with a low SCI rate in a high-risk patient collective undergoing TEVAR. Monitoring and drainage by an automatic modus was feasible, reproducible, and reliable but associated with relevant drainage-associated complications. © The Author(s) 2015.
    Journal of Endovascular Therapy 04/2015; 22(3). DOI:10.1177/1526602815579904
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    ABSTRACT: To report the occurrence of a type IIIb endoleak after endovascular repair of a thoracic aortic aneurysm caused by endoanchor dislocation. An 84-year old female patient underwent thoracic endovascular repair for aneurysmal disease of her thoracic aorta. The procedure included primary left subclavian artery revascularization and the placement of endoanchors in order to enhance fixation of the endograft within the aortic arch. Dislocation of one of the endoanchors resulted in a graft defect leading to a type IIIb endoleak and aortic diameter expansion. Endoanchors represent a promising adjunct in endovascular repair settings. However, their use requires careful procedure planning and special attention during follow-up. Copyright © 2015 Elsevier Inc. All rights reserved.
    Annals of Vascular Surgery 03/2015; 29(5). DOI:10.1016/j.avsg.2015.01.018
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    ABSTRACT: The purpose of this study was to identify morphologic factors affecting type I endoleak formation and bird-beak configuration after thoracic endovascular aortic repair (TEVAR). Computed tomography (CT) data of 57 patients (40 males; median age, 66 years) undergoing TEVAR for thoracic aortic aneurysm (34 TAA, 19 TAAA) or penetrating aortic ulcer (n = 4) between 2001 and 2010 were retrospectively reviewed. In 28 patients, the Gore TAG® stent-graft was used, followed by the Medtronic Valiant® in 16 cases, the Medtronic Talent® in 8, and the Cook Zenith® in 5 cases. Proximal landing zone (PLZ) was in zone 1 in 13, zone 2 in 13, zone 3 in 23, and zone 4 in 8 patients. In 14 patients (25 %), the procedure was urgent or emergent. In each case, pre- and postoperative CT angiography was analyzed using a dedicated image processing workstation and complimentary in-house developed software based on a 3D cylindrical intensity model to calculate aortic arch angulation and conicity of the landing zones (LZ). Primary type Ia endoleak rate was 12 % (7/57) and subsequent re-intervention rate was 86 % (6/7). Left subclavian artery (LSA) coverage (p = 0.036) and conicity of the PLZ (5.9 vs. 2.6 mm; p = 0.016) were significantly associated with an increased type Ia endoleak rate. Bird-beak configuration was observed in 16 patients (28 %) and was associated with a smaller radius of the aortic arch curvature (42 vs. 65 mm; p = 0.049). Type Ia endoleak was not associated with a bird-beak configuration (p = 0.388). Primary type Ib endoleak rate was 7 % (4/57) and subsequent re-intervention rate was 100 %. Conicity of the distal LZ was associated with an increased type Ib endoleak rate (8.3 vs. 2.6 mm; p = 0.038). CT-based 3D aortic morphometry helps to identify risk factors of type I endoleak formation and bird-beak configuration during TEVAR. These factors were LSA coverage and conicity within the landing zones for type I endoleak formation and steep aortic angulation for bird-beak configuration.
