Stenting of stenotic mesenteric arteries for symptomatic chronic mesenteric ischemia.

BACKGROUND: We report the results of our single center series of patients with chronic mesenteric ischemia (CMI) to determine the role of stenting in the management of patients. PATIENTS AND METHODS: We retrospectively reviewed all patients with CMI treated endovascularly with stent revascularisation from January 2008 to January 2011.CMI diagnosis was made according to clinical symptoms, including postprandial abdominal pain, food fear, and weight loss. Additionally, the diagnosis was confirmed by duplex ultrasonography and/or computed tomography angiography and/or contrast-enhanced magnetic resonance angiography. RESULTS: All 45 patients presented with typical CMI symptoms: 45/45 (100 %) had postprandial pain, 31/45 (68.8 %) had a weight loss of more than 10 kilograms, and 11/45 (24.4 %) suffered from ischemic colitis combined with lower gastrointestinal bleeding. In three patients occlusion could not be crossed, therefore considered as technical failure. A total of 55 arteries were stented in the remaining 42 patients. Nineteen patients underwent SMA stenting alone, eight underwent celiac stenting, alone and three patients underwent stenting of inferior mesenteric artery (IMA) alone. We performed combined stenting of the celiac artery and superior mesenteric artery in ten patients, and one patient underwent a combined stenting of the celiac artery and the IMA. All three mesenteric arteries were stented in only one patient. Primary technical success was achieved in 42/45 (94.8 %) patients. Clinical symptom relief was achieved in 39/45 (86.6 %) patients with abdominal pain. Increased body weight was observed in 28/31 (90.3 %) patients with an average weight gain of 8.8 kilograms (5 - 12 kilograms), and 10/11 (90.9 %) patients recovered from ischaemic colitis/lower gastrointestinal bleeding. CONCLUSIONS: Stent revascularisation can be considered as the first-line therapy for patients with chronic mesenteric ischemia.

[Surgery of high-grade asymptomatic stenosis of the internal carotid artery]. / Operative Therapie der hochgradigen, asymptomatischen Karotisstenose.

OBJECTIVE: Surgery of carotid artery stenosis is an evidence-based procedure. In Germany approximately 25 percent of the strokes are caused by arteriosclerotic processes in the extracranial internal carotid artery and are consequently potentially avoidable by an appropriate treatment. The symptoms, the stenosis degree as well as the perioperative risk represent the basis for the indication. The perioperative complication rate should be under 3 percent for those cases with asymptomatic stenoses and under 6 percent for those with symptomatic stenoses. INDICATION: The most frequently applied operation procedures comprise carotid thrombo-endarterectomy (TEA) including patch graft and the eversion endarterectomy. In the following video we present both methods in a 76-year-old female patient with an asymptomatic 95 percent stenosis as well as in an 84-year-old female patient with an asymptomatic 85 percent stenosis operated under regional anaesthesia. METHOD: Regional anaesthesia is performed through installation of a high cervical block under reclination of the head to the contralateral side. Then incision of the skin and the platysma along the front of the sternocleidomastoid muscle. Preparation of the carotid bifurcation with minimal manipulation as well as protection of the surrounding neural structures. Afterwards clamping of the vessels under permanent neurological monitoring and controlled hypertonia. Open thrombo-endarterectomy after longitudinal arterial incision with plaque removal en bloc and closure by using a bovine patch graft in four-point seam technique. This method should be preferred in cases with long-segment stenosis as well as in cases with a small lumen internal carotid artery. In the framework of eversion endarterectomy, we perform a tangential resection of the ACI on the bifurcation. The plaque cylinder is mobilised afterwards and is removed through eversion of the whole vessel. Then the reinsertion of the ACI in the bifurcation can be performed with an additional shortening of the artery in cases of kinking. In this way short- segment stenosis lend themselves to fast and safe treatment. In all cases digital subtraction angiography is recommended by the authors for intraoperative quality monitoring. CONCLUSION: In the hands of experienced vascular surgeons, the open carotid TEA including patch graft and the eversion endarterectomy under regional anaesthesia represent highly effective procedures for symptomatic/asymptomatic carotid stenosis. The S3-guidelines for the therapy of carotid artery stenosis will be published this year and should be consulted for the interdisciplinary therapy decision.

