Experimental Assessment of Physician Modified Proximal Scalloped Stent Graft to Extend Proximal Landing Zone in the Aortic Arch.

OBJECTIVE/BACKGROUND: The aim of the study was to assess a model of physician modified scalloped stent graft (PMSG) on currently available thoracic aortic devices to extend the proximal landing zone in either zone 2, 1 or 0 of the aortic arch while preserving flow in the supra-aortic vessels on human cadaveric aorta. METHODS: Fresh human aortas were harvested at autopsy from adult subjects. A proximal scallop was made on the stent grafts based on direct measurements on the aortas to extend the proximal landing zone in zone 0 (n = 5), zone 1 (n = 5), and zone 2 (n = 5). A previously described benchtop closed system pulsatile flow model was used to mimic flow and pressure conditions in the aorta to deploy the stent graft as close to physiological conditions as possible. Deployment accuracy of the scallop opposite the aortic arch branch ostia was assessed by completion angiography and post-procedural analysis of the aortas. RESULTS: Fifteen proximal scalloped stent grafts were deployed in the aortic arch of 15 human cadaveric aortas under fluoroscopy. The expected proximal landing zone was achieved in all cases (zone 2 = 5; zone 1 = 5; zone 0 = 5). Post-procedural angiography and direct visual analysis showed supra-aortic vessel patency and deployment of the scallop opposite the aortic arch branch ostia in all cases. CONCLUSION: PMSG to extend the proximal landing zone in zone 2, 1, or 0 in order to treat urgent diseases of the proximal descending aorta or the inner circumference of the aortic arch by a totally endovascular approach while preserving flow in the supra-aortic trunks is experimentally feasible.

Endovascular management of rupture in acute type B aortic dissections.

OBJECTIVE: Reports of thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection (ABAD) bring together a large range of clinical presentations. With a 30 day mortality of 50% when managed with open surgery, rupture is the most devastating complication of ABAD. This study investigated the outcome of TEVAR for ABAD complicated by rupture (r-ABAD) to assess the results of this particularly critical subgroup. METHODS: A review of consecutive TEVAR for r-ABAD in two tertiary referral centers was performed using a prospectively maintained database. RESULTS: Between 2000 and 2013, 24 patients (mean age 71 years; 14 males) underwent TEVAR for r-ABAD. Sixteen (67%) were in shock (Systolic blood pressure <80 mmHg) before surgery. Seven patients had coverage of the left subclavian artery, of whom four had partial arch debranching procedures via cervical access concomitant with TEVAR. Median length of aortic coverage was 150 mm, median proximal oversizing was 13.3% (range 6.2-33.3%). Technical success was achieved in 100%. There were four in hospital deaths (16%). Two patients (8%) had paraplegia, but neither stroke nor renal insufficiency requiring dialysis occurred. During a mean follow up of 28 months, there was one aortic dissection related death and eight patients (40% of the surviving patients) required re-intervention. All re-interventions were managed endovascularly. At last follow up CT scan, eight patients (40%) had complete remodeling of the aortic wall. CONCLUSION: With 16% in hospital mortality and 8% early major complications, this study confirms the feasibility of TEVAR for r-ABAD with a lower peri-operative morbidity and mortality rate compared with open surgery. Given the high rate of re-intervention, close follow up is required in surviving patients.

Open surgical secondary procedures after thoracic endovascular aortic repair.

