Claude Angel

Sixteen-slice computed tomography after acute myocardial infarction: from perfusion defect to the culprit lesion.

A 58-year-old man without a prior medical history was admitted for acute chest pain associated with ST depression in leads Vl, V5, V6, and D1 with elevated serum levels of troponin and creatine kinase (peak creatine kinase level, 487 IU). A moderate-sized non-Q-wave myocardial infarction was diagnosed, and initial medical treatment included β-blockers, aspirin, and heparin. A 16-slice CT scan was performed before conventional coronary angiography. Submillimeter-sized ECG-gated slices were acquired after injection of 90 cm3 of nonionic iodinated contrast medium. Images were …

Transcatheter closure of patent ductus arteriosus: Past, present and future

This review aims to describe the past history, present techniques and future directions in transcatheter treatment of patent ductus arteriosus (PDA). Transcatheter PDA closure is the standard of care in most cases and PDA closure is indicated in any patient with signs of left ventricular volume overload due to a ductus. In cases of left-to-right PDA with severe pulmonary arterial hypertension, closure may be performed under specific conditions. The management of clinically silent or very tiny PDAs remains highly controversial. Techniques have evolved and the transcatheter approach to PDA closure is now feasible and safe with current devices. Coils and the Amplatzer Duct Occluder are used most frequently for PDA closure worldwide, with a high occlusion rate and few complications. Transcatheter PDA closure in preterm or low-bodyweight infants remains a highly challenging procedure and further device and catheter design development is indicated before transcatheter closure is the treatment of choice in this delicate patient population. The evolution of transcatheter PDA closure from just 40 years ago with 18F sheaths to device delivery via a 3F sheath is remarkable and it is anticipated that further improvements will result in better safety and efficacy of transcatheter PDA closure techniques.

Comparison of delayed enhancement patterns on multislice computed tomography immediately after coronary angiography and cardiac magnetic resonance imaging in acute myocardial infarction

Objective: Recent experimental and limited clinical studies have demonstrated the usefulness of delayed enhancement multislice computed tomography (MSCT) for assessing myocardial infarct size (IS) and transmurality. The aim of this study is to compare MSCT enhancement patterns immediately after coronary angiography (CAG) in an acute myocardial infarction (AMI) setting with cardiac magnetic resonance (CMR) enhancement during the second week follow-up. Methods: 26 patients admitted for an AMI were evaluated by MSCT immediately after CAG without iodine re-injection. All but three were reperfused. The same patients had delayed enhancement CMR imaging at 10 (SD 4)-day follow-up. Myocardial enhancement was considered transmural (non-viable) when involving >75% of myocardial thickness, subendocardial (1 − ⩽75%) or normal (viable for the two latter). Two or more >75% enhanced segments were required to define transmurality on patient-level or culprit artery-level analysis. A semi-quantitative scale score was defined for the 17 left ventricular segments. IS was computed from these scores. Results: On segment analysis, sensitivity, specificity, accuracy, positive and negative predictive values of MSCT for transmurality assessment were 84%, 96%, 94%, 85% and 96%, respectively, compared to CMR. On patient analysis, these respective values were 90%, 80%, 88%, 95% and 67%. IS assessed by the two methods were highly correlated (r = 0.94, p<0.0001) and the regression line did not statistically differ from the identity line. Conclusion: MSCT enhancement immediately following CAG without iodine re-injection for an AMI is a reliable method for evaluating transmurality and IS. This very early evaluation could be an interesting alternative to CMR.

Multicenter Safety and Efficacy Analysis of Assisted Closure after Antegrade Arterial Punctures Using the StarClose Device

Purpose: To evaluate the safety and efficacy of the StarClose device for closure of antegrade punctures following infrainguinal endovascular interventions. Methods: A retrospective review was conducted of 221 consecutive patients treated with the StarClose device in a 12-month period at 5 centers (4 French and 1 British). Of these, 107 patients (69 men; median age 75 years, range 44–93) were from the UK cohort (111 closures), and 94 patients (75 men; median age 67 years, range 32–95) were from the French cohort (111 closures). Technical success, complication rates, demographic data, medical history, and procedural details were gathered for all patients. Residual bleeding and the requirement for additional manual compression were recorded when the device failed. Clinical evaluation was performed at discharge; color-coded duplex ultrasonography was done in a subset of French patients. Results: The overall technical success rate was 94.6% (210/222; 95% CI 3.1%–9.2%). The results were similar in the 2 cohorts: 95.5% (106/111; 95% CI 1.9%–10.1%) in the UK and 93.7% (104/111; 95% CI 3.1%–12.4%) in France. The 12 failures (5 UK and 7 France) were due to several mechanisms: device failure (n=5), obesity (n=1), groin scarring (n=2), and unexplained (n=4). In 2 failed cases, open surgical closure of the arteriotomy was performed because pressure hemostasis failed. Two pseudoaneurysms were observed: one after immediate failure was successfully treated by prolonged pressure; the other, after apparent success of the device, required surgical therapy. The incidence of serious vascular complication was 1.8% (4/222; 95% CI 0.7%–4.5%); 2 patients from each cohort. Conclusion: The StarClose device safely and effectively closes antegrade punctures after infrainguinal endovascular intervention, even in patients who would be considered to be at high risk for puncture-site bleeding. However, a randomized trial would be required to support any definitive recommendations.

