Mathieu Rodière

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.

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.

Endovascular Stent-graft Management of Aortic Intramural Hematomas

PURPOSE To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH). MATERIALS AND METHODS From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months). RESULTS The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%. CONCLUSIONS Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.

CT-guided biopsy of nonresolving focal air space consolidation.

Objectives To evaluate the diagnostic accuracy of percutaneous computed tomography (CT)-guided coaxial core needle biopsy in patients with nonresolving pulmonary focal air space consolidations and negative fiberoptic bronchoscopy results. Methods From 1997 to 2005, 23 patients (11 woman, 12 men; age range, 45 to 81 y; mean age, 66 y) presenting with nonresolving pneumonia persisting more than 8 weeks (mean, 22 wk; range, 8 to 40 wk) with negative fiberscopic results, underwent coaxial percutaneous biopsy using an automated core needle (18-gauge) under CT guidance. Histologic and bacteriologic evaluations were obtained. The final diagnosis was confirmed by surgical pathology, culture results, or clinical follow-up. Results Specimens adequate for histopathologic evaluations were obtained in 20 (87%) cases. Final diagnoses were lung cancer (n=15) and benign diseases (infectious pneumonia, 3; lipoid pneumonia, 1; Erdheim Chester disease: 1; and nonspecific chronic pneumonia, 3). Diagnostic yield of core needle biopsy was 78% (18 of 23). The sensitivity and specificity for malignancy were 87% and 100%, respectively. Immediate pneumothorax was present in 11 patients of cases, but only 2 patients required pleural drainage. Discussion CT-guided lung biopsy using a core needle biopsy provides a high degree of diagnostic accuracy and allows specific characterization of nonresolving pulmonary focal air space consolidation.

First magnetic resonance coronary artery imaging of bioresorbable vascular scaffold in-patient

A 39-year-old man, active smoker with a history of hypercholesterolaemia, was referred for invasive coronary angiography for ST-segment elevation acute coronary syndrome. Coronary angiogram showed complete occlusion of the left anterior descending artery (LAD). Thromboaspiration was successfully performed with TIMI 3 flow at the end of the procedure. Therefore, no stenting procedure was immediately performed, and a control coronary angiography was performed …

Aortic Expansion Assessed by Imaging Follow-up after Acute Aortic Syndrome: Effect of Sleep Apnea

