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ABSTRACT: Aim: Spinal cord ischemia is a well-known complication in the treatment of thoracoabdominal aneurysms (TAAA). Despite the fact that endovascular treatment of TAAA is less invasive, spinal cord ischemia rate is not reduced if compared to open repair. Methods: We report the results of our experience of spinal cord function monitoring by measuring motor evoked potentials (MEP) during endovascular treatment of TAAA type II and III. Depending on the level of the MEPs the decision is made whether to stage the procedure or not. We treated ten patients according to this protocol. Results: In two patients, MEPs decreased 50% or more and procedures were staged. Both experienced no neurological complications after first and second procedure. No MEPs decrease was seen during the second procedures. One of the other eight patients had a temporary right lower leg pararesis. Conclusion: In conclusion we state that our first experience demonstrates the value of assessing spinal cord function during extensive endovascular TAAA repair with subsequent strategies to prevent paraplegia.
The Journal of cardiovascular surgery 02/2013; 54(1 Suppl 1):117-24. · 1.56 Impact Factor
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ABSTRACT: Aim: The aim of this study was to assess if chronic intermittent pressure of a thoracoabdominal aortic aneurysm (TAAA) induces structural changes in vertebral bodies and if eroded vertebral bones can still be found after the extermination of syphilis. Methods: A retrospective analysis of computed tomography (CT) scans of patients with TAAA was performed. In the anatomical regions were the TAAA was in close contact with the vertebral bodies, the vertebral body alteration was distinguished into 4 categories. Category 0: no changes; 1: discrete changes, minimal asymmetry; 2: obvious asymmetry of the vertebral body with sustained cortical layer; 3: severe destruction of the vertebral body with loss of the cortical layer. Results: Eighty-six CT scans of patients (mean age 63; range 25-82 years) with TAAA pathology were examined (24 female, 62 male). The mean aneurysm diameter was 6.5 cm (4.3-14 cm). The results for scoring were: category 0: 33 patients; category 1: 46 patients; category 2: 5 patients and category 3: 2 patients. One of the category 3 patients suffered from acute spinal cord compression with complete paraplegia. In total, 62% of patients showed some degree of changes at vertebral bodies adjacent to the TAAA. Conclusion: Intermittent pressure by either dissecting or non-dissecting TAAAs may induce structural changes in the vertebral bodies of the spine. Severe destruction of the bone is a rare, but existing complication.
The Journal of cardiovascular surgery 02/2013; 54(1 Suppl 1):135-40. · 1.56 Impact Factor
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ABSTRACT: At present, endovascular therapy is a well-established treatment for different types of thoracic aortic pathologies. There is growing evidence, that thoracic endovascular aortic repair (TEVAR) has advantages over open repair with regard to perioperative morbidity and mortality in the treatment of thoracic aortic aneurysms. However, in up to 50% of TEVAR procedures the proximal end of the stent-graft will (partly) cover the origin of the left subclavian artery (LSA) in order to achieve a save sealing zone. Intracranial stroke and paraplegia are feared complications and might be associated with LSA exclusion from the circulation. Unfortunately, no reliable technique is available to assess the individual risk of stroke and paraplegia in case of LSA coverage, so that the indication for LSA revascularization continues to be matter of assuming and guessing. The quality of available evidence on necessity or superfluity to revascularize the LSA is very low and studies report, to some extent, controversial outcome after intentional LSA coverage. In the light of the devastating consequences for patients in case of neurological complications due to LSA coverage the question of prophylactic LSA revascularization remains a significant problem which is elucidated and discussed in this manuscript.
The Journal of cardiovascular surgery 02/2013; 54(1 Suppl 1):91-5. · 1.56 Impact Factor
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ABSTRACT: During the past two decades, minimally invasive endovascular procedures have changed therapeutic strategies. Such techniques have now become the method of choice for practically all vascular and aortic pathologies. This development is especially apparent in the treatment of aortic aneurysms. The purpose of this report is to provide a critical review about the current standard of care of abdominal and thoracic aorta based on an electronic Medline literature search. For elective infrarenal aneurysms, endovascular aneurysm repair (EVAR) has become a widely accepted alternative to open repair in cases with appropriate morphology. Currently, fenestrated (FEVAR) or branched endografts offer promising short- and mid-term results in juxtarenal aneurysms, however, these techniques are complex, technically challenging, and expensive. The alternative chimney or sandwich graft technique are becoming more common because they are feasible using standard endografts. Thoracic endovascular aortic repair (TEVAR) is already the gold standard for some descending pathologies. Complex thoracoabdominal aneurysms still require open surgery in centres of excellence, whereby, total endovascular repair or hybrid procedures have proved to be feasible in such specialist centres for selected patients.
Zentralblatt für Chirurgie 10/2012; 137(5):418-24. · 1.02 Impact Factor
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ABSTRACT: Das Profil des „klassischen“ Gefäßchirurgen hat sich innerhalb der letzten Jahre in den meisten europäischen Ländern verändert.
