Diagnostik venöser Erkrankungen

Zusammenfassung: Die venösen Erkrankungen der unteren Extremitäten stellen mit der Varikose, der Thrombophlebitis, der tiefen Beinvenenthrombose und der chronischen venösen Insuffizienz aufgrund des weitverbreiteten und im Alter zunehmenden Vorkommens relevante Krankheitsbilder hinsichtlich Diagnostik und Therapie dar. Die Diagnose der Varikose und Thrombophlebitis kann in der Mehrheit der Fälle klinisch gestellt werden, und apparative Diagnostik, meist Ultraschall, wird zur Dokumentation, für das Therapiekonzept oder zur Operationsplanung benötigt. Umgekehrt kann die tiefe Beinvenenthrombose klinisch nicht sicher diagnostiziert werden und bedarf einer der klinischen Wahrscheinlichkeit entsprechenden adäquaten Diagnostik. Die farbkodierte Duplexsonographie und die Kompressionssonographie sind in geübten Händen als nichtinvasive Verfahren zu den Methoden der Wahl avanciert. Goldstandard bleibt jedoch wegen der geringsten Untersucherabhängigkeit die Phlebographie, welche in der klinischen Routine weitgehend durch nichtinvasive Verfahren abgelöst wurde. Die Spiral-Computertomographie wie auch die Kernspintomographie sind wegen der Kosten nicht für die breite Anwendung geeignet, können aber bei diagnostischer Unsicherheit, vor allem bei Beckenvenenthrombosen, sinnvoll eingesetzt werden. Im Vergleich zur Phlebographie ergeben die Schichtbilder wie auch die Duplexsonographie zusätzliche Informationen über die die Gefäße umgebenden Strukturen und können allenfalls eine Differentialdiagnose sichern. Die Computertomographie und die Phlebographie sind durch ihre Kontrastmittelund Strahlungsbelastung limitiert. Die chronische venöse Insuffizienz kann durch eine genaue Anamneseerhebung und klinische Untersuchung meist relativ sicher festgestellt werden. Funktionelle und morphologische Untersuchungsmethoden wie die Plethysmographie, Duplexsonographie und Phlebographie eignen sich hier je nach klinischer Fragestellung zur Sicherung der Diagnose, zur Evaluation einer operativen Sanierung der Venen und zur Bestimmung der Ätiologie der chronischen venösen Insuffizien

Stent grafting of acute hepatic artery bleeding following pancreatic head resection

The purpose of this study was to report the potential of hepatic artery stent grafting in cases of acute hemorrhage of the gastroduodenal artery stump following pancreatic head resection. Five consecutive male patients were treated because of acute, life-threatening massive bleeding. Instead of re-operation, emergency angiography, with the potential of endovascular treatment, was performed. Because of bleeding from the hepatic artery, a stent graft (with the over-the-wire or monorail technique) was implanted to control the hemmorhage by preserving patency of the artery. The outcome was evaluated. In all cases, the hepatic artery stent grafting was successfully performed, and the bleeding was immediately stopped. Clinically, immediately after the procedure, there was an obvious improvement in the general patient condition. There were no immediate procedure-related complications. Completion angiography (n=5) demonstrated control of the hemorrhage and patency of the hepatic artery and the stent graft. Although all patients recovered hemodynamically, three individuals died 2 to 10days after the procedure. The remaining two patients survived, without the need for re-operation. Transluminal stent graft placement in the hepatic artery is a safe and technically feasible solution to control life-threatening bleeding of the gastroduodenal artery stum

The use of flat panel angioCT (DynaCT) for navigation through a deformed and fractured carotid stent

Navigation through a previously deployed and deformed stent is a difficult interventional task. Inadvertent navigation through the struts of a stent can potentially lead to incomplete secondary stent extension and vessel occlusion. Better visualisation of the pathway through the stent can reduce the risks of the procedural complications and reduce the reluctance of the interventionalist to navigate through a previously deployed stent. We describe a technique of visualisation of the pathway navigated by a guidewire through a previously deployed deformed and fractured carotid stent by the use of DynaCT. Three-dimensional reconstruction of the stent/microwire allows excellent visualisation of the correct pathway of the microwire within the sten

