Jean-Philippe Berthet

Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease

BACKGROUND Descending necrotizing mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high mortality associated with this disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial. METHODS Over a 10-year period, 12 patients were treated at our institution. Surgical treatment consisted of 1 or several cervical drainages, associated with drainage of the mediastinum through a thoracic approach in 11 patients. Thoracic procedures included radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication, and pleural drainage with adequate placement of chest tubes for mediastinopleural irrigation. Transcervical mediastinal drainage was performed in only 1 patient. RESULTS The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the second required new drainage through a thoracotomy. The patient who had transcervical mediastinal drainage without a thoracic approach presented an abscess limited to the anterior and superior mediastinum. In 3 patients, ongoing mediastinal sepsis required a second thoracotomy. CONCLUSION A stepwise approach with transcervical mediastinal drainage is first justified in patients with very limited disease to the upper mediastinum. However, ongoing mediastinal sepsis requires new drainage, through a major thoracic approach, without delay. Extensive mediastinitis can not be adequately treated without mediastinal drainage including a thoracotomy. This aggressive surgical policy has allowed us to maintain a low mortality rate (16.5%) in a series of 12 patients with this highly lethal disease.

Endovascular repair for acute traumatic rupture of the thoracic aorta

BACKGROUND We report endovascular treatment of acute traumatic rupture of the thoracic aorta as a potential alternative to open surgery for high-risk patients. METHODS Between January 2001 and July 2002, 9 patients with acute traumatic rupture of the thoracic aorta were treated with a stent-graft. In all cases the endovascular management was selected because of age, associated polytrauma, or comorbidities. Preoperative workup included chest computed tomography scan, transoesophageal echography, and angiography. The devices used were the Excluder and the Talent stent-grafts. RESULTS Eight patients underwent immediate repair and 1 patient was treated within 5 days of the accident because of delayed diagnosis of aortic rupture after surgical management of spleen rupture. The stent-graft was successfully expanded in all patients through the common femoral artery (n = 7) or the common iliac artery (n = 2). There was no perioperative death, renal failure, or neurologic complication (paraplegia or stroke). In 1 patient the computed tomography scan at 7 days postoperatively showed proximal endoleak requiring placement of a second stent-graft. Follow-up ranged from 4 to 20 months. All spiral computed tomography scans performed during follow-up revealed no evidence of endoleak, migration, or alteration of the stent-graft. CONCLUSIONS Endovascular repair in the acute phase of traumatic rupture of the thoracic aorta is technically feasible and safe, and may represent an alternative to open surgery for high-risk patients.

Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: Midterm results

OBJECTIVE The aim of this study was to assess the short- and midterm results after endovascular repair of the aortic arch in high-risk patients or after previous aortic surgery. METHODS From November 1998 to November 2008, 57 thoracic stent grafts were implanted in 44 patients (sex ratio, 4.5; mean age, 66.5 +/- 16.5 years) for aortic arch repair (zone 0 to 2 according to the arch map proposed by Ishimaru) of 19 degenerative aneurysms, 12 traumatic transections of the aorta, 8 complicated aortic dissections, 4 postcoarctectomy aortic pseudoaneurysms, and 1 penetrating atheromatous ulcer. All patients were considered to be at high surgical risk owing to serious comorbidities (American Society of Anesthesiologists score > or = III [79.5%]) or previous aortic surgery. Endovascular repair was performed in an emergency setting in 27.3% (n = 12) of the patients. Thirty-four underwent a hybrid technique with supra-aortic debranching and simultaneous or staged endovascular stent grafting. Debranching was performed to provide an adequate proximal aortic landing zone, in 28 patients by a cervical approach and in 6 patients by a sternotomy approach. RESULTS The technical success rates for aortic zone 0 patients (n = 6), zone 1 patients (n = 4), and zone 2 patients (n = 34) were, respectively, 100%, 100%, and 97%. The 30-day mortality rate was 20.4%. The actuarial survival was 70% over a mean follow-up of 29.9 months. The rate of stroke was 6.8%. Two (4.5%) cases of paraplegia were observed, 1 of which was reversible after cerebrospinal fluid drainage. The rate of endoleak was 15.9% (n = 7): 3 type I, 3 type II, and 1 type III. There were no cases of device migration, but 1 stent-graft collapse occurred 20 days after exclusion of an aortic traumatic transection. CONCLUSION Hybrid endovascular aortic arch reconstructions, although some of these adjunctive procedures remain major operations, provide attractive alternatives for treating aortic arch lesions in high-risk patients who would otherwise be unsuitable for open repair, with acceptable primary results and encouraging midterm efficacy to prevent rupture.