[Antithrombotic therapy after peripheral vascular treatment: what is evidence-based?]. / Antithrombotische Therapie nach peripheren Gefäßeingriffen. Was ist evidenzbasiert?

Peripheral arterial occlusive disease is one manifestation of the systemic disease atherosclerosis. The initial therapy for every arteriosclerotic disease is aimed at reducing cardiovascular risk factors by lifestyle modification and medication. Patients who require surgical revascularisation need long-term antiplatelet therapy or anticoagulation. This therapy has to be differentiated according to the vascular territory involved and the method used for revascularisation. After local thrombendarterectomy, alloplastic bypass graft surgery of the aortic, aorto-iliac, aorto-femoral or femoro-popliteal region above the knee, long-term ASA 100 mg/d or clopidogrel 75 mg/d should be initiated. After alloplastic bypass grafting below the knee the combination of ASA 100 mg/d and clopidogrel 75 mg/d should be used. In contrast, after venous grafts the patency rate is improved by anticoagulation with vitamin K antagonists (INR 2-3), if there is a low risk of bleeding. If there is a contraindication to vitamin K antagonists, ASA 100 mg/d should be used. After revascularisation, a structured surveillance programme should be implemented aiming at controlling cardiovascular risk factors and monitoring the vascular state, as well as the anticoagulation and the antiplatelet therapy.

Presence of Borrelia burgdorferi sensu lato antibodies in the serum of patients with abdominal aortic aneurysms.

Infectious agents are likely to play a role in the pathogenesis of chronic inflammatory diseases, including abdominal aortic aneurysms (AAAs). The goal of this study was to determine if Borrelia burgdorferi sensu lato (sl), a microorganism responsible for Lyme disease, is involved in the etiology of AAAs. The presence of serum antibodies against B. burgdorferi sl was measured with enzyme-linked immunosorbent assay (ELISA) and confirmed by Western blotting in 96 AAA and 108 peripheral artery disease (PAD) patients. Polymerase chain reaction (PCR) was used for the detection of Borrelia-specific DNA in the aneurysm wall. Among AAA patients 34% and among PAD patients 16% were seropositive for B. burgdorferi sl antibodies (Fisher's exact test, p = 0.003; odds ratio [OR] 2.79; 95% confidence interval [CI] 1.37-5.85). In the German general population, 3-17% are seropositive for Borrelia antibodies. No Borrelia DNA was detected in the aneurysm wall. Our findings suggest a relationship between AAAs and B. burgdorferi sl. We hypothesize that the underlying mechanism for B. burgdorferi sl in AAA formation is similar to that by the spirochete Treponema pallidum; alternatively, AAAs could develop due to induced autoimmunity via molecular mimicry due to similarities between some of the B. burgdorferi sl proteins and aortic proteins.

[Imaging diagnostics of osteitis, osteomyelitis and joint infections]. / Bildgebende Diagnostik bei Osteitis/Osteomyelitis und Gelenkinfekten.

Imaging diagnostics and surgical treatment of bone and joint infections are of paramount interest. The main purpose of our survey is to give a detailed overview about methods, indications, image criteria and efficiency of imaging diagnostics as a state of the art presentation. In conclusion we attempt to give some recommendations for clinical scenarios and diagnostic procedures concerning bone and joint infections. This paper has been prepared under the patronage of the AG Septische Chirurgie of the Deutsche Gesellschaft für Unfallchirurgie in Germany. It is our aim to update the paper with respect to the technical and clinical improvements and to publish it again after a number of years.

Rupture prone aneurysm of the inferior mesenteric artery complicated by mid aortic syndrome with occluded celiac and superior mesenteric arteries.

We present the case of a 45-year-old male patient with a large aneurysm of the inferior mesenteric artery complicated by mid aortic syndrome with occlusion of the celiac trunk and superior mesenteric artery. The vascular pathology was detected by CT imaging after presentation and hospitalization with symptoms of acute cholecystitis. After resolve of the acute symptoms, the aneurysm was resected and the proximal inferior mesenteric artery interponated with a reversed saphenous vein bypass graft. Besides presenting this case we review the literature concerning the rare descriptions of inferior mesenteric artery aneurysms.

