Renovascular hypertension: results in adulthood of renal autotransplantation performed in children.

BACKGROUND: This study describes the long-term results of renal autotransplantation for renovascular hypertension performed in children who are now 21 years of age or older. METHODS: Sixteen children (4 boys, 12 girls) with a mean age of 11.2 years at the time of the procedure underwent ex-vivo surgery at the university hospital of Saint-Etienne between 1992 and 2008. Acetylsalicylic acid was used for antiplatelet therapy in the postoperative period, without routine anticoagulation. The mean follow-up period was 15 years. The clinical course of these patients was retrospectively reviewed in adulthood and the results analyzed. RESULTS: The children were treated with a mean of 2.37 drugs per patient, and the mean preoperative blood pressure of the entire patient population was 151/89 mmHg. Mean preoperative creatinine clearance was 80 ml/min/1.73 m2. There was no postoperative death. One patient experienced a thrombosis immediately after the surgery, leading to a redo surgery. In this patient diuresis was restarted, but without efficient concentration and filtration, ultimately leading the patient to have a renal transplant after 1 year. At the end of the follow-up period, eight of the 16 patients (50%) were cured and the others were improved. At the last follow-up the mean blood pressure was 127/70 mmHg, and the mean number of drugs per patient was 0.68. The mean creatinine clearance at last follow-up was 104.3 ml/min/1.73 m2. Three patients had secondary procedures, with two undergoing percutaneous angioplasty (at postoperative months 9 and 12, respectively) and one having an hepatorenal bypass at postoperative year 4. Primary patency was 12/16 (75%); primary assisted patency was 15/16 (94%); secondary patency was 16/16 (100%). CONCLUSION: This study shows that renal autotransplantation has good and stable long-term results and is an effective conservative strategy for treating renovascular hypertension in children, thus avoiding nephrectomy.

Carotid artery surgery: high-risk patients or high-risk centers?

BACKGROUND: Carotid angioplasty and stenting has been proposed as an alternative to carotid endarterectomy (CEA) in patients deemed as at high risk for this surgical procedure. To date, definitely accepted criteria to identify "high-risk" patients for CEA do not exist. Our objective was to assess the relevance of numerous supposed high-risk factors in our experience, as well as their possible effect on our early postoperative results. METHODS: A retrospective review of 1,033 consecutive CEAs performed during a 5.6-year period at a single institution was conducted (Vascular Surgery Department, St. Etienne University Hospital, France). Early results in terms of mortality and neurologic events were recorded. Univariate and multivariate analyses for early risk of stroke, myocardial infarction, and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. RESULTS: The cumulative 30-day stroke and death rate was 1.2%. A total of 10 strokes occurred and resulted in three deaths. The postoperative stroke risk was significantly higher in the subgroup of patients treated for symptomatic carotid artery disease: 2,6% (P = 0,004). Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. CONCLUSION: Patients with significant medical comorbidities, contralateral carotid occlusion, and high carotid lesions can undergo surgery without increased complications. Those parameters should not be used as exclusion criteria for CEA.

Redo aortic valve surgery with endovascular control of the internal thoracic artery graft.

BACKGROUND AND AIM OF THE STUDY: Redo aortic valve surgery (AVS) in patients with patent pedicled internal thoracic artery (ITA) grafts remains a challenging procedure because of the possibility of injury to the grafts and difficulties in optimal myocardial protection. This procedure is associated with a significant mortality and morbidity. Different approaches to myocardial protection and ITA graft dissection and control have been described. An intraoperative technique is proposed that provides endovascular control of the ITA graft, using an angioplasty balloon positioned during cross-clamping. METHODS: Ten consecutive patients with previous coronary artery bypass grafting (CABG) and a patent pedicled ITA who underwent AVS were studied. The ITA grafts were occluded by using an angioplasty balloon during cross-clamping, but were not dissected and controlled. RESULTS: Endovascular control of the ITA graft was feasible in all cases, without complication. Two intraoperative complications (both graft injuries) were observed; one injury of an ITA graft, and one injury of a radial artery graft. There was no postoperative mortality. One myocardial infarct was related to the injury of a radial graft. The clamped ITA grafts were studied at two months after the procedure in five patients, and showed all grafts to be patent. At a mean follow up of 13 months, all patients were alive without any coronary events. CONCLUSION: The endovascular control of a patent ITA graft during redo AVS is a safe and simple technique that reduces the risk of ITA graft injury and also improves myocardial protection.