OBJECTIVES: Improved outcomes of thoracic endovascular aortic repair (TEVAR) compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. As the number of TEVAR survivors has grown, reports of complications have similarly increased. Although secondary endovascular rescue measures are often undertaken, patients with serious complications are often converted, ultimately, to open repair. The aim of this study was to assess causes and midterm results of open surgical secondary procedures after thoracic endovascular aortic repair. METHODS: A total of 236 patients underwent TEVAR. Fourteen of these patients required open repair because of six aortobronchial fistulas, four retrograde type A dissections, two aneurysm enlargement without endoleak, one thoracic stent-graft collapse, and one aortoesophageal fistula. Eight (57.1%) patients underwent surgical repair using cardiopulmonary bypass. Six stent-grafts were totally removed, and eight stent-grafts were left in situ. Four patients underwent supracoronary ascending aorta replacement, and one an extensive replacement of the aortic arch through sternotomy. Three patients had descending aortic replacement through left thoracotomy combined with a total esophagectomy in one case. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass and stent-graft explantation. One patient was treated by exclusion bypass of the descending thoracic aorta. Pulmonary resection and large pleural or intercostal muscle flap interposition to wrap the stent-graft left in situ was done in four cases of aortobronchial fistula. RESULTS: All patients survived the surgical procedure. Ten patients (71%) had an uneventful postoperative course. There were two in-hospital deaths (14.3%). Both died from multi-organ failure in the early postoperative course after surgical repair of a stent-graft infection and an aortoesophageal fistula. One patient suffered a definitive paraplegia and a secondary aortoesophageal fistula requiring reoperation for esophageal repair. One patient, treated by pulmonary resection and flap interposition to wrap the stent-graft, underwent stent-graft explantation and in situ descending aortic replacement because of stent-graft reinfection. Actuarial survival was 87.7% after a mean follow-up of 26.3 months (range 9-72 months). CONCLUSIONS: Complications or prevention of complications after TEVAR either due to device failure or adverse events may require conversion to open repair or additional open surgical procedure. Open repair can be performed by a team experienced in management of diseases of the thoracic aorta and a low mortality rate achieved despite the precarious preoperative conditions and complex aortic pathologies of patients.

Endovascular repair of aorto-iliac artery injuries after lumbar-spine surgery.

OBJECTIVE: This study aims to describe the endovascular management of abdominal-aortic- or common-iliac-artery injuries after lumbar-spine surgery. METHODS: Patients treated for abdominal-aortic- or common-iliac-artery injuries after lumbar-spine surgery during a 13-year period were identified from an endovascular database, providing prospective information on techniques and outcome. The corresponding patient records and radiographic reports were analysed retrospectively. RESULTS: Seven patients were treated with acute (n = 3) or subacute (n = 4) injuries of the common iliac artery (n = 6) or abdominal aorta (n = 1) after lumbar-spine surgery. Vascular injuries included arterial lacerations (n = 3), arteriovenous fistulas (n = 2) and pseudo-aneurysms (n = 2). The mean age of the patients was 51.7 years (30-60 years), 71.4% were women. These lesions were repaired by transluminal placement of stent grafts: Passager (n = 3), Viabahn (n = 1), Wallgraft (n = 1), Zénith (n = 1) and Advanta V12 (n = 1). Exclusion of the injury was achieved in all cases. Mortality was nil. There were no procedure-related complications. During a median follow-up of 8.7 years (range 0.3-13 years), all stent grafts remained patent. CONCLUSIONS: Sealing of common iliac artery or abdominal aortic lesions as a complication of lumbar-disc surgery with a stent graft is effective and is suggested as an excellent alternative to open surgery for iatrogenic great-vessel injuries, particularly in critical conditions.

Preoperative assessment of anatomical suitability for thoracic endovascular aortic repair.

Endovascular treatment of descending thoracic aortic pathologies requires a preoperatively determined interventional strategy. Its feasibility depends mainly on anatomic factors: the morphology of the proximal and distal fixation sites, the diameter and disease state of the access vessels. These factors represent important predictors of success and the most important exclusion criteria. Current diagnostic evaluation of aortic aneurysm for endovascular repair relies primarily on CT scan associated with 3D-reconstruction to assess the anatomical suitability for endograft implantation. In patients with an inadequate length of the proximal or distal neck, the left subclavian artery or the coeliac trunk can be overstented to effectively exclude thoracic aortic lesions. Deliberate coverage of aortic side branches should be decided prior to the procedure (guided by a extensive anatomical assessment) or carefully be avoided in order to reduce major morbidity, especially cerebral embolization, spinal cord ischemia and ischemic abdominal complications.

Imaging of postoperative complications following surgery for lung cancer.