    Langenbeck s Archives of Surgery 02/2015; 400(4). DOI:10.1007/s00423-015-1291-1
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    ABSTRACT: To compare biomechanical rupture risk parameters of asymptomatic, symptomatic and ruptured abdominal aortic aneurysms (AAA) using finite element analysis (FEA). Retrospective biomechanical single center analysis of asymptomatic, symptomatic, and ruptured AAA. Comparison of biomechanical parameters from FEA. From 2011 to 2013 computed tomography angiography (CTA) data from 30 asymptomatic, 15 symptomatic, and 15 ruptured AAAs were collected consecutively. FEA was performed according to the successive steps of AAA vessel reconstruction, segmentation and finite element computation. Biomechanical parameters Peak Wall Rupture Risk Index (PWRI), Peak Wall Stress (PWS), and Rupture Risk Equivalent Diameter (RRED) were compared among the three subgroups. PWRI differentiated between asymptomatic and symptomatic AAA (p < .0004) better than PWS (p < .1453). PWRI-dependent RRED was higher in the symptomatic subgroup compared with the asymptomatic subgroup (p < .0004). Maximum AAA external diameters were comparable between the two groups (p < .1355). Ruptured AAA showed the highest values for external diameter, total intraluminal thrombus volume, PWS, RRED, and PWRI compared with asymptomatic and symptomatic AAA. In contrast with symptomatic and ruptured AAA, none of the asymptomatic patients had a PWRI value >1.0. This threshold value might identify patients at imminent risk of rupture. From different FEA derived parameters, PWRI distinguishes most precisely between asymptomatic and symptomatic AAA. If elevated, this value may represent a negative prognostic factor for asymptomatic AAAs. Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
    European Journal of Vascular and Endovascular Surgery 12/2014; 49(3). DOI:10.1016/j.ejvs.2014.11.010
  • Zentralblatt für Chirurgie 10/2014; 139(05):562-568. DOI:10.1055/s-0034-1383084
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    ABSTRACT: To compare postoperative morphological and rheological conditions after eversion carotid endarterectomy versus conventional carotid endarterectomy using computational fluid dynamics.
    Vascular 10/2014; DOI:10.1177/1708538114552836
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    ABSTRACT: Background: Recently used endografts for envascular aneurysm repair (EVAR) exclude the pathology by fixation at both the proximal and distal landing zone. Due to endoleaks and migration EVAR is associated with a relevant rate of secondary interventions. The Nellix® system (Endologix Inc., CA, USA) was developed to seal the complete aneurysm using a polymer filling, therefore stabilising endograft-position and reducing the rate of endoleaks and reinterventions. The present contribution introduces the method, describes the technique of implantation and presents the first clinical results. Material und Methods: The Nellix system consists of two balloon-expandable stent grafts made of a cobalt-chromium composition, surrounded with ePTFE and the so-called endobags. During the implantation each endobag is filled with a non-biodegradable polymer, sealing the aneurysm lumina including the proximal and distal landing zone. Hence, lumbar arteries will be sealed to reduce the probability of a type II endoleak. Results: Longterm durability as well as the structural integrity of the Nellix system has been proven over 4 years in sheep experiments. The technical success in a multicentre, prospective registry was 94 % without the appearance of severe adverse events (migration, occlusion, secondary endoleak). Conclusion: EVAS is a new and different concept of endovascular AAA repair. Recent clinical data of the Nellix system are promising showing a high technical success rate while the need for secondary intervention is low. Further studies in larger cohorts are needed.
    Zentralblatt für Chirurgie 10/2014; 139(5):e25. DOI:10.1055/s-0034-1383254
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    ABSTRACT: Objective The objective of this study was to review the current anatomic indications for and early results of aortouni-iliac (AUI) devices for endovascular aneurysm repair. Methods A total of 128 patients receiving an Endurant (Medtronic Inc, Minneapolis, Minn) AUI device in the U.S. Investigational Device Exemption trial (44 patients) or the Endurant Stent Graft Natural Selection Global Postmarket Registry (84 patients) were reviewed. Preoperative computed tomography imaging of patients in the Investigational Device Exemption trial and case report forms of Registry patients were used to determine anatomic indications. Baseline characteristics and early results were compared with those of 1305 patients receiving a bifurcated (BIF) device in sister studies. Results The indication for the AUI device was unclear from case report forms in two Registry cases. The remaining 126 patients had a unilateral iliac occlusion in 30 (23%), a severely narrowed aortic segment in 58 (45%), severe iliac occlusive disease in 28 (22%), severe iliac tortuosity in 29 (23%), or complex iliac aneurysms in 19 (15%). Two patients had a previous aortobifemoral graft; 38 patients (30%) had multiple indications. The AUI cohort included more women than the BIF group did (19% vs 10%; P < .01) and had more severe comorbidities. Successful deployment was achieved in all AUI cases. The 30-day mortality was 2% (BIF cohort, 1%; P = .21). More AUI patients underwent repair under general anesthesia (81% vs 64%; P < .01), and procedures were longer (110.9 ± 54.9 minutes vs 99.2 ± 44.3 minutes; P = .02). Except for longer intensive care unit stays (19.6 ± 80.0 hours vs 9.0 ± 34.8 hours; P = .01) and higher myocardial infarction rates (4% vs 1%; P < .01), outcomes of the AUI cohort were similar to those of the BIF cohort. There were no migrations, ruptures, fractures, or open conversions at up to 1-year follow-up. Conclusions The AUI configuration extends endovascular aneurysm repair feasibility to several hostile anatomic conditions. Despite increased comorbidities in the recipient patient population and associated higher rates of postoperative myocardial infarction and respiratory complications, early outcomes with the new generation of AUI devices are acceptable and comparable to those after treatment with BIF configurations.
