Increased augmentation index in patients with Ehlers-Danlos syndrome

Background

Ehlers-Danlos Syndrome (EDS) comprises a heterogeneous group of diseases characterized by joint hypermobility, connective tissue friability, and vascular fragility. Reliable prognostic factors predicting vascular disease progression (e.g. arterial aneurysms, dissections, and ruptures) in EDS patients are still missing. Recently, applanation tonometry derived augmentation index (AIx), an indirect marker of arterial stiffness, has shown to be positively associated with progression of aortic disease in Marfan syndrome. In this study, we assessed aortic AIx in patients with EDS and matched healthy controls.

Methods

We performed noninvasive applanation tonometry in 61 adults with EDS (43 women and 18 men aged 39.3 ± 14.6 years) and 61 age-, gender-, height-, and weight-matched healthy controls. Radial artery pulse waveforms were recorded and analyzed using the SphygmoCor System (AtCor Medical, Sydney, NSW, Australia). Calculated AIx was adjusted to a heart rate of 75/min. Groups were compared and association between AIx and EDS was determined by univariate and multivariate regression analysis.

Results

EDS patients were categorized in classical type EDS (34%), hypermobile type EDS (43%), vascular type EDS (5%), or remained unassignable (18%) due to overlapping features. EDS patients showed a significantly increased aortic AIx compared to healthy controls (22.8% ± 10.1 vs 14.8% ± 14.0, p < 0.001). EDS showed a positive association with AIx; independent of age, sex, height, blood pressure, medication, and pack years of smoking.

Conclusions

Patients with EDS showed elevated AIx, indicating increased arterial stiffness when compared to healthy controls. Further investigations are needed in order to assess the prognostic value of increased AIx for cardiovascular outcomes in patients with EDS.

Duplex Ultrasound Investigation for the Detection of Obstructed Iliocaval Venous Stents

OBJECTIVE

Duplex ultrasound (DUS) is used for routine surveillance of stents in iliocaval veins, but direct visualisation is often challenging. Duplex ultrasound criteria for detecting venous stent obstruction (VSO) have not been defined to date.

METHODS

A nested case control study of 120 patients (42 ± 17 years, 53% women, mean 2.7 ± 1.8 stents) was performed, and the performance of various duplex parameters for detecting VSO (defined as > 50% lumen diameter reduction or occlusion) was tested, confirmed by biplane venography or intravascular ultrasound (IVUS). Forty patients with VSO (25 with stent occlusion, 15 with >50% in stent stenosis) were matched to 80 control patients by age, gender and index diagnosis who fulfilled the following criteria: (1) ongoing symptom control (Villalta score < 5), (2) good image quality of entire stent segment, (3) spontaneous colour Doppler signal > 50% of lumen in entire stent segment, (4) at least two DUS where the baseline DUS was obtained within 24 h after successful venous intervention.

RESULTS

The best test was the combination of peak flow velocity and flow pattern analysis at the stent inlet. A peak flow velocity >10 cm/s and a flow pattern spontaneously modulated by respiration ruled out VSO with a specificity of 93.7% (95% CI 86.0%-97.3%). A peak flow velocity ≤10 cm/s or any Doppler flow pattern other than spontaneously modulated by respiration was 92.1% (95% CI 79.2%-97.3%) sensitive to detect VSO.

CONCLUSION

The combination of peak flow velocity and analysis of Doppler flow pattern at the stent inlet is accurate to diagnose or rule out stent occlusion. Indirect criteria should always be combined with direct visualisation of iliocaval stents since those may be less sensitive for detecting stent stenosis.

Cartilage repair surgery prevents progression of knee degeneration

PURPOSE

To investigate, whether cartilage repair surgery for focal osteochondral defects at the knee results in less degenerative changes over 6 years in a MR imaging follow-up than morphologically initially identical defects in non-operated control subjects from the osteoarthritis initiative (OAI).

METHODS

A total of 32 individuals received baseline and follow-up MRI. In n = 16 patients with cartilage repair [osteochondral autograft transfer system (OATS), n = 12; spongiosa-augmented matrix-associated autologous chondrocyte implantation (MACI), n = 4] MRI was performed preoperatively and after 5.7 ± 2.3 year follow-up. Baseline MRIs of non-operated subjects from the OAI were screened for initially identical cartilage defects (n = 16). Morphological knee abnormalities were assessed using WORMS, AMADEUS and MOCART scores. A sagittal 2D MSME sequence was implemented for quantitative cartilage T2 relaxation time measurements in all (0, 2, 4, 6 and 8-years) follow-ups from the OAI and in the postoperative MRI protocol.

RESULTS

For both groups, focal osteochondral defects were located at the femoral condyle in 8/16 cases (5 medial, 3 lateral) and at the patella in 8/16 cases. At baseline, the mean cartilage defect size ± SD was 1.4 ± 1.3 cm² for the control group and 1.3 ± 1.2 cm² for the cartilage repair group (n.s.). WORMS scores were not significantly different between the cartilage repair group and the control group at baseline [mean difference ± SEM (95%CI); 0.5 ± 2.5 (- 4.7, 5.7), n.s.]. During identical follow-up times, the progression of total WORMS scores [19.9 ± 2.3 (15.0, 24.9), P < 0.001] and of cartilage defects scores in the affected (P < 0.001) and in the opposing (P = 0.029) compartment was significantly more severe in non-operated individuals (P < 0.05). In non-operated subjects, T2 values increased continuously from baseline to the 8-year follow-up (P = 0.001).

CONCLUSIONS

Patients with cartilage repair showed less progression of degenerative MRI changes at 6-year follow-up than a control cohort from the OAI with initially identical osteochondral defects. Patients with focal cartilage defects may profit from cartilage repair surgery since it may prevent progression of early osteoarthritis at the knee joint.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Cardiac biomarkers but not measures of vascular atherosclerosis predict mortality in patients with peripheral artery disease

BACKGROUND

Peripheral artery disease (PAD) becomes more prevalent with advancing age and is associated with elevated risk of cardiovascular events and shortened life expectancy. We investigated the prognostic performance of cardiac and vascular biomarkers in a cohort of PAD patients.