The complications following surgery for lung cancer vary depending upon the comorbidities and the type of surgery. Hemorrhage, infections and pulmonary edemas are not specific to the type of resection but frequently occur following pneumonectomies. Morbidity following pneumonectomies is related to the significant changes in the contents of the intrathoracic space. Pulmonary infarction and torsion are emergency situations that develop following lobectomy. CT shows features of localized congestion and stenosis or occlusion of a vein or bronchus. Rapid identification of severe events, in particular by systematic CT is essential for appropriate management of a postoperative or delayed complication of lung cancer surgery.

Normal postoperative appearances of lung cancer.

The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through open surgery through a thoracotomy or by video-assisted mini-invasive surgery for lobectomies and sublobar resections. Understanding the procedures involved allows the normal postoperative appearances to be interpreted and these normal anatomical changes to be distinguished from potential postoperative complications. Surgery results in a more or less extensive physiological adaptation of the chest cavity depending on the lung volume, which has been resected. This adaptation evolves during the initial months postoperatively. Chest radiography and computed tomography can show narrowing of the intercostal spaces, a rise of the diaphragm and shift of the mediastinum on the side concerned following major resections.

Typical and atypical bronchopulmonary carcinoid tumors: a clinicopathologic and KI-67-labeling study.

Expression of a proliferating antigen by KI-67 immunohistochemistry was analyzed with a SAMBA 2005 computer-assisted image processor (Traitement de l'Information for des Techniques Nouvelles, Grenoble, France) in 47 surgically resected bronchopulmonary carcinoids embedded in paraffin. The clinicopathologic characteristics and KI-67 labeling, expressed in percentage of stained nuclear surface relative to the total nuclear surface, of 31 typical carcinoids and 16 atypical carcinoids were compared and assessed with respect to patient survival. The proliferation status was significantly higher in histologically atypical than in typical carcinoids. Moreover, using a 4% cutoff, we observed a significant difference for the 4-year overall survival rate. Semiquantitative analysis of the proliferation index by KI-67 immunostaining seemed to be an effective means of identifying high risk subsets among patients with histologically atypical carcinoids and for whom adjuvant chemotherapy could be proposed.

Descending necrotizing mediastinitis. Advantage of mediastinal drainage with thoracotomy.

Descending necrotizing mediastinitis can occur as a complication of oropharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed diagnosis and inadequate mediastinal drainage through a cervical or minor thoracic approach are the primary causes of a high published mortality rate (near 40%). Between 1985 and 1992, six men (mean age, 49 years) with descending necrotizing mediastinitis were surgically treated at our institution. The primary oropharyngeal infection was peritonsillar abscess (three cases) and odontogenic abscess (three cases). In all cases, occurrence of respiratory insufficiency associated with serious cervical infection suggested the mediastinitis diagnosis. Computed tomographic scans confirmed the mediastinitis, showing mediastinal abscess and mediastinal emphysema. All patients underwent surgical drainage of the deep neck infection combined with mediastinal drainage through a thoracic approach. The outcome was favorable in five patients who had mediastinal drainage through a thoracotomy; the patient who had mediastinal drainage through a minor thoracic approach (anterior mediastinotomy) died of tracheal fistula on postoperative day 18. In our experience, aggressive mediastinal drainage by a thoracotomy approach regardless of the level of mediastinal involvement led to improvement in survival of these patients, with a 17% mortality rate.

Immunohistochemical study of P-glycoprotein distribution in lung cancer.

