Biomedical subjects

T Umscheid

Publications and source records attributed to T Umscheid.

At least 19 recordsLinked to original sources

PubMed2006

Certification of vascular centers - a project of the German Society for Vascular Surgery.

OBJECTIVES: Due to the progress vascular medicine has made in conventional vascular surgery, endovascular procedures, and conservative therapy close, interdisciplinary cooperation is required. In order to assure the contextual and structural quality of vascular centers, the German Society for Vascular Surgery established a list of criteria for certification of each interdisciplinary vascular center. MATERIAL AND METHODS: Between July 2002 and December 2005, 77 centers have submitted a written application and have been audited by the commission for quality assurance of the German Society for Vascular Surgery, 59 vascular centers were certified for a period of 3 years with one center in each in Austria and in Switzerland, 13 centers were not certified (16.8%), and the applications of 5 centers are still pending. This analysis is based on 57 German certified vascular centers. RESULTS: Each center treats a median of 1149 inpatients (11% of these are emergency admissions) and 2,159 outpatients per year. Sixty percent of the patients treated have an arterial disease. All centers have vascular surgery and radiology departments. In 11 out of 57 centers, angiology services are offered in cooperation with affiliated physicians. Each vascular center has an average of 4.2 vascular surgeons, 3 radiologists and 1 angiologist. All centers offer radiological and ultrasound diagnostics (CT angiography in 100%, MRT in 95%, duplex sonography in 100%). Each clinic executes a median of 521 (233-1436) arterial operations and 263 (37-1055) arterial interventions. In addition, they execute varicose surgeries (n=217), shunt applications/revisions (n=58), minor amputations (n=57) and major amputations (n=42). They conduct 338 (92-3606) conservative therapies per year (POAD, diabetic foot, phlebothrombosis, chronic venous insufficiency). CONCLUSIONS: The certification of interdisciplinary vascular centers is a new approach to assure the contextual and structural quality of interdisciplinary vascular centers.

Ambulatory Surgical Procedures↗

PubMed2006

[Results of the certification of vascular centers by the German Society for Vascular Surgery].

INTRODUCTION: Advances in conventional vascular surgery, endovascular procedures and conservative treatment require close interdisciplinary cooperation. The term Vascular Centre indicates to patients and referring doctors optimal professional and organisational competence. METHODS: 73 applications by vascular centres for certification were made between June 2002 and December 2005, of which after audit 54 were successful for three years, including one centre each in Austria and Switzerland. 13 centres were not accepted and six are still under consideration. This analysis is based on the data of 52 certified centres in the Federal Republic of Germany. RESULTS: A mean of 1149 patients were hospitalized in these centres per year (12 % emergency admissions) and 2159 patients per year were treated as outpatients, 60 % with arterial vascular disease. All centres have vascular surgery and radiology department, 10 of the 52 centres cooperate with specialists in private practice to provide an angiology service. A mean of 460 arterial vascular operations and 239 arterial interventional procedures were performed at each centre annually. In addition there were operations for varicose veins (n = 217), shunt operations (n = 58) and major amputations (n = 42). Inpatient or outpatient conservative treatment (for peripheral vascular disease, diabetic foot syndrome, phlebothrombosis or chronic venous insufficiency) was given to a mean of 338 patients annually. CONCLUSIONS: Certification of interdisciplinary vascular centres provides structural and medical data and the beginnings of comparing such centres. A future task will be standardization of documentation and continuing assessment of the quality of results.

Certification↗

PubMed2005

[Elective therapy of asymptomatic infrarenal aortic aneurysms. Comparison of mortality and morbidity between endovascular and open repair].