Neben den offenen rekonstruktiven Gefäßeingriffen werden heute auch endovaskuläre Prozeduren routinemäßig von Gefäßchirurgen
durchgeführt. Dies erfordert eine Anpassung der nationalen Ausbildungscurricula für angehende Gefäßchirurgen, um dem neuen
Qualifikationsprofil gerecht werden zu können. Auch wenn die Union of Medical Specialists in Europe (UEMS) bereits Richtlinien
für ein Trainingsprogramm in der Gefäßchirurgie vorgegeben hat, gibt es dennoch enorme länderspezifische Abweichungen zwischen
den verschiedenen Curricula in Europa, die nationale Prioritäten und Rahmenbedingungen widerspiegeln. Um diesen Abweichungen
entgegen zu wirken, ist es entscheidend, für die Zukunft verbindliche Lern- und Ausbildungsziele zu definieren, um so einheitliche
Standards in der offenen und endovaskulären Gefäßchirurgie in Europa zu gewährleisten. Ein „ideales Ausbildungscurriculum“
sollte ein modulares Trainingsprogramm beinhalten, das schrittweise die technischen Fertigkeiten sowohl für klassisch-rekonstruktive
als auch interventionelle Gefäßprozeduren vermittelt. Optional sollte ein „akademischer Pfad“ an Universitätskliniken für
Studienabsolventen angeboten werden, die eine akademische Ausbildung in der Gefäßchirurgie anstreben.
In most European countries the profile of the classical vascular surgeon has evolved towards that of a vascular specialist
within the last decade. Not only do vascular surgeons perform open vascular procedures but nowadays they also routinely perform
endovascular techniques. Consequently, national training programs for aspiring vascular surgeons have to be adapted to this
new qualification profile. Even though the Union of Medical Specialists in Europe (UEMS) has proposed guidelines for coordinating
training in vascular surgery, there are still enormous variations in the various curricula within Europe which reflect national
priorities and boundary conditions. To counter these discrepancies it is important to introduce uniform and binding educational
aims and curricula in vascular surgery/medicine in order to facilitate excellent yet equal standards of open and endovascular
procedures in Europe. An ideal educational curriculum consists of a modular training program which bolsters the trainee’s
experience level in both vascular as well as endovascular procedures. In addition, this training program should also provide
a basis for an academic vascular surgery fellowship which combines both basic laboratory research and comprehensive clinical
training.
SchlüsselwörterAusbildungscurriculum-Gefäßchirurgische Ausbildung in Europa-Offen-chirurgische Eingriffe-Endovaskuläre Prozeduren-Akademischer Karrierepfad
KeywordsEducational curriculum-Vascular training in Europe-Open surgical reconstruction-Endovascular procedures-Academic career pathway
Gefässchirurgie 05/2012; 15(8):596-602. · 0.24 Impact Factor
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ABSTRACT: Offene chirurgische Eingriffe an der thorakalen Aorta zur Ausschaltung von Aneurysmen können heutzutage mit vergleichsweise
niedriger Morbidität und Mortalität in hochspezialisierten Zentren durchgeführt werden. Als weiteres Behandlungsverfahren
steht die endovaskuläre Ausschaltung von thorakalen Aneurysmen („thoracic endovascular aortic repair“, TEVAR) zur Verfügung,
die ebenfalls mit sehr guten Ergebnissen verbunden ist. Allerdings kann die Auswahl des Verfahrens derzeit nicht anhand evidenzbasierter
Daten getroffen werden, da bislang keine Ergebnisse prospektiver, randomisierter Studien zur Verfügung stehen. Aus diesem
Grunde sind bei der Auswahl des Operationsverfahrens im Wesentlichen das Patientenalter, die Komorbidität, die Ätiologie des
Aneurysmas und die anatomischen Voraussetzungen für die TEVAR zu berücksichtigen. In diesem klinischen Review werden die aktuellen
Ergebnisse der unterschiedlichen Therapieverfahren zur Behandlung von thorakalen Aneurysmen gegenübergestellt und kritisch
bewertet.
Open surgical repair of thoracic aortic aneurysms can nowadays be performed with low morbidity and mortality rates in specialized
cardiovascular centers. In recent years, thoracic endovascular aortic repair (TEVAR) and hybrid aortic procedures have also
been established as treatment options for a variety of thoracic aortic lesions, including thoracic aneurysm. However, decision
making in choosing between the distinct treatment options in patients with thoracic aortic aneurysms cannot be based on the
results of randomized trials. Therefore, the level of evidence is poor and factors, such as the etiology of the aneurysms,
comorbidity, anticipated life expectancy, aortic diameter, and morphology (including suitability of landing zones), are of
relevance and have to be considered for an individual therapy. This article reviews recent publications on open surgical,
endovascular, and hybrid thoracic aortic aneurysms repair.
