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Hartert M, Deppe C, Fink L, Kappes J. Chest wall tumor following intravesical BCG instillation for non-muscle invasive bladder cancer. J Clin Tuberc Other Mycobact Dis 2024; 35:100438. [PMID: 38623461 PMCID: PMC11017275 DOI: 10.1016/j.jctube.2024.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Mycobacterium bovis bacille Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for non-muscle invasive bladder cancer (NMIBC), administered after its transurethral resection. Although its instillation is generally well tolerated, BCG-related infectious complications may occur in up to 5% of patients. Clinical manifestations may arise in conjunction with initial BCG instillation or develop months or years after the last BCG instillation. The range of presentations and potential severity pose an imminent challenge for clinicians. We present a case of an isolated subcutaneous chest wall abscess in an immunocompetent 52-year-old patient nearly two years after intravesical BCG instillation for NMIBC, an absolute rarity. As the enlarging chest wall tumor may be misinterpreted as malignancy, its expedient diagnosis and prompt treatment are of critical importance.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Claudia Deppe
- Department of Internal Medicine and Pneumology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Ludger Fink
- Institute of Pathology, Cytopathology, and Molecular Pathology, Supraregional Joint Practice for Pathology, Member of the German Center for Lung Research, Wetzlar, Germany
| | - Jutta Kappes
- Department of Internal Medicine and Pneumology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Huertgen M. Portrayal of video-assisted mediastinoscopic lymphadenectomy's range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective. J Cardiothorac Surg 2023; 18:152. [PMID: 37069572 PMCID: PMC10111845 DOI: 10.1186/s13019-023-02277-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious - at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 - to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure. CASE PRESENTATION We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up. CONCLUSION Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA's important role as a diagnostic and therapeutic tool.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany.
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany
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3
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Hartert M, Wolf M, Huertgen M. Pyopericardium and extensive mediastinal abscess following EBUS-TBNA for mediastinal staging of NSCLC: a case report. Mediastinum 2023; 7:4. [PMID: 36926285 PMCID: PMC10011863 DOI: 10.21037/med-22-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
Background Based on the algorithm on preoperative mediastinal staging in patients with non-small cell lung cancer (NSCLC), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. It represents both a safe minimal invasive procedure with complication rates of less than 1.5% and a valid tool with a high sensitivity defining mediastinal nodal disease. However, infectious complications like mediastinitis or pyopericardium are most feared. Case Description A 54-year-old woman was admitted to our hospital for further investigation of a suspected NSCLC of the right upper lobe. EBUS-TBNA was performed to receive both diagnosis and samples of the mediastinal lymph nodes. Two weeks after EBUS-TBNA, the patient presented with symptoms of cardiogenic/septic shock: hypotension, tachycardia, chest pain and fever. Prompt diagnosis of concomitant infectious mediastinitis and extensive pyopericardium in consequence of EBUS-TBNA was obvious. Besides systemic antibiotics, bilateral thoracoscopic interventions finally made the breakthrough. The patient could be discharged roughly three weeks after emergent re-admittance. As being finally diagnosed with NSCLC (stage IIIA squamous cell carcinoma), the patient underwent-subsequent to induction chemotherapy-a definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease. Conclusions It is to be expected that with increasing application of EBUS-TBNA as mediastinal staging tool, the number of serious infection-related complications will rise accordingly. The efficacy of antibiotic prophylaxis after EBUS-TBNA has not yet been proved and is therefore not included in any guideline. Our case gives an impression on the severity of delayed infectious complications after EBUS-TBNA and outlines up-front surgery as primary objective to broadly debride all contagious abscess-/empyema sites. With increased use of EBUS-TBNA as mediastinal staging tool, clinicians should be aware of this rare but highly critical peri-interventional complication in order to closely monitor endangered patients.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Michael Wolf
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Tripsky J, Brandt A, Huertgen M. Non-intubated Uniportal Subxiphoid Video-Assisted Thoracoscopic Surgery for Extended Thymectomy in Myasthenia Gravis Patients: A Case Series. J Chest Surg 2022; 55:417-421. [PMID: 35822441 PMCID: PMC9579843 DOI: 10.5090/jcs.22.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/26/2022] [Accepted: 05/04/2022] [Indexed: 11/25/2022] Open
Abstract
Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Jan Tripsky
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Andreas Brandt
- Department of Anesthesiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Melcher B, Huertgen M. Correction to: Association of early-onset myasthenia gravis and primary Sjögren's syndrome: a case-based narrative review. Clin Rheumatol 2022; 41:3267-3268. [PMID: 35951273 DOI: 10.1007/s10067-022-06328-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany.
