Laurent Chiche

Leiomyosarcoma of the Inferior Vena Cava: Experience in 22 Cases

From 1979 to 2004, 22 patients were seen with leiomyosarcomas of the inferior vena cava (IVC). Twenty were treated surgically. Involvement of the IVC included the infrarenal segment in 3 cases, the suprarenal and/or retrohepatic segment in 13, and the suprahepatic segment in 4. Nineteen patients underwent wide tumor resection followed by ligation of the IVC in 5 cases, replacement with a PTFE prosthesis in 13, and cavoplasty in 1. An intracardiac tumor extension was resected during hypothermic circulatory arrest in 1 patient. Vascular exclusion of the liver was used in 5 cases and simple clamping of the IVC in 13 cases. There were 1 intraoperative death due to cardiac failure and 3 postoperative deaths due to multiple organ failure, liver failure, and duodenal fistula after treatment of a bleeding ulcer. Fifteen of the 16 surviving patients underwent adjuvant chemotherapy associated with radiation therapy in 4 cases. One patient was lost from follow-up at 10 months. Four patients including one with metastasis are still alive with a mean follow-up of 18.3 months. Eleven patients died after a mean follow-up period of 43.7 months due to local recurrence and/or distant metastasis in 9 cases and complications of chemotherapy in 2. The 3- and 5-year mean actuarial survival rates in patients who underwent resection were 52.0% and 34.8%, respectively. Leiomyosarcoma of the IVC is a serious disease. Although surgical resection combined with chemotherapy is usually not curative, it can achieve reasonably long-term survival. We recommend aggressive operative management using the latest vascular surgery and oncology techniques.

Aortoesophageal fistula: value of in situ aortic allograft replacement.

Purpose The purpose of this report is to describe our experience in management of aortoesophageal fistulas (AEF) with special emphasis on the value of in situ aortic allograft replacement. Patients Nine patients presenting with AEF were observed between May 1988 and April 2002. There were 4 men and 5 women with a mean age of 54.3 years (range, 32–77 years). Six patients presented secondary AEF after aortic repair. Two patients presented primary AEF after rupture of an atherosclerotic aneurysm into the esophagus. In the remaining patient, AEF was caused by swallowing a fishbone. In 6 cases involving true AEF with a direct communication between the aorta and esophagus, massive exsanguinating hematemesis occurred. It was usually preceded by minor sentinel bleeding. Two patients presented esophagoparaprosthetic fistula (EPPF). One patient presented primary AEF that was contained by a large thrombus in the communication. The clinical picture in these 3 patients involved severe sepsis without hemorrhage. Results Two patients died as a result of massive hemorrhage before assessment and surgical treatment could be undertaken. One 77-year-old woman presenting EPPF refused to undergo surgery and died because of infection. The remaining 6 patients underwent surgical treatment with various outcomes. One man died during thoracotomy caused by exsanguinating hemorrhage. One woman presenting EPPF was treated by exclusion followed by ascending aorta to abdominal aorta bypass grafting, removal of the prosthesis, esophageal exclusion, and directed esophageal fistula. She died of infection. The other 4 patients were treated by in situ aortic allograft replacement. The damaged esophagus was repaired by using the Thal technique in 1 patient. In the remaining 3 cases subtotal esophagectomy was performed in association with cervical esophagostomy, ligation of the abdominal esophagus, gastrostomy, and jejunostomy. One patient died of sepsis during the first 24 hours after the operation. The other 3 patients underwent secondary esophagoplasty and survived with no further sign of infection. Mean duration of follow-up in the survivor group was 53 months (range, 15-95 months). Overall 6 patients, including 3 that did not undergo surgical treatment, died and 3 patients survived. Conclusion Our experience confirms that AEF is a rare but catastrophic disorder. In situ allograft replacement usually in association with subtotal esophagectomy appears to be an excellent salvage modality whenever emergency surgery is feasible.

Takayasu Arteritis and Pregnancy

To assess the relationship between Takayasu arteritis (TAK) and pregnancy outcome.

