Minimal-invasiver Zugang für EVAR: Chirurgisch oder rein interventionell?

Zusammenfassung: Komplikationen kommen sowohl beim rein chirurgischen als auch rein interventionellen (perkutanen) Gefäßzugang nicht selten vor. Sie beinhalten eine nicht zu unterschätzende Morbidität und können sogar zum Tod führen. Wir beschreiben eine Technik, die die Vorteile der chirurgisch offenen mit den rein perkutanen Zugangsmethoden kombiniert: die minimale chirurgische Freilegung des Zugangsgefäßes, gefolgt von einer schnellen und sicheren Punktion mittels einer modifizierten, offenen Seldinger-Technik unter direkter taktiler und visueller Kontrolle. Diese einzigartige Kombination verschiedener Techniken erhöht die Sicherheit des Gefäßzugangs derart, dass lokale Komplikationen fast vollständig vermieden werden können. Ökonomische und sicherheitsrelevante Betrachtungen werden diskutiert, abgerundet durch einen ausgewogenen Überblick über die Vorteile der verschiedenen Technike

Advanced training model for beating heart coronary artery surgery: the Zurich heart-trainer

Objective: Coronary artery surgery with beating heart technique is gaining increasing popularity. However, it is a challenging technique even for well-trained cardiac surgeons. Thus, a training model for beating heart surgery was developed to increase safety and accuracy of this procedure. Methods: The model consists of differentially hardened polyurethane resembling mechanical properties of the human heart. The covering used in this model is a 1:1 replica of the human thoracic wall with optionally embedded skeletal structures. Sternotomy, lateral thoracotomy or trocar placement is possible to access the lungs, the pericardium and the heart with adjacent vessels. Disposable artificial coronaries variable in size, wall quality or wall thickness are embedded in the synthetic myocardium. Two-layer vessels, which can simulate dissection, are available. Bypass conduits utilize the same material. Coronaries/bypasses as well as part of the ascending aorta are water-tight and can be rinsed with saline. Lungs can be inflated. A purpose-built pump induces heart movement with adjustable or randomized stroke volume, heart rate and arrhythmia induction. Results: The model was tested in a recent ‘Wet-Lab' course attended by 30 surgeons. All conventional instruments and stabilizers with standard techniques can be used. Training with beating or non-beating heart was possible. Time needed for an anastomosis was similar to clinical experience. Each artificial tissue showed its individual nature-like qualities. Various degrees of difficulty can be selected, according to stroke volume, heart rate, arrhythmia, vessel size and vessel quality. The model can be quickly and easily set up and is fully reusable. Conclusions: The similarity to human tissue and the easy set-up make this completely artificial model an ideal teaching tool to increase the confidence of cardiac surgeons dealing with beating heart and minimally invasive surger

Left ventricular assist device as bridge to heart transplantation - lessons learned with the MicroMed DeBakey axial blood flow pump

Objective: The MicroMed DeBakey left ventricular assist device (LVAD) axial blood flow pump was used as bridge to heart transplantation (HTx) in patients with terminal heart failure. The aim was to evaluate this novel mechanical circulatory support system in regard to overall outcome. Methods: Prospective study in 15 HTx candidates (mean age 40±7 years) with terminal heart failure and maximal medical treatment due to ischemic cardiomyopathy (CMP, n=5), dilated CMP (n=3), restrictive CMP (n=2), unclassified CMP (n=1), metabolic CMP (n=1), valvular CMP (n=1) and congenital CMP (n=2). All patients were implanted with a MicroMed DeBakey LVAD. A rescue procedure was necessary in eight critical patients, while seven underwent elective LVAD implantation. Procedures were performed via median sternotomy, in normotherm femoro-femoral CPB (mean duration 59±1 min). Oral Marcoumar© (INR 2.0-3.0) and Aspirin© (100 mg daily) were started as soon as possible. Patients were discharged into a specialized rehabilitation clinic from which it was possible to release them home after a few weeks. Results: Successful implantation and discharge from ICU (mean stay 10±7 days) was possible in 11 patients. Seven were transplanted (mean support 50.7 days) and one is awaiting HTx (support >310 days) in the comfort of his home (NYHA I). Survival was 100% among the transplanted patients. Of the seven elective implants, five, and of the eight rescue procedures three patients underwent successful HTx. Four patients died early, while three patients died late on pump support due to intracranial hemorrhage (n=2, 73 and 76 days) and chest infection (n=1, 124 days). All survivors were discharged from hospital, with significant decrease in NYHA class (mean 3.8-2.4 (n=11)). Treadmill testing showed increased exercise tolerance, from 35 to 71 W (n=4). Plasma BNP values (mean 950-162 ng/l (n=4)) and pulmonary resistance (mean 316-194.5 dyne s/cm5 (n=3)) decreased significantly during LVAD support. Conclusions: The MicroMed DeBakey LVAD is simple to implant; outpatient treatment is safe and efficient. Patients' condition and pulmonary resistances normalize within 6 weeks, making previously considered inoperable patients amenable for HTx. HTx can be performed in low-risk situation, allowing better donor-recipient matching and improving overall outcom