METHODS

A total of 95 PAD patients were enrolled (mean age 68 years, range 47 to 86 years, 73 males). Carotid intima-media thickness (cIMT), ankle brachial index (ABI), high sensitive cardiac troponin T, and N-terminal pro-B-type Natriuretic Peptide (NT-proBNP) were measured.

RESULTS

During a median follow-up time of 9.5 years, 44 patients died and 51 patients survived. Upon Kaplan-Meier survival analysis hs-TnT (P < .001) or NT-proBNP levels (P < .001) above the median but not cIMT above the median (P = .488) or ABI below the median (P < .436)were associated with reduced survival rate. Upon univariate cox regression and after adjustment for age, gender, prior cerebral artery disease, and diabetes mellitus only the association between hs-cTnT and mortality remained significant (HR 1.93, 95% CI 1.33-2.79, P < .001). In receiver operating curve analysis hs-cTnT (area under the curve [AUC]: 0.77, 95% CI: 0.67-0.87, P < .001) NT-proBNP (AUC: 0.74, 95% CI: 0.64-0.84, P < .001) as well as hs-cTnT, and NT-proBNP combined (AUC: 0.79, 95% CI: 0.69-0.88, P < .001) were superior to cIMT (AUC: 0.64, 95%, CI: 0.53-0.76, P = .022) and ABI (AUC: 0.57, 95% CI: 0.44-0.68, P = .313) in discriminating risk for mortality.

CONCLUSION

hs-cTnT and NT-proBNP should be taken into account for prognosis of patients with PAD.

Early Recoil After Balloon Angioplasty of Erection-Related Arteries in Patients With Arteriogenic Erectile Dysfunction

Purpose: To evaluate the incidence of elastic recoil in patients presenting with erectile dysfunction (ED) undergoing endovascular revascularization of the pudendal or penile arteries. Methods: A consecutive series of 21 ED patients (mean age 58.3±9.3 years) undergoing minimally invasive revascularization of 31 arteries was analyzed. ED lesions included the pudendal arteries (n=27) and the penile artery (n=4). Mean lesion length was 20.6±13.9 mm. Minimal lumen diameter (MLD) measurements were assessed at baseline, immediately after balloon angioplasty, and 10 minutes thereafter. Early recoil was defined as an MLD reduction >10%. Elastic recoil with >10% lumen compromise was treated with drug-coated balloons, while severe elastic recoil (>30%) required drug-eluting stents (DES). The International Index of Erectile Function (IIEF-15) score was obtained prior to and 3 months after the procedure to obtain information on functional outcomes subsequent to angioplasty. Results: Mean MLD at baseline was 0.9±0.6 mm, which improved to 2.0±0.9 mm immediately after balloon dilation. At 10 minutes after dilation, the MLD was 1.7±1.0 mm. Elastic recoil was observed in all 31 lesions and resulted in a mean lumen compromise of 21.2%. Severe (>30%) recoil was observed in 14 arteries, which underwent DES therapy. The IIEF-15 score improved from 31.3±11.2 at baseline to 49.8±16.8 (p<0.001) at the 3-month follow-up. Conclusion: Endovascular revascularization constitutes a safe and feasible treatment modality to restore erectile function in patients with arteriogenic ED and ineffective conservative management. Early elastic recoil is very frequent subsequent to balloon dilation of small-caliber erection-related arteries. Thus, mechanical scaffolding with DES is required in a high subset of ED patients to provide favorable early angiographic and clinical results.

Sensitivities of in vivo markers of arterial organ damage in patients with peripheral atherosclerosis

Abstract. Background: Biomarkers of vascular diseases such as ankle-brachial index (ABI), peripheral pulse pressure (pPP), central pulse pressure (cPP), and pulse wave velocity (PWV) allow assessment of arterial organ damage (AOD). However, the utility of markers other than ABI in patients with peripheral arterial disease (PAD), which are also associated with a significant increase of cardiovascular events, remains unclear. Patients and methods: Asymptomatic (n = 21) and symptomatic patients (n = 46) with a positive sonography for PAD or history of lower limb revascularization were included. ABI, pPP, cPP, and PWV were assessed. PWV were performed using a brachial cuff-based method (aortic PWV (aPWV)) and oscillography (carotid-femoral pulse wave velocity (cfPWV)), respectively. The two methods for PWV were compared using Bland Altman analysis. Sensitivities of ABI, pPP, cPP, cfPWV, and aPWV for AOD were calculated. Results: Sixty-seven patients (35.8 % female, mean age 69, range 39–91 years) had a significantly higher aPWV than cfPWV (median 10.5 m/s (IQR: 8.8–12.65 m/s) vs. median 9.0 m/s (IQR: 7.57–10.55 m/s), p = 0.0013). There was no correlation between cfPWV and age (r = 0.311, p = 0.116). Bland Altman analysis revealed a mean difference of -1.04 (-2SD; -6.38 to + 2SD; 4.31). The sensitivities for AOD were 68.7 % for ABI, 61.2 % for aPWV, 40.3 % for cfPWV, 31.3 % for peripheral PP, and 10.4 % for central aortic PP (p < 0.001). Conclusions: Brachial-derived aPWV differs from the gold standard assessment (cfPWV), which may be underestimated in PAD due to atherosclerotic obstructions along the aorto-iliac segment. The sensitivities of noninvasive in vivo markers of AOD vary widely and tend to underestimate the actual presence of AOD.

