Jean Noel Fabiani

One-year outcomes following repair of thoracoabdominal aneurysms with the multilayer flow modulator: report from the STRATO trial.

Purpose To evaluate endovascular repair of type II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients with contraindications for open surgery and fenestrated stent-grafts. Methods In this prospective, multicenter, nonrandomized trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (19 men; mean age 75.8 years) with Crawford type II (43.5%) and III (56.5%) TAAA (mean diameter 6.5 cm) were treated with the MFM between April 2010 and February 2011. The primary efficacy outcome measure was stable aneurysm thrombosis with associated branch vessel patency at 12 months; the primary safety endpoint was 30-day and 12-month all-cause mortality. Results The rate of technical success was 100%. In 20 patients with computed tomography scans at 12 months, the primary efficacy outcome was met in 15 patients. The rate of primary patency of covered branch vessels was 96% (53/55); 1 patient with 2 occluded visceral branches underwent successful surgical reintervention. Endoleaks were identified in 5 patients (3 attachment site and 2 at device overlap), 4 of whom underwent reintervention (3 additional MFMs and 1 stent-graft implanted). At 12 months, aneurysm diameter was stable in 18 of 20 patients; the mean ratio of residual aneurysm flow volume to total volume had decreased by 28.9%, and the mean ratio of thrombus volume to total lumen volume had increased by 21.3% (n=17). There were no cases of device migration, loss of device integrity, spinal cord ischemia, or aneurysm rupture. Conclusion At 1 year, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency. Follow-up is ongoing.

Ambulatory blood pressure profile after carotid endarterectomy in patients with ischaemic arterial disease.

Objective To assess the circadian blood pressure profile observed 3 months after endarterectomy. Design Twenty-five patients undergoing unilateral or bilateral carotid endarterectomy were compared with a control population of 20 patients, matched for age, sex, weight and drug therapy. Casual mean blood pressure measured by mercury sphygmomanometry was similar in both groups. Results Non-invasive ambulatory blood pressure monitoring showed that, whereas mean arterial pressure was identical in both groups, the group undergoing surgery had a significant increase in pulse pressure and its variability over 24 h. Such abnormalities predominated during the nocturnal period, in which the reduction in systolic blood pressure was less pronounced in the operated group than in controls. For all parameters there was no significant difference between subjects with unilateral or bilateral endarterectomy. Conclusion This study provides evidence that patients with carotid endarterectomy were characterized in the long term by an increase in the pulsatile component of blood pressure and its variability, in association with a disturbance in the physiological circadian rhythm. Such findings were not identified using casual blood pressure measurements.

Cardiac Surgery in Patients with Human Immunodeficiency Virus Infection: Indications and Results

Ten patients with human immunodeficiency virus (HIV) infections underwent cardiac surgery using cardiopulmonary bypass. All were in Centers for Disease Control (CDC) group II. The cardiac involvement was either urgent or severely symptomatic in all cases. One patient died due to acquired immunodeficiency syndrome (AIDS) unrelated cause. No complications were encountered in this series. Eight of the nine survivors were available for follow‐up. Three of these eight patients progressed to AIDS (CDC group IV) and subsequently died. Five patients are alive and in CDC group II. Prognosis of the HIV infection and the natural history of the cardiac disease are the two main elements to be considered whenever cardiac surgery is required.

Endoluminal Gingival Fibroblast Transfer Reduces the Size of Rabbit Carotid Aneurisms via Elastin Repair

Objective—Matrix metalloproteinase-9 is considered to play a pivotal role in aneurismal formation. We showed that gingival fibroblasts (GF) in vitro reduced matrix metalloproteinase-9 activity via increased secretion of tissue inhibitor of metalloproteinase 1. We aimed to evaluate in vivo the efficacy of GF transplantation to reduce aneurism development in a rabbit model. Methods and Results—Seventy rabbit carotid aneurisms were induced by elastase infusion. Four weeks later, GF, dermal fibroblast, or culture medium (DMEM) were infused into established aneurisms. Viable GF were abundantly detected in the transplanted arteries 3 months after seeding. GF engraftment resulted in a significant reduction of carotid aneurisms (decrease of 23.3% [P<0.001] and 17.6% [P=0.01] of vessel diameter in GF-treated arteries, 1 and 3 months after cell therapy, respectively), whereas vessel diameter of control DMEM and dermal fibroblast–treated arteries increased. GF inhibited matrix metalloproteinase-9 activity by tissue inhibitor of metalloproteinase 1 overexpression and matrix metalloproteinase-9/tissue inhibitor of metalloproteinase 1 complex formation, induced elastin repair, and increased elastin density in the media compared with DMEM-treated arteries (38.2 versus 18.0%; P=0.02). Elastin network GF-induced repair was inhibited by tissue inhibitor of metalloproteinase 1 blocking peptide. Conclusion—Our results demonstrate that GF transplantation results in significant aneurism reduction and elastin repair. This strategy may be attractive because GF are accessible and remain viable within the grafted tissue.

