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BACKGROUND: Visceral mediastinal tumors are rare with challenging surgical approaches due to their location in close proximity with the great vessels and the pulmonary trunk. The aim of this paper is to discuss surgical strategies for complex cases of primary mediastinal tumors. METHODS: We present two cases of patients with middle mediastinal tumor, one synovial sarcoma and one paraganglioma. For both patients, surgical access was performed through a sternotomy with beating heart cardio-pulmonary bypass and aortic transection, allowing optimal exposure of the carina, of the common pulmonary artery and its bifurcation. Both tumors were resected 'en-bloc'. The postoperative course was uneventful and the two patients had a 3 months postoperative follow-up CT-scan showing no evidence of recurrence. RESULTS: Surgery remains the cornerstone of treatment for synovial sarcoma and for paraganglioma of the visceral mediastinum and this location may be difficult to deal with. Many different surgical accesses exist and our approach of ascending aortic transection allows optimal exposure to the pulmonary artery, but also provides access to the upper airways. CONCLUSION: For visceral mediastinal tumor with close contact with vascular and respiratory structures, aortic transection allows an excellent exposure and control of the tumor with oncological resection.
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Neoplasias del Mediastino , Paraganglioma , Sarcoma Sinovial , Humanos , Neoplasias del Mediastino/diagnóstico por imagen , Neoplasias del Mediastino/cirugía , Neoplasias del Mediastino/patología , Mediastino/patología , Paraganglioma/cirugía , Arteria Pulmonar/patologíaRESUMEN
The objective of this study was to assess the level of interest in preconception carrier screening among reproductive-aged persons presenting for gynecologic care and to identify demographic factors predictive of pursuing screening. Patients aged 18-40 who were presenting for gynecologic care at a single U.S. academic medical center were provided with information about current options for preconception carrier screening and were offered genetic counseling referral with the possibility to undergo screening. Outcomes of interest were desire for genetic counseling referral and attendance at genetic counseling visit. Statistical analyses were performed as appropriate using R version 3.6.1 with variables significant at 0.1 included in a multivariable logistic regression. Of 193 participants, 79 (41%) desired genetic counseling referral. Participants aged 25-34 (OR 3.39, 95% CI 1.47-8.10) and nulliparas (OR 2.69, 95% CI 1.23-6.03) were more likely to desire referral. Thirty-five participants (44.3% of those who desired referral) attended a visit with genetic counseling. Having an advanced degree (OR 3.27, 95% CI 1.06-10.4) was associated with visit attendance. Thirteen participants underwent screening, and five were found to be a carrier of at least one X-linked or autosomal recessive condition. Surprisingly, presenting for a gynecologic visit directly related to planning a pregnancy was not associated with increased interest in preconception carrier screening. Nulliparas and those aged 25-34 likely expressed greater interest in referral due to high potential for future childbearing in these groups. The increased level of visit attendance in participants with advanced degrees is likely confounded by the high level of health literacy and financial resources in this group.
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Asesoramiento Genético , Reproducción , Centros Médicos Académicos , Adolescente , Adulto , Femenino , Tamización de Portadores Genéticos , Pruebas Genéticas , Humanos , Tamizaje Masivo , Atención Preconceptiva , Embarazo , Adulto JovenRESUMEN
BACKGROUND: Postoperative pulmonary recovery after lobectomy has showed early benefits for the video-assisted thoracoscopic surgery and sparing open techniques over nonsparing techniques. Robotic-assisted procedures offer benefits in term of clinical outcomes, but their advantages on pulmonary recovery and quality of life have not yet been distinctly prospectively studied. METHODS: Eighty-six patients undergoing lobectomy over a period of 29 months were prospectively studied for their pulmonary function recovery and pain score level during the in-hospital stay and at 1, 2, and 6 months. Quality of life was evaluated at 2 and 6 months. Forty-five patients were operated by posterolateral limited thoracotomy and 41 patients by robotic approach. The postoperative analgesia protocol differed for the two groups, being lighter for the robotic group. RESULTS: The pulmonary tests were not significantly different during the in-hospital stay. At 1 month, the forced expiratory volume in 1 second, forced vital capacity, vital capacity, and maximal expiratory pressure were significantly better for the robotic group (p = 0.05, 0.04, 0.05, and 0.02, respectively). There was no significant difference left at 2 and 6 months. Pain intensity was equivalent during the in-hospital stay but was significantly lower for the robotic group at 1 month (p = 0.02). At 2 and 6 months, pain and quality of life were comparable. CONCLUSION: Robotic technique can offer similar pulmonary and pain recovery during the in-hospital stay with a lighter analgesia protocol. It clearly favors the early term recovery compared with the open limited technique. The objective and subjective functional recovery becomes equivalent at 2 and 6 months.