Long-Term Outcomes and Prognostic Factors of Complications in Takayasu Arteritis: A Multicenter Study of 318 Patients

Background: Because of the wide variation in the course of Takayasu arteritis (TA), predicting outcome is challenging. We assess long-term outcome and prognosis factors for vascular complications in patients with TA. Methods: A retrospective multicenter study of characteristics and outcomes of 318 patients with TA fulfilling American College of Rheumatology and Ishikawa criteria was analyzed. Factors associated with event-free survival, relapse-free survival, and incidences of vascular complications were assessed. Risk factors for vascular complications were identified in a multivariable model. Results: The median age at TA diagnosis was 36 [25–47] years, and 276 patients (86.8%) were women. After a median follow-up of 6.1 years, relapses were observed in 43%, vascular complications in 38%, and death in 5%. Progressive clinical course was observed in 45%, carotidodynia in 10%, and retinopathy in 4%. The 5- and 10-year event-free survival, relapse-free survival, and complication-free survival were 48.2% (42.2; 54.9) and 36.4% (30.3; 43.9), 58.6% (52.7; 65.1) and 47.7% (41.2; 55.1), and 69.9% (64.3; 76.0) and 53.7% (46.8; 61.7), respectively. Progressive disease course (P=0.018) and carotidynia (P=0.036) were independently associated with event-free survival. Male sex (P=0.048), elevated C-reactive protein (P=0.013), and carotidynia (P=0.003) were associated with relapse-free survival. Progressive disease course (P=0.017), thoracic aorta involvement (P=0.009), and retinopathy (P=0.002) were associated with complication-free survival. Conclusions: This nationwide study shows that 50% of patients with TA will relapse and experience a vascular complication ⩽10 years from diagnosis. We identified specific characteristics that identified those at highest risk for subsequent vascular complications.

Open surgery remains a valid option for the treatment of recurrent carotid stenosis

OBJECTIVE The choice between open surgery (OS) and transluminal carotid angioplasty with stenting (CAS) for the treatment of primary carotid stenosis remains controversial. However, CAS is considered a valid option for selected cases, such as recurrent carotid stenosis (RCS). Tertiary RCS seems to be a concerning issue after CAS but few large reports focused on the durability of CAS and OS. We report our early and long-term results with OS for RCS. METHODS From 1989 to 2006, perioperative data regarding 4245 consecutive surgical carotid reconstructions was prospectively collected. Patients whose indication was RCS were subjected to further analysis. Indications for surgery were symptomatic RCS >50% or asymptomatic RCS >80%. Freedom from neurologic event was defined as the absence of any ipsilateral symptom at any time after the procedure. Kaplan-Meier analysis was used to estimate freedom from reintervention, freedom from restenosis >50% and occlusion, freedom from neurologic event and survival. RESULTS A total of 119 patients (2.8%) with RCS underwent OS. The average time from the primary OS was 59.4 +/- 54.5 months (range, 2-204). Forty-nine patients (41%) were symptomatic. In 103 patients (87%), the technique did not differ from a primary approach. Postoperative (<30 days) combined stroke and death rate was 3.3%. Cranial nerve injury occurred in 5 cases (4.2%). With a mean follow-up of 53 +/- 48 months (range, 1-204), 3 patients had an ipsilateral stroke (including one hemorrhagic stroke) and 7 were diagnosed with a tertiary RCS >50%. At 5 years, Kaplan-Meier estimates of freedom from reintervention, freedom from restenosis and occlusion, freedom from neurologic event, and survival were 99%, 91%, 89%, and 91%, respectively. CONCLUSION OS for RCS is not a high-risk procedure and provides excellent long-term results, with low rates of tertiary RCS and reinterventions. The comparison between OS and CAS in this indication suffers from the absence of standardized follow-up paradigms after primary OS and the lack of prospective randomized trial comparing the two techniques. Despite these limitations in the available data, we conclude that OS should remain the first line therapy when treatment of RCS is indicated.

Open surgical repair of descending thoracic aortic aneurysms in the endovascular era: a 9-year single-center study.

The purpose of this study was to present a single centers experience with elective treatment of descending thoracic aortic aneurysms (DTAAs) in the endovascular era. From July 1997 to May 2005, we operated on 173 patients for DTAA. A total of 52 patients (30.1%) underwent endovascular stent-graft repair (group I). Endovascular repair was carried out exclusively in high-surgical risk patients in whom preoperative spinal cord arteriography usually demonstrated that the origin of the Adamkiewicz artery was located outside the zone to be covered by the stent graft. The remaining 121 patients (69.9%) underwent open surgical repair (group II), with partial cardiopulmonary bypass in 78 cases (64.5%) and deep hypothermic circulatory arrest in 43 (35.5%). The two treatment groups differed significantly with regard to age, prevalence of chronic obstructive pulmonary disease, number of aneurysms involving the upper segment or full length of the descending thoracic aorta, and percentage of patients in whom spinal cord arteriography was either deemed unnecessary or demonstrated that the origin of the Adamkiewicz artery was located within the coverage zone. In-hospital mortality was 15.4% (8/52) in group I vs. 5.0% (6/121) in group II (p = 0.02). Five deaths after endovascular repair were due to technical causes. All neurological deficits due to spinal cord ischemia (9/121, 7.4%) including 3.3% of irreversible flaccid paraplegia occurred in group II (p = 0.04). The findings of this study show that open surgical repair achieves excellent results when high-risk surgical candidates are recommended for endovascular repair. However, since preoperative spinal cord arteriography was a selection criterion for endovascular repair, the improvement in mortality was accompanied by a concentration of spinal cord ischemic complications in the patients having open surgical repair. The high mortality associated with endovascular repair in our series should decrease as deployment skill and endovascular technology improve.