Fixed low-dose ultrasound-assisted catheter-directed thrombolysis followed by routine stenting of residual stenosis for acute ilio-femoral deep-vein thrombosis

Patients with ilio-femoral deep-vein thrombosis (DVT) are at high risk of developing the postthrombotic syndrome (PTS). In comparison to anticoagulation therapy alone, extended venography-guided catheter-directed thrombolysis without routine stenting of venous stenosis in patients with ilio-femoral DVT is associated with an increased risk of bleeding and a moderate reduction of PTS. We performed a prospective single-centre study to investigate safety, patency and incidence of PTS in patients with acute iliofemoral DVT treated with fixed-dose ultrasound-assisted catheter-directed thrombolysis (USAT; 20 mg rt-PA during 15 hours) followed by routing stenting of venous stenosis, defined as residual luminal narrowing >50%, absent antegrade flow, or presence of collateral flow at the site of suspected stenosis. A total of 87 patients (age 46 ± 21 years, 60% women) were included. At 15 hours, thrombolysis success ≥50% was achieved in 67 (77%) patients. Venous stenting (mean 1.9 ± 1.3 stents) was performed in 70 (80%) patients, with the common iliac vein as the most frequent stenting site (83%). One major (1%; 95% CI, 0–6%) and 6 minor bleedings (7%; 95%CI, 3–14%) occurred. Primary and secondary patency rates at 1 year were 87% (95% CI, 74–94%) and 96% (95% CI, 88–99%), respectively. At three months, 88% (95% CI, 78–94%) of patients were free from PTS according to the Villalta scale, with a similar rate at one year (94%, 95% CI, 81–99%). In conclusion, a fixed-dose USAT regimen followed by routine stenting of underlying venous stenosis in patients with iliofemoral DVT was associated with a low bleeding rate, high patency rates, and a low incidence of PTS.

Percutaneous sclerotherapy for spongiform venous malformations - analysis of patient-evaluated outcome and satisfaction

BACKGROUND

Congenital venous malformations are frequently treated with sclerotherapy. Primary treatment goal is to control the often size-related symptoms. Functional impairment and aesthetical aspects as well as satisfaction have rarely been evaluated.

PATIENTS AND METHODS

Medical records of patients who underwent sclerotherapy of spongiform venous malformations were reviewed and included in this retrospective study. The outcome of sclerotherapy as self-reported by patients was assessed in a 21 item questionnaire.

RESULTS

Questionnaires were sent to 166 patients with a total of 327 procedures. Seventy-seven patients (48 %) with a total of 159 procedures (50 %) responded to the survey. Fifty-seven percent of patients were male. The age ranged from 1 to 38.1 years with a median age of 16.4 years. The lower extremities were the most common treated area. Limitations caused by the venous malformation improved in the majority of patients (e.g. pain improvement 87 %, improvement of swelling 83 %) but also worsening of symptoms occurred in a minority of cases. Seventy-seven per cent would undergo sclerotherapy again.

CONCLUSIONS

Sclerotherapy for treatment of venous malformations results in significant reduction of symptoms. Multiple treatments are often needed, but patients are willing to undergo them.

Erectile dysfunction – overview from a cardiovascular perspective

Abstract. Erectile dysfunction (ED) is an evolving health problem with growing incidence in the ageing male population with potentially predictive value for cardiovascular and other chronic diseases. ED shares the common cardiovascular risk factors. The aetiology of ED is numerous including neurogenic, psychogenic, arteriogenic, and venogenic reasons. The origin of arteriogenic ED is frequently atherosclerosis. Patients not adequately responding to conservative measures including oral medication are often referred to further vascular diagnostics and therapy. At present, the refinements in endovascular therapy allow for minimal-invasive revascularization of erection-related arteries. The role of endovascular therapy in the complex framework of the multifactorial causes of ED requires further scientific scrutiny.

Minimally invasive medial supraorbital, combined subfrontal-interhemispheric approach to the anterior communicating artery complex-a cadaveric study

INTRODUCTION

In selected cases, microsurgical clipping remains a valuable treatment alternative to endovascular occlusion of anterior communicating artery (AComA) aneurysms. Their clipping is challenging and carries a risk of postsurgical cognitive impairment. We evaluate the microsurgical anatomy of a new, minimally invasive combined interhemispheric-subfrontal approach to the AComA complex via a medial supraorbital craniotomy.

METHODS

In this descriptive anatomic study, four alcohol-embedded, silicon-injected human cadaver heads were used. In each of the two cadavers, the AComA complex was approached from either the right or left side. An operating microscope and standard microsurgical instruments were used.

RESULTS

After a medial eyebrow incision, a medial supraorbital minicraniotomy was performed. The frontal sinus was opened and cranialized. Following the dural opening, a subfrontal arachnoid dissection was performed to identify the optico-carotid complex. By following the A1 segment, a low-lying AComA complex could be visualized. Shifting the corridor towards the midline enabled an interhemispheric dissection. This dissection resulted in a wide superior-inferior corridor. Higher-lying AComA complexes could also be visualized. The achieved exposure of the AComA complex would allow safe dissection and clipping of low- and high-lying AComA aneurysms, with minimal retraction and preservation of the surrounding anatomical structures, in particular the perforators.

CONCLUSIONS

We demonstrate the anatomy of a novel approach for surgical clipping of AComA aneurysms. Our study suggests that this approach provides good exposure without concomitant structural and vascular injury and thus might reduce the risk of procedure-related morbidity.

Credentialing in interventional therapy in Europe – comparison of curricula including endovascular therapy of arterial diseases

Abstract. The prevalence of peripheral artery disease (PAD) is continuously increasing. In addition, the treatment of PAD has changed substantially over the last decades. Novel treatment modalities and diagnostic tools were developed and endovascular therapy was established as a first-line therapy. In consequence, vascular medicine has become an interdisciplinary field, involving different specialties such as internal medicine/cardiology, internal medicine/angiology, vascular surgery, and (interventional) radiology. Attributed to the expanding field and to ensure high quality and standardized training, various curricula were developed. Not only within the different medical disciplines but across countries. We compared the training programmes in Germany, Switzerland, and Europe and found a great variety in these curricula and programmes. Nevertheless, we identified first attempts to harmonize training requirements within the various societies: the interdisciplinary guidelines of the German Society for Cardiology (DGK) and the German Society of Angiology, the adoption of European standards on a national level, and the Swiss initiative of the Union of Vascular Societies of Switzerland (UVSS). The standard and level of training is high in all curricula and societies. However, further harmonization is needed to optimize patient care and ensure a uniform quality level across different vascular societies.

