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INTRODUCTION: Open surgical repair of suprarenal abdominal aortic aneurysm (SRAAA) and type IV thoraco-abdominal aortic aneurysm (TAAA) remains a surgical challenge because of the inducted intraoperative visceral and renal ischemia. We reported a novel three-step technique named "Debranch, Perfuse, Reconstruct" (DPR), using debranching and passive arterial shunt to reduce these ischemic complications. The main aim of this study was to evaluate the 30-day and 1-year mortality of these DPR technique. The secondary aim was to evaluate the impact on renal function and the primary patency of the repaired arteries METHODS: This retrospective study included all consecutive patients who underwent elective surgery for SRAA or type IV TAAA using DPR technique between January 2011 and June 2022. Debranch: Using partial side clamping, a multibranch graft was implanted side-to-end into the descending thoracic aorta. The left renal artery (LRA) was anastomosed end to end to the graft. As needed, the superior mesenteric artery (SMA), the celiac trunk (CT), and the right renal artery (RRA) could also be anastomosed to the graft. Perfusion: cannulas were connected to the last branch of the multibranch graft to perfuse other arteries during aortic cross-clamping. Repair: a tube or bifurcated graft was used for the aortic repair. The branch used as a passive temporary arterial shunt were ligated at the end of the intervention. Clinical, radiological, and biological pre- and postoperative were reviewed using a standardized database. Procedural complications and re-interventions were analyzed as well as artery patency. RESULTS: There were 40 patients who underwent DPR technique, the mean age was 67 ± 13 years, 2 women.: 23 patients presented with a SRAA et 17 with a type IV TAAA. The 30-day and 1-year mortality rate were 2.5% (one patient). Two respiratory complications (5%) and three mesenteric ischemic complications (7%) have been recorded. No patient developed signs of cardiac or spinal cord dysfunction. We did not observe a significant change in postoperative renal function. CT, SMA, LRA, and RRA bypass patency rates at one year were 95%, 100%, 90%, and 100%, respectively. CONCLUSIONS: The SRAA and type IV TAAA repair with DPR technique provides short visceral and renal ischemia times with a low mortality rate. This technique could be an option to consider for visceral and renal protection during open surgical repair.
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OBJECTIVE: The aim of this study was to evaluate the outcomes of cold stored saphenous vein allografts (CSVAs) for haemodialysis vascular access. METHODS: A retrospective, two centre study was conducted between January 2016 and December 2020 of all patients who had CSVA placement for haemodialysis vascular access. Primary, primary assisted, and secondary patency were analysed, as well as procedural complications and re-interventions. RESULTS: One hundred and nine patients (n = 55 women) with a mean age of 67.2 ± 13.6 years, with no options for creating an autogenous arteriovenous fistula, were included in the study. At one year, primary, primary assisted, and secondary patency were 37.6%, 59.0%, and 73.3%, respectively; and at two years 19.9%, 42.5%, and 54.9%, respectively. During a mean follow up period of 26 ± 18 months, five patients (4.6%) had an access infection, with no related death. During the follow up period, 32 patients (29.4%) died and 13 patients (11.9%) underwent a kidney transplant. None of these patients showed immunoconversion before transplantation. The cumulative incidence of adverse events by the Fine-Gray method was calculated. Considering competing risks (death and renal transplantation), 9.2% of patients lost their vascular access at one year and 18% at two years. Moreover, 57.8% patients had stenosis, mainly on the outflow (45.9%), and 49.5% had thrombosis. CONCLUSION: With a comparable patency rate associated with a low infection rate, CSVA offers a potential alternative to expanded polytetrafluoroethylene grafts. This creates haemodialysis vascular access when the venous capital is exhausted in patients with reported risk factors for vascular access infection, i.e., insertion in the thigh, advanced age, diabetes mellitus, immunocompromised state, obesity, or revision of an infected prosthetic graft.
