V. Chabbert

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.

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.

Rôle de l'embolisation dans les angiomyolipomes du rein

Resume Objectifs Presenter l’experience de deux centres dans l’embolisation des angiomyolipomes (AML) du rein afin de preciser la place de cette technique dans le traitement en urgence d’une hemorragie et dans le traitement preventif ou prechirurgical. Materiel et Methodes Sur une periode de 10 ans, 35 AML chez 34 patients ont ete traites par embolisation. Ce geste a ete realise en urgence, a visee hemostatique, dans 16 cas et de facon programmee, a visee preventive, dans 19 cas : six de ces patients etaient completement asymptomatiques et 13 avaient des antecedents lointains de douleurs ou d’hematome. L’embolisation a ete realise par catheterisme selectif (necessitant un microcatheter coaxial dans 19 cas) a l’aide de particules non resorbables, de spires metalliques ou d’alcool. Resultats L’embolisation d’hemostase a ete efficace en un temps dans 80 % des cas. Une nouvelle embolisation a ete necessaire dans 2 cas et une chirurgie dans 8 cas. Une chirurgie differee et programmee a ete effectuee dans 6 de ces cas. Les embolisations preventives ont necessite une seance dans 17 cas et 2 seances dans les 2 autres. La reduction de taille tumorale etait de 28 % apres un suivi moyen de 18 mois. Quatre patients ont eu une chirurgie conservatrice programmee par la suite. Conclusion L’embolisation d’hemostase est la methode de choix pour la prise en charge en urgence des AML hemorragiques. L’embolisation preventive est une alternative a la chirurgie dans le traitement des AML symptomatiques ou non, dont la place reste a definir.

Diagnostic management of pulmonary embolism using clinical assessment, plasma D-dimer assay, complete lower limb venous ultrasound and helical computed tomography of pulmonary arteries. A multicentre clinical outcome study.

The objective of the study was to assess the clinical validity of a non-invasive diagnostic strategy for acute pulmonary embolism using clinical assessment combined with both ELISA D-dimer and complete lower limb ultrasound (US) examination of proximal and distal veins, before single-detector helical computed tomography (CT) of pulmonary arteries. We expected the strategy to have a high diagnostic exclusion power and to safely decrease the number of CT scans. This prospective, multicenter outcome study included 274 consecutive outpatients. All underwent a priori clinical probability, D-dimer and bilateral complete lower limb US assessments. Only patients with a high clinical probability and both tests negative, or positive D-dimer and negative US assessments, underwent CT. This was deemed necessary in 114 patients (42%). At baseline, venous thromboembolism (VTE) was detected in 110 patients (40%), either by US showing proximal (n=65) or distal (n=36) thrombosis, or by CT (n=9). Anticoagulant was withheld in the remaining patients with negative results in both D-dimer and US but a non-high clinical probability (n=59), or in both US and CT (n=90), or with negative US (n=6) and inadequate CT (n=9). All patients underwent a three-month clinical follow-up. VTE occurred in one patient with inadequate CT, yielding an incidence of 0.6% [95% confidence interval: 0.1-3.4]. No patient died from VTE or had major bleeding. Using clinical probability, ELISA D-dimer and complete US before helical CT is a safe strategy resulting in a substantial reduction in CT scans.

Serum bilirubin and platelet count: a simple predictive model for survival in patients with refractory ascites treated by TIPS.

BACKGROUND & AIMS Refractory ascites in patients with cirrhosis is associated with poor survival. TIPS is more effective than paracentesis for the prevention of recurrence of ascites but increases the risk of encephalopathy while survival remains unchanged. A more accurate selection of the patients might improve these results. The aim of the present study was to identify parameters of prognostic value for survival in patients with refractory ascites treated with TIPS. METHODS One hundred and five consecutive French patients with cirrhosis and refractory ascites treated with TIPS were used to assess parameters associated with 1-year survival. The model was then tested in two different cohorts: a local and prospective one including 40 patients from Toulouse, France, and an external one including 48 patients from Barcelona, Spain. RESULTS The actuarial rate of survival in the first 105 patients was 60% at 1 year. Using multivariate analysis, only lower bilirubin levels and higher platelet counts were independently associated with survival. The actuarial 1-year survival rate in patients with both a platelet count above 75×10(9)/L and a bilirubin level lower than 50 μmol/L [3mg/dl] was 73.1% as compared to 31.2%, in patients with a platelet count below 75×10(9)/L or a bilirubin level higher than 50 μmol/L. These results were confirmed in the two different validation cohorts. CONCLUSIONS The combination of a bilirubin level below 50 μmol/L and a platelet count above 75×10(9)/L is predictive of survival in patients with refractory ascites treated with TIPS. This simple score could be used at bedside to help choose the best therapeutic options.

Stent-graft treatment of penetrating thoracic aortic ulcers.

Purpose: To evaluate the efficacy of stent-graft placement for the treatment of penetrating thoracic aortic ulcers. Methods: Ten patients (7 men; mean age 73.8 years, range 69–79) were treated for penetrating thoracic aortic ulcers using Talent or Excluder stent-grafts. Preoperative examinations included computed tomographic angiography (CTA), transesophageal echography, and digital subtraction angiography (DSA). Follow-up included predischarge multimodal imaging and periodic CTA scans after discharge. Endoleaks, aortic diameter changes, and clinical complications were tracked. Results: Technical success was achieved in 100%, but 1 major neurological complication led to death 3 months after the procedure. Radiological follow-up detected 4 early endoleaks (3 type I and a type II), all of which spontaneously regressed, and 1 secondary type II endoleak. The mean aortic diameter decreased by 22% over a mean 9-month follow-up. Conclusions: Aortic ulcers are potentially lethal lesions. Considering its low morbidity and mortality, endovascular repair could widen the treatment options for these lesions.