After surgical treatment of type A acute aortic syndrome (AAS), some patients exhibit aneurysmal aorta expansion (AAE) either upstream or downstream of the prosthetic tube. The mechanisms promoting AAE are not fully understood. It is recognized that intermediary mechanisms involved in obstructive sleep apnea (OSA) pathophysiology affect thoracic aorta expansion. The thoracic aorta of a patient with OSA is continuously strained by repetitive surges in blood pressure, transmural stretching resulting from huge variations in intrathoracic pressure, and intermittent hypoxiarelated vascular remodeling (1–4). To date, there are no data available on the effect of OSA on AAE after surgery for type A AAS. We retrospectively analyzed 62 patients initially surgically treated for type A AAS who were prospectively followed up by computed tomography or magnetic resonance imaging at 3 and 6 months postsurgery, and annually thereafter. At the 3-year median-term follow-up visit, the maximum rate of aortic diameter expansion (V : maxAo) was calculated to detect patients with stable aortic aneurysm or AAE. Patients with surgical or radiologic intervention on downstream aorta and Marfan syndrome were excluded. Independent observers, blinded to the clinical data, analyzed aortic images. V : maxAo was calculated as follows: (D22D1)/T, with D1 being the initial diameter and D2 the final diameter (maximum increase at the same anatomical level) between the first and the most recent postoperative measurements. The normal aortic expansion rate is 1 to 2 mm/yr (5). We classified patients into two groups: group 1, with no abnormal increase in aortic diameter (V : maxAo, 2 mm/yr), and group 2, for whom V : maxAo> 2 mm/yr. At the 3-year visit, all patients underwent 24-hour blood pressure monitoring (ABPM), biological assays, carotid-to-femoral pulse wave velocity measurement, and full polysomnography and answered the Epworth sleepiness scale questionnaire. SA was defined by an apnea–hypopnea index above 5 per hour of sleep and was considered central when more than 50% of apneas and hypopneas were central. All patients gave informed consent to participate in this institutional review board–approved study. The patients had undergone the following operations: replacement of the ascending aorta with an interposition tube graft (35 patients), of the ascending aorta and the aortic arch (5 patients), and of the ascending aorta and aortic valve by a composite graft (Bentall technique, 21 patients), and one patient had an interposition graft with separate aortic valve replacement. Table 1 summarizes the general characteristics of the study population that were similar for the two groups with the exception of the polysomnographic parameters. The prevalence of OSA was 72% throughout the population, and 18% of the patients presented with central SA. The prevalence of central SA and OSA was similar in patients with or without AAE (15% vs. 19% and 70% vs. 74% [P = 0.6], respectively). However, hypoxia during sleep was worse in patients with AAE, who had a significantly lower mean nocturnal SpO2 than those without AAE (92.56 1.9 vs. 93.66 1.7; P, 0.04) (Figure 1). The Epworth sleepiness score was 5.66 4.9 in patients without AAE and 7.16 5.6 in patients with AAE (P = 0.39). The prevalence of office hypertension (BP values. 135/80 mm Hg) was 77%, with 40% of patients exhibiting resistant hypertension. Using ABPM, 44% of patients had 24-hour hypertension, 42% had daytime hypertension, and 57% had nighttime hypertension. The prevalence of office and 24-hour ABPM hypertension was similar in both groups. The baseline aortic dimensions did not influence secondary dilatation (r = 0.11; P = 0.6). In patients with increasing aortic diameter, V : maxAo was significantly correlated with 24-hour systolic BP (r = 0.374; P = 0.013) and mean nocturnal SpO2 (r =20.381; P = 0.02). On multivariate analysis, the V : maxAo was independently (adjusted for age, body mass index, creatinine level) and positively correlated with mean nocturnal SpO2 (b =20.479; P = 0.01). In multivariate logistic regression analysis, only mean nocturnal SpO2 was independently (adjusted for the same parameters) and significantly predictive of absence of AAE (odds ratio = 0.549; 95% confidence interval, 0.35–0.862; P = 0.009). Figure E1 in the online supplement shows images in a patient who presented with severe OSA and AAE. Our original data set demonstrates the high prevalence of SA in patients with surgical procedures for type A AAS. Our study demonstrates a positive association between AAE and SA severity, as assessed by the degree of intermittent hypoxia. To date, only one study has reported the prevalence of OSA in patients who presented AAS. Sampol and colleagues compared 19 patients with a history of operated type A or medically treated type B aortic dissection with 19 hypertensive patients without aortic disease (6). They found that patients with aortic disease more frequently suffered from severe OSA than patients with hypertension. However, this case–control study did not permit us to clarify whether SA is a risk factor for AAE and was not designed to evaluate deterioration in patients with aortic disease. Here we used a retrospective study that included, by design, some limitations. We show the deleterious role of SA-linked intermittent hypoxia on the evolution of aortic diameters. We have previously described the deleterious role of hypoxia that increases carotid (7) and aortic (8) root diameters in patients with OSA. Nocturnal hypoxia increases sympathetic activity. Supported by the French Society of Hypertension and the Clinical Research Department at Grenoble University Hospital.

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

IntroductionMesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.Materials and MethodsThe medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, and the complications of embolization.ResultsSix endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.ConclusionIn mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia.

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

PURPOSE We aimed to compare clinical outcomes and early adverse events of operative management (OM), nonoperative management (NOM), and NOM with splenic artery embolization (SAE) in blunt splenic injury (BSI) and identify the prognostic factors. METHODS Medical records of 136 consecutive patients with BSI admitted to a trauma center from 2005 to 2010 were retrospectively reviewed. Patients were separated into three groups: OM, NOM, and SAE. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors. RESULTS The total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management. CONCLUSION Patients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury.

Potentially simple score of late gadolinium enhancement cardiac MR in acute myocarditis outcome.

To determine the value of cardiac MRI for the monitoring and the prognosis of patients with acute myocarditis. Cardiac MRI plays an increasingly important role in the diagnosis of acute myocarditis. However, it is less established as a prognostic tool, which requires specific postprocessing of images.

Polytraumatism and solid organ bleeding syndrome: The role of imaging

In multiple injuries, features of bleeding from solid organs mostly involve the liver, spleen and kidneys and may be treated by embolization. The indications and techniques for embolization vary between organs and depend on the pathophysiology of the injuries, type of vascularization (anastomotic or terminal) and type of embolization (curative or preventative). Interventional radiologists should have a full understanding of these indications and techniques and management algorithms should be produced within each facility in order to define the respective place of the different treatment options.