[Interventional endovascular therapy of infrarenal abdominal aortic aneurysm]. / Die interventionelle/endovaskuläre Therapie des infrarenalen abdominellen Aortenaneurysmas.

The catheter-based interventional therapy (endovascular aortic repair EVAR) of abdominal aortic aneurysms (AAA) has gained an established place in the spectrum of therapeutic options. The procedure is characterized by low peri-interventional morbidity and mortality. Multislice computed tomography (CT) has a dominant role in defining the correct indications and in selecting an appropriate stent graft prior to the intervention. The rate of acute conversions could be reduced from 2.9 % to 0 % in our own elective patient population since 2010. In our vascular centre the proportion of patients treated by EVAR was 39.5 % (102 out of 258). The procedure is used routinely in patients who have an increased risk for general anesthesia or open surgery due to concomitant diseases. It is also used in patients with a reduced local operability due to prior surgery, abdominal diseases or radiation therapy. Arterial closure devices allow a completely percutaneous approach in a certain group of patients. However, after EVAR a life-long surveillance is mandatory because delayed therapy failure has been described. In younger patients who do not have a higher risk open surgery is still an option. The paper describes techniques, results und complications of EVAR.

[CT-guided cutting needle biopsies of thoracic lesions in patients with negative bronchoscopic findings]. / CT-gesteuerte Stanzbiopsien thorakaler Läsionen bei Patienten mit bronchoskopisch negativen Voruntersuchungen.

PURPOSE: The usefulness and the complication rate of CT-guided core biopsies for obtaining specimens for histopathological examinations in patients with uncertain thoracic lesions were evaluated. MATERIALS AND METHODS: Under local anesthesia CT-guided core biopsies were performed in 121 patients using tru-cut systems (14-18 gauge). Prior to CT all patients underwent bronchoscopy without obtaining sufficient material for a definite histopathological diagnosis. The following areas were punctured: lungs 84 (69%), pleura, chest-wall, ribs 24 (20%) and mediastinum 13 (11%). The diameter of the punctured lesion averaged 4.3 cm. RESULTS: Using CT-guided puncture techniques specimens could be obtained in 118 (97.5%) out of 121 patients. Of these 118 specimens 3 (2.5%) showed marked artifacts and necrosis, which obscured a definite histopathological opinion. In the end the biopsies from 115 (95.0%) out of 121 patients could be used whereby 84 (73.0%) were classified as malignant and 31 (27.0%) as benign. Due to further operations or bronchoscopic procedures in 35 patients additional material was obtained for histopathological tests. In 3 (8.6%) of those 35 patients newly malignant disease was diagnosed, therefore these specimens showed a relevant discrepancy as compared to the result of the CT-guided biopsy. Obviously the vital central part of the tumor was not biopsied due to poor delineation caused by peritumoral infiltration. A small pneumothorax or haemoptysis was seen in 17 (14.3%) out of 121 patients. CONCLUSIONS: Despite negative bronchoscopic findings CT-guided core biopsies will deliver sufficient specimens for histopathological tests in 95% of patients with uncertain thoracic lesions. Infiltrations surrounding the vital part of the tumor may obscure the correct targeting and lead to false negative results in a few patients. Severe complications were not seen in this study, although they might happen in rare cases according to reports in the literature. Therefore CT-guided core biopsies represent an efficient and safe procedure in patients with thoracic lesions.

[Thrombosis of developmental venous anomaly and consecutive venous infarction]. / Thrombose eines venösen Angioms mit sekundärem Stauungsinfarkt.

Developmental venous anomalies (DVA) are congenital aberrations in the cerebral venous system reflecting failure of normal embryogenesis. They are considered the most common intracranial vascular malformation. Although they are generally regarded as benign entities, their clinical significance remains controversial--case reports do exist considering DVA to be the origin of thrombosis, cerebral ischemia, and hemorrhage. We report a 26-year-old patient suffering from thrombosis of a DVA.

[PACS: from project to reality. Report of experiences on full digitalisation of the radiology department of a major hospital]. / PACS: Vom Projekt zur Realität. Erfahrungsbericht über die vollständige Digitalisierung der Radiologischen Abteilung eines Schwerpunktkrankenhauses.