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BACKGROUND: Carotid body tumors (CBTs) are rare but require surgical resection given their potential for growth and malignancy. For some surgical teams, tumor hypervascularity justifies preoperative embolization to facilitate resection and limit complications. The objective of our study was to evaluate 2 different practices of surgical resection with or without preoperative embolization in a 2-center cohort. METHODS: A consecutive series of patients who underwent CBT surgery, from January 2011 to June 2019, were divided into 2 groups, as to whether they were (embolized CBT [ECBT]) or not (nonembolized CBT [NECBT]) preoperatively embolized. Both groups were compared specifically according to the duration of operation, postoperative complications, and length of stay. RESULTS: Twenty-two patients with a mean age of 48.5 ± 14.3 years were included. In the series, 23 CBTs were resected: 13 were embolized preoperatively; the mean time between embolization and surgery was 2.62 ± 1.50 days. Both groups were comparable based on characteristics of population and tumor, with a mean size of 33.2 ± 11.9 mm. We noted a significant increase in operation duration in the ECBT group: 151 min (±40.9) vs. 87.0 min (±21); P < 0.01. There was no difference between the 2 groups regarding cranial nerve (50% vs. 46%; P = 1), sympathetic nervous system (20% vs. 23%; P = 1), or vascular nerve (20% vs. 23%; P = 0.18) complications. No cerebrovascular accident was identified. The length of stay was 3.60 days (±1.78) vs. 3.73 days (±1.19; P = 0.44). CONCLUSIONS: This study reflects the experience of 2 centers in the management of CBT which is a rare pathology with no standardized treatment. Our series showed no significant difference between the ECBT and NECBT groups regarding postoperative complications and length of hospital stay. The reduction in operating time in the NECBT group remains to be demonstrated.
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Tumor del Cuerpo Carotídeo , Embolización Terapéutica , Humanos , Adulto , Persona de Mediana Edad , Tumor del Cuerpo Carotídeo/diagnóstico por imagen , Tumor del Cuerpo Carotídeo/cirugía , Tumor del Cuerpo Carotídeo/patología , Estudios Retrospectivos , Resultado del Tratamiento , Embolización Terapéutica/efectos adversos , Complicaciones Posoperatorias/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
BACKGROUND: Minimally invasive approaches for lumbar fusion are aimed at reducing soft tissue injury in order to minimize surgical morbidity and facilitate recovery. METHOD: Applied to oblique lateral lumbar interbody fusion (OLIF), Da Vinci® robot (DVR) assistance can help specially in obese patients. Positioning and important anatomical landmarks are reviewed. Indications, advantages, and limitations are discussed, and a step-by-step description of the procedure is presented. OLIF can be achieved efficiently through this approach with lesser blood loss, shorter hospital stays, and reduced rate of general complications. CONCLUSION: The use of DVR assistance for OLIF is a promising new technique.
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Procedimientos Quirúrgicos Robotizados , Fusión Vertebral , Humanos , Tiempo de Internación , Vértebras Lumbares/cirugía , Región Lumbosacra , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Fusión Vertebral/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: Failed endovascular infrarenal aortic aneurysm repair (EVAR) due to development of late type Ia endoleak exposes patients to the risk of rupture and should be treated. The purpose of this study was to evaluate the results of fenestrated/branched EVAR (F/BEVAR) for treatment of failed EVAR with type Ia endoleak. METHODS: From January 2010 to December 2019, a prospective multicentre study was conducted (ClinicalTrials.gov identifier: NCT04532450) that included 85 consecutive patients who had undergone F/BEVAR to treat a type Ia endoleak following EVAR. The primary outcome was overall freedom from any re-intervention or death related to the F/BEVAR procedure. RESULTS: In 30 cases (35%) EVAR was associated with a short < 10 mm or angulated (> 60°) infrarenal aortic neck, poor placement of the initial stent graft (n = 3, 4%), sizing error (n = 2, 2%), and/or stent graft migration (n = 7, 8%). Type Ia endoleak was observed after a period of 59 ± 25 months following EVAR. The authors performed 82 FEVAR (96%) and three BEVAR (4%) procedures with revascularisation of 305 target arteries. Overall technical success was 94%, with three failures including one persistent Type Ia endoleak and two unsuccessful stent graft implantations. Intra-operative target artery revascularisation was successful in 303 of 305 attempts. The in hospital mortality rate was 5%. Cardiac, renal and pulmonary complications occurred in 6%, 14%, and 7% of patients, respectively. Post-operative spinal cord ischaemia occurred in four patients (4.7%). At three years, the survival rate was 64% with overall freedom from any re-intervention or aneurysm related death of 40%, and freedom from specific F/BEVAR re-intervention of 73%. At three years, the secondary patency rate of the target visceral arteries was 96%. During follow up, 27 patients (33%) required a revision procedure of the fenestrated (n = 11) or index EVAR stent graft (n = 16), including six open conversions. CONCLUSION: While manufactured F/BEVAR was effective in treating type Ia endoleak in patients with failed EVAR, it was at the cost of a number of secondary endovascular and open surgical procedures.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/mortalidad , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Francia , Humanos , Masculino , Estudios Prospectivos , Reoperación , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