Structured surveillance of patients with peripheral arterial occlusive disease after peripheral vascular interventions.

Longterm follow-up and surveillance after either an endovascular or an open surgical vascular intervention is an essential part of the angiologist's or vascular surgeon's care for patients with peripheral arterial disease. This includes diagnosis and treatment of cardiovascular risk factors, selection and monitoring of antiplatelet and/or anticoagulant therapy after revascularization, and surveillance of the results of the vascular intervention. This integrated approach to patients' care will improve patients' prognosis quoad vitam and quoad extremitatem and their quality of life. We summarize the rationale and evidence-based practical approaches and guidelines for structured long term surveillance of patients with peripheral arterial disease after a vascular intervention.

[Arterial injuries combined with open fractures--management and therapy]. / Arterielle Gefässverletzungen im Rahmen offener Frakturen--Management und Versorgung.

Vascular injuries are an uncommon finding. In times of peace vascular injuries occur in approximately 1-4 % during traffic accidents. Especially challenging is the treatment of open fractures combined with arterial lesions. These fractures are usually accompanied with severe soft tissue damage and injuries to neurological structures. The overall prognosis of these trauma patients is dependent on fast and sufficient diagnostics and therapy. In particular, for unstable patients time-consuming diagnostics can be dispensed and a primarily operative therapy should be targeted. Vascular reconstruction by direct suture is sometimes only possible with interposition and should be the primary goal. Interposition should be performed with autologous vein material because of the high risk of infection. Here we demonstrate on the basis of our patients the interdisciplinary -management of such trauma patients in our hospital.

Isolated aneurysm of the internal jugular vein.

True venous aneurysms are rare. We report the case of a 70-year-old male with the extremely uncommon finding of an aneurysm of the internal jugular vein. Due to their rarity, no general guidelines for the treatment of these aneurysms have been established. Upon surgical exclusion of the aneurysm, a progressive swelling of the right side of the face was noted in this patient leading to the decision to interpose a thin-walled ePTFE prosthesis for want of a suitable vein graft. Upon follow-up three years later, the patient is completely asymptomatic and the prosthesis is patent in Doppler sonography.

[Analysis of tissue inhibitor of metalloproteinase-2 gene polymorphisms in a caucasian population with abdominal aortic aneurysms]. / Analyse von Genvarianten des Gewebeinhibitors der Metalloproteinase-2 (TIMP-2) bei Patienten mit abdominalem Aortenaneurysma.

BACKGROUND: The formation of sporadic abdominal aortic aneurysm (AAA) is explained by a remodelling of the extracellular matrix (ECM) and breakdown of structural components of the vascular wall. Matrix metalloproteinases are the principle matrix-degrading proteases and are known to play a major role in the remodelling of the extracellular matrix in arterial vessels. Their activity is controlled by tissue inhibitors of metalloproteinases (TIMPs). Decreased TIMP-1 and TIMP-2 expression in the extracellular matrix of the walls of AAAs has been demonstrated in several studies. This case-control study was designed to investigate the possible impact of genetic variants of the TIMP-2 gene in the aetiology of AAA and to reproduce a recently described significant difference in allele frequency of the SNP 303G>A in a German population. METHODS: TIMP-2 single nucleotide polymorphisms (SNPs) were analysed in a study sample of 50 patients with AAA and 41 controls. Differences in genotype and allele frequencies of the identified polymorphisms were determined after sequencing the entire coding region and selected parts of the promoter using the automated laser fluorescence technique. RESULTS: Six polymorphisms were identified, one of which is described for the first time, located in the intron, (231+23C>T). An association of the SNP 303G>A with the phenotype was not confirmed in our study (p=0.648). However, the CT genotype of the SNP -479C>T was more frequent in patients with AAA than in the control group (p=0.054). CONCLUSIONS: In our analysis of the TIMP-2 gene, we identified one new SNP. A previously published association of the SNP 303G>A with the phenotype could not be validated in our population. However, we detected an association for the CT genotype of one polymorphism in the promoter region (g-479C>T) and AAA. This result has to be proved in a second study sample.

[Misleading anisocoria in a comatose 15-year-old with head injury]. / Irreführende Anisokorie bei komatöser 15-Jähriger mit Kopfverletzung.

