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Biomedical subjects

R Pamler

Publications and source records attributed to R Pamler.

18 recordsLinked to original sources
PubMed2002

[What is the cost of vascular operations? A prospective cost analysis of conventional and combined endovascular interventions].

Current and future legislation demand improved efficiency in the medical services. The aim of this study was to analyse the costs of vascular surgery in order to reveal potential ways of reducing expense. Taking into account the staff, equipment and operating theatre supplies, we analyzed 58 elective operations comprising 47 conventional and 11 combined endovascular procedures. The mean overall costs calculated for the different operations were: 5.269 DM for a transfemoral embolectomy (n = 3), 8.504 DM for a patchplasik of the profunda arteria (n = 8), 10.265 DM for a femoro-popliteal bypass with a prosthesis (n = 6)--13.180 DM with a vein (n = 2), 9.864 DM for conventional iliac artery reconstruction (n = 7)--iliac endovascular combined procedure (n = 4) 14.494 DM, 14.951 DM for a Y-prosthesis in case of stenosis (n = 3)--13.288 DM in case of infrarenal aortic aneurysm (IAA, n = 4), 11.954 DM for a tube prosthesis in case of IAA (n = 3), 23.571 DMY-stent prothesis for IAA (n = 5), 19.914 DM stent for a thoracic aneurysm (n = 2), 7.153 DM a carotid thrombendarterectomy (n = 6), 5.503 DM for varicosis surgery (n = 5). Because of the high cost of materials, the total outlay for combined endovascular procedures appeared to be high when compared to conventional vascular surgery. Substantial savings concerning the operation may only be achieved if facility structure and qualification of staff meets the particular requirements.

Adult↗
PubMed2002

[The contribution of MRI to the detection of endovascular aneurysm repair].

PURPOSE: Evaluation of MR-imaging in the follow-up of patients after endovascular repair of abdominal aortic aneurysms concerning detection of endoleaks. MATERIALS AND METHODS: In the postoperative follow-up after endovascular repair of aortic aneurysms, 10 consecutive patients (mean age: 68 years) were suspected to have an endoleak by helical CT and were scheduled for conventional angiography, preceded by supplemental MR-imaging to confirm or refute the diagnosis. The images of helical CT and MRI were evaluated by two independent readers concerning leak, feeding vessel and artifacts. RESULTS: The follow-up MRI was able to detect all endoleaks (type 1 endoleak, n = 7; type 2 endoleak, n = 3) compared to all but one detected by helical CT. Of the 10 patients with an endoleak, MR-angiography visualized the feeding vessel in 7 patients and CT in one patient. MRI did show fewer metal artifacts from the stent wire than CT. For the visualization of feeding vessels and endoleaks, MRA achieved statistically significant superiority. In a single case, helical-CT was not reliable because of strange metal artefacts after previous coil embolization. CONCLUSION: MRI is comparable to helical-CT in detecting endoleaks and superior to CT in demonstrating the anatomy of the feeding vessel after endovascular repair of aortic aneurysms. The major advantages are fewer artifacts after coil embolization and absent radiation exposure.

Aged↗
PubMed2001

Endoleaks after endovascular repair of aortic aneurysm: are they predictable?-initial results.

PURPOSE: To evaluate the predictability of endoleak. MATERIALS AND METHODS: Thirteen women and 60 men (mean age, 69.8 years) underwent transfemoral insertion of endoluminal stent-grafts for treatment of aortic aneurysms. Follow-up included helical computed tomography (CT) at 3-month intervals. In the cases of endoleak, angiography also was performed to document the number of leak sites, their size and position, the feeding artery, the size of the aneurysm, the amount of thrombus, and the visualization of the lumbar arteries and inferior mesenteric artery. These data were correlated (Student t test) with the probability of endoleak. RESULTS: A total of seven (10%) endoleaks were identified at CT in 68 patients. The feeding vessels were lumbar arteries in three cases, the inferior mesenteric artery in three cases, and the median sacral artery in one case. Of all factors, only the number of lumbar arteries visualized preoperatively (P <.005) had a significant correlation with probability of endoleak. In 71% (five of seven patients) of the cases of lumbar endoleak, four lumbar arteries were patent, whereas among the 61 patients with successfully repaired aneurysm, only eight (13%) had four patent lumbar arteries. Endoleaks were never found in the primarily thrombosed sections of an aneurysm. CONCLUSION: Prediction of endoleaks with absolute certainty remains elusive. The single correlating risk factor identified from the data was patency of four or more lumbar arteries visualized preoperatively at CT.

