Survival outcomes following urgent lung transplantation in France and the USA.

INTRODUCTION: Lung graft allocation can be based on a score (Lung Allocation Score) as in the USA or sequential proposals combined with a discrete priority model as in France. We aimed to analyse the impact of allocation policy on the outcome of urgent lung transplantation (LT). METHODS: US United Network for Organ Sharing (UNOS) and French Cristal databases were retrospectively reviewed to analyse LT performed between 2007 and 2017. We analysed the mortality risk of urgent LT by fitting Cox models and adjusted Restricted Mean Survival Time. We then compared the outcome after urgent LT in the UNOS and Cristal groups using a propensity score matching. RESULTS: After exclusion of patients with chronic obstructive pulmonary disease/emphysema and redo LT, 3775 and 12 561 patients underwent urgent LT and non-urgent LT in the USA while 600 and 2071 patients underwent urgent LT and non-urgent LT in France. In univariate analysis, urgent LT was associated with an HR for death of 1.24 (95% CI 1.05 to 1.48) in the Cristal group and 1.12 (95% CI 1.05 to 1.19) in the UNOS group. In multivariate analysis, the effect of urgent LT was attenuated and no longer statistically significant in the Cristal database (HR 1.1 (95% CI 0.91 to 1.33)) while it remained constant and statistically significant in the UNOS database (HR 1.12 (95% CI 1.05 to 1.2)). Survival comparison of urgent LT patients between the two countries was significantly different in favour of the UNOS group (1-year survival rates 84.1% (80.9%-87.3%) vs 75.4% (71.8%-79.1%) and 3-year survival rates 66.3% (61.9%-71.1%) vs 62.7% (58.5%-67.1%), respectively). CONCLUSION: Urgent LT is associated with adverse outcome in the USA and in France with a better prognosis in the US score-based system taking post-transplant survival into account. This difference between two healthcare systems is multifactorial.

Is Night Surgery a Nightmare for Lung Transplantation?

Night work is frequently associated with sleep deprivation and is associated with greater surgical and medical complications. Lung transplantation (LT) is carried out both at night and during the day and involves many medical healthcare workers. The goal of the study was to compare morbidity and mortality between LT recipients according to LT operative time. We performed a retrospective, observational, single-center study. When the procedure started between 6 AM and 6 PM, the patient was allocated to the Daytime group. If the procedure started between 6 PM and 6 AM, the patient was allocated to the Nighttime group. Between January 2015 and December 2020, 253 patients were included. A total of 168 (66%) patients were classified into the Day group, and 85 (34%) patients were classified into the Night group. Lung Donors' general characteristics were similar between the groups. The 90-day and one-year mortality rates were similar between the groups (90-days: n = 13 (15%) vs. n = 26 (15%), p = 0.970; 1 year: n = 18 (21%) vs. n = 42 (25%), p = 0.499). Daytime LT was associated with more one-year airway dehiscence (n = 36 (21%) vs. n = 6 (7.1%), p = 0.004). In conclusion, among patients who underwent LT, there was no significant association between operative time and survival.

Single Primary Retrograde Access to Treat Femoro-Popliteal Occlusive Lesions.