Indirect immunoperoxidase was used to determine the reactivity of C219 (P-glycoCHEK C219, Centocor Diagnostics, Malvern, PA), a monoclonal antibody (Mab) with high affinity for an internal epitope of the P-glycoprotein encoded by the multidrug resistance (MDR1) gene, in 40 surgically resected primary lung tumours. C219 reactivity was qualitatively classified in seven small cell lung cancers (SCLC), 29 non small cell lung cancers (NSCLC), and four carcinoid tumours. Ploidy was analysed by means of static cytometry using a computer-assisted image processor following Feulgen staining of cytologic prints of 32/40 lung tumours. Indirect immunoperoxidase reactivities of Mabs S-L 11.14 and MOC-1 were also studied to characterize the expression of cluster 1 lung cancer antigens and hence to determine among the NSCLC those which expressed the neural cell adhesion molecule (NCAM). Eighteen (45%) lung tumours strongly expressed P-glycoprotein as an immunostaining of many islets of malignant cells or almost all malignant cells. In addition, 8/40 tumours (20%) showed a weak reactivity (few immunostained cells) and 14/40 (35%) no reactivity. There was no difference of reactivity when NSCLC were compared with SCLC. The expression of P-glycoprotein in NSCLC did not vary significantly when the stage of disease was considered. Among the 29 NSCLC, 10 (36%) expressed S-L 11.14 and MOC-1. The NCAM positive NSCLC did not show any difference of P-glycoprotein expression in comparison with NCAM negative ones. Finally, C219 immunoperoxidase reactivity did not significantly differ according to the ploidy status. In conclusion, the internal epitope of the P-glycoprotein encoded by the MDR1 gene is frequently expressed by lung tumours of any histological type. This expression is not higher in Stage III and IV lung cancers in comparison with Stage I and II ones, or in NSCLC in comparison with SCLC either. Thus, the C219 related epitope seems to have a weak implication in the lower chemosensitivity of both advanced stages and NSCLC.

Detection of lymph node metastases in lung cancer: comparison of 131I-anti-CEA-anti-CA 19-9 immunoscintigraphy versus computed tomography.

Mediastinal lymph node metastasis is one of the most important prognostic variables of lung cancer. We designed a study to compare immunoscintigraphy (IS) using iodine-131 anti-carcinoembryonic antigen (CEA) and anti-carbohydrate 19-9 (CA 19-9) monoclonal antibody and computed tomography (CT-scan), in the setting of mediastinal staging. Seventeen patients were involved in a prospective, blind study, to compare IS with CT-scan imaging of the mediastinum. Sensitivity and specificity of both methods were analyzed with reference to pathological staging by mediastinal lymph node sampling. IS imaging was not possible in two patients owing to a thyroid uptake and one patient refused surgery. Among the 14 evaluable patients, sensitivity and specificity were 0.83 and 0.12 for IS, and 0.66 and 0.50 for CT-scan, respectively. We used different thresholds of positivity for both methods in order to evaluate the sensitivity-specificity relationship. When compared with that of IS, the area under the receiver operating characteristic (R.O.C.) curves of the CT-scan was bigger. Although one patient had pathologically confirmed N2 with negative CT-scan and positive IS, the results of IS were hampered by a very high level of false positivity. Finally, there was no relationship between positivity of IS and a high serum CEA level. Lack of specificity and the insufficient sensitivity of the iodine-131 anti-CEA-anti-CA 19-9, lead to the conclusion that IS adds weak information to a CT-scan, in the non-invasive mediastinal staging of lung cancer. More efficient radionuclides and markers are needed in the setting of lung cancer staging.

Membranous tracheal rupture after endotracheal intubation.

BACKGROUND: Tracheobronchial rupture after tracheal intubation has been infrequently reported. We report 6 cases of membranous tracheal rupture after endotracheal intubation treated at our institution over 7 years. METHODS: Overinflation of the tracheal cuff was speculated to be a frequent cause of the tracheal damage because the lesion was always a linear laceration of the posterior membranous wall. The diagnosis was suspected on the basis of common signs such as subcutaneous emphysema, respiratory distress, pneumomediastinum, and pneumothorax. Fiberoptic bronchoscopy was the best means of confirming the diagnosis and determining the location and extent of the lesion. In 5 patients, extensive laceration with severe respiratory disorders required emergent repair through a right posterolateral thoracotomy. RESULTS: There were two postoperative deaths unrelated to the tracheal lesion. A patient with a small tracheal defect and favorable clinical presentation showed a rapid positive outcome after conservative treatment. CONCLUSIONS: Tracheal intubation-related airway ruptures are rare but probably underestimated. Early recognition and emergent repair are essential, because failure to do so could result in potentially lethal events.