SchlüsselwörterAortenaneurysma, thorakales-Chirurgisches Verfahren-Endovaskuläre Aneurysmaausschaltung-Offene Aortenchirurgie-Hybridprozeduren
KeywordsAortic aneurysms, thoracic-Surgical procedure-Thoracic endovascular aortic aneurysm repair-Open thoracic aortic repair-Hybrid procedures
Gefässchirurgie 04/2012; 15(6):468-476. · 0.24 Impact Factor
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ABSTRACT: Der mit Symptomen verbundene Kollaps des wahren thorakalen Lumens durch einen komprimierenden thrombosierten Falschkanal ist Der mit Symptomen verbundene Kollaps des wahren thorakalen Lumens durch einen komprimierenden thrombosierten Falschkanal ist
eine seltene Morphologie der Typ-B-Dissektion. Der Kollaps kann mit einer vital bedrohenden Organmalperfusion oder peripheren eine seltene Morphologie der Typ-B-Dissektion. Der Kollaps kann mit einer vital bedrohenden Organmalperfusion oder peripheren
Extremitätenischämie assoziiert sein. Wir berichten über eine erfolgreiche endovaskuläre Behandlung eines „true lumen collapse“ Extremitätenischämie assoziiert sein. Wir berichten über eine erfolgreiche endovaskuläre Behandlung eines „true lumen collapse“
bei einer 65-jährigen Patientin, die mit akuter Paraparese beider Beine und einem akuten Nierenversagen 5Wochen nach dem bei einer 65-jährigen Patientin, die mit akuter Paraparese beider Beine und einem akuten Nierenversagen 5Wochen nach dem
Initialereignis zur Aufnahme kam. Der Kollaps des wahren Lumens wurde durch eine extensive Thrombosierung des Falschkanals Initialereignis zur Aufnahme kam. Der Kollaps des wahren Lumens wurde durch eine extensive Thrombosierung des Falschkanals
bei fehlendem „reentry“ verursacht. bei fehlendem „reentry“ verursacht.
A symptomatic true lumen collapse within the descending aorta due to extensive false lumen thrombosis is a rare morphology A symptomatic true lumen collapse within the descending aorta due to extensive false lumen thrombosis is a rare morphology
in type B dissection. Because of organ malperfusion, it represents a life-threatening situation. Here we present successful in type B dissection. Because of organ malperfusion, it represents a life-threatening situation. Here we present successful
management of a symptomatic true lumen collapse in a 65-year-old patient. She suffered from sudden paraparesis in both legs management of a symptomatic true lumen collapse in a 65-year-old patient. She suffered from sudden paraparesis in both legs
combined with acute renal failure 5 weeks after acute type B dissection and underwent thoracic stent grafting in an emergency combined with acute renal failure 5 weeks after acute type B dissection and underwent thoracic stent grafting in an emergency
setting. The true lumen collapse was caused by extensive thrombosis of the false lumen in combination with the absence of setting. The true lumen collapse was caused by extensive thrombosis of the false lumen in combination with the absence of
a distal reentry point. a distal reentry point.
SchlüsselwörterTyp-B-Aortendissektion-Kollaps wahres Lumen-Organmalperfusion-Akutes Nierenversagen-Thorakaler Stentgraft SchlüsselwörterTyp-B-Aortendissektion-Kollaps wahres Lumen-Organmalperfusion-Akutes Nierenversagen-Thorakaler Stentgraft
KeywordsType B dissection-True lumen collapse-Organ malperfusion-Renal failure-TEVAR KeywordsType B dissection-True lumen collapse-Organ malperfusion-Renal failure-TEVAR
Gefässchirurgie 04/2012; 15(1):38-42. · 0.24 Impact Factor
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ABSTRACT: Die Therapie der thorakalen und abdominellen Aortenaneurysmen wird zunehmend von den endovaskulären Methoden bestimmt. Allerdings
ist die Datenlage hinsichtlich dieser Therapieformen noch nicht vollständig und eindeutig. Es fehlen zum Teil valide Langzeitergebnisse.
Die endovaskulären Methoden haben durch die Entwicklung der fenestrierten Stentgrafts auch Einzug in die Therapie der thorakoabdominellen
Aortenaneurysmen gehalten, wobei diese Eingriffe zurzeit nur von einigen wenigen Zentren erfolgreich durchgeführt werden.
Aber auch hier fehlen die Langzeitergebnisse. Es werden noch viele technische Verbesserung notwendig sein, um die endovaskulären
Optionen als echte Alternative zum bisherigen Goldstandard, dem offenen Aortenersatz mit allen protektiven Modalitäten wie
dem Linksherzbypass, der distalen Aorten- und selektiven Nieren- und Viszeralarterienperfusion, der Liquordrainage und zuletzt
dem Neuromonitoring mittels motorisch evozierter Potenziale in den klinischen Alltag einführen zu können. Die hybriden Prozeduren,
welche endovaskuläre und offene Verfahren simultan oder zweizeitig einsetzen, haben ihre Wertigkeit hinsichtlich der Langzeitergebnisse
noch zu validieren. Ungleich schwerer wird die Entscheidung der Therapieform bei Patienten mit Bindegewebserkrankungen wie
dem Marfan-Syndrom, dem Ehlers-Danlos-Syndrom Typ IV (EDSIV) und dem Loeys-Dietz-Syndrom (LDS). Vor allem bei den Patienten
mit EDSIV erzielt die offene Chirurgie nur mäßig gute Ergebnisse, sodass sie zurzeit nur bei bedrohlichen Blutungen und einigen
wenigen, ausgewählten elektiven Situationen empfohlen wird. Allerdings zeigen die bisherigen nur sehr limitierten endovaskulären
Erfahrungen keine echte Verbesserung der Ergebnisse. Für das Marfan-Syndrom und LDS sind die offen chirurgischen Ergebnisse,
wahrscheinlich aufgrund des jungen Alters der Patienten, oft besser als die Resultate bei Patienten mit degenerativatherosklerotischen
Aneurysmen. Wir möchten von unseren Erfahrungen mit der offenen Chirurgie an Patienten mit Marfan-Sydnrom (n=22), EDS IV (n=1)
und LDS (n=1) berichten und anhand einer Literaturrecherche die Ergebnisse anderer Zentren sowohl endovaskulär als auch offen-chirurgisch
darstellen.
