[Considerations about the endovascular treatment of infrarenal aortic aneurysms]. / Consideratii privind tratamentului endovascular al anevrismelor aortice infrarenale.

The introduction of the endovascular repair of aortic aneurysm (EVAR) in the clinical practice by Parodi was a milestone in the development of aortic surgery. This minimal invasive procedure promised a significant lower postoperative mortality and complications rate. Despite numerous controversies, the endovascular technique was wide accepted and fast implemented in the clinical practice. But the first prospective randomized trials showed that the benefit of the patients was limited and this innovative approach leads to particular postoperative problems. Due to a continuous improvement of the endovascular devices and increasing experience in endovascular treatment a lot of early problems have been resolved. The new generation of endografts makes possible the endovascular approach of aneurysm with shorter or angulated proximal neck. However, the anatomical suitability is still the most important limited factor of the endovascular treatment. An accurate analysis of suitability, the proper choice of the device and correct implantation allows good postoperative results. The significance of specific complications must be recognized in order to make the right surgical decision.

[Aneurysm treatment with the "Talent stent graft". An update after 4 years of experience]. / Die Aneurysmabehandlung mit dem "Talent-Stentgraft". Eine Bilanz nach 4-jähriger Erfahrung.

INTRODUCTION: The negative experience with stent grafts of the first generation shows the important role of the endograft in the treatment of abdominal aortic aneurysm. The midterm results of a stent graft (Talent) widely used in Germany were analyzed up to 4 years after the first implantation. PATIENTS AND METHODS: We report on 73 patients treated at our department using the Talent stent graft. The study analyzes patient data before, during, and after the operation as well as the results of clinical follow-up and CT scan examinations performed 3-47 months after treatment. RESULTS: In 72 cases the implantation was successful. Endoleaks were found in three cases (type I n = 2, type III n = 1). Three patients had a complication at the vascular access site (3.9%). In one patient the short contralateral leg did not open. During the follow-up five patients died (7%). In two patients the graft limb occluded (3.3%). A migration of the graft components did not occur. In two cases a persistent type II endoleak was found (3.3%). CONCLUSIONS: The Talent stent graft showed good stability and easy adjustment. Even patients with a large aneurysm neck have been successfully treated. Problems while implanting the graft were only observed in cases of kinking of the iliac artery. A greater flexibility of the introducer system and a better rotational stability of the graft inside the introducer would be advisable.

[First experiences with clinical pathways in carotid surgery]. / Erste Erfahrungen mit klinischen Ablaufpfaden am Beispiel der Carotischirurgie.

The introduction of guidelines for carotid surgery into praxis. Early experiences with the clinical pathway. With the use of DRG's for reimbursements, a new organization of clinical pathways may play an increasingly important role in the delivery of health care. The impact of clinical pathways as a management tool in the treatment of patients with carotid occlusive disease was studied. Representatives of all involved disciplines identified in which sequence, where, when, by whom and which care a patient with carotid disease should receive. The individual steps of care were analysed, estimating their utility and determining a new plan for a patient's care. The clinical pathway specifies a target time window, defining exactly the internal and external logistics. The early experiences demonstrate that clinical pathways can be a useful tool for improving the quality of health care by improving cost and process transparency. Hospital length of stay was reduced by 2.3 days.

[Treatment of aortic aneurysm with a complete percutaneous technique]. / Aortenaneurysmabehandlung mit komplett perkutaner Technik - Eine Zwischenbilanz nach Behandlung von 80 Patienten -

BACKGROUND AND OBJECTIVE: The treatment of aortic aneurysms is achievable also without laparotomy. With a special technique it is now possible to perform the endovascular aneurysm repair totally percutaneous using an endovascular suture device. With the purpose to reduce the invasiveness of the treatment of abdominal aneurysms, the new technique was used also during procedures requiring large bore devices up to 14-27F. The aim of this retrospective study was to report on results after performing the new technique in 80 patients and on the benefits and limits of its use. PATIENTS AND METHODS: From 1.10.1999 to 31.12.2001, 102 patients with aneurysm disease were treated by endovascular techniques. In 80 cases (68 men, 12 women; mean age 71.3 years) a completely percutaneous procedure was planned. The diameter of the introducer sheaths was 18-27F for the main body of the stent-graft and 14-18F for the contralateral limb. Most patients were operated under spinal anesthesia. Postoperative control included complete physical examination and duplex ultrasound scans. RESULTS: In 5 of 80 cases the implantation of the endograft could not be performed percutaneously. In 5 of 145 femoral arteries (3.4 %) effective hemostasis could not be achieved. Complications requiring surgery (two pseudoaneurysms, two arterial occlusions) occurred in 4 cases (2.8 %). By duplex ultrasound normal findings were detected in the remaining 136 cases (93,8 %). In 68 of 80 treated patients (85 %) complete percutaneous technique was successful. CONCLUSIONS: Using the preclose-technique it was possible to suture the artery even after using large bore introducer sheaths without cut down. Patient selection, exact puncture technique and accurate use of the device are important factors for success. The technological improvement of the arterial closure devices will allow a more frequent use of the percutaneous technique for aneurysm repair in the future.

