Biebl, Matthias

Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization or with angioplasty and stenting. As experience has been gained, endovascular treatment appears safe and effective in selected patients. Currently, surgical revascularization has better success and patency rates but also a higher short- and midterm mortality and morbidity, especially in patients at high surgical risk. A 72-year-old female with severe respiratory dysfunction presented with CMI resulting in profound malnutrition. Serial percutaneous interventions averted urgent surgery and reversed the mesenteric ischemia. Nine months later, after repeated angioplasty and stenting had failed, elective uncomplicated iliomesenteric bypass, in a medically optimized patient, resolved the ischemia. At an 18-month follow-up, the graft remained widely patent and the patient asymptomatic with a body weight corresponding to her ideal body weight. Compared to surgical revascularization, reocclusion or restenosis occurs more frequently after endovascular treatment of CMI, and reintervention may be necessary. Nevertheless, percutaneous intervention effectively provides relief from mesenteric ischemia and has lower perioperative complication rates compared to surgery in patients at high surgical risk. After initial relief of the CMI, the patient's condition may improve, allowing for more definitive secondary surgical revascularization, if needed.

Group Milleri streptococci (GMS), a heterogeneous group of streptococci, are associated with purulent infections. This study was a retrospective analysis of all consecutive thoracic infections of GMS between 2001 and 2004. Of 246 surgical GMS infections, thoracic infections accounted for 4.5 per cent, including 10 pleural infections (eight empyemas and two infected pleural effusions) and one mediastinal infection. The etiology of pleural infection was parapneumonic (7), second to esophageal perforation (1), liver transplantation (1), and liver resection (1). Polymicrobial infections were present in 64 per cent. All patients underwent removal of the infected masses, including drainage (3), thoracoscopic decortication (5), thoracotomy with debridement (2), and incision with drainage (1). The case fatality rate was 9 per cent (there was one patient with congestive heart disease unfit to undergo surgical empyema evacuation) and the recurrence rate was 27.3 per cent (three patients). Combined antibiotic/surgical treatment was successful in all other cases. GMS isolates were susceptible to clindamycin and all β-lactam antibiotics except ceftazidime, but were resistant to aminoglycosides. If found intrathoracically, GMS frequently progress to severe empyema. Therefore, timely removal of pleural collection by percutaneous drainage or surgical intervention seems indicated. If surgery is required, thoracoscopic decortication may be the preferred approach.

The purpose of this study was to analyze the effect of gender on deployment, early morbidity, and survival after endovascular aortic aneurysm repair (EVAR) using the Zenith Endovascular Graft. Data were obtained from the U.S. Multicenter Zenith Endograft trial and complemented with results from the Zenith female registry, including 40 women (10.9%) and 326 men (89.1%). Data analysis included preoperative medical risk factors, aneurysm morphology, deployment, and postoperative morbidity data, and 30-day and 1-year results. Preoperatively, women more often had experienced thromboembolic events (13% vs 4.3%; P = 0.04), but less angina pectoris (24% vs 49%; P = 0.002) or myocardial infarction (18% vs 38%; P = 0.01) compared with men. Women had more angulated aneurysm necks and narrower iliac arteries compared with men. Procedural success, cardiovascular, pulmonary, renal, bowel-related, neurologic, or other adverse events were comparable, as were 30-day and 1-year survival. Females experienced more wound dehiscences (5.0% vs 0.0%; P = 0.01) and open surgical conversions in the first year (5%) compared with men (0.31%) ( P = 0.03). With more challenging aneurysm morphologies, women were found to be at a higher risk for conversion in the first year after EVAR using the Zenith endograft. This however does not translate into inferior survival or higher overall morbidity compared with men.

Purpose: To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs. Methods: Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs ≤16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b). Results: The mean CIA diameter increased by 1.0±1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5±1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6±18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed. Conclusion: Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

Purpose: To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft. Methods: A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if p<0.05. Results: Overall rates of mortality (12.5% for women versus 13.2% for men, p=0.94) and aneurysm rupture (2.5% for women versus 0% for men, p=0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p=0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p=0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p=0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p=0.10). None of the patients developed device migration .10 mm or required intervention for migration. Conclusion: While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.