The therapy of thoracic and abdominal aortic aneurysms is becoming more and more dominated by endovascular options. Fenestrated
and branched stent grafts have been introduced for treatment of thoraco-abdominal aortic aneurysms in some dedicated centers.
However, the long-term results of these therapeutic methods are lacking and technical improvements will be necessary. The
gold standard at present is open aortic repair incorporating all protective measures, such as left heart bypass, distal aortic
perfusion and selective perfusion of the renal and visceral arteries, spinal fluid drainage and monitoring of the spinal cord
function by means of motor evoked potentials. Hybrid procedures which combine open and endovascular procedures to reduce surgical
trauma have recently been reported but long-term results are also lacking. In patients suffering from connective tissue diseases,
such as Marfan’s syndrome, Ehlers-Danlos syndrome type IV (EDS IV) and Loeys-Dietz syndrome (LDS) it is more difficult to
decide which of these options will be the best. Especially in patients with EDS IV the results of open surgery are moderate
so that surgery is recommended only for patients with life-threatening bleeding and some very carefully selected elective
patients. However, the experiences with endovascular treatment are very limited and no improvement in the results was observed.
In patients with Marfan’s and Loeys-Dietz syndromes the results of open surgery are significantly better than in patients
with atherosclerotic degenerative aortic aneurysms, maybe due to the younger age of the Marfan’s and Loeys-Dietz patients.
We report about our experiences with open surgery in patients with Marfan’s syndrome (n=22), EDS IV (n=1) and LDS (n=1) and
give a review of the literature on this subject.
SchlüsselwörterBindegewebskrankheiten-Thorakoabdominelles Aortenaneurysma-Endovaskuläre Therapie
KeywordsConnective tissue diseases-Thoraco-abdominal aortic aneurysm-Endovascular therapy
Gefässchirurgie 04/2012; 15(3):191-198. · 0.24 Impact Factor
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ABSTRACT: ZielDas Ziel unserer Studie war die Evaluierung der Dual-Source CT-Angiographie von Karotisstenosen im Vergleich zur MR-Angiographie
und farbkodierten Duplexsonographie.
Material und MethodeBei 15 symptomatischen Patienten wurden insgesamt 30Karotiden hinsichtlich ihres Stenosegrades evaluiert. Dabei wurden für
die angiographischen Methoden die NASCET-Kriterien und für die Sonographie die DEGUM-Kriterien angewendet. Jeder Patient wurde
mit Farbduplex, der kontrastverstärkten 3T-MR-Angiographie und der kontrastverstärkten Dual-Source CT-Angiographie: (Röhre
A: 140kV, 55 mAs; Röhre B: 80kV, 230 mAs; 64×0,6mm coll., pitch 0,65rot. 0,33s) untersucht. Die CT-Bilder wurden in 1mm
dicken Schichten rekonstruiert. Dabei wurde eine sofortige Knochensubtraktion durchgeführt. Alle Dual-Source CT- und MR-Angiographien
wurden durch denselben, erfahrenen Radiologen, alle Ultraschalluntersuchungen durch dieselbe, erfahrene Neurologin befundet.
Die einzelnen Ergebnisse wurden miteinander verglichen und korreliert.
ErgebnisseDer durchschnittliche Stenosegrad wurde im CT mit 48%, im MRT mit 49% und im Ultraschall mit 47% angegeben. Es gab keinen
statistisch signifikanten Unterschied hinsichtlich der Stenosegradbestimmung zwischen CT und MRT (p=0,83), oder zwischen CT
und Ultraschall (p=0,75). Die Korrelationskoeffizienten wurden zwischen CT und MRT mit r=0,8327 und zwischen CT und Ultraschall
mit r=0,8260 errechnet.
SchlussfolgerungDie Diagnostik von Karotisstenosen mit Hilfe der Dual-Source CT-Angiographie erlaubt eine sichere Bestimmung des Stenosegrades.
Die Ergebnisse sind mit denen der MR-Angiographie und der farbkodierten Duplexsonographie vergleichbar.
AimThe aim of this study was to evaluate the accuracy of dual source CT angiography of the carotid artery in comparison with
MR angiography and color-coded duplex ultrasound (US).