Heart transplantation following cardiomyoplasty: a biological bridge §

OBJECTIVE Dynamic cardiomyoplasty (CMP) was proposed as a treatment for refractory heart failure; more than 2000 procedures have been performed worldwide. Heart transplantation was indicated afterwards in some CMP patients with recurrent heart failure symptoms. This study reviews the multicentric French experience with CMP followed by heart transplantation. METHODS From 1985 to 2007, 212 patients (mean age 53+/-11 years) with refractory heart failure (LVEF=22+/-9%, mean NYHA 3.2) underwent CMP in France. Heart transplantation was performed in 26 patients (12.3%), mean age: 51+/-11 years, within 2.3+/-3 years after CMP. Transplantation was indicated for persistent heart failure, i.e. no immediate improvement after CMP (19%) and for recurring heart failure (81%). RESULTS The surgical technique of heart transplantation following cardiomyoplasty presents few particularities. Routine extracorporeal bypass was instituted between the vena cavas and the ascending aorta. As in most of these patients the CMP procedure had been performed without the need of extracorporeal circulation, hearts were free of previous cannulations for cardiopulmonary bypass. The latissimus dorsi muscle flap was divided as far as possible inside the left pleural cavity and its vascular pedicle was obturated. The proximal portion of the muscle as well as the muscular pacing electrodes were kept in place in the pleural cavity. The adhesions between the flap and the heart were not released so as to achieve an en bloc resection of the heart and the muscle flap. During removal of the recipients heart, care was taken not to injure the left phrenic nerve that was frequently in tight relation with the latissimus dorsi muscle. Heart transplantation was then performed in a routine manner, the donor heart being anastomosed to remnant atria and great vessels. Mean follow-up was 5.5 years (longest 13.5 years). Survival at 10 years was 40% for early heart transplantation (done within 4 months of CMP) and 57% for transplantation performed at 3+/-2.8 years after CMP. CONCLUSIONS Heart transplantation after CMP is technically feasible. Hospital mortality was higher when urgent transplantation was required. Long-term survival results are similar to those for primary heart transplantation. Cardiomyoplasty, when it fails, does not preclude transplantation, and when indicated, CMP could be considered as a biological bridge to heart transplantation.

Three-Year Outcomes With the Multilayer Flow Modulator for Repair of Thoracoabdominal Aneurysms: A Follow-up Report From the STRATO Trial.

Purpose: To evaluate midterm outcomes of endovascular repair of types II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients unsuitable for open surgery or fenestrated stent-grafts. Methods: In the prospective, multicenter, nonrandomized STRATO trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (mean age 75.8 years; 19 men) with Crawford type II and III TAAA (mean diameter 6.5 cm) were implanted between April 2010 and February 2011. Outcomes included all-cause mortality and stable aneurysm thrombosis with associated branch vessel patency. Results: Through 36 months, there were 7 deaths (none confirmed as aneurysm-related), and no cases of spinal cord injury, device migration or fracture, or respiratory, renal, or peripheral complications. Three patients were lost to follow-up and 2 devices were explanted. The device was patent in the 11 remaining patients at 3 years. Stable aneurysm thrombosis was achieved for 15 of 20 patients at 12 months, 12 of 13 at 24 months, and 10 of 11 at 36 months. The rate of branch patency was 96% at 12 months (primary patency), 100% at 24 months, and 97% at 36 months. Nine patients suffered from endoleaks (attachment site or device overlap); 9 patients underwent 11 reinterventions (3 surgical). Maximum aneurysm diameter was stable for 18 of 20 patients at 12 months, 11 of 13 at 24 months, and 9 of 11 at 36 months. For 10 patients with computed tomography at 36 months, the mean ratio of aneurysm flow volume to total volume had decreased by 83%; the mean ratio of thrombus volume to total volume increased by 159%. Conclusion: Through 3 years, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency.

Improvement of Postischemic Renal Function by Limitation of Initial Reperfusion Pressure

PURPOSE This study was designed to determine whether lowering the initial reperfusion pressure can improve renal function after ischemia. MATERIALS AND DESIGN: Sixty minutes of warm renal ischemia was induced in 2 groups of 8 minipigs by clamping the left renal artery. Right kidneys were kept in situ as controls. In the standard reperfusion group, ischemic kidneys were immediately reperfused at systemic pressure. In the controlled reperfusion group, the renal artery reperfusion pressure was maintained at 60 mm. Hg for the initial 20 minutes of reperfusion by use of a regulating pump and then at systemic pressure for the next 100 minutes. RESULTS On the basis of the postischemic anuria rate, glomerular filtration rate and renal histology, renal tolerance to ischemia was significantly improved in the controlled reperfusion group. CONCLUSION These findings of improved renal function recovery after warm ischemia by controlled low reperfusion pressure may have clinical relevance to the reperfusion technique used after renal transplantation in humans.