RATIONALE: Short telomere length (TL) in leukocytes is associated with atherosclerotic cardiovascular disease (ASCVD). It is unknown whether this relationship stems from having inherently short leukocyte TL (LTL) at birth or a faster LTL attrition thereafter. LTL represents TL in the highly proliferative hematopoietic system, whereas TL in skeletal muscle represents a minimally replicative tissue. OBJECTIVE: We measured LTL and muscle TL (MTL) in the same individuals with a view to obtain comparative metrics for lifelong LTL attrition and learn about the temporal association of LTL with ASCVD. METHODS AND RESULTS: Our Discovery Cohort comprised 259 individuals aged 63±14 years (mean±SD), undergoing surgery with (n=131) or without (n=128) clinical manifestation of ASCVD. In all subjects, MTL adjusted for muscle biopsy site (MTLA) was longer than LTL and the LTL-MTLA gap similarly widened with age in ASCVD patients and controls. Age- and sex-adjusted LTL (P=0.005), but not MTLA (P=0.90), was shorter in patients with ASCVD than controls. The TL gap between leukocytes and muscle (LTL-MTLA) was wider (P=0.0003), and the TL ratio between leukocytes and muscle (LTL/MTLA) was smaller (P=0.0001) in ASCVD than in controls. Findings were replicated in a cohort comprising 143 individuals. CONCLUSIONS: This first study to apply the blood-and-muscle TL model shows more pronounced LTL attrition in ASCVD patients than controls. The difference in LTL attrition was not associated with age during adulthood suggesting that increased attrition in early life is more likely to be a major explanation of the shorter LTL in ASCVD patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02176941.
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Aterosclerosis/genética , Acortamiento del Telómero , Anciano , Aterosclerosis/patología , Femenino , Humanos , Leucocitos/metabolismo , Masculino , Persona de Mediana Edad , Fibras Musculares Esqueléticas/metabolismoRESUMEN
BACKGROUND: The treatment of aortic infections is complex, and the material of reconstruction remains discussed. Several alternatives were suggested in the literature. The current consensus is the use of biological material. The aim of this study was to evaluate the short-term results of bovine pericardium xenografts. METHODS: Between November 2016 and June 2019, we included consecutively all the patients presenting with native aortic infections in which arterial reconstruction was carried out with tubular bovine pericardium grafts sutured longitudinally. We collected the preoperative, peroperative, and postoperative clinical, radiological, biological, and bacteriological characteristics. The recurrence of infection, the graft failures, and the morbimortality were analyzed. RESULTS: Twelve patients including three women were treated. Their mean age was 68.4 ± 9 years. They presented 2 thoracic, 4 thoracoabdominal, 4 abdominal, and 2 aortoiliac aneurysms. The diagnosis was made using angio-CT in all the cases and was confirmed by positron emission tomography (PET) scan in 7 cases and blood cultures in 9 cases. Peroperative cultures were positive in 11 cases. Antibiotics were given in 9 patients before operation for a median duration of 9 (3-19) days and in all the patients postoperatively for a median duration of 42 (1-540) days. The median follow-up was 355 (98-839) days. Six medical complications occurred, including 2 (16.6%) leading to death in the immediate postoperative period. No reoperation was needed. The PET scan returned positive in 1/10 cases (10%) during the follow-up. The diameter of the grafts was preserved, without any defect observed on the angio-CT. CONCLUSIONS: Short-term results showed a mechanical resistance to infection of the bovine pericardium. This biological material offers a promising alternative with multiple advantages including availability, simplicity of preparation, and adaptability to the various locations of the aortic infection.
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Aneurisma Infectado/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Bioprótesis , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Aneurisma Ilíaco/cirugía , Pericardio/trasplante , Anciano , Aneurisma Infectado/diagnóstico por imagen , Aneurisma Infectado/microbiología , Animales , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/microbiología , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/microbiología , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Bovinos , Femenino , Xenoinjertos , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/microbiología , Aneurisma Ilíaco/mortalidad , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Falla de Prótesis , Recurrencia , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Percutaneous angioplasty and stenting is nowadays the treatment of choice for atherosclerotic stenotic lesions of the supraaortic trunks. Stent migration is a seldom published complication that can alter the short-term results of these procedures. Herein, we report three cases, from three different institutions, of secondary autoexpandable stent migration, after endovascular treatment of major arch vessel stenosis, and their subsequent endovascular management using three different retrieval techniques. Technical success was achieved in all cases. There were no immediate complications related to the retrieval of the migrated stents. A late complication of iliac thrombosis required complementary surgical intervention. Percutaneous retrieval of migrated self-expanding stents is feasible and can be effectively performed with few complications as a first-line option.