Anisocoria after blunt head trauma, associated with altered vigilance, is not unusually assumed to expanding intracranial mass lesion. Obvious signs of head-trauma and vomiting might strengthen this diagnosis. We report from an unconscious 15-year-old girl (Glasgow-Coma-Scale score 3) that showed these symptoms secondary after head-trauma due to alcohol intoxication but turned out to be misleading after cranial computed tomography (CT). Surprisingly, an artificial eye was found that previously remained undetected in clinical examination. Artificial eyes implemented after enucleation therapy in retinoblastoma or eye-trauma are nowadays perfectly fitting. Prehospital discrimination of artificial eyes and natural eyes might be difficult in comatose emergency patients. Neurological examination should check corneal reflex and manual palpation of the bulbus. Independent from anisocoria, patients presenting GCS 3 and head injury need rapid admission to CT-diagnostic, neurosurgical treatment respectively.

[Vascular recanalization techniques: renal artery stenoses]. / Vaskuläre Rekanalisationstechniken: Nierenarterienstenosen.

Decisive for the evaluation for radiological interventional therapy of renal artery stenosis, are the morphologic diagnostic by Duplex sonography, non-invasive cross-sectional angiography and digital subtraction angiography in addition to the anamnesis and clinical constellation. A standardized diagnostic algorithm and an evidence-based indication status contribute just as importantly to improvement of outcome as the implementation of uniform peri-interventional measures and a structured procedure for angiography, percutaneous transluminal renoangioplasty and follow-up. The aim of this article is to provide a practical introduction for the current radiological management of renal artery stenosis.

Neurodegenerative diseases of the retina and potential for protection and recovery.

Recent advances in our understanding of the mechanisms in the cascade of events resulting in retinal cell death in ocular pathologies like glaucoma, diabetic retinopathy and age-related macular degeneration led to the common descriptive term of neurodegenerative diseases of the retina. The final common pathophysiologic pathway of these diseases includes a particular form of metabolic stress, resulting in an insufficient supply of nutrients to the respective target structures (optic nerve head, retina). During metabolic stress, glutamate is released initiating the death of neurones containing ionotropic glutamate (N-methyl-D-aspartat, NMDA) receptors present on ganglion cells and a specific type of amacrine cells. Experimental studies demonstrate that several drugs reduce or prevent the death of retinal neurones deficient of nutrients. These agents generally block NMDA receptors to prevent the action of glutamate or halt the subsequent pathophysiologic cycle resulting in cell death. The major causes for cell death following activation of NMDA receptors are the influx of calcium and sodium into cells, the generation of free radicals linked to the formation of advanced glycation endproducts (AGEs) and/or advanced lipoxidation endproducts (ALEs) as well as defects in the mitochondrial respiratory chain. Substances preventing these cytotoxic events are considered to be potentially neuroprotective.

[Ventral fusion of a fracture of the cervical spine in ankylosing spondylitis and struma permagna]. / Ventrale Versorgung einer Fraktur der Halswirbelsäule bei Morbus Bechterew und Struma permagna.

Fractures of the cervical spine in ankylosing spondylitis are rare. The rate of neurological complications is increased compared to fractures of the normal spine. Concerning its mechanical characteristics the ankylosing spine is similar to a long bone. Because of the deformity and the stiffness of the spine conventional orthoses do not provide enough stability and individualized techniques are necessary to perform safe rescue and transport. Because of severe instability an operation is indicated in most cases. The most stable fixation is the combined ventral and dorsal fusion. The dorsal approach is associated with an increased rate of complications, so we favour primary ventral fusion with long interlocking plates. This can be done even in difficult anatomic situations. If the screws can be tightened well, additional dorsal fusion is not necessary.

Contrast-enhanced ultrasonography to detect liver metastases : a prospective trial to compare transcutaneous unenhanced and contrast-enhanced ultrasonography in patients undergoing laparotomy.

