[Certification of vascular centers. Influence on quality and healthcare structures]. / Zertifizierung von Gefäßzentren. Auswirkungen auf Qualität und medizinische Versorgungsstrukturen.

Diagnosis and therapy of vascular diseases are increasingly being performed following a multimodal, interdisciplinary and less invasive approach. The introduction of specialized, organ-related centers is a logical consequence in view of a better treatment quality and a more effective use of resources. The German societies of radiology, vascular surgery and angiology jointly developed a process of certification, which has been successfully applied to more than 100 units in Germany. In this article the terms and results of the process are described and possible effects on the quality and structures of the healthcare system are discussed.

[Diminishing boundaries between vascular surgery and interventional radiology from the view of a radiologist]. / Schwindende Fachgrenzen zwischen Gefässchirurgie und interventioneller Radiologie aus Sicht des Radiologen.

Vascular surgeons increasingly claim that percutaneous interventional treatment of peripheral arterial disease belongs to their discipline.In further medical training interventional radiology is exclusively bound to the discipline of radiology and necessitates a minimum of 250 procedures for valid qualification. Training in vascular surgery requires 25 endovascular procedures which do not, however, fulfill the criteria of percutaneous interventional procedures for a number of reasons.The desired expansion of vascular surgery to include the complete field of vascular medicine is not based on adequate specific training, is functionally unnecessary and not achievable for practical reasons. However, this desired expansion endangers the consensus of an interdisciplinary concept of treatment as represented by interdisciplinary vascular centers which offer a high level of competence.

[Treatment guidelines for aneurisms of the aorta]. / Behandlungsrichtlinien bei Aortenaneurysmen.

Aneurysmatic diseases of the aorta usually have a bad prognosis in the case of acute rupture. Guidelines exist for surgical treatment but are relatively old and have not yet been brought up to date. By introducing new techniques, thoracic aneurysms are predominantly treated by endoluminal means, for asymptomatic type B dissections, however, a stent graft insertion cannot be principally recommended. For thoracoabdominal aneurysms, a combined endoluminal and open surgical approach is still under evaluation. For the relatively frequent problem of infrarenal abdominal aortic aneurysms, an endoluminal approach is more and more taken although randomized trials have not yet shown an improvement concerning long-term mortality in favor of endografts. Interdisciplinary guidelines do not yet exist.

[Follow-up in uterine fibroid embolization]. / Nachsorge bei Myomembolisation.

Follow-up controls in patients after uterine fibroid embolization (UFE) should monitor clinical improvement of symptoms, document shrinkage of the fibroids, exclude malignancies and detect and treat potential complications of the intervention.A close cooperation with the referring gynecologist, sufficiently and carefully informing the patient about the routine follow-up procedure, potential complications and their clinical signs are necessary to fulfill this goal.Imaging is usually based on ultrasound imaging but may be supplemented by MRI. There are different complications in the early phase after UFE and in the later postembolization phase.

[Chitosan pads vs. manual compression to control bleeding sites after transbrachial arterial catheterization in a randomized trial]. / Randomisierte Untersuchung zur Anwendung eines Chitosan-Gerinnungspads zur Blutstillung bei transbrachialen Angiographien.

PURPOSE: Until now, no mechanical closure devices were available to achieve fast and secure hemostasis for vessel closure after catheterization of small arterial vessels. MATERIAL AND METHODS: Eighty patients were randomized to evaluate the effect on hemostasis by use of a chitosan pad (Chito-Seal, Abbott Vascular Devices, Galway/Ireland) in comparison to manual compression after diagnostic transbrachial arterial catheterization. Hemostasis after three minutes and one hour as well as local development of a hematoma after one and twenty-four hours were assessed. RESULTS: The use of chitosan pads significantly decreased the bleeding time in the first three minutes after manual compression time (p < 0.01). Significant decrease in bleeding risk at three minutes by use of the chitosan closure pads was also found in subgroups of patients with hypertension (p < 0.001) or diabetes (p < 0.01) and also in patients under anticoagulation therapy (p < 0.01). In addition, long-term protection from bleeding complications such as the risk of hematoma was decreased by the use of chitosan closure pads one hour (p < 0.01) or twenty-four hours (p < 0.001) after catheter removal. CONCLUSION: The use of an intravascular anchor or suture system is not safely applicable in these vessels due to the small diameter of the brachial artery. Our results document a significant improvement in hemostasis by using chitosan pads in these cases.

[Guidelines of the German Radiological Society for percutaneous vertebroplasty]. / Leitlinien der Deutschen Röntgengesellschaft zur Vertebroplastie.