The Effect of a New Angiographic Imaging Technology on Radiation Dose in Visceral Embolization Procedures

PURPOSE

To evaluate the impact of a new angiographic imaging technology on radiation dose during visceral embolization procedures involving both fluoroscopy and digital subtraction angiography.

MATERIAL AND METHODS

A retrospective analysis from a single-center consecutive series of patients was performed comparing 2 angiographic imaging systems. The AlluraClarity (CIQ; Philips Healthcare, Best, the Netherlands) was used in 100 patients (n = 59 male, mean age: 70.6 years) from July 2013 to April 2014 and compared to the former AlluraXper (AX) technology used in 139 patients (n = 71 male, mean age: 70.1 years) from May 2011 to June 2013. Patients were categorized according to body mass index (BMI [kg/m²])-group 1: BMI <25, group 2: BMI ≥25 and <30, and group 3: BMI ≥30. Fluoroscopy time, the total dose of iodinated contrast administered, and procedural AirKerma (Ka, r [mGy]) were obtained.

RESULTS

Mean BMI was 26.4 ± 5.0 kg/m² in the CIQ and 26.4 ± 7.1 kg/m² in the AX group ( P = .93). Fluoroscopy time and the amount of contrast media were equally distributed. Ka, r was 1342.9 mGy versus 2214.8 mGy ( P < .001, t test) when comparing CIQ to AX. Comparing CIQ to AX, BMI subgroup analysis revealed a mean Ka, r of 970.1 to 1586.1 mGy ( P = .003, t test), 1484.7 to 2170.1 mGy ( P = .02, t test), and 1848.8 to 3348.9 mGy ( P = .001, t test) in BMI groups 1, 2, and 3, respectively.

CONCLUSION

The CIQ technology significantly reduced mean radiation dose by 39.4% for visceral embolization procedures when compared to fluoroscopy time and contrast media dose. This dose relationship was consistent across all BMI groups.

Use of a stent graft in tumor erosion of the common femoral artery with life-threatening bleeding

We report a case of a 56-year-old male patient with a life-threatening left common femoral artery bleeding due to tumor erosion. The patient had a history of advanced high-grade pleomorphic leiomyosarcoma of the left groin with pulmonary metastasis. Clinical examination revealed a massive tumor bulking at the left groin with necrosis and phleb- and lymphedema. Given the circumstances, open surgery was not possible. Thus, it was decided to treat the patient with an endovascular procedure. The postprocedural course was uneventful, the patient received blood product and was hemodynamically stable. He was discharged at day six with ambulatory follow-up. Endovascular therapy using stent grafts to exclude a life-threatening bleeding is a valuable alternative treatment option in oncologic patients with limited life expectancy, which are unsuitable for surgery.

Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology

PURPOSE

Anterior cruciate ligament (ACL) ruptures are often associated with primary meniscal and cartilage lesions. Late reconstruction of ACL-deficient knees may increase the risk of developing secondary meniscal and cartilage lesions; hence, the timing of ACL repair is of the utmost importance. Because meniscus outcome is also a potential predictor for osteoarthritis (OA), this study compared ACL repair within the first 6 months after injury to that of surgery conducted 7-12 months after injury with regard to the incidence of meniscal and cartilage lesions.

METHODS

This prospective cross-sectional study included all complete isolated primary ACL ruptures treated in our institution within 1 year after trauma over a 12-month period. Exclusion criteria were revision ACL, complex ligament injuries, previous knee surgery, and missing injury data. Cartilage lesions were classified according to the score established by the International Cartilage Repair Society (ICRS score) and meniscal tears according to their treatment options.

RESULTS

Two hundred and thirty-three of 730 patients (162 men, 71 women) with ACL repair met the inclusion criteria. 86.3 % of surgical interventions were conducted within 6 months and 13.7 % after 6 months of trauma. Severe cartilage lesions grade III-IV did not significantly differ between the different time points of ACL repair (<6 months 39.9 %; >6 months 31.3 %; p = n.s.). Medial meniscus lesions received significantly higher meniscal repair in early compared to delayed ACL repair. Significantly higher rate of meniscal repair of the medial meniscus was seen in cases of early ACL repair compared to delayed (<6 months 77.2 %, >6 months 46.7; p = 0.022). The rate of medial meniscal repair in early ACL repair was significantly higher for women (89.5-0 %; p = 0.002), however, not for men (73.3-53.8 %; p = n.s.). No differences were found for lateral meniscal lesions, with regard to neither the different time points (p = n.s.) nor the sex (p = n.s.).

CONCLUSIONS

Because of the significantly higher rate of prognostically advantageous meniscal repair, the recommendation for an ACL reconstruction within 6 months after trauma was made to preserve the meniscus and reduce the risk of developing OA.

LEVEL OF EVIDENCE

Prospective cross-sectional cohort study, Level II.

Bleeding Risk Profile in Patients With Symptomatic Peripheral Artery Disease

Purpose: To assess the bleeding risk profile using the HAS-BLED score in patients with symptomatic peripheral artery disease (PAD). Methods: A post hoc analysis was performed using data from a series of 115 consecutive patients (mean age 72.4±11.4 years; 68 men) with symptomatic PAD undergoing endovascular revascularization. The endpoint of the study was to assess bleeding risk using the 9-point HAS-BLED score, which was previously validated in cohorts of patients with and without atrial fibrillation. For the purpose of this study, the low (0–1), intermediate (2), and high-risk (≥3) scores were stratified as low/intermediate risk (HAS-BLED <3) vs high risk (HAS-BLED ≥3). Results: The mean HAS-BLED score was 2.76±1.16; 64 (56%) patients had a HAS-BLED score ≥3.0. Patients with PAD Rutherford category 5/6 ischemia had an even higher mean HAS-BLED score (3.20±1.12). Logistic regression analysis revealed aortoiliac or femoropopliteal segment involvement, chronic kidney disease, as well as Rutherford category 5/6, to be independent risk factors associated with a HAS-BLED score ≥3. Conclusion: Patients with PAD, especially those presenting with Rutherford category 5/6 ischemic symptoms, have high HAS-BLED scores, suggesting increased risk for major bleeding. Prospective clinical validation of the HAS-BLED score in patients with PAD may help with the risk-benefit assessment when prescribing antithrombotic therapy.