OBJECTIVE: To assess the time needed and the resulting effects of a complete digitalisation of a radiological department of a major hospital (856 beds, 28,000 in-patients, 35,000 out-patients/year) a pilot study was performed. This had to be done without interrupting routine services. RESULTS: After intensive preparations were performed and the hospital-network was completed, within a two year period all radiological functions (mammography excluded), reporting stations and archives were changed to a complete digital workflow. All modalities (provided by 3 different companies) are now connected by DICOM-work lists. The picture-files (4 GB/day) are automatically routed to the work-stations (n = 10), where the reporting and file shows are performed, to the digital archive and to the peripheral viewing-stations (n = 44). The distribution of the digital pictures takes place all over the hospital including the ORs and special units. We accomplished, to connect electronically the report and the image data. The clinical file shows are also performed completely digitally. The access to the data of the deep archive is possible by the dept. of radiology without any manual interaction. The film consumption was reduced to an amount of less than 10%, as compared to the prior PACS situation. Since PACS has been introduced the radiological productivity increased by more than 15% and throughput-time was clearly reduced. CONCLUSIONS: The complete digitalisation increases productivity and attractiveness of a hospital-radiology and helps to shorten diagnostic and therapeutic decision-making. The transfer from a conventional to a digital workflow is possible without interrupting the clinical services. Extensive preparations and ongoing assistance of such projects though are clearly needed.

Electroporative fast pore-flickering of the annexin V-lipid surface complex, a novel gating concept for ion transport.

In contact with lipid bilayers and Ca2+-ions, the intracellular protein human annexin V (wild-type), Mr = 35,800, forms two types of cation-selective channels for the transport of Ca2+-, K+-, Na+- and Mg2+-ions, depending on the protein concentration [AN]. Type (I) channel events are large and predominant at high values [AN] > or = K = 5 nM at 296 K. At 50 mM Ca2+, symmetrical on both membrane sides, AN added at the cis side, the conductance is gCa(I) = 22 +/- 2 pS and at symmetrical 0.1 M K+-conditions: gK(I) = 32 +/- 3 pS, associated with two mean open-times tau1(I) = 0.68 +/- 0.2 ms and tau2(I) = 31 +/- 2 ms. Monoclonal anti-AN antibodies added to the trans-side first increase the mean open-times and then abolish the channel activity, suggesting that type (I) channels refer to a membrane spanning protein complex, probably a trimer T, which at [AN] > K changes its membrane organization to a higher oligomer, probably to the side-by-side double-trimer T2. The smaller type (II) channel events are predominant at low [AN] < or = K and refer to the (electroporative) adsorption complex of the monomer. The conductances g(i)(II) for symmetrical concentrations depend non-linearly on the voltage Um = Uext + U(AN), where U(AN) = 0.02 +/- 0.002 V is the electrostatic contribution of the Ca2+-AN complex and Uext the externally applied voltage. There is only one mean open-time tau(o)(II) which is voltage-dependent according to a functional of b x Um2 where b = 113.9 +/- 15 V(-2), yielding an activation Gibbs free energy of Ga = RT x b x Um2. The conformational flicker probability f(i)(II) in g(i)(II) = g(i)0(II) x gamma(i) x f(i)(II) is non-linearly voltage-dependent according to a functional of a x Um2. The Nernst term gamma(i) refers to asymmetrical ion concentrations. From a = 50 V(-2), independent of the ion type, we obtain f(i)0(II) = 0.03 +/- 0.002 and the conductances for the fully open-channel states: gCa0(II) = 69 +/- 3 pS (0.05 M Ca2+) and gK0(II) = 131 +/- 5 pS (1.2 M K+). From the electroporation term a = pi[r(p)2]epsilon0(epsilon(w) - epsilon(m))/(2 kTd) we determine the mean pore radius of the complex in its fully open state as r(p)= 0.86 +/- 0.05 nm. The adsorbed annexin V (Ca2+) monomer appears to electrostatically facilitate the electric pore formation at the contact interface between the protein and the lipid phase. The complex rapidly flickers and thus limits the ion transport in a voltage-dependent manner.

Perspectives for microelectrode arrays for biosensing and membrane electroporation.