Summary. In recent years, endovascular operations on infrarenal aortic aneurysm (EVAR) have not only been acknowledged as an alternative, but have become an indispensable "tool of the trade" for the vascular surgeon. As documented in many studies, perioperative morbidity is definitely much lower than in open surgery. In the long term, open surgery is also subject to complications such as rupture or aorto-enteral fistulae which necessitate secondary operations with their associated risks. There are some valid studies documenting a significantly lower mortality for EVAR than for open surgery. These datas were recently confirmed with high evidence level by the published results of UK-EVAR trial 1. The other randomized trials are currently ongoing. If the lower morbidity and lethality rate for EVAR is confirmed in these studies, the establishment of the indication for aortic aneurysm must be reconsidered with regard to the risk profile and the maximum diameter. The fact that long-term results are not yet available for the endovascular operation introduces a factor of uncertainty. Intensive follow-up observation is therefore an absolute prerequisite in patients who have undergone endovascular treatment. If the establishment of the indication is appropriate, with the new vascular prosthesis endoleaks are no longer an insoluble problem. The two methods should not be regarded as mutually competitive, but as complementary components of the treatment spectrum at every vascular center.

Aortic Aneurysm, Abdominal↗

PubMed2002

[Outcome quality in vascular surgery].

INTRODUCTION: For the assessment of outcome quality, the acquisition and evaluation of internal and external treatment data is necessary. Vascular surgery is characterized in main topics of treatment such as carotid stenoses, aortic aneurysms, peripheral arterial disease, and varicose veins by clearly defined outcome indicators. Nevertheless, the determination of the quality of outcome is difficult because of the differing standards. METHODS: For an external, comparative quality assurance, the quality assurance commission of the German Society for Vascular Surgery has established a program, "Quality Management for the carotid TEA and the BAA" according to section 137 SGB V, and has developed a questionnaire for recording the quality of treatment of varicose veins. RESULTS: The evaluation of all the questionnaires submitted to an independent institute enables the participating departments to have a comprehensive evaluation of their own quality of outcome and provides a tool to compare it with defined quality levels (benchmarking). CONCLUSION: For every physician, the perception of his own quality of outcome represents a fundamental requirement, which continues to gain importance within the context of future health policies.

Aortic Aneurysm, Abdominal↗

PubMed2001

An update of the Zenith endovascular graft for abdominal aortic aneurysms: initial implantation and mid-term follow-up data.

PURPOSE: To evaluate the initial and mid-term results of the Zenith endovascular grafting system for infrarenal abdominal aortic aneurysms. METHODS: Prospective databases at seven centers were used to assess a cohort of patients that underwent treatment for aortic, aortoiliac, or iliac aneurysms since 1995. Data were analyzed to yield descriptive characteristics that pertained to the patients, the aortic morphologic features, the graft configuration, and the complications. Follow-up imaging data were used to determine size changes of the aneurysm sac, endoleak rates, and further complications. Finally survival data were expressed with a Kaplan-Meier analysis. RESULTS: A total of 528 patients were treated with the Zenith endograft. Most of the patients (66%) were considered to be at a high physiologic risk for open repair. Successful graft implantation was accomplished in all but four patients. An overall endoleak rate of 15% was noted, of which 4% was treated urgently because they were thought to represent attachment site faults. The mean follow-up period was 18 months. A total of eight endograft migrations were detected after 2 years of follow-up with an early version of the system. There were three late conversions; two ruptures occurred during the follow-up period. CONCLUSION: This early and mid-term data support the use of the Zenith endovascular graft for the treatment of aortic and aortoiliac aneurysms in properly selected patients. The risks of significant complications or aneurysm rupture are low.

Angioplasty↗

PubMed2000

Endovascular treatment of an aortic aneurysm ruptured into the inferior vena cava.

PURPOSE: To report the endovascular repair of a rare abdominal aortic aneurysm (AAA) rupture into the inferior vena cava. METHODS AND RESULTS: A 74-year-old man with a 6.0-cm saccular aortic aneurysm and a previously undiagnosed aortocaval fistula of more than 2 weeks' duration was treated successfully with a Vanguard bifurcated stent-graft. The aneurysm was excluded and no endoleak or communication between the aorta and inferior vena cava was seen on computed tomographic imaging at the 6-month evaluation. CONCLUSIONS: Aortic endografting in this life-threatening complication is an effective treatment option that avoids the significant blood loss encountered in conventional repair.

