Medico-economic impact of thoracoscopy versus thoracotomy in lung cancer: multicentre randomised controlled trial (Lungsco01).

BACKGROUND: Lungsco01 is the first study assessing the real benefits and the medico-economic impact of video-thoracoscopy versus open thoracotomy for non-small cell lung cancer in the French context. METHODS: Two hundred and fifty nine adult patients from 10 French centres were randomised in this prospective multicentre randomised controlled trial, between July 29, 2016, and November 24, 2020. Survival from surgical intervention to day 30 and later was compared with the log-rank test. Total quality-adjusted-life-years (QALYs) were calculated using the EQ-5D-3L®. For medico-economic analyses at 30 days and at 3 months after surgery, resources consumed were valorised (€ 2018) from a hospital perspective. First, since mortality was infrequent and not different between the two arms, cost-minimisation analyses were performed considering only the cost differential. Second, based on complete cases on QALYs, cost-utility analyses were performed taking into account cost and QALY differential. Acceptability curves and the 95% confidence intervals for the incremental ratios were then obtained using the non-parametric bootstrap method (10,000 replications). Sensitivity analyses were performed using multiple imputations with the chained equation method. RESULTS: The average cumulative costs of thoracotomy were lower than those of video-thoracoscopy at 30 days (€9,730 (SD = 3,597) vs. €11,290 (SD = 4,729)) and at 3 months (€9,863 (SD = 3,508) vs. €11,912 (SD = 5,159)). In the cost-utility analyses, the incremental cost-utility ratio was €19,162 per additional QALY gained at 30 days (€36,733 at 3 months). The acceptability curve revealed a 64% probability of efficiency at 30 days for video-thoracoscopy, at a widely-accepted willingness-to-pay threshold of €25,000 (34% at 3 months). Ratios increased after multiple imputations, implying a higher cost for video-thoracoscopy for an additional QALY gain (ratios: €26,015 at 30 days, €42,779 at 3 months). CONCLUSIONS: Given our results, the economic efficiency of video-thoracoscopy at 30 days remains fragile at a willingness-to-pay threshold of €25,000/QALY. The economic efficiency is not established beyond that time horizon. The acceptability curves given will allow decision-makers to judge the probability of efficiency of this technology at other willingness-to-pay thresholds. TRIAL REGISTRATION: NCT02502318.

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms.

OBJECTIVE: Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS: This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS: Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS: Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

Outcomes of Left Subclavian Artery Transposition for Hybrid Aortic Arch Debranching.

BACKGROUND: The aim of this study was to evaluate outcomes of left subclavian artery (LSA) revascularization for hybrid aortic arch debranching. METHODS: Between 1998 and 2015, 68 patients (41 men; mean age, 67 ± 16 years) underwent thoracic endovascular aortic repair (TEVAR) with LSA coverage, 19.2% (n = 13) were never revascularized, and the remaining patients underwent LSA revascularization (n = 55; 80.8%). Revascularization was achieved by LSA-carotid transposition via a medial approach in 81.8% (n = 45) and a lateral approach in 18.2% (n = 10). The indication for TEVAR was aneurysmal disease in 30.9% (n = 17), dissection in 29% (n = 16; acute, n = 5), traumatic aortic injury in 21.8% (n = 12), pseudoaneurysm in 10.9% (n = 6), aortobronchial fistula in 5.5% (n = 3), and penetrating atherosclerotic ulcer in 1.9% (n = 1). Elective cases accounted for 52.7% (n = 29). Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter. RESULTS: LSA revascularization was achieved in all the cases. Thirty-day mortality rate was 12.7%. Thirty-day mortality related to LSA revascularization was 0%. No patient suffered a stroke. Vocal cord paralysis was detected in 7.2% of patients (n = 4). Hematoma requiring surgical drainage was observed in 3.6% of patients (n = 2). Lymph leak requiring revision surgery was observed in 1.8% of patients (n = 1). Phrenic nerve palsy was not observed. The local complication rate was significantly higher (P = 0.03) in patients with LSA transposition via a lateral approach (20%; n = 2) when compared to patients with LSA revascularization via a medial approach (11.1%; n = 5). After a mean follow-up of 31.5 months (range, 2-171 months), the patency of the LSA revascularization was maintained in all patients. CONCLUSIONS: During TEVAR, when LSA coverage is required, LSA revascularization is a durable procedure associated with a low morbidity rate. LSA transposition via a medial approach would appear to be associated with significantly fewer complications.

