Frédéric Thony

Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures.

OBJECTIVE The purpose of this study was to describe a blinded intra-aortic balloon occlusion (IABO) procedure in pelvic fractures (PF) for patients with critically uncontrollable hemorrhagic shock (CUHS). METHODS Of 2,064 patients treated for PF, 13 underwent IABO during initial resuscitation to control massive pelvic bleeding leading to CUHS. Our IABO procedure consists of internal aortic occlusion without fluoroscopy, using a latex balloon inflated in the infrarenal aorta. Retrospectively collected data included demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiologic parameters, and survival. RESULTS All balloons were successfully placed, and a significant increase in systolic blood pressure (70 mm Hg, p = 0.001) was observed immediately after IABO. Twelve of 13 patients became transferrable. Angiography performed after IABO was positive for arterial injury in 92% of patients, and 9 patients benefitted from arterial embolization. Survival rate was 46% (6 of 13) and was inversely related to the length of inflation (p = 0.026) and the mean Injury Severity Score (p = 0.011). CONCLUSION This IABO procedure can be life saving in the management of patients with CUHS from PF, permitting transport to angiography. However, the decision for such treatment must be as quickly as possible after trauma to reduce the time of occlusion.

Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study.

Purpose: To evaluate endovascular procedures in the management of acute ischemic complications and rupture of the false lumen in aortic dissections. Methods: Data on patients with aortic dissection and noncardiac acute complications (peripheral ischemia or thoracic aortic rupture) treated with endovascular techniques were collected from 10 institutions and retrospectively analyzed. From March 1997 to January 2000, 58 patients (50 men; mean age 59.6±12.8 years) were treated for 19 (33%) type A and 39 (67%) type B dissections. Twelve (21%) patients had thoracic aortic rupture; 46 (79%) patients had one or more peripheral ischemic complications that included bowel pain (19, 41%), anuria associated with acute renal insufficiency (18, 39%), lower limb ischemia (15, 33%), and/or uncontrolled hypertension with renal ischemia (14, 30%). Results: In the thoracic rupture cohort, all 12 patients were treated successfully with stent-grafts; one distal endoleak required a secondary procedure. There were 2 (12%) periprocedural deaths; one patient developed transient paraplegia after a secondary surgical procedure. In the 46 patients treated with stent implantation, fenestration, or both for peripheral ischemic symptoms, 44 (96%) had patency restored to the malperfused vessel. Eight (17%) patients died within 30 days. Over a mean follow-up of 8.2±8.9 months, the false lumen had thrombosed in 7 (70%) of the stent-graft patients. In the 38 surviving ischemic patients, the diameters of the true and false lumens and maximum transverse aorta all increased; only 4 (11%) had total thrombosis of the false lumen. Conclusions: Endovascular treatment of noncardiac acute complications associated with aortic dissection has favorable early and midterm outcomes.

Endovascular treatment of superior vena cava obstruction in patients with malignancies

Abstract. The aim of this study was to report our experience on the management of superior vena cava obstruction (SVCO) secondary to malignant disease, using endovascular procedures. Twenty-six patients with SVCO due to primary or secondary tumors of the lung or the mediastinum, or catheter inserted for treatment of an extra-thoracic neoplasm, had an endovascular therapy which consisted of stenting, angioplasty, thrombo-aspiration or local fibrinolysis. Immediately after the procedure, rapid relief of symptoms occurred in 24 (90 %) of the patients. The mean Kishis score decreased from 5.5 to 0.96. Immediate complications included one death related to pericarditis bleeding following fibrinolysis. Three patients relapsed after 20 days, 4 months and 6 months, and needed a second stenting. At 6 months the primary patency rate was 83 % and the secondary patency rate was 89 %. Endovascular treatment of SVCOs is a simple and safe procedure to restore the patency of the superior vena cava in malignant SVCO. It should be indicated in most cases as first-line treatment and performed as early as possible.

Early Results of Endovascular Treatment of the Thoracic Aorta Using the Valiant Endograft

Endovascular repair of the thoracic aorta has been adopted as the first-line therapy for much pathology. Initial results from the early-generation endografts have highlighted the potential of this technique. Newer-generation endografts have now been introduced into clinical practice and careful assessment of their performance should be mandatory. This study describes the initial experience with the Valiant endograft and makes comparisons with similar series documenting previous-generation endografts. Data were retrospectively collected on 180 patients treated with the Valiant endograft at seven European centers between March 2005 and October 2006. The patient cohort consisted of 66 patients with thoracic aneurysms, 22 with thoracoabdominal aneurysms, 19 with an acute aortic syndrome, 52 with aneurysmal degeneration of a chronic dissection, and 21 patients with traumatic aortic transection. The overall 30-day mortality for the series was 7.2%, with a stroke rate of 3.8% and a paraplegia rate of 3.3%. Subgroup analysis demonstrated that mortality differed significantly between different indications; thoracic aneurysms (6.1%), thoracoabdominal aneurysms (27.3%), acute aortic syndrome (10.5%), chronic dissections (1.9%), and acute transections (0%). Adjunctive surgical procedures were required in 63 patients, and 51% of patients had grafts deployed proximal to the left subclavian artery. Comparison with a series of earlier-generation grafts demonstrated a significant increase in complexity of procedure as assessed by graft implantation site, number of grafts and patient comorbidity. The data demonstrate acceptable results for a new-generation endograft in series of patients with diverse thoracic aortic pathology. Comparison of clinical outcomes between different endografts poses considerable challenges due to differing case complexity.