In many countries, percutaneous vertebroplasty became a widely accepted therapeutic option in osteoporotic and neoplastic fractures of the vertebral bodies which is employed in more and more patients. Under image guidance the method can be safely performed and provides a high success rate regarding stabilization of vertebral fractures and pain relief. Due to the increasing interest in vertebroplasty in Germany the German Radiological Society-Working Group on Interventional Radiology decided to produce guidelines for percutaneous vertebroplasty. This guidelines are based on the recent standard of knowledge and represent a guide for practical performance of this procedure. Based on the technical development of the method, indications and implementation of the method in multimodal therapy regimens may change over the next years. Therefore, this guidelines are not a rigid body of rules but a basis for an ongoing development adjusted to the scientific progress and the interdisciplinary discussion.

[Transbrachial selective carotid DSA in outpatients: safety and efficacy]. / Diagnostische Sicherheit und Effizienz ambulanter transbrachialer selektiver Karotisangiographien.

PURPOSE: To describe safety and efficacy of transbrachial selective carotid digital subtraction angiography (DSA) in outpatients. MATERIALS AND METHODS: From July 1999 to November 2001, selective carotid angiography was performed in 141 outpatients preferably using a left brachial arterial approach. The average age of the patients was 68 years (range: 39 - 89 years). After flush aortography through a 4F-pigtail catheter, bilateral selective common carotid artery (CCA) catheterization was performed with 4F-Sidewinder-1 or Sidewinder-2 catheters. In 49 patients, Doppler-sonography was performed before or after arteriography. A total of 41 patients underwent carotid surgery. RESULTS: Selective catheterization of the CCA was successful in 96 % of the cases. The diagnostic quality of the opacified aorta and CCA images was good to excellent. The overall complication rate did not exceed 2.1 %, and severe complications were not observed. One patient showed transient neurological symptoms and another mild nausea and agitation, probably as toxic reaction to the contrast medium. A single local hematoma developed after unsuccessful puncture of the brachial artery. CONCLUSION: Transbrachial selective carotid DSA is safe, reliable and well-tolerated in outpatients and achieves a superimposition-free CCA visualization.

[Evolution of inflammatory parameters after fibroid embolization]. / Entwicklung der Entzündungsparameter nach Myomembolisation.

PURPOSE: To describe the rise of classical laboratory tests for inflammation following transarterial uterine fibroid embolization (UFE) in order to monitor the normal course following UFE. MATERIALS AND METHODS: In 20 females, white blood cell (WBC) count and C-reactive protein (CRP) were determined before and up to 5 days after UFE. With the exception of one noninflammatory complication, the post-procedure course was uneventful in all patients. The measured values were correlated with both the total uterine volume and the amount of instilled embolizing agent. RESULTS: Following UFE, an increase in the WBC count to an average maximum of 10.8 +/- 3.5/wL (range 5.9 - 18.6/wL) was found. In 13 of 20 patients, the WBC count was above normal on at least one day following UFE. The increase reached the maximum on the third post-interventional day and subsided within 5 days after the UFE. The CRP values increased significantly to an average maximum of 41.9 +/- 28.8 mg/l. The maximum was found on the 2nd post-interventional day in 8 patients, on the 3rd day in 11 patients and on the 4th day in one patient. No correlation to the total uterine volume or to the amount of the instilled embolizing agents was detected. CONCLUSION: Following uncomplicated UFE, a steep increase in CRP occurs with no or only a mild increase in the WBC count, which does not indicate an infected fibroid. The maximum is reached on the 3rd or 4th post-interventional day, followed by a decline in CRP and normalization of the WBC count.

[A novel hirudin coating of vascular endoprostheses: experimental results]. / Eine neuartige Hirudinbeschichtung vaskulärer Endoprothesen: Experimentelle Ergebnisse.

PURPOSE: Does hirudin coating improve the patency of iliac artery endoprostheses in comparison to non-hirudin-coated endoprostheses? MATERIALS AND METHODS: Nitinol stents and stentgrafts covered with polytetrafluoroethylene (PTFE) were coated with the polymer polyamino-p-xylylene-co-poly-p-xylylene using chemical vapor deposition (CVD) technique. Hirudin was covalently bound to the surface of the endoprostheses via the amino-group. External factors (mounting of the prosthesis, sterilization, storage time and temperature, release) affecting the hirudin activity were evaluated in vitro. Five types of prostheses were compared in vivo: (1) plain and (2) CVD- and hirudin-coated stents; (3) plain, (4) CVD-coated, and (5) CVD- and hirudin-coated PTFE-stentgrafts. In 20 sheep, 16 protheses of each type were inserted in arteries pretreated with a Fogarty maneuver. The animals were followed for either 1 (n = 10) or 6 (n = 10) months. Immediately after implantation and after 1, 3, and 6 months, intravascular ultrasound (IVUS) and angiography were performed. The vascular specimens were analyzed histologically. RESULTS: Within 10 weeks, the hirudin activity of coated stents dropped 60 % due to external factors; the activity of coated PTFE stentgrafts dropped 20 %. After 1, 3, and 6 months, IVUS and histology revealed a significantly reduced patency of the hirudin-coated stentgrafts compared to the other prostheses. Only IVUS showed a significantly reduced patency of hirudin coated stents after 1 and 3 months compared to plain and CVD-coated PTFE-stentgrafts. The reduced patency was caused by neointimal hyperplasia. CONCLUSIONS: In an experimental setting, hirudin coating did not improve the patency of vascular endoprostheses.