Midterm Outcomes of Thoracic Aortic Stent-Grafts: Complications and Imaging Techniques

Purpose: To evaluate the midterm outcomes of thoracic aortic stent-grafting and the performance of computed tomographic angiography (CTA), radiography, and magnetic resonance angiography (MRA) in endograft surveillance. Methods: Forty-seven patients with traumatic thoracic aortic ruptures (n=16), aneurysms (n=14), false aneurysms (n=3), penetrating ulcers (n=3), and dissections (n=11) treated with stent-grafts were monitored in follow-up using chest radiography and CTA in all patients and MRA in 23 patients. Two perpendicular maximal aortic diameters, the sum of these diameters, and the elliptical cross-sectional area were determined and compared to baseline for the entire group and in subgroup analyses according to lesion type. CTA, MRA, and radiography were compared for their ability to detect endoleak, monitor stent-graft configuration, and measure aortic diameters. Results: The mortality rate was 8.5%. Severe complications were observed in 14.8% (6% neurological complications); 12 (25.5%) patients had primary endoleaks. Over a mean 11-month follow-up (range 0.25–46 months), the aortic diameters decreased for all patients without endoleak (p<0.001). In the diameter/area subgroup analyses, only the traumatic rupture cohort demonstrated significant decreases in all 4 measurements. CTA and MRA measurements correlated well, but chest radiography was superior to both for visualizing stent-graft shape. In terms of endoleak detection, MRA missed only 1 (12.5%) endoleak (type II) seen on CTA; there were no false positive results with MRA. Conclusions: Morbidity and mortality observed after thoracic stent-grafting are acceptable. Radiography is better for monitoring stent-graft conformation, while CTA provides the best overall morphological information. The performance of MRA in endoleak detection is encouraging.

Endovascular Treatment of Aberrant Systemic Arterial Supply to Normal Basilar Segments of the Right Lower Lobe: Case Report and Review of the Literature

We report the case of a 17-year-old man with acute chest pain due to a partial thrombosis of a pseudosequestration. Unlike a true sequestration, there was a normal bronchial distribution and the involved lung parenchyma was normal on CT scan. A therapeutic transarterial embolization of the aberrant systemic artery from the proximal abdominal aorta was performed successfully. The patient did not suffer from further chest pain during the follow-up of 12 months. A contrast-enhanced CT scan 4 months later demonstrated complete occlusion of the embolized aberrant artery. Our case represents an alternative treatment to surgery for this rare abnormality.

Pseudoaneurysm and aortobronchial fistula after surgical bypass for aortic coarctation: management with endovascular stent-graft.

Purpose: To report the endovascular repair of an aortobronchial fistula at the distal anastomosis of a complex thoracic graft. Case Report: A 61-year-old man operated 18 years prior for aortic coarctation presented with hemoptysis. An aortobronchial fistula was suspected, but spiral computed tomography and angiography showed only a small pseudoaneurysm at the distal anastomosis without revealing the fistulous tract. A Talent stent-graft was successfully deployed through a femoral access, but the large delivery system injured the external iliac artery, producing a retroperitoneal hemorrhage. Prompt balloon occlusion of the aorta and subsequent bypass graft repair of the arterial injury prevented serious sequelae. The patient recovered without further complications. Follow-up imaging to 2 years has documented exclusion of the pseudoaneurysm with no hemoptysis or signs of new false aneurysm formation. Conclusions: Endovascular exclusion of anastomotic pseudoaneurysms even in complicated cases can be an efficient treatment option, but the procedure must be carefully planned and executed in order to achieve good results.

Vers une nouvelle prise en charge des ruptures traumatiques aiguës de l’isthme aortique

Resume But Evaluer la faisabilite et la fiabilite de la mise en place d’endoprotheses pour traiter les ruptures aigues post-traumatiques de l’isthme aortique : presentation de notre experience de 16 patients. Materiels et methodes Entre janvier 1996 et decembre 2001, 16 patients, âges en moyenne de 36 ans, ont ete traites par cette technique. Tous presentaient des lesions associees et 9 d’entre eux, une instabilite hemodynamique non liee a la rupture isthmique. Apres un delai variant de 9 a 245 jours (moyenne 78 jours), une endoprothese aortique etait mise en place par une equipe pluridisciplinaire. Un suivi regulier etait realise par scanner et echographie transoesophagienne. Resultats L’endoprothese a permis l’exclusion du faux anevrisme dans 100 % des cas. La procedure durait en moyenne 120 minutes et 80 % des patients ont pu etre extubes sur table. Le sejour moyen aux soins intensifs etait de 24 heures. La seule complication etait une compression de la bronche souche gauche par le faux anevrisme, traitee avec succes par une endoprothese bronchique. Le recul maximal etait de 7 ans. Conclusion La mise en place d’endoprothese pour rupture aigue de l’isthme aortique est une technique fiable et peut etre proposee comme alternative a la chirurgie pour les polytraumatises dont les lesions associees augmentent le risque chirurgical.