Patients with Acute Limb Ischemia Might Benefit from Endovascular Therapy—A 17-Year Retrospective Single-Center Series of 985 Patients

Acute lower limb ischemia (ALI) is a common vascular emergency, requiring urgent revascularization by open or endovascular means. The aim of this retrospective study was to evaluate patient demographics, treatment and periprocedural variables affecting the outcome in ALI patients in a consecutive cohort in a tertiary referral center. Primary outcome events (POE) were 30-day (safety) and 180-day (efficacy) combined mortality and major amputation rates, respectively. Secondary outcomes were perioperative medical and surgical leg-related complications and the 5-year combined mortality and major amputation rate. Statistical analysis used descriptive and uni- and multivariable Cox regression analysis. In 985 patients (71 ± 9 years, 56% men) from 2004 to 2020, the 30-day and 180-day combined mortality and major amputation rates were 15% and 27%. Upon multivariable analysis, older age (30 d: aHR 1.17; 180 d: 1.27) and advanced Rutherford ischemia stage significantly worsened the safety and efficacy POE (30 d: TASC IIa aHR 3.29, TASC IIb aHR 3.93, TASC III aHR 7.79; 180 d: TASC IIa aHR 1.97, TASC IIb aHR 2.43, TASC III aHR 4.2), while endovascular treatment was associated with significant improved POE after 30 days (aHR 0.35) and 180 days (aHR 0.39), respectively. Looking at five consecutive patient quintiles, a significant increase in endovascular procedures especially in the last quintile could be observed (17.5% to 39.5%, p < 0.001). Simultaneously, the re-occlusion rate as well as the number of patients with any previous revascularization increased. In conclusion, despite a slightly increasing early re-occlusion rate, endovascular treatment might, if possible, be favorable in ALI treatment

Endovascular aortic repair with sac embolization for the prevention of type II endoleaks (the EVAR-SE study): study protocol for a randomized controlled multicentre study in Germany

Background Beyond a certain threshold diameter, abdominal aortic aneurysms (AAA) are to be treated by open surgical or endovascular aortic aneurysm repair (EVAR). In a quarter of patients who undergo EVAR, inversion of blood flow in the inferior mesenteric artery or lumbar arteries may lead to type II endoleak (T2EL), which is associated with complications (e.g. AAA growth, secondary type I endoleak, rupture). As secondary interventions to treat T2EL often fail and may be highly invasive, prevention of T2EL is desirable. The present study aims to assess the efficacy of sac embolization (SE) with metal coils during EVAR to prevent T2EL in patients at high risk. Methods Over a 24-month recruitment period, a total of 100 patients undergoing EVAR in four vascular centres (i.e. Klinikum rechts der Isar of the Technical University of Munich, University Hospital Augsburg, University Hospital Dresden, St. Joseph’s Hospital Wiesbaden) are to be included in the present study. Patients at high risk for T2EL (i.e. ≥ 5 efferent vessels covered by endograft or aneurysmal thrombus volume <40%) are randomized to one group receiving standard EVAR and another group receiving EVAR with SE. Follow-up assessments postoperatively, after 30 days, and 6 months involve contrast-enhanced ultrasound scans (CEUS) and after 12 months an additional computed tomography angiography (CTA) scan. The presence of T2EL detected by CEUS or CTA after 12 months is the primary endpoint. Secondary endpoints comprise quality of life (quantified by the SF-36 questionnaire), reintervention rate, occurrence of type I/III endoleak, aortic rupture, death, alteration of aneurysm volume, or diameter. Standardized evaluation of CTA scans happens through a core lab. The study will be terminated after the final follow-up visit of the ultimate patient. Discussion Although preexisting studies repeatedly indicated a beneficial effect of SE on T2EL rates after EVAR, patient relevant outcomes have not been assessed until now. The present study is the first randomized controlled multicentre study to assess the impact of SE on quality of life. Further unique features include employment of easily assessable high-risk criteria, a contemporary follow-up protocol, and approval to use any commercially available coil material. Overcoming limitations of previous studies might help SE to be implemented in daily practice and to enhance patient safety. Trial registration ClinicalTrials.gov NCT05665101. Registered on 23 December 2022