Aged↗
PubMed2001

Geometric changes in aortic endografts over a 2-year observation period.

PURPOSE: To report geometric changes in bifurcated aortic endografts observed over a 2-year follow-up period. METHODS: Twenty-two patients (21 men; mean age 68 years, range 57-83) with abdominal aortic aneurysms were treated with an endovascular stent-graft. Follow-up examinations included spiral computed tomographic scanning postoperatively and at 3, 6, 9, 12, 18, and 24 months after treatment. Geometric changes were measured using 3-dimensional reconstructed images in anteroposterior (AP) and lateral projections. Locations for the measurements were the proximal neck, the midportion of the endograft, and the graft limbs at the origin of the iliac arteries. RESULTS: Lateral changes predominated, demonstrating maximum angles on the side of the inserted left limb. For the proximal neck, the stent angle changed by a mean -0.71 degrees in the AP and 4.0 degrees in the lateral projection. At the midgraft, changes were -0.56 degrees for AP and 12.5 degrees for lateral. The right limb showed an angle of 6.43 degrees in AP and -0.43 degrees in lateral, whereas the left limb angles changed 1.38 degrees in AP and 11.71 degrees in the lateral plane after 2 years. There was no statistically significance difference in these changes from baseline. CONCLUSIONS: Aortic endografts are exposed to a significant amount of movement after insertion, but the resultant changes are very inhomogeneous, unpredictable, and ongoing even after 2 years. The most vulnerable location seems to be the attachment zone of the modular graft limb. These geometric changes might be one cause for late complications, including leaks and limb dislocations.

Aged↗
PubMed2001

Endovascular grafting of traumatic aortic aneurysms in contaminated fields.

PURPOSE: To evaluate the potential of endovascular stent-grafts to treat traumatic aortic lesions in contaminated areas. METHODS: Four patients (3 women; ages 26-78 years) underwent stent-grafting to repair an aortic rupture sustained in a motorcycle accident, aortic lacerations secondary to surgical treatment of spondylitis in 2 patients, and an aortobronchial fistula following surgical thoracic aortic repair 10 years earlier. Stent-grafts (2 Corvita, 1 Talent, and 1 Vanguard) were placed endoluminally into the infected areas via a transfemoral approach. Follow-up included erythrocyte sedimentation rate, white blood count, C-reactive protein, blood cultures, and computed tomography (CT). RESULTS: The stent-grafts were successfully placed in all cases and excluded the aortic lesion. Under supportive antibiotic therapy, inflammation parameters returned to normal. CT imaging showed no evidence of paraprosthetic infection, nor were there any other complications over a follow-up that ranged from 3 to 34 months. CONCLUSIONS: Endovascular therapy may be an alternative in the acute management of aortic ruptures in the setting of infection. Long-term results are required for definitive evaluation of the method.

Adult↗
PubMed2001

Endovascular interventions on persistent sciatic arteries.

PURPOSE: To report our experience with interventional procedures used to treat complete and incomplete persistent sciatic arteries (PSA). CASE REPORTS: Three female patients with PSAs displayed varying symptoms referable to this rare anatomical variant. In the first woman, a 1-year history of intermittent lower limb ischemia and an acute event prompted angiography, which demonstrated proximal occlusion of 2 crural vessels and a partially thrombosed sciatic artery aneurysm. To prevent further embolism, the aneurysm was excluded with a stent-graft. Endograft patency and aneurysm exclusion have been maintained up to 22 months. In a 41-year-old diabetic with chronic limb ischemia and digital gangrene, a flow-limiting stenosis of the sciatic artery was stented, restoring adequate pedal perfusion. The stent remained patent at the 18-month follow-up. The third patient suffered from a tumor-related pelvic hemorrhage originating from retrograde perfusion through the PSA, which had been ligated during previous surgery. Attempted embolization via a collateral connection between the incomplete PSA and the popliteal artery failed, and the patient died. CONCLUSIONS: Vasculopathies involving the sciatic artery are uncommon but may be amenable to interventional techniques, such as coil embolization and stent implantation. PSA aneurysm exclusion with a stent-graft may represent a new therapeutic alternative to standard surgery that obviates potential sciatic nerve damage, but the durability of the repair remains to be determined.