INTRODUCTION: The retrograde puncture of a distal artery is considered a bailout procedure in case of anterograde approach failure for peripheral artery disease (PAD) treatment. A single primary retrograde access has been suggested as an efficient and safe option. As scant data are available, we present our results using this approach. MATERIAL AND METHODS: Between August 2019 and October 2022, we performed this technique in selected patients with femoro-popliteal PAD. Chronic total occlusions (CTOs) were selected on the basis of the CTOP classification. An ultrasound-guided retrograde puncture of a tibial artery at the ankle level was performed, followed by the preferential use of 4F materials. Hemostasis of the puncture site was obtained using manual compression. Postoperative duplex scan examination systematically included an evaluation of the punctured artery. Demographics, intraoperative, and follow-up data were collected retrospectively. The results are expressed as means with standard deviations and numbers with percentages when appropriate. RESULTS: In total, 55 procedures were performed in 46 patients (9 bilateral). Of these, 57% (N=26) were considered at risk for femoral puncture (obesity, history of groin surgery, challenging crossover approach) and 54% (N=25) presented with critical limb-threatening ischemia (CLTI). The TASC-II femoro-popliteal classification was generally B (60%) and also C (33%) or D (7%). Mean lesion length was 105.6±49.4 mm and 65% were CTOs. Most patients were operated in an outpatient setting (N=25; 54%) under potentialized local anesthesia (N=41, 89%). The punctured site was the posterior tibial artery in 73% (N=40). The procedure time was 65.1±25.7 minutes, and the fluoroscopy time was 10.7±8.5 minutes. The technical success rate was 100%. There were no intraoperative complications. All patients could walk the same day. One CLTI patient presented an erysipelas related to the puncture in postoperative period. At 30 days, the primary patency of the treated and the punctured arteries were 98% and 100%, respectively. CONCLUSION: A single primary retrograde access can be used safely to treat femoro-popliteal PAD. It represents a valuable alternative to the femoral puncture and allows fast ambulation. Prospective and long-term studies on larger populations are necessary to confirm our results. CLINICAL IMPACT: This study demonstrates that a single primary retrograde access can be used safely without damaging the punctured artery to treat femoro-popliteal lesions, especially in claudicant patients. Chronic total occlusions can be treated successfully using this technique. This approach represents a valuable alternative to the femoral puncture and allows fast ambulation without risk of major bleeding.

Volumetric Analysis of Progressive Remodeling of Isolated Mesenteric Artery Dissection Treated by Conservative Therapy.

PURPOSE: To characterize remodeling of conservatively treated isolated mesenteric artery dissection (IMAD) using 3-dimensional (3D) volumetric analysis. MATERIAL AND METHODS: Patients with Type I/II (classification of Yun) treated by conservative therapy between January 2018 and January 2020 were prospectively included. Semiautomatic morphological analysis of the superior mesenteric artery (SMA) included volumetric measurements of the true lumen (TL), false lumen (FL), and overall lumen (OL) and 3D aortomesenteric angles from computed tomography angiography data at admission (T0), 1 month (T1), and 12 months (T12). The SMA morphology of patients with IMAD (n = 15, mean age 53 years ± 7; 87% men) was also compared with that of control individuals (n = 51, mean age 56 years ± 4; 94% men). RESULTS: A significant reduction in OL volume was observed (P <.001), whereas TL volume remained stable (P =.23). The TL/OL volume ratio significantly increased over time (P =.001) from 53% at T1 to 78% at T12. Aortomesenteric 3D angles at 2, 4, and 6 cm from the ostium showed a progressive decrease toward values observed in the control group (P =.013, P =.002, and P =.027, respectively). At T12, 5 patients (33%) had complete remodeling, and aneurysmal change was observed in 2 patients (<20 mm). Smoking and SMA angle at a distance of 6 cm from the ostium (T0) were the only factors affecting remodeling negatively at T12. CONCLUSIONS: One-year remodeling in IMAD followed an overall decrease in OL volume related to a decrease in FL volume. Smokers and patients with larger SMA angles at baseline showed poorer remodeling. Spontaneous arterial remodeling in IMAD might favor conservative therapy.

Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification.