Electrochemical microelectrode devices are among the great challenges for bioelectrochemistry, cell biology and recently also for biomedical research and new clinical electrotherapies. Two representative cases in cell biology and medical research for new trends in the technical devices are selected, heading at new diagnostic and therapeutic clinical applications. One example is from the field of biosensing cholinergic neurotransmitter substances by the nicotinic acetylcholine receptor (AcChoR) in solid-supported lipid bilayer membrane and the other one refers to new developments of electrode systems for the electrochemical delivery of drugs and genes to biological cell aggregates and tissue by the powerful method of membrane electroporation. In both cases addressed to, the new developments include the use of electrical feedback control of electrode arrays for biosensing processes as well as for the extent and duration of tissue electroporation. In line with the impressive advances in medical microsurgery, where increasingly smaller organ targets become accessible, microelectrode systems have become a continuous technical challenge for bioanalytical purposes and, as discussed here in some detail, for the new field of the electroporative delivery of effector substances like drugs and genes, using miniaturized electrochemical electrode arrays.

CT-guided lumbar sympathectomy: results and analysis of factors influencing the outcome.

PURPOSE: To prospectively analyze the effectiveness of computed tomography-guided percutaneous lumbar sympathectomy (CTLS) in patients with peripheral arterial occlusive disease in relation to angiographic findings and vascular risk factors. METHODS: Eighty-three patients were treated by CTLS. After clinical evaluation of the risk profile and diagnostic intraarterial digital subtraction arteriography, 14 patients underwent unilateral, and 69 bilateral one-level treatment. Follow-up studies took place on the day following the intervention, after 3 weeks, and after 3 months. RESULTS: A total of 152 interventions were performed in 83 patients. After 3 months, clinical examination of 54 patients (5 patients had died, 24 were lost to follow-up) revealed improvement in 46% (25/54), no change in 39% (21/54), and worsening (amputation) in 15% (8/54). There was no significant statistical correlation among any of the analyzed factors (diabetes mellitus, arterial hypertension, smoking, hyperlipidemia, obesity, hyperuricemia, number of risk factors, ankle-arm index, and angiography score) and the outcome after CTLS. Three major complications occurred: one diabetic patient developed a retroperitoneal abscess 2 weeks after CTLS, and in two other patients ureteral strictures were detected 3 months and 2 years after CTLS, respectively. CONCLUSION: As no predictive criteria for clinical improvement in an individual patient could be identified, CTLS, as a safe procedure, should be employed on a large scale in patients who are unsuitable for treatment by angioplasty or revascularization.

[The possibilities and risks of outpatient PTA in patients with peripheral arterial obstructive disease]. / Möglichkeiten und Risiken der ambulanten PTA bei Patienten mit peripherer arterieller Verschlusskrankheit.

PURPOSE: To evaluate risk and feasibility of outpatient PTA in patients with iliac-femoral artery disease we conducted a prospective study. MATERIAL AND METHOD: Out of a total group of 263 patients we selected 100 p. (38%) according to pre-defined criteria. The following criteria and others excluded the patients from outpatient procedures: insulin-dependent diabetes, poorly controlled hypertension, cardiac failure grade III and IV, chronic haemodialysis, severe overweight, elective stent implants. RESULTS: 90 of 100 patients for whom we had planned an outpatient procedure, could leave the day-clinic after a maximum of 10 hours of observation. For 10 patients we changed the procedure to an inpatient stay because of prolonged heparinisation, sudden elevation of arterial pressure, secondary stent implants and the need for local fibrinolysis therapy. Complications showed a trend to be lower in the outpatient group than in the inpatient group (2.0% vs 4.3%). CONCLUSIONS: Performing iliac-femoral PTA on an outpatient basis demands strict selection criteria and a close tie-up to a day clinic. In 2/3 of our patients we preferred to perform PTA on an inpatient basis. A higher incidence of risks was seen in the inpatient group.

Semiclosed iliac recanalisation by an inguinal approach--modified surgical techniques integrating interventional procedures.

OBJECTIVES: Technical success and early outcome of modified surgical techniques integrating interventional procedures for iliac recanalisation performed through an incision in the groin. MATERIALS: Sixty-one consecutive iliac arteries in 59 patients with long occlusions in 16, occlusions of the common iliac in 11, occlusions of the external iliac in 24 and multiple stenoses of the iliac in 10 cases underwent semiclosed recanalisation through a groin incision. METHODS: Passage of the lesion by guidewire permits retrograde ring-stripper endarterectomy over the wire as a guiding splint or thrombectomy with a double lumen balloon catheter. Residual lesions are corrected by balloon or stent angioplasty. Adequate outflow is established by femoral patch plasty. RESULTS: Conversion to a standard operation was required in 10 limbs (failure to recanalise the lesion in nine, rupture after angioplasty in one). Initial technical success was achieved in the remaining 51 limbs (recanalisation by ring stripper endarterectomy in 36, thrombectomy in 14, both in six, additional intraoperative angioplasty in 42). Five postoperative thromboses were successfully treated by a combined surgical and interventional approach accounting for a 1-month 100% secondary patency. CONCLUSION: Iliac recanalisation through the groin by modified ring stripper endarterectomy or modified thrombectomy in combination with intraoperative angioplasty is a safe and effective procedure. Long-term results are required to evaluate the procedure.