Hybrid Aortic Repair of Dissecting Aortic Arch Aneurysm after Surgical Treatment of Acute Type A Dissection.

BACKGROUND: The aim of this study was to evaluate the short-term and midterm results of hybrid repair of dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections. METHODS: Between 2003 and 2014, 7 consecutive patients, previously operated for acute type A dissection, underwent hybrid repair of their aortic arch for a dissecting aortic arch aneurysm (6 men, mean age 62 ± 11 years). Aneurysm formation requiring treatment in these aortic arches was observed from 2 to 20 years after the initial aortic dissection repair. A hybrid technique was used in all patients, with supra-aortic debranching through a redo sternotomy and either simultaneous (6 patients) or staged endovascular stent grafting (1 patient). Two patients were treated in an emergent setting (1 ruptured and 1 symptomatic aneurysm). Two patients required a more extensive aortic repair of either the thoracic aorta (n, 1) or of the thoracoabdominal aorta (n, 1). One patient underwent, saphenous vein bypass from the ascending aorta to the anterior descending coronary artery on full cardiopulmonary bypass. Follow-up computed tomography scans were performed at 1 week, 3, and 6 months, and annually thereafter. RESULTS: Technical success was achieved in all the cases. One transient ischemic attack, 1 stroke, and 1 episode of transient spinal cord ischemia were observed. Thirty-day mortality was not observed. A type I endoleak at 6 months was successfully treated with deployment of a second stent graft. After a mean follow-up of 3.5 ± 3.1 years (range, 0.4-9.6 years), no aortic-related mortality was observed. No cases of stent-graft migration or secondary rupture were observed. CONCLUSIONS: Our experience demonstrates the promising potential of endovascular repair of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. The potential to diminish the magnitude of the surgical procedure and the consequences of aortic arch exposure, and above all avoiding the need for circulatory arrest are promising and mandate further investigation to determine the efficacy and durability of this technique.

Assessment of abdominal branch vessel patency after bare-metal stenting of the thoracoabdominal aorta in a human ex vivo model of acute type B aortic dissection.

OBJECTIVE: The purpose of this study was to assess the efficiency of bare-metal stenting of the thoracoabdominal aorta in a human ex vivo model of acute type B aortic dissection and the impact of this approach on the patency of the visceral and renal arteries. METHODS: Fifteen human cadaveric aortas were harvested. Type B aortic dissections were surgically initiated 2 cm below the left subclavian artery. Aortas were thereafter connected to a bench top pulsatile flow to induce propagation of the dissection. A 5-mm 30° lens (Richard Wolf, Vernon Hills, Ill) was introduced successively into the false lumen and the true lumen to monitor the propagation of the dissection. Bare-metal stents were deployed into the true lumen from the primary entry tear to the infrarenal aorta. Measurement of systolic pressure was taken within the abdominal branch vessels before and after stenting. A pressure gradient drop of 15 mm Hg or more after bare-metal stenting was considered hemodynamically relevant. RESULTS: Dissection was propagated at least to the renal aorta in 11 cases (73%) and to the infrarenal aorta in 3 cases (20%). Of the 60 abdominal branch vessels studied, 22 (36.7%) were supplied by the false lumen. After extensive aortic bare-metal stenting, complete reattachment of the dissection flap was observed in all cases. Regarding visceral and renal artery patency after bare-metal stenting, a significant pressure gradient drop was reported in 54.5% (n = 12) when these arteries were supplied by the false lumen, whereas those originating from the true lumen had a significantly less common pressure gradient drop (7.9% [n = 3]; P < .0001). CONCLUSIONS: Bare-metal stenting in this model of acute type B aortic dissection was effective in true lumen reexpansion but induced a high (54.5%) rate of significant pressure drop in the visceral and renal arteries when they were supplied by the false lumen.

Saccular Thoracoabdominal Aneurysms in Systemic Lupus Erythematosus.

Aortic aneurysm is a rare but a serious complication of systemic lupus erythematosus. We report the case of a 59-year-old man with systemic lupus erythematosus disease who presented with symptomatic saccular thoracoabdominal aneurysms. The 2 aneurysms were resected and 2 silver-coated tube grafts were interposed. Surgical pathology revealed lymphoplasmacytic aortitis, without pathogenic agents. This is the first case of a double localization of saccular thoracoabdominal aneurysms with inflammatory aortitis caused by lupus. In patients with a history of systemic lupus erythematosus, with or without active inflammation, screening for aortic disease should be selectively performed if other risk factors for aortic aneurysm are present.

Reintervention after thoracic endovascular aortic repair of complicated aortic dissection.

OBJECTIVE: This study assessed predictive factors for reintervention after thoracic endovascular aortic repair (TEVAR) for complicated aortic dissection (C-AD). METHODS: An institutional review of consecutive TEVAR for C-AD was performed. RESULTS: Between 2000 and 2011, 41 patients underwent TEVAR for a C-AD involving the descending thoracic aorta. Primary indications included aneurysm >55 mm in 24, rapid aneurysmal enlargement or impending rupture in 6, saccular aneurysm >20 mm in 1, malperfusion in 1, intractable chest pain in 3, and rupture in 6. Technical success was achieved in 100%. The 30-day mortality rate was 5% (n = 2). Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing ≥20% (odds ratio [OR], 16; P = .011), bare-spring stent in the proximal landing zone of the stent graft (OR, 12; P = .032), and anticoagulant therapy (OR, 78; P = .03) were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention (P = .002), whereas complete false lumen thrombosis at the stent graft level was protective (P < .05). CONCLUSIONS: This study confirms the feasibility of TEVAR for C-AD, although the rate of reintervention is high. Excessive oversizing, a bare-spring stent graft in the proximal landing zone, large aortic dilatation, and anticoagulant therapy were factors associated with reintervention. Complete false lumen thrombosis at the stent graft level was protective.

Human ex-vivo model of Stanford type B aortic dissection.

OBJECTIVE: To report a new human ex vivo model of type B aortic dissection (TBAD) and to assess if the locations of the primary entry tear determine the patterns of dissection propagation. METHODS: Twenty fresh human aortas were harvested. TBADs were surgically initiated 2 cm below the left subclavian artery at four different locations (lateral, n = 5; medial, n = 5; anterior, n = 5; posterior, n = 5). Aortas were thereafter connected to a bench-top pulsatile flow model to induce antegrade propagation of the dissection. RESULTS: Antegrade propagation of the dissection was achieved and reached at least the celiac trunk (CT) in all the cases. Dissection was propagated to the renal aorta in 16 (80%) and infrarenal aorta in seven cases (35%). Left renal artery with or without the CT originated more often from the false channel when primary entry tear was lateral. Right renal artery and the CT most often originated from the false channel when primary entry tear was medial. When the CT was the only one originating from the false channel, primary entry tear was more often anterior, whereas when it originated from the true channel, it was more often posterior. CONCLUSIONS: This human ex vivo model of TBAD is reproducible, since, in all the aortas, extended dissection was achieved and provides the first model of human aortic dissection with infrarenal aorta extension allowing future assessment of endovascular devices developed for human use. Furthermore, it allows clarification of the patterns of aortic dissection propagation and visceral and renal artery involvement according to the site of the primary entry tear.

Improvement in conformability of the latest generation of thoracic stent grafts.

OBJECTIVE: Poor aortic arch apposition increases the risk of technical failure after thoracic endovascular repair. The aim of this study was to assess the conformability of the latest generation of thoracic stent grafts in relation to the degree of device oversizing and aortic arch angulation. METHODS: A benchtop pulsatile flow model was designed to test stent graft anchorage in a 2-cm-long proximal landing zone at varying landing zone angles (from 140° down to 70°) and stent graft oversizing (12%-28%). The experiments were performed using 10 human thoracic cadaveric aortas and four stent grafts: C-TAG, Zenith TX2 Pro-Form, Valiant Captivia, and Relay. Device-wall apposition was measured as a function of landing zone angulation and oversizing during static and dynamic (60 pulses/min, 300/150 mm Hg) tests. RESULTS: The Valiant stent graft remained apposed to the aortic wall at each increment of neck angulation and device oversizing. Lack of apposition of the proximal anchorage segment was observed with the C-TAG above 120° landing zone angulation (1-2 mm) and with the Relay above 110° landing zone angulation (1-4 mm). Lack of "body" apposition (1-4 mm) was first observed with the Zenith Pro-Form stent graft above 110° angulation (P = .001). When the device was not apposed to the aortic wall, an increase in stent graft oversizing significantly (P = .01) decreased device-wall apposition. CONCLUSIONS: The requirement for close conformability has influenced the design of next-generation devices. Manufacturers have modified devices and/or their deployment system to specifically address this problem. When compared with the results of our previous experimental test, this study demonstrates that these alterations have resulted in a marked improvement in the performance of commercially available stent graft systems.