| | - Balint Melcher
- Institute of Pathology, Franz-Weis-Str. 13, 56073, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany
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Hartert M, Melcher B, Huertgen M. Association of early-onset myasthenia gravis and primary Sjögren's syndrome: a case-based narrative review. Clin Rheumatol 2022; 41:3237-3243. [PMID: 35913580 DOI: 10.1007/s10067-022-06294-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/07/2022] [Accepted: 07/10/2022] [Indexed: 11/29/2022]
Abstract
Coexistent myasthenia gravis (MG) and primary Sjögren's syndrome (pSS) is an absolute rarity. That is kind of a surprise as both entities seem to share the same corresponding immunologic mechanisms. We hereby report the case of a 41-year-old woman with coincident early-onset MG (EOMG) and pSS. Because EOMG was the leading clinical feature, she was primarily treated by innovative non-intubated uniportal subxiphoid video-assisted thoracoscopic surgery (VATS) thymectomy. As the association of EOMG and pSS is so unusual, we contextualize our findings with the relevant literature. Particular relevance is an anti-nuclear antibody screening throughout the clinical course of MG and-in reverse-a screening for MG variables when pSS patients complain either muscle fatigability or fatigable ptosis. As pSS patients do not develop any serious morbidity, supervising MG progress in patients with both diseases is of utmost importance. Apart from conscientious pSS diagnosis, prompt adjusting of EOMG progress is the essential aspect of targeted treatment. In this context, it is relevant that therapeutic decisions are made in a multidisciplinary approach. Due to its rarity, multicenter prospective studies of larger sample sizes are indispensably needed to obtain a better understanding of this unusual link.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany.
| | - Balint Melcher
- Institute of Pathology, Franz-Weis-Str. 13, 56073, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany
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Hartert M, Tripsky J, Huertgen M. Technique for ectopic intrathymic parathyroid adenoma: the uniportal subxiphoid approach. J Surg Case Rep 2021; 2021:rjab520. [PMID: 34909166 PMCID: PMC8666194 DOI: 10.1093/jscr/rjab520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/01/2021] [Indexed: 11/14/2022] Open
Abstract
Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quarter of them being ectopic, most likely located in the superior mediastinum within the thymus. Besides the challenge of their prompt and correct diagnosis, utmost care should be taken during surgical resection as leaving behind parathyroid tissue may result in metastasis and recurrence of hyperparathyroidism. With tumor excision via median sternotomy or thoracotomy being the conventional approaches for a long period, video-assisted thoracoscopic surgery (VATS) is of gaining popularity. As the lateral thoracic approach lacks in clarity on the contralateral mediastinum, the newest evolution in VATS—the supxiphoid approach—closes the gap to the insufficient intraoperative visibility and hence optimizes postoperative outcome. We hereby present the practicality of the uniportal subxiphoid resection of an ectopic mediastinal PA.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Jan Tripsky
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Weber D, Herber S, Huertgen M. Heterotopic ossification of a pedicled intercostal muscle flap. Eur J Cardiothorac Surg 2021; 62:6456174. [PMID: 34878130 DOI: 10.1093/ejcts/ezab518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/25/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Dietmar Weber
- Department of Diagnostic and Interventional Radiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Sascha Herber
- Department of Diagnostic and Interventional Radiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Mann WJ, Senbaklavaci Ö. Relocation of an infected tracheostoma: anterior mediastinal tracheostomy as Mission:Impossible. Interact Cardiovasc Thorac Surg 2021; 33:319-321. [PMID: 33792686 DOI: 10.1093/icvts/ivab071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
Infected tracheostomas are frequently associated with high morbidity and mortality rates-especially in patients after neck-oncological surgery with subsequent radiochemotherapy. A 59-year-old male patient with a history of hypopharynx carcinoma, successive laryngectomy and adjuvant radiochemotherapy developed an oesophagotracheal fistula with massive inflammation and periodical bleedings, uncontrollable by regular stent alternations. In a multidisciplinary setting, the decision was made to treat the patient with an anterior mediastinal tracheostomy. Extending usual anterior mediastinal tracheostomy indications, we present an ultimate treatment option for infected tracheostomas and highly advocate this interdisciplinary venture, as it significantly improves quality of life.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Wolf Jürgen Mann
- Department of Otorhinolaryngology, Head and Neck Surgery, Professor emeritus at University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Ömer Senbaklavaci
- Department of Thoracic Surgery, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Hartert M, Wolf M, Ferber J, Huertgen M. Thoracoabdominal actinomycosis - Chameleon through kaleidoscope. Respir Med Case Rep 2020; 31:101281. [PMID: 33251103 PMCID: PMC7677701 DOI: 10.1016/j.rmcr.2020.101281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 11/22/2022] Open
Abstract
Actinomyces is a gram-positive anaerobic bacterium that generally inhabits the human commensal flora of the bronchial system, the gastrointestinal and urogenital tract. In the rare case of becoming invasive under certain circumstances, the resulting Actinomycosis affects most commonly cervicofacial, thoracic, abdominal and pelvic regions. Due to its rarity and presenting with nonspecific clinical symptoms, thoracic and/or abdominal Actinomycosis in particular are highly intriguing clinical conditions that can easily be mistaken for other diseases including malignancies. Astute considerations are therefore necessary whenever we are challenged diagnostically to allow early diagnosis and thus avoiding gratuitous invasive surgery. In order to highlight different issues of this ultimate chronic disease we report a particular case of thoracoabdominal Actinomycosis.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Michael Wolf
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | | | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Tripsky J, Huertgen M. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging & treatment of non-small cell lung cancer (NSCLC). Mediastinum 2020; 4:3. [PMID: 35118271 PMCID: PMC8794437 DOI: 10.21037/med.2019.09.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/18/2019] [Indexed: 11/06/2022]
Abstract
Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Jan Tripsky
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Hartert M, Wolf M, Marko C, Huertgen M. Glomus tumor of the trachea - Synopsis of histology & methodology of treatment. Respir Med Case Rep 2019; 28:100905. [PMID: 31341765 PMCID: PMC6630016 DOI: 10.1016/j.rmcr.2019.100905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022] Open
Abstract
Glomus tumors are neoplasms arising from modified smooth muscle cells surrounding arteriovenous anastomosis in the dermis and subcutaneous tissues, which are contributing to blood flow regulation and temperature control on the skin surface. Glomus cells are sparse or absent in visceral organs, making extracutaneous presentation of glomus tumors an extremely rare finding. We briefly report histological considerations on glomus tumors of the trachea and sum the multidisciplinary aspects of their staged endoscopic and surgical management using the example of a rare case presentation.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
- Corresponding author. Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany.