Closing the gap between coil and balloon in the neurointerventional armamentarium? Initial clinical experience with a nitinol vascular occlusion plug

Introduction: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. Methods: Between 2005 and 2007 four patients (mean age 38.5years, range 16-62years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. Results: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. Conclusion: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointervention

Thoracic endovascular aortic repair: impact of urgency on outcome and quality of life

Objectives: Endovascular repair of the descending thoracic aorta is a very promising technique in elective and, particularly, emergency situations. This study assessed the impact of urgency of the procedure on outcome and mid-term quality of life in surviving patients. Methods: Post hoc analysis of prospectively collected data of 58 consecutive patients (January 2001-December 2005) with surgical pathologies of the descending thoracic aorta treated by endovascular means. Six patients were excluded due to recent operations on the ascending aorta before thoracic endovascular repair. The remaining patients (n=52) were 69±10 years old, and 43 were men (83%). Twenty-seven had been treated electively, and 25 for emergency indications. Reasons for emergency were acute type B aortic dissections with or without malperfusion syndrome in 14, and aortic ruptures in 11 cases. Follow-up was 29±16 months. Endpoints were perioperative and late morbidity and mortality rates and long-term quality of life as assessed by the short form health survey (SF-36) and Hospital Anxiety and Depression Scale questionnaires. Results: Cohorts were comparable regarding age, sex, cardiovascular risk factors, and comorbidities. Perioperative mortality was somewhat higher in emergency cases (12% vs 4%, p=0.34). Paraplegia occurred in one patient in each cohort (4%). Overall quality of life after two and a half years was similar in both treatment cohorts: 72 (58-124) after emergency, and 85 (61-105) after elective endovascular aortic repair (p=0.98). Normal scores range from 85 to 115. Anxiety and depression scores were in the normal range and comparable. Conclusions: Thoracic endovascular aortic repair is an excellent and safe treatment option for the diseased descending aorta, particularly in emergency situations. Early morbidity and mortality rates can be kept very low. Mid-term quality of life was not affected by the urgency of the procedure. Similarly, mid-term anxiety and depression scores were not increased after emergency situation

17β-Estradiol inhibits proliferation and migration of human vascular smooth muscle cells: similar effects in cells from postmenopausal females and in males

Objectives: Cardiovascular disease is rare in premenopausal women, but increases after the menopause when hormone replacement therapy reduces coronary events. Vascular smooth muscle cell (SMC) proliferation and migration occur in atherosclerosis, restenosis and venous graft disease. We studied the effects of 17β-estradiol on SMC proliferation and migration. Methods: SMC were cultured from saphenous veins of postmenopausal women and age-matched men. Cell growth was determined by 3H-thymidine incorporation and cell counting. Migration of SMC was assessed in 4-well chambers. SMC were seeded in one corner and PDGF-BB in filter paper glued onto the opposite wall. Results: PDGF-BB (5 ng/ml for 24 h) similarly stimulated 3H-thymidine incorporation in female (511 ± 57%; n = 8) and male (528 ± 62%; n = 12) SMC. This was reduced by 17β-estradiol (10−8-10−6 M; female 313 ± 52%; male 337 ± 54%; P < 0.05). PDGF-BB increased the number of SMC (P < 0.0001 at 10 days) obtained from females (153 ± 3%; n = 5) and males (150 ± 4%; n = 5), which was inhibited by 17 β-estradiol (10−6 M; female 134 ± 7%; male 128 ± 5%; P < 0.05). Similar results were obtained with basic fibroblast growth factor. In contrast to 17β-estradiol, another steroid (dexamethasone) had no effects on 3H-thymidine incorporation in these cells stimulated with PDGF-BB. PDGF-BB (0.01-1 ng) stimulated SMC migration (P < 0.05) which was inhibited by 17β-estradiol (10−10-10−6 M; n = 5; P < 0.005). Conclusion: 17β-Estradiol inhibits growth-factor-induced SMC proliferation and migration regardless of gender. These effects of 17β-estradiol may contribute to its cardiovascular protective properties in postmenopausal women during replacement therap