Aneurysmal extension to the iliac bifurcation increases the risk of complications and secondary procedures after endovascular repair of abdominal aortic aneurysms.

BACKGROUND: To compare the outcome of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) in patients with and without associated common iliac artery aneurysm (CIAA) extending to the iliac bifurcation. METHODS: Review of 157 patients who underwent endovascular aneurysm repair between 1999 and 2007. Group 1 included 133 patients with and without CIAA and suitable distal common iliac neck (type A, B, C, or D). Group 2 included 24 patients with associated CIAA extending to the iliac bifurcation (type E). Stent-grafts were Powerlink (Endologix, Irvine, CA) in 42, Zenith (Cook, Bjaeverskov, Danemark) in 55, and Talent (Medtronic, Sunnyvale, CA) in 60 patients. Forty patients had aorto-uni-iliac stent-grafts. RESULTS: No difference in overall mortality and AAA rupture was observed. AAA-related complication-free survival at 5 year was 72 +/- 5% and 41 +/- 14% in group 1 and 2, respectively (p = 0.006). Secondary intervention-free survival was 84 +/- 5% and 55 +/- 12% in group 1 and 2, respectively (p = 0.0008). Incidence of distal type 1 endoleak and stent-graft thrombosis was 17 and 8 % in group 2, 3.8 and 0.8 % in group 1, respectively (p = 0.07 and p = 0.01, respectively). CONCLUSION: AAA-related complications and secondary interventions occur more frequently in patients with type E AAA. Distal type 1 endoleak and stent-graft thrombosis are more frequent in these patients. These results warrant further development of technologies that are better adapted for treatment of CIAAs, such as branched and flexible stent-grafts.

Pseudoaneurysms postangioplasty of the renal artery: case reports and review of the literature.

Pseudoaneurysms postangioplasty of the renal artery are a life-threatening complication but are poorly known due to their rarity. The aim of this report is to study this complication through three personal case reports and 10 cases found in a literature review. The data analysis led us to highlight important aspects about four main elements: initial procedure events, time to presentation, symptoms leading to diagnosis, and treatment.

Infrarenal iterative aortic surgery: early and late morbi-mortality observed in 61 patients.

The aim of this study was to analyze the early and late results of iterative aortic surgery after bypass of infrarenal aorta. Results from Clermont-Ferrand and Saint-Etienne hospitals have been collected. Between January 1993 and December 2001, 61 patients (59 men and two women, mean age 65 years) underwent a partial or complete second aortic reconstruction through a direct approach. Three different indications that required redo surgery were detected. Twenty-three patients presented with an infection (37%), 17 with an occlusive pathology (28%), and 21 with an aneurysm (34%). Medical or endoluminal treatment could no longer be considered. Mean period of time for redo surgery was 101 months (range 1-294). Eighteen of the procedures were emergency surgeries. A polyester prosthesis was used in 45 cases, an arterial allograft in 15 cases, and autogenous venous material in one case. In 22 cases (36%) a visceral, renal, or infracrural revascularization was associated. Four patients died (6.5%): three with an infection and one with an occlusive pathology. Global morbidity rate was 64%. Twelve vascular surgical complications (19%) required redo surgery: seven limb ischemia, three hemorrhage, and two colic ischemia. The preoperative factors generating severe complications were a septic context, renal insufficiency, and American Society of Anesthesiologists grade 3 or 4. Follow-up concerned the 57 surviving patients with a 43-month mean period of time (range 4-105). Actuarial survival rate was 80.7% at 3 years and could be compared to that observed after infrarenal aortic first surgery. Primary and secondary global patency rates were, respectively, 66.4 +/- 6.7% and 94.6 +/- 3% at 3 years with no major amputation. In our series including 37% of septic patients and nearly 30% of patients operated on in emergency, aortic iterative surgery led to mortality and morbidity rates twice and four times as important as those resulting from infrarenal aortic initial surgery, respectively. In the long term, patient survival and limb salvage rates were quite similar to those obtained with de novo surgery.