Resistin / Fizz3 expression in relation to obesity and peroxisome proliferator-activated receptor-gamma action in humans.

Recent studies in murine models suggest that resistin (also called Fizz3 [1]), a novel cysteine-rich protein secreted by adipocytes, may represent the long-sought link between obesity and insulin resistance (2). Furthermore, peroxisome proliferator-activated receptor-gamma (PPAR-gamma) agonists appear to inhibit resistin expression in murine adipocytes, providing a possible explanation for the mode of action of this class of insulin sensitizers (2). Using a fluorescent real-time reverse transcriptase-polymerase chain reaction-based assay, we found that resistin mRNA levels in whole adipose tissue samples were increased in morbidly obese humans compared with lean control subjects. However, in freshly isolated human adipocytes, resistin mRNA levels were very low and showed no correlation with BMI. Resistin mRNA was undetectable in preadipocytes, endothelial cells, and vascular smooth muscle cells, but it was readily detectable in circulating mononuclear cells. Although exposure of human mononuclear cells to PPAR-gamma agonists markedly upregulated fatty acid-binding protein-4 expression, these agents had no effect on mononuclear cell resistin expression. Finally, resistin mRNA was undetectable in adipocytes from a severely insulin-resistant subject with a dominant-negative mutation in PPAR-gamma (3). We conclude that the recently described relationships of murine resistin/Fizz3 expression with obesity, insulin resistance, and PPAR-gamma action may not readily translate to humans. Further studies of this novel class of proteins are needed to clarify their roles in human metabolism.

Rupture of abdominal aortic aneurysm previously treated by endovascular stentgraft.

We describe a case of abdominal aortic aneurysm (AAA) with rupture 16 months after treatment by an endograft. A 76-year-old patient on Coumadin after aortic valve replacement had initially successful exclusion by stentgraft. There was no evidence of an endoleak seven months after stentgraft repair, although a computed tomography scan detected an enlargement of the aneurysm sac. Sixteen months after initial endograft surgery, rupture of the aneurysm occurred and we performed open emergency surgery. We treated the aneurysm by conventional technique, and the patient survived the rupture. This case emphasized the fact that patients after endograft AAA repair require a close follow-up. An expansion of the aneurysm sac after the procedure should signal failed exclusion, even if a computed tomography scan does not demonstrate an endoleak. Anticoagulation can be an important factor in failure after endoluminal graft treatment. Supravisceral aortic cross clamping is helpful in dealing with a stented aorta.

Structure-activity relationship of nucleobase ligands of uridine phosphorylase from Toxoplasma gondii.

Seventy-nine nucleobase analogs were evaluated as potential inhibitors of Toxoplasma gondii uridine phosphorylase (UrdPase), and the apparent Ki (appKi) values for these compounds were determined. Based on the inhibition data, a structure-activity relationship for the binding of nucleobase analogs to the enzyme was formulated, using uracil as a reference compound. Two compounds were identified as very potent inhibitors of T. gondii UrdPase, 5-benzyloxybenzylbarbituric acid and 5-benzyloxybenzyluracil, which had appKi values of 0.32 and 2.5 microM, respectively. A comparison of the results from the present study, with similar studies on mammalian UrdPase and thymidine phosphorylase (dThdPase) (Niedzwicki et al., Biochem Pharmacol 32: 399-415, 1993) revealed that there are both similarities and differences between the catalytic site of T. gondii UrdPase and the catalytic sites of the mammalian enzymes with respect to binding of uracil analogs. One compound, 6-benzyl-2-thiouracil, was identified as a potent, specific inhibitor (appKi = 14 microM) of T. gondii UrdPase, relative to mammalian UrdPase and dThdPase.

Radioautographic study of glycoprotein synthesis and migration in the major sublingual gland of the Mongolian gerbil (Meriones unguiculatus).

Intracellular glycoprotein synthesis and migration in the major sublingual gland of the Mongolian gerbil were studied with light-microscopic radioautography, using L-4, 5-[3H]-leucine, D-1-[3H]-glucose and N-[3H]-acetyl-D-mannosamine as precursors. The time elapsed from the beginning of the synthesis of the secretion products to their release was longer in the mucous acinar cells than in any other exocrine cell investigated until now. A slow addition of the terminal sugars (especially sialic acid) to the glycoprotein molecule and a prolonged storage of the glycoproteins in the apical granules were assumed to be the reasons for this delay in schedule. The secretion in the serous demilune cells was much faster than in the mucous acinar cells. The lack of uptake of labelled mannosamine showed that the demilunes are likely to produce substances different from those of the mucous acinar cells, presumably a protein-rich material with a high turnover.