| | - Michael Wolf
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | | | - Martin Huertgen
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R, Bachet JE, Carrel TP, Grabenwöger M, Schepens MA, Czerny M. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg 2015; 47:943-57. [DOI: 10.1093/ejcts/ezv142] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hartert M, Senbaklavacin O, Gohrbandt B, Fischer BM, Buhl R, Vahld CF. Lung transplantation: a treatment option in end-stage lung disease. Dtsch Arztebl Int 2015; 111:107-16. [PMID: 24622680 DOI: 10.3238/arztebl.2014.0107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list. METHOD We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO). RESULTS The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%). CONCLUSION Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery at the University Medical Center of the Johannes Gutenberg University Mainz, Department of Hematology, Pneumology and Oncology at the University Medical Center of the Johannes Gutenberg University Mainz
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Hartert M, Conzelmann LO, Mehlhorn U, Schnelle N, Werner C, Vahl CF. Cross-clamping a porcelain aorta: an alternative technique for high-risk patients. J Cardiovasc Surg (Torino) 2014; 59:737-745. [PMID: 24525522 DOI: 10.23736/s0021-9509.16.07834-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Aortic cross-clamping in patients with porcelain aorta is associated with high mortality and morbidity rates. The aim is to establish a new approach to improve the outcome in this high-risk population. METHODS Between September 2007 and November 2012, 42 patients with an aortic (N.=33; 81.3±6.4 years) or mitral valve disease (N.=9; 80.3±5.7) combined with a porcelain aorta underwent aortic (AVR) or mitral valve replacement (MVR). After arterial cannulation via distal aortic arch or femoral artery, longitudinal aortotomy under total cardiopulmonary bypass (CPB) was performed. The aorta was slowly clamped, thus mobilized atherosclerotic material could leave the aorta through the open incision. Subsequent to the actual operation, the aorta was gradually unclamped. Again, plaques were flushed out via the still open aortotomy ("open proximal ascending aorta"). RESULTS Intraoperatively, no technical no problems occurred. Mean CPB time was 92.2±27.9 min (AVR) and 92.3±36.3 min (MVR); cardiac ischemia time was 74.3±26.7 min (AVR) and 77.1±31.6 min (MVR). Surgical revision was necessary in three patients (7.1%) due to major bleedings. Two AVR-patients suffered from minor stroke and one MVR-patient from major stroke (neurological deficit rate =7.1%). Transient ischemic attacks occurred in three patients (7.1%), another three patients (7.1%) required temporary hemofiltration. Neither gastrointestinal disorders nor respiratory failure or valve-related problems were noted. 30-day mortality was 6.9%. CONCLUSIONS Cross-clamping with "open proximal ascending aorta" is effective and the incidence of stroke and systemic embolization in patients with porcelain aorta is low compared to literature.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany -
| | - Lars O Conzelmann
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Uwe Mehlhorn
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Nalan Schnelle
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Christian Werner
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Christian-Friedrich Vahl
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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Hartert M, Abugameh A, Vahl CF. Herausforderung Porzellanaorta. Z Herz- Thorax- Gefäßchir 2013. [DOI: 10.1007/s00398-013-1039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Senbaklavaci Ö, Taspinar H, Hartert M, Vahl CF. Impact of previous cardiovascular surgery on postoperative morbidity and mortality after major pulmonary resection for non-small cell lung cancer. Langenbecks Arch Surg 2013; 398:903-7. [PMID: 23760754 DOI: 10.1007/s00423-013-1081-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 04/03/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the impact of previous cardiovascular surgery on the postoperative morbidity and mortality following major pulmonary resection for non-small cell lung cancer (NSCLC). METHODS Medical records of 227 patients, who underwent major pulmonary resection for NSCLC from 2003 to 2012 at our department, were reviewed retrospectively. Thirty-one patients with a mean age of 65.8 years had previous cardiovascular surgery (group A) including coronary artery revascularization in 11 patients, peripheral arterial revascularization in 6 patients, carotis endarterectomy in 9 patients, and combined coronary artery revascularization and carotis endarterectomy in 5 patients, whereas 167 patients (mean age = 62.0 years) had no cardiovascular comorbidity (group B). Twenty-nine patients with nonsurgically treated cardiovascular comorbidity were excluded from this study. RESULTS There were no significant differences in overall postoperative morbidity (22.6 % in group A vs. 19.2 % in group B) and mortality (no mortality in group A vs. 2.4 % in group B) between both groups. CONCLUSIONS Major pulmonary resections for NSCLC can be performed safely in patients with previous cardiovascular surgical history who are fulfilling the common cardiopulmonary criteria of operability. Operative risk in this subpopulation is comparable to that in patients without cardiovascular comorbidity.
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Affiliation(s)
- Ömer Senbaklavaci
- Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.
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Senbaklavaci O, Taspinar H, Hartert M, Ergun S, Keranen S, Vahl CF. Lobar lung resection in elderly patients with non-small cell lung carcinoma: impact of cardiac comorbidity on surgical outcome. Swiss Med Wkly 2013; 142:w13742. [PMID: 23297101 DOI: 10.4414/smw.2012.13742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PRINCIPLES The aim of this study was to evaluate the impact of cardiac comorbidity on the perioperative morbidity and mortality after lobar lung resection for lung cancer in patients aged 70 years and older. METHODS The medical records of all 68 patients ≥70 years, who underwent lobar lung resection for non-small cell lung cancer (NSCLC) from 2003 to 2011 at our department, were reviewed retrospectively. Twenty-two patients with a mean age of 76.3 years had cardiac comorbidities (Group A) including previous cardiac operations in 4 patients, previous myocardial infarction in 5 patients, previous coronary stent insertion in 3 patients, medically treated coronary artery disease in 10 patients and medically treated valvular heart disease in 2 patients whereas 46 patients (mean age = 74.5 years) had no previous cardiac history (Group B). RESULTS There were no significant differences in postoperative morbidity (13.6% in Group A vs. 17.4% in Group B) between both groups. No in-hospital mortality was observed in both groups. CONCLUSION In our experience lobar lung resections for NSCLC in elderly patients with cardiac comorbidity seem to be a safe therapy option for this increasing subpopulation. Though, our retrospective data with the small number of study objects require further confirmation in larger prospective trials.
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Affiliation(s)
- O Senbaklavaci
- Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg University Mainz, Germany.
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Hartert M, Senbaklavaci Ö, Schuon R, Taspinar H, Ergün S, Mann W, Vahl CF. Successful relocation of an infected tracheostomy at the level of the inferior manubrium sterni: No mission impossible. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Hartert M, Senbaklavaci Ö, Kreitner KF, Vahl CF. From partial anomalous pulmonary venous drainage to chronic thromboembolic pulmonary hypertension: successful surgical correction of a 14 year misinterpreted clinical feature. Thorac Cardiovasc Surg 2011. [DOI: 10.1055/s-0030-1269277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hartert M, Peivandi A, Conzelmann L, Kayhan N, Mehlhorn U, Vahl CF. Cross-clamping with open aortic root as standard surgical approach in patients with porcelain aorta. Thorac Cardiovasc Surg 2011. [DOI: 10.1055/s-0030-1269336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hartert M, Dahm M, Neufang A, Vahl CF. Minimum cause--maximum effect: the travelogue of a bullet. Interact Cardiovasc Thorac Surg 2010; 11:698-700. [PMID: 20709697 DOI: 10.1510/icvts.2010.245100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This case report involves a 57-year-old male, accidentally shot in the chest with a small bore firearm. The bullet entered the left hemithorax, disrupting the left internal mammarian artery. It then penetrated the anterior wall of the right ventricle causing a pericardial tamponade. After leaving the base of the right heart it perforated the diaphragm, the liver, the spleen and the pancreas. Finally, it penetrated the abdominal aorta 3 cm proximally to the coeliac trunk and reached its final position paravertebrally. This case report illustrates that the management of even minimum gunshot wounds requires a maximum variety of surgical skills.
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Affiliation(s)
- Marc Hartert
- Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany.
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ter Wolbeek C, Hartert M, Conzelmann LO, Peivandi AA, Czerny M, Gottardi R, Beyersdorf F, Weigang E. Value and pitfalls of neurophysiological monitoring in thoracic and thoracoabdominal aortic replacement and endovascular repair. Thorac Cardiovasc Surg 2010; 58:260-4. [PMID: 20680900 DOI: 10.1055/s-0030-1249904] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of our study was to analyze the neurophysiological monitoring method with regard to its potential problems during thoracic and thoracoabdominal aortic open or endovascular repair. Furthermore, preventive strategies to the main pitfalls with this method were developed. METHODS Between 11/2000 and 05/2007 in 97 cases open surgery or endovascular stentgraft-implantation was performed on the thoracic or thoracoabdominal aorta. Intraoperatively, neurophysiologic motor- and somatosensory-evoked potentials were monitored. RESULTS Our cases were divided into four groups: event-free patients with normal potentials (A, 63 cases), with correlation of modified evoked potentials and neurological outcome (B, 14 cases), false-positive or false-negative results (C, 4 cases), and medication interaction or technical issues (D, 16 cases). We observed a sensitivity of 93 % and a specificity of 96 % for the neurophysiological monitoring. CONCLUSIONS Monitoring spinal cord function during surgical and endovascular interventions on the thoracic and thoracoabdominal aorta is necessary. It can be made more effective by precisely analyzing the interference factors of the neurophysiological monitoring method itself. Successful strategies of immediate troubleshooting could be identified.
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Affiliation(s)
- C ter Wolbeek
- Cardiovascular Surgery, University Cardiovascular Center Freiburg-Bad Krozingen, Freiburg, Germany
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Kuroczynski W, Kampmann C, Huth R, Hartert M, Heinemann M, Vahl CF. Sternal augmentation plasty utilizing homologous bone tissue after Fontan operation. Thorac Cardiovasc Surg 2010. [DOI: 10.1055/s-0029-1246820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kuroczynski W, Kampmann C, Hartert M, Huth R, Heinemann M, Vahl CF. Clinical outcome up to 13.3 years after successful completion of the Fontan procedure in early childhood. Thorac Cardiovasc Surg 2010. [DOI: 10.1055/s-0029-1246773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hartert M, Peivandi AA, Conzelmann LO, Kayhan N, Mehlhorn U, Dahm M, Vahl CF. Re-evaluation of cross-clamping with open aortic root as an alternative surgical approach in patients with porcelain aorta. Thorac Cardiovasc Surg 2010. [DOI: 10.1055/s-0029-1247024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hartert M, Gemechu AK, Neufang A, Dahm M, Vahl CF. Minimum cause – maximum effect: the travelogue of a bullet. Thorac Cardiovasc Surg 2010. [DOI: 10.1055/s-0029-1246749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kuroczyński W, Kampmann C, Peivandi AA, Hartert M, Knuf M, Heinemann MK, Vahl CF. Mid-term results of a modified arterial switch operation using the direct reconstruction technique of the pulmonary artery. Cardiol J 2010; 17:574-579. [PMID: 21154259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND There is ongoing discussion as to whether it is beneficial to avoid pulmonary sinus augmentation in the arterial switch operation. We report a single-surgeon series of mid-term results for direct pulmonary artery anastomosis during switch operation for transposition of the great arteries (TGA). METHODS This retrospective study includes 17 patients with TGA, combined with an atrial septal defect, patent foramen ovale or ventricular septal defect. Patient data was analyzed from hospital charts, including operative reports, post-operative course, and regular follow-up investigations. The protocol included cardiological examination by a single pediatric cardiologist. Echocardiographic examinations were performed immediately after arrival on the intensive unit, before discharge, and then after three, six, and 12 months, followed by yearly intervals. Pulmonary artery stenosis (PAS) was categorized into three groups according to the Doppler-measured pulmonary gradient: grade I (trivial stenosis) = increased pulmonary flow with a gradient below 25 mm Hg; grade II (moderate stenosis) = a gradient ranging from 25 to 49 mm Hg; and grade III (severe stenosis) = a gradient above 50 mm Hg. Follow-up data was available for all patients. The length of follow-up ranged from 1.2 to 9.7 years, median: 7.5 years (mean 6.1 years ± 14 months). RESULTS During follow-up, 12 patients (70.6%) had no (or only trivial) PAS, five patients (29.4%) had moderate stenosis without progress, and no patient had severe PAS. Cardiac catheterization after arterial switch operation was performed in 11 patients (64.7%) and showed a good correlation with echocardiographic findings. During follow-up there was no reintervention for PAS. CONCLUSIONS Direct reconstruction of the neo-pulmonary artery is a good option in TGA with antero-posterior position of the great vessels, with very satisfactory mid-term results.
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Kuroczynski W, Hartert M, Ewald P, Heinemann M, Pruefer D, Vahl CF. Delayed sternal closure after cardiac operations in a pediatric population – risk factors. Thorac Cardiovasc Surg 2009. [DOI: 10.1055/s-0029-1191529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kuroczynski W, Hartert M, Peivandi AA, Ewald P, Pruefer D, Vahl CF. Surgical treatment of adult atrial septal defect. Thorac Cardiovasc Surg 2009. [DOI: 10.1055/s-0029-1191355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hartert M, Peivandi AA, Kayhan N, Mehlhorn U, Dahm M, Vahl CF. Cross-clamping with open aortic root: A treatment strategy for old patients with porcelain aorta. Thorac Cardiovasc Surg 2009. [DOI: 10.1055/s-0029-1191382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kuroczynski W, Hartert M, Heinemann M, Vahl CF. Coarctation repair in adults: beneficial effects on postoperative blood pressure regulation. Thorac Cardiovasc Surg 2009. [DOI: 10.1055/s-0029-1191354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Weigang E, Luehr M, von Samson P, Hartert M, Goebel H, Wetzig M, Bernard V, Siegenthaler MP, Beyersdorf F. Development of a Special Balloon Occlusion Device to Prevent Adverse Events in High-Risk Patients during Open Aortic Surgery. Eur Surg Res 2008; 37:204-9. [PMID: 16260869 DOI: 10.1159/000087864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 07/08/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To prevent clamp injury that may occur during aortic surgery, we aimed to develop a special balloon occlusion (BO) device to lower the thromboembolic risk in patients with severe atherosclerosis during aortic aneurysm repair. METHODS The study comprised two test phases: a laboratory-testing series focussing on flexible artificial aortas, and an experimental series conducted on 10 pigs. RESULTS The device proved to be effective during the laboratory tests and the experiments on pigs. No complications such as intraoperative balloon rupture, dislocation, or occlusion leaks occurred. No damage to the aortic vessels was observed in further histological examinations. CONCLUSIONS This BO device has the potential to become an alternative to cross-clamping for vascular surgeons in patients with severely atherosclerotic vessels.
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Affiliation(s)
- E Weigang
- Department of Cardiovascular Surgery, University Hospital Freiburg, Germany.
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Hartert M, Weigang E, ter Wolbeek C, Beyersdorf F. Value of cerebrospinal fluid drainage in perioperative management of thoracoabdominal aortic aneurysms. Thorac Cardiovasc Surg 2008. [DOI: 10.1055/s-2008-1037847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Weigang E, ter Wolbeek C, Hartert M, Siegenthaler MP, Sircar R, Etz CD, Vahl CF, Beyersdorf F. Value and pitfalls of neurophysiological monitoring in thoracic and thoracoabdominal aortic surgery. Thorac Cardiovasc Surg 2008. [DOI: 10.1055/s-2008-1037846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kuroczyński W, Hartert M, Pruefer D, Pitzer-Hartert K, Heinemann M, Vahl CF. Surgical treatment of aortic coarctation in adults: Beneficial effect on arterial hypertension. Cardiol J 2008; 15:537-542. [PMID: 19039758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the outcome after surgical repair of aortic coarctation in adults, analysing its effect on arterial blood pressure. METHODS Twenty-five adults (9 women, 16 men), mean age 43.4 years (19 to 70 years), underwent aortic coarctation surgical repair. All patients suffered from preoperative hypertension. Mean blood pressure was 182/97 mm Hg. Sixteen (64%) patients demonstrated reduced load capacity. Operative technique was resection and end-to-end anastomosis for 5 patients (20%), interposition of a Dacron-tube graft for 3 patients (12%), Dacron-patch dilatation was performed in 7 (28%) patients, and in 10 (40%) patients we performed an extra-anatomical bypass graft. RESULTS Early mortality occurred in 1 patient (4%). The mean blood pressure was reduced [systolic 182 mm Hg vs. 139 mm Hg (p < 0.001), diastolic 97 mm Hg vs. 83 mm Hg (p < 0.001)] in all patients. In 12 patients, blood pressure normalized immediately after surgery, in 7 patients it remained slightly elevated (systolic blood pressure between 140-160 mm Hg), and 1 patient suffered from prolonged arterial hypertension. Preoperatively, all patients were treated with antihypertensive drugs. Eleven of 20 patients received long-term medication during follow- up. In the remaining 4 patients, medication lists were unobtainable in retrospect. The mean follow-up was 7.1 years (min. 1.0 years; max. 16.6 years). One patient (5%) died from cardiac failure 12.4 years after the operation. On average, the New York Heart Association (NYHA) class was improved by 0.92. CONCLUSIONS The surgical repair of aortic coarctation in adults can be performed with low surgical risk. Surgery reduces hypertension and permits more effective medical treatment.
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Affiliation(s)
- Włodzimierz Kuroczyński
- University Hospital Mainz, Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg-University, Mainz, Germany.
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Hartert M, Weigang E, ter Wolbeek C, Beyersdorf F. Per aspera ad astra: The long road of spinal cord protection in thoracoabdominal aortic procedures. Thorac Cardiovasc Surg 2008. [DOI: 10.1055/s-2008-1037708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Weigang E, Sircar R, von Samson P, Hartert M, Siegenthaler MP, Luehr M, Richter H, Szabó G, Czerny M, Zentner J, Beyersdorf F. Efficacy and Frequency of Cerebrospinal Fluid Drainage in Operative Management of Thoracoabdominal Aortic Aneurysms. Thorac Cardiovasc Surg 2007; 55:73-8. [PMID: 17377857 DOI: 10.1055/s-2006-924708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Paraplegia remains the most dreaded complication following thoracoabdominal aortic repair. We investigated the efficacy of cerebrospinal fluid drainage as a spinal cord-protecting modality. We also evaluated the correlation between the frequency of cerebrospinal fluid drainage and the Crawford classification. METHODS Spinal cord function was monitored during 20 open surgical procedures (group I) and 27 stent-graft implantations (group II). Evoked potentials and intracranial pressure were monitored in each operation. If intracranial pressure exceeded 15 mmHg, cerebrospinal fluid was drained. RESULTS Cerebrospinal fluid drainage was necessary in 75 % of patients in group I (Crawford type I: 33 %, type II: 40 %, type III: 20 %, type IV: 7 %) and in 22 % of patients in group II (Crawford type I: 33 %, type II: 66 %). Evoked potential alterations correlated with an increase in intracranial pressure. Timely cerebrospinal fluid drainage reversed these changes in 72 %. Three patients remained paraplegic. CONCLUSION Cerebrospinal fluid drainage is a valuable neuroprotective interventional tool to lower the risk of spinal cord ischemia. The combination of neurophysiological monitoring and cerebrospinal fluid drainage optimizes the prevention of paraplegia during aortic repair.
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Affiliation(s)
- E Weigang
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Freiburg, Germany.