Determinants of Transcutaneous Ear Lobe CO2 Tension (PtCO2) at 37°C During On-Pump Cardiac Surgery.

OBJECTIVE There are no available criteria for determining the optimal flow rate and mean arterial pressure level in patients undergoing cardiopulmonary bypass (CPB). Transcutaneous carbon dioxide tension (PtCO2) has been proposed for microcirculation monitoring and it could be useful for guiding hemodynamic optimization under CPB. The goal of this exploratory study was to determine the factors that influence PtCO2 variations during CPB. DESIGN Cutaneous ear lobe CO2 tension was monitored along with hemodynamic parameters every 10 minutes during CPB, until aortic unclamping. SETTING French university teaching hospital. PARTICIPANTS Patients scheduled for cardiac surgery requiring CPB were prospectively included. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS A total of 41 patients were included (520 observations). There was a statistically significant association between PaCO2 and PtCO2 (beta = 0.493 [0.154-0.832], p = 0.043), mostly when PaCO2 was outside the normal range. When PaCO2 was normal, PtCO2 was inversely correlated with mean arterial pressure (after adjustment for PaCO2 and body temperature: Beta -0.245, SE = 0.037, p<0.001) but not with CPB flow rate (p = 0.11). CONCLUSION The factors that influence PtCO2 during CPB cardiac surgery are PaCO2, body temperature, and mean arterial pressure. When PaCO2 is normal, a PtCO2 elevation might be explained by insufficient mean arterial pressure. Whether low PtCO2 values during CPB should trigger the administration of vasoconstrictors remains to be evaluated.

213: Efficacy and cost-effectiveness of reinterventions for type 2 endoleak with enlargement of the aneurysmal sac after endovascular abdominal aortic aneurysm

Background Type 2 endoleaks after endovascular aortic repair (EVAR) still represent a problematic issue for vascular surgeon to stop the aneurysmal degeneration of the unsuccessfully excluded aneurysm. This study was designed to assess the efficacy of secondary interventions performed on continuing expanding abdominal aortic aneurysms (AAA) after EVAR with an identified type 2 endoleak. Methods We retrospectively reviewed patients treated by EVAR for AAA, in which follow-up data of more than 1 year were available. Endoleak incidences, sac diameters, and secondary procedures were collected. Patients with type 2 endoleaks and continuing expanding AAA were identified. Primary endpoint was the efficacy of these reinterventions on the postoperative AAA diameter course. Secondary endpoints were the aneurysm-related morbidity and mortality, and the cost effectiveness of these complementary procedures. Results Out of 232 reviewed patients treated by EVAR for AAA, with a mean follow-up of 3 years (37±30 months), 15 type 1 (6.5%), 94 type 2 (40.5%), and 8 type 3 (3.5%) endoleaks were identified. Among the 94 AAA with a type 2 endoleak, 21 presented a sac regression (22.5%), 46 were stable (49.5%), and 27 presented a sac enlargement (28%). Eight of these last subgroup of patients had another type of endoleak associated that required particular treatments. Among the 19 patients presenting a type II endoleak responsible for sac enlargement, 15 were indicated for embolisation procedures, 1 was treated by immediate open repair, and 3 are still under surveillance. Among the 15 patients treated by embolisation, 9 (60%) had still an aortic sac enlargement postoperatively, requiring finally 6 open repairs with one postoperative death. The mean extra cost by patient induced by secondary procedures for type 2 endoleak was 27110±3098 Euros. Conclusion In our experience, endovascular reinterventions for type 2 endoleaks associated with an aortic sac enlargement after EVAR have a poor efficiency on the stabilization of AAA diameter. These procedures entail extra costs and morbidity that should be taken into account in their indication. Download full-size image

305: Early results from an emergency center dedicated for acute aortic syndromes with round-the-clock access

Background Acute aortic syndromes (AAS) represent a wide range of life-threatening pathologies. We assessed the feasibility and early results of an immediate, round-the-clock, protocolized management of patients with AAS. Method In January 2009, we set up the SOS-Aorta program regrouping intensivists, cardio-vascular and endovascular surgeons available around the clock. All patients admitted via SOS-aorta were included in a prospective registry. We compared the early results of this registry to the one of a retrospective cohort of patients admitted for AAS before the creation of this program. Result From January 2006 to December 2011, a total of 451 patients were admitted for AAS (174 before and 287 after SOS-Aorta). The average number of patients treated annually was 58±6.6 in the 3-years before SOS-Aorta. It increased significantly to 96±17 (p Conclusion Setting-up the SOS-Aorta program has increased significantly the number of patients admitted for AAS. It resulted in a significant improvement of in-hospital mortality for these patients with otherwise immediate severe prognosis.