Heparin-induced thrombocytopenia with abdominal aortic stent-graft acute thrombosis.

We report a case of heparin-induced thrombocytopenia in a patient on low molecular weight heparin bridge therapy who developed acute abdominal aortic stent-graft thrombosis 1 week after uncomplicated endovascular abdominal aortic aneurysm repair. The diagnosis was confirmed by a computed tomographic scan of the abdomen. The patient was successfully treated by conversion to open repair. The postoperative course was marked by subacute left limb ischemia related to an in vivo cross-reactivity of danaparoid with the heparin immune complex. To our knowledge, this is the first case report of heparin-induced thrombocytopenia with acute abdominal aortic stent-graft thrombosis.

VATS versus Open Lobectomy following Induction Therapy for Stage III NSCLC: A Propensity Score-Matched Analysis.

Objectives: This study aims to evaluate the perioperative and oncologic outcomes of thoracoscopic lobectomy for advanced stage III NSCLC. Methods: We retrospectively reviewed 205 consecutive patients who underwent VATS or open lobectomy for clinical stage III lung cancer between January 2013 and December 2020. The perioperative and oncologic outcomes of the two approaches were compared. Long-term survival was assessed using the Kaplan−Meier estimator. Propensity score-matched (PSM) comparisons were used to obtain a well-balanced cohort of patients undergoing VATS and open lobectomy. Results: VATS lobectomy was performed in 77 (37.6%) patients and open lobectomy in 128 (62.4%) patients. Twelve patients (15.6%) converted from VATS to the open approach. PSM resulted in 64 cases in each group, which were well matched according to twelve potential prognostic factors, including tumor size, histology, and pTNM stage. Between the VATS and the open group, there were no significant differences in unmatched and matched analyses, respectively, of the overall postoperative complications (p = 0.138 vs. p = 0.109), chest tube duration (p = 0.311 vs. p = 0.106), or 30-day mortality (p = 1 vs. p = 1). However, VATS was associated with shorter hospital stays (p < 0.0001). The five-year overall survival (OS) and five-year Recurrence-free survival (RFS) were comparable between the VATS and the open groups. There was no significant difference in the recurrence pattern between the two groups in both the unmatched and matched analyses. Conclusion: For the advanced stage III NSCLC, VATS lobectomy achieved equivalent postoperative and oncologic outcomes when compared with open lobectomy without increasing the risk of procedure-related locoregional recurrence.

Arterial Sleeve Lobectomy: Does Pulmonary Artery Reconstruction Type Impact Lung Function?

BACKGROUND: The aim of this single-center retrospective cohort study was to assess the impact of arterial reconstruction technique on lung perfusion. The second objective was to ascertain the functional validity of arterial sleeve lobectomy. METHOD: Between January 2001 and December 2020, a total of 81 patients underwent lobectomy with pulmonary artery (PA) reconstruction for lung cancer at the University Hospital of Montpellier. After excluding patients with an incomplete postoperative pulmonary function test, we conducted a comparative analysis of the preoperative and postoperative functional outcomes (FEV1) of 48 patients, as well as the preoperative and postoperative Technetium99m scintigraphic pulmonary perfusion results of 28 patients. Then, we analyzed postoperative perfusion results according to the pulmonary artery reconstruction techniques use. RESULTS: PA reconstruction types were as follows: 9 direct angioplasties (19%), 14 patch angioplasties (29%), 7 end-to-end anastomoses (15%), 6 prosthetic bypasses (12%), 11 arterial allograft bypasses (23%), and 1 custom-made xenopericardial conduit bypass. Regardless of the type of vascular reconstruction performed, the comparative analysis of lung perfusion revealed no significant difference between the preoperative and postoperative perfusion ratio of the remaining parenchyma (median = 29.5% versus 32.5%, respectively; p = 0.47). Regarding the pulmonary functional test, postoperative predicted FEV1 significantly underestimated the actual postoperative measured FEV1 by about 260 mL (11.4%) of the preoperative value. The patency rate was 96% and the 5-year overall survival was 49% for a mean follow up period of 34 months. CONCLUSION: Lobectomy with PA reconstruction is a valid parenchymal-sparing technique in terms of perfusion and respiratory function.