Type II endoleak prevention with coil embolization during endovascular aneurysm repair in high-risk patients

OBJECTIVE This study evaluated endoleak level and size decrease of infrarenal abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) with coil embolization in patients at high risk for type II endoleak. METHODS Between 2009 and 2013, 83 of 187 patients (44.3%) who underwent EVAR for AAA also underwent coil embolization of the aneurysm sac immediately after complete stent graft release because of risk factors for type II endoleak, including absence of a circumferential thrombus, two or more pairs of patent lumbar arteries, or a patent inferior mesenteric artery. Coil embolization was achieved using a 4F catheter with a microcatheter placed between the stent graft and the aneurysm wall. Computed tomography and color duplex ultrasound imaging were performed 1, 6, 12, and 24 months later to look for an endoleak and assess aneurysm sac diameter. RESULTS Mean follow-up was 24 ± 11 months (range, 6-53 months). A mean of 12 coils (range, 4-23) was used. Technical success was achieved in all patients, with no procedurally related complications. Follow-up computed tomography showed type II endoleak in one patient. Aneurysm sac diameter was significantly decreased after 6 months (P = .001), 12 months (P = .001), and 24 months (P = .001). Surgery was required in one patient for common femoral artery occlusion unrelated to the procedure and in another patient for distal type I endoleak. CONCLUSIONS Aneurysm sac coil embolization during EVAR for patients at risk for type II endoleak is technically feasible, safe, and effective in preventing type II endoleak. This procedure leads to rapid AAA shrinkage. Thus, coil embolization could be used routinely to improve EVAR outcomes for patients at risk for type II endoleak.

Aortic Wrapping for Stanford Type A Acute Aortic Dissection: Short and Midterm Outcome

BACKGROUND Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. METHODS We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). RESULTS Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. CONCLUSIONS The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative.

Ascending Aorta Stenting After Off-Pump Aortic Wrapping in Stanford A Retrograde Aortic Dissection

We report 4 cases of off-pump ascending aorta wrapping combined with ascending aorta stenting in retrograde Stanford A acute aortic dissection (SAAD). Since 2008, 18 patients have undergone wrapping of the ascending aorta at our institution. Four patients had a persistent circulating false lumen in the ascending aorta after wrapping, with a threat to the aortic root. We chose an endovascular approach with ascending aorta stenting. Follow-up computed tomography showed a reapplication of the intimal flap in the reinforced aorta. Ascending aorta stenting after aortic wrapping for retrograde SAAD is a safe and efficient technique to prevent proximal progression of the dissection.

Angioplastie pulmonaire et cœur pulmonaire chronique post-embolique

La thrombose pulmonaire chronique est la cause la plus frequente d’hypertension pulmonaire obstructive (Classification de Nice, groupe 4). Le traitement de reference est la thromboendarteriectomie chirurgicale, mais seuls 60 % des patients sont operables. Les patients inoperables ont un pronostic sombre.Le caractere distal des lesions, la severite hemodynamique et les comorbidites frequentes de ces patients sont les principaux freins a la chirurgie.Les equipes japonaises ont propose une technique percutanee de desobstruction par angioplastie au ballon sur les lesions segmentaires et sous-segmentaires pour les patients inoperables. Depuis 2013, les equipes interventionnelles du CHU de Grenoble et Paris Sud (Bicetre-CCML) ont developpe cette technique en France. A ce jour une cinquantaine de patients ont pu etre traites en France.Dans notre experience, ce traitement permet une amelioration fonctionnelle et hemodynamique franche, rapide et prolongee avec une baisse de 60 % des resistances arterielles pulmonaires apres 2 a 6 seances. Les risques principaux sont l’hemoptysie et l’hypoxie post-procedure. Cette technique innovante necessite encore validation et standardisation afin de trouver sa place au sein de l’algorithme therapeutique pour cette pathologie severe et invalidante.

Hybrid treatment of an aortic pseudoaneurysm arising at the innominate artery junction secondary to superior vena cava stenting

Pseudoaneurysm of the innominate artery secondary to superior vena cava stenting has never been reported. We report the case of a 42-year-old woman previously treated for a Masaoka stage III thymoma with superior vena cava replacement through median sternotomy followed by adjuvant radiation therapy. Four years later, the patient came back with a large pseudoaneurysm at the junction of the innominate artery and ascending aorta. To avoid resternotomy, endovascular deployment of a stent graft in the ascending aorta with a periscope stenting in the left common carotid artery after axilloaxillary bypass was performed to treat this aortic pseudoaneurysm.

First experience with paclitaxel-coated balloon angioplasty in patients with adult transplant coronary artery disease: is it an alternative to drug-eluting stents?

First experience with paclitaxel-coated balloon angioplasty in patients with adult transplant coronary artery disease: Is it an alternative to drug-eluting stents? Philippe Brenot, MD, Matthias W. Waliszewski, PhD, Noc T. Tho, MD, Lucile Houyel, MD, and Claude Y Angel, MD From the Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France; and the Medical Scientific Affairs Vascular Systems, B. Braun Melsungen AG, Berlin, Germany.