Ludovic Canaud

Endovascular Repair of Acute Uncomplicated Aortic Type B Dissection Promotes Aortic Remodelling: 1 Year Results of the ADSORB Trial

OBJECTIVES Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33). CONCLUSIONS The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.

Endovascular Repair of Aorto-iliac Artery Injuries after Lumbar-spine Surgery

OBJECTIVE This study aims to describe the endovascular management of abdominal-aortic- or common-iliac-artery injuries after lumbar-spine surgery. METHODS Patients treated for abdominal-aortic- or common-iliac-artery injuries after lumbar-spine surgery during a 13-year period were identified from an endovascular database, providing prospective information on techniques and outcome. The corresponding patient records and radiographic reports were analysed retrospectively. RESULTS Seven patients were treated with acute (n = 3) or subacute (n = 4) injuries of the common iliac artery (n = 6) or abdominal aorta (n = 1) after lumbar-spine surgery. Vascular injuries included arterial lacerations (n = 3), arteriovenous fistulas (n = 2) and pseudo-aneurysms (n = 2). The mean age of the patients was 51.7 years (30-60 years), 71.4% were women. These lesions were repaired by transluminal placement of stent grafts: Passager (n = 3), Viabahn (n = 1), Wallgraft (n = 1), Zénith (n = 1) and Advanta V12 (n = 1). Exclusion of the injury was achieved in all cases. Mortality was nil. There were no procedure-related complications. During a median follow-up of 8.7 years (range 0.3-13 years), all stent grafts remained patent. CONCLUSIONS Sealing of common iliac artery or abdominal aortic lesions as a complication of lumbar-disc surgery with a stent graft is effective and is suggested as an excellent alternative to open surgery for iatrogenic great-vessel injuries, particularly in critical conditions.

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications.

OBJECTIVES To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy.

Preoperative Assessment of Anatomical Suitability for Thoracic Endovascular Aortic Repair

Abstract Endovascular treatment of descending thoracic aortic pathologies requires a preoperatively determined interventional strategy. Its feasibility depends mainly on anatomic factors: the morphology of the proximal and distal fixation sites, the diameter and disease state of the access vessels. These factors represent important predictors of success and the most important exclusion criteria. Current diagnostic evaluation of aortic aneurysm for endovascular repair relies primarily on CT scan associated with 3D-reconstruction to assess the anatomical suitability for endograft implantation. In patients with an inadequate length of the proximal or distal neck, the left subclavian artery or the coeliac trunk can be overstented to effectively exclude thoracic aortic lesions. Deliberate coverage of aortic side branches should be decided prior to the procedure (guided by a extensive anatomical assessment) or carefully be avoided in order to reduce major morbidity, especially cerebral embolization, spinal cord ischemia and ischemic abdominal complications.

Assessment of abdominal branch vessel patency after bare-metal stenting of the thoracoabdominal aorta in a human ex vivo model of acute type B aortic dissection

OBJECTIVE The purpose of this study was to assess the efficiency of bare-metal stenting of the thoracoabdominal aorta in a human ex vivo model of acute type B aortic dissection and the impact of this approach on the patency of the visceral and renal arteries. METHODS Fifteen human cadaveric aortas were harvested. Type B aortic dissections were surgically initiated 2 cm below the left subclavian artery. Aortas were thereafter connected to a bench top pulsatile flow to induce propagation of the dissection. A 5-mm 30° lens (Richard Wolf, Vernon Hills, Ill) was introduced successively into the false lumen and the true lumen to monitor the propagation of the dissection. Bare-metal stents were deployed into the true lumen from the primary entry tear to the infrarenal aorta. Measurement of systolic pressure was taken within the abdominal branch vessels before and after stenting. A pressure gradient drop of 15 mm Hg or more after bare-metal stenting was considered hemodynamically relevant. RESULTS Dissection was propagated at least to the renal aorta in 11 cases (73%) and to the infrarenal aorta in 3 cases (20%). Of the 60 abdominal branch vessels studied, 22 (36.7%) were supplied by the false lumen. After extensive aortic bare-metal stenting, complete reattachment of the dissection flap was observed in all cases. Regarding visceral and renal artery patency after bare-metal stenting, a significant pressure gradient drop was reported in 54.5% (n = 12) when these arteries were supplied by the false lumen, whereas those originating from the true lumen had a significantly less common pressure gradient drop (7.9% [n = 3]; P < .0001). CONCLUSIONS Bare-metal stenting in this model of acute type B aortic dissection was effective in true lumen reexpansion but induced a high (54.5%) rate of significant pressure drop in the visceral and renal arteries when they were supplied by the false lumen.