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Pulmón/cirugía , Neumonectomía , Procedimientos Quirúrgicos Robotizados , Toracotomía , Anciano , Analgésicos/uso terapéutico , Femenino , Humanos , Pulmón/patología , Pulmón/fisiopatología , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Neumonectomía/efectos adversos , Estudios Prospectivos , Calidad de Vida , Recuperación de la Función , Procedimientos Quirúrgicos Robotizados/efectos adversos , Toracotomía/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
We present an unusual case of cardiac tamponade in a 17-year-old girl immunocompetent patient due to Salmonella enterica ssp. bredeney following infection of a bronchogenic cyst. The patient was admitted to hospital with pleuritic chest pain, dyspnoea and fever. Pulmonary angio-CT showed a bronchogenic cyst compressing the left atrium. The echocardiography showed diffuse pericardial effusion with right ventricular collapse consistent with cardiac tamponade. Pericardiocentesis was performed and microbiological cultures of the pericardial fluid became positive for Salmonella species confirmed later as bredeney subspecies by PCR. Empirical antibiotherapy was started with intravenous (IV) ceftriaxone. Bronchogenic cyst infection was suspected and confirmed by 18FDG PET CT. The patient was successfully treated by complete resection of the cyst and continuation of IV ceftriaxone followed by oral amoxicillin/clavulanate for a total duration of 6 weeks. She then completely recovered and didn't present any relapse after 6 months of follow up.
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Quiste Broncogénico , Taponamiento Cardíaco , Infecciones por Salmonella , Salmonella , Adolescente , Antibacterianos/uso terapéutico , Quiste Broncogénico/complicaciones , Quiste Broncogénico/diagnóstico , Quiste Broncogénico/tratamiento farmacológico , Quiste Broncogénico/microbiología , Taponamiento Cardíaco/diagnóstico , Taponamiento Cardíaco/etiología , Femenino , Humanos , Infecciones por Salmonella/complicaciones , Infecciones por Salmonella/diagnóstico , Infecciones por Salmonella/tratamiento farmacológico , Infecciones por Salmonella/microbiologíaRESUMEN
OBJECTIVES: Approximately half of the patients undergoing lung biopsy for nonresolving acute respiratory distress syndrome exhibit another histologic pattern than diffuse alveolar damage, with some of the pathologies characterized by a potential response to corticosteroids. This study aimed to assess whether open lung biopsy performed in the ICU for nonresolving acute respiratory distress syndrome was able to identify steroid-sensitive diseases and whether patients with a steroid-sensitive pathology experienced different clinical courses and outcomes. DESIGN: Retrospective analysis. SETTING: One 22-bed mixed ICU within a tertiary medical center. PATIENTS: Patients age greater than or equal to 16 years old who met the Berlin definition for acute respiratory distress syndrome and underwent open lung biopsy from January 2007 to January 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 695 patients diagnosed with acute respiratory distress syndrome were identified, 51 (7%) of whom underwent open lung biopsy. An alternative diagnosis to diffuse alveolar damage was found in 29 patients (57%), and a steroid-sensitive pathology was identified in 19 (37%). In-hospital and 180-day mortality rates were 55% and 61%, respectively. There was a significant difference in hospital mortality and 180-day mortality rates between patients with steroid-sensitive pathology and those with steroid-resistant pathology (37% vs 65%; p < 0.045 and 37% vs 75%; p < 0.007, respectively). We did not identify any variable that could reliably predict a steroid-sensitive histologic pattern before open lung biopsy. CONCLUSIONS: Open lung biopsy was able to identify a steroid-sensitive pathology in a significant proportion of nonresolving acute respiratory distress syndrome patients. These patients had a better outcome, with lower hospital mortality and 180-day mortality.
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Corticoesteroides/uso terapéutico , Pulmón/patología , Síndrome de Dificultad Respiratoria/patología , Anciano , Biopsia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome de Dificultad Respiratoria/tratamiento farmacológico , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: By increasing lung volume and decreasing respiration-induced tumour motion amplitude, administration of continuous positive airway pressure (CPAP) during stereotactic ablative radiotherapy (SABR) could allow for better sparing of the lungs and heart. In this study, we evaluated the effect of CPAP on lung volume, tumour motion amplitude and baseline shift, as well as the dosimetric impact of the strategy. METHODS: Twenty patients with lung tumours referred for SABR underwent 4D-computed tomography (CT) scans with and without CPAP (CPAP/noCPAP) at two timepoints (T0/T1). First, CPAP and noCPAP scans were compared for lung volume, tumour motion amplitude, and baseline shift. Next, CPAP and noCPAP treatment plans were computed and compared for lung dose parameters (mean lung dose (MLD), lung volume receiving 20 Gy (V20Gy), 13 Gy (V13Gy), and 5 Gy (V5Gy)) and mean heart dose (MHD). RESULTS: On average, CPAP increased lung volume by 8.0% (pâ¯< 0.001) and 6.3% (pâ¯< 0.001) at T0 and T1, respectively, but did not change tumour motion amplitude or baseline shift. As a result, CPAP administration led to an absolute decrease in MLD, lung V20Gy, V13Gy and V5Gy of 0.1â¯Gy (pâ¯= 0.1), 0.4% (pâ¯= 0.03), 0.5% (pâ¯= 0.04) and 0.5% (pâ¯= 0.2), respectively, while having no significant influence on MHD. CONCLUSIONS: In patients referred for SABR for lung tumours, CPAP increased lung volume without modifying tumour motion or baseline shift. As a result, CPAP allowed for a slight decrease in radiation dose to the lungs, which is unlikely to be clinically significant.