Aged↗

PubMed2000

[Intermediate-term complications and problems after endovascular aortic stent prostheses].

From August 1994 to December 1998 321 patients were treated with endovascular stentgrafts for aortic aneurysm exclusion in our hospital. Primary exclusion rate was 91% (primary leakage 8.7%) and hospital mortality was 3.7%. 6 different types of grafts were used, 5 of them commercially available. Midterm complications are due to configuration changes of the grafts, material deterioration, side branch reperfusion and changes in aortic morphology. The common pattern of clinical expression of these complications is secondary leakage (60 cases) and graft limb occlusion (37 occurrences in 30 patients). 50% of the secondary endoleaks have been treated up to now leaving the remaining patients under a thorough follow-up. Graft limb thrombosis was treated in all but three, well compensated, patients. Midterm results of the first commercially available endografts are not yet satisfying in contrast to conventional aortic repair. The recently available grafts are promising as they have a better kink resistance, no graft sutures and fewer modular components.

Adult↗

PubMed1999

Frame dislocation of body middle rings in endovascular stent tube grafts.

OBJECTIVES: To understand the cause, and propose a mechanism for frame dislocation in endovascular grafts. MATERIALS AND METHODS: Five tube grafts were explanted due to secondary distal leakage 15-21 months after operation. One bifurcated graft was removed during emergency operation after aortic rupture caused by secondary leakage. A second bifurcated graft was harvested from a patient with thrombotic occlusion of one limb, who died after transurethral prostatic resection. The inside of the grafts were examined endoscopically. The stent was inspected after removal of the fabric, broken ligatures were counted and examined by scanning electron microscopy. The fabric strength was tested by probe puncture. RESULTS: We found 17-44% of the stent ligatures of the body middle rings to be loose. The knots were intact. Degradation of the polyester textile was not observed. CONCLUSIONS: Continuous movements in the grafted aorta and blood pressure impose permanent stress to the stent frame and the polyester fabric resulting in morphological changes in the body middle ring of grafts. The clinical implications of the suture breakages are unknown although they may be related to distal secondary leakage in tube grafts.

Aortic Aneurysm, Abdominal↗

PubMed1999

Time-related alterations in shape, position, and structure of self-expanding, modular aortic stent-grafts: a 4-year single-center follow-up.

PURPOSE: To report the nature and ramifications of structural and positional changes over time in tube and modular bifurcated aortic stent-grafts. METHODS: Two hundred ninety-one patients received endovascular aortic grafts (primarily Stentor/Vanguard) between August 1994 and August 1998. Follow-up surveillance (clinical and laboratory examination, biplanar noncontrast radiography, and contrast-enhanced computed tomography) has been maintained on all patients for 4 years. Changes in the configuration and position of endografts have been noted and their sequelae charted. RESULTS: Three types of endograft shape changes have been documented: mild -- slight distortions visible on plain radiographs (n = 90, 31.0%), significant -- angulations reaching 60 degrees to 90 degrees (n = 65, 22.3%), and severe -- angulations > or = 90 degrees (n = 10, 3.4%). Changes in position never gave rise to late migration at the proximal attachment site, whereas at the distal ends, the endograft easily retracted from the iliac arteries (n = 8). Structural alterations (rupture of the stent frame, sutures, or fabric, and total graft disintegration) were more common in the original Stentor model. Shape, position, and structural alterations were mutually dependent and led to secondary endoleaks (n = 26) and graft limb thrombosis (n = 37). Late surgical conversion was necessary in 3 (1.0%) patients. CONCLUSIONS: Tortuosity of the native vessels is a source of complication in long-term follow-up just as it is during implantation. Given the late appearance of complications in this patient cohort, it would seem that the durability of an endograft cannot be evaluated with < 3 years of follow-up.

