Francis Joffre

Long-term results of endovascular stent placement in the superior caval venous system.

AbstractPurpose: To present the long-term results in superior caval stenting for symptomatic obstruction. Methods: Forty-nine stents were placed in 30 patients: 16 (53%) with malignant lesions, five (17%) with benign lesions and nine (30%) hemodialysis patients. Self-expandable stents were deployed on a first-line basis. Patients were followed clinically as well as by various imaging techniques and survival analysis was performed. Results: Stent deployment was possible in all cases. Reocclusion was seen in 13 patients, of whom eight belonged to the hemodialysis group. Primary and secondary patency rates for malignant, benign and hemodialysis patients were respectively 74%, 50% and 22%, and 74%, 75% and 56% at 1 year. We had 7% complications and one death from iatrogenic superior vena cava injury. Conclusion: Primary stenting of superior caval obstruction is a first-choice treatment method achieving good mid-term patency. Patients with hemodialysis shunts must be closely monitored for early reintervention.

Application of the Suchey-Brooks Method to Three-dimensional Imaging of the Pubic Symphysis

Age determination is a major field of interest in forensic anthropology. Among the different methods based on macroscopic skeletal study, the Suchey-Brooks method, which analyzes the pubic symphysis, is one of the most reliable. We applied the Suchey-Brooks method to three-dimensional computed tomographic reconstructions of the pubic symphysis. We demonstrated excellent agreement between the results of analysis of bone samples and those of the three-dimensional images, in particular regarding ridges of the articular surface and delimitation of the extremities. The accuracy of age estimation did not significantly differ (Wilcoxon test) between the Suchey-Brooks method applied to bones and the same method applied to CT images. Using high-quality images, this approach seems as reliable as the standard Suchey-Brooks method and offers several advantages: no bone preparation, no damage to bone material, and the possibility of application to living individuals.

Aortoduodenal fistula after endovascular stent-graft of an abdominal aortic aneurysm.

Despite satisfying short- and middle-term effectiveness and feasibility, endovascular stent-grafting for abdominal aortic aneurysm is still under evaluation. We report a case of an aortoduodenal fistula after the use of this technique. Enlargement of the upper aneurysmal neck was followed by caudal migration of the major portion of the stent-graft, which resulted in kinking of the device in the aneurysmal sac. Ulcerations were found on adjacent portions of both the aneurysmal sac and the adjacent duodenum. Only the textile portion of the prosthetic contralateral limb separated the aortic lumen from the corresponding duodenal lumen. Early detection of complications after stent-grafting is essential to allow successful treatment, either surgical or endoluminal.

Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism

A limited ultrasound (US) confined to the popliteal and femoral veins is usually performed to detect deep vein thrombosis (DVT) in patients with clinically suspected acute pulmonary embolism (PE). Our objective was to assess the diagnostic accuracy of complete lower limb US examining both the proximal and distal veins in this setting. In this prospective study, 210 consecutive patients were included. Complete US was performed by independent operators and compared blindly with a reference strategy combining clinical probability, ventilation perfusion scan and pulmonary angiography to a three-month clinical follow-up. Simultaneously, VIDAS D-dimer (DD) assay and helical computed tomography (HCT) of the lungs were assessed independently and blindly. PE was present in 74 patients (35%). Complete US detected DVT in 91 patients (43%), proximal in 51 and distal in 40. Sensitivity and specificity with a 0.95 confidence interval were respectively 0.93 [0.85 - 0.97] and 0.84 [0.77 - 0.89]. Limited US detected DVT in only 46 patients (22%). Sensitivity and specificity were respectively 0.55 [0.44 - 0.66] and 0.96 [0.92 - 0.98]. For DD they were 0.92 [0.83 - 0.96] and 0.24 [0.17 - 0.32] and for HCT 0.84 [0.73 - 0.90] and 0.87 [0.80 - 0.92]. Complete lower limb US has higher sensitivity and capacity to exclude PE than limited US, but a slightly lower specificity. Complete US results also compared favourably with those of HCT and DD. The utility of including this method in diagnostic strategies for PE needs to be assessed in cost-effectiveness analysis and in outcome studies.

New identification possibilities with postmortem multislice computed tomography.

Historically, radiographical identification has been done by comparing conventional antemortem and postmortem X-ray images. The advent of new technologies such as multislice computed tomography (MSCT) is making traditional antemortem examination increasingly less frequent. The authors present the results of MSCT study of 35 corpses, which demonstrated features potentially useful for identification purposes in ten cases. These features, which relate to abnormalities of postcranial bone as well as of the internal organs, are presented. Attempts were made to find any antemortem X-rays or MSCTs on the cases described to compare the two antemortem and postmortem images. Although antemortem imaging was recovered for only two cases (one case with a skeletal abnormality and one case with a visceral abnormality), it permitted for both cases the comparison of antemortem and postmortem MSCTs.

Midterm results of aortic diameter outcomes after thoracic stent-graft implantation for aortic dissection: a multicenter study.