Adult↗
PubMed2000

[Ischemia of the lower extremity due to a persistent a. ischiadica--a possible interventional therapeutic approach].

The sciatic artery is a rarely seen variant of the vessels of the lower limb. Anatomically it is the prolongation of the inferior gluteal artery and accompanies the sciatic nerve from the sciatic foramen to the knee. More than other vessels, the sciatic artery shows vasculopathies like diffuse dilatation or aneurysms. This report describes an interesting case of embolic acute ischemia, caused by a persistent sciatic artery with an aneurysm. We treated the ischemia with intra-a. lysis and bridged the aneurysm with an covered stent.

Acute Disease↗
PubMed2000

Treatment of leaks after endovascular repair of aortic aneurysms.

PURPOSE: To evaluate leaks after the endovascular repair of aortic aneurysms and treat them with occlusive therapy. MATERIALS AND METHODS: Seventy patients (11 women, 59 men), aged 26-82 years (mean, 69.2 years), underwent transfemoral insertion of endoluminal stent-grafts for treatment of aortic aneurysms. Indications were traumatic pseudoaneurysms (n = 5) or arteriosclerotic aneurysms (n = 65). Aneurysms were thoracic (n = 5) or infrarenal (n = 65). To exclude the possibility of leaks, spiral computed tomography (CT) was performed at 3-month intervals. Patients with leaks that persisted unchanged longer than 3 months were referred for angiography and occlusive therapy. RESULTS: At CT, 21 leaks were identified in 17 of 70 patients (24%). Only 11 of those 17 patients (65%) had leaks identified with conventional aortography. Selective angiography, however, depicted all of these. Eighteen of 21 leaks proved amenable to occlusive treatment: surgery (n = 1), further stent implantation (n = 4), or embolization (n = 13). In one leak, spontaneous occlusion occurred after 3 months. Two leaks in either the iliolumbar or the median sacral artery were inaccessible; one remained untreated, and the other was unsuccessfully treated. Mean follow-up of occlusive therapy was 6.8 months (range, 2-14 months). CONCLUSION: Successful occlusion of perigraft leaks is feasible in most cases and can be performed without major complications.

Adult↗
PubMed2000

Malpositioned or dislocated aortic endoprostheses: repositioning using percutaneous pull-down maneuvers.

PURPOSE: To present the capabilities and potential complications of 2 percutaneous techniques for repositioning malpositioned or dislodged aortic endografts. METHODS: Seven male patients (median age 67.9 years, range 59 to 78) required correction of misplaced or dislocated endografts in the thoracic (n = 1) or infrarenal abdominal aorta (n = 6). In 1 patient, an infrarenal bifurcated stent-graft was mistakenly deployed across a renal artery; repositioning was accomplished by tugging caudally on a guidewire placed across the endograft bifurcation and exteriorized from both femoral arteries. An inflated balloon catheter was used to reposition 3 dislocated aortic devices (1 thoracic, 2 infrarenal) and 3 iliac graft limbs that had disconnected from the main graft body 6 to 12 months after implantation. RESULTS: Repositioning maneuvers were successful in all cases, with the devices being moved from 5 to 27 mm (median 7.8 mm). There were no procedure-related complications. CONCLUSIONS: Nonsurgical repositioning of misplaced aortic prostheses is technically feasible in individual cases. The risk associated with the procedure, however, cannot yet be evaluated.

Aged↗
PubMed2000

Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach.

