Pascal Branchereau

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.

Proximal Fixation of Thoracic Stent-Grafts as a Function of Oversizing and Increasing Aortic Arch Angulation in Human Cadaveric Aortas

Purpose: To assess the fixation of 4 commercially available thoracic stent-grafts as a function of oversizing and increasing aortic arch angulation. Methods: A benchtop pulsatile flow model was devised to test stent-graft anchorage in a 2-cm-long proximal landing zone at varying landing zone angles (70° to 140°) and stent-graft oversizing (5% to 37%). The experiments were performed using 15 human thoracic cadaveric aortas and 4 stent-grafts with different proximal anchoring mechanisms: TAG, Zenith TX, Valiant, and Relay. The lack of device-wall apposition was measured as a function of landing zone angulation and oversizing during static and dynamic (60 pulses/min, 300/150 mmHg) tests; stent-graft collapse was also investigated. Results: The Valiant stent-graft remained apposed to the aortic wall at each increment of neck angulation and degree of oversizing. Lack of apposition of the proximal anchorage segment (Relay: bare spring; TAG: scalloped flares) was observed with the Relay above 80° landing zone angulation (1–7 mm) and with the TAG above 90° angulation (1–6 mm). The lack of device-wall apposition was greater with Relay than TAG (p=0.009), but the “body” of these devices always remained well apposed. Lack of “body” apposition (1.0–7.5 mm) was first observed with the Zenith stent-graft above 70° angulation (p<0.001). No stent-graft collapse was seen. An increase in stent-graft oversizing significantly (p<0.01) increased the lack of device-wall apposition for the TAG, Zenith, and Relay devices. Conclusion: In the face of severe aortic arch angulation, stent-grafts with hooks do not improve fixation. Major factors in stent-graft design that contribute to secure proximal anchorage seem to be radial force and the presence of a proximal open stent segment.

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.

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.

Infrainguinal cutting balloon angioplasty in de novo arterial lesions

BACKGROUND This prospective, non-randomized study evaluated the short- and mid-term feasibility, safety, primary patency, and limb salvage of cutting balloon percutaneous transluminal angioplasty (CB-PTA) for the treatment of peripheral arterial occlusive disease (PAOD). METHODS AND RESULTS All data were collected for 128 consecutive patients who underwent CB-PTA to improve infrainguinal arterial circulation between January 2003 and July 2007. One-hundred thirty-five limbs with PAOD (claudication, n = 19; critical limb ischemia [CLI], n = 116) were treated. Patency was evaluated by clinical examination and duplex ultrasonography. A total of 203 lesions (183 stenoses, 20 occlusions) were treated in 66 femoropopliteal and 69 infrapopliteal arterial segments. The TransAtlantic Inter-Societal Consensus (TASC) classification of the primary lesions was A in 41.5%, B in 45.2%, C in 8.2%, and D 5.1%. Mean follow-up was 16.1 +/- 9.7 months. The overall technical success rate was 96.3% and the complication rate was 8.9%. There were two (1.5%) perioperative deaths. The primary patency rate was 82.1% at 12- and 24-months in patients with claudication (femoropopliteal lesions). The 1- and 2-year results for femoropopliteal and infrapopliteal lesions in patients with CLI were: primary patency 64.4% and 51.9 %, respectively; limb salvage 84.2% and 76.9%; survival 92.6% and 88.5%. More distal lesions and TASC classification were significant independent risk factors for outcome (P < .05). Treatment of multiple segment lesions was an independent predictor of a favorable outcome (P = .04). CONCLUSION CB-PTA is safe and feasible for the treatment of infrainguinal arterial occlusive disease, with relatively low mid-term restenosis rates compared to other endovascular treatments. However, these data cannot be extrapolated to potential outcomes for lesions >10 cm in length. Further follow-up will be necessary to evaluate the long-term results of CB-PTA.

Minimum 10-year follow-up of endovascular repair for acute traumatic transection of the thoracic aorta

OBJECTIVE Thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the descending thoracic aorta seems, in the short term, to be associated with better outcomes than open repair, but long-term data are lacking. METHODS A review was conducted of a prospectively maintained database of patients who underwent TEVAR for traumatic rupture of the descending thoracic aorta in our unit, with a minimum 10-year follow-up. Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter. Particular attention was focused on device-related issues. RESULTS Among the 53 patients, 17 had a minimum 10-year follow-up: mean age was 45.8 ± 17 years (range: 18-78 years); 4 were women. Mean follow-up was 11.6 years (range: 10.1-13.1 years). Technical success was achieved in 100% of cases. The distribution of the proximal landing zone was zone 2 in 4 cases, zone 3 in 13 cases. A case of inadvertent coverage of supra-aortic trunks occurred intraoperatively. An early proximal type I endoleak was successfully treated by proximal implantation of an additional second stent-graft. No perioperative death was observed, and none of the patients suffered transient or permanent paraplegia, or cerebral complication. After a minimum 10-year follow-up, all patients were still alive. Follow-up computed tomography scans did not reveal any stent-graft migration or collapse, or secondary endoleaks. However, we observed that the proximal and distal aortic neck dilated to some extent, as is the natural history of the thoracic aorta. This dilation was more marked in patients aged <30 years. CONCLUSIONS Our minimum 10-year follow-up study of endovascular repair for acute traumatic transection of the thoracic aorta demonstrated that the reduction in the operative mortality rate of TEVAR, compared with open repair, lasts over time, without any device-related issues. Longer-term follow-up is necessary to determine whether the thoracic aorta expansion continues and becomes clinically significant.

Hemi-aortic arch debranching for hybrid aortic arch repair by sequential transposition of the left common carotid and subclavian arteries.

OBJECTIVE The aim of this study was to assess the short-term and midterm results after hemi-aortic arch debranching for hybrid aortic arch repair by sequential transposition of the left common carotid artery and of the left subclavian artery. METHODS From November 1998 to August 2011, 11 patients underwent a hybrid technique with supra-aortic debranching (by sequential transposition of the left common carotid artery and of the left subclavian) and simultaneous endovascular stent grafting for zone 1 lesions. There were 8 men and 3 women (mean age, 62.9 ± 20.9 years; range, 15-89 years). Aortic arch lesions treated included 4 complicated aortic dissections, 3 degenerative aneurysms, 2 postcoarctectomy aortic pseudoaneurysms, 1 mycotic aneurysm, and 1 traumatic transection of the arch. Four (36%) operations were performed in an emergency setting. RESULTS Endovascular exclusion success was achieved in 90.9% of the patients (type I endoleak: 1/11). One iliac artery rupture occurred intraoperatively. The 30-day mortality rate was 0%. Overall actuarial survival was 82% and 71.8% at 1 and 2 years. Mean follow-up is 31 ± 25 months (range, 3-72 months). No instance of permanent cerebral or spinal cord ischemia was observed. Two type II endoleaks are currently observed. There was no device migration. CONCLUSIONS Hybrid aortic arch repair by sequential transposition of the left common carotid artery and of the left subclavian artery for zone 1 lesions provides an attractive alternative for treating hemi-aortic arch lesions in high-risk patients with minimal atherosclerotic disease in the aorta and great vessels with acceptable primary results and encouraging midterm efficacy to prevent rupture. This hybrid strategy avoiding prosthetic bypass offers several advantages over conventional repair, including the potential to treat patients who are not candidates for open repair and single-stage treatment of some pathologic conditions previously requiring 2-stage repair.