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Angioplastia de Balón/efectos adversos , Aorta Torácica , Enfermedades de la Aorta/terapia , Remoción de Dispositivos/métodos , Migración de Cuerpo Extraño/terapia , Stents , Anciano , Angioplastia de Balón/instrumentación , Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Constricción Patológica , Remoción de Dispositivos/instrumentación , Femenino , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Dispositivos de Acceso VascularRESUMEN
PURPOSE: The growth phases of medically treated abdominal aortic aneurysms (AAA) are frequently associated with an 18F-fluorodesoxyglucose positron emission tomography (FDG-PET) pattern involving low baseline and subsequent higher FDG uptake. However, the FDG-PET patterns associated with the endovascular aneurysm repair (EVAR) of larger AAA are presently unknown. This study aimed to investigate the relationship between serial AAA FDG uptake measurements, obtained before EVAR and 1 and 6 months post-intervention and subsequent sac shrinkage at 6 months, a well-recognized indicator of successful repair. METHODS: Thirty-three AAA patients referred for EVAR (maximal diameter: 55.4 ± 6.0 mm, total volume: 205.7 ± 63.0 mL) underwent FDG-PET/computed tomography (CT) before EVAR and at 1 and 6 months thereafter, with the monitoring of AAA volume and of a maximal standardized FDG uptake [SUVmax] averaged between the axial slices encompassing the AAA. RESULTS: Sac shrinkage was highly variable and could be stratified into three terciles: a first tercile in which shrinkage was absent or very limited (0-29 mL) and a third tercile with pronounced shrinkage (56-165 mL). SUVmax values were relatively low at baseline in the 1st tercile (SUVmax: 1.69 ± 0.33), but markedly increased at 6 months (2.42 ± 0.69, p = 0.02 vs. baseline). These SUV max values were by contrast much higher at baseline in the 3rd tercile (SUVmax: 2.53 ± 0.83 p = 0.009 vs. 1st tercile) and stable at 6 months (2.49 ± 0.80), while intermediate results were documented in the 2nd tercile. Lastly, the amount of sac shrinkage, expressed in absolute values or in percentages of baseline AAA volumes, was positively correlated with baseline SUVmax (p = 0.001 for both). CONCLUSION: A low pre-EVAR FDG uptake and increased AAA FDG uptake at 6 months are associated with reduced sac shrinkage. This sequential FDG-PET pattern is similar to that already shown to accompany growth phases of medically treated AAA.
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Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares , Tomografía de Emisión de Positrones , Aorta , Aneurisma de la Aorta Abdominal/cirugía , Fluorodesoxiglucosa F18 , Humanos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
We present our experience with 5 patients with chronic limb threatening ischemia (CLTI) treated with distal revascularization and omental flap coverage. We decided to investigate the efficacy and safety of negative-pressure wound therapy (NPWT) in promoting the fixation and remodeling of the omental flap as there is some evidence in the literature about the optimization of results for skin graft and dermal substitutes. Surgical revascularization was always the first procedure attempted; wound coverage was realized 3-5 days after the primary procedure (omental free-flap in 3 patients and omental flow-through flap in 2 patients). NPWT with small foam at -75 mm Hg was applied on the second postoperative day after flap coverage. Effective remodeling of the flap was defined as the flap overcoming the wound edge no more than 10 mm. Limb salvage rate was 100%; in all the patients, and we observed satisfactory fixation and remodeling of the omental flap after 10-20 days of NPWT, secondary skin grafting within 3-4 weeks after revascularization, and adequate and complete mobilization within 6 months after hospital discharge. We did not report any relapsing infection nor any recurrent wound up to 2 years of follow-up. Distal revascularization combined with omental free-flap or flow-through flap is highly effective for limb salvage in CLTI patients with complex wounds. NPWT may be an useful adjunct to promote fixation and remodeling of the omental flap before secondary skin grafting. It may reduce secondary issues related to omental flap coverage allowing rapid and satisfactory mobilization of patients.