PURPOSE: To evaluate the use of a superior mesenteric artery (SMA) approach to embolize type II endoleaks arising from the inferior mesenteric artery (IMA). TECHNIQUE: When reperfusion of the aneurysmal sac via the SMA occurs through the IMA, as shown by computed tomography (CT) and angiography, the IMA origin can be accessed via the marginal artery or the anastomosis of Riolan. The SMA is catheterized with a 5-F catheter, and a coaxial catheter is advanced to the leak to deliver 2- to 8-mm-diameter minicoils to embolize the IMA origin and entire aneurysmal sac. Embolization usually requires from 1 to 2 hours to complete. In our experience with this technique in 11 cases, complications have not occurred, and there has been only one very small residual leak that sealed the next day. Over a 24.5-month follow-up (range 12-39), the endoleaks have remained sealed according to serial color duplex scans. CONCLUSIONS: Successful percutaneous treatment of type II endoleak due to IMA inflow can be accomplished using an SMA access via the Riolan anastomosis or marginal artery. The procedure appears to be safe and has no adverse effects.

Aged↗
PubMed2000

Does successful embolization of endoleaks lead to aneurysm sac shrinkage?

PURPOSE: To determine whether embolization of endoleaks after endovascular repair of aortic aneurysms is associated with a decrease in the diameter of the aneurysm. METHODS: Fifteen patients (13 men; median age 76 years) demonstrated primary endoleaks persisting > or =3 months after endovascular abdominal aortic aneurysm repair with a variety of commercial endografts. In 8 patients, coil embolization failed to completely obliterate the leak, whereas embolotherapy proved successful in the remaining 7 patients. Surveillance of endoleaks and the effect of their embolization on aneurysm size were followed with serial computed tomographic (CT) scans. Follow-up after embolization extended for at least 12 months. RESULTS: Patients with persistent leak exhibited a slight increase in mean aneurysm area from 21.41+/-4.25 to 22.47+/-6.70 cm2. Medians differed from 20.03 (range 16.59-28.73) to 23.03 (range 14.14-33.69) cm2 (p = 0.0078, 95% confidence interval [CI] = 0.0075 to 0.0081). Successfully treated patients, however, showed a mean decrease from 20.58+/-3.63 (median 19.87) to 16.36+/-6.46 cm2 (median 18.10) at 1 year (p = 0.0156, 95% CI = 0.0151 to 0.0160). The medians differed significantly between groups (p < 0.05). CONCLUSIONS: Persistent endoleaks after endovascular aortic aneurysm treatment led to an increase in the diameter of the aneurysm, whereas complete occlusion was associated with a significant decrease in aneurysm diameter.

Aged↗
PubMed2000

Angiography of leaks after endovascular repair of infrarenal aortic aneurysms.

OBJECTIVE: We examined whether leaks that persist after stent grafting are associated with outflow arteries. SUBJECTS AND METHODS: Selective angiography was performed in 21 patients with persistent leaks after undergoing endovascular repair of infrarenal aneurysms of the abdominal aorta. Late leaks occurred in five patients whose prostheses were originally sealed. Before angiography, the size and position of leaks were determined with CT and color Doppler sonography. RESULTS: Superselective angiography was successful in 19 of 21 patients. In two patients, angiography was performed over the afferent artery supplying the leak. We found one outflow artery at the site of the leak in 10 patients (47%); two outflow arteries in five (23.8%); and as many as five outflow arteries in three (14%). Angiography overlooked outflow arteries in three patients (14%). The lumbar and inferior mesenteric, urethral, and testicular arteries were identified as outflow arteries. CONCLUSION: Other than feeder arteries, persistent leaks are associated with outflow vessels that contribute to the patency of leaks.

Adult↗
PubMed1999

Leakages after endovascular repair of aortic aneurysms: classification based on findings at CT, angiography, and radiography.