Overall survival and mortality risk factors in Takayasu's arteritis: A multicenter study of 318 patients

OBJECTIVE To report the long term mortality in Takayasu arteritis (TA) and to identify prognosis factors. METHODS We analyzed the causes of death and the factors associated with mortality in a cohort of 318 patients [median age at diagnosis was 36 [25-47] years and 276 (86%) patients were women] fulfilling American College of Rheumatology and/or Ishikawa criteria of TA. A prognostic score for death and vascular complications was elaborated based on a multivariate model. RESULTS Among 318 TA patients, 16 (5%) died after a median [IQR] follow-up of 6.1 [2.8-13.0] years. The median age at death was 38 [25-47] years with 88% of women. Main causes of death included mesenteric ischemia (n = 4, 25%) and aortic aneurysm rupture (n = 4, 25%). The mortality rate at 5 and 10 years was of 1.9% and 3.9%, respectively. Caucasians (p = 0.049) and smokers (p = 0.002) TA patients were more likely to die. There was an increased mortality in TA (SMR with 95% confidence interval, 2.73 [1.69-4.22]) as compared to age and sex matched healthy controls. We defined high risk patients for death and vascular complications according to the presence of two of the following factors (i.e a progressive clinical course, thoracic aorta involvement and/or retinopathy). In the high risk TA group, the 5-year incidence of death and vascular complication was 48.5% compared to 21.6% (p = 0.001) in those with low risk. CONCLUSION The overall mortality in our Takayasu cohort was 5% after a median follow-up of 6.1 years. We identified specific characteristics that distinguish TA patients at highest risk for death and vascular complications.

Anévrismes de l’aorte abdominale : quel bilan morphologique préopératoire pratiquer ?

En pediatrie, les catheters centraux sont devenus un element indispensable pour les traitements intraveineux de longue duree. L’obstruction totale ou partielle, sous-estimee, est la complication la plus frequente, le remplacement, source de risques physiques, psychologiques et financiers. La prevention de l’obstruction est primordiale. La pharmacopee offre differents produits chimiques et biochimiques pour desobstruer ces dispositifs centraux. Souvent, le diagnostic, les prescriptions, les protocoles sont empiriques ou relevent d’habitudes. La composition, l’importance, la longueur du bouchon sont toujours meconnus. Les thrombolytiques, au premier rang desquels l’urokinase extractive, sont actuellement le traitement de choix pour la majorite des obstructions. Cependant, le mecanisme, les doses utiles, et la duree necessaire restent encore imprecis.

Surgical Technique for Extent IV Thoraco-Abdominal Aortic Aneurysms

Surgical repair of extent IV thoraco-abdominal aortic aneurysms is usually simple because distal aortic perfusion is in most cases not justified. Since the Adamkiewicz artery is usually located proximal to the upper level of the aneurysm, a beveled proximal anastomosis includes in standard repairs the ostia of the celiac, superior mesenteric, and renal arteries. Direct anastomosis of the left renal artery is performed separately. Devastating complications, mainly related to the duration of digestive, renal, or spinal cord ischemia, are, however, encountered when this technique is not fully mastered. In this chapter our current anesthetic and surgical management for standard and specific cases of extent IV thoraco-abdominal aortic aneurysms is described.

Deep Hypothermic Circulatory Arrest for Thoracic Aneurysmectomy through the Left Chest

Deep hypothermic circulatory arrest (DHCA) is a useful adjunct in descending thoracic and thoraco-abdominal aneurysmectomy. We have used it in 237 cases including a variety of indications, the most frequent being type B aortic dissection. This chapter describes our surgical techniques, indications, and results of DHCA for descending thoracic and thoraco-abdominal aneurysmectomy.