BACKGROUND/AIMS: The advent of contrast-enhanced ultrasound (CEUS) has called into question the efficacy of standard ultrasonographic techniques. In this study, we evaluated B-mode and color-duplex imaging and CEUS in the detection of liver metastases, using intraoperative and histological findings as a reference. MATERIALS AND METHODS: Before laparotomy, 108 patients suspected of having liver metastases were prospectively examined with B-mode and color-duplex imaging, followed by contrast-enhanced ultrasound (2.4 ml SonoVue). Patients with unresectable tumors (n=8) were excluded from the analysis. The sonographic diagnosis in the remaining 100 patients was compared to the intraoperative and histological findings. RESULTS/FINDINGS: CEUS improved the sensitivity for detecting liver lesions from 56.3% (B-mode) to 83.8% (CEUS) (p=0.004). In particular, the contrast agent led to an improvement in ultrasonographic detection in the following cases: nodular metastases smaller than one centimeter; after adjuvant chemotherapy; for tumors near the surface of the liver; and for lesions situated around the ligamentum teres. INTERPRETATION/CONCLUSIONS: CEUS provides significant improvement in the detection of liver metastases, and should therefore, be performed routinely in the surveillance of cancer patients.

Matrix metalloproteinase 2 polymorphisms in a caucasian population with abdominal aortic aneurysm.

BACKGROUND: The formation of sporadic abdominal aortic aneurysm (AAA) is explained by remodeling of the extracellular matrix (ECM) and breakdown of structural components of the vascular wall. Matrix metalloproteinase 2 (MMP2) is one of the principal matrix-degrading proteases and is known to play a major role in the remodeling of the extracellular matrix in arterial vessels. Increased MMP2 expression in the extracellular matrix of the walls of AAAs has been shown in several studies. To investigate the possible impact of genetic variants of the MMP2 gene in the etiology of AAA, we conducted this case-control study. PATIENTS AND METHODS: We analyzed MMP2 single-nucleotide polymorphisms (SNPs) in 51 patients with AAA and 48 controls. Differences in genotype and allele frequencies of identified polymorphisms were determined after sequencing the entire coding region and three selected parts of the promoter. RESULTS: Eighteen polymorphisms were identified, 6 of which are newly described, with 3 located in the introns (c.IVS1+31C>G, c.IVS7-18G>A, c.IVS10+26C>T) and 3 located in the coding region (c.124G>A, c.1368C>T, c.1860C>T). There were no statistically significant differences in genotype or allele frequencies between the two groups. CONCLUSIONS: Our analysis of the entire coding region and three parts of the promoter of the MMP2 gene failed to show an association between genetic polymorphisms and AAA, suggesting that variations in the MMP2 gene do not contribute to the development of AAA.

[Therapeutic options in the treatment of pyogenic liver abscess]. / Ultraschall-, CT-gesteuerte und operative Therapie bei pyogenen Leberabszessen.

BACKGROUND/AIMS: Pyogenic liver abscess is a rare and life-threatening disease. Our aim is to discuss the aetiology and problems of diagnosis and treatment of this disease, based on our own clinical experience. We present and compare different therapeutic options, i. e. ultrasound-guided percutaneous abscess drainage, CT-guided drainage and open surgical drainage. PATIENTS/METHODS: In a time period of 8 years, 62 patients with pyogenic liver abscesses were treated. The therapeutic procedure used most frequently was ultrasound-guided percutaneous abscess drainage in 41 patients, followed by CT-guided drainage in 13 cases. 8 patients were primarily treated with surgical drainage or liver resection, respectively. RESULTS: With an overall mortality of 9.6 % we achieved an encouraging result. The comparison of mortality between groups treated with ultrasound-guided percutaneous abscess drainage (7.3 %) and CT-guided drainage (7.7 %) revealed no significant prognostic difference. The comparison of local complications and drainage failure between ultrasound-guided percutaneous abscess drainage (2.4 %) and CT-guided drainage (15.4 %), however, showed better results for the ultrasound-guided interventions (1/41 vs. 2/13 patients). Two patients undergoing open surgical drainage died due to an advanced septic shock syndrome. CONCLUSIONS: Our study suggests that ultrasound duplex imaging with percutaneous abscess drainage is a reliable and effective approach for the treatment of pyogenic liver abscess. Based on other studies in the literature and our own results we developed a diagnostic and therapeutic algorithm for the treatment of liver abscesses.

Quality of life and long-term results after ruptured abdominal aortic aneurysm.