Carotid atherosclerotic plaques: proteomics study after a low-abundance protein enrichment step.

Atherosclerosis is one of the most important causes of cardiovascular and cerebrovascular events. Although phenotypic differentiation between stable and unstable plaques is currently possible, proteomic analysis of the atherosclerotic plaque could offer a global view of the atherosclerosis pathology. With the objective to highlight the detection of low-abundance proteins, we reduced the dynamic range of proteins by combinatorial peptide ligand library treatment of human carotid artery atherosclerotic plaques. After enrichment step, abundance of major proteins was decreased, revealing different protein profiles as assessed by both SDS-polyacrylamide gel electrophoresis and two-dimensional electrophoresis comparative analyses. Identification of proteins that were contained in a spot allowed finding large differences between noncomplicated and complicated plaques from carotid atherosclerotic lesions. Novel low-abundance proteins were detected correlating very well with biological alterations related to atherosclerosis (heat shock protein 27 (HSP27) isoforms, aldehyde dehydrogenase, moesin, Protein kinase C delta-binding protein, and inter-α trypsin inhibitor family heavy chain-related protein (ITIH4)). At the same time, the differential expression of known proteins of interest such as hemoglobin ß-chain and heat shock protein 27 between noncomplicated and hemorrhagic complicated plaques was maintained after enrichment step. The detection of different isoforms of a low-abundance protein such as heat shock protein 27 species was actually improved after enrichment of tissue protein extracts. All of these findings clearly support further investigations in view to confirm the role of these proteins as possible biomarkers.

Endovascular repair of a left common carotid pseudoaneurysm associated with a jugular-carotid fistula after gunshot wound to the neck.

The management of traumatic injury of the common carotid artery has traditionally required a conventional surgical intervention, which is associated with a high mortality rate. Endovascular procedures might offer a less invasive alternative to treat these injuries, with a lower rate of mortality and morbidity. We report the case of a 30-year-old man who presented after penetrating injury due to a low-velocity gunshot wound to the neck. Angiography demonstrated a high-flow arteriovenous fistula and large false aneurysm of the common carotid artery. A self-expanding covered stent was placed across the injured portion of the artery, resulting in thrombosis of the aneurysm and preservation of the parent artery, without any significant complication. Covered stent placement is an alternative approach to treating carotid artery pseudoaneurysms associated with a jugular-carotid fistula.

Endoluminal treatment of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection.

BACKGROUND: The aim of this study was to evaluate the short- and midterm results following endovascular repair of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection. METHODS: Between 2003 and 2010, six consecutive patients previously operated for acute type A dissection underwent endovascular repair of dissecting aortic arch aneurysm (six men, mean age: 63 ± 9.8 years); one of the aneurysms was ruptured. Follow-up computed tomography scans were performed at 1 week, at 3 and 6 months, and annually thereafter. RESULTS: All endografts were successfully deployed (TAG [2], Valiant [4]). All the patients underwent hybrid technique with supra-aortic debranching (through a sternotomy approach in four cases and through a cervical approach in two cases) and simultaneous or staged endovascular stent-grafting. During the same operative time, one patient underwent, on full cardiopulmonary bypass, saphenous vein bypass from the ascending aorta to the anterior descending coronary artery. One permanent neurologic event was observed. After a mean follow-up of 22.3 ± 14.6 months, no aortic-related mortality was observed. No cases of stent-graft migration or secondary rupture were observed. The ruptured aortic arch aneurysm presented a type I endoleak at 6 months and was successfully treated with a second endograft. One patient died of an unrelated cause 7 months after surgical repair. CONCLUSIONS: Our experience demonstrates promising potential of endovascular repair of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection. The potential to diminish the magnitude of the surgical procedure and the consequences of aortic arch exposure, and above all avoiding the need for circulatory arrest, is promising and mandates further investigation to determine the efficacy and durability of this technique.