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Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Terapia de Presión Negativa para Heridas , Epiplón/cirugía , Colgajos Quirúrgicos , Procedimientos Quirúrgicos Vasculares , Cicatrización de Heridas , Anciano , Enfermedad Crónica , Humanos , Isquemia/diagnóstico , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Trasplante de Piel , Factores de Tiempo , Resultado del TratamientoRESUMEN
Venous malformations are the most common slow-flow vascular malformations; they are not prone to volume decrease over time, and invasive treatment is usually required. There are 2 main techniques to address the definitive therapy of these lesions, sclerotherapy and surgical excision, each with its own advantages and disadvantages. We report the case of a 56-year-old man who came to our attention with persistent pain after multiple unsuccessful attempts to treat a large venous malformation located in the area of the right knee. After radical excision of the painful lesion, we covered the resulting major tissue loss (20 cm × 15 cm) with a free omental flap. The arterial and venous anastomoses were on the region above the knee pedicles. The postoperative course was uneventful. A secondary skin grafting was performed. The patient is doing well at 1-year follow-up. The omental flap may be a bailout solution for tissue loss coverage in the knee area when the use of the common fascia-cutaneous or muscular flaps is not possible.
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Rodilla/irrigación sanguínea , Epiplón/cirugía , Colgajos Quirúrgicos , Malformaciones Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares , Venas/cirugía , Biopsia , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Trasplante de Piel , Resultado del Tratamiento , Malformaciones Vasculares/diagnóstico por imagen , Venas/anomalías , Venas/diagnóstico por imagenRESUMEN
PURPOSE: The gastro-omental artery (GOA) with the greater omentum (GO) is known for its high quality as a vascular graft, its resistance to infections as an omental flap and for its multiple applications in surgery. A better knowledge of anatomical variations of GO and its vascularization can improve the application in surgery and decrease complications. The purpose of this study was to measure diameters and lengths of the right GOA (RGOA) and study the interindividual variability of these anatomical structures. METHODS: In 100 cadaveric dissections, we carried out dissection of the RGOA and of the GO. In 70 unfixed cadavers, the transillumination technique was used to identify all RGOA branches. In the remaining 30 cadavers, prepared with Winckler's solution, barium sulfate with colored latex was injected. Digital X-ray was used to measure RGOA lengths, internal diameters and the distribution of the omental branches. The gastro-omental vein was also dissected. RESULTS: The mean proximal and distal diameters of RGOA were 2.68 (± 0.39) mm and 0.94 (± 0.24) mm, respectively. The mean length was 244.3 (± 34.4) mm. The thickness of the omentum ranged from 5 to 15.5 mm. The arteria omentalis magna, defined in this study for the fist time as the longest and widest omental branch, was present in 73.3% cases. The trans-omental arch was present in 6% cases. CONCLUSIONS: This morphometric study allowed us to define the vascularization and the anatomical variations of RGOA and GO. This may lead to improvement of applications in surgery and decrease complications.
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Arteria Gastroepiploica/anatomía & histología , Epiplón/irrigación sanguínea , Anciano de 80 o más Años , Variación Anatómica , Cadáver , Disección , Humanos , Masculino , Epiplón/trasplante , Colgajos Quirúrgicos/irrigación sanguíneaRESUMEN
INTRODUCTION: Although carotid stenosis can cause both territorial and border-zone (BZ) cerebral infarcts (CI), the influence of CI topography on postoperative complications after surgery remains unclear. We compared early outcomes after endarterectomy on the basis of CI location: territorial (T group) or BZ group. MATERIAL AND METHODS: During the period between 2009 and 2013, ischaemic stroke patients who had undergone surgery for symptomatic carotid stenosis were identified from prospective databases from 3 French centres. The outcome was the identification of a combined stroke/death rate 30 days after endarterectomy. RESULTS: Two hundred and eighty-nine patients were included, 216 (74.7%) in the T group and 73 (25.3%) in the BZ group. The mean degree of stenosis was comparable in the 2 groups (78 ± 12% in the T group vs. 80 ± 12% in the BZ group, p = 0.105), with, however, more sub-occlusions (stenosis >90%) in the BZ group (38.4 vs. 23.1%, p = 0.012). The mean time between the time CI developed and the time surgery was performed was 19.6 ± 24.8 days, with a majority of patients being operated upon within 2 weeks following the formation of CI (66.7% in the T group vs. 60.3% in the BZ group, p = 0.322). The combined endpoint was significantly more frequent in the BZ group (9.6 vs. 1.9%, p = 0.003), with 4 ischaemic strokes and 3 deaths. In multivariate analysis, BZ CI was an independent predictor of postoperative stroke or death at 30 days (HR 4.91-95% CI [1.3-18.9], p = 0.020). CONCLUSION: BZ infarcts carry a greater risk of postoperative complications after carotid surgery, thus suggesting that topography of the CI should be considered in the decision-making process regarding surgery.
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Estenosis Carotídea/cirugía , Infarto Cerebral/diagnóstico por imagen , Endarterectomía Carotidea/efectos adversos , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/mortalidad , Infarto Cerebral/etiología , Infarto Cerebral/mortalidad , Toma de Decisiones Clínicas , Bases de Datos Factuales , Endarterectomía Carotidea/mortalidad , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The aberrant right subclavian artery or arteria lusoria (AL) is the most frequent anatomical variation of the supra-aortic trunks (SAT). Treatment is only warranted in the presence of an aneurysm because of the risk of rupture, or in symptomatic cases with signs of compression of the esophagus or the trachea, with embolisms causing right upper limb ischemia of vertebrobasilar cerebrovascular accidents. The conventional surgical treatment of AL is the closure of the origin of AL and the revascularization of the right subclavian artery through a left thoracotomy. With the appearance of endovascular techniques, some of these patients can be treated with minimally invasive hybrid techniques. The aim of this study is to evaluate the feasibility of the endovascular treatment of AL based on the radioanatomical analysis of the thoracic angio-computed tomographies. METHODS: We analyzed 180 thoracic angio-computed tomographies using millimeter cuts (<1.2 mm) performed between 2010 and 2015 in the Nancy University Hospital in which an AL was fortuitously discovered. Symptomatic ALs and pediatric patients were excluded. The diameters of the SATs and the aorta and the distances between the SATs were measured. The data were processed with the t-test using the SPSS 22 software. RESULTS: Our results showed the presence of a Kommerell diverticulum in 36 cases (20%) and of a bi-carotid trunk in 91 cases (50.5%). The average distance between the left subclavian artery (LSCA) and AL was 5.4 ± 4.3 mm. To obtain a proximal neck >20 mm for the implantation of a thoracic stent graft, a double transposition or bypass was always necessary (LSCA to left common carotid artery, AL to right common carotid). An additional debranching of the left common carotid artery was necessary in 33.8% of the cases and of all the SATs in 2.9% of the cases. CONCLUSIONS: The radio-anatomical study showed that no patient was eligible for conventional thoracic endovascular aneurysm repair to treat an aneurysmal AL. The hybrid approach is feasible using a double transposition or a bypass before the implantation of a stent graft, if needed associated with a debranching of the common carotid arteries.
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Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Implantación de Prótesis Vascular/métodos , Anomalías Cardiovasculares/diagnóstico por imagen , Anomalías Cardiovasculares/cirugía , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/métodos , Arteria Subclavia/anomalías , Adulto , Anciano , Anciano de 80 o más Años , Puntos Anatómicos de Referencia , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Arteria Carótida Común/diagnóstico por imagen , Arteria Carótida Común/cirugía , Procedimientos Endovasculares/instrumentación , Estudios de Factibilidad , Femenino , Francia , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Interpretación de Imagen Radiográfica Asistida por Computador , Programas Informáticos , Stents , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The omental flow-through flap (OFTF) is based on the use of an anatomic unit composed of the right gastro-omental artery (bypass) with its omental branch or branches supplying the greater omentum (flap). The greater omentum flap is known for its capacity of resistance to infection, for its use in the treatment of ischemic lesions and as a high-flow tissue. Several hypotheses regarding the hemodynamic behavior of a distal bypass with a flap were discussed in the literature. We made the assumption that the OFTF was a low peripheral resistance flap and that the greater omentum did not induce a steal phenomenon. We demonstrated the anatomical feasibility of the experimental model with a morphologic study in the pig. The mail objective of this study was to measure the blood flow to evaluate the hemodynamic effects of the OFTF. METHODS: Twelve domestic pigs were used for this study. Four cadavers of pigs were dissected for the anatomic study of the OFTF, and 8 live pigs were used for the experimental surgery and hemodynamic measurements. Hemodynamic measurements were taken before transplantation on in situ arteries using periarterial ultrasonic flow transducers. After transplantation of the OFTF, flows were measured before, then during clamping and unclamping of the flap. RESULTS: OFTF was feasible in the porcine model. With the experimental model, the flow increased by 56.15% in the distal part of the bypass after the implantation of the flap with decrease of peripheral resistances. CONCLUSIONS: Our results suggest that the OFTF is a low resistance flap and that the greater omentum does not induce a steal phenomenon. This anatomic unit could be used to carry out simultaneously limb revascularization and cover a tissue loss.
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Hemodinámica , Epiplón/irrigación sanguínea , Epiplón/trasplante , Colgajos Quirúrgicos/irrigación sanguínea , Animales , Velocidad del Flujo Sanguíneo , Estudios de Factibilidad , Modelos Animales , Flujo Sanguíneo Regional , Sus scrofa , Resistencia VascularRESUMEN
BACKGROUND: Arterial complications among drug addicts are rare. Their appearance can engage the vital prognosis of the patient and present a major risk of amputation. The injection of products with high cellular toxicity induces septic necrosis of the arterial wall and adjacent tissues. It is frequently responsible for acute hemorrhage. The data in the literature concerning surgical treatment are discussed. The goal of our study was to analyze the immediate and midterm results of the surgical management of these arterial lesions. METHODS: Between January 2005 and April 2012, 31 drug addicts (4 women; 31.4 ± 7.2 years) presenting with 33 arterial lesions were treated. They presented with a humeral (n = 15), femoral (n = 13), or axillar (n = 3) false aneurysm. Two patients had an arterial thrombosis. The clinical manifestations were an acute hemorrhage (n = 16), a septic syndrome (n = 7), a pulsatile mass (n = 6), and an acute ischemia (n = 4). In situ revascularization was carried out in 20 cases, in 15 patients with a bypass (9 venous and 6 prosthetic), in 2 with a venous patch, in 2 by direct suture, and in 1 by transposition of the superficial femoral artery in the deep femoral artery. Extra-anatomic bypass revascularization was performed in 6 cases (4 venous and 2 prosthetic). The other techniques used were ligature (n = 5) and medical care (n = 2). Two patients had an additional procedure with a musculocutaneous epigastric pedicled flap in order to fill the loss of substance. RESULTS: The early rate of reinterventions was 38.7% at 30 days (12 patients), because of a suture line hemorrhage related to sepsis (n = 6), a bypass thrombosis (n = 5), and of acute ischemia after a arterial ligature. These complications occurred mainly on extremities, having had an anatomic revascularization (n = 9). Six extra-anatomic revascularizations had to be performed in second intention. The average follow-up was 8.6 months (range: 1-73.5 months), and 15 patients were lost to follow-up at 6 months. The patients were followed by duplex ultrasonography and/or angioscanner. Primary and secondary actuarial patencies at 1, 3, and 6 months were 61%, 46%, 46%, and 91%, 81%, and 71%, respectively. The rate of salvage of extremities was 100%. CONCLUSION: Our study reveals the difficulty of the management of these arterial lesions. The local and general septic process is primarily responsible for early complications. Arterial restoration with extra-anatomic bypass makes it possible to be distant from the infection. This technique can be associated with a covering flap.
Asunto(s)
Aneurisma Falso/cirugía , Arterias/cirugía , Consumidores de Drogas , Abuso de Sustancias por Vía Intravenosa/complicaciones , Trombosis/cirugía , Procedimientos Quirúrgicos Vasculares , Lesiones del Sistema Vascular/cirugía , Enfermedad Aguda , Adulto , Aneurisma Falso/diagnóstico , Aneurisma Falso/etiología , Aneurisma Falso/mortalidad , Arterias/lesiones , Implantación de Prótesis Vascular , Femenino , Hemorragia/etiología , Hemorragia/cirugía , Humanos , Inyecciones Intraarteriales , Isquemia/etiología , Isquemia/cirugía , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Complicaciones Posoperatorias/cirugía , Procedimientos de Cirugía Plástica , Sistema de Registros , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Abuso de Sustancias por Vía Intravenosa/mortalidad , Colgajos Quirúrgicos , Técnicas de Sutura , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodos , Procedimientos Quirúrgicos Vasculares/mortalidad , Lesiones del Sistema Vascular/diagnóstico , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/mortalidad , Venas/trasplanteRESUMEN
BACKGROUND: The incidence of critical limb ischemia increases with the aging of the population. Two-thirds of patients with critical limb ischemia present with trophic disorders. Revascularization decreases the rate of amputation. Infected wounds with exposure of the tendons, bones, or points of articulation cannot heal in spite of bridging and local debridement. Surgery associated with a distal venous bypass or recanalization and a free flap makes it possible to cover major tissue loss and offers a hemodynamic advantage by increasing the flow of the bypass, thanks to the vascular bed added by the flap. It is a complex surgery because of the multiplicity of anastomoses on the same arterial axis, with a risk of thrombosis and complications related to the venous autograft. To mitigate these disadvantages, we propose a new surgical method based on the use of a single anatomic unit, the epiploic bypass flap (BF), based on the gastroepiploic artery (GEA) as the inflow for a bypass and a free flap. The objective of this work was to analyze the anatomic feasibility of an epiploic BF and to determine its limits. METHODS: One hundred anatomic preparations were conducted with a measure of the internal and external diameters and the lengths of GEA and its branches and a radiograph after injection of a radiopaque product. A first clinical application was carried out. RESULTS: According to the data, our study confirms the anatomic feasibility of a BF. The average available length of GEA is 245 mm (range: 210-280 mm). The average proximal diameter is 3 mm, and the distal diameter is 1.5 mm. The most distal epiploic branch that feeds the bypass is approximately 180 mm (range: 161-195 mm) of the origin of the GEA. The anatomic unit based on the GEA provides an arterial graft that is relatively long and a large flap that is both malleable and resistant to infection. CONCLUSIONS: Epiploic BF is a surgical technique that allows for distal revascularization and a simultaneous cover of the limb extremity. This technique can be useful in patients requiring a distal revascularization associated with a cutaneous cover.