Fixed low-dose ultrasound-assisted catheter-directed thrombolysis for intermediate and high-risk pulmonary embolism

Aims No standardized local thrombolysis regimen exists for the treatment of pulmonary embolism (PE). We retrospectively investigated efficacy and safety of fixed low-dose ultrasound-assisted catheter-directed thrombolysis (USAT) for intermediate- and high-risk PE. Methods and results Fifty-two patients (65 ± 14 years) of whom 14 had high-risk PE (troponin positive in all) and 38 intermediate-risk PE (troponin positive in 91%) were treated with intravenous unfractionated heparin and USAT using 10 mg of recombinant tissue plasminogen activator per device over the course of 15 h. Bilateral USAT was performed in 83% of patients. During 3-month follow-up, two [3.8%; 95% confidence interval (CI) 0.5-13%] patients died (one from cardiogenic shock and one from recurrent PE). Major non-fatal bleeding occurred in two (3.8%; 95% CI, 0.5-13%) patients: one intrathoracic bleeding after cardiopulmonary resuscitation requiring transfusion, one intrapulmonary bleeding requiring lobectomy. Mean pulmonary artery pressure decreased from 37 ± 9 mmHg at baseline to 25 ± 8 mmHg at 15 h (P < 0.001) and cardiac index increased from 2.0 ± 0.7 to 2.7 ± 0.9 L/min/m2 (P < 0.001). Echocardiographic right-to-left ventricular end-diastolic dimension ratio decreased from 1.42 ± 0.21 at baseline to 1.06 ± 0.23 at 24 h (n = 21; P < 0.001). The greatest haemodynamic benefit from USAT was found in patients with high-risk PE and in those with symptom duration < 14 days. Conclusion A standardized catheter intervention approach using fixed low-dose USAT for the treatment of intermediate- and high-risk PE was associated with rapid improvement in haemodynamic parameters and low rates of bleeding complications and mortalit

Long-term outcome of symptomatic severe ostial vertebral artery stenosis (OVAS)

Introduction: The optimal management of patients with symptomatic severe ostial vertebral artery stenosis (OVAS) is currently unclear. We analyzed the long-term outcome of consecutive patients with OVAS who received either medical treatment (MT) or vertebral artery stenting (VAS). Methods: Thirty-nine (>70%) patients with severe OVAS were followed for a mean period of 2.8years. The decision for VAS (n = 10) or MT (n = 29) was left to the clinician. The Kaplan-Meier method was used to assess the risk of recurrent stroke, transient ischemic attack (TIA), or death over the study period. Results: Patients in the VAS group were significantly younger and more likely to have bilateral VA disease (P = 0.04 and P = 0.02). VAS was successfully performed in all ten patients. The periprocedural risk within 30days was 10% (one TIA). The overall restenosis rate was 10%. One restenosis occurred after 9months in a patient treated with bare-metal stent. At 4years of follow-up, VAS showed a nonsignificant trend toward a lower risk for the combined endpoint of TIA and stroke in posterior circulation compared to medical treatment (10% vs. 45%, P = 0.095; relative risk (RR) = 0.24, 95% confidence interval (CI) 0.031-1.85). Patients with bilateral VA disease had a significantly lower recurrence risk after VAS compared with medical treatment (0% vs. 91% at 4years, P = 0.004; RR 0.10, 95% CI 0.022-0.49) Conclusion: VAS was performed without permanent complications in this small series of patients with symptomatic severe OVAS. The long-term benefit seems to be confined to patients with bilateral but not to those with unilateral VA diseas

Closing the gap between coil and balloon in the neurointerventional armamentarium? Initial clinical experience with a nitinol vascular occlusion plug

INTRODUCTION: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. METHODS: Between 2005 and 2007 four patients (mean age 38.5 years, range 16-62 years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. RESULTS: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5 min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. CONCLUSION: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointerventions