Abstract Since the introduction of endovascular aneurysm repair (EVAR) in 1991, the endovascular therapy with newest stent grafts has assumed a prominent role in the clinical management of abdominal aortic aneurysms (AAA) with a superior perioperative mortality of EVAR and an equivalent mid-term outcome, compared to open surgery. Newest techniques using chimney or periscope grafts and customized fenestrated and branched stent grafts allow the endovascular treatment of complex pararenal AAA. This article reviews EVAR in the treatment of AAA, evidence based results and advanced indication by newest interventional techniques and technical developments. Key Points: • EVAR has become standard treatment of abdominal aortic aneurysm with equivalent results to open surgery. • Technical advancements and the introduction of newest stent grafts continually expand the indication of EVAR. • Chimney- and periscope grafts as well as custom-made prothesis systems allow endovascular treatment of complex para- and suprarenal aneurysms. Citation Format: • Ketelsen D, Thomas C, Schmehl J et al. Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms: Standards, Technical Options and Advanced Indications. Fortschr Röntgenstr 2014; 186: 337 – 347

Zusammenfassung Anamnese und klinischer Befund: Wir berichten über einen Patienten mit Bauch- und rechtsseitigen Flankenschmerzen, der klinisch das Bild eines akuten Abdomens bot. Untersuchungen: Laborchemisch ergaben sich Hinweise auf ein entzündliches Geschehen und der Nachweis einer Hämaturie. Doppler-Duplexsonographisch und in der Computertomographie konnten eine chronische idiopathische Periaortitis diagnostiziert werden. Infolge der inflammatorisch-fibrosierenden Erkrankung kam es zu einem Harnstau sowie einer Fornixruptur der rechten Niere. Diagnose, Therapie und Verlauf: Nach operativer Anlage einer Harnleiterschiene und Einleitung einer immunsuppressiven Therapie kam es rasch zu einer Besserung der Symptome. Folgerung: In der Differenzialdiagnose eines akuten Abdomens sollten Erkrankungen der Aorta mit bedacht werden. Insbesondere bei Männern mit anatomischen Komplikationen gilt es ein inflammatorisch-fibrosierendes Geschehen auszuschließen.

The occurrence of both deep vein thrombosis and pulmonary embolism is already promoted by physiological mechanisms in pregnancy and the postpartum period. Besides pre-existing risk factors, transient phenomena are present during pregnancy that increase the risk of venous thromboembolic disease. The clinical signs of thromboembolism are often non-specific. Diagnostic algorithms have not been tested in pregnant women. Due to the clinical relevance, confirmation of the diagnosis is, however, essential. The medical history, clinical examination and laboratory diagnostics are fundamental components in the diagnostic process, but cannot, on their own, exclude a venous thromboembolism. The technical assessment of the veins by ultrasound is the method of choice with regard to venous thrombosis. This manuscript describes the diagnosis and treatment of venous thromboembolism during pregnancy.

ZusammenfassungDas Auftreten sowohl der tiefen Beinvenenthrombose als auch einer Lungenarterienembolie wird bereits durch physiologische Mechanismen in der Schwangerschaft und im Wochenbett begünstigt. Es kommt neben vorbestehenden Risikofaktoren zu transienten Erscheinungen, die das Risiko für venöse thromboembolische Erkrankungen erhöhen. Die Klinik von Thromboembolien ist oft unspezifisch. Erprobte Diagnosealgorithmen bestehen in der Schwangerschaft nicht. Aufgrund der klinischen Relevanz ist jedoch eine Diagnosesicherung unerlässlich. Die Anamnese, Klinik und Labordiagnostik sind wesentliche Bestandteile in der Diagnosefin-dung, können aber alleine eine venöse Thromboembolie nicht ausschließen. Eine apparative Beurteilung der betroffenen Venen durch die Sonographie ist dabei die Untersuchungsmethode der Wahl. Die vorliegende Arbeit beschreibt die Diagnostik und Therapie venöser Thromboembolien in der Schwangerschaft.

We report on a young female patient with flank pain and a swelling of the lower limb of the left side.In magnetic resonance angiography as well as Doppler-duplex ultrasound an iliofemoral phlebothrombosis of the left side due to vena cava inferior hypoplasia with collateral circulation was diagnosed. Oral contraception could play a role as a trigger. The patient also presented activated protein C resistance/ heterozygous factor V Leiden mutation.According to the CaVenT study we treated the patient successfully with catheter-directed thrombolysis. Follow-ups presented a patency of the iliofemoral vein.In young patients with short duration of a proximal deep vein thrombosis and after exclusion of contraindications a catheter-directed lysis should be considered as a treatment option. The differential diagnostic of a (bilateral) ilio-femoral vein thrombosis in young patients should include an anomaly of the venous system.

AIMS/HYPOTHESIS:We have previously found that the mass of perivascular adipose tissue (PVAT) correlates negatively with insulin sensitivity and post-ischaemic increase in blood flow. To understand how PVAT communicates with vascular vessels, interactions between perivascular, subcutaneous and visceral fat cells with endothelial cells (ECs) were examined with regard to inflammatory, metabolic and angiogenic proteins. To test for possible in vivo relevance of these findings, circulating levels of the predominant secretion product, hepatocyte growth factor (HGF), was measured in individuals carefully phenotyped for fat distribution patterns.METHODS:Mono- and co-cultures of human primary fat cells with ECs were performed. mRNA expression and protein production were studied using Luminex, cytokine array, RealTime Ready and ELISA systems. Effects of HGF on vascular cells were determined by WST assays. In patients, HGF levels were measured by ELISA, and the mass of different fat compartments was determined by whole-body MRI.RESULTS:In contrast with other fat cell types, PVAT cells released higher amounts of angiogenic factors, e.g. HGF, acidic fibroblast growth factor, thrombospondin-1, serpin-E1, monocyte chemotactic protein-1 and insulin-like growth factor-binding protein -3. Cocultures showed different expression profiles from monocultures, and mature adipocytes differed from pre-adipocytes. HGF was preferentially released by PVAT cells and stimulated EC growth and smooth muscle cell cytokine release. Finally, in 95 patients, only PVAT, not visceral or subcutaneous mass, correlated independently with serum HGF levels (p = 0.03; r = 0.225).CONCLUSIONS:Perivascular (pre-)adipocytes differ substantially from other fat cells with regard to mRNA expression and protein production of angiogenic factors. This may contribute to fat tissue growth and atherosclerotic plaque complications. Higher levels of angiogenic factors, such as HGF, in patients with increased perivascular fat mass may have pathological relevance.

PURPOSE:Ultrasound is a widely used diagnostic tool. In medical education, it can be used to teach sonographic anatomy as well as the basics of ultrasound diagnostics. Some medical schools have begun implementing student tutor-led teaching sessions in sonographic abdominal anatomy in order to meet the growing demand in ultrasound teaching. However, while this teaching concept has proven to be feasible and well accepted, there is limited data regarding its effectiveness. We investigated whether student tutors teach sonographic anatomy as effectively as faculty staff sonographers.MATERIALS AND METHODS:50 medical students were randomly assigned to one of two groups. 46 of these could be included in the analysis. One group was taught by student tutors (ST) and the other by a faculty staff sonographer (FS). Using a pre/post-test design, students were required to locate and label 15 different abdominal structures. They printed out three pictures in three minutes and subsequently labeled the structures they were able to identify. The pictures were then rated by two blinded faculty staff sonographers. A mean difference of one point in the improvement of correctly identified abdominal structures between the pre-test and post-test among the two groups was regarded as equivalent.RESULTS:In the pre-test, the ST (FS) correctly identified 1.6 ± 1.0 (2.0 ± 1.1) structures. Both the ST and FS group showed improvement in the post-test, correctly identifying 7.8 ± 2.8 vs. 8.9 ± 2.9 structures, respectively (p < .0001 each). Comparing the improvement of the ST (6.2 ± 2.8 structures) versus the FS (6.9 ± 3.2) showed equivalent results between the two groups (p < .05 testing for equivalence).CONCLUSION:Basic abdominal sonographic anatomy can be taught effectively by student tutors.

Purpose: Though increased thyroid perfusion assessed by colour-coded Doppler ultrasound (CDUS) is characteristic of Graves' disease (GD), sometimes perfusion assessment by CDUS is not possible. In these cases, arterial spin labelling (ASL), a novel magnetic resonance imaging (MRI) technique allowing non-invasive thyroid perfusion quantification, may have additional diagnostic value. We aimed to evaluate the potential of ASL-MRI for assessment of increased blood perfusion in patients with GD compared to CDUS.Materials and Methods: Thyroid perfusion was measured by CDUS (volume flow rate calculated from pulsed wave Doppler signals and vessel diameter) and ASL-MRI at 1.5 T in 7 patients with GD and 10 healthy controls.Results: In patients with GD, average perfusion in both thyroid lobes was markedly increased compared to controls. Both techniques applied for volume related perfusion as well as absolute volume flow in thyroid feeding vessels provided similar results (all p = 0.0008). Using a cut-off value of 22 ml/min for the volume flow rate assessed by CDUS in the four feeding vessels allowed discrimination between patients with GD and controls in all cases. After adjusting thyroid perfusion for the differences in organ volume, both CDUS and ASL revealed also complete discrimination between health and disease.Conclusion: Thyroid perfusion measurement by ASL-MRI reliably discriminate GD from normal thyroid glands. In patients in whom thyroid arteries cannot be depicted by CDUS for technical or anatomical reasons, ASL-MRI may have additional diagnostic value.

高血压患者的血压变异性(BPV)增大导致终末期靶器官损害。BPV增大与自主神经功能的改变(包括交感神经过度兴奋)相关。该研究假设经导管射频消融去肾交感神经支配术(RDN)对BPV有较好的效果。连续收治的难治性高血压患者11例进行双侧RDN,年龄(68.9±7.0)岁,在平均服用(5.6±2.2)种降压药的情况下,基线收缩压为(189±23)mmHg。RDN前和6月后进行24h动态血压监测(ABPM)。评估BPV的主要指标为24h收缩压标准差(SDsys)的平均值、次要指标为最大收缩压(MAXsys)和24h内连续两次收缩压读数的最大差值(Δmaxsys)。RDN6月后,在服用相同降压药的情况下,SDsys[(13.5±2.5)比(16.9±4.6)mmHg,P=0.003],MAXsys[(172±20)比(190±22)mmHg,P<0.01]和Δmaxsys[(28±7)比(40±15)mmHg,P=0.006]均明显降低。11例患者中有10例SDsys(90.9%),11例MAXsys(100%)和9例Δmaxsys(81.8%)降低。RDN6月后,诊室收缩压明显降低[(30.4±27.7)mmHg,P=0.007]。在难治性高血压患者中,RDN明显降低BPV。与对平均血压的影响比较,RDN对BPV的影响更明显。

Fragestellung: Bluthochdruck, Dyslipidämie und Typ II-Diabetes sind mit der Adipositas assoziiert. Adipöses Gewebe sezerniert Zyto- und Chemokine (Adipokine), die direkt oder indirekt mit den Insulinsignaltransduktionswegen interagieren. Zudem werden inflammatoryische Zytokine und angiogenetische Faktoren freigesetzt. Perivaskuläre Fettzellen (PVFZ) nehmen eine Sonderstellung ein, da sie ein ektopes Fettgewebe bilden, das ohne anatomische Barriere direkt an die Adventitia der arteriellen Gefäßwand angrenzt. Eine kürzliche Studie unserer Arbeitsgruppe konnte zeigen, dass die Masse an perivaskulärem Fett (PVF) in Patienten negativ mit der Insulinsensitivität und dem postischämisches Blutfluss korreliert. Das Expressionsmuster und das sekretorische Potential humaner PVFZ sollte daher mit subkutanen (SKFZ) und viszeralen (VFZ) verglichen werden.