Results of a European multicentre iliac stent trial with a flexible balloon expandable stent.

PURPOSE: to determine the 12 months success rate with a balloon expandable, flexible stainless steel stent in iliac artery obstructions. MATERIALS AND METHODS: one-hundred and twenty-six consecutive patients with iliac obstructive disease and who demonstrated an unsatisfactory angioplasty result with a post-dilatation gradient of at least 10 mmHg, or a primary occluded lesion were included in the study. Follow-up was by Doppler sonography, ankle pressures with and without exercise and clinical parameters. RESULTS: after stent placement, the mean percentage diameter stenosis decreased from 79 to 4%, with a mean intra-arterial pressure gradient of 3 mmHg. Primary stent patency was 94% at 6 months and 89% at 12 months. Primary clinical result at 6 months was 88% and at 12 months 81%. Primary assisted clinical result (after re-pta) at 6 and 12 months was 89 and 86%, respectively. The Ankle Brachial Index (ABI) after exercise at 1 month follow-up was reduced from 0.88 to 0.75, with minor deterioration at 6 months to 0.72, and at 12 months to 0.68. The 1, 6, and 12 months follow-up Piek Systolic Velocity (PSV) ratios across the stented lesions remained stable at a mean of 1.4, 1.6, and 1.6, respectively. However, respectively 44, 39 and 34% of the patients still experienced symptoms of claudication. CONCLUSIONS: the results presented here support the suggestion stenting to be an effective device in the treatment of iliac artery obstructive disease. This study also, confirms other study results concerning haemodynamic patency after iliac stenting on the indication of a 10 mmHg pressure gradient after pta and the discrepancy between good haemodynamic patency and clinical result.

[New international networks in radiology graduate and continuing education: www.eurorad.org--a EAR Project for online publication of radiological data]. / Neue internationale Wege in der radiologischen Fort- und Weiterbildung: www.eurorad.org--ein Projekt der EAR zur Onlinepublikation radiologischer Daten.

Eurorad (www.eurorad.org) is a joint project of EAR and has support of 27 national and 8 subspeciality radiology societies. Eurorad is the first noncommercial radiological publication that is exclusively based on the internet as a communication line with all steps of submission, reviewing and publication being performed online. Eurorad wants to build up a huge and exhaustive case file of diagnostic and interventional radiology. Like all scientific publications, Eurorad bases on an editor in chief and 13 section editors who are responsible for organizing each section of Eurorad. Each section has a number of peer reviewer with an overall total of more than 100. For submission and publication, all cases are structured in the same manner with case report, method and discussion. For the time being, Eurorad hosts 779 cases, of whom 346 are free available on the net. The actual rejection rate is 4.5%, other cases are under review.

[Simple localization of peripheral pulmonary nodules - CT-guided percutaneous hook-wire localization]. / Einfache Lokalisation von intrapulmonalen Rundherden - CT-gesteuerte perkutane Hakenmarkierung.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is an alternative approach to small intrapulmonary nodules, if transbronchial or percutaneous biopsy have failed. We investigated the feasibility and effectiveness of the percutaneous CT-guided placement of hook-wires to localize such nodules before video-assisted thoracoscopy. SUBJECTS AND METHODS: 19 patients with new by diagnosed intrapulmonary nodules underwent CT-guided hook-wire localization by application of a X-Reidy -Set (Cook, Inc., Bjaeverskov, Denmark). The average age of the patient was 63 years (range: 19 - 80 years), the mean distance between the nodule and the pleura visceral was 7.58 mm (range: 0 - 25 mm) and the mean diameter was 11.58 mm (range: 5 - 25 mm). After localization, the patients underwent a VATS resection of the lesion within a mean time of 30 min (range 10 - 48 min). RESULTS: In all cases, resection of the nodules was successful. In 4 older patients the marking was complicated by poor cooperability. At the end of manipulation the end of the hook was distanced from the nodule. But also in these cases, resection was successfully performed. 8 patients developed an asymptomatic pneumothorax: 5 of them in a minor (max. 1.5 cm rim), three of them in a moderate (max. 3 cm rim) dimension. In 4 patients, in whom the tumor was hit directly by the needle, local bleeding occurred. In one case, haemoptoe was present. In no patient did a dislocation of the hookwire-system occur. CONCLUSION: CT-guided placement of a hook-wire system is a simple and reasonable procedure which facilitates safe VATS resection of small pulmonary nodules.