Dissection of the abdominal aorta in blunt trauma: endovascular or conventional surgical management? ☆

BACKGROUND Dissection of the abdominal aorta caused by blunt trauma is a rare injury, often complicated by thrombosis within the true and false lumens and sometimes aortic rupture. The mortality rate with conservative medical management is approximately 75%, whereas it ranges from 18% to 37% with surgical treatment. METHODS At our institution, 7 of the 87 patients admitted because of blunt aortic trauma, between January 1995 and January 2002, had abdominal aortic dissection. RESULTS Four patients were treated using endovascular techniques by percutaneous stent placement. The indications for endovascular management were lower limb ischemia in one case and extension of the dissection in two; one patient was asymptomatic. Aortic dissection was complicated by ischemic paraplegia in two patients, and both were treated by conventional operative repair. One patient was managed medically because of a minimal intimal disruption. No deaths were related to the aortic dissection or its treatment. Angiographic and computed tomographic (CT) studies showed thrombosis of the false lumen and complete obliteration of the dissection in the endovascular group. The neurologic condition of the two paraplegic patients either cleared completely or partially improved. CONCLUSION In the absence of ischemic paraplegia or other injuries that require emergency surgery, endovascular treatment is a safe and efficient method for treating traumatic infrarenal aortic dissection.

Lessons learned from midterm follow-up of endovascular repair for traumatic rupture of the aortic isthmus

OBJECTIVE The aim of this study was to evaluate the short- and midterm results following endovascular repair of a traumatic rupture of the aortic isthmus. METHODS Between January 2001 and January 2007, 27 patients underwent endovascular repair for acute traumatic rupture of the aortic isthmus (8 women, 19 men, mean age 40.2 +/- 16.7 years [19-78]). All patients underwent a computed tomography scan resulting in the preoperative diagnosis of aortic disruptions. Twenty-one patients were treated within the first 5 days following diagnosis. Follow-up computed tomography scans were performed at 1 week, at 3 and 6 months, and annually thereafter. The median follow-up was 40 months. RESULTS All endografts were successfully deployed (Excluder-TAG [16], Talent [10], Zenith [2]). Three patients required common iliac artery access. The morbidity rate was 14.8%: two cases of inadvertent coverage of supra-aortic trunks occurred peroperatively, a proximal type I endoleak was successfully treated by a proximal implantation of a second endograft, and one collapse of an endograft was successfully treated by open repair and explantation. No patient suffered transient or permanent paraplegia, cerebral complication, endograft migration, or secondary endoleak. The overall mortality rate was 3.7%. CONCLUSIONS Short and midterm results following endovascular treatment for traumatic rupture of the aortic isthmus favor the proposition of endovascular repair as the first-line treatment in hemodynamically unstable patients. In hemodynamically stable patients, the preoperative morphological evaluations aim to assess aortic anatomy and thereby detect possible technical limitations (aortic diameter <20 mm, severe aortic isthmus angulation, short proximal aortic neck <20 mm, conical aorta). In the presence of any one of these technical restrictions, open surgical treatment should be discussed to avoid major per- or postoperative complications related to endovascular repair. Further studies and long-term survival studies are mandatory to determine the efficacy and durability of this technique.

Endovascular repair for acute rupture of the descending thoracic aorta.