Menschen mit Diabetes mellitus leiden und sterben nach wie vor besonders häufig an den ­mikro- und makrovaskulären Komplikationen ihrer Erkrankung. Besonders hoch ist dabei die Mortalität des akuten Koronarsyndroms und des zerebrovaskulären Insults [1] [2] . Über 60 % der Todes­fälle unter männlichen insulintherapierten Typ-2-Diabetikern und über 50 % bei Diabetikerinnen im Alter zwischen 40 und 59 Jahren sind Folge ischämischer Schlaganfälle [3]. In der UKPDS-Studie wiesen bei Rekrutierungsstart bereits fast 50 % der Patienten mit Diabetes mellitus mikro- oder makrovaskuläre Komplikationen auf [4]. Dabei liegt dem typischen makro­vaskulären Ereignis die Ruptur atherosklerotischer arterieller Plaques zugrunde, welche die ­Adhäsion und Aggregation von Thrombozyten auslöst, die schließlich einen arteriellen Gefäßverschluss mit konsekutiver Ischämie der Gefäßstrombahn bewirken [5]. Auch venöse Thromboembolien sind bei Diabetikern häufiger als bei Stoffwechselgesunden [6].

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Fragestellung: Vor kurzem haben wir eine metabolisch benigne (MBA) oder metabolisch gesunde Adipositas identifiziert und charakterisiert. Eine Lebensstilintervention stellt eine hocheffektive, sichere und deshalb auch öfters empfohlene Strategie zur Behandlung der Adipositas und Verbesserung des metabolischen Phänotyps bei Menschen mit hohem Risiko, einen Typ 2 Diabetes und kardiovaskuläre Erkrankungen zu entwickeln, dar. So stellt sich die Frage, ob Menschen mit einer MBA anders als andere adipöse Menschen auf eine strukturierte Lebensstilintervention ansprechen.

OBJECTIVE:In obesity, particularly increased visceral- (VAT), but not total (TAT) adipose tissue mass is a major source of proinflammatory cytokine expression and secretion. VAT, more than TAT, is associated with endothelial dysfunction (ED), which is an accepted risk factor for atherosclerosis. Consequently, we hypothesized that during a lifestyle intervention specifically a decrease in VAT, rather than TAT, is associated with improved ED and vascular adhesion molecules in type 2 diabetes prone subjects. METHODS:Analyses were done in 189 individuals (age: 45.4±0.8 years) at increased risk of type 2 diabetes, who underwent a 9-month lifestyle intervention. ED expressed as flow mediated dilation (FMD) of the brachial artery, sE-selectin, sV-CAM, sI-CAM, TAT and VAT (measured by magnetic resonance tomography) was determined. RESULTS:There was a mean decrease in body weight (-3%, p<0.0001), TAT (-7.6%, p<0.0001) and VAT (-12.5%, p<0.0001), while FMD increased (+9.1%, p=0.04). The change in FMD was not associated with change in body weight (p=0.35) or TAT (p=0.21) but with a decrease in VAT (r=-0.19, p=0.009). In a post hoc analysis, the subjects were divided by the median change in VAT into responders and non-responders. FMD increased only in the responders (from 6.2±0.4% to 8.0±0.5%, p=0.0005) but not in the non-responders (p=0.15). Also sE-selectin significantly decreased only in the responders (from 54±4 ng/ml to 47±3 ng/ml; p=0.03). CONCLUSION:During a lifestyle intervention, not weight loss or decrease in TAT, but decrease in VAT is associated with improved ED in individuals prone to type 2 diabetes. Therefore, primary cardiovascular prevention should focus specifically on reducing VAT rather than body weight alone.