Predictors of complications in acute type B aortic dissection

Objectives: Medical treatment is generally advocated for patients with acute type B aortic dissection without complications. The objective of this retrospective analysis was to determine whether there are any initial findings that can help predict the long-term course of the disease. Methods: Case records of the 130 patients treated for type B aortic dissection between 1988 and 1997 were reviewed; 41 (31%) were operated on in the acute phase (≪14 days), 31 (24%) were operated on in the chronic phase and 58 (45%) were treated medically. Results: Overall acute mortality was 10.8%; 22% for patients operated on in the early phase and 5.6% for medically treated patients. Age (P=0.002), persistent pain (P=0.01) and malperfusion (P=0.001) were significant independent predictors of the need for surgery. Paraplegia/para paresis (P=0.0001), leg ischaemia (P=0.003), pleural effusion (P=0.003), rupture (P=0.0001), shock (P=0.0001), age (P=0.003), cardiac failure (P=0.002) and aortic diameter ≫4.5cm (P=0.002) were significant predictors of poor survival. Age and shock also emerged as independent risk factors. Patients without malperfusion (P=0.0001), pleural effusion (P=0.003), rupture (P=0.0001) and shock (P=0.0001) had a significantly better event-free survival (freedom from repeat surgery and death). The actuarial survival rate for high-risk patients (malperfusion, rupture, shock) was 62% at 1 year and 40% at 5 years; the corresponding values for low-risk patients were 94 and 84%, respectively. Conclusions: Rupture, shock and malperfusion are significant predictors of poor survival in patients with acute type B aortic dissectio

Acute traumatic aortic rupture: early stent-graft repair

Objective: Prospective evaluation of early stent-graft repair of acute traumatic aortic rupture. Methods: Twelve patients with acute traumatic aortic rupture of the descending aorta, out of a series of 337 endovascular aortic procedures, were treated by implantation of self-expanding stent-grafts. The procedures were performed within a mean post-injury time-period of 5±7 days (median: 1 day). The feasibility of stent-grafting was assessed by CT scanning and echography. Implantation was performed under local (n=6), or general anesthesia (n=6) if patients were already intubated (n=5) or required a common iliac artery access (n=1). Results: The immediate technical success rate was 100%. There were no post-procedure complications in all but one patient, who died 12 h postoperatively (8% mortality). Complete sealing of the aortic rupture in the remaining 11 patients was confirmed by postoperative CT scans. There were no intervention-related morbidity or mortality during the mean follow-up of 17 months. One patient with peri-graft leakage was successfully repaired with an additional stent-graft 12 months postoperatively. Conclusion: Non-delayed or early stent-grafting in acute traumatic rupture of the descending aorta is feasible. This technique seems to be a valuable option, in particular when associated lesions may interfere with the surgical outcome. Immediate post-procedural CT scanning and/or echography should be performed, in order to rule out residual leakag

Simultane Behandlung von obliterativen Karotispathologien und koronarer Herzkrankheit: Aktuelles Konzept und Resultate der letzten 5Jahre

Zusammenfassung: Einführung: Die kombinierte Karotisendarteriektomie und aorto-coronare Baypassoperation (C-CABG) weisen ein hohes peri-operatives Risiko auf. Als Alternative wird in letzter Zeit das Stenting der Artera carotis interna propagiert. Das Fehlen von Level I Evidenz hat uns motiviert, die Resultate unserer C-CABG der letzten 5 Jahre zu evaluieren. Methoden und Patienten: Retrospektive Monozenterstudie von 113C-CABG, durchgeführt zwischen Januar 2000 und Dezember 2004. Das mediane Alter der Patienten betrug 65Jahre (22Patienten waren 80Jahre alt oder älter). Die Karotisendarteriektomie wurde vor der aortokoronaren Bypassoperation in derselben Narkose durchgeführt. Resultate: Die 30-Tages-Mortalität war ausschließlich kardial bedingt und betrug 4,4% (5/113). Die neurologischen Komplikationen waren ein Schlaganfall, der innerhalb von 30Tagen vollständig regredient war, und 3TIA (3,5%, 4/113). Schlussfolgerung: C-CABG mit initial durchgeführter Karotisendarteriektomie ist ein sicheres Verfahren mit niedriger neurologischer Komplikationsrate. Der riskante Anteil des kombinierten Eingriffs ist nicht die Karotisendarteriektomie, sondern die aortokoronare Revaskularisation. Demzufolge scheint das Stenting beim kombinierten Eingriff als Alternative nicht gerechtfertigt, solange keine klaren Vorteile hinsichtlich der Früh- und Langzeitresultate gegenüber der alleinigen Karotisendarteriektomie vorliege

Aortic stent-grafting: successful introduction into the combined procedure for coronary artery bypass grafting and aortic aneurysm repair

Objectives: Coronary artery bypass grafting (CABG) and combined stent-grafting (SG) were evaluated to reduce morbidity and mortality of patients with descending or infrarenal aortic aneurysm. Methods: CABG and SG (thoracic n=6, infrarenal n=36) were performed during the same hospitalization in 42 patients (mean age of 73±14 years). In 29 patients (mean Euroscore: 9), SG was performed under local anesthesia 9±3 days after coronary surgery (simultaneous) and in 13 patients (mean Euroscore: 7) during the same anesthesia (synchronous). In the latter group, 11 out of 13 patients underwent off-pump CABG. All aneurysms were treated by implantation of commercially available self-expanding grafts. Results: CABG was successful in all, but one patient with left internal mammary artery hypoperfusion syndrome, requiring an additional distal saphenous graft to the left anterior descending coronary artery. SG was uneventful in 98% (41/42 patients). Postoperative computerized tomography showed incomplete sealing in seven patients (17%), but only the two attachment endoleaks had to be treated by one proximal and one distal SG extension. Overall hospital stay for the synchronous repair was 12.5±6 days and that of the simultaneous group 17.5±7 days. Thirty-day mortality was 5% (2/42) as one patient of the simultaneous group experienced a lethal cerebral embolism during SG and one patient of the synchronous group developed an untreatable infection. In the follow-up of 4 years, there were two vascular reinterventions but no additional procedure-related morbidity or mortality. Conclusions: This experience shows that combined CABG and SG of thoracic or infrarenal aortic aneurysm is a safe and less-invasive alternative to the open graft repair, especially in the older patients or patients with severe comorbiditie