From the Aortic Bifurcation to the Groin: Long-term Outcomes of Covered Kissing Stent Placement in Combination with Iliofemoral Reconstruction for Extensive Iliofemoral Occlusive Disease.

BACKGROUND: The aim of this study was to evaluate outcomes of extensive iliofemoral reconstruction combining both iliac covered kissing stents (ICKS) with stenting of the external iliac artery (SEIA) and/or surgical femoral endarterectomy (SFE). METHODS: From November 2010 to November 2017, patients with extensive iliofemoral occlusive disease-classified as Trans-Atlantic Inter-Society Consensus class D-treated by ICKS in combination with SEIA and/or SFE were included. Patients received ICKS + SEIA, ICKS + SFE, or ICKS + SEIA + SFE. Demographics, procedure details, and postoperative outcomes were recorded. Primary end points were primary patency (PP), primary assisted patency (PAP), and secondary patency (SP). Long-term patency was assessed by annual clinical and ultrasonographic examination. RESULTS: Among 156 consecutive ICKS procedures performed during the study period, 59 patients were included (81% men; median age, 65 years). In all, 32 patients (54%) underwent ICKS + SEIA, 17 (29%) patients underwent ICKS + SFE, and 10 (17%) patients underwent ICKS + SEIA + SFE. Operative indication was either disabling claudication (n = 46, 78%) or critical limb-threatening ischemia (n = 13, 22%). A total of 92 limbs were revascularized, including 121 covered balloon-expandable stents and 65 self-expanding nitinol stents, with 100% technical success. Thirty-day mortality was 3% (2/59) and 5 (8%) patients suffered from local complications, with no early reintervention. Long-term patency rates were as follows: at 2 years, overall PP, PAP, and SP were 82%, 86%, and 96%, respectively; at 5 years, overall PP, PAP, and SP were 73%, 79%, and 95%, respectively. After a mean follow-up of 34 ± 29 months, 25% (15/59) patients underwent late reinterventions for either de novo iliac or femoral stenosis (n = 9), iliac occlusion (n = 4), or external iliac in-stent restenosis (n = 2). CONCLUSIONS: Treatment of extensive iliofemoral occlusive disease involving ICKS in combination with SEIA and/or SFE is safe and effective, providing satisfactory long-term secondary patency, at the price of a significant reintervention rate.

Acute Kidney Injury after Open Repair of Intact Abdominal Aortic Aneurysms.

BACKGROUND: These last years, considerable attention has been given to renal issues following endovascular aortic repair but acute kidney injury (AKI) also remains one of the most frequent complications following open repair (OR). Since AKI definition has evolved, our aim was to review the etiology, incidence, classifications, and consequences of AKI after OR for intact abdominal aortic aneurysm (AAA). METHODS: A review of the English language literature published between 2004 and 2016 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Studies regarding ruptured AAA, combination of emergency and elective repairs without results stratification, and thoracoabdominal aneurysms were excluded, as well as studies not using recent consensual AKI classifications. RESULTS: In total, 6 studies including 658 patients (394 from prospective studies and 264 from retrospective studies) used recent consensual classifications (risk injury failure loss end-stage renal disease [RIFLE], Acute Kidney Injury Network classification [AKIN], kidney disease-improving global outcomes [KDIGO], and Aneurysm Renal Injury Score [ARISe]) and were considered for analysis. After infrarenal clamping, AKI rates were quite similar between studies, observed in 24% cases when using the RIFLE classification, 20% cases with the AKIN criteria, and 26.3% cases when using the ARISe classification. Pooled rates of renal replacement therapy (RRT) and 30-day mortality were 0.3% and 1.4%, respectively. In the long term, no patient mandated chronic RRT. After suprarenal clamping, 2 retrospective studies used the RIFLE criteria to define the incidence of AKI, and the pooled AKI rate was 36.8%. The AKI rate was 26.5% in smaller retrospective study using the KDIGO criteria. Rates of RRT and 30-day mortality were 3.8% and 2.9%, respectively. In the long term, 1.2-3% of patients mandated chronic RRT. CONCLUSIONS: AKI is a common but generally transient complication after OR for AAA. Its incidence depends on definitions used, and few studies were found to use recent consensual AKI criteria. In the future, large prospective studies using consensual AKI definitions will facilitate comparison between repair strategies.

A novel hybrid approach using antegrade visceral debranching from both axillary arteries for thoracoabdominal aneurysm repair.

Hybrid aortic surgery combining visceral debranching and stent grafting is an alternative to conventional open surgery and branched stent grafting for thoracoabdominal aneurysm repair. Visceral aortic branch bypasses are usually performed from the iliac arteries or the infrarenal or ascending aorta. Herein, we describe a new debranching technique to treat a painful Crawford type III thoracoabdominal aneurysm in a high-risk patient who was deemed unsuitable for open, endovascular, or traditional hybrid repair. The superior mesenteric artery and the right renal arteries were exposed via a right retroperitoneal approach and revascularized from the right axillary artery. Splenic and left renal arteries were exposed via a left retroperitoneal approach and revascularized from the left axillary artery.

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 ±â€¯12.1 years) were included. The mean length of remnant small bowel was 47 ±â€¯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 ±â€¯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.

Predictive factors for complications of anatomical pulmonary segmentectomies.

OBJECTIVES: The role of anatomical pulmonary segmentectomy is increasing, but there are few data about its complication rate. We have analysed the postoperative morbidity, mortality and risk factors in a consecutive series of 228 segmentectomies performed in our department. METHODS: Between January 2007 and December 2011, 221 patients underwent 228 segmentectomies. There were 99 women (45%) and 122 men (55%). The mean age was 61 years (range 18-86 years). The mean forced expiratory volume in 1 s (FEV1) was 87%, and 30 patients had an FEV1 of ≤60%. Fifty-seven patients had a previous history of pulmonary resection. Indications for segmentectomy were: primary lung cancer (111 cases), metastases (71 cases), benign non-infectious (25 cases) and benign infectious diseases (21 cases). The approach was a posterolateral thoracotomy (Group PLT) in 146 patients (64%) and a thoracoscopy (Group TS) in 82 (36%). The two groups were homogenous in terms of age, gender, indications of surgery and type of segmentectomy. RESULTS: The mortality rate at 3 months was 1.3% (3 patients). The overall complication rate was 34%. Ten patients were reoperated for the following reasons: haemothorax (4 cases), ischaemia of the remaining segment (3 cases), active bleeding (1 case), prolonged air leak (1 case) and dehiscence of thoracotomy (1 case). The average duration of drainage was 5 days (range 1-34 days) and the average length of stay was 9 days (range 3-126 days). On univariate analysis, FEV1, male gender and thoracotomy were statistically significant risk factors for complications. On multivariate analysis, the same three predictive factors of complications independently of age were found statistically significant: preoperative FEV1 < 60% [odds ratio (OR) = 5.9, 95% CI (2.5-13.7), P < 0.001] male gender [OR = 2.04, 95% CI (1.2-3.6), P < 0.013] and thoracotomy [OR = 2.14, 95% CI (1.33-3.46), P = 0.001]. CONCLUSIONS: Pulmonary anatomical segmentectomies have an acceptable morbidity rate. Postoperative complications are more likely to develop in male gender patients, with FEV1 ≤ 60% and operated by open surgery.

Bidirectional cavopulmonary shunt with additional pulmonary blood flow: a failed or successful strategy?

OBJECTIVES: In patients with single ventricle physiology, Fontan circulation is considered as the optimal surgical approach, although it entails a growing incidence of late complications. It has been speculated that the association of bidirectional cavopulmonary shunt (BCPS) and additional pulmonary blood flow (APBF) might provide long-lasting palliation. The present study was undertaken to assess the long-term outcome of this strategy. METHODS: A group of 70 patients with single ventricle physiology, who underwent BCPS with APBF between 1990 and 2000, were reviewed retrospectively. Median age at operation was 2 years (range: 0.1-27 years). Unilateral BCPS was performed in 60 patients (86%), bilateral BCPS in 9 and the Kawashima procedure in 1. APBF was provided through antegrade pulmonary outflow tract in 43 patients (61%) and by aortopulmonary shunt in 27 (39%). Two patients died early and three were lost to follow-up. Mean follow-up of the 65 remaining patients was 13.5 ± 4 years. End-points were death, need for heart transplantation (HTx) or Fontan completion and functional outcome. RESULTS: Five patients died (two after HTx, three from ventricular failure); overall actuarial survival was 89 ± 4% at 15 years. Six patients underwent HTx (one after Fontan completion) with two early deaths and no late mortality. Fifty-one patients underwent Fontan completion (11 with additional palliative procedures before completion); there was no early or late mortality following Fontan completion; one patient underwent HTx. Among the remaining six patients with BCPS and APBF, two were not suitable for Fontan completion and four remained suitable. Overall, clinical failure (mortality, HTx, unsuitability for Fontan completion) occurred in 13 patients (19%). Risk factors for clinical failure were older age at BCPS (P = 0.01) and postoperative complications after BCPS (P = 0.001). Considering late mortality, HTx and Fontan completion as strategic failures, the actuarial freedom from these events was 20 ± 5% at 10 years. CONCLUSIONS: BCPS with APBF approach: (i) fails as a strategy for definitive palliation, (ii) provides a high survival rate, (iii) does not preclude a successful Fontan completion and (iv) may delay the long-term deleterious consequences of Fontan circulation. Palliation by BCPS with APBF should be achieved early in life.