[Pyogenic liver abscess. Analysis and follow-up examination of a personal patient sample 1981-1992]. / Der pyogene Leberabscess. Analyse und Nachuntersuchung unseres Patientenkollektivs 1981-1992.

From January 1, 1981 to January 1, 1992 a total of 30 liver abscesses were treated in the University Clinic for Surgery in Cologne. 23 patients underwent an primary operative treatment and seven patients received a controlled guided percutaneous drainage. During the observation period four patients (13.3%) died by the effect of the liver abscess. 20 patients (66.7%) were subjected to clinical, laboratorical and computertomographical post examinations. The primary rate of operation success amounted to 47.8%, that of controlled guided percutaneous drainage of 42.8% (NS). The secondary success rate (that means after successful operative reintervention) amounted to 86.9% by the operative and to 85.7% by the percutaneous drainaged cases. During the post examination no relapse was determinated. Larger or chambered liver abscesses as well as extrahepatic spreading required operative drainage and, in cases of multifocal spreading, a resection with concomitant antibiotics. In case of solitary abscesses the controlled guided percutaneous drainage is the least harmful and low-prices method.

[Digital cineradiography (DCR) of the act of swallowing. The initial clinical experiences]. / Digitale Cine-Radiographie (DCR) des Schluckaktes. Erste klinische Erfahrungen.

Twenty-seven patients with different swallowing disorders were studied by employing digital cineradiography (DCR) for rapid imaging of the pharynx with a temporal resolution of up to 50 frames per second and a maximum spatial resolution of .8 per/mm. To facilitate therapy planning, the DCR study can be transferred to the otorhinolaryngologist via videotape. DCR is capable to substitute analog cine or video techniques in the pre- and postoperative examination of patients with swallowing disorders.

[A rare constellation of findings: bile duct cancer, ulcerative colitis, deep venous thrombosis of the leg]. / Seltene Befundkonstellation: Gallengangskarzinom, Colitis ulcerosa und tiefe Beinvenenthrombose.

A case of a 28-year-old patient with long-standing chronic ulcerative colitis is presented, in whom cholangiocarcinoma was diagnosed by CT and ultrasound guided liver biopsy. This association is well known, because the incidence of bile duct carcinoma in patients with chronic ulcerative colitis is increased. A possible precursor of the disease is thought to be primary sclerosing cholangitis which also more frequently occurs in patients with ulcerative colitis. Our patient was initially hospitalized for deep venous thrombosis, which in retrospect had to be interpreted as a paraneoplastic syndrome.

Heart rate variability and the reaction of heart rate to atropine in brain dead patients.

Heart rate variation and the atropine test as an expression of the bulbar parasympathetic activity might complete the clinical examination in the diagnosis of brain death, but are certainly unreliable as confirmatory tests.

[Treatment of ankylosing spondylitis with slow-release diclofenac sodium in a single daily dose]. / Behandlung der Spondylitis ankylosans mit der Retardform von Diclofenac-Natrium in einmal täglicher Dosierung.

The efficacy and tolerability of slow-release diclofenac sodium were investigated in 40 patients with ankylosing spondylitis. The patients received one coated tablet of 100 mg daily in the morning for 21 days in addition to standard physiotherapy. The efficacy of the trial treatment was evaluated by measuring the chin-to-manubrium sterni and fingertips-to-floor distances, Schober's sign, and chest expansion. Every morning and evening the severity of pain and the degree of spinal stiffness were recorded by the patients on visual analogue scales. A significant improvement of the symptoms was found in 35 of the patients as compared to the initial findings. The slow-release formulation of diclofenac Na was very well tolerated. The necessity of balneophysical therapy in ankylosing spondylitis is emphasized, which in most cases will only be possible in combination with adequate drug therapy.