Purpose: To report the endovascular treatment of acute descending thoracic aortic rupture as an alternative to open surgery in high-risk patients. Methods: Between November 1999 and April 2001, 10 patients (7 men; median age 75 years) underwent endovascular stent-grafting of the descending thoracic aorta for acute rupture from an aneurysm (n = 7) or blunt trauma (n = 3). All patients were evaluated as high operative risk. The aortic rupture was associated with isolated mediastinal hematomas (n = 7), left hemothorax (n = 2), or aortobronchial fistula (n = 1). The Excluder Thoracic Endoprosthesis was used predominantly. Results: The mean interval to the endovascular repair was 45.3 ± 28.4 hours. All stent-grafts were successfully deployed. Two patients required common iliac artery access, and 2 needed covered stents for iatrogenic iliac artery rupture. There was 1 postoperative death (myocardial infarction) and no renal failure, neurological complications, embolization, stent-graft migration, or perigraft leak. One patient died 4 months later from an unrelated cause. At a mean follow-up of 7.9 ± 5.1 months, all aneurysms and rupture sites were excluded with no evidence of endoleak or hematoma. Conclusions: Endoluminal treatment is a feasible technique for the management of acute rupture of the descending thoracic aorta. Long-term studies are required to assess the effectiveness and durability of this technique in comparison to open repair.

Carotid artery stenting for stenosis following revascularization or cervical irradiation.

Purpose: To assess the safety and efficacy of carotid artery stenting (CAS) for stenosis following revascularization or cervical irradiation. Methods: Twenty-two CAS procedures performed on 21 patients (20 men; mean age 69.3 years, range 58–87) from June 1997 to June 2000 were retrospectively reviewed. There were 5 radiation-induced carotid stenoses in 4 patients and 17 postsurgical restenoses. The mean interval between carotid revascularization and CAS was 48.1 months (range 6–264), while the elapsed time from irradiation to CAS was always >8 years (range 8–28). Seven patients screened during this period were excluded from CAS because of a duplex-defined >50% hypoechoic lesion and/or angiographic documentation of an irregular ulcerated stenosis. Results: Four Palmaz and 16 Wallstents were successfully deployed in 20 arteries; 1 access failure prompted conversion to surgery and a stent delivery failure resulted in 1 patient receiving balloon dilation only (technical success 91%). No complications were encountered in the periprocedural period, and no neurological events were observed during a mean follow-up of 16.6 months (range 3–36). One patient died at 20 months from an unrelated cause. One (4.8%) restenosis was detected after 1 year in the patient who did not receive a stent. Conclusions: CAS is a safe alternative to conventional surgery in patients with carotid artery stenosis following surgical revascularization or cervical irradiation provided preoperative testing excludes stenoses at risk for embolism.

Surgical conversion after thoracic endovascular aortic repair

OBJECTIVE Improved early and late outcomes of thoracic endovascular aortic repair compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. However, rare but serious complications due to device failure or adverse events may occur, requiring conversion to open repair. METHODS In our experience, 186 patients underwent thoracic endovascular aortic repair. Seven of these patients (3.7%) required open repair because of 3 retrograde type A dissections, 1 thoracic stent-graft collapse, 1 aneurysm enlargement without endoleak, 1 aortoesophageal fistula, and 1 stent-graft infection. All patients but 1 underwent surgical repair using cardiopulmonary bypass. Four stent-grafts were totally removed, and 3 endografts were left in situ. Three patients underwent supracoronary ascending aorta replacement via a sternotomy. Three patients underwent a descending aortic replacement via a left thoracotomy. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass, and stent-graft explantation. RESULTS Thirty-day mortality was 28%. Four patients had an uneventful postoperative course. One patient was treated for postoperative sternitis. Two patients with stent-graft infections died of multiorgan failure in the early postoperative course. No stroke, paraplegia, or renal failure occurred. With a mean follow-up of 21.4 months (range, 2-60 months), 5 patients had no adverse events. CONCLUSIONS Complications due to device failure or adverse events may occur after thoracic endovascular aortic repair, requiring conversion to open repair. Our experience suggests that in some clinical or anatomic situations, caution should be recommended when offering endovascular procedures to patients with thoracic aortic diseases. Open conversion can be performed with encouraging results by a team experienced in the management of thoracic aortic diseases. With the increasing use of thoracic endovascular aortic repair, more patients will present with indications of surgical conversion.

