Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta--7 years' experience.

OBJECTIVES: To present a single centers' 7-year experience in the endovascular treatment of acute traumatic lesions of the descending thoracic aorta (ATL of the DTA). MATERIALS & METHODS: Between March 1999 and December 2006, 34 consecutive acute traumatic lesions of the descending aorta (23 men, mean age 44 years) were treated endovascularly. Stentgrafts used were TAG Excluder, Zenith TX2 and Talent. In 23 patients the Left Subclavian Artery (LSA) was covered. Mean procedural duration was 20 to 75 minutes. RESULTS: Exclusion of the rupture site was achieved in all cases with no conversion to open surgery. Overall 30-day mortality was 8.8%. Two patients died on post operative day (pod) 1 and one on pod 22 from cranial injuries. No death or neurological deficit related to the endovascular treatment was reported. Four type I endoleaks required treatment either by balloon reexpansion (n=2) or by additional stentgraft implantation (n=2). In two patients the stentgraft collapsed totally several days postoperatively. Two patients required secondary surgical procedures (iliac access complication and revascularisation of the left subclavian artery n=1). The average follow-up was 43.8 months (1-93 months). No stentgraft related abnormality has been subsequently documented. CONCLUSIONS: The endovascular treatment of ATL of the DTA may offer the best means of therapy in a polytrauma patient.

Improved non-invasive T-Staging in non-small cell lung cancer by integrated 18F-FDG PET/CT.

AIM: In this prospective study, reliability of integrated (18)F-FDG PET/CT for staging of NSCLC was evaluated and compared to MDCT or PET alone. PATIENTS, METHODS: 240 patients (pts) with suspected NSCLC were examined using PET/CT. Of those patients 112 underwent surgery comprising 80 patients with NSCLC (T1 n = 26, T2 n = 37, T3 n = 11, T4 n = 6). Imaging modalities were evaluated independently. RESULTS: MDCT, PET and PET/CT diagnosed the correct T-stage in 40/80 pts (50%; CI: 0.39-0.61), 40/80 pts (50%; CI: 0.39-0.61) and 51/80 pts (64%; CI: 0.52-0.74), respectively, whereas equivocal T-stage was found in 15/80 pts (19%; CI: 0.11-0.19), 12/80 pts (15%; CI: 0.08-0.25) and 4/80 pts (5%; CI: 0.01-0.12), respectively. With PET/CT, T-stage was more frequently correct compared to MDCT (p = 0.003) or PET (p = 0.019). Pooling stages T1/T2, T-stage was correctly diagnosed with MDCT, PET and PET/CT in 54/80 pts (68%; CI: 0.56-0.78), 56/80 pts (70%; CI: 0.59-0.80) and 65/80 pts (81%; CI: 0.71-0.89). T3 stage was most difficult to diagnose. T3 tumors were correctly diagnosed with MDCT in 2/11 pts (18%; CI: 0.02-0.52) versus 0/11 pts (0%; CI: 0.00-0.28) with PET and 5/11 pts (45%; CI: 0.17-0.77) with PET/CT. In all imaging modalities, there were no equivocal findings for T4 tumors. Of these, MDCT found the correct tumor stage in 4/6 pts (67%; CI: 0.22-0.95), PET in 3/6 pts (50%; CI: 0.12-0.88) and PET/CT in 5/6 pts (83%; CI: 0.36-0.99). CONCLUSION: Integrated PET/CT was significantly more accurate for T-staging of NSCLC compared to MDCT or PET alone. The advantages of PET/CT are especially pronounced combining T1- and T2-stage as well as in advanced tumors.

[Thoracic, abdominal, and pelvic vascular injuries]. / Gefässverletzungen im Thorax, Abdomen und Becken.

This paper reviews the surgical management of vascular injuries. Precise clinical and ultrasound evaluation is mandatory during the first steps of emergency treatment. For further documentation of the extent and site of arterial injuries in hemodynamically stable patients, computed tomography and angiography are crucial in differential diagnosis. Especially during the acute phase, the latter is indicated for evaluating the interventional therapy. The key to successful treatment of vascular injuries is immediate surgical control of hemorrhaging vessels.

Lymph node staging in lung cancer using [18F]FDG-PET.

BACKGROUND: Mediastinal lymph node staging is essential to determine treatment options in patients with NSCLC. Positron emission tomography (PET) detects increased glucose uptake in malignant tissue using the glucose analogue 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG). PATIENTS AND METHODS: In the present study were evaluated 155 patients with focal pulmonary tumors who underwent both preoperative computed tomography (CT) and FDG-PET scanning (116 malignant and 39 benign lesions). RESULTS: Findings in 155 patients included 116 malignant and 39 benign lesions. For N-staging, FDG-PET showed a sensitivity of 88%, a specificity of 91%, and an accuracy of 89%. Corresponding figures for CT were 77%, 76%, and 77%, respectively. CONCLUSIONS: FDG-PET is an effective, noninvasive method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to operability, FDG-PET could differentiate reliable between patients with N1/N2 disease and those with unresectable N3 disease.