Ferrimagnetism and disorder in epitaxial Mn(2-x)Co(x)VAl thin films

The quaternary full Heusler compound Mn(2-x)Co(x)VAl with x = 1 is predicted to be a half-metallic antiferromagnet. Thin films of the quaternary compounds with x = 0...2 were prepared by DC and RF magnetron co-sputtering on heated MgO (001) substrates. The magnetic structure was examined by x-ray magnetic circular dichroism and the chemical disorder was characterized by x-ray diffraction. Ferrimagnetic coupling of V to Mn was observed for Mn2VAl (x = 0). For x = 0.5, we also found ferrimagnetic order with V and Co antiparallel to Mn. The observed reduced magnetic moments are interpreted with the help of band structure calculations in the coherent potential approximation. Mn2VAl is very sensitive to disorder involving Mn, because nearest-neighbor Mn atoms couple anti-ferromagnetically. Co2VAl has B2 order and has reduced magnetization. In the cases with x >= 0.9 conventional ferromagnetism was observed, closely related to the atomic disorder in these compounds.Comment: 10 pages, 4 figure

Röntgenabsorptionsspektroskopie und magnetischer Röntgenzirkulardichroismus an dünnen Heusler Filmen

Verbindungen aus nicht ferromagnetischen Bestandteilen, die ferromagnetische Eigenschaf-ten zeigen, sind seit Anfang des 20. Jahrhunderts bekannt und werden nach ihrem Entdecker als Heusler-Verbindungen bezeichnet. Seitdem haben sie nichts von ihrer Faszination eingebüßt, besitzen sie doch eine Fülle besonderer Eigenschaften mit Anwendungen z.B. in der Spintronik.rnAuf der Suche nach geeigneten Legierungen ist es wünschenswert, zunächst grundlegende Eigenschaften wie das magnetische Moment elementspezifisch bestimmen zu können. Hierfür sind Methoden wie Röntgenabsorptionsspektroskopie und magnetischer Röntgenzirkulardichroismus (XAS/XMCD) prädestiniert.rnIm Rahmen dieser Arbeit wurde eine Apparatur entwickelt, mit deren Hilfe XAS- und XMCD-Messungen an dünnen Heusler-Filmen durchgeführt werden können. Da Grenzflächeneigenschaften von besonderem Interesse sind, wurde der experimentelle Aufbau so gewählt, dass gleichzeitig Volumen und Oberflächeneigenschaften untersucht werden können. Durch Vergleich dieser Messdaten erhält man Zugang zu den Grenzflächeneigenschaften.rnSo konnte mit XAS-Messungen nachgewiesen werden, dass sich die chemischen Eigenschaften an der Grenzfläche mancher Filme von denen im Volumen des Films unterscheiden (Oxidation bzw. Interdiffusion der Abdeckschicht). Auch stöchiometrische Unterschiede zwischen Oberfläche und Volumen konnten so identifiziert werden.rnMit Hilfe von XMCD-Messungen wurden elementspezifische magnetische Momente bestimmt und mit theoretischen Vorhersagen verglichen. Auch hierbei konnten Oberflächen- und Volumenmomente miteinander verglichen werden. So wurde z.B. unter Verwendung einer Schichtserie die Anzahl magnetischer Totlagen an beiden Grenzflächen bestimmt. Diese Informationen sind wichtig, um die Qualität dünner Filme steigern zu können.rnDes Weiteren war es auch möglich, temperaturabhängige Änderungen in der Ni2MnGa Zustandsdichte, die von der Theorie vorhergesagt wurden, in den XAS-Spektren nachzuweisen. Schließlich wurde noch eine Methode entwickelt, die es erlaubt, unter bestimmten Voraussetzungen auf die partielle unbesetzte Zustandsdichte (PDOS) zu schließen. Dies liefert wichtige Hinweise auf Lage und Breite der bisher nur theoretisch vorhergesagten Bandlücke. Es ist mit der hier vorgestellten Methode nicht möglich, die gesamte PDOS für alle Elemente zu vermessen, doch können so relativ leicht vielversprechende Kandidaten für weitere Untersuchungen gefunden werden.rnThere is a class of compounds consisting of non-ferromagnetic components, which nonetheless exhibit ferromagnetic behavior. They are referred to as Heusler compounds, named after F. Heusler, who discovered them at the beginning of the 20th century. Since then they haven’t lost any of their fascination, as they exhibit a plethora of special properties with applications in e.g. spintronics.rnWhen searching for suitable alloys, it is desirable to first determine the basic properties like the magnetic moment for each element. Methods like X-ray absorption spectroscopy (XAS) and X-ray magnetic circular dichroism (XMCD) are well suited for this purpose.rnAccordingly, a system capable of performing XAS and XMCD measurements on thin Heusler films was employed for this thesis. Since interface properties are of particular interest, the experimental setup was designed to allow for the simultaneous investigation of surface and bulk properties. A comparison of these measurements provides access to the interface properties.rnXAS measurements proved that the chemical properties at the interface of some films deviate from the bulk due to oxidation and interdiffusion. Stoichiometric differences between bulk and interface could be identified as well.rnThe element specific magnetic moments were determined using XMCD and compared with theoretical predictions, once again separating bulk and surface. For example, a layer series was used to determine the number of magnetic dead layers at both interfaces. This information is important for improvements in the quality of thin films.rnFurthermore, using XAS it was possible to confirm temperature dependent changes in the density of states of Ni2MnGa, which had been predicted by theory. Finally, a method was developed that allows inferring the partial unoccupied density of states (PDOS) under certain conditions. This provides important information on the position and width of the theoretically predicted band gap. It is not possible to measure the whole PDOS for all elements with this method, but it is relatively easy to identify promising candidates for further investigations.r

