Philippe Otal

Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study.

An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long‐term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed‐up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P<0.05). Actuarial rates of being free of encephalopathy were 67% in Group 1 and 51% in Group 2 (P<0.05). Probability of survival was 58% and 45% at 2 years, respectively, in Groups 1 and 2 (NS). The mean Child–Pugh score improved only in Group 1 (from 8.1±1.6 to 7±2.2 at 2 years –P<0.05). We also compared the Doppler‐US parameters between patent and dysfunctioning shunts. In patent shunts, the mean velocity within the portal vein was significantly higher but the performance of Doppler‐US was not accurate enough to predict shunt dysfunction. In conclusion, the improvement in TIPS patency by using covered prostheses is maintained over time with a decreased risk of encephalopathy, while the risk of death was not increased.

Long-term results of endovascular stent placement in the superior caval venous system.

AbstractPurpose: To present the long-term results in superior caval stenting for symptomatic obstruction. Methods: Forty-nine stents were placed in 30 patients: 16 (53%) with malignant lesions, five (17%) with benign lesions and nine (30%) hemodialysis patients. Self-expandable stents were deployed on a first-line basis. Patients were followed clinically as well as by various imaging techniques and survival analysis was performed. Results: Stent deployment was possible in all cases. Reocclusion was seen in 13 patients, of whom eight belonged to the hemodialysis group. Primary and secondary patency rates for malignant, benign and hemodialysis patients were respectively 74%, 50% and 22%, and 74%, 75% and 56% at 1 year. We had 7% complications and one death from iatrogenic superior vena cava injury. Conclusion: Primary stenting of superior caval obstruction is a first-choice treatment method achieving good mid-term patency. Patients with hemodialysis shunts must be closely monitored for early reintervention.

Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study.

Purpose: To evaluate endovascular procedures in the management of acute ischemic complications and rupture of the false lumen in aortic dissections. Methods: Data on patients with aortic dissection and noncardiac acute complications (peripheral ischemia or thoracic aortic rupture) treated with endovascular techniques were collected from 10 institutions and retrospectively analyzed. From March 1997 to January 2000, 58 patients (50 men; mean age 59.6±12.8 years) were treated for 19 (33%) type A and 39 (67%) type B dissections. Twelve (21%) patients had thoracic aortic rupture; 46 (79%) patients had one or more peripheral ischemic complications that included bowel pain (19, 41%), anuria associated with acute renal insufficiency (18, 39%), lower limb ischemia (15, 33%), and/or uncontrolled hypertension with renal ischemia (14, 30%). Results: In the thoracic rupture cohort, all 12 patients were treated successfully with stent-grafts; one distal endoleak required a secondary procedure. There were 2 (12%) periprocedural deaths; one patient developed transient paraplegia after a secondary surgical procedure. In the 46 patients treated with stent implantation, fenestration, or both for peripheral ischemic symptoms, 44 (96%) had patency restored to the malperfused vessel. Eight (17%) patients died within 30 days. Over a mean follow-up of 8.2±8.9 months, the false lumen had thrombosed in 7 (70%) of the stent-graft patients. In the 38 surviving ischemic patients, the diameters of the true and false lumens and maximum transverse aorta all increased; only 4 (11%) had total thrombosis of the false lumen. Conclusions: Endovascular treatment of noncardiac acute complications associated with aortic dissection has favorable early and midterm outcomes.

Aortoduodenal fistula after endovascular stent-graft of an abdominal aortic aneurysm.

Despite satisfying short- and middle-term effectiveness and feasibility, endovascular stent-grafting for abdominal aortic aneurysm is still under evaluation. We report a case of an aortoduodenal fistula after the use of this technique. Enlargement of the upper aneurysmal neck was followed by caudal migration of the major portion of the stent-graft, which resulted in kinking of the device in the aneurysmal sac. Ulcerations were found on adjacent portions of both the aneurysmal sac and the adjacent duodenum. Only the textile portion of the prosthetic contralateral limb separated the aortic lumen from the corresponding duodenal lumen. Early detection of complications after stent-grafting is essential to allow successful treatment, either surgical or endoluminal.

New identification possibilities with postmortem multislice computed tomography.

Historically, radiographical identification has been done by comparing conventional antemortem and postmortem X-ray images. The advent of new technologies such as multislice computed tomography (MSCT) is making traditional antemortem examination increasingly less frequent. The authors present the results of MSCT study of 35 corpses, which demonstrated features potentially useful for identification purposes in ten cases. These features, which relate to abnormalities of postcranial bone as well as of the internal organs, are presented. Attempts were made to find any antemortem X-rays or MSCTs on the cases described to compare the two antemortem and postmortem images. Although antemortem imaging was recovered for only two cases (one case with a skeletal abnormality and one case with a visceral abnormality), it permitted for both cases the comparison of antemortem and postmortem MSCTs.

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.

Long-term clinical and imaging follow-up of nonoperated branch duct form of intraductal papillary mucinous neoplasms of the pancreas.