OBJECTIVE: The aim of this study was to propose computed tomography angiography (CTA) based anatomical segmentation of the superior mesenteric artery (SMA), in order to standardise the reporting of occlusive lesions in acute mesenteric ischaemia (AMI). METHODS: A retrospective CTA evaluation of patients with occlusive AMI admitted between 2016 and 2021. After the screening of 468 patients, 95 were included. The SMA was segmented into proximal (S1, ostium to the inferior pancreaticoduodenal artery), middle (S2, from the inferior pancreaticoduodenal to the ileocolic artery), and distal (S3, downstream the ileocolic artery) sections. The jejunal arteries were labelled J1 to J6, and the middle, right, and ileocolic arteries C1, C2, and C3. Two radiologists independently applied the proposed segmentation to a cohort of patients with occlusive AMI to describe occlusive lesions. Intra- and inter-rater agreement was assessed with kappa statistics. RESULTS: Occlusions involved one segment in 50 (53%) patients (S1, n = 27 [28%]; S2, n = 12 [13%]; S3, n = 11 [12%]); two segments in 37 (39%) patients (S2/S3, n = 31 [33%]; S1/S2, n = 3 [3%]; S1/S3, n = 3 [3%]); and all three segments in eight patients (S1/S2/S3, 8%). The median number of jejunal arteries was four (interquartile range 3, 4.5). C1 and C2 were present in 93 (98%) and 23 patients (24%), respectively. Almost perfect intra-rater agreement was obtained for S1 (91% agreement, κ = 0.82, 95% confidence interval [CI] 0.72 - 0.92); substantial agreement was obtained for S2 (90% agreement, κ = 0.80, 95% CI 0.68 - 0.92) and S3 (86% agreement, κ = 0.72, 95% CI 0.58 - 0.86). Almost perfect inter-rater agreement (with the second junior reading) was obtained for S1 (97% agreement, κ = 0.95, 95% CI 0.89 - 1.0), S2 (91% agreement, κ = 0.82, 95% CI 0.72 - 0.92), and S3 (agreement 96%, κ = 0.91, 95% CI 0.83 - 0.99). CONCLUSION: A standardised CTA based anatomical segmental description of SMA occlusive lesions in AMI is proposed; it provided substantial to almost perfect intra- and inter-rater agreement for most anatomical segments.

Risk of Bronchial Complications After Lung Transplantation With Respiratory Corynebacteria. Results From a Monocenter Retrospective Cohort Study.

Corynebacterium spp. are associated with respiratory infections in immunocompromised hosts. A link with bronchial complications after lung transplantation (LTx) has been suggested. We aimed to assess the link between respiratory sampling of Corynebacterium spp. and significant bronchial complication (SBC) after LTx. We performed a single center retrospective study. Inclusion of LTx recipients with at least one respiratory Corynebacterium spp. sample (July 2014 to December 2018). Subjects were matched to unexposed LTx recipients. Primary outcome was SBC occurrence after Corynebacterium spp. isolation. Secondary outcomes were Corynebacterium spp. persistent sampling, chronic lung allograft dysfunction (CLAD) onset and all-cause mortality. Fifty-nine patients with Corynebacterium spp. sampling with 59 without isolation were included. Corynebacterium spp. identification was not associated with SBC occurrence (32.4% vs. 21.6%, p = 0.342). Previous SBC was associated with further isolation of Corynebacterium spp. (OR 3.94, 95% CI [1.72-9.05]). Previous SBC and corticosteroids pulses in the last 3 months were the only factors associated with increased risk of Corynebacterium spp. isolation in multivariate analysis. Corynebacterium spp. sampling was significantly associated with CLAD onset (27.1% vs. 6.9%, p = 0.021). Corynebacterium spp. isolation was not associated with SBC but with higher risk of CLAD. Whether CLAD evolution is affected by Corynebacterium spp. eradication remains to be investigated.

Low HDL-Cholesterol Concentrations in Lung Transplant Candidates are Strongly Associated With One-Year Mortality After Lung Transplantation.

High-density lipoproteins (HDLs), whose main role is the reverse transport of cholesterol, also have pleiotropic anti-inflammatory, antioxidant, anti-apoptotic and anti-infectious properties. During sepsis, HDL cholesterol (HDL-C) concentration is low, HDL particle functionality is altered, and these modifications are correlated with poor outcomes. Based on the protective effects of HDL, we hypothesized that HDL-C levels could be associated with lung transplantation (LT) outcome. We thus looked for an association between basal HDL-C concentration and one-year mortality after LT. In this single-center prospective study including consecutive LTs from 2015 to 2020, 215 patients were included, essentially pulmonary fibrosis (47%) and chronic obstructive pulmonary disease (COPD) (38%) patients. Mortality rate at one-year was 23%. Basal HDL-C concentration stratified nonsurvivors to survivors at one-year (HDL-C = 1.26 [1.12-1.62] mmol/L vs. HDL-C = 1.55 [1.22-1.97] mmol/L, p = 0.006). Multivariate analysis confirmed that HDL-C concentration during the pretransplant assessment period was the only variable inversely associated with mortality. Moreover, mortality at one-year in patients with HDL-C concentrations ≤1.45 mmol/L was significantly higher (log-rank test, p = 0.00085). In conclusion, low basal HDL-C concentrations in candidates for LT are strongly associated with mortality after LT. To better understand this association, further studies in this field are essential and, in particular, a better characterization of HDL particles seems necessary.