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Weigang E, Lühr M, Hartert M, Samson PV, Euringer W, Uhl M, Beyersdorf F, Siegenthaler M. Endovascular repair of aortic arch and type-I thoracoabdominal aortic aneurysm after surgical supra-aortic revascularization – how to do it? Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Weigang E, Hartert M, Siegenthaler MP, Beckmann NA, Sircar R, Szabò G, Etz CD, Luehr M, von Samson P, Beyersdorf F. Perioperative Management to Improve Neurologic Outcome in Thoracic or Thoracoabdominal Aortic Stent-Grafting. Ann Thorac Surg 2006; 82:1679-87. [PMID: 17062227 DOI: 10.1016/j.athoracsur.2006.05.037] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 05/08/2006] [Accepted: 05/11/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Thoracic or thoracoabdominal aortic stent-graft repair has shown a reduction in morbidity and mortality rates due to the procedure's advantages (no aortic cross-clamping, continuous distal aortic perfusion, no reperfusion injury). However, 3% to 12% of the patients are at risk of spinal cord ischemia. We investigated spinal cord protective measures with evoked potentials, cerebrospinal fluid drainage, and prevention of hypotension to minimize postoperative neurologic deficit. METHODS Between November 2000 and July 2005, vital parameters and spinal cord function were monitored, including cerebrospinal fluid pressure and transcranial motor-evoked and somatosensory-evoked potentials in 36 stent-graft procedures (31 patients) on the thoracic or thoracoabdominal aorta. RESULTS Stent-graft placement was technically successful in all patients. We achieved a survival rate of 100% without neurologic deficit after fast-track extubation. Eleven of 31 patients exhibited changes in evoked potentials during stent-graft deployment. In 12 of 31 patients (including the 11 with evoked potential alterations), cerebrospinal fluid pressure exceeded 15 mm Hg. Cerebrospinal fluid drainage and vital parameter adjustment were executed in those instances. We observed intraoperative evoked potential total recovery in 10 of 11 patients after these interventions. CONCLUSIONS Interventions to improve spinal cord perfusion led to total recovery of spinal function in most patients (10/11). Therefore, spinal cord protective measures with motor- and somatosensory-evoked potential monitoring, cerebrospinal fluid drainage, and prevention of hypotension can reduce the incidence of spinal cord ischemia and improve the neurologic outcome of patients undergoing endovascular thoracic or thoracoabdominal aortic repair.
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Affiliation(s)
- Ernst Weigang
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany.
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Weigang E, Hartert M, Siegenthaler MP, Pitzer-Hartert K, Luehr M, Sircar R, von Samson P, Beyersdorf F. Neurophysiological monitoring during thoracoabdominal aortic endovascular stent graft implantation☆. Eur J Cardiothorac Surg 2006; 29:392-6. [PMID: 16439144 DOI: 10.1016/j.ejcts.2005.11.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 11/21/2005] [Accepted: 11/23/2005] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the benefit of neurophysiological monitoring during thoracic and thoracoabdominal endovascular stent graft implantation. METHODS The spinal cords of 21 patients undergoing endovascular stent graft implantation on the thoracic and thoracoabdominal aorta were monitored with transcranial motor-evoked potentials (tcMEP) and somatosensory-evoked potentials (SSEP). All patients underwent mild systemic hypothermia (34-35 degrees C), constant cerebrospinal fluid (CSF) pressure and vital parameter monitoring. If CSF pressure exceeded 15 mmHg, CSF-drainage was carried out. RESULTS Three of the 21 patients (14%) exhibited short-term loss of tcMEP and SSEP after the deployment of the self-expanding endoprosthesis. We observed an intraoperative recovery of the evoked potentials in all cases. CSF-drainage was necessary in three of them. One patient, whose potentials were stable intraoperatively, developed paraparesis 3 weeks after the intervention. CONCLUSIONS Neurophysiological monitoring has proved to be an ideal monitoring method to detect spinal cord ischemia during thoracic and thoracoabdominal endovascular stent graft implantation. Due to the advantages of endovascular therapy (no aortic cross-clamping, continuous distal perfusion, and no reperfusion injury), changes in potentials were seldom observed.
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Affiliation(s)
- Ernst Weigang
- Department of Cardiovascular Surgery, University Hospital Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany.
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Weigang E, Frydrychowicz A, Luehr M, Harloff A, Siegenthaler MP, von Samson P, Hartert M, Beyersdorf F, Markl M. Time-resolved 3D-phase-contrast MR reveals hemodynamic changes in typ-A aortic dissection after aortic root replacement. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Weigang E, Hartert M, Sircar R, Breisacher C, Luehr M, Pitzer-Hartert K, von Samson P, Siegenthaler MP, Zentner J, Beyersdorf F. Efficacy and frequency of cerebrospinal fluid drainage in operative management of thoracoabdominal aortic aneurysms. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Weigang E, Hartert M, von Samson P, Sircar R, Pitzer K, Genstorfer J, Zentner J, Beyersdorf F. Thoracoabdominal Aortic Aneurysm Repair: Interplay of Spinal Cord Protecting Modalities. Eur J Vasc Endovasc Surg 2005; 30:624-31. [PMID: 16023390 DOI: 10.1016/j.ejvs.2005.05.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2005] [Accepted: 05/15/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of this study was to assess the complementary use of different methods of measuring spinal cord perfusion during thoracoabdominal aortic surgery. METHODS The spinal cords of 28 patients undergoing surgery on the thoracoabdominal aorta were monitored with transcranial electrical stimulation (tcMEP) and somatosensory-evoked potentials (SSEP). Available approaches of spinal cord-protection included: Moderate systemic hypothermia, constant cerebrospinal fluid (CSF) drainage and pressure monitoring, reimplantation of segmental arteries, cardiopulmonary bypass (CPB), and staged clamping. RESULTS Fourteen of 19 patients (75%) undergoing open surgical treatment (Group I) exhibited loss of tcMEP after proximal aortic clamping. In nine cases (47%), we observed recovery of tcMEP after intraoperative interventions, while two patients subsequently developed paraplegia and three died. Seventeen of 19 patients showed loss of SSEP, with recovery in 12 cases (63%). During stent-graft implantation (Group II), one of nine patients (11%) demonstrated tcMEP loss with intraoperative, intervention-related recovery. The SSEP-recording course remained stable. CONCLUSIONS tcMEP/SSEP monitoring has proved to be an excellent means of detecting spinal cord ischaemia during surgery on thoracoabdominal aortic aneurysms. The prognostic value of tcMEP monitoring should be considered superior to that of SSEP measurements, because of its direct and rapid response to spinal malperfusion. Through combined neurophysiological monitoring, vital parameter balancing and intraoperative interventions, spinal cord perfusion improves and recovery of tcMEP and SSEP is achievable, reducing the prevalence of postoperative paraplegia.