Impact of stent-graft development on outcome of endovascular repair of acute traumatic transection of the thoracic aorta.

Purpose To analyze the impact of stent-graft design on the outcome of endovascular repair of acute traumatic thoracic aortic transection. Methods Forty-eight patients (38 men; mean age 37±11 years) underwent endovascular repair for an acute traumatic aortic rupture between April 2001 and March 2011. Up to October 2007, 32 patients (mean age 41±16 years; group 1) were treated with the first generation of commercially available thoracic stent-grafts (10 Talent, 20 Excluder/TAG, 2 Zenith). From November 2007, 16 patients (mean age 42±19 years; group 2) were treated with second-generation thoracic stent-grafts (13 Valiant and 3 C-TAG). The 2 groups were statistically comparable. Follow-up computed tomography was performed at 1 week; at 3 and 6 months; and annually thereafter. Results In the 2 groups, the mortality rate related to aortic repair was nil. All the patients have completed each of their scheduled follow-up evaluations and CT scans. The morbidity rate was significantly reduced (p=0.0003) from 18.7% (first generation) to 6.2% (second generation). Type I endoleak (n=1), inadvertent coverage of the supra-aortic trunks (n=3), and stent-graft collapse (n=2) occurred only with the first-generation stent-grafts. One iliac artery rupture occurred with a second-generation stent-graft. Conclusion Enhanced stent-graft conformability and more accurate delivery systems have significantly decreased the morbidity of endovascular repair of acute traumatic transection of the thoracic aorta. The increasing clinical experience may also have contributed to improved results.

Chest-wall reconstruction in case of infection of the operative site: is there any interest in titanium rib osteosynthesis?

OBJECTIVES To describe the management of thoracic reconstructions in the presence of primary chest-wall infection (PCWI) or secondary deep chest-wall infection (SCWI), focussing on local tolerance of a titanium rib osteosynthesis system. METHODS PCWI included infected chest wall tumours (CWT), infected T3 non-small-cell lung carcinoma (NSCLC) and open flail chest. SCWI was defined by deep infection of previous thoracic-wall reconstructions. Infection was identified by preoperative bacterial analysis of the tumour or surgical site. In PCWI, a one-step procedure combined extensive resection of infected tissues and rigid reconstruction of the defect; skeletal rigidity was achieved using titanium implants. In SCWI, we removed all synthetic material except titanium implants. In both groups, the surgical field was thoroughly cleaned and implants were wrapped or covered by flaps. RESULTS From January 2005 to December 2011, 11 patients (54 ± 10.2 years) with either PCWI (3 CWT, 3 T3 NSCLC, 1 open flail chest) or SCWI (3 CWT, 1 funnel chest) were treated. Infection was polymicrobial in all but 1 case. Bacteria observed in PCWI patients were multidrug resistant. In PCWI, we resected 4.2 ± 0.6 ribs en bloc with the lung (n = 5), the skin and the pectoralis major and then used mesh and 2.1 ± 1.2 titanium implants for reconstruction (n = 6). The mean defect was 1154.4 ± 318 cm(3). Surgical SCWI management removed polytetrafluoroethylene-mesh and preserved the titanium implants. A Vicryl mesh (n = 3) and greater omentum flap (n = 3) were added. One of the 2 postoperative deaths in the PCWI group was related to infection recurrence. No other patient had infection at the 6-month follow-up with leucocyte-labelled scintigraphy. CONCLUSION Titanium rib osteosynthesis is reliable in two complex and life-threatening situations: PCWIs and SCWIs. In combination with a flap, this allows rapid, reliable, rigid reconstruction of infected full-thickness chest-wall defects in a single-step procedure.

Heparin-Induced Thrombocytopenia With Abdominal Aortic Stent-Graft Acute Thrombosis

We report a case of heparin-induced thrombocytopenia in a patient on low molecular weight heparin bridge therapy who developed acute abdominal aortic stent-graft thrombosis 1 week after uncomplicated endovascular abdominal aortic aneurysm repair. The diagnosis was confirmed by a computed tomographic scan of the abdomen. The patient was successfully treated by conversion to open repair. The postoperative course was marked by subacute left limb ischemia related to an in vivo cross-reactivity of danaparoid with the heparin immune complex. To our knowledge, this is the first case report of heparin-induced thrombocytopenia with acute abdominal aortic stent-graft thrombosis.