Surgical treatment of clavicular nonunion with the anatomical precontoured Meves compression plate

Die Pseudarthrose des mittleren Claviculadrittels stellt sich oft mit lokalen Schmerzen, Bewegungseinschränkung und neurologischen oder Durchblutungsstörungen dar. Für ein gutes postoperatives Ergebnis ist die anatomisch korrekte und mechanisch stabile Rekonstruktion unerlässlich. In dieser Arbeit wurden Patienten mit der anatomisch präkonturierten Meves-Kompressionsplatte behandelt. Es konnte eine sichere Heilung der Claviculapseudarthrose mit gutem bis sehr gutem klinischen Ergebnis unter der Verwendung der anatomisch präkonturierten Meves-Kompressionsplatte erzielt werden.Pseudarthroses of the clavicle after fractures of the medial third often present with local pain, compromised shoulder function, or neurovascular symptoms. Reconstruction of normal clavicular anatomy and solid fusion is a prerequisite for good clinical outcome after surgical treatment. In this study, patients with clavicular pseudarthrosis were treated with the anatomical precontoured Meves plate. In our patients, secure healing of clavicular nonunion was achieved with the anatomical precontoured Meves plate, with good or excellent clinical outcomes

Early and midterm outcomes of open and endovascular revascularization of chronic mesenteric ischemia

Background: Revascularization strategies for chronic mesenteric ischemia (CMI) include open (OR) and endovascular (ER) modalities. The primary objective of this study was to analyze the safety and effectiveness of OR and ER and the impact of clinical and morphological variables on early and midterm outcomes in a consecutive series of CMI patients in a tertiary referral center. Patients and methods: From 2004 to 2017, all CMI patients treated with OR and ER were retrospectively identified. Patient records, preoperative imaging, as well as peri- and postoperative outcomes were analyzed. Univariable and multivariable analysis was performed to identify clinical or morphological variables affecting reintervention rates within 2 years. Results: In total, 63 patients (33% male; mean age 71, range 60-76 years) were treated by ER (41 patients) or OR (22 patients) for CMI. Mean follow-up was 26 (10-71) months. 30-day mortality was 0.0% after ER and 4.5% after OR (p = 0.069); 30-day morbidity was 9.8% vs. 31.8%, respectively (p = 0.030). Length of stay was significantly longer after OR (14 vs. 4 days; p < 0.001). Freedom from reintervention rate after 2 years was 82% after OR and 73% after ER (p = 0.14). Overall survival did not differ after 2 years (OR 85% vs. ER 86%; p = 0.35). Multivariable analysis revealed that smoking was associated with higher risk of reintervention (hazard ratio, HR: 4.14; 95% confidence interval, CI 1.11-15.53; p = 0.03). Additionally, a nonsignificant trend of lower reintervention rates after OR was detected (HR 0.23 95% CI 0.05-1.08; p = 0.06). Conclusion: Due to a lower invasiveness, despite the higher reintervention rate, an "endovascular first" strategy is justified and recommended