Open versus endovascular repair for patients with acute traumatic rupture of the thoracic aorta

OBJECTIVE The study objective was to compare the outcome between open and endovascular repair of acute traumatic rupture of the thoracic aorta. METHODS Seventy-five patients (mean age 38.6 ± 10.7 years) with an acute traumatic aortic rupture were referred to the Arnaud de Villeneuve Hospital between January 1990 and January 2010. Between January 1990 and December 2000, 35 patients (33 men, mean age 35.8 ± 11.3 years) underwent surgical repair using cardiopulmonary bypass. From January 2001, an endovascular approach was deliberately chosen; 40 patients (30 male, mean age 41 ± 10.1 years) underwent endovascular repair. The 2 groups were statistically comparable. RESULTS The overall mortality rates for the surgical and endovascular groups were 11.4% (intraoperative mortality: 8.5%) and 2.5% (intraoperative mortality: 0%), respectively. The mortality rates related to aortic repair for the surgical and endovascular groups were 11.4% and 0%, respectively. In the surgical group, the morbidity rate was 14.2%: 4 cases of recurrent nerve palsy and 1 case of false anastomotic aneurysm were diagnosed at 52 months. In the endovascular group, the morbidity rate was 20%: 3 cases of intraoperative inadvertent coverage of supra-aortic trunks (requiring a secondary procedure in 2 cases after 1 and 2 years to revascularize the supra-aortic trunks), 1 proximal type I endoleak (requiring deployment of a second stent-graft at day 2), 2 stent-graft collapses in the first postoperative month (treated by open repair and explantation in 1 case and by the deployment of a second stent-graft in 1 case), 1 vertebrobasilar insufficiency after left subclavian artery coverage, and 1 intraoperative iliac rupture (surgically repaired). No cases of paraplegia or stroke were observed. The median follow-up was 7.7 (range, 0.4-15) years. CONCLUSIONS Compared with open repair, endovascular repair of traumatic thoracic aortic rupture is associated with a lower death rate but failed to reach statistical significance, most likely because of underpowering. These results prompt us to consider endovascular repair as the first-line therapy for acute traumatic rupture of the thoracic aorta, except in some rare but challenging anatomic situations. New stent-graft designs, sizes, and deployment systems could improve the results of endovascular repair in these indications.

The combination of polytetrafluoroethylene mesh and titanium rib implants: an innovative process for reconstructing large full thickness chest wall defects †

OBJECTIVES The reconstruction of large full thickness chest wall defect after resection of T3/T4 non-small cell lung cancer (NSCLC) or primary chest wall tumours presents a technical challenge for thoracic surgeons and is a critical factor in determining post-operative outcome. When the defect is large, complications are common with a 27% mean rate of respiratory morbidity. METHODS Since 2006, 31 patients underwent reconstruction for wide chest wall defects using titanium implants and strong mesh. The reconstruction was achieved using a layer of polytetrafluoroethylene or a XCM biologic tissue mesh shaped to match the defect and sutured under maximum tension to re-establish the skeletal continuity. The mesh was placed close to the lung and was fixed onto the bony framework and onto the titanium plate. In one case, we used XCM biologic tissue because of a large infected T3 NSCLC. A horizontal titanium rib osteosynthesis system was used to reestablish the rigidity of the thoracic wall by bridging the defect except for one case in which we use a vertical rib osteosynthesis system. RESULTS Twenty-six patients underwent a complete R0 resection with the removal of a mean of 4.67 ± 1.5 [3-9] ribs, including the sternum in 14 cases. The mean defect area was 198 ± 91.2 [95-400] cm². Reconstruction required a mean of 2.06 ± 1.1 [1-4] titanium plates. There were two cases of deep wound infection that required surgical removal of the osteosynthesis system in one patient. Only one patient developed a major complication in the form of respiratory failure. There were two postoperative deaths neither of which was directly related to the surgical procedure. CONCLUSIONS Our experience and initial results show that titanium rib osteosynthesis in combination with strong biologic or synthetic mesh can easily and safely be used in a one-stage procedure for the reconstruction of major chest wall defects.