[18F] 3-deoxy-3'-fluorothymidine positron emission tomography: alternative or diagnostic adjunct to 2-[18f]-fluoro-2-deoxy-D-glucose positron emission tomography in the workup of suspicious central focal lesions?

BACKGROUND: 2-[(18)F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography has been established as a standard diagnostic imaging method in the preoperative workup of suspicious pulmonary focal lesions, showing a sensitivity of more than 90% and a specificity of about 80%. Determination of malignant pulmonary lesions with FDG positron emission tomography depends on the assessment of glucose metabolism. However, false-positive findings can occur in inflammatory processes, such as sarcoidosis or pneumonia. The thymidine analogue 3-deoxy-3[(18)F]-fluorothymidine (FLT) is a new positron emission tomography tracer that more specifically targets proliferative activity of malignant lesions. The objective of this study was to determine whether FLT positron emission tomography, in comparison with FDG positron emission tomography, provides additional information in the preoperative workup of central pulmonary focal lesions. METHODS: In this prospective study FLT and FDG positron emission tomography examinations were performed as a part of the preoperative workup in 20 patients with histologically confirmed bronchial carcinoma, 7 patients with benign lesions, and 1 patient with an atypical carcinoid. Results were compared with final pathologic findings. RESULTS: For staging of the primary tumor, FLT positron emission tomography revealed a sensitivity of 86% and a specificity of 100% compared with a sensitivity of 95% and a specificity of 73% for FDG positron emission tomography. For N staging, the sensitivity of FLT positron emission tomography was 57% and the specificity was 100%, and for FDG positron emission tomography, the sensitivity was 86% and the specificity was 100%, respectively. CONCLUSIONS: Our preliminary findings indicate specific FLT uptake in malignant lesions. The number of false-positive findings in FDG positron emission tomography might be reduced with FLT positron emission tomography. Therefore positron emission tomography imaging with FLT represents a useful supplement to FDG in assessing the malignancy of central pulmonary focal lesions.

[Clinical pathways -- intervention or surgery for acute ischemia of the extremities]. / Die akute Extremitätenischämie. Clinical pathways-wann operieren, wann interventionell behandeln.

There is still controversial discussion concerning the therapy of limb-threatening ischaemia. In a retrospective study, we investigated and compared surgical and percutaneous interventional methods in the treatment of both embolic and thrombotic vascular occlusions in patients with pre-existing arteriosclerotic disease and attempted to propose therapy guidelines for these methods in the therapy of acute limb ischaemia. Percutaneous mechanical thrombectomy represents a viable therapeutic alternative to surgical or surgical-interventional modalities, particularly in patients with occlusions consisting of soft, embolic material or located in infrapopliteal vessels. The indication for each respective method should be interdisciplinary and must be based on the individual patients' clinical and angiographic findings. Additional intraoperative endovascular procedures increase the range of therapeutic options and permit optimal revascularisation of vessels both proximal and distal to the site of occlusion.

Vacuum-sealed mesh graft transplantation in chronic cutaneous ulcers of the lower leg.

BACKGROUND: The covering of defects caused by chronic ulcers on limbs affected by peripheral arterial disease or chronic venous insufficiency is often difficult due to extensive secretion and edema, while chronic bacterial contamination of the wound bed further compromises the conditions for successful healing. PATIENTS AND METHODS: Vacuum-sealed dressing (VSD) offers the option of a closed dressing system for moist wound care that assures firm contact with the wound surface and protection against contamination with nosocomial microbes and decontamination of existing bacteria by means of constant drainage of secretion independent of gravity. VSD is particularly useful in difficult wounds featuring extensive secretion and unfavorable localization and offers many advantages over conventional dressing techniques in terms of improved healing of skin transplants. A total of 35 patients with chronic leg ulcers were treated with vacuum-sealed mesh graft transplantation. RESULTS: Complete healing of the mesh graft transplant was observed in 20 patients (57%). Twelve patients (34%) experienced partial healing (75-90%) of the transplant, while three patients exhibited less than 75% healing of the graft and therefore required a second mesh graft transplantation. CONCLUSIONS: VSD is a simple, quick and inexpensive technique that promotes excellent healing of skin transplants. It is particularly useful in difficult wounds with extensive secretion and/or contamination or infection.

Intraoperative, perioperative and late complications with endovascular therapy of aortic aneurysm.