Aged↗

PubMed1998

Rupture of abdominal aortic aneurysm previously treated by endovascular stentgraft.

We describe a case of abdominal aortic aneurysm (AAA) with rupture 16 months after treatment by an endograft. A 76-year-old patient on Coumadin after aortic valve replacement had initially successful exclusion by stentgraft. There was no evidence of an endoleak seven months after stentgraft repair, although a computed tomography scan detected an enlargement of the aneurysm sac. Sixteen months after initial endograft surgery, rupture of the aneurysm occurred and we performed open emergency surgery. We treated the aneurysm by conventional technique, and the patient survived the rupture. This case emphasized the fact that patients after endograft AAA repair require a close follow-up. An expansion of the aneurysm sac after the procedure should signal failed exclusion, even if a computed tomography scan does not demonstrate an endoleak. Anticoagulation can be an important factor in failure after endoluminal graft treatment. Supravisceral aortic cross clamping is helpful in dealing with a stented aorta.

Aged↗

PubMed1998

A method for adjusting a malpositioned bifurcated aortic endograft.

PURPOSE: To report the successful application of a method to adjust a malpositioned bifurcated stent-graft after endovascular aortic aneurysm repair. METHOD AND RESULTS: A 62-year-old male patient underwent endovascular repair of a 5.1-cm abdominal aortic aneurysm (AAA) with a Vanguard bifurcated stent-graft. After complete deployment of the stent-graft, the intraoperative completion angiogram disclosed unexpected occlusion of the left renal artery. Intra-aortic adjustment of the bifurcated graft was possible with a crossover guidewire, which was pulled caudally. The method worked perfectly to restore blood flow to the left renal artery. The patient is well 16 months postoperatively without any evidence of endoleak or graft migration; the left renal artery remains open. CONCLUSIONS: A technique is demonstrated for intra-aortic repositioning of a bifurcated stentgraft to correct insufficient deployment. If required, this technique should be attempted before conversion to an open procedure.

Angiography, Digital Subtraction↗

PubMed1998

Combined surgical and endovascular removal of thrombus entirely occluding a bifurcated aortic stent-graft.

PURPOSE: To explore a method combining interventional, endovascular, and conventional surgical techniques for treating a completely occluded bifurcated stent-graft after endovascular aortic aneurysm repair. METHODS AND RESULTS: A 60-year-old patient underwent endovascular repair of an abdominal aortic aneurysm (AAA) with a Talent bifurcated stent-graft. Five months later, after chronic thrombotic occlusion of the right iliac limb, he presented with acute occlusion of the entire stent-graft. Local intra-arterial infiltration thrombolysis successfully reconstituted flow through the main aortic segment and left iliac limb. With a combination of conventional surgical and intraoperative endovascular procedures, thrombectomy and recanalization of the right iliac limb was completed by stenting a severe stenosis of the proximal iliac limb. CONCLUSIONS: A combination of techniques may be essential for successful management of thrombotic complications after endovascular AAA repair.

Acute Disease↗

PubMed1997

Three-year experience with modular stent-graft devices for endovascular AAA treatment.

PURPOSE: To evaluate feasibility and present early results of endovascular abdominal aortic aneurysm (AAA) exclusion using modular stent-grafts. METHODS: In a 3-year period ending July 1997, 201 patients were treated with self-expanding stent-grafts for AAAs with infrarenal necks > or = 10 to 15 mm long and < or = 32 mm wide; subtotal mural thrombus, calcification, and even angulation to some extent were acceptable, as were iliac arteries up to 18 mm wide. The patients were treated with either the Stentor/Vanguard device (178 cases) or the Talent endograft (23 cases). Follow-up on all patients was conducted at 3, 6, 12, 18, and 24 months. RESULTS: The technical aneurysm exclusion rate was 89% (178/201). There were 18 primary endoleaks (9.0%; 2 proximal, 16 distal), 4 (2.0%) conversions to open surgery, and 1 (0.5%) failure to deploy the graft. Seven (3.5%) patients died in the perioperative period, 5 due to multiorgan failure early in the series and two of hemorrhagic complications. Five (2.5%) renal artery occlusions were encountered; in one case, the graft was removed after 3 weeks. Nineteen late endoleaks were found in follow-up, related primarily to the iliac limb graft extensions of the Stentor device, graft material problems, or unknown causes. To date, 10 primary and 13 secondary endoleaks have been treated endovascularly. Twenty (10.0%) graft-limb thromboses were treated either by thrombolysis, thrombectomy, or a femorofemoral bypass. CONCLUSIONS: Endovascular grafting is technically feasible and becomes easier with improvements of the introducer systems and the grafts. The seemingly high complication rate in this series is due to the liberal patient selection criteria.

