Chirurgische und interventionelle Behandlung der chronisch-kritischen Beinischämie

Die chronisch-kritische Beinischämie (CLI) ist die schwerste Form der peripher-arteriellen Verschlusskrankheit und geht mit einem erhöhten Risiko für letale kardiovaskuläre Ereignisse einher. Die meisten Patienten überleben aber die ersten Jahre nach Diagnosestellung und sind für den Erhalt ihrer Selbständigkeit auf eine nachhaltige Verbesserung der Beindurchblutung angewiesen. Dieser CME-Artikel fasst die chirurgischen und endovaskulären Optionen zur Revaskularisierung zusammen und geht auf deren Nachhaltigkeit bei CLI ein. Grenzen der verfügbaren Evidenz werden aufgezeigt. Sie beruhen vor allem auf dem Fehlen einer einheitlichen Definition des Behandlungserfolges. Ein klinisch orientierter Lösungsvorschlag wird diskutiert, der helfen könnte, die verschiedenen Behandlungsindikationen zu schärfen. Da sich aber nur die wenigsten Patienten gleich gut für verschiedene Verfahren eignen, werden CLI-Patienten auch in Zukunft am besten in einem interdisziplinär arbeitenden Team betreut sein.Chronic critical limb ischemia (CLI) represents the most severe form of peripheral arterial occlusive disease and is associated with an increased risk for fatal cardiovascular events. However, most patients survive the first years after diagnosis and, to remain independent, depend on durable improvement of limb perfusion. This CME article summarizes the various surgical and endovascular options of revascularization in the context of CLI and discusses their durability. Available evidence is limited which is mainly due to a lack of a generally accepted outcome definition of clinical treatment success. A recently proposed clinically driven measure of success is discussed and how its use could improve definition of specific indications. As only few patients are clinically equally suitable for various treatment options, CLI patients will certainly remain to be managed best within interdisciplinary teams with close collaboration between surgeons and interventionalists

In-Vivo Quantification of Femoro-popliteal Artery Deformations: Percutaneous Transluminal Angioplasty vs. Nitinol Stent Placement

Purpose: To quantify the deformations of the femoro-popliteal (FP) arteries in patients undergoing endovascular revascularization of the FP arterial tract and to compare the effects of primary Nitinol stent implantation on the post-treatment arterial deformations with the effects of percutaneous transluminal angioplasty (PTA). Methods: 35 patients with peripheral arterial disease (PAD) were recruited for the study. During endovascular interventions, angiographic images were acquired with the legs straight and with a hip/knee flexion of 20°/70°. Image acquisition was performed before PTA for all patients; after PTA for 17 patients that only underwent balloon angioplasty; and after primary Nitinol stent implantation for the remaining 18 patients. A semi-automatic approach was used to reconstruct the 3D patient-specific artery models from 2D radiographs. Axial shortening and curvature changes in the arteries were calculated in-vivo for the calcified, ballooned and stented regions, as well as the regions that are distal and proximal to the diseased and treated segments. Results: Leg flexion resulted in arterial shortening in all investigated segments. The ballooned arteries exhibited higher shortening compared to their stented counterparts (post-balloon: 7.6% ± 4.9%; post-stent: 3.2% ± 2.9%; P: 0.004). Leg flexion also led to an increase in the curvatures of all the segments of the FP arteries. Although there were no statistically significant differences between the bending behaviors of the arteries treated with different methods, 40% of the stented arteries exhibited arterial kinking during leg flexion. Conclusion: The choice of the treatment method affects the post-interventional axial deformations of the FP arteries, but does not influence their curvatures. While PTA results in a more flexible artery, stents restrict the arteries’ shortening capabilities. Depending on the anatomical position of the stents, this axial stiffening of the arteries may lead to chronic kinking, which may cause occlusions and, consequently, impact the long-term success of the procedure

Cost-effectiveness analysis of paclitaxel-coated balloons for endovascular therapy of femoropopliteal arterial obstructions.

PURPOSE To explore the cost-effectiveness of using drug-eluting balloon (DEB) angioplasty for the treatment of femoropopliteal arterial lesions, which has been shown to significantly lower the rates of target lesion revascularization (TLR) compared with standard balloon angioplasty (BA). METHODS A simplified decision-analytic model based on TLR rates reported in the literature was applied to baseline and follow-up costs associated with in-hospital patient treatment during 1 year of follow-up. Costs were expressed in Swiss Francs (sFr) and calculated per 100 patients treated. Budgets were analyzed in the context of current SwissDRG reimbursement figures and calculated from two different perspectives: a general budget on total treatment costs (third-party healthcare payer) as well as a budget focusing on the physician/facility provider perspective. RESULTS After 1 year, use of DEB was associated with substantially lower total inpatient treatment costs when compared with BA (sFr 861,916 vs. sFr 951,877) despite the need for a greater investment at baseline related to higher prices for DEBs. In the absence of dedicated reimbursement incentives, however, use of DEB was shown to be the financially less favorable treatment approach from the physician/facility provider perspective (12-month total earnings: sFr 179,238 vs. sFr 333,678). CONCLUSION Use of DEBs may be cost-effective through prevention of TLR at 1 year of follow-up. The introduction of dedicated financial incentives aimed at improving DEB reimbursements may help lower total healthcare costs

[Aortic aneurysms and aortic dissection : Epidemiology, pathophysiology and diagnostics.]

Aortic aneurysms and aortic dissection represent a significant health risk due to the demographic developments and current life styles. The mortality of ruptured aortic aneurysms is up to 80 % and the prevalence of aneurysms varies depending on the localization (thoracic or abdominal). Most commonly affected is the infrarenal abdominal aorta; however, there is evidence that the prevalence is diminishing but in contrast the incidence of thoracic aortic aneurysms is increasing. Aortic dissection is often fatal and is the most common acute aortic disease but the incidence is presumed to be underestimated. The pathogenesis of aortic aneurysms is manifold and is based on an interplay between degenerative, proteolytic and inflammatory processes. An aortic dissection arises from a tear in the intima which results in a separation of the aortic wall layers with infiltration of bleeding and the danger of aortic rupture. Various genetic disorders of connective tissue promote degeneration of the aortic media, most notably Marfan syndrome. Risk factors for aortic aneurysms and aortic dissection are nicotine abuse, arterial hypertension, age and male gender. Aortic aneurysms initially have an uneventful course and as a consequence are mostly discovered incidentally. The clinical course and symptoms of aortic dissection are very much dependent on the section of the aorta affected and the manifestations are manifold. Acute aortic dissection is in 80 % of cases first manifested as sudden extremely severe pain. The diagnostics and subsequent course control can be achieved by a variety of imaging procedures but the modality of choice is computed tomography