Tracheoesophagogastric anastomosis fistula: a rare complication of esophagectomy.

Fistulas between trachea and esophagogastric anastomosis after esophagectomy are uncommon. We describe 2 patients with such a lesion successfully managed with single-stage repair. The fistula was divided, the tracheal defect was closed directly or with a free pericardial graft, and the esophagogastric anastomosis was redone. A muscle or pleural flap was used to separate the tracheal and digestive suture lines. This treatment of a potentially life-threatening condition yielded excellent results without postoperative complications.

Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease.

BACKGROUND: Descending necrotizing mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high mortality associated with this disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial. METHODS: Over a 10-year period, 12 patients were treated at our institution. Surgical treatment consisted of 1 or several cervical drainages, associated with drainage of the mediastinum through a thoracic approach in 11 patients. Thoracic procedures included radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication, and pleural drainage with adequate placement of chest tubes for mediastinopleural irrigation. Transcervical mediastinal drainage was performed in only 1 patient. RESULTS: The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the second required new drainage through a thoracotomy. The patient who had transcervical mediastinal drainage without a thoracic approach presented an abscess limited to the anterior and superior mediastinum. In 3 patients, ongoing mediastinal sepsis required a second thoracotomy. CONCLUSION: A stepwise approach with transcervical mediastinal drainage is first justified in patients with very limited disease to the upper mediastinum. However, ongoing mediastinal sepsis requires new drainage, through a major thoracic approach, without delay. Extensive mediastinitis can not be adequately treated without mediastinal drainage including a thoracotomy. This aggressive surgical policy has allowed us to maintain a low mortality rate (16.5%) in a series of 12 patients with this highly lethal disease.

Carcinoid tumors of the lung: do atypical features require aggressive management?

Atypical carcinoids are an intermediate form of tumor between low-grade malignant typical carcinoid and high-grade malignant small cell carcinoma, which represent the two ends of the spectrum of neuroendocrine bronchopulmonary tumors. Between 1983 and 1993, 27 patients with atypical carcinoids underwent surgical treatment. The histologic diagnosis of an atypical carcinoid was established if the criteria proposed by Arrigoni and associates were fulfilled. Seven pneumonectomies, 16 lobectomies, 2 segmentectomies, and 2 wedge resections were performed. Thirteen patients (48.1%) had regional nodal metastases and 6 patients (22%) had N2 disease at the time of surgical therapy. Distant metastases developed in 5 patients (18.5%) after initial treatment. The 10-year survival in patients with an atypical carcinoid was 49%, versus the 84% 10-year survival rate observed in patients with a typical carcinoid. We conclude that the aggressive behavior of atypical carcinoids precludes the use of limited surgical resection and requires a more aggressive approach, with lobectomy and mediastinal lymph node dissection constituting a minimal procedure. The same criteria used for well-differentiated lung carcinoma should apply to this form of neuroendocrine lung tumor. Adjuvant chemotherapy is recommended for patients with stage III or distant metastases.

Use of active shunt for surgical repair of intrapericardial inferior vena caval injury.

We report a case of intrapericardial inferior vena caval disruption due to goring by a bull, and we describe the surgical repair of this uncommon penetrating cardiac injury. Review of the literature indicates that, as with other penetrating cardiac injuries, this rare lesion requires aggressive treatment involving an emergency thoracotomy. The use of an atrial caval active shunt was necessary for successful surgical management, and therefore we conclude that surgical treatment of this lesion is comparable with surgical repair of hepatic veins and retrohepatic vena caval injuries incurred during blunt vascular trauma or penetrating abdominal injuries.

Cervical-to-petrous internal carotid artery saphenous vein in situ bypass for the treatment of a high cervical dissecting aneurysm: technical case report.