Material and methodsFrom 15 symptomatic patients 30 carotid arteries were evaluated for the degree of stenosis following the NASCET criteria for
angiography and the DEGUM criteria for sonography. Each patient was examined using duplex ultrasound, 3T MR angiography and
contrast-enhanced dual source CT angiography (DSCT) (tube A 140kV, 55mA, tube B 80kV, 230mA; 64×0.6mm coll, pitch 0.65
rot. 0.33s) of the extracranial carotid artery. Images were reconstructed in 1mm section thickness and direct bone removal
was performed for optimal visualization after the scan. All dual source CT and MR angiography images were evaluated and measured
by the same experienced radiologist and all duplex ultrasound results by the same neurologist. Measurement results were compared
and correlated.
ResultsThe mean degree of stenosis was 48% by CT (SD 35%), 49% by MR (SD 38%) and 47% by US (SD 41%). There was no statistically
significant difference in stenosis evaluation between CT and MR (p=0.83) or between CT and US (p=0.75). The correlation coefficient
between CT and MR was r=0.8327, between CT and US r=0.8424 and between US and MR r=0.8260.
ConclusionDual source CT evaluation of the carotid arteries allows a reliable measurement of carotid artery stenosis. Results are comparable
to MR angiography and US.
Gefässchirurgie 04/2012; 14(6):500-504. · 0.24 Impact Factor
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ABSTRACT: ZusammenfassungIn diesem Kapitel wird das klinische Ergebnis nach Operationen thorakaler (TAA) und thorakoabdominaler (TAAA) Aortenaneurysmen
bei Patienten mit Marfan-Syndrom analysiert.
Methode: Während eines 6-Jahres-Zeitraums wurden 206 Patienten aufgrund eines TAA oder TAAA operiert. Bei 22 von ihnen wurde ein Marfan-Syndrom
nachgewiesen, ihr Durchschnittsalter betrug 40 Jahre. Sechs Patienten hatten ein thorakales Aortenaneurysma, bei einem davon
war der gesamte Bogen und bei zwei Patienten der distale Hemibogen mitbetroffen. Die TAAA wurden nach Crawford klassifiziert,
dabei fanden sich 11 Typ-II-TAAA (2 den gesamten Bogen betreffend, 3 mit distaler Hemibogenbeteiligung), 4 Typ-III- und ein
Typ-IV-TAAA. Alle Patienten hatten bereits eine Aortendissektion erlitten, und 15 Patienten waren schon einmal voroperiert
worden. Die Patienten wurden nach unserem Standardprotokoll operiert: lumbale Liquordrainage, distale Aorten- und selektive
Organperfusion sowie Monitoring motorisch evozierter Potentiale. Patienten mit simultaner Aortenbogenrekonstruktion (via Linksthorakotomie)
wurden zusätzlich mittels transkranieller Dopplersonographie und EEG überwacht. Bei vier Patienten war ein Herz-Kreislauf-Stillstand
mit moderater Kühlung erforderlich.
Ergebnisse: Kein Patient verstarb während des Krankenhausaufenthaltes. Es traten keine postoperativen Majorkomplikationen wie Paraplegie,
Nierenversagen, Schlaganfall oder Myokardinfarkt auf. Die durchschnittliche Beatmungszeit lag bei 1,5 Tagen. Folgende Minorkomplikationen
wurden beobachtet: revisionspflichtige Nachblutung (1), Pneumonie (2) und ARDS (1). Während der Nachbeobachtung von jetzt
durchschnittlich 38 Monaten überlebten alle Patienten. Die CT-Kontrollen zeigten kein neues oder falsches Aneurysma, mit Ausnahme
eines Patienten, der sechs Jahre nach einer TAAA-Typ-II-Operation ein viszerales Patchaneurysma entwickelt.
Schlussfolgerung: Die offen chirurgische Therapie der thorakalen und thorakoabdominalen Aortenaneurysmen bei Patienten mit Marfan-Syndrom erzielt
exzellente kurz- und mittelfristige Ergebnisse. In dieser Serie führte das chirurgische Protokoll mit Liquordrainage, selektiver
Organ- und distaler Aortenperfusion sowie Monitoring motorisch evozierter Potentiale zu einer nur geringen Morbidität und
100 %iger Überlebensrate. Diese Ergebnisse sollten in der Diskussion über endovaskuläre Therapieoptionen bei Patienten mit
Marfan-Syndrom berücksichtigt werden.
SummaryWe assessed the surgical outcome of descending thoracic aortic aneurysm repair (DTAA) and thoracoabdominal aortic aneurysm
(TAAA) repair in patients with Marfan syndrome.
Methods: During a six years period, 206 patients underwent DTAA and TAAA repair. In 22 patients, Marfan syndrome was confirmed. The
median age was 40 years with a range between 18 and 57 years. The extend of the aneurysms included 6 DTAA (1 with total arch,
2 with distal hemi-arch), 11 type II TAAA (2 with total arch, 3 with distal hemi-arch), 4 type III and one type IV TAAA. All
patients suffered from previous type A (n=6) or type B (n=16) aortic dissection and 15 already underwent aortic procedures
like Bentall (n=7) and ascending aortic replacement (n=8). All patients were operated on according to the standard protocol
with cerebrospinal fluid drainage, distal aortic and selective organ perfusion and monitoring motor evoked potentials. In
patients undergoing simultaneous arch replacement (via left thoracotomy), transcranial Doppler and EEG assessed cerebral physiology
during antegrade brain perfusion. In four patients circulatory arrest under moderate hypothermia was required.