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.

A regional trauma system to optimize the pre-hospital triage of trauma patients

IntroductionPre-hospital triage is a key element in a trauma system that aims to admit patients to the most suitable trauma center, and may decrease intra-hospital mortality. We evaluated the performance of a pre-hospital procedure in a regional trauma system through measurements of the quality of pre-hospital medical assessment and the efficacy of a triage protocol.MethodsOur regional trauma system included 13 hospitals categorized as Level I, II or III trauma centers according to their technical facilities. Each patient was graded A, B or C by an emergency physician, according to the seriousness of their injuries at presentation on scene. The triage was performed according to this grading and the categorization of centers. This study is a registry analysis of a three-year period (2009 to 2011).ResultsOf the 3,428 studied patients, 2,572 were graded using the pre-hospital grading system (Graded group). The pre-hospital gradation was closely related with injury severity score (ISS) and intra-hospital mortality rate. The triage protocol had a sensitivity of 92% (95% confidence interval (CI) 90% to 93%) and a specificity of 41% (95% CI 39% to 44%) to predict adequate admission of patients with ISS more than 15. A total of 856 patients were not graded at the scene (Non-graded group). Undertriage rate was significantly reduced in the Graded group compared with the Non-graded group, with a relative risk of 0.47 (95% CI 0.40 to 0.56) according to the definition of the American College of Surgeons Committee on Trauma (P <0.001). Where adjusted for trauma severity, the expected mortality rate at discharge from hospital was higher than observed mortality, with a difference of +2.0% (95% CI 1.4 to 2.6%; P <0.01).ConclusionsImplementation of a regional trauma system with a pre-hospital triage procedure was effective in detecting severe trauma patients and in lowering the rate of pre-hospital undertriage. A beneficial effect on outcome of such an organization is suggested.

Renal artery entrapment by the diaphragmatic crus

The aim of this study is to describe renal artery entrapment (RAE) by the diaphragmatic crus and to elucidate the diagnostic and therapeutic approach to this entity. From 1995 to 2002, 15 patients (mean age 65) were found to have a RAE. They were investigated by CT scan (n=14) and/or MRA (n=2) for hypertension (n=7), chronic renal insufficiency (n=4) or aneurysms (n=4). The right (n=11) or the left (n=4) renal artery (RA) was involved. The compression was ostial (n=8) or truncal (n=7), and was ≥50% in eight cases. The course of the RA along the aorta on angiographic views (n=8) or a concentric ostial stenosis in a patient free of atheromatous lesions (n=7) were two findings suggestive of an RAE. Seven RAEs were indicated for treatment but only three were treated, by mean of stenting. Among the latter, two stents were patent at 6-month follow-up and one evolved to restenosis because of a stent fracture. RAEs may be suspected on angiographic views and proved by cross-sectional imaging because of specific imaging features. It is of importance to detect this etiology of RA stenosis because angioplasty with stenting is probably not always advisable.

European Society of Hypertension scientific newsletter: hypertension and aortic diseases.

Hypertension, one of the major cardiovascular risk factors, promotes the formation of atheromatous lesions in the large arteries, including the aorta. It also favors aortic aneurysm and acute aortic syndrome such as aortic dissection or hematoma. In patients with aortic disease, beta-blockers and/or renin–angiotensin–aldosterone system inhibitors should be preferentially used to decrease blood pressure and improve arterial wall properties.

Blunt splenic injury: Outcomes of proximal versus distal and combined splenic artery embolization

PURPOSE To assess clinical outcomes of blunt splenic injuries (BSI) managed with proximal versus distal versus combined splenic artery embolization (SAE). MATERIALS AND METHODS All consecutive patients with BSI admitted to our trauma centre from 2005 to 2010 and managed with SAE were reviewed. Outcomes were compared between proximal (P), distal (D) or combined (C) embolization. We focused on embolization failure (splenectomy), every adverse events occurring during follow up and material used for embolization. RESULTS Fifty patients were reviewed (P n = 18, 36%; D n = 22, 44%; C n = 8, 16%). Mean injury severity score was 20. The technical success rate was 98%. Four patients required splenectomy (P n = 1, D n = 3, C n = 0). Clinical success rate for haemostasis was 92% (4 re-bleeds: P n = 2, D n = 2, C n = 0). Outcomes were not statistically different between the materials used. Adverse events occurred in 65% of the patients during follow up. Four percent of the patients developed major complications and 56% developed minor complications attributable to embolization. There was no significant difference between the 3 groups. CONCLUSION SAE had an excellent success rate with adverse events occurring in 65% of the patients and no significant differences found between the embolization techniques used. Proximal preventive embolization appears to protect in high-grade traumatic injuries.

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

BACKGROUND The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach. METHODS This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more]. RESULTS Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n=8) and/or operating room (n=2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24. CONCLUSIONS An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.