Aged↗

PubMed1997

[3 years experience with endovascular stent prostheses in aortic aneurysm].

Since August 1994 we changed our concept of the treatment of infrarenal aortic aneurysms at the Surgical Department of the Städtische Kliniken Frankfurt Höchst. All patients morphologically suitable for endovascular aortic stenting were offered the new device. From the technical point of view stentgraft implantation is safe and its feasibility has been proven. The primary success rate was 88%. Perioperative mortality was 3.6%, primary leakage (10%) During follow-up thrombotic stentgraft occlusion (10%), renal artery closure (2%) and secondary leakage (10%) revealed a major problem. Most complications, however, could be treated interventionally without harm for the patient. We conclude form our results that good selection is the main key to avoid complications in the early phase of endovascular grafting.

Aged↗

PubMed1996

[Difficulties and complications in transfemoral implantation of stent prostheses in infrarenal abdominal aortic aneurysms].

Between August 31st, 1994 and January 31st 1996, 69 patients received transfemoral application of stentgrafts for treatment of AAA. Only 10 patients received tube grafts in contrast to 59 bifurcated grafts, which were assembled within the aortic lumen. All aneurysms were symptomatic, growing or sacciform. Risk factors seemed to be aggravated in comparison to conventional operations. 59 operations were technically successful, three were converted to open laparotomy, because of technical malfunction twice and misplacement once. 5 postoperative deaths occurred from multiorgan failure. 7 patients were discharged with primary persisting leakage. All patients exhibited reactions to the stentgraft deployment, which mainly referred to the clotting system and/or arterial pressure. Postoperatively nearly all patients presented a "post-implantation syndrome" over days up to 4 weeks. The observed difficulties and complications can be attributed in part to a "learning curve", in part to difficult anatomic situations, which we included in our series. During follow up at 3, 6 and 12 months 7 secondary leakages were observed, three times because of a documented desintegration, once because of suspected beginning desintegration at a stent-graft junction, and three times because of possible failure of graft material. The leakages could be repaired by interventional procedures.

Aged↗

PubMed1995

[Laparoscopic cholecystectomy: a prospective study of 1,775 unselected patients].

1775 patients with symptomatic cholecystolithiasis were treated by laparoscopic cholecystectomy without selection or contraindications. Complications should be compared with those of conventional cholecystectomy. 73.5% of our patients were female, the median age was 62 years (min. 9, max. 91 years). They presented uncomplicated cholecystolithiasis in 85%, acute cholecystitis in 11% and cirrhotic gallbladder in 4.5%. The rate of conversion to laparotomy was 2.9% for uncomplicated cholecystolithiasis and 11% for each cholecystitis and cirrhotic gallbladders. In general 4.4% were converted. These conversions were due to complications in 0.9% (bile duct lesions 0.7%, bowel perforation 0.2%), due to adhesions or inflammatory alterations in 3%. Perioperative letality was 0.3%, but only 0.15% were related directly to the operation. Other complications were bile duct strictures 0.3%, postoperative hemorrhage 0.3%, ileus 0.2%, perforation of diaphragm/pneumothorax 0.1%. Suspected bile duct stones were proved and treated by preoperative ERCP in 5.6%. Routinely performed intraoperative cholangiography detected unsuspected stones in 4%. These were removed mostly by postoperative ERCP. We consider laparoscopic cholecystectomy a safe method for the treatment of every stage of symptomatic cholecystolithiasis. There are no contraindications, if the operation is performed by an experienced team. Intraoperative cholangiography should remain standard. Complications in unselected patients are comparable to those of conventional cholecystectomy. The rate of bile duct lesions is equal (0.7%), a further decrease is expected (learning curve). According to this data, it is no longer justified, to perform cholecystectomy primarily by laparotomy, if there is experience with the laparoscopic method. Laparotomy by itself is no complication, it should be applied only, if the surgeon considers the operation inadequate to be continued laparoscopically.