OBJECTIVES: Quality of life as an endpoint of surgery and the long-term prognosis for patients who have survived surgery for a ruptured abdominal aortic aneurysm (RAAA) is not well-documented. PATIENTS AND METHODS: The records of all patients from 1993 to 2000 who underwent resection of RAAA were reviewed. Survival data were calculated from direct contact with the patients or follow-up records. All patients who were alive at the time of our study were invited to participate in follow-up investigations. They received the internationally comparable WHO-QOL-BREF-test. RESULTS: In a period of 7 years, 80 patients underwent surgery for RAAA. The average follow-up time was 5.1 years (1-7.9 years). Our data show that 51% of our patients died within 6 months postoperatively because of the complications of the aortic rupture (in-hospital mortality 39%). Patients who survived the first 6 months after surgery died for the same reasons as the normal population. However, patients who were younger than 75 at the time of RAAA had a higher relative survival rate than a matched sample of the population. There was no significant difference in the quality of life between the study group and the general population. CONCLUSIONS: RAAA survivors had no difference in long-term survival as compared to the general population and also had very few long-term complications. The WHOQOL-BREF-test suggests that the quality of life of survivors of RAAA is similar to the general population.

Prevalence and treatment of bleeding complications in chronic pancreatitis.

OBJECTIVES: As spontaneous major haemorrhage in patients with chronic pancreatitis is rare, limited data have been reported, and no evidence-based guidelines are currently available regarding the optimal treatment modality. PATIENTS AND METHODS: We report our experience with 36 patients with severe bleeding complications from a series of 541 patients presenting with chronic pancreatitis (representing a prevalence of 6.7% of admitted patients), treated in one surgical department over a period of 9.5 years, with a median follow-up of 4.1 years. RESULTS: Haemorrhage was indirectly related to chronic pancreatitis in eight patients (22.2%) with ulcer or variceal bleeding. Three patients (8.4%) demonstrated spleen infarction or rupture. The most common causes of major haemorrhage were pseudoaneurysms in 25 patients (69.4%). Nine of them were treated with primary embolization. Sixteen patients with pseudoaneurysms underwent surgery. The only mortalities (8.3%) observed were from bleeding-associated complications of pseudoaneurysms. Two patients died after surgery, and one after primary embolization. We observed a higher re-bleeding rate after surgery (25% vs 11% after embolization). The presence of haemorrhagic shock, and the amount of blood transfused, were significant determinants of hospital mortality. Patient age, pseudoaneurysm location, and treatment modality had no significant influence on mortality. CONCLUSIONS: Any haemodynamically stable patient with haemorrhage due to arterial pseudoaneurysms should undergo angiography with embolization when technically possible. If there are no other pancreas-related indications for surgery, embolization remains the definitive treatment. If embolization is not available or has failed, surgery is indicated, although perioperative morbidity will be higher.

[The dermatologic consultation]. / Das dermatologische Konsil.

BACKGROUND: Dermatology and venereology, as a cross-sectional discipline, plays an important role in the interdisciplinary care of inpatients. Nonetheless, only a few studies on dermatological consultations have been performed. We reviewed the dermatological consulting service at the University Hospital of the Martin-Luther-University, Halle, Germany. PATIENTS AND METHODS: All consultations performed in 2001 and 2002 were retrospectively assessed. In addition, the time spent in consulting activities was prospectively recorded over a period of six months (January-June 2003). RESULTS: A total of 2390 consultations were evaluated. Most of the consultations (42.8%) were made on internal medicine wards, followed by pediatrics (11.7%), neurology (9.9%) and cardiothoracic surgery (5.7%). Infectious skin diseases accounted for the most frequent diagnosis at 24.4%. The time lapse between request and performance of the consultation averaged 1.1 days. Patients older than 40 years needed dermatological consultation more frequently than younger patients. The duration of consultation averaged 23 minutes (time to site, patient examination, documentation). Thus, the man-hours required for the consulting service is 33.6 per month. CONCLUSION: The study emphasizes that dermatological consultation services make an important contribution to the care of inpatients. In light of increasing specialization in medicine, the consulting service guarantees interdisciplinary treatment of the patients and is thus an important quality parameter for inpatient care.