Objectives The aim of our study was to perform a 10-year imaging and clinical prospective follow-up of patients with nonoperated branch duct (BD) intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Methods Forty-nine patients with BD-IPMN who displayed a low probability for malignancy were followed up including a clinical component and a series of imaging techniques such as computed tomography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. Results After a mean follow-up period of 77 months, 77.5% of patients remained free of symptoms. An increase in the size and number of BD cysts without mural nodules and with no significant increase of main duct size occurred in 18 patients at an average interval of 47 months. Five patients were operated on owing to recurrent pancreatitis and/or an increase in the size of either cysts or the main duct (mean time delay after diagnosis: 20 months). Pathologically, they were diagnosed as benign adenoma (n = 1) or borderline (n = 4). Conclusions Our long-term clinical and imaging follow-up indicated that none of the patients with BD-IPMNs developed malignancy. Therefore, BD-IPMNs with no signs of malignancy should be managed conservatively. We propose that following a 2-year patient follow-up, biannual imaging follow-ups could be sufficient. Abbreviations IPMN - intraductal papillary mucinous neoplasm of the pancreas, BD - branch duct, MPD - main pancreatic duct, EUS - endoscopic ultrasound, CT scan - computed tomographic examination, MRCP - magnetic resonance cholangiopancreatography

High Occlusion Rate in Experimental Transjugular Intrahepatic Portosystemic Shunt Created with a Dacron-covered Nitinol Stent

PURPOSE To assess whether the use of a prosthesis covered by a Dacron sheath might prevent pseudointimal hyperplasia in a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS A TIPS procedure was performed in nine pigs, after creation of a portal vein microembolization model of portal hypertension, by using a Dacron-covered nitinol stent. The first centimeter on the lower extremity of this specially made prototype was uncovered, to avoid portal vein thrombosis. Three weeks later, the seven surviving animals underwent transjugular hemodynamic and angiographic follow-up and were then killed for gross and histologic evaluation. RESULTS Shunt insertion was possible in all pigs; two died of complications of the procedure. After 3 weeks only two shunts were patent, although a 50%-60% narrowing of the initial portion of the shunt was present; the remaining shunts were occluded. Histologic examination showed pseudointimal hyperplasia associated, in the cases of occlusion, with a luminal thrombosis. CONCLUSION This Dacron-covered stent did not prevent pseudointima formation over the stent and resulted in a high early occlusion rate, probably related to a pronounced tissue fibrotic response likely due to Dacron-induced inflammation.

Cardiac MRI in pulmonary artery hypertension: correlations between morphological and functional parameters and invasive measurements

ObjectiveTo compare cardiac MRI with right heart catheterisation in patients with pulmonary hypertension (PH) and to evaluate its ability to assess PH severity.Materials and methodsForty patients were included. MRI included cine and phase-contrast sequences, study of ventricular function, cardiac cavity areas and ratios, position of the interventricular septum (IVS) in systole and diastole, and flow measurements. We defined four groups according to the severity of PH and three groups according to IVS position: A, normal position; B, abnormal in diastole; C, abnormal in diastole and systole.ResultsIVS position was correlated with pulmonary artery pressures and PVR (pulmonary vascular resistance). Median pulmonary artery pressures and resistance were significantly higher in patients with an abnormal septal position compared with those with a normal position. Correlations were good between the right ventricular ejection fraction and PVR, right ventricular end-systolic volume and PAP, percentage of right ventricular area change and PVR, and diastolic and systolic ventricular area ratio and PVR. These parameters were significantly associated with PH severity.ConclusionCardiac MRI can help to assess the severity of PH.

First-in-man Phase 1 Clinical Trial of Gene Therapy for Advanced Pancreatic Cancer: Safety, Biodistribution, and Preliminary Clinical Findings

This phase 1 trial was aimed to determine the safety, pharmacokinetics, and preliminary clinical activity of CYL-02, a nonviral gene therapy product that sensitizes pancreatic cancer cells to chemotherapy. CYL-02 was administrated using endoscopic ultrasound in 22 patients with pancreatic cancer that concomitantly received chemotherapy (gemcitabine). The maximum-tolerated dose (MTD) exceeded the maximal feasible dose of CYL-02 and was not identified. Treatment-related toxicities were mild, without serious adverse events. Pharmacokinetic analysis revealed a dose-dependent increase in CYL-02 DNA exposure in blood and tumors, while therapeutic RNAs were detected in tumors. No objective response was observed, but nine patients showed stable disease up to 6 months following treatment and two of these patients experienced long-term survival. Panels of plasmatic microRNAs and proteins were identified as predictive of gene therapy efficacy. We demonstrate that CYL-02 nonviral gene therapy has a favorable safety profile and is well tolerated in patients. We characterize CYL-02 biodistribution and demonstrate therapeutic gene expression in tumors. Treated patients experienced stability of disease and predictive biomarkers of response to treatment were identified. These promising results warrant further evaluation in phase 2 clinical trial.