Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Surgical treatment of renal cell carcinoma with right atrial thrombus: early experience and description of a simplified technique.

Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.