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine.

OBJECTIVES: This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC). METHODS: Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10. RESULTS: There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence. CONCLUSIONS: VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.

Patient risk factors for conversion during video-assisted thoracic surgery-the Epithor conversion score.

OBJECTIVES: Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score. METHODS: We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020. RESULTS: From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients' preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort). CONCLUSIONS: Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS-an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS.

Temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic vessels for hybrid repair of a ruptured aortic arch aneurysm.

Hybrid repair of ruptured aortic arch repair has been proposed as a valuable approach. However, the presence of an anterior mediastinal hematoma must be carefully detected because of the inherent risk of rupture at sternotomy. We report the case of a patient presenting a ruptured aortic arch aneurysm with anterior rupture who underwent hybrid repair using a temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic trunks. We propose this adjunctive technique as a means of allowing a safe endovascular exclusion of aortic arch lesions and avoiding the risk of acute and total aortic rupture in case of anterior rupture of aortic arch aneurysms.

Impact of stent-graft development on outcome of endovascular repair of acute traumatic transection of the thoracic aorta.

PURPOSE: To analyze the impact of stent-graft design on the outcome of endovascular repair of acute traumatic thoracic aortic transection. METHODS: Forty-eight patients (38 men; mean age 37 ± 11 years) underwent endovascular repair for an acute traumatic aortic rupture between April 2001 and March 2011. Up to October 2007, 32 patients (mean age 41 ± 16 years; group 1) were treated with the first generation of commercially available thoracic stent-grafts (10 Talent, 20 Excluder/TAG, 2 Zenith). From November 2007, 16 patients (mean age 42 ± 19 years; group 2) were treated with second-generation thoracic stent-grafts (13 Valiant and 3 C-TAG). The 2 groups were statistically comparable. Follow-up computed tomography was performed at 1 week; at 3 and 6 months; and annually thereafter. RESULTS: In the 2 groups, the mortality rate related to aortic repair was nil. All the patients have completed each of their scheduled follow-up evaluations and CT scans. The morbidity rate was significantly reduced (p = 0.0003) from 18.7% (first generation) to 6.2% (second generation). Type I endoleak (n = 1), inadvertent coverage of the supra-aortic trunks (n = 3), and stent-graft collapse (n = 2) occurred only with the first-generation stent-grafts. One iliac artery rupture occurred with a second-generation stent-graft. CONCLUSION: Enhanced stent-graft conformability and more accurate delivery systems have significantly decreased the morbidity of endovascular repair of acute traumatic transection of the thoracic aorta. The increasing clinical experience may also have contributed to improved results.

Midterm results of endovascular repair of thoracic aortic false aneurysm formation after coarctation repair.

BACKGROUND: The aim of this study was to evaluate the short-term and midterm results of endovascular repair of false aneurysm formation after coarctation repair. METHODS: Between November 1998 and August 2009, seven patients underwent endovascular repair for false aneurysm formation after coarctation repair (two women, five men; mean age: 45.4 ± 12.1 years; range: 30-60 years). Follow-up computed tomography scans were performed at 1 week, 3 months, 6 months, and annually thereafter. RESULTS: All endografts were successfully deployed (Excluder-TAG in three patients, Talent in one patient, Valiant in three patients). Among them, six patients underwent hybrid technique with supra-aortic debranching and simultaneous or staged endovascular stent grafting as follows: transposition of the left common carotid artery (LCCA) into the brachiocephalic trunk which was later followed by transposition of the left subclavian artery into the LCCA in one case and transposition of the left subclavian artery into the LCCA in remaining five cases. No major complications occurred. A mean follow-up of 44.8 ± 41.3 months (range: 1-131 months) demonstrated no endoleak, rupture, conversion, or migration. CONCLUSIONS: Short-and mid-term results of endovascular treatment of false aneurysm formation after coarctation repair favor the proposition of endovascular repair as a first-line treatment option. Long-term survival studies are mandatory to determine the efficacy and durability of this technique.