Adolescent↗

PubMed1995

[Laparoscopic selective vagotomy (posterior truncal vagotomy and anterior linear stomach resection) in complicated duodenal ulcer].

32 patients with complicated duodenal ulcer (bleeding, recurrence, perforation) were treated by laparoscopic posterior truncal vagotomy and anterior linear gastric resection in our modification (access to the posterior vagus via the omental bursa) of the method of Gomez-Ferrer/Taylor. Instead of the seromyotomy along the lesser curve we resect a 1 cm broad strip out of the anterior gastric wall. In one patient with additional hiatus hernia the anterior vagal trunc was cut accidentally. Converted to laparotomy this case was completed as truncal vagotomy and pyloroplasty. No disorders of postoperative gastric emptying were found. 17 patients were followed up 6 weeks postoperatively. 14 showed complete healing of the ulcer, 2 patients showed healing in progress. A follow up after 12 months obtained information about 18 patients: 7 were free of symptoms, 11 complained about intermittent pains or fullness. 8 of these 11 patients were controlled by gastroscopy, not any ulcer or gastritis or disorder of gastric emptying could be found. We see advantages of our method over Kathkouda's modification of Taylor's procedure in the simplicity of the method, the primary hemostasis and a short operating time by using the stapler. We consider our procedure a minimal invasive, quick, safe treatment for duodenal ulcer disease with lasting effect at reasonable cost, especially in complicated cases like recurrent ulcer, bleeding or penetrating ulcer and in noncompliant patients that are not suitable for medical treatment.

Adult↗

PubMed1991

Preliminary results of biliary excretion of ramipril after T-drainage in cholecystectomy patients.

Four cholecystectomy patients, aged between 52 and 56 years, weighing between 64 and 90 kg, received 5 mg of ramipril as a single dose in order to investigate the pharmacokinetics and excretion pattern of ramipril. All patients had a T-drainage that allowed bile collection. Serum was collected at regular intervals, bile was collected hourly for 6 h followed by a 6- and 12-h fraction, and urine was collected every 2 h for 8 h followed by a 4- and 12-h fraction. The concentrations of ramipril and ramiprilat in serum and ramipril, ramiprilat, ramipril glucuronide, ramiprilat glucuronide, diketopiperazine, and diketopiperazine acid in bile and urine were determined and the amounts excreted in urine and bile over 24 h were calculated. There were great interindividual differences in maximum concentrations as well as in the time to reach maximum concentrations in plasma and bile as well as in the excretion pattern between urine and bile. The highest concentrations in bile were found for diketopiperazine acid (3,080 ng/ml) and ramipril glucuronide (2,414 ng/ml). In general, only minimal amounts of unchanged ramipril (prodrug) were detected in the bile. In the urine, the major metabolites excreted were diketopiperazine acid, ramiprilat, and diketopiperazine in amounts of 537, 188, and 124 micrograms, respectively. In bile, the main substances excreted were diketopiperazine acid and ramiprilat glucuronide, which amounted to 501 and 314 micrograms, respectively. Biliary excretion may be the explanation for the noncomplete urinary recovery of ramipril and its metabolites.

Angiotensin-Converting Enzyme Inhibitors↗