Abstract P4-13-07: Impact of physical activity/exercise on adverse events and quality of life during treatment with everolimus and exemestane for ER+ women - Results of the 3rd interim analysis of BRAWO

Introduction

BRAWO is a non-interventional study collecting data of 3000 breast cancer patients treated with everolimus and exemestane (advanced or metastatic, hormone-receptor-positive, HER2-negative breast cancer). We introduce results of the 3rd preplanned interim analysis with data cut-off 08/01/ 2015, including 1300 patients. Since physical activity/exercise was reported to influence side effects as well as quality of life (QoL) of various cancer types and therapies, this analysis focuses on the impact of the physical activity/exercise history, development on adverse effects (AE) of the medical treatment and QoL.

Methods

Patients were asked to complete the EORTC QLQ-C30 QoL questionnaire and visual analogue scales (VAS-KAS) measuring their present-, past ten year- and lifetime physical activity/exercise level. To differentiate between activity/exercise levels, VAS were divided in three equal components (inactive, somewhat active, very active). Questionnaires and information about AE (e. g. stomatitis, fatigue, nausea, diarrhea, etc.) were collected before starting the medical treatment and were repeated each three months. Logistic regression model was used to estimate the impact of baseline physical activity/exercise on AE at any time point of the therapy. ANOVA models were used to calculate the impact of the baseline activity/exercise level on QoL at the last completed data set of each patient.

Results

Median age of patients was 66 years, median weight was 70 kg, median BMI was 25.9, median time since primary diagnosis was 6.2 years, and 54.4% had visceral metastases at baseline. The median PFS for the first 1300 patients was 7.1 months (95% CI, 6.5-8.0). Patients who reported to be very active (exercise) at the week prior to baseline (4.4%) showed significant lower numbers of AE compared to patients who indicate to be somewhat (14.8%) or inactive (80.8%). In contrast to the exercise level, physical activity in everyday life did not affect the AE incidence. Neither lifetime nor past ten year activity/exercise level is associated with the occurrence of AE. Regarding QoL, very active as well as somewhat active women (measured at baseline for almost each time period) showed significant higher QoL values compared to inactive women during the last assessment before death/progress.

Conclusion

Exercise prior to medical treatment with Everolimus and Exemestane may impact AE during therapy. Since physical activity did not show such a relation, this analysis highlights the importance of specific guidelines for preventive/rehabilitative exercise programs. More knowledge about dose-response relationships is needed. Furthermore a livelong healthy, "active" lifestyle may increase QoL, even in patients with advanced and terminal breast cancer disease.

Citation Format: Bloch W, Baumann F, Zimmer P, Grischke E-M, Fasching PA, Decker T, Uleer C, Schneeweiss A, Salat C, Wimberger P, Mundhenke C, Förster F, Kluth-Pepper B, Schubert J, Tesch H, Schütz F, Lüftner D, Jackisch C. Impact of physical activity/exercise on adverse events and quality of life during treatment with everolimus and exemestane for ER+ women - Results of the 3rd interim analysis of BRAWO. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-07.

[While Others are Sleeping - Performance of Major Trauma Care at Night]

Introduction: The literature indicates that medical staff suffer from a decline in cognitive and physical performance at night. This study evaluates the process quality and outcomes of emergency care during night-time and daytime. Method: Out of 1,226 prospectively registered patients, 420 were included into this study (observation period: 76 months). Inclusion criteria were an ISS ≥ 16 and admission to trauma room during "DAY" (8 am to 4 : 49 pm) or "NIGHT" (9 pm to 5 : 59 am). The fundamental part was the 130 items of the TraumaRegister DGU. The additional 350 items contain data about prehospital treatment, trauma room management and intensive care. Data were collected by a research assistant over a 24-h period. Results: The study sample contained 268 DAY-patients and 152 NIGHT-patients. Patients admitted during night were injured more severely: ISS 34.9 (± 16.4) vs. 31.1 (± 14.2), p = 0.015 and younger: 33.3 (± 16.6) vs. 43.6 (± 22.3) years old, p < 0.001. However, this had no impact on outcome prediction scores like RISC, RISC2 or TRISS, p ≥ 0.775. Furthermore, no difference in process quality was observed like the time to gain an arterial access: NIGHT 4.5 (± 3.7) vs. DAY 5.0 (± 3.7) min, p = 0.116, time for splinting 3.8 (± 3.7) vs. 3.4 (± 3.1) min, p = 0.922, or other parameters, like time to CT: 26.9 (± 11.2) vs. 26.6 (± 14.5) min, p = 0.520. Nor was there any difference in outcome: 17.8 % of the NIGHT-patients (RISC-prognosis: 23.8 %, SMR 0.74) died in hospital, and 18.3 % of the DAY-patients (RISC-prognosis: 24.0 %, SMR 0.77), p = 0.894. As well the comparison of the Glasgow Outcome Scale revealed no difference: NIGHT 3.8 (± 1.5) vs. DAY 3.8 (± 1.6), p = 0.491. Discussion: Although evidence suggests a drop of performance by medical staff at night, this effect could not be demonstrated. Considering this, the level of process quality and outcome - regardless of the time of arrival - remained constant on a high level. These results might be attributable to the quality management and the standardisation of the treatment.