PURPOSE: To ascertain whether the configuration and location of leakages identified at computed tomography (CT) could provide evidence of their angiographically and fluoroscopically confirmed causes. MATERIALS AND METHODS: Fifty patients aged 26-79 years underwent endovascular repair of traumatic (n = 4) or arteriosclerotic (n = 46) aortic aneurysms (four thoracic, 46 infrarenal). Radiographic examinations in three planes and helical CT were performed 1 week after implantation and every 3 months thereafter. Angiography was performed when there was evidence of a leakage at CT. RESULTS: CT demonstrated evidence of leakages in 13 patients. Broad-based leakages immediately adjacent to the prosthesis were termed "perigraft leakages." If the area most affected by the leakage lay along the border of the aneurysm, then retrograde leakages were apparent at angiography. If the leakage was ventral to the prosthesis, then its source was the inferior mesenteric artery; if it was dorsolateral, then it was supplied by either the lumbar arteries or the median sacral artery through the hypogastric artery. One circumferential leakage could not be evaluated adequately at CT or angiography. Radiography depicted a rupture of the stent mesh in the middle of the prosthesis. Selective angiography demonstrated all types of leakages and permitted CT classification. CONCLUSION: The cause of a leakage can be determined with CT on the basis of its configuration and location in the majority of cases.

Adult↗
PubMed1998

Mechanical thrombolysis of acute occlusion of both the superficial and the deep femoral arteries using a thrombectomy device.

OBJECTIVE: Our objective was to evaluate the efficacy of the Amplatz thrombectomy device for recanalization of acute occlusions of both the superficial and the deep femoral arteries. MATERIALS AND METHODS: Eighteen patients with acute occlusions of the femoral arteries (eight male, 10 female; 10-87 years old) were treated using the Amplatz thrombectomy clot macerator. The duration of occlusion was 16 +/- 8 hr. Eighteen patients underwent treatment of the deep femoral artery, and 16 patients had additional involvement of the superficial femoral artery. After primary recanalization of the deep femoral artery, the superficial femoral artery was also recanalized using the Amplatz thrombectomy device. Nine patients required additional aspiration thrombectomy of the tibial arteries, five patients required additional aspiration thrombectomy of side branches of the deep femoral artery, and 12 patients required additional local thrombolysis with urokinase. RESULTS: In 14 (78%) of 18 patients, recanalization of the deep femoral artery was complete without demonstrable residual thrombi. Arterial spasms were observed in five patients (28%). The rate of limb salvage was 94% at a mean follow-up interval of 8.9 +/- 4.1 months. In the 18 patients, the ankle-brachial pressure index went from a median value of 0.56 before therapy to a median value of 0.91 after therapy. No severe complications occurred. CONCLUSION: Mechanical thrombolysis in the deep femoral artery with the Amplatz thrombectomy device is an effective, rapid method of treatment and is rarely associated with complications. In cases of concomitant occlusion of the tibial arteries, recanalization should always be attempted because the deep femoral artery may provide a functionally decisive collateral artery between the iliac and tibial vasculature.

Adolescent↗
PubMed1998

[Value of stent-assisted aneurysm treatment].

The aim of this study was to compare the outcome of consecutive patients with abdominal aortic aneurysms treated by open operation and endoluminal procedure. Between October 1996 and April 1998 consecutive patients with abdominal aortic aneurysms underwent surgical repair. Of these, 50 patients had conventional open repair, and 48 patients were treated endoluminally. Follow-up was made by clinical examination in the operation group; the stent group was controlled by spiral CT and angiography 1, 3, 6, and 12 months after operation. No significant difference was found in the perioperative mortality rate between the open repair group and the stent group. This study suggests that the endovascular procedure is safe and results in a shorter length of hospital stay and a shorter length of intensive care unit stay. As there are no long-term results, the endoluminal method requires a careful follow-up.

Angioplasty, Balloon↗
PubMed1996

[Management of iatrogenic hemorrhage after mechanical vascular recanalization].

Nine patients with hemorrhage due to revascularization procedures underwent successful embolization (5), surgery (2), covered stent implantation (1), or long-lasting ballon dilatation (1). Bleeding was the result of Fogarty thrombectomy (3), ring stripper revascularization (1), balloon dilatation (3), or perforation of the artery with the guide wire (1). In all cases, bleeding was stopped successfully without sequelae for the patients. In spite of the preceeding hemorrhage, local fibrinolysis with 1,000,000 units of urokinase was performed on the same day in 3 patients without any complications being observed.

Adult↗