    Journal of Vascular Surgery 10/2014; DOI:10.1016/j.jvs.2014.08.063
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    ABSTRACT: Current commercially available modular stentgrafts are associated with relevant reintervention rates during follow-up. The Nellix Endovascular Aneurysm Sealing (EVAS) System is a potential device to overcome these limitations of EVAR. Device implantations outside of manufacturer instructions for use due to challenging neck anatomies are very common. This article presents very early experience in the treatment of patients with post EVAR complications and challenging neck anatomies.
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    ABSTRACT: Congenital malformations, tumors and aortic infections are rare and mostly asymptomatic. Unspecific clinical symptoms may cause delayed verification of the underlying disease. Contrast enhanced computer tomography- and magnetic resonance angiography are important sectional imaging methods for diagnostic completion. Consistent guidelines concerning diagnosis and therapy of rare aortic diseases are non-existent. Aortic tumors must be resected by open surgery, aortic infections in general require medical treatment and anomalies, if indicated, are treated more and more by endovascular or hybrid procedures. Therefore, it is recommended to treat these entities in an interdisciplinary approach in specialized aortic centers.
    Der Chirurg 09/2014; 85(9):800-5. DOI:10.1007/s00104-014-2721-2
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    ABSTRACT: 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.
    Journal of Vascular Surgery 09/2014; DOI:10.1016/j.ejvs.2014.05.012
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    ABSTRACT: Objectives The European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT) provides “real-world” outcomes for the new C3 Gore Excluder stent-graft, and evaluates the new deployment mechanism. This report presents the 1-year results from 400 patients enrolled in this registry. Methods Between August 2010 and December 2012, 400 patients (86.8% male, mean age 73.9 ± 7.8 years) from 13 European sites were enrolled in this registry. Patient demographics, treatment indication, case planning, operative details including repositioning and technical results, and clinical outcome were analyzed. Results Technical success was achieved in 396/400 (99%) patients. Two patients needed intraoperative open conversion, one for iliac rupture, the second because the stent-graft was pulled down during a cross-over catheterization in an angulated anatomy. Two patients required an unplanned chimney renal stent to treat partial coverage of the left renal artery because of upward displacement of the stent-graft. Graft repositioning occurred in 192/399 (48.1%) patients, most frequently for level readjustment with regard to the renal arteries, and less commonly for contralateral gate reorientation. Final intended position of the stent-graft below the renal arteries was achieved in 96.2% of patients. Thirty-day mortality was two (0.5%) patients. Early reintervention (≤30 days) was required in two (0.5%) patients. Mean follow-up duration was 15.9 ± 8.8 months (range 0–37 months). Late reintervention (>30 days) was required in 26 (6.5%) patients. Estimated freedom from reintervention at 1 year was 95.2% (95% CI 92.3–97%), and at 2 years 91.5% (95% CI 86.8–94.5%). Estimated patient survival at 1 year was 96% (95% CI 93.3–97.6%) and at 2 years 90.6% (95% CI 85.6–93.9%). Conclusions Early real-world experience shows that the new C3 delivery system offers advantages in terms of device repositioning resulting in high deployment accuracy. Longer follow-up is required to confirm that this high deployment accuracy results in improved long-term durability.