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Affiliation(s)
- E Weigang
- Department of Cardiovascular Surgery, University Hospital, Freiburg, Germany.
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Luehr M, Hartert M, Richter H, von Samson P, Goebel H, Wetzig M, Maersch U, Siegenthaler MP, Beyersdorf F, Weigang E. Entwicklung eines neuen Ballonokklusions-Device alternativ zur Gefäßklemme bei offenen Eingriffen an der Aorta. Z Herz- Thorax- Gefäßchir 2005. [DOI: 10.1007/s00398-005-0516-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Weigang E, Hartert M, von Samson P, Pechstein U, Genstorfer J, Pitzer K, Zentner J, Beyersdorf F. Improved Spinal Cord Perfusion during Thoracoabdominal Aortic Repair. Thorac Cardiovasc Surg 2005; 53:69-73. [PMID: 15786003 DOI: 10.1055/s-2004-830521] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The study's aim is to evaluate whether intraoperative neurophysiological monitoring with transcranial motor-evoked potentials (tcMEP) permits early recognition of neuronal lesions, thus making interventions to prevent irreversible spinal cord damage possible. MATERIAL AND METHODS TcMEP monitoring was carried out in twelve patients (mean age 60 years) during open surgical thoracoabdominal aortic replacement. Current approaches for corrective, spinal cord-protecting interventions consist of: raising distal perfusion by increasing cardiopulmonary bypass (CPB) flow, catecholamine application, reducing central venous pressure, reimplantation of segmental arteries, and cerebrospinal fluid (CSF) drainage. RESULTS Nine patients exhibited loss of tcMEP after segmental aorta clamping. In five patients we observed a recovery of tcMEP through counteractive measures. Three patients died intraoperatively, one patient presented with postoperative paraplegia and loss of tcMEP. CONCLUSION TcMEP loss is associated with spinal cord ischaemia, causing postoperative paraplegia. TcMEP monitoring is an excellent method to detect spinal cord ischaemia at an early stage.
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Affiliation(s)
- E Weigang
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany.
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Weigang E, Hartert M, Sircar R, V Samson P, Pitzer K, Genstorfer J, Zentner J, Beyersdorf F. Setup of Neurophysiological Monitoring with tcMEP/SSEP During Thoracoabdominal Aneurysm Repair. Thorac Cardiovasc Surg 2005; 53:28-32. [PMID: 15692915 DOI: 10.1055/s-2004-830431] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The article describes a procedure for the intraoperative neurophysiological placement of electrodes to control the spinal cord function during thoracoabdominal aortic aneurysm repair. MATERIAL AND METHODS Intraoperative monitoring is performed by motor-evoked myogenic potentials after transcranial electric stimulation (tcMEP) and somatosensory-evoked potentials (SSEP). In tcMEP, the stimulating percutaneous needle electrodes are placed at C3 and C4 according to the 10 - 20 system for EEG recordings. TcMEP are recorded from the anterior tibial and gastrocnemius muscles on both sides. The SSEP electrodes are placed laterally and caudally onto the malleolus medialis in order to stimulate the tibial nerve. The stimulus is documented via electrodes attached to the scalp within the sensory cortex region. RESULTS The application of the electrodes is both easy to learn and can be performed without further difficulties. Once attached, the electrodes provide a quick assessment and interpretation of spinal cord function. The identification of external sources of disturbance during the monitoring (e. g. insufficient impedance, unfavourable electrode positioning, and technical interference caused by medical equipment) enables the supervisor to differentiate between normal and abnormal neurological responses. CONCLUSIONS TcMEP and SSEP allow an adequate, direct, and reliable intraoperative assessment of spinal cord function, enabling the surgeon to diagnose an impending ischaemia and act accordingly. This measurement technique provides the surgical team with a means of integrating neurological aspects during thoracoabdominal aneurysm repair.
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Affiliation(s)
- E Weigang
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany.
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Weigang E, Hartert M, v. Samson P, Luehr M, Genstorfer J, Beyersdorf F. Usage of a silicon balloon catheter device in aortic surgery. Thorac Cardiovasc Surg 2005. [DOI: 10.1055/s-2005-862127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Weigang E, Maersch U, Genstorfer J, Chang X, Hartert M, Beyersdorf F. Implementation of a database for the follow-up of aortic diseases. Thorac Cardiovasc Surg 2004. [DOI: 10.1055/s-2004-816751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Weigang E, Sircar R, Hartert M, Genstorfer J, Zentner J, Beyersdorf F. Thorcoabdominal aneurysm repair: update on improved methods of surgical intervention preventing paraplegia. Thorac Cardiovasc Surg 2004. [DOI: 10.1055/s-2004-816733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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