Primary Self-EXPANDing Nitinol Stenting vs Balloon Angioplasty With Optional Bailout Stenting for the Treatment of Infrapopliteal Artery Disease in Patients With Severe Intermittent Claudication or Critical Limb Ischemia (EXPAND Study)

Purpose: To compare primary placement of a self-expanding nitinol stent to percutaneous transluminal angioplasty (PTA) with bailout stenting in infrapopliteal arteries of patients with severe intermittent claudication or critical limb ischemia (CLI). Methods: In the EXPAND trial ( ClinicalTrials.gov; identifier NCT00906022), 92 patients (mean age 72.9±9.5 years; 62 men) undergoing treatment for infrapopliteal stenosis in 11 European centers were randomized 1:1 to either self-expanding nitinol stenting with the Astron Pulsar/Pulsar-18 nitinol stent or PTA with bailout stenting. The primary endpoint was sustainable clinical improvement after 12 months, defined as a ≥1-category increase for Rutherford category 3 patients or a ≥2-category increase for CLI patients (Rutherford categories 4/5) compared with baseline. Furthermore, target lesion revascularization (TLR), mortality, and amputation were assessed after 12 months. Results: Sustained clinical improvement at 1 year was observed in 74.3% of the patients treated with primary stenting and in 68.6% of the patients treated with PTA and bailout stenting (p>0.05). Kaplan-Meier estimates of freedom from TLR (76.6% and 77.6%), mortality (7.4% vs 2.1%), and amputation [8.9% (major 6.7%) vs 13.2% (major 8.7%)] at 1 year were not significantly different. Conclusion: Primary self-expanding nitinol stenting did not show statistically different clinical outcomes compared to angioplasty with bailout stenting for infrapopliteal lesions.

[The relevant axial deviation: Diagnostics and therapy for correction osteotomies of the femur]

Intraoperative assessment of the femoral axis, length and torsion can be difficult. A postoperative torsional discrepancy is a common but rarely diagnosed condition. A clinical evaluation of femoral torsion is limited, especially in the early postoperative period. Conventional radiographs are a reliable diagnostic tool for evaluation of discrepancies of leg length and axis. Computed tomography remains the gold standard for assessment of torsional discrepancies. Because of the wide variability of the physiological femoral torsion, the clinical impact of a torsional discrepancy in individual cases remains unclear. There is a general recommendation for revision in cases of intraindividual deviations of more than 15°; however, most patients with deviations even greater than 15° are asymptomatic. Therefore, the indications for correction should be carefully considered in each individual case. The patient level of activity is a crucial point in decision-making for correction osteotomy. Before correction osteotomy, the surgeon has to make a detailed biomechanical analysis of the leg. Early correction is recommended in most cases. Detailed knowledge of the patient medical history is needed for preoperative planning. Prior surgeries can have a significant impact on the choice of the surgical approach and stabilization technique.

Percutaneous Large Arterial Access Closure Techniques

Endovascular repair has replaced open surgical repair as the standard of care for treatment of abdominal and thoracic aortic aneurysms in appropriately selected patients owing to its decreased morbidity and length of stay and excellent clinical outcomes. Similarly, there is a progressive trend toward total percutaneous repair of the femoral artery using percutaneous suture-mediated closure devices over open surgical repair due to decreased complications and procedure time. This article describes the techniques of closure for large-bore vascular access most commonly used in endovascular treatment of abdominal and thoracic aortic aneurysms, but could similarly be applied to any procedure requiring large-bore arterial access, such as transcatheter aortic valve replacement.

Single-Center Experience Comparing the Application of Small-Caliber versus Large-Caliber Arterial Access Closure in a Consecutive Series of Patients

PURPOSE

To compare the closure of ≤ 8-F versus 9-F to 12-F femoral access using the 8-F Angio-Seal VIP device (St. Jude Medical, Inc, St. Paul, Minnesota).

MATERIALS AND METHODS

In this investigator-initiated, retrospective analysis, a consecutive series of 137 patients (n = 92 male patients [67.2%]; overall mean age, 71.0 y ± 9.8) was evaluated. Common femoral artery access was performed in all patients, and either unfractionated heparin or bivalirudin was used for anticoagulation. Access site complications were defined as follows: type 0, no bleeding; type 1, no actionable bleeding; type 2, actionable bleeding.

RESULTS

The 8-F Angio-Seal VIP device was used for closure of ≤ 8-F femoral access in 76 patients (55.5%) and for 9-F to 12-F femoral access in 61 patients (44.5%). Access site complications were observed after 8-F Angio-Seal deployment in 11 patients (8.0%) (≤ 8 F, n = 5 [6.6%]; 9-12 F, n = 6 [9.8%]; P = .54). Comparing ≤ 8-F with 9-F to 12-F femoral access, type 1 complications were observed in 3 and 6 patients (P = .19) and type 2 complications were observed in 2 and 0 patients (P = .50), respectively. All type 1 complications were managed by applying external compression. Type 2 complications (n = 2 pseudoaneurysms) were treated with thrombin injection in 1 patient and secondary percutaneous intervention in 1 patient.

CONCLUSIONS

Use of the 8-F Angio-Seal for the closure of > 8-F femoral access is safe and effective. Complication rates when using the 8-F Angio-Seal for closure of ≤ 8-F and 9-F to 12-F femoral access are comparable.

Exercise-induced Natural Killer Cell Activation is Driven by Epigenetic Modifications

Exercise has been proven to reduce the risk and progression of various diseases, such as cancer, diabetes and neurodegenerative disorders. Increasing evidence suggests that exercise affects the cytokine profile and changes distribution and function of tumor-competitive immune cells. Initial studies have shown that different exercise interventions are associated with epigenetic modifications in different tissues and cell types, such as muscle, fat, brain and blood. The present investigation examines the effect of an intense endurance run (half marathon) on global epigenetic modifications in natural killer (NK) cells in 14 cancer patients compared to 14 healthy controls. We were able to show that histone acetylation and NKG2D expression, a functional NK cell marker, were elevated for at least 24 h after the run. Thus, this is the first study to present a potential mechanism of how exercise may impact NK cell activity on the subcellular level. Further studies should focus on epigenetic mechanisms and dose-dependent effects of exercise.

