Vincent Bach

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.

Giant aneurysm of the proximal segment of the left anterior descending artery in a patient with Behçet's disease – a combined approach

Behçets disease is an autoimmune, multisystem disease presenting with recurrent oral and genital ulceration as well as ocular involvement. Aneurysmal degeneration of coronary arteries remains a rare phenomenon in Behçets disease. The case of a patient with Behçets disease who presented with severe stenosis of the left anterior descending artery associated with a giant aneurysm of the proximal segment is described. Surgical revascularization was proposed, followed by percutaneous embolization of the aneurysm.

Percutaneous Drainage of Postoperative Pericardial Effusion in Cardiac Surgery

BACKGROUND AND AIM OF THE STUDY  Postoperative pericardial effusion is frequent and can be complicated by cardiac tamponade. Although the different drainage techniques are well described in the setting of medical effusion, there is not a standard postoperative effusion treatment. The aim of this work was to assess the feasibility and effectiveness of the percutaneous pericardial drainage. METHODS This a retrospective study involving 197 patients from 1990 to 2008. Drainage was performed by subxiphoid puncture (91.9%) or left parasternal puncture (8.1%) between 3 and 690 days following a cardiac procedure via median sternotomy. Effusion thickness was at least 10 mm in the subcostal echocardiography view. RESULTS No deaths directly related to the procedure were observed. Complete and enduring drainage was achieved in 158 patients (80.2%). The procedure failed for 22 patients (11.2%) because no fluid was drained in 14 cases (7.1%) and a right ventricular puncture in 8 cases (4.1%). Recurrence of the effusion, which occurred for 17 patients (8.6%), was more frequent if an effusion of more than 5 mm persisted after the first drainage (P = 0.024) and if the drainage was performed outside the operating room because of emergency (P = 0.046). Risk factors for mortality were recurrence of the effusion (P = 0.04) and drainage performed outside the operating room (P = 0.007). CONCLUSIONS Percutaneous pericardial drainage is effective to treat postoperative pericardial effusion. When the effusion is thicker than 10 mm and accessible, it can be the initial strategy and surgical drainage can serve as an alternate strategy in case of failure and complications of this procedure.

Type A acute aortic dissection: why does the false channel remain patent after surgery?

Purpose: To understand why the false channel (FC) remains patent after surgery of type A acute aortic dissection (TAAAD). Materials and Methods: Postoperative contrast-enhanced computed tomography scans of 129 patients operated for TAAAD were analyzed, and a color-Doppler ultrasound examination (CDUS) of the supra-aortic vessels (SAVs) was performed in 12 patients. Results: The FC remained patent in 107 (82.9%) patients. The entry site was situated near the distal anastomosis in 43 (40.2%) patients and far from it in 44 (41.1%) patients. In 10 (9.35%) patients, an entry site was observed only in the SAVs. In 10 (9.35%) patients, no entry site was seen. Of the 12 patients explored with CDUS, a retrograde filling of the FC was observed in 11 patients. Conclusion: The frequent postoperative circulating aortic FC can be explained by the persistence of the primary entry tear, the presence of iatrogenic tears, and/or a retrograde filling in the SAVs.

Cardiac Thrombosis in a Patient During Extracorporeal Life Support

SYSTEMIC ANTICOAGULATION is needed during extracorporeal life support (ECLS) mainly to prevent clotting in he cannulae, tubing, and oxygenator. In addition, this may educe the risk of end-organ damage from microemboli. Howver, the literature is poor on this point. There are no guideines, no clear goals, and no clear protocol in the textbooks. The mpact of coated circuits on thrombotic complications is still ontroversial. Moreover, lower degrees of anticoagulation or o anticoagulation for a short period of time is suggested in ase of major bleeding.1 Left ventricular thrombus associated with the use of left ventricular assist devices is a relatively frequent complication.2 However, the occurrence of cardiac thrombosis during ECLS assistance is not well documented and the relationship with poor anticoagulation is not clear. The authors report 2 cases of massive cardiac thrombosis during ECLS.

Hemorrhagic tamponade due to cardiac angiosarcoma.

Prognosis of angiosarcoma, the most common primary malignant cardiac tumor, is very poor. An early detection and treatment may extend survival beyond one year. Newer imaging modalities, including magnetic resonance imaging (MRI), play an important role in the evaluation of cardiac masses. The case of a man admitted to the emergency room for a cardiac tamponade is reported. Thoracic computed tomography and MRI diagnosed a pericardial tumor, for which surgical biopsy revealed an angiosarcoma. Chemotherapy was started, and the patient survived for 28 months. Etiologies of hemorrhagic tamponades are discussed, as well as treatment of cardiac angiosarcoma.