Impact of Culture-Positive Preservation Fluid on Early Morbidity and Mortality After Lung Transplantation.

The prevalence, risk factors and outcomes associated with culture-positive preservation fluid (PF) after lung transplantation (LT) are unknown. From January 2015 to December 2020, the microbiologic analyses of PF used to store the cold ischaemia-placed lung graft(s) of 271 lung transplant patients were retrospectively studied. Culture-positive PF was defined as the growth of any microorganism. Eighty-three (30.6%) patients were transplanted with lung grafts stored in a culture-positive PF. One-third of culture-positive PF were polymicrobial. Staphylococcus aureus and Escherichia coli were the most frequently isolated microorganisms. No risk factors for culture-positive PF based on donor characteristics were identified. Forty (40/83; 48.2%) patients had postoperative pneumonia on Day 0 and 2 (2/83; 2.4%) patients had pleural empyema with at least one identical bacteria isolated in culture-positive PF. The 30-day survival rate was lower for patients with culture-positive PF compared with patients with culture-negative PF (85.5% vs. 94.7%, p = 0.01). Culture-positive PF has a high prevalence and may decrease lung transplant recipient survival. Further studies are required to confirm these results and improve understanding of the pathogenesis of culture-positive PF and their management.

Ultrasonography in thoracic and abdominal stab wound injury: results from the FETTHA study.

BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

Colonic involvement in acute mesenteric ischemia: prevalence, risk factors, and outcomes.

OBJECTIVES: This study aimed to investigate the prevalence, risk factors, and outcomes of colonic involvement in patients with acute mesenteric ischemia (AMI). METHODS: CT scans from a prospective cohort of 114 AMI patients treated in an intestinal stroke center between 2009 and 2018 were blindly reviewed by two radiologists. Colon involvement was defined on CT scan by the presence of at least one of the following CT colonic features: wall thickening, pneumatosis, decreased wall enhancement, dilatation, or perforation. In addition, the clinical, biological, and radiological characteristics of patients with and without colonic involvement were compared to identify risk factors for colonic involvement on CT and its impact on morbidity and mortality. RESULTS: Colonic involvement was identified in 32/114 (28%) patients with AMI, the right colon being more frequently involved (n = 29/32, 91%). Wall thickening (n = 27/32) was the most common CT finding. Occlusion of the inferior mesenteric artery was the only statistically significant risk factor for colonic involvement (35% vs. 15%, p = 0.02). Patients with colonic involvement on CT vs. those without had more frequently transmural colonic necrosis (13% vs. 0%, p = 0.006), short bowel syndrome (16% vs. 4%, p = 0.04), need for long-term parenteral support (19% vs. 5%, p = 0.03), and death during follow-up (22% vs. 10%, p = 0.03). DISCUSSION: In patients with AMI, colonic involvement is associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment. KEY POINTS: • In a prospective cohort of acute mesenteric ischemia patients from an intestinal stroke center, 28% had an associated colonic involvement on CT. • Colonic involvement on CT most commonly affected the right colon, and the occlusion of the inferior mesenteric artery was the only risk factor. • Colonic involvement on CT was associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment.

Endovascular revascularization of acute arterial mesenteric ischemia: report of a 3-year experience from an intestinal stroke center unit.