PURPOSE: To describe the incidence and management of the intraoperative, perioperative and late complications of endovascular aortic aneurysm repair. METHODS: Endovascular aneurysm repair was attempted in 130 patients between October, 1995 and January, 2000. Follow-up including computed tomography (CT) was performed in the immediate postoperative period and then at 3, 6, 9 and 12 months and biannually thereafter. The median follow-up period was 20 months. RESULTS: Intra- and perioperative problems occurred in 26 patients (20%). Conversion to open surgery was required in five cases (4%). The primary technical success rate was 86%. Three patients (2%) died within the first 30 postoperative days. Late problems occurred in 28 patients (26%). These included: endoleaks (type I: 5%; type II: 10%; type III: 1%) and limb occlusion (3%). The cumulative rate of freedom from secondary intervention was in the first 65 patients treated: 86% and 65% after 1 and 3 years, respectively, and in the last 65 patients: 90% at 1 year. CONCLUSIONS: Endovascular aneurysm repair is associated with a higher complication rate than open surgery.

Influence of treatment of type II leaks on the aneurysm surface area.

OBJECTIVE: to determine whether interventional treatment of type II endoleaks leads to a decrease in aneurysm surface area. MATERIAL AND METHOD: type II endoleaks were detected in a group of 14 male patients (median age: 70.2 years) following endovascular repair of a total number of 160 infrarenal aneurysms of the abdominal aorta. The surface area of the aneurysm was determined by computed tomography (CT) pre- and postoperatively and at subsequent follow-up examinations. If type II endoleaks were documented at CT, patients underwent treatment by means of coil embolisation. RESULTS: interventional treatment resulted in successful occlusion of type II endoleaks in eight patients. One of the cases exhibited spontaneous occlusion. Occlusion was associated with an average decrease in aneurysm surface area of 3.3 cm(2)( p =0.01). In one of these patients, treatment resulted in a temporary occlusion of the endoleak, also with associated decrease in aneurysm size. After recurrence of the type II endoleak, however, the patient experienced an increase in aneurysm surface area. In the remaining four patients the type II endoleaks persisted, resulting in a non significant increase in aneurysm surface area. CONCLUSION: only complete occlusion of endoleaks results in decrease in the size of the aneurysm sac. Because of endotension and the risk of rupture we favour an early interventional treatment of type II endoleaks.

[Chances in surgical treatment of bronchial carcinoma under palliative conditions]. / Chancen der operativen Therapie des Bronchialkarzinoms bei palliativer Indikation.

UNLABELLED: Palliative surgery aims at symptomatic relief in patients in whom curative therapy seems not feasible. When diagnostic imaging techniques describe advanced stage IIIa, IIIb or IV malignancy, despite of palliative intention curative resection may still be possible. Objective of the present study was to investigate lung cancer patients undergoing surgery with palliative intent and to compare their prognosis with patients whose tumor resection had been complete (R0) or incomplete (R1/R2). PATIENTS AND METHOD: Patients were assigned to one of the three groups on the basis of the following criteria: palliative intention with subsequent complete resection (group I, n = 11); curative intention with subsequent incomplete resection (group II, n = 38), palliative intention with incomplete resection (group III, n = 23). Additionally 3 patients were operated on by explorative thoracotomy. A total number of 75 patients was therefore investigated. Median follow-up period was 34.5 months. Survival rates were calculated using the Kaplan-Meier method. RESULTS: The following procedures involving resection of pulmonary tissue were performed: pneumonectomy (n = 10), extended pneumonectomy (n = 32), lobectomy (n = 5), extended lobectomy (n = 11), sleeve lobectomy (n = 7), bilobectomy (n = 3), extended bilobectomy (n = 4). The 30 days hospital mortality rate was 13%. Median survival times were 25.5 months in group I, 12.8 months in group II and 7.7 months in group III (statistical significance: group I vs. group II/III, p < 0.05). CONCLUSIONS: Results of the present study show that patients with bronchial carcinoma in advanced tumor stages III and IV may still benefit from pulmonary resection, particularly when reduction of their somatic complaints is considered. In 11 patients, R0 resection was feasible leading to a statistically significant prolongation of their survival rates.

Endograft treatment of anastomotic aneurysms following conventional open surgery for infrarenal aortic aneurysms.

OBJECTIVE: to evaluate the use of endograft therapy for treating anastomotic aneurysm following open surgical repair of infrarenal aneurysms of the abdominal aorta. METHODS: four male patients (age 47-75 years) at high surgical risk (ASA IV n=3, ASA III n=1) developed secondary aneurysms at the site of the central (four aneurysms) and additional peripheral (two aneurysms) anastomosis of their tube or bifurcation prosthesis an average of 13 years (range 1-23 years) after conventional open surgical correction of infrarenal aneurysm of the abdominal aorta. In two patients, there was covered rupture of the aneurysm sac. The aneurysm diameter was 4.8 cm, 8.0 cm, 7.4 cm, 7.0 cm, respectively (mean 6.8 cm). Follow-up included helical CT imaging at 1 week, 3 months and 6 months postoperatively. RESULTS: anastomotic aneurysm was successfully treated in all four cases. No evidence of endoleak was observed during the follow-up period. Two patients died 14 and 18 days after surgery due to myocardial infarction and cerebrovascular accident. The endovascular repair of the two patients who died was intact. CONCLUSION: although no long-term results are available, the use of a graft-in-graft method to repair anastomotic aneurysms following conventional implantation of tube or bifurcation prostheses appears to be effective, particularly in patients at high surgical risk.