Enterovirus in arteriosclerosis: a pilot study.

BACKGROUND: Various pathogens have been suspected to play a role in the initiation or amplification of the atherosclerotic lesions. Both experimental and epidemiological arguments plead for a possible role of enterovirus in this process. OBJECTIVE: To determine the prevalence of enterovirus genome in atherosclerotic plaques, in comparison with Chlamydia pneumoniae, human cytomegalovirus (hCMV) and herpes simplex virus. STUDY DESIGN: Pilot study on 18 patients who underwent artery resection. Five artery samples were tested for each patient and each pathogen by using PCR techniques whose sensitivity was evaluated for this kind of specimen. The quality of the extraction step was assessed by amplification of a fragment of the human aldolase A gene. RESULTS: The genome of at least one infectious agent was detected in artery samples from 7 of the 18 patients (38.9%). In all cases, only one of the five aliquots was found positive; a confirmation was done by sequencing the PCR product. With regards to enterovirus, four patients (22.2%) were detected positive (one of them being also positive for hCMV). CONCLUSIONS: These results suggest that small amounts of enterovirus genome are commonly found in lesions of patients with advanced arteriosclerosis. Further studies are needed to evaluate the clinical significance of this association.

How to manage hypertension with atherosclerotic renal artery stenosis?

The management of atherosclerotic renal artery stenosis (ARAS) in patients with hypertension has been the topic of great controversy. Major contemporary clinical trials such as the Cardiovascular Outcomes for Renal Artery lesions (CORAL) and Angioplasty and Stenting for Renal Atherosclerotic lesions (ASTRAL) have failed to show significant benefit of revascularization over medical management in controlling blood pressure and preserving renal function. We present here the implications and limitations of these trials and formulate recommendations for management of ARAS.

Incidental disclosure of asymptomatic coronary embolic occlusion related to mitral valve papillary fibroelastoma: an unusual finding and a review of the literature.

Cardiac papillary fibroelastoma (CPF) located on mitral and aortic valves are known to produce systemic embolism mainly represented by strokes, whereas myocardial infarction and sudden death usually result from specific locations around LVOT. Coronary artery embolic occlusion originating from a mitral location has not yet been reported. The case is reported of a 42-year-old man referred for surgical treatment of a mitral valve papillary fibroelastoma disclosed after transitory and completely regressive left hemicorporeal deficiency and previous myocardial infarct. Due to the left chamber location, surgery was scheduled and complete removal of the mass achieved. These findings emphasize the potential life-threatening complications of CPF and, independent of risk factors, the need to perform systematic coronary angiography before surgical excision is considered.

Giant coronary artery aneurysm mimicking a compressive cardiac tumor Imaging features and operative strategy.

Giant atheromatous coronary aneurysms mimicking a cardiac tumor remain exceptional. We report the case of a patient who experienced a severe inferior myocardial infarction related to a giant thrombosed coronary aneurysm masquerading a cardiac tumor and compressing right cardiac cavities with mechanical detrimental consequences on tricuspid, mitral and aortic valvular competence. The contribution of imaging was essential to assess diagnosis, understand the physiopathogeny of myocardial and valvular consequences and plan the optimal surgical strategy.

Paroxysmal postural dyspnea related to a left atrial ball thrombus.

We report herein an uncommon clinical observation of a 82-year-old woman with paroxysmal postural dyspnea related to a giant ball-thrombus located in the left atrium and partly protruding through the mitral orifice. No mitral stenosis was otherwise disclosed. The patient had a previous medical history of chronic atrial fibrillation without any anticoagulant therapy. The atrial mass was easily removed and the postoperative course was uneventful. Disclosure of such a free-floating ball-thrombus in the left atrial cavity requires prompt surgical treatment because of high risks of acute hemodynamic decompensation due to obstruction of the left ventricular inflow or, more rarely, systemic embolic events.