OBJECTIVE: To report the 3-year experience of endovascular revascularization of acute arterial mesenteric ischemia (AMI) from an intestinal stroke center unit (ISCU). METHOD: All data from patients admitted to the ISCU between January 2016 and January 2019 for arterial AMI who underwent endovascular recanalization were prospectively acquired and retrospectively analyzed. Patient demographics, clinical and laboratory characteristics at presentation, and CT scans were reviewed. The type (thrombolysis, thrombectomy, stenting) and the outcome of endovascular procedures (technical success or failure, complications) were noted. Care pathways were described focusing on post-procedural treatments (surgical revascularization, bowel resection) and the mortality rate was evaluated in subgroups. RESULTS: Fifty-eight patients (34 men [59%], mean 69 ± 29 years) were included. Endovascular revascularization was technically successful in 51/58 (88%) patients, and 10 (17%) patients had post-procedural complications. Stenting and in situ thrombolysis were performed in most patients (n = 33 and n = 19, respectively). Thirty-two patients (55%) were recurrence-free and required no further treatment after the procedure, while 9 (16%), 5 (9%), and 5 (9%) patients underwent 2nd-line bowel resection, surgical revascularization, or both. Overall, 46 (79%), 45 (78%), and 34 patients (63%) were alive at 3 months, 1 year, and 3 years. No significant difference in survival was found in care pathways or baseline characteristics. CONCLUSION: Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. Results of endovascular revascularization shall only be interpreted as part of a multidisciplinary patient management strategy. KEY POINTS: • Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. • Several techniques are available to perform endovascular revascularization, and their use depends on the cause, the location, and the quality of underlying arteries of patients. • Results of endovascular revascularization shall only be interpreted in relation to its role in an integrated multidisciplinary and patient management strategy.

Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre.

OBJECTIVE: This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC). METHODS: All patients with symptomatic IMAD referred to the ISC from January 2016 to January 2020 were included prospectively. Patients with aortic dissection and asymptomatic IMAD were not included. The standardised medical protocol included anticoagulation and antiplatelet therapy, gastrointestinal resting, and oral antibiotics. Operations were considered for acute mesenteric ischaemia (AMI). RESULTS: Among the 453 patients admitted to an ISC during the study period, 34 (median age, 53 years [41 - 67]; 82% men) with acute symptomatic IMAD were included. According to the classification of Yun et al., IMADs were reported as follows: type I (n = 7, 20%), type IIa (n = 6, 18%), type IIb (n = 15, 44%), and type III (i.e., complete superior mesenteric artery [SMA] occlusion; n = 6, 18%). Overall, nine (26%) patients had AMI (type I/II, n = 3; type III, n = 6). On initial computerised tomography angiogram, nine (26%) patients had an associated visceral arterial dissection or pseudoaneurysm. All patients with types I/II (n = 28, 82%) followed a favourable clinical course with conservative therapy, with no need for any operation. All patients with type III (n = 6, 18%) underwent urgent laparotomy with SMA revascularisation (open, n = 4; stenting, n = 1) and or bowel resection (early, n = 3; late, n = 1). Rates of intestinal resection and short bowel syndrome were 12% and 8.8%, respectively. After a median follow up of 26 months [18 - 42], recurrence of symptoms occurred in four (12%) patients and aneurysmal change in 14 (41%), with no re-intervention. CONCLUSION: Although IMAD was associated with a high frequency of AMI, a standardised protocol produced a low rate of intestinal resection. Conservative therapy seems appropriate in types I/II patients, whereas urgent SMA revascularisation should aim to avoid intestinal resection or death in type III patients.

Thrombosis of Medium-Sized and Large Arteries During Covid-19 Infection: Results of the COVIVASC Study.