Results: In-hospital mortality did not occur. Major postoperative complications like paraplegia, renal failure, stroke and myocardial
infarction were not encountered. Median intubation time was 1.5 days (range 0.33-30 days). Other complications included bleeding
requiring surgical intervention (n=1), arrhythmia (n=2), pneumonia (n=2) and respiratory distress syndrome (n=1). At a median
follow-up of 38 months all patients were alive. Using CT surveillance, new or false aneurysms were not detected, except in
one patient who developed a visceral patch aneurysm six years after open type II repair.
Conclusion: Surgical repair of descending and thoracoabdominal aortic aneurysms provides excellent short- and mid-term results in patients
with Marfan syndrome. In this series, a surgical protocol with cerebrospinal fluid drainage, distal aortic and selective organ
perfusion and monitoring motor evoked potentials resulted in low morbidity and absent mortality. These outcomes of open surgery
should be considered when discussing endovascular aneurysm repair in Marfan patients.
12/2010: pages 111-120;
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ABSTRACT: Spinal cord ischemia after open surgical repair for rAAA is a rare event. We estimated the current incidence and tried to identify risk factors. We also report a new case.
Group A consisted of 10 reports on open repair for rAAA from 1980 until 2009. Only series of ≥100 patients were considered to estimate the incidence. Thirty three case reports from 1956 until 2009 were identified (group B). Case reports from group B were not encountered in group A. Group B patients were stratified according to the type of neurological deficit as described by Gloviczki (type I complete infarction and type II infarction of the anterior two third).
Group A consisted of 1438 patients. In group A 86% were male with a mean age of 72.1 years. The incidence of post-operative paraplegia was 1.2% (range 0-2.8%). In-hospital mortality was 46.9%. Of the 33 patients of group B were 86% male with a mean age of 68.0 years. Most patients developed a type I (42%) or type II (33%) deficit. In-hospital mortality was 51.6%. No significant differences between different types were encountered.
Spinal cord ischemia after ruptured AAA is a rare complication with an incidence of 1.2% (range 0-2.8%).
European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 11/2010; 40(5):589-95. · 2.92 Impact Factor
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ABSTRACT: Marfan Syndrome is a heritable disorder of connective tissue leading to aortic aneurysms and other cardiovascular complications associated with reduced life expectancy. Marfan patients with thoracic aortic aneurysms (TAAs) or with thoracoabdominal aortic aneurysms (TAAAs) should be treated by means of open surgery, requiring an extensive protocol, including extracorporeal circulation, neuromonitoring and adjunctive modalities to provide organ protection. Then, open surgical repair of TAA(A)s are associated with excellent results. However, in the last time a gradual change to endovascular treatment in Marfan patients is observable. Particularly in patients with an increased surgical risk due to redo sternotomy or thoracotomy, endovascular treatment might be an alternative due to its less invasive approach. Consequently, thoracic endovascular aortic repair comprises a therapeutic alternative in individual situations even in Marfan patients, when the landing zones are safe and appropriate. In cases of failed endovascular therapy, however, conversion to open surgery remains still an option with acceptable results, although the distal and proximal clamping positions change inappropriate with larger extensions due to the aortic stent.
The Journal of cardiovascular surgery 10/2010; 51(5):693-9. · 1.56 Impact Factor
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ABSTRACT: Stroke and paraplegia are devastating complications of thoracic and thoracoabdominal aortic surgery. The aim of this study was to analyse the value of transcranial Doppler ultrasound (TCD), electroencephalogram (EEG) and motor-evoked potentials (MEP) in preventing neurological complications. Moreover, the principles, technology and surgical protocols are described.
In 2009, 22 patients (4 females, 18 males) underwent thoracic or thoracoabdominal open aortic repair. We performed 2 arches with descending aortic replacement, 5 arches with TAAA repair, 2 type II, 9 type III, 3 type IV and one type V TAAA aortic repair. In 6 patients, the neuromonitoring included TCD, EEG and MEPs. In 15 patients only MEP monitoring was necessary. In one patient who was operated on in an emergency setting, neuromonitoring was not performed. The surgical approach was a left thoracotomy in 3 and a left thoracolaparotomy in 19 patients. The surgical protocol included cerebrospinal fluid drainage (n=22), moderate (n=19) or deep hypothermia (n=2), and extracorporeal circulation (n=21) with retrograde aortic perfusion and selective cerebral and/or viscerorenal perfusion.
In 21 patients, the neuromonitoring could be established successfully. Using TCD and EEG, a relevant cerebral ischaemia during supraaortic clamping was excluded. With a mean distal arterial pressure of 60 mmHg, the MEPs remained adequate in 15 patients (68.2%). Increasing of the blood pressure restored the MEPs in one patient. In 5 patients (22.7%), a reimplantation of segmental arteries (n=4) or of the left subclavian artery (n=1) re-established spinal cord perfusion, as indicated by restored MEPs. We had no absent MEPs at the end of the procedures. Delayed paraparesis developed in 2 patients with a haemodynamic instability during the postoperative course. Paraplegia was not observed.
TCD, EEG and MEPs are reliable techniques to unmask cerebral or spinal cord ischaemia during aortic surgery. Immediate operative strategies based on neuromonitoring information prevent neurological complications in aortic surgery.
Zentralblatt für Chirurgie 10/2010; 135(5):421-6. · 1.02 Impact Factor
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ABSTRACT: According to the results of the large trials on carotid endarterectomy (CEA), this type of surgery is only warranted if perioperative mortality and morbidity are kept considerably low. Less attention has been paid to methods of cerebral protection during CEA, although intraoperative transcranial Doppler (TCD) can visualise intracerebral microemboli (MES) during routine carotid dissection, although MES occur throughout the CEA, only those during dissection are related to neurological outcome. Prevention of MES by means of early control of the distal internal carotid artery dislodging from the carotid artery plaque during dissection is very likely the mechanism behind an eventual benefit from this approach. Hence, the amount of MES might serve as a surrogate parameter for the risk of periprocedural neurological events. So, the aim of the present study was to evaluate whether early control of the distal carotid artery during CEA is capable of reducing the number of MES by means of a prospective randomised trial.
Twenty-eight patients (29 procedures) could be prospectively included in our study. Before surgery we randomly assigned the patients to two groups: group A (N.=12): CEA by means of early control of the distal internal carotid artery; group B (N.=17): CEA with dissection of the total carotid bifurcation before clamping the arteries. Periprocedurally, we continuously monitored the cerebral blood flow in the ipsilateral middle cerebral artery by means of TCD. Pre- and postoperative morbidity were independently verified by a neurologist <2 days before and not later than five days after the procedure. Values of microembolic signs during dissection were summarised with arithmetic means and standard deviations. For further analysis non parametric Wilcoxon test was performed between both methods. P-values <0.05 were considered as statistically significant. Wilcoxon test was performed to compare both methods concerning clamp- and procedure times.
We performed EEA 26 times, in three patients a longitudinal arteriotomy with endarterectomy and patchplasty was performed, in one of these patients a shunt was necessary. In 12 twelve patients MES occurred during the dissection before clamping. Eight of these patients belonged to group B and four patients to group A. The mean number of MES during dissection for group A was 2.4 (SD 4.6; 5-15) and for group B 3.9 (SD 7.1; 2-28). There is no statistically significant difference in the Wilcoxon-test; P=0.4375. There was no patient showing reperfusion syndrom or clinical signs of a new cerebral infarction or any other neurological deficit. There were no other major complications like myocardial infarction or death as well as no minor complications like periphereal nerve lesions, bleeding or wound healing disturbance.
In this prospective, randomised trial early control of the distal internal carotid artery did not reduce the occurrence of MES during dissection of the carotid bifurcation. Also, the total number of MES throughout the procedure and postoperatively was comparable between both groups. The procedure related times as well as the clinical outcome did not differ significantly. Thus, early control of the distal internal carotid artery has got no advantage but also no disadvantage as compared to the traditional CEA technique. However, a limitation of the study is the small number of patients included.
The Journal of cardiovascular surgery 06/2010; 51(3):369-75. · 1.56 Impact Factor
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ABSTRACT: Paraplegia is one of the most severe complications of the repair of open descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. To reduce these complications, a comprehensive strategy for spinal cord protection is mandatory. Motor evoked potentials provide the surgeon with important information about spinal cord integrity throughout the operation. Neuroprotective measures include extracorporeal circulation, cerebrospinal fluid drainage, hypothermia, and selective segmental artery revascularization.
Cardiology clinics 05/2010; 28(2):351-60. · 1.25 Impact Factor
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European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 04/2010; · 2.92 Impact Factor
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ABSTRACT: This study investigated the relation between abdominal aortic aneurysm (AAA) wall stress, AAA growth rate and biomarker concentrations. With increasing wall stress, more damage may be caused to the AAA wall, possibly leading to progression of the aneurysm and reflection in up- or downregulation of specific circulating biomarkers. Levels of matrix metalloproteinase-9, tissue inhibitor of matrix metalloproteinase-1, C-reactive protein and alpha 1-antitrypsin were therefore evaluated.
Thirty-seven patients (maximum AAA diameter 41-55mm) with two, three or four consecutive computed tomography angiography (CTA) scans were prospectively included. Diameter growth rate in mm/year was determined between each pair of two sequential CTA scans. AAA wall stress was computed by finite element analysis, based on the first of the two sequential CTA scans only (n=69 pairs). Biomarker information was determined in 46 measurements in 18 patients. The relation between AAA diameter and wall stress was determined and the AAA's were divided into three equally sized groups (relative low, medium and high stress). Growth rate and biomarker concentrations were compared between these groups. Additionally, correlation coefficients were computed between absolute wall stress, AAA growth and biomarker concentrations.
A relative low AAA wall stress was associated with a lower aneurysm growth rate. Growth rate was also positively related to MMP-9 plasma concentration (r=0.32). The average MMP-9 and CRP concentrations increased with increasing degrees of relative wall stress, although the absolute and relative wall stress did not correlate with any of the biomarkers.