European consensus on the diagnosis and management of fibromuscular dysplasia.

The main objectives of this expert consensus are to raise awareness about fibromuscular dysplasia, which is more frequent and more often systemic than previously thought and can sometimes have devastating consequences; to provide up-to-date recommendations for the diagnosis, evaluation, and management of the disease; and to identify research priorities. The emphasis has been put on recommendations for daily practice. The main topics covered include definition, classification, diagnosis, and management of fibromuscular dysplasia in adult patients with symptomatic involvement of the renal arteries, supra-aortic trunks, and digestive and peripheral arteries.

Takayasu arteritis in children.

Takayasu arteritis (TA) is a large vessel vasculitis that usually affects young female patients during the second and third decades of life, but has been reported in children as young as 24 months of age. Aim of this report was to describe four children (two girls) with TA, as well as summarizing main published studies. The mean age at presentation of our cases was 11 years (range 8-15). Three patients were Caucasians and one Asian. Arterial hypertension was the commonest mode of presentation followed by systemic symptoms. Other related symptoms were due to ischemia and consisted of abdomen, chest, and limb pain. An abdominal bruit was noted in only one patient. Inflammation markers were always abnormal. Angiography was performed in all cases; left subclavian artery and common carotid artery were more frequently involved. Renal artery stenosis was observed in two patients. One boy was diagnosed as having an associated immune deficiency (Wiskott-Aldrich syndrome). Treatment modalities included prednisone (n = 4), methotrexate (n = 3), and mycophenolate mofetil (MMF) (n = 1). Surgery was required in two patients. Follow-up ranged from 3 to 10 years since diagnosis. In three cases antihypertensive drugs and methotrexate were stopped, and prednisone was reduced to 7.5 mg/day.

Surgery of the abdominal aorta and its branches in children: late follow-up.

BACKGROUND: The aim of this study was to evaluate the late results in adult patients who underwent surgery of the abdominal aorta as children. METHODS: During a 17-year period, eight children underwent surgery for lesions of the abdominal aorta. There were 6 boys and 2 girls, with an average age of 10 years. The presenting symptom that led to diagnosis of abdominal aortic lesions was hypertension in five cases and lower-limb claudication in three. The underlying disease was middle aortic syndrome in three cases, infrarenal aortic hypoplasia in two, infrarenal aortic aneurysm in two, and Takayasu's disease in one. Five children had associated renal artery lesions, including four with bilateral lesions and one with a unilateral lesion. Aortic bypass was used in all cases. A straight tube graft was placed between the distal descending thoracic or supraceliac aorta and the infrarenal aorta in six cases, and a bifurcated bypass was placed between the infrarenal aorta and the iliac arteries in two. Renal artery revascularization procedures (n = 9) included ex vivo repair with renal autotransplantation in five cases, direct reimplantation on the arch of Riolan in two, and direct reimplantation of the renal artery onto the aortic graft in two. RESULTS: One patient died on postoperative day 1. The remaining seven patients recovered uneventfully. Mean follow-up was 10.2 years. No patient was lost to follow-up. Further surgical intervention was required in three patients. The indications for additional surgery were fibrosis of a renal artery reimplanted onto the graft at 3 years, deterioration of the aortoaortic graft at 5 years, and false iliac aneurysm at 20 years. All seven patients had normal physical development. The average increase in height and weight were 28.5 cm and 26.2 kg, respectively. All patients had normal sexual function, and two are parents. All patients are currently asymptomatic. Short Form 36 scores for quality-of-life parameters were 78% to 83%. CONCLUSIONS: Late results of abdominal aortic surgery in children, in our experience, are encouraging. Quality of life in adulthood was excellent. Insofar as possible, correction should be deferred until the child is 8 to 10 years old so that a prosthesis of sufficient diameter can be used.

Mid-term results of endovascular treatment for descending thoracic aorta diseases in high-surgical risk patients.

