Quentin Pellenc

Spontaneous and Isolated Dissection of the Superior Mesenteric Artery: Proposal of a Management Algorithm

BACKGROUND Spontaneous and isolated dissection of the superior mesenteric artery (SIDSMA) is a rare pathology, and the treatment of symptomatic forms is not consensual. The objective of this study was to analyze the management of a series of patients presenting a symptomatic SIDSMA within a structure taking care of intestinal vascular emergencies. METHODS From January 2010 to January 2014, the patients presenting a symptomatic SIDSMA were included retrospectively. The clinical and radiologic data as well as the treatment and the follow-up were analyzed. RESULTS Nine patients were included. Among them, 2 patients presenting with acute mesenteric ischemia were revascularized surgically in emergency, and 1 patient presenting a rupture of a superior mesenteric artery aneurysm had an arteriography followed by medical care. The 6 other patients received medical treatment. Among these, 2 patients developed mesenteric angina requiring surgical revascularization during the follow-up. CONCLUSIONS The revascularization of spontaneous and isolated dissections of the superior mesenteric artery is indicated in the cases complicated with acute mesenteric ischemia, aneurysmal rupture, or in the event of appearance of mesenteric angina or aneurysmal evolution. It should also be discussed in the event of failure of the medical treatment.

Surgical revascularization of the celiac artery for persistent intestinal ischemia in short bowel syndrome

BACKGROUND AND OBJECTIVES Without prompt superior mesenteric artery (SMA) revascularization, acute mesenteric ischemia (AMI) frequently leads to death or short bowel syndrome (SBS). In SBS patients, persistent or chronic intestinal ischemia (PII) of the remnant bowel can lead to recurrences of AMI. Since SMA revascularization is sometimes unfeasible, celiac artery (CA) revascularization may improve blood supply to the remnant bowel. The aim of this study was to describe and to assess our experience of the CA revascularization in case of SMA occlusion unsuitable for revascularization in the setting of PII in SBS patients. METHODS All consecutive patients with i) SBS consecutive to AMI, ii) persistent intestinal ischemia (PII), iii) irreversible SMA occlusion, i.e unsuitable for radiological or surgical revascularization and iv) occlusion or severe stenosis of the CA were included. RESULTS Thirteen patients (7 males/6 females, mean age = 47.2 ± 12.1 years) were included. The mean length of remnant small bowel was 47 ± 39 cm and 77% of patients had a stoma. The types of revascularization included anterograde aorto-hepatic bypass n = 11 (84%), ilio-hepatic bypass n = 1 (8%) and endarterectomy n = 1 (8%). Major adverse events were observed in 5 cases: bypass graft infection (n = 2), hemorrhagic pericarditis (n = 2), hemorrhagic shock (n = 2) and aortic false aneurysm (n = 1). After a mean follow-up of 27.0 ± 25.2 months, symptoms of PII relieved in 12 cases (92%) allowing for digestive surgical rehabilitation with continuity restoration in 7 patients (54%). PN was weaned for 2 patients. One-year and 3-year survival rates were 73.8% and 73.8% respectively. No recurrence of AMI or further need for bowel resection was noticed. CONCLUSION For patients with SBS suffering from PII with CA occlusion or stenosis without possibility of SMA revascularization, the surgical revascularization of the CA allowed digestive rehabilitation with acceptable morbidity and mortality rates.

Impact of connecting continuous renal replacement therapy to the extracorporeal membrane oxygenation circuit

PURPOSE Continuous veno-venous haemofiltration (CVVH) directly connected to extracorporeal membrane oxygenation (ECMO) may ensure better blood flow and allow prolonged circuit life. The objective of this study was to assess circuit life of CVVH connected to ECMO and to a dialysis catheter. MATERIALS AND METHODS In this prospective observational study, patients receiving CVVH via ECMO were compared to time-matched patients receiving CVVH via a conventional dialysis catheter. CVVH circuit life and the safety and efficacy of the two CVVH procedures were analysed. Time to event was estimated using Kaplan-Meier analysis and compared using the log-rank test. RESULTS Seventeen patients were included in each group, with 43 sessions in the ECMO group and 56 sessions in the DC group. Median CVVH circuit life was 48 [21-72] vs 20 [6-39] hours in the ECMO and DC groups, respectively (relative risk of termination of the session: 2.4, 95% CI [1.41-3.9], log rank P=0.0009). CVVH blood flow was higher in the ECMO group. Despite higher anticoagulant doses in the catheter group, the circuit clotting rate was lower in the ECMO group. Effluent volume was slightly higher in the ECMO group (39ml/kg/h [33-47] vs 34ml/kg/h [32-39]), but with no biological impact. CVVH via ECMO was well tolerated with no major drawbacks. CONCLUSIONS In patients requiring ECMO, CVVH connected to ECMO instead of DC could be proposed as an alternative approach, allowing more stable blood flow and prolonged CVVH circuit life.

Endovascular Repair as a Bridge to Open Repair of a Ruptured Descending Thoracic Aspergillus Aortitis

Invasive aspergillosis rarely involves the thoracic aorta and is associated with a poor prognosis. A 56-year-old heart transplant recipient presented with invasive aspergillosis, primary Aspergillus aortitis, and a ruptured thoracic aorta pseudoaneurysm. Open surgical repair was not possible because of severe sepsis. Therefore, a sequential surgical strategy was planned, including emergency thoracic endovascular aortic repair, followed by antifungal treatment and definitive open repair with explantation of the endograft and placement of a cryopreserved arterial allograft under extracorporeal membrane oxygenator support. The infection did not reoccur during follow-up, and the patient remained alive and well 13 months after the operation.

A Rare Case of Acquired Thoracic Aortic Coarctation Treated Medically

A 51-year-old woman originating from Africa presented to our institution with newly intermittent claudication, headache, and dyspnea associated with a 4-month history of weight loss and tiredness. Clinical examination showed hypertension and a marked pressure gradient between the upper and lower limbs (140/80 versus 80/50 mm Hg). There was no sign of digestive claudication or renal insufficiency. Computed tomography angiography demonstrated an 80% segmental stenosis of the descending thoracic aorta associated with aortic wall thickening >95 mm in length (Figure A), together with pulmonary infiltrates and cervicomediastinal lymphadenopathies. Combined positron emission tomography-computed tomography showed a hypermetabolism of the aortic thickening (Figure B) and cervicomediastinal lymphadenopathies. The surgical biopsy of a cervical lymphadenopathy showed the presence of granuloma consistent with a tuberculosis infection. Figure. A , PET scan showing hypermetabolism of aortic thickening. B …

Sternum-Sparing Hybrid Repair of a Symptomatic Innominate Artery Aneurysm in a Frail Patient with Bovine Aortic Arch

We present the case of a 65-year-old man with a bovine aortic arch variation, who presented a symptomatic aneurysm of the innominate artery. Standard open repair was contraindicated and an hybrid approach was performed, regarding general status (Organisation Mondiale de la Santé (OMS) Performance Status score 3 and American Society of Anesthesiologists Physical Status classification system score 3). Right common carotid artery and right subclavian artery were revascularized surgically from the left common carotid artery. Proximal aneurysm exclusion was performed with a vascular plug. Follow-up computed tomography angiography confirmed the exclusion of the innominate artery aneurysm. Vascular plugs can be used safely through a sternum-sparing hybrid approach to treat symptomatic innominate artery aneurysms in frail patients.