Management von Standard- und komplexen Aorten Pathologien

Einleitung Aufgrund der Entwicklung von Technologie und chirurgischen Verfahren ist die Aortenchirurgie zu einem routinemäßigen chirurgischen Eingriff geworden. Die Sterblichkeits- und Morbiditätsraten haben sich in den letzten Jahrzehnten aufgrund eines verbesserten perioperativen Managements stetig verbessert. Trotz dieser Entwicklung bleibt die Behandlung der „komplexen“ Aorta eine große Herausforderung für Chirurgen und Anästhesisten (1). Definitionen Der Begriff „Standard“-Aortenchirurgie hängt in den meisten Fällen vom geplanten chirurgischen Eingriff ab. Er bezeichnet einige morphologische und anatomische Kriterien, die ein gutes und problemloses Vorgehen bei der Aortenoperation vorhersagen können (1, 2). Aus diesem Grund tauchen Begriffe wie „Standard-EVAR-Chirurgie“, oder „Standard-offene-Aortenchirurgie“ eher in der Alltagssprache der Gefäßchirurgen auf. Mit der Weiterentwicklung zahlreicher neuer Modalitäten in der minimalinvasiven Aortenchirurgie, und der Standarisierung von Aorteneingriffen werden neue Begriffe wie „Standard-TEVAR“, „Standard-Iliac-Side-Branch“ oder „Standard-fEVAR“ möglicherweise häufiger in der Sprache der Gefäßchirurgen verwendet (3). Bei der Standard-EVAR-Operation handelt es sich in den meisten Fällen um ein infrarenales Aortenaneurysma mit einer proximalen Halslänge von mindestens 10 mm und einer ausreichenden iliakalen Landezone. Darüber hinaus bedeutet „Standard-offene-Aortenchirurgie“ eine Operation, bei der eine infrarenale Klemmung der Aorta möglich ist. Für die komplexe Aortenchirurgie gibt es in der Literatur keine klare oder einheitliche Definition (4). Die meisten Definitionen der „komplexen“ Aorta basieren auf morphologischen und anatomischen Abweichungen von den EVAR-Gebrauchsanweisungen (Instructions for Use, IFU) oder auf der Ausdehnung des Aneurysmas oberhalb der Nierenarterien. In diese Kategorie fallen juxta- und supra-renale Aneurysmen, sowie thorakale und thorako-abdominelle Aneurysmen, die keine proximale und distale Landungszone aufweisen (5, 6). Andere Kriterien wie Ruptur oder Infektion der Aorta sind in diesen Definitionen nicht enthalten

Aortic aneurysm and aortic graft infection related to Mycobacterium bovis after intravesical Bacille Calmette–Guérin therapy—a case series

Background: So called "mycotic" aortic aneurysms account for only 0.7 to 1.3% of all aortic aneurysms and are commonly caused by Staphylococcus aureus and Salmonella species. Bacillus Calmette-Guerin (BCG), a live attenuated strain of Mycobacterium bovis, is part of the therapy of non-muscle-invasive bladder cancer (NMIBC). Case presentation: We report a case series of three patients with a mycobacterial graft infection related to BCG after surgical treatment of a presumed mycotic aortic aneurysm as an extremely rare complication after NMIBC treatment. All three patients developed aortic aneurysm after BCG instillation and subsequent mycobacterial graft infection. Conclusion: Diagnosis requires a high degree of suspicion because of its nonspecific symptoms and imaging. The pathogen is not detected by standard microbiological testing. Treatment includes triple antimycobacterial therapy and radical surgical interventions. Graft preservation may be considered if no anastomosis is involved

Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery

Purpose: To report and compare the results of endovascular and open surgical treatment for erosion bleeding of visceral arteries following pancreatitis and pancreatic surgery. Materials and Methods: This retrospective study included 65 consecutive patients (46 males, mean age 63 +/- 14 years) presenting with visceral artery erosions between January 2011 and December 2020. Endpoints were technical success, freedom from reintervention, stent-graft-related complications, and 30-day and one-year mortality. Results: The causes of erosion bleeding included complications of surgical treatment for the pancreas and upper gastrointestinal tract (75%), pancreatitis (19%), and spontaneous bleeding (6%). Pancreatectomy was performed in 34 (52%) patients, representing 2% of all pancreatectomy procedures (n = 1645) performed in our hospital during the study period. A total of 37 (57%) patients underwent endovascular treatment (EVT), and 28 (43%) patients had open surgery (OS) as a primary treatment. Eight of 37 (22%) patients in the EVT group underwent stent-graft treatment of the eroded vessels and 28 (78%) coil embolization. Six (9%) patients underwent reintervention with no significant differences between EVT and OS groups (11% vs. 7%, p = 0.692). Postoperative morbidity and complications in 52% of all patients were higher in the OS group than in the EVT group (41% vs. 68%, p = 0.029). The in-hospital 30-days mortality rate for all patients was 25%, and it was higher in the OS group than in the EVT group (14% vs. 39%, p = 0.017). Conclusions: An endovascular-first strategy for treating visceral arteries erosions may be preferred to reduce the complications associated with open surgery if patients are hemodynamically stable and have no anastomotic insufficiency. Endovascular treatment may be associated with better in-hospital survival when compared to primary open surgery. Further studies are required to identify the optimal approach

Effect of Revascularization on Intramuscular Vascular Endothelial Growth Factor Levels in Peripheral Arterial Disease

Vascular endothelial growth factor (VEGF) is a potent driver of angiogenesis, which may help to relieve ischemia in peripheral arterial disease (PAD). We aimed to investigate the role of intramuscular VEGF in ischemic and non-ischemic skeletal muscle in PAD patients before and after surgical or endovascular revascularization and different stages of PAD. Biopsies of the gastrocnemius and vastus muscles from twenty PAD patients with stenosis or occlusion of the superficial femoral artery were obtained both during revascularization and 8 weeks postoperatively. The gastrocnemius muscle was considered ischemic, while vastus muscle biopsies served as intraindividual controls. The levels of vascular endothelial growth factor in muscle lysates were then determined by ELISA. Preoperative VEGF levels were significantly higher in ischemic muscles compared to the controls (98.07 ± 61.96 pg/mL vs. 55.50 ± 27.33 pg/mL, p = 0.004). Postoperative values decreased significantly (p = 0.010) to 54.83 ± 49.60 pg/mL in gastrocnemius biopsies. No significant change was observed in vastus muscle biopsies, with mean postoperative VEGF values found at 54.16 ± 40.66 pg/mL. Since all patients still had indications for revascularization, impairment of angiogenesis mechanisms can be assumed. More research about angiogenesis in PAD is needed with the ultimate goal to improve conservative treatment

Studying rainfall changes and water erosion of soil by using the WEPP model in Lattakia, Syria

Changes of soil erosion and rainfall have been simulated by using the Water Erosion Prediction Project (WEPP) model between 2016 and 2039 in Lattakia, Syria. This study was conducted in 6 locations that are characterized by two different ecosystems (agricultural, forest). The results show a linear decrease in rainfall amount of about 7.11 mm per year (170 mm for the whole studying period). For the years 2025, 2026 and 2030, three snowy storm events have been predicted, while the year 2030 will record the highest rainfall amount of 1816.1 mm. According to the WEPP model, the average of estimated soil erosion amount in Alhamara has reached 19 t/ha/y for the agricultural system while it is estimated to be 2.03 t/ha/y for the forest system. The general average of soil erosion in the study area (taking into consideration the variety of slope) within the agricultural system has reached 14.086 t/ha/y, which indicates that there will be a dangerous impact of future erosion on the sustainability of natural sources (soil, water) in the study area

Giant saccular aneurysm of the internal carotid artery with adhesion to the vagus nerve: A Case Report

INTRODUCTION AND IMPORTANCE: Aneurysms of the carotid artery are rare and potentially a risk factor for developing neurological events. This case report describes the treatment of a giant saccular aneurysm of the right extracranial internal carotid artery (ICA) with adhesion to the vagus verve. CASE PRESENTATION: An 85 -year-old female presented with an asymptomatic pulsating mass on the right neck. Ultrasonography and MR angiography revealed a giant aneurysm of the right internal carotid artery with a massive tortuosity. Intraoperatively, a massive adhesion of the vagus nerve to the aneurysm was found. A resection of the aneurysm followed by a spatulated end -to -end anastomosis was performed. Postprocedural neurological symptoms included a transient paralysis of the vagus nerve that recovered within six weeks. CLINICAL DISCUSSION: The treatment options of ICA aneurysms include open surgical and endovascular interventions. Endovascular treatment may be a good option for aneurysms with a particular morphology. However, open surgery is the favorable option for immense ICA aneurysms with a tortuous anatomical path. CONCLUSION: Aneurysm resection with end -to -end anastomosis is a possible surgical option in the case of tortuous extracranial ICA aneurysms. Leaving parts of the aneurysmal wall prevented occurring persisting damage of the adhesive vagus nerve