We report the initial experience of two cardiovascular surgery centers in the treatment of descending thoracic aorta lesions with covered stent grafts in high-surgical risk patients. From April 1999 to November 2004, 54 patients, mean age 64 years (range 16-83), were treated by stent graft for a lesion of the descending aorta (degenerative aneurysms n = 22, aortic dissections n = 12, chronic post traumatic aneurysms n = 5, anastomotic false aneurysms n = 2, penetrating ulcers n = 4, intramural hematomas n = 5, traumatic rupture n = 4), with 42.6% treated on an emergency basis. Three devices were used: Talent (n = 49), Excluder (n = 4), and Zenith (n = 1). In three patients, combined surgery of the proximal aorta was performed. Prior bypass of the left supra-aortic arteries was performed in four patients. The follow-up was clinical and radiological (plain chest film and computed tomographic scan) at 1, 3, 6, 12, 18, and 24 months and yearly thereafter. The stent graft was successfully deployed in all cases. Two early deaths related to the stent graft (one migration and aortic rupture and one stroke) and one related to adult respiratory distress syndrome occurred. Morbidity was 16.6% (iliac access damage n = 4, groin reintervention n = 3, transient ischemic attack n = 1, tamponade n = 1). The follow-up was 100% complete (mean 22.8 months, range 3-51). Fifteen primary endoleaks (type I n = 6, type II n = 8, type III n = 1) and one secondary endoleak were reported. They were treated by additional stent graft (n = 7) and elective surgical conversion (n = 1). Six endoleaks resolved spontaneously at 6 months, and two are being monitored. Twelve endoleaks (75%) occurred in patients treated for degenerative aneurysms. Freedom from secondary reintervention was 81.3% at 3 years. Two transient paraparesias were observed at 3 and 18 months. Of the 13 deaths observed during the follow-up, only one was related to the stent graft. Actuarial survival at 12 and 24 months was 90.0% and 75.4%, respectively. Mortality results are encouraging in this specific cohort of high-surgical risk patients. A new kind of morbidity is observed, related to endoleaks, whose necessary management could hinder the durability of the technique.

Off-pump myocardial revascularization in a diabetic patient with severe hemophilia B and impaired left ventricular function: hematological and operative strategies.

Coronary surgery with diabetes and severe hemophilia B is a challenging situation requiring specific and adequate therapeutic considerations. We herein report the case of a 52-year-old diabetic patient with severe factor IX deficiency and impaired ventricular function, who was scheduled for myocardial revascularization because of exertional angina and recurrent myocardial infarctions following infusions of factor IX concentrate. The patient underwent a successful off-pump direct myocardial revascularization with neither hemorrhagic nor thrombotic complications. Hematological protocols and operative strategies are assessed and discussed.

Beating-heart approach and moderately delayed surgical management of postinfarction ventricular septal rupture: an advisable approach to improve results?

Early repair of postinfarction ventricular septal rupture is usually associated with significant mortality and morbidity. Assessing conditions to moderately delay the surgical intervention and reduce cardioplegic arrest may be an interesting approach to improve hospital results. Results of five non-selected patients in whom surgery was moderately delayed and performed according a policy of reducing the cardioplegic-induced ischemia were reviewed. Surgical options are discussed as well as observed advantages.

Urgent carotid artery repair: retrospective study of 21 cases.

The purpose of this retrospective study was to assess the outcome of urgent surgical repair in patients with symptomatic carotid artery lesions. The study population included 21 patients who underwent carotid artery repair less than 24 hr after diagnostic work-up. Indications included crescendo transient ischemic attacks in 5 cases, fluctuating neurological deficits in 11, and stroke in evolution in 5. Immediate mortality was 9.5%. Mean follow-up was 55 months. Actuarial survival rates at 1 and 5 years were 90% and 62%, respectively. Actuarial neurological deficit-free rates at 1 and 5 years were 95% and 76%, respectively. The results of this study document the effectiveness of urgent carotid artery repair for treatment of acute cerebral ischemia. Although higher than elective surgery, morbidity and mortality are acceptable, given the severity of illness in this patient population.