Although lower relative wall stress was associated to a lower AAA growth rate, no relation was found between biomarker concentrations and wall stress. Future research may focus on more and extensive biomarker measurements in relation to AAA wall stress.
European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 04/2010; 39(4):410-6. · 2.92 Impact Factor
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ABSTRACT: Rupture risk estimation of abdominal aortic aneurysms (AAA) is currently based on the maximum diameter of the AAA. A more critical approach is based on AAA wall stress analysis. For that, in most cases, the AAA geometry is obtained from CT-data and treated as a stress free geometry. However, during CT imaging, the AAA is subjected to a time-averaged blood pressure and is therefore not stress free. The aim of this study is to evaluate the effect of neglecting these initial stresses (IS) on the patient-specific AAA wall stress as computed by finite element analysis. Additionally, the contribution of the nonlinear material behavior of the AAA wall is evaluated. Thirty patients with maximum AAA diameters below the current surgery criterion were scanned with contrast-enhanced CT and the AAA's were segmented from the image data. The mean arterial blood pressure (MAP) was measured immediately after the CT-scan and used to compute the IS corresponding with the CT geometry and MAP. Comparisons were made between wall stress obtained with and without IS and with linear and nonlinear material properties. On average, AAA wall stresses as computed with IS were higher than without IS. This was also the case for the stresses computed with the nonlinear material model compared to the linear material model. However, omitting initial stress and material nonlinearity in AAA wall stress computations leads to different effects in the resulting wall stress for each AAA. Therefore, provided that other assumptions made are not predominant, IS cannot be discarded and a nonlinear material model should be used in future patient-specific AAA wall stress analyses.
Journal of biomechanics 06/2009; 42(11):1713-9. · 2.66 Impact Factor
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ABSTRACT: Biomechanically, rupture of an Abdominal Aortic Aneurysm (AAA) occurs when the stress acting on the wall due to the blood pressure, exceeds the strength of the wall. Peak wall stress estimations, based on CT reconstruction, may be prone to observer variation. This study focuses on the robustness and reproducibility of AAA wall stress assessment and the relation with geometrical features of the AAA.
The AAAs of twenty patients were reconstructed by three operators. Both the peak and 99-percentile stress were used for intra- and inter-operator variability using the intraclass correlation coefficient (ICC). A regression analysis was performed to relate the stress parameters with the maximum diameter. Outliers were analyzed by their geometrical characteristics.
The intra-operator ICC was 0.73-0.79 for the peak stress and 0.94 for the 99-percentile stress. The inter-operator ICC was 0.71 for the peak stress and 0.95 for the 99-percentile stress. A significant linear relation with the diameter was found only for the 99-percentile stress.
The 99-percentile stress is more reproducible than peak wall stress. A significant relation between wall stress and diameter was found. Other geometrical features had no statistical relation with high stress.
European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 11/2008; 36(6):668-76. · 2.92 Impact Factor
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ABSTRACT: We assessed the surgical outcome of descending thoracic aortic aneurysm repair (DTAA) and thoracoabdominal aortic aneurym (TAAA) repair in patients with Marfan syndrome.
During a six year period, 206 patients underwent DTAA and TAAA repair. In 22 patients, Marfan syndrome was confirmed. The median age was 40 years with a range between 18 and 57 years. The extend of the aneurysms included 6 DTAA (1 with total arch, 2 with distal hemi-arch), 11 type II TAAA (2 with total arch, 3 with distal hemi-arch), 4 type III and one type IV TAAA. All patients suffered from previous type A (n=6) or type B (n=16) aortic dissection and 15 already underwent aortic procedures like Bentall (n=7) and ascending aortic replacement (n=8). All patients were operated on according to the standard protocol with cerebrospinal fluid drainage, distal aortic and selective organ perfusion and monitoring motor evoked potentials. In patients undergoing simultaneous arch replacement (via left thoracotomy), transcranial Doppler and EEG assessed cerebral physiology during antegrade brain perfusion. In four patients circulatory arrest under moderate hypothermia was required.
In-hospital mortality did not occur. Major postoperative complications like paraplegia, renal failure, stroke and myocardial infarction were not encountered. Mean pre-operative creatinine level was 125mmol/L, which peaked to a mean maximal level of 130 and returned to 92mmol/L at discharge. Median intubation time was 1.5 days (range 0.33-30 days). Other complications included bleeding requiring surgical intervention (n=1), arrhythmia (n=2), pneumonia (n=2) and respiratory distress syndrome (n=1). At a median follow-up of 38 months all patients were alive. Using CT surveillance, new or false aneurysms were not detected, except in one patient who developed a visceral patch aneurysm six years after open type II repair.
Surgical repair of descending and thoracoabdominal aortic aneurysms provides excellent short- and mid-term results in patients with Marfan syndrome. In this series, a surgical protocol with cerebrospinal fluid drainage, distal aortic and selective organ perfusion and monitoring motor evoked potentials resulted in low morbidity and absent mortality. These outcomes of open surgery should be considered when discussing endovascular aneurysm repair in Marfan patients.
European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 03/2008; 35(2):181-6. · 2.92 Impact Factor