Prospective comparison of duplex ultrasound and angiography for intra-operative completion studies after carotid endarterectomy

Objective: The application of intra-operative completion studies may have contributed to the ongoing improvement of peri-operative outcomes in carotid surgery. Methods: This prospective study aimed to compare angiography and duplex ultrasound (IDUS) as intra-operative completion studies after carotid endarterectomy (CEA) with respect to differences in the rating of vessel wall defects and interobserver reliability. Patients undergoing CEA for symptomatic or asymptomatic carotid stenosis were included. After CEA, angiography and IDUS were performed. Intra-operatively obtained video footage was evaluated at a later date by three independent and blinded raters with different levels of clinical experience. Rating was done according to a four step rating scale, with higher grades representing more severe defects. Standard statistical methods (Pearson's chi square test; permutation test; Wilcoxon signed rank test; Kendall's coefficient of concordance, Wt) were applied. Results: In total, 150 patients (mean ± standard deviation age 72 ± 7 years, 68.7% male, 33.3% symptomatic) were enrolled between March 2016 and September 2017. Significantly more defects requiring intra-operative revision (grades 3 and 4 on rating scale) were detected by IDUS, which, in part, remained undetected by angiography: 22 (14.7%) vs. 10 (6.7%) (p = .040). Defects were also judged to be more severe with IDUS than with angiography: median rating grade 1: 74 (49.3%) vs. 102 (68.0%); grade 2: 54 (36.0%) vs. 38 (25.3%); grade 3: 21 (14.0%) vs. 9 (6.0%); grade 4: 1 (0.7%) vs.1 (0.7%) (p < .001). Furthermore, Wt was significantly higher for IDUS compared with angiography (0.70 vs. 0.57; p = .003). Conclusion: IDUS revealed more defects after CEA than angiography. Despite both techniques only showing moderate interobserver reliability, IDUS is less dependent on the surgeon's subjectivity than angiography. Taking into account the absence of procedure associated risks (i.e., adverse effects of iodinated contrast media and Xray), IDUS could be considered as an alternative intra-operative morphological assessment tool in carotid surgery

Lack of durability after transarterial ethylene-vinyl alcohol copolymer-embolization of type II endoleak following endovascular abdominal aortic aneurysm repair

Summary: Background: Type II endoleak (T2EL) after endovascular aortic repair is associated with AAA sac enlargements in up to 25%, reduction of attachment zones and rarely with aortic rupture. Indications for therapy and efficacy of interventions of T2EL are not clearly established. Transarterial embolization with application of ethylene-vinyl alcohol copolymer has been described with varying outcomes. Aim of this study is to evaluate durability of OnyxTM embolization (OE) in T2EL in a consecutive series at a single tertiary vascular center. Patients and methods: Demographic data, technical success, pre- and postoperative aneurysm growth, morbidity, mortality and reintervention rates during hospital stay as well as in follow up were recorded in patients treated with OE for T2EL between 01/2015 and 12/2017. The primary endpoint was defined as persistence or reoccurrence of T2EL (durability of OE). Results: In total 15 patients (78 ± 6 years, 13 men) were treated with OE because of sac enlargement (average growth of 12 ± 8%, n = 12), persistent bleeding after AAA rupture (n = 2) or persistent T2EL with stable but large aneurysm diameter (n = 1). Mean length of stay was 8 ± 11 days. Technical success was 93.3% (n = 14). Inhospital-morbidity was 26.7%, in-hospital- and 1-year-mortality rate were 6.6% (n = 1) and 20.0% (n = 3). T2EL persisted in 20.0% (n = 3) despite of OE. Re-EL-II occurred after 40 (30–114) days in 33.3% (n = 5). Reintervention rate was 13.3% (n = 2, at day 48 and 319). Altogether clinical success with stable aneurysm diameter was achieved in 80.0% (n = 12), but durable elimination of EL was only achieved in 46.7% of patients (n = 7). Conclusions: OE is technically possible in more than 90% of patients but might be associated with severe complications. Durability of this treatment is low, since T2EL persist or reoccur in more than 50% of all patients. OE of T2EL should be reserved for few selected cases