Experimental Investigation of the Soil-Water Characteristic Curves (SWCC) of Expansive Soil: Effects of Sand Content, Initial Saturation, and Initial Dry Unit Weight

Soil-water characteristic curve (SWCC) is an essential parameter in unsaturated soil mechanics, and it plays a significant role in geotechnical engineering to enhance theoretical analysis and numerical calculations. This study investigated the effects of key factors, such as the percentage of sand, initial degree of saturation, and initial dry unit weight, on the SWCC of expansive soil by measuring the matric suction using a pressure apparatus method. The empirical equation of SWCC was obtained using the Van Genuchten and Fredlung Xing models, and the processing of experimental data checks the fitting of the two empirical models. The findings revealed that the Fredlung Xing model fit the relationship between matric suction and volumetric water content of expansive soil better than the Van Genuchten model, indicating that the pressure apparatus approach’s experimental data are correct and acceptable. The study also found that the matric suction increased with decreasing percentage of added sand at the same volumetric moisture content, and the increase in initial dry unit weight increased the matric suction, with the water retention capacity decreasing significantly after adding 20% sand. Moreover, as the initial degree of saturation increased, the volumetric water content decreased, and the characteristic curves became identical when the initial saturation degree reached 90%. Finally, to minimize the water retention capacity of expansive soils, the study recommended adding a percentage of sand not less than 30% to the expansive clay sample

Development of a Novel Scoring Model to Estimate the Severity Grade of Mesenteric Artery Stenosis

Objective: This study aimed to derive a new scoring model from estimating the severity grade of mesenteric artery stenosis. We sought to analyze the relationship between the new scoring model and the development, treatment, and mortality of chronic mesenteric ischemia (CMI). Methods: This retrospective study included 242 patients (128 (53%) women and 114 (47%) men) with suspected CMI from January 2011 to December 2020. A weighted sum six-point score (CSI-score; the celiac artery is abbreviated by “C”, superior mesenteric artery by “S”, and inferior mesenteric artery by “I”) based on the number of affected vessels and the extent and grade of the stenosis or occlusion of the involved visceral arteries was derived by maximizing the area under the ROC curve. The calculated CSI-score ranged from 0 to 22. The patients were divided according to the best cut-off point into low-score (CSI-score < 8) and high-score (CSI-score ≥ 8) groups. Results: The area under the receiver operating characteristic curve (AUC) of the CSI-score was 0.86 (95% CI, 0.82–0.91). The best cut-off point of “8” represented the highest value of Youden’s index (0.58) with a sensitivity of 87% and specificity of 72%. The cohort was divided according to the cut-off point into a low-score group (n = 100 patients, 41%) and high-score group (n = 142 patients, 59%) and according to the clinical presentation into a CMI group (n = 109 patients, 45%) and non-CMI group (n = 133 patients, 55%). The median CSI-score for all patients was 10 (range: 0 -22). High-scoring patients showed statistically significant higher rates of coronary artery disease (54% vs. 36%, p = 0.007), chronic renal insufficiency (50% vs. 30%, p = 0.002), and peripheral arterial disease (57% vs. 16%, p < 0.001). A total of 109 (45%) patients underwent invasive treatment of the visceral arteries and were more often in the high-score group (69% vs. 11%, p < 0.001). Of those, 79 (72%) patients underwent primary endovascular treatment, and 44 (40%) patients underwent primary open surgery or open conversion after endovascular treatment. Sixteen (7%) patients died during the follow-up, with a statistically significant difference between high- and low-scoring patients (9% vs. 0%, p = 0.008). The score stratification showed that the percentage of patients treated with endovascular and open surgical methods, the recurrence of the stenosis or failure of the endovascular treatment, the need for a bypass procedure, and the mortality rates significantly increased in the subgroups. The CSI-score demonstrated an excellent ability to discriminate between patients who needed treatment and those who did not, with an AUC of 0.87 (95% CI, 0.82–0.91). Additionally, the CSI-score’s ability to predict the patients’ mortality was moderate, with an AUC of 0.73 (95% CI, 0.62–0.83). Conclusions: The new scoring model can estimate the severity grade of the stenosis of the mesenteric arteries. Our study showed a strong association of the score with the presence of chronic mesenteric ischemia, the need for treatment, the need for open surgery, and mortality