FDG positron emission tomography in the diagnosis of peripheral pulmonary focal lesions.

Positron emission tomography (PET) using fluoride-18-marked fluoride deoxyglucose (FDG) represents a metabolically based imaging technique capable of providing information on the potential malignancy of peripheral pulmonary focal lesions. In the present prospective study, we investigated the effectiveness of FDG-PET in determining the dignities of 67 such lesions in 35 patients. Findings of FDG-PET were compared with those of computed tomography (CT), as well as with surgical and histological reports, and the value of FDG-PET as a diagnostic method evaluated. FDG-PET correctly identified 38 lesions as positive for malignancy, 18 correctly as negative, 7 incorrectly as negative, and 4 incorrectly as positive. Based on lesions, this yields a sensitivity of 84.4% and a specificity of 81.8%. All malignant focal lesions with a diameter of over 1.2 cm were correctly identified (sensitivity: 100%). In cases of intense FDG uptake, differentiation between a primary lesion, a metastasis, and an acute inflammation is often not possible.

How useful is positron emission tomography for lymphnode staging in non-small-cell lung cancer?

UNLABELLED: The introduction of positron emission tomography (PET) raises the question of the new method's capabilities in the staging of mediastinal lymphnodes, since PET differentiates between metabolically active and inactive tissues. 80 patients with histologically confirmed non-small-cell lung cancer (NSCLC) underwent PET scanning with 18-F-marked fluorodeoxyglucose (FDG). Extensive dissection of mediastinal lymphnodes (18-28 lymphnodes recovered) was performed in 78 cases. Metastasis to mediastinal lymphnodes were observed in 25 patients (N2: 22; N3: 3). RESULTS: Primary Tumor: FDG-PET showed significant enhancement of the primary tumor in 78 of 80 patients (sensitivity: 97%). Lymphnode Involvement: FDG-PET was positive in 23 of 25 patients with surgically confirmed lymphnode involvement (sensitivity: 92%). After a median follow up interval of 18 months, 11 patients with false positive lymphnode uptake were still alive; 10 of them showed no tumor recurrency. On the basis of these findings, enlarged mediastinal lymphnodes visualized at CT, but negative at FDG-PET are free of metastatic involvement with a sensitivity of 92%. FDG uptake of mediastinal lymphnodes at PET, however, should not be interpreted as proof of malignancy.

Comparison of virtual and fiberoptic bronchoscopy.

Preoperative diagnostic procedures in the treatment of non-small-cell lung carcinoma (NSCLC) include fiberbronchoscopy (FBS) and CT scanning of the thorax and abdomen. The introduction of double-detector helical computed tomography has led to improved image resolution which allows three-dimensional reconstruction of the bronchial tree. A special computer simulation provides a virtual endoscopic view into the inner surface of the bronchial system. In order to determine whether the so-called virtual bronchoscopy (VBS) accurately reflects the anatomic situation of the bronchial tree, neoplastic lesion, and postoperative control of sleeve resections, we performed a virtual bronchoscopy in 24 patients with NSCLC and in 6 patients following sleeve resections and compared the results with the findings of fiberoptic bronchoscopy. An anatomic computer simulation of the bronchial tree was created in 100% of the investigated patients. Central tumor stenosis or occlusion was visualized by VBS as well as by FBS. In peripheral tumorous lesions VBS revealed the correct diagnosis in only 75%. VBS, however, enables viewing beyond the stenosis. FBS remains the gold standard in the endoscopic diagnostic procedures, showing not only airway patency but also mucosal changes in the vicinity of the tumorous lesion. VBS, however, gives further information about the poststenotic area in occlusive main bronchus stenosis. Furthermore, adequate control investigation of airway patency in patients following sleeve resections or stent implantation can be performed by VBS.

[Paraganglioma of the carotid bifurcation. Diagnostic and therapeutic strategy]. / Das Paragangliom der Carotisgabel. Diagnostische und therapeutische Strategie.

The carotid body tumors are semimalignant tumors. According to our results, the best diagnostic procedure is a combination of Doppler color flow imaging ultrasound, computed tomography and selective angiography. In our opinion, the treatment of choice is radical resection of the tumor with the carotid bifurcation, especially to reduce recurrence of the tumor. Considering the problems in recurrent tumors, consequent monitoring of the patients is necessary.