Purpose: To evaluate aortic diameter outcomes after stent-graft implantation for aortic dissection in the descending thoracic aorta. Methods: Fifty patients with type A dissection after ascending aortic surgery (n = 10), type B dissection (n=34), or intramural hematoma (n = 6) underwent stent-graft repair in 3 centers. Thrombosis and aortic diameter were analyzed by computed tomographic angiography at different levels of the aorta before stent-graft implantation, at discharge, and at follow-up. Measurements were standardized. Results: In all, 67 stent-grafts were implanted for acute (n = 18) and chronic (n=32) dissection. Stent-graft placement was successfully performed with high technical success (100%) despite 4 major complications (iliac thrombosis in 2 cases, aortic rupture, and a type A dissection) in 3 (6%) patients. Complete thrombosis of the thoracic false lumen was observed in 42% and 63% of cases at discharge and at follow-up (mean 15 months), respectively. At follow-up, the diameters of the entire aorta (mean 5 mm, p<0.05) and the false lumen (mean 11 mm, p<0.0001) decreased. Diameters of the abdominal aorta remained stable in association with persistent false lumen perfusion at this level. Aortic diameter results were better in the subgroup of patients with intramural hematoma compared to patients with Marfan syndrome. Three early deaths unrelated to the stent-graft procedure occurred; 2 patients with partial thrombosis of the false lumen died in follow-up secondary to aortic diameter growth. Conclusion: Complete thrombosis of the false lumen by stent-graft coverage of the entry tear results in decreased diameter of the entire aorta. In patients with partial thrombosis of the false lumen, the aneurysm continues to enlarge.

Application of the Iscan method to two- and three-dimensional imaging of the sternal end of the right fourth rib.

Abstract:  Age determination is a major field of interest in physical and forensic anthropology. Among the different methods based on macroscopic skeletal study, the Iscan method, which analyzes the sternal end of the right fourth rib, is one of the most reliable. We applied the Iscan method to two‐ and three‐dimensional multislice computed tomography (MSCT) reconstructions of the sternal end of the right fourth rib on 39 ribs. The intra‐observer variability on MSCT reconstructions was good (gamma coefficient equal to 0.86; value of the Krippendorff’s alpha reliability equal to 0.79); inter‐observer variability on MSCT reconstructions was also good (gamma coefficient ranging from 0.82 to 0.88; value of the Krippendorff’s alpha reliability ranging from 0.78 to 0.86). We demonstrated excellent agreement between the results of analysis of bone samples and those of the two‐ and three‐dimensional images, in particular regarding bone projections, morphology of the pit and of its rim. The accuracy of age estimation did not significantly differ between the Iscan method applied to dry bones and the same method applied to MSCT images. Determination of the Krippendorff’s alpha reliability coefficient for the inter‐error method confirmed the agreement between phase estimations obtained with the two methods (ranging from 0.55 to 0.71). The real civil age was comprised in 21 cases out of 36 for assessment performed on dry bones and in 23 cases out of 36 on MSCT reconstructions, which represented 58.3% and 63.9%, respectively. Use of MSCT reconstructions in forensic anthropology offers many advantages: no bone preparation, no damage to bone material, and the possibility of application to living individuals.

High Occlusion Rate in Experimental Transjugular Intrahepatic Portosystemic Shunt Created with a Dacron-covered Nitinol Stent

PURPOSE To assess whether the use of a prosthesis covered by a Dacron sheath might prevent pseudointimal hyperplasia in a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS A TIPS procedure was performed in nine pigs, after creation of a portal vein microembolization model of portal hypertension, by using a Dacron-covered nitinol stent. The first centimeter on the lower extremity of this specially made prototype was uncovered, to avoid portal vein thrombosis. Three weeks later, the seven surviving animals underwent transjugular hemodynamic and angiographic follow-up and were then killed for gross and histologic evaluation. RESULTS Shunt insertion was possible in all pigs; two died of complications of the procedure. After 3 weeks only two shunts were patent, although a 50%-60% narrowing of the initial portion of the shunt was present; the remaining shunts were occluded. Histologic examination showed pseudointimal hyperplasia associated, in the cases of occlusion, with a luminal thrombosis. CONCLUSION This Dacron-covered stent did not prevent pseudointima formation over the stent and resulted in a high early occlusion rate, probably related to a pronounced tissue fibrotic response likely due to Dacron-induced inflammation.

Rôle de l'embolisation dans les angiomyolipomes du rein

Resume Objectifs Presenter l’experience de deux centres dans l’embolisation des angiomyolipomes (AML) du rein afin de preciser la place de cette technique dans le traitement en urgence d’une hemorragie et dans le traitement preventif ou prechirurgical. Materiel et Methodes Sur une periode de 10 ans, 35 AML chez 34 patients ont ete traites par embolisation. Ce geste a ete realise en urgence, a visee hemostatique, dans 16 cas et de facon programmee, a visee preventive, dans 19 cas : six de ces patients etaient completement asymptomatiques et 13 avaient des antecedents lointains de douleurs ou d’hematome. L’embolisation a ete realise par catheterisme selectif (necessitant un microcatheter coaxial dans 19 cas) a l’aide de particules non resorbables, de spires metalliques ou d’alcool. Resultats L’embolisation d’hemostase a ete efficace en un temps dans 80 % des cas. Une nouvelle embolisation a ete necessaire dans 2 cas et une chirurgie dans 8 cas. Une chirurgie differee et programmee a ete effectuee dans 6 de ces cas. Les embolisations preventives ont necessite une seance dans 17 cas et 2 seances dans les 2 autres. La reduction de taille tumorale etait de 28 % apres un suivi moyen de 18 mois. Quatre patients ont eu une chirurgie conservatrice programmee par la suite. Conclusion L’embolisation d’hemostase est la methode de choix pour la prise en charge en urgence des AML hemorragiques. L’embolisation preventive est une alternative a la chirurgie dans le traitement des AML symptomatiques ou non, dont la place reste a definir.

Modular component separation and reperfusion of abdominal aortic aneurysm sac after endovascular repair of the abdominal aortic aneurysm: A case report

Transluminal placement of a stent graft in patients with an abdominal aortic aneurysm is a new endovascular technique that offers a potentially less invasive and less risky alternative to open surgery. Complications after stent graft placement are not infrequent, but in most cases secondary endovascular intervention is successful. We describe a late major leak in the aneurysmal sac caused by a distal migration of the iliac limb of a bifurcated graft. This late complication was successfully treated by covered stent placement, excluding and thrombosing completely the reformed aneurysm.