BACKGROUND: COVID-19 infection is associated not only with venous thromboses but also with arterial thromboses (COV-ATs) in relation with an endothelial dysfunction, a coagulopathy and rhythm disorders. The incidence, the topography, and the prognosis of COV-ATs remain poorly known. The objective of this study was to report the overall experience of the Greater Paris University Hospitals (Assistance Publique - Hopitaux de Paris, AP-HP) during the first pandemic wave of COVID-19 infection. METHODS: After approval by the ethics committee, a study using the AP-HP clinical data warehouse was carried out between March and May 2020. Overall, 124,609 patients had a polymerase chain reaction for COVID-19 in our hospitals, of which 25,345 were positive. From 20,710 exploitable stays, patients tested positive for COVID who presented an episode of acute COV-AT (except coronary and intracranial arteries) were selected on the basis of the French medical classification for clinical procedures codes. The data are presented as absolute values with percentages and/or means with standard deviation. RESULTS: Over the studied period, 60 patients (aged 71±14 years, 42 men) presented a COV-AT at the time of their hospitalization, an incidence of 0.2%. The arterial complication occurred 3±7 days after the COVID infection and was inaugural in 30% of the cases (n = 18). The sites of COV-AT were the lower extremities (n = 35%, 58%), the abdominal aorta (n = 10%, 17%), the thoracic aorta (n = 7%, 12%), the upper limbs (n = 7%, 12%), the cerebral arteries (n = 7%, 12%), the digestive arteries (n = 6%, 10%), the renal arteries (n = 2%, 3%), and the ophthalmic artery (n = 1%, 2%). Multiple COV-ATs were observed in 13 patients (22%). At the time of diagnosis, 20 (33%) patients were in intensive care, including six (10%) patients who were intubated. On computed tomography angiography, COVID lesions were classified as moderate and severe in 25 (42%) and 21 (35%) cases, respectively. Revascularization was attempted in 27 patients (45%), by open surgery in 16 cases, using endovascular techniques in 8 cases and with a hybrid approach in three cases. Six patients (22%) required reinterventions. The duration of hospitalization was 12±9 days. Early mortality (in-hospital or at 30 days) was 30% (n = 18). Nine (15%) patients presented severe nonlethal ischemic complications. CONCLUSIONS: Arterial involvement is rare during COVID-19 infection. The aorta and the arteries of the limbs are the privileged sites. The morbi-mortality of these patients is high. Future studies will have to determine if the systematization of anticoagulation therapy decreases the incidence and the severity of the condition.

Favorable, arduous or fatal postoperative pathway within 90 days of lung transplantation.

INTRODUCTION: The maximum gain in quality of life after lung transplantation (LT) is expected between six months and one year after LT, as the occurrence of chronic lung allograft dysfunction may mask the beneficial effects beyond one year. Thus, the postoperative period could be the cornerstone of graft success. We sought to describe the factors present before postoperative admission to the ICU and associated with favorable, arduous or fatal pathway within 90 days of LT. MATERIALS AND METHODS: We conducted a retrospective single-center study between January 2015 and December 2020. Using multinomial regression, we assessed the demographic, preoperative and intraoperative characteristics of patients associated with favorable (duration of postoperative mechanical ventilation < 3 days and alive at Day 90), arduous (duration of postoperative mechanical ventilation ≥ 3 days and alive at Day 90) or fatal (dead at Day 90) pathway within 90 days of LT. RESULTS: A total of 269 lung transplant patients were analyzed. Maximum graft cold ischemic time ≥ 6 h and intraoperative blood transfusion ≥ 3 packed red blood cells were associated with arduous and fatal pathway at Day 90, whereas intraoperative ECMO was strongly associated with fatal pathway. CONCLUSION: No patient demographics influenced the postoperative pathway at Day 90. Only extrinsic factors involving graft ischemia time, intraoperative transfusion, and intraoperative ECMO determined early postoperative pathway.

ECMO support as a bridge to lung transplantation is an independent risk factor for bronchial anastomotic dehiscence.