The Importance of Patency in Patients with Critical Limb Ischemia Undergoing Endovascular Revascularization for Infrapopliteal Arterial Disease

Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease (PAD) and frequently occurs in medically frail patients. CLI patients frequently exhibit multi-segmental PAD commonly including the tibial arterial segment. Endovascular therapy has been established as first-line revascularization strategy for most CLI patients. Restenosis was reported to occur in up to more than two-thirds of CLI patients undergoing angioplasty of complex tibial arterial obstructions. Nevertheless, favorable clinical outcomes were observed for infrapopliteal angioplasty when compared with bypass surgery, despite higher patency rates for the latter. Based on these observations, infrapopliteal patency was considered to be only of secondary importance upon clinical outcomes in CLI patients. In contrast to these earlier observations, however, recent findings from two randomized clinical trials indicate that infrapopliteal patency does impact on clinical outcomes in CLI patients. The purpose of the present manuscript is to provide a critical reappraisal of the present literature on the clinical importance of tibial arterial patency in CLI patients undergoing endovascular revascularization and to discuss utility and limitations of currently available anti-restenosis technologies.

Posterolateral fusion in acute traumatic thoracolumbar fractures: a comparison of demineralized bone matrix and autologous bone graft

INTRODUCTION Alternative fusion expanders are in clinical use for instrumented posterolateral fusion (PLF) to avoid donor site morbidity in autologous bone graft (ABG) harvesting. Purpose of this study was to evaluate demineralized bone matrix (DBM) in PLF as alternative to the gold standard of ABG in acute traumatic vertebral body fractures of the thoracolumbar spine. MATERIAL AND METHODS We retrospectively identified 101 patients with acute traumatic vertebral body fractures of the thoracic and lumbar spine who were treated with instrumented PLF in our level one trauma center between 2005 and 2011. Patients with a primary paraplegia, osteodepriving disease or loss to follow-up had been excluded. Until August 2008, autologous bone graft harvested from the posterior iliac crest was used in PLF (control group n = 46). Starting September 2008, DBM was used as fusion expander in PLF (study group n = 16). Clinical and radiological evaluation was performed with a minimum followup of 18 months to assess the clinical and radiological outcome. RESULTS We found a fusion rate of 94% in patients undergoing PLF with the use of DBM and 100% with the use of ABG. There was one major complication of deep infection in the DBM group and two cases of superficial wound infection in the ABG group. We discovered a trend of reduced operating time with the use of DBM. CONCLUSIONS DBM leads to a similar fusion rate as the use of ABG in patients undergoing PLF for acute traumatic vertebral body fractures of the thoracic and lumbar spine. DBM is associated with reduced operating time.

LEVEL OF EVIDENCE III

case-control study Key words: demineralized bone matrix instrumented posterolateral fusion, acute traumatic vertebral body fracture, thoracolumbar spine, autologous bone graft.

Does patency matter in patients with critical limb ischemia undergoing endovascular revascularization?

Restenosis is the major drawback in patients undergoing tibial angioplasty. In contrast to earlier observations, tibial patency was shown to impact on clinical outcomes in current randomized trials and is thus attributed more importance. Accordingly, intentions to reduce tibial restenosis have been intensified. Both drug-eluting balloons (DEB) and drug-eluting stents (DES) were shown to reduce tibial restenosis when compared with its plain counterparts. However, both endovascular technologies have its limitations for tibial arterial application. While DEB technology may not address elastic recoil, a pathophysiological mechanism frequently observed in tibial arteries and a significant contributor to restenosis, currently available DES do not fully address tibial arterial lesion morphology. Purpose of the present manuscript is to outline the problem and the incidence of tibial arterial restenosis, its importance on clinical outcomes and to provide an overview on technical developments aimed at its prevention.

[Aortic aneurysms and aortic dissection: epidemiology, pathophysiology and diagnostics]

Aortic aneurysms and aortic dissection represent a significant health risk due to the demographic developments and current life styles. The mortality of ruptured aortic aneurysms is up to 80 % and the prevalence of aneurysms varies depending on the localization (thoracic or abdominal). Most commonly affected is the infrarenal abdominal aorta; however, there is evidence that the prevalence is diminishing but in contrast the incidence of thoracic aortic aneurysms is increasing. Aortic dissection is often fatal and is the most common acute aortic disease but the incidence is presumed to be underestimated. The pathogenesis of aortic aneurysms is manifold and is based on an interplay between degenerative, proteolytic and inflammatory processes. An aortic dissection arises from a tear in the intima which results in a separation of the aortic wall layers with infiltration of bleeding and the danger of aortic rupture. Various genetic disorders of connective tissue promote degeneration of the aortic media, most notably Marfan syndrome. Risk factors for aortic aneurysms and aortic dissection are nicotine abuse, arterial hypertension, age and male gender. Aortic aneurysms initially have an uneventful course and as a consequence are mostly discovered incidentally. The clinical course and symptoms of aortic dissection are very much dependent on the section of the aorta affected and the manifestations are manifold. Acute aortic dissection is in 80 % of cases first manifested as sudden extremely severe pain. The diagnostics and subsequent course control can be achieved by a variety of imaging procedures but the modality of choice is computed tomography.

Fixed low-dose ultrasound-assisted catheter-directed thrombolysis for intermediate and high-risk pulmonary embolism

AIMS

No standardized local thrombolysis regimen exists for the treatment of pulmonary embolism (PE). We retrospectively investigated efficacy and safety of fixed low-dose ultrasound-assisted catheter-directed thrombolysis (USAT) for intermediate- and high-risk PE.