Asunto(s)
Colgajos Tisulares Libres/irrigación sanguínea , Arteria Gastroepiploica/trasplante , Isquemia/cirugía , Pierna/irrigación sanguínea , Recuperación del Miembro/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Anciano de 80 o más Años , Cadáver , Estudios de Factibilidad , Femenino , Humanos , Isquemia/patología , Masculino , Trasplante Autólogo , Resultado del TratamientoRESUMEN
BACKGROUND: The da Vinci robot (DVR) is the most widely used robot in abdominal, urological, and gynecological surgery. Due to its minimally invasive approach, the DVR has demonstrated its effectiveness and improved safety in these different disciplines. The aim of our study was to report its use in an anterior approach of complex lumbar surgery. METHODS: In a retrospective multicenter observational study, 10 robotic-assisted procedures were performed from March 2021 to May 2022. Six oblique lumbar interbody fusion procedures and 4 lumbar corpectomies were performed by anterolateral approach assisted by the DVR. The characteristics of the patients and the intraoperative and postoperative data were recorded. RESULTS: Six men and 4 women underwent surgery (mean age 50.5 years; body mass index 28.6 kg/m2). No vascular injuries were reported, and no procedures required conversion to open surgery. Mean surgical time were 219 minutes for 1-level oblique lumbar interbody fusion (3 patients), 286 minutes for 2-level oblique lumbar interbody fusion (3 patients), and 390 minutes for corpectomy (4 patients). Four patients experienced nonserious adverse events due to lumbar plexus nerve damage. One patient had a vertebral body plate fracture requiring posterior revision surgery, and 1 patient had a psoas hematoma requiring transfusion. No abdominal wall complications or surgical site infection were found. Seven patients were reviewed at 12 months, none had complications, and all showed radiological evidence of fusion. CONCLUSIONS: The use of the DVR in lumbar surgery allows a safe minimally invasive transperitoneal approach, but to date, only hybrid procedures have been performed.
Asunto(s)
Procedimientos Quirúrgicos Robotizados , Robótica , Fusión Vertebral , Masculino , Humanos , Femenino , Persona de Mediana Edad , Fusión Vertebral/métodos , Región Lumbosacra/cirugía , Radiografía , Vértebras Lumbares/cirugía , Estudios Retrospectivos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Resultado del TratamientoRESUMEN
Although the respiratory tract is the main target of SARS-CoV-2, other tissues and organs are permissive to the infection. In this report, we investigated this wide-spectrum tropism by studying the SARS-CoV-2 genetic intra-host variability in multiple tissues. The virological and histological investigation of multiple specimens from a post-mortem COVID-19 patient was performed. SARS-CoV-2 genome was detected in several tissues, including the lower respiratory system, cardio-vascular biopsies, stomach, pancreas, adrenal gland, mediastinal ganglion and testicles. Subgenomic RNA transcripts were also detected, in favor of an active viral replication, especially in testicles. Ultra-deep sequencing allowed us to highlight several SARS-CoV-2 mutations according to tissue distribution. More specifically, mutations of the spike protein, i.e., V341A (18.3%), E654 (44%) and H655R (30.8%), were detected in the inferior vena cava. SARS-CoV-2 variability can contribute to heterogeneous distributions of viral quasispecies, which may affect the COVID-19 pathogeny.