BACKGROUND: Airway complications are frequent after lung transplantation (LT), as they affect up to 23% of recipients. The implication of perioperative extracorporeal membrane oxygenation (ECMO) support and haemodynamic instability has never been specifically assessed. The first aim of this study was to explore the impact of perioperative ECMO support on bronchial anastomotic dehiscence (BAD) at Day 90 after LT. METHODS: This prospective observational monocentric study analysed BAD in all consecutive patients who underwent LT in the Bichat Claude Bernard Hospital, Paris, France, between January 2016 and May 2019. BAD visible on bronchial endoscopy and/or tomodensitometry was recorded. A univariate analysis was performed (Fisher's exacts and Mann-Whitney tests), followed by a multivariate analysis to assess independent risk factors for BAD during the first 90 days after LT (p < 0.05 as significant). The Paris North Hospitals Institutional Review Board approved the study. RESULTS: A total of 156 patients were analysed. BAD was observed in the first 90 days in 42 (27%) patients and was the main cause of death in 22 (14%) patients. BAD occurred during the first month after surgery in 34/42 (81%) patients. ECMO support was used as a bridge to LT, during and after surgery in 9 (6%), 117 (75%) and 40 (27%) patients, respectively. On multivariate analysis, ECMO as a bridge to LT (p = 0.04) and septic shock (p = 0.01) were independent risk factors for BAD. CONCLUSION: ECMO as a bridge to LT is an independent risk factor for BAD during the first 90 days after surgery. Close monitoring of bronchial conditions must be performed in these high-risk recipients.

Clinical and histopathologic predictors of therapeutic response to bronchial thermoplasty in severe refractory asthma.

BACKGROUND: Phenotypes and endotypes predicting optimal response to bronchial thermoplasty (BT) in patients with severe asthma remain elusive. OBJECTIVE: Our aim was to compare the clinical characteristics and hallmarks of airway inflammation and remodeling before and after BT in responder and partial responder patients with severe asthma refractory to oral steroids and to omalizumab. METHODS: In all, 23 patients with severe refractory asthma were divided into BT responders (n = 15) and BT partial responders (n = 8), according to the decrease in asthma exacerbations at 12 months after BT. Clinical parameters were compared at baseline and 12 months after BT, and hallmarks of airway inflammation and remodeling were analyzed by immunohistochemistry in bronchial biopsy specimens before and 3 months after BT. RESULTS: At baseline, the BT responders were around 8 years younger than the BT partial responders (P = .02) and they had a greater incidence of atopy, higher numbers of blood eosinophils (both P = .03) and IgE levels, higher epithelial IFN-α expression, and higher numbers of mucosal eosinophils and IL-33-positive cells (P ≤ .05). A reduction in blood eosinophil count, serum IgE level, type 2 airway inflammation, and numbers of mucosal IL-33-positive cells and mast cells associated with augmented epithelial MUC5AC and IFN-α/ß immunostaining was noted after BT in responders, whereas the numbers of mucosal IL-33-positive cells were augmented in BT partial responders. Most of these changes were correlated with clinical parameters. Subepithelial membrane thickening and airway smooth muscle area were similar in the 2 patient groups at baseline and after BT. CONCLUSION: By reducing allergic type 2 inflammation and increasing epithelial MUC5AC and anti-viral IFN-α/ß expression, BT may enhance host immune responses and thus attenuate exacerbations and symptoms in BT responders. Instead, targeting IL-33 may provide a clinical benefit in BT partial responders.

Midterm results after covered stenting of the superior mesenteric artery.

OBJECTIVE: Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. METHODS: Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. RESULTS: During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. CONCLUSIONS: Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.

Staged hybrid repair of type II thoracoabdominal aneurysms.

BACKGROUND: Open repair of type II thoracoabdominal aortic aneurysms (TAAAs) remains a challenging procedure. Staged procedures could decrease the incidence and severity of complications after complex aortic repair. In the present report, we have described a strategy using thoracic endovascular aortic repair (TEVAR) for proximal repair, followed by distal open repair. METHODS: From 2014 to 2018, 14 patients had undergone TEVAR, followed by distal open repair, for type II TAAAs. All patients should have a suitable proximal landing zone according to the current guidelines. In cases of chronic dissection, false lumen embolization was performed to achieve total exclusion. RESULTS: The mean patient age was 48 ± 15 years. Of the 14 patients, 5 had had Marfan syndrome (36%) and 6 had undergone previous aortic arch repair (43%). Ten patients had had a chronic dissection. The maximal aortic diameter was 73 ± 12 mm. The TEVAR technical success rate was 100%. The aortic length coverage was 211 ± 63 mm. The number of covered segmental arteries was 6 (range, 4-13). Two endoleaks were observed, one type Ib and one type II. The delay between TEVAR and open repair was 12 ± 8 weeks. Cerebrospinal fluid drainage was used in 13 patients. Six patients had undergone segmental artery reattachment during surgery. No spinal cord ischemic event was observed. One patient had died 5 weeks after open repair of multiple organ failure. During the 32 months of follow-up, no aortic-related deaths had occurred. No new aortic procedure was needed. The type Ib endoleak had resolved during open repair, and the type II TAAA had resolved spontaneously. The mean maximal thoracic aortic diameter had significantly decreased to 49 ± 8 mm (P < .0001). Aneurysmal shrinkage of ≥5 mm was observed in 13 patients (93%). CONCLUSIONS: Staged hybrid repair of type II TAAAs appears to be efficient, with low morbidity and mortality rates. This technique could improve postoperative outcomes after open repair, and TEVAR might have a role in ischemic preconditioning to protect against spinal cord ischemia.