METHODS AND RESULTS

Fifty-two patients (65 ± 14 years) of whom 14 had high-risk PE (troponin positive in all) and 38 intermediate-risk PE (troponin positive in 91%) were treated with intravenous unfractionated heparin and USAT using 10 mg of recombinant tissue plasminogen activator per device over the course of 15 h. Bilateral USAT was performed in 83% of patients. During 3-month follow-up, two [3.8%; 95% confidence interval (CI) 0.5-13%] patients died (one from cardiogenic shock and one from recurrent PE). Major non-fatal bleeding occurred in two (3.8%; 95% CI, 0.5-13%) patients: one intrathoracic bleeding after cardiopulmonary resuscitation requiring transfusion, one intrapulmonary bleeding requiring lobectomy. Mean pulmonary artery pressure decreased from 37 ± 9 mmHg at baseline to 25 ± 8 mmHg at 15 h (P < 0.001) and cardiac index increased from 2.0 ± 0.7 to 2.7 ± 0.9 L/min/m(2) (P < 0.001). Echocardiographic right-to-left ventricular end-diastolic dimension ratio decreased from 1.42 ± 0.21 at baseline to 1.06 ± 0.23 at 24 h (n = 21; P < 0.001). The greatest haemodynamic benefit from USAT was found in patients with high-risk PE and in those with symptom duration < 14 days.

CONCLUSION

A standardized catheter intervention approach using fixed low-dose USAT for the treatment of intermediate- and high-risk PE was associated with rapid improvement in haemodynamic parameters and low rates of bleeding complications and mortality.

Restenosis after infrapopliteal angioplasty - clinical importance, study update and further directions

Patients with critical limb ischemia (CLI) represent the most severe form of peripheral arterial disease (PAD) and exhibit high mortality rates. Frequently, PAD in CLI patients involves the infrapopliteal arterial segment challenging endovascular revascularization strategies. Restenosis remains the major drawback of tibial angioplasty encountered in more than two thirds of CLI patients undergoing tibial revascularization. In contrast to earlier observations, tibial patency was recently shown to be essential to attain an optimal clinical outcome in CLI patients subsequent to tibial angioplasty. The exact pathopyhsiological mechanisms of tibial restenosis remains unclear. To date, most of our knowledge on tibial restenosis and its pathophysiology is derived from coronary arteries, based on the similarity of coronary arteries to tibial artery morphology. Nervetheless, multiple antirestenosis concepts are investigated within clinical trials to reduce tibial restenosis.Purpose of the present manuscript is to provide a current update on the pathophysiology of tibial restenosis and potential antirestenosis strategies.

Infrapopliteal lesion morphology in patients with critical limb ischemia: implications for the development of anti-restenosis technologies

PURPOSE

To angiographically evaluate infrapopliteal arterial lesion morphology in a consecutive series of patients presenting with critical limb ischemia (CLI) and undergoing infrapopliteal angioplasty.

METHODS

A prospective analysis was undertaken of a consecutive series of CLI patients undergoing endovascular therapy in a tertiary referral center in the year 2011. Morphological assessment of baseline angiograms obtained prior to revascularization included lesion length, assessment of calcification using a semi-quantitative scoring system, and reference vessel diameter (RVD) measurement. Delta RVDs were assessed subtracting distal RVDs from proximal RVDs. A total of 197 infrapopliteal lesions in 105 CLI patients (n=106 limbs) were assessed. Of these, 136 lesions were treated by endovascular means.

RESULTS

The average length of treated lesions was 87.1±43.8 mm in stenoses and 124.0±78.3 mm in chronic occlusions (p<0.001). Mean RVD proximal to the lesions was 1.88 mm whereas it was 1.66 mm distal to the lesions (p≤0.03). Mean arterial calcification was 1.15.

CONCLUSION

This prospective angiographic series underlines the complex nature and extensive longitudinal involvement of infrapopliteal lesions in CLI patients. These findings should be taken into consideration for anti-restenosis concepts in this challenging subgroup of peripheral artery disease patients.

Diurnal changes of lower leg volume in obese and non-obese subjects

BACKGROUND/AIM

Obesity is a risk factor for chronic venous disease. However, the mechanisms behind this association are poorly understood. We tested the hypothesis that obese subjects have a higher diurnal leg volume increase compared with non-obese subjects.

METHODS

In this prospective cohort study including obese (body mass index, BMI ≥30 kg m(-)(2)) and non-obese (BMI ≤25 kg m(-)(2)) subjects without venous insufficiency, lower leg volume was assessed by optoelectronic volumetry in the morning and in the evening. All subjects underwent duplex ultrasound and light reflection rheography (venous pump power and venous refill time, VRT) to investigate lower extremity venous function. A pedometer was carried between the morning and evening visit to assess the daily number of footsteps. A backward multivariable linear regression model was used to determine factors associated with diurnal lower leg volume increase.

RESULTS

Forty-two limbs in 24 obese subjects and 29 limbs in 15 non-obese subjects were analyzed. Obese subjects had larger common femoral vein diameters (17.1±2.4 vs 15.5±2.4 mm, P<0.01) and slower peak, mean and minimal velocities (25.1±10.6 vs 44.3±14.3 cm s(-1); 6.8±2.4 vs 12.7±5.6 cm s(-1); -0.2±6.4 vs -6.3±11.9 cm s(-1); P<0.01 for all) than non-obese subjects. VRT was shorter in obese subjects (40.5±15.0 vs 51.0±12.1 s, P<0.01) and decreased significantly in the course of the day only in obese subjects (P<0.01). Obesity, male gender, CEAP (Clinical-Etiology-Anatomy-Pathophysiology) class, total time between the two visits and difference between morning and evening VRT were positively associated with higher lower leg volume increase; morning VRT and the total number of footsteps showed a negative association (P<0.04 for all).

CONCLUSION

Obesity was found to be an independent predictor of higher diurnal leg volume increase. One potential mechanism is a progressive failure of venous valve function in the course of the day in obese subjects.