The purpose of this study was to evaluate the incidence and durability of additional proximal cuffs during endovascular abdominal aortic aneurysm repair (EVAR). A retrospective review of 90 EVAR patients was conducted. Postoperative survival, proximal sealing zone–related complications, and secondary procedures were analyzed. Additional proximal cuffs were used in 11%. Their use did not affect postoperative survival ( p = .58), type I endoleak rate (4.4%; p = .19), or the need for sealing zone–related secondary procedures (6.3%; p = .38) compared with patients without cuff placement but was related to a higher cumulative graft migration rate (2.2% overall p = .02). Two patients (2.5%; p = .79) underwent conversion to open surgery, both for proximal sealing zone–related complications. Application of proximal cuffs appears to be an effective intraoperative adjunctive procedure to achieve a proximal seal during EVAR, with favorable midterm results. However, the risk of late endograft migrations may be elevated in this group.

The purpose of this study was to review the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using custom-made aortouni-iliac (AUI) devices with femorofemoral bypass. Between June 1999 and March 2001, 23 consecutive patients (1 female, 22 male) at high risk of open aortic aneurysm repair underwent EVAR with custom devices in an AUI configuration. The mean follow-up was 37 months (range 2–72 months), and the mean age was 76.8 years (range 67.5–88.7 years). Increased surgical risk was evidenced by 92% and 69% of patients with significant pulmonary or cardiac disease, respectively. The preoperative mean aneurysm diameter ( n = 23) 62 ± 8.2 mm was significantly greater than the postoperative diameter, ( n = 23) 54 ± 16.4 mm. Ten endoleaks occurred. Migration of the stent graft occurred in 9% ( n = 2). Secondary interventions were necessary in 23%, whereas tertiary interventions were required in 9%. Patients at high risk of open aneurysm repair received sufficient protection from aneurysm rupture with custom-made AUI devices.

The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA). Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications. Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension ( p < .05) and blood pressure lability ( p < .01), as well as postoperative nausea ( p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.

AbstractBackgroundThe purpose of the present study was to compare surgical and endovascular revascularization for chronic mesenteric ischemia (CMI).MethodsForty‐nine patients underwent surgical (SG) or endovascular (EG) treatment. Relief of symptoms was considered the primary endpoint; patency, morbidity, and mortality were secondary endpoints. For statistical analysis, significance was assumed if P values ≤ 0.05.ResultsTwenty‐six patients (53%) underwent surgical revascularization; 23 patients (47%), endovascular repair. Mean follow‐up was 25 ± 21 months (SG) versus 10 ± 10 (EG) months (P = 0.07). Except for body mass indices (SG 18.9 ± 2.7 versus EG 23.6 ± 4.8; P = 0.001), preoperative data were comparable. Freedom from symptoms was 100% (SG) versus 90% (EG) after intervention (P = 0.194), and 89% (SG) versus 75% (EG) at the end of follow‐up. Reocclusion or re‐stenosis occurred in 8% (SG) versus 25% (EG) (log‐rank test: P = 0.003), and mesenteric ischemia developed in 0% (SG) versus 9% (EG) (P = 0.04). Reintervention for CMI was required in 0% (SG) versus 13% (EG) (P = 0.01). Surgical patients experienced more early complications (42% versus EG 4%; P = 0.02) and longer hospital stays (11.6 ± 10.9 days versus EG 1.3 ± 0.5 days; P < 0.001). Overall mortality at the end of follow‐up was 31% (SG) versus 4% (EG) (log‐rank test: P = 0.08), including all patients with combined open mesenteric and aortic reconstruction (P = 0.001).ConclusionsSurgical treatment has superior long‐term patency and requires fewer reinterventions, but it is also more invasive with greater morbidity and mortality compared to endovascular treatment. Endovascular techniques may be preferable in patients with significant co‐morbidities, concomitant aortic disease, or indeterminate symptoms.

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.