OBJECTIVE AND IMPORTANCE: We describe a novel cervical-to-petrous internal carotid artery (ICA) saphenous vein in situ bypass for the treatment of a high cervical dissecting aneurysm. The cervical ICA has no major collateral branches and can be used as a tunnel for the vein graft. CLINICAL PRESENTATIONS: A 25-year-old man was involved in a car accident. A cerebral angiogram revealed a right ICA dissection with aneurysm formation at the C1-C2 level. The patient recovered fully and was anticoagulated. Six months after the initial angiogram, a second angiogram disclosed ICA stenosis (80%) and persistence of the traumatic dissecting aneurysm. Definitive surgical bypass was considered the most appropriate course of action. TECHNIQUE: The horizontal portion of the petrous ICA was exposed by an extradural subtemporal approach. The cervical arteries were exposed by a separate surgical incision. After dividing the petrous ICA and the cervical ICA, the cervical ICA was dilated using a Fogarty balloon embolectomy catheter. A saphenous vein graft was inserted inside the lumen of the cervical ICA and was anastomosed to the ICA end-to-end both proximally and distally (cervical-to-petrous ICA in situ bypass). The graft was patent on the follow-up angiogram. CONCLUSION: We describe a new technique that could be considered an alternative to the classical extra-anatomic cervical-to-petrous ICA bypass procedures.

[Tracheal neurofibroma and Recklinghausen's disease]. / Neurofibrome trachéal et maladie de Recklinghausen.

Neurogenic tumours arising in the trachea are rare; the association with Von Recklinghausen's disease is exceptional. Only two cases of tracheal neurofibroma with neurofibromatosis have been reported. We report on another patient, a thirty year old man, who presented with acute shortness of breath; laser resection was performed via an endotracheal approach, then, a few days later, resection of the exotracheal tumor and tracheal segment was performed. Postoperatively, the patient did well for nine years without any respiratory complaint or neurofibromatosis relapse.

[Heterogeneity of bronchial carcinoid tumors. Place of atypical forms]. / Hétérogénéité des carcinoïdes bronchiques. Place des formes atypiques.

Atypical carcinoid is an intermediate form between low grade malignant typical carcinoid and high grade malignant small cell carcinoma which are the two ends of the spectrum of neuroendocrine bronchopulmonary tumors. Between 1983 and 1993, twenty-three atypical carcinoids underwent surgical treatment. Histologic diagnosis of atypical carcinoid was established if the criteria proposed by Arrigoni et al, were fulfilled. Diagnosis was most frequently based on screening chest roentgenogram (56%). CT-scan findings showed a nodular peripheral mass in 65% of patients and central mass or atelectasis in 35% of patients. Four pneumonectomies, 15 lobectomies, 2 segmentectomies and 2 wedge resections were performed. Nine patients (39%) had regional nodal metastases and 4 patients (17%) had mediastinal nodal metastases (N2 disease) at the time of surgery. There were 4 death related to recurrence of the disease with distant metastasis in 3 patients (14%). Ten-year survival in atypical form was 59% contrasting with the 90% ten-year survival rate in patient with typical form operated on the same period. Because of their aggressive behavior, atypical carcinoids were comparable to well differentiated carcinoma of the lung and require an aggressive approach with lobectomy and mediastinal lymph node dissection being a minimum procedure.

[A rare pulmonary tumor: pneumoblastoma. Apropos of a case and review of the literature]. / Une tumeur pulmonaire rare: le pneumoblastome. A propos d'un cas et revue de la littérature.

A case of pneumoblastoma concerning a 33 year old man, incidentally discovered on a systematic chest X Ray, is reported. The radiologic findings include a voluminous and peripherical mass with necrotic zones. The pathologic findings in optic microscopy and the special technics consist in the three cellular contingents which form the pneumoblastoma: clusters of indifferentiated cells, epithelial cells and spindle cells. All the features show clearly a blastomatic character very similar to a foetal lung which allows to differentiate the pulmonary blastoma from carcinosarcoma. The authors, through a review of the literature, demonstrate the rarity (less than 100 cases reported), the malignant evolution which metastasis and the age (strong majority of adults) which characterize this pathology.