    European Journal of Vascular and Endovascular Surgery 08/2014; 48(2). DOI:10.1016/j.ejvs.2014.04.009
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    ABSTRACT: Purpose : To evaluate a finite element analysis (FEA) model as a predictive tool for abdominal aortic aneurysm (AAA) rupture risk assessment. Methods : FEA of asymptomatic infrarenal AAAs in 15 men (mean age 72 years) was performed preoperatively using semiautomatic finite element analysis software (A4clinics) to calculate peak wall stress (PWS) and regions of highest and lowest rupture risk index (RRI). The areas of high and low RRI identified on the preoperative FEA were sampled during open surgery; aortic wall specimens were prepared for histological analysis. A semiquantitative score compared the histological findings from high and low rupture risk samples. Results : Significant correlation was found between histological AAA wall integrity and RRI in individual patients. AAA wall regions with highest RRI showed advanced histological disintegrity compared to regions with lower RRI within the same AAA: mean smooth muscle cells: 0.43 vs. 1.21, respectively (p=0.031); elastic fibers: 0.57 vs. 1.29, respectively (p=0.008); cholesterol plaque: 2.60 vs. 2.20, respectively (p=0.034); and calcified plaque: 2.27 vs. 1.40, respectively (p=0.017). The amount of calcified plaque was significantly correlated with PWS (r=0.528, p=0.043) by univariate regression analysis. However, there was no correlation between PWS or RRI and the histological findings between patients. Conclusion : These preliminary results show that high rupture risk regions estimated by FEA contain increased histopathological degeneration compared to low rupture risk samples within the same AAA. Until now, the role of FEA in predicting individual AAA rupture risk has not been established as a validated diagnostic tool. However, these data provide promising results for FEA model verification.
    Journal of Endovascular Therapy 08/2014; 21(4):556-564. DOI:10.1583/14-4695.1
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    ABSTRACT: The value of prophylactic atropine use during carotid artery stenting (CAS) in primary carotid stenosis to prevent procedural hemodynamic depression is well accepted. However, its impact in case of recurrent stenosis after eversion carotid endarterectomy (E-CEA), which is known to be associated with decreased baroreflex function due to discontinuation of the carotid sinus nerve, has not been investigated so far.
    Journal of Vascular Surgery 07/2014; 61(1). DOI:10.1016/j.jvs.2014.06.117
  • Endoskopie heute 07/2014; 27(02):107-114. DOI:10.1055/s-0034-1366652

Publication Stats

2k Citations
516.02 Total Impact Points

Institutions

  • 2008–2015
    • Universität Heidelberg
      • • Department of Diagnostic and Interventional Radiology
      • • Department of Vascular Surgery (Mannheim)
      Heidelburg, Baden-Württemberg, Germany
  • 2013
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 2002–2012
    • Friedrich-Alexander Universität Erlangen-Nürnberg
      Erlangen, Bavaria, Germany
  • 2011
    • University of Kragujevac
      • Department of Mechanical Engineering
      Krabujevac, Central Serbia, Serbia
  • 2009
    • Deutsches Herzzentrum München
      München, Bavaria, Germany
    • Technische Universität München
      München, Bavaria, Germany
  • 2008–2009
    • Ethianum Klinik Heidelberg
      Heidelburg, Baden-Württemberg, Germany
  • 2007–2009
    • Vascular and Endovascular Surgery Institute of São Paulo
      San Paulo, São Paulo, Brazil
  • 2006
    • Klinikum Hanau GmbH
      Hanau, Hesse, Germany
  • 2005
    • German Cancer Research Center
      • Division of Radiology
      Heidelberg, Baden-Wuerttemberg, Germany
  • 2004
    • Universität Mannheim
      Mannheim, Baden-Württemberg, Germany