Specific Genomic Alterations in High-Grade Pulmonary Neuroendocrine Tumours with Carcinoid Morphology.

INTRODUCTION: High-grade lung neuroendocrine tumours with carcinoid morphology have been recently reported; they may represent the thoracic counterparts of grade 3 digestive neuroendocrine tumours. We aimed to study their genetic landscape including analysis of tumoral heterogeneity. METHODS: Eleven patients with high-grade (>20% Ki-67 and/or >10 mitoses) lung neuroendocrine tumours with a carcinoid morphology were included. We analysed copy number variations, somatic mutations, and protein expression in 16 tumour samples (2 samples were available for 5 patients allowing us to study spatial and temporal heterogeneity). RESULTS: Genomic patterns were heterogeneous ranging from "quiet" to tetraploid, heavily rearranged genomes. Oncogene mutations were rare and most genetic alterations targeted tumour suppressor genes. Chromosomes 11 (7/11), 3 (6/11), 13 (4/11), and 6-17 (3/11) were the most frequently lost. Altered tumour suppressor genes were common to both carcinoids and neuroendocrine carcinomas, involving different pathways including chromatin remodelling (KMT2A, ARID1A, SETD2, SMARCA2, BAP1, PBRM1, KAT6A), DNA repair (MEN1, POLQ, ATR, MLH1, ATM), cell cycle (RB1, TP53, CDKN2A), cell adhesion (LATS2, CTNNB1, GSK3B) and metabolism (VHL). Comparative spatial/temporal analyses confirmed that these tumours emerged from clones of lower aggressivity but revealed that they were genetically heterogeneous accumulating "neuroendocrine carcinoma-like" genetic alterations through progression such as TP53/RB1 alterations. CONCLUSION: These data confirm the importance of chromatin remodelling genes in pulmonary carcinoids and highlight the potential role of TP53 and RB1 to drive the transformation in more aggressive high-grade tumours.

Blood transfusion of the donor is associated with stage 3 primary graft dysfunction after lung transplantation.

BACKGROUND: The first aim of this study was to assess the association between stage 3 PGD and pre-donation blood transfusion of the donor. The secondary objectives were to assess the epidemiology of donor transfusion and the outcome of LT recipients according to donor transfusion status and massive donor transfusion status. METHODS: This was an observational, prospective, single-center study. The results are expressed as absolute numbers, percentages, medians, and interquartile ranges. Statistical analyses were performed using Chi squared, Fischer's exact tests, and Mann-Whitney U tests (P < .05 was considered significant). A multivariate analysis was performed. RESULTS: Between January 2016 and February 2019, 147 patients were included in the analysis. PGD was observed in 79 (54%) patients, 45 (31%) of whom had stage 3 PGD. Pre-donation blood transfusion was administered in 48 (33%) donors (median of 3[1-9] packed red cells (PRCs)). On multivariate analysis, stage 3 PGD was significantly associated with donor blood transfusion (OR 2.69, IC (1.14-6.38), P = .024). Mortality at days 28 and 90 was not significantly different according to the pre-donation transfusion status of the donor. CONCLUSION: Pre-donation blood transfusion is associated with stage 3 PGD occurrence after LT. Transfusion data of the donor should be included in donor lung assessment.