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Presión de las Vías Aéreas Positiva Contínua/métodos , Neoplasias Pulmonares/cirugía , Radiocirugia/métodos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Interpretación de Imagen Asistida por Computador , Mediciones del Volumen Pulmonar , Masculino , Persona de Mediana Edad , Movimientos de los Órganos/fisiología , Radiometría , Tomografía Computarizada por Rayos XRESUMEN
Background To evaluate pulmonary function, pain, and quality of life at midterm after robotic lobectomy performed in a single institution. Methods Sixty-five consecutive patients underwent robotic thoracic surgery over 32 months using a complete four-arm portal technique. Sixty-one patients underwent lobectomies predominantly for stage I non-small cell lung cancer. Pulmonary function tests were repeated at midterm follow-up. Pain and quality of life were evaluated during the follow-up on a subgroup of 39 patients, excluding the learning period. Results At a mean of 7-month follow-up, there was no significant difference in preoperative and midterm postoperative pulmonary function. A total of 62.5% of the patients reported a variable intensity of discomfort or pain at the surgical site, with a mean pain intensity score of 2.1 ± 1.4. Mean pain interference score were weak (1.8 ± 1.9), with patients with moderate pain reporting significantly higher pain interference scores than those with mild pain (p = 0.0025). Only one patient suffered from neuropathic-like pain. Quality of life was globally favorable and related to the pain level, with a significant interference on the physical component. Conclusion Robotic lobectomy does not appear to have an impact on midterm pulmonary function. Persistent postoperative pain is mild, nonneuropathic-like, with weak interference on daily activities. Quality of life is satisfactory but related to the pain level.
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Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Dolor Postoperatorio/etiología , Neumonectomía/efectos adversos , Calidad de Vida , Procedimientos Quirúrgicos Robotizados/efectos adversos , Actividades Cotidianas , Adulto , Anciano , Anciano de 80 o más Años , Bélgica , Carcinoma de Pulmón de Células no Pequeñas/patología , Carcinoma de Pulmón de Células no Pequeñas/fisiopatología , Femenino , Humanos , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/fisiopatología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/psicología , Neumonectomía/métodos , Recuperación de la Función , Pruebas de Función Respiratoria , Estudios Retrospectivos , Factores de Riesgo , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: The aim of this study was to independently evaluate the real-world performances of Eluvia paclitaxel drug-eluting stents (DES) (Boston Scientific, Marlborough, Massachusetts) for the treatment of external iliac and femoropopliteal artery lesions. MATERIALS AND METHODS: We prospectively collected, and retrospectively reviewed, data for all patients who underwent an endovascular treatment with an Eluvia DES for the treatment of an external iliac or femoropopliteal lesion. Patient demographics, concomitant procedures, arterial lesions characteristics, procedural details, and follow-up were reviewed. RESULTS: Between April and October 2016, 15 Eluvia DES were placed in 15 consecutive adult patients with a technical success of 100%. The treated lesions had a mean length of 93.9 ±58 mm. Sixty percent of the lesions were total occlusions and 13% were restenosis of previous stents. An additional inflow treatment was performed in 40% of the cases. At six months, two patients were lost at follow-up and one had an occluded stent. We had a primary patency rate and freedom from TLR of 92%. All remaining patients had an improved Rutherford class, improved quality of life and wound healing, and an increase in walking distance. Survival and limb salvage rates were 100%. CONCLUSIONS: This study confirms the good result of DES, in general, and of the Eluvia stent, in particular, in the treatment of external iliac and femoropopliteal arterial lesions, with a primary patency rate and a freedom from TLR of 92% at six months. A larger number of patients and longer follow-up will be required to determine the true real-world efficacy of the Eluvia DES, but short-term experience is encouraging.
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Stents Liberadores de Fármacos , Arteria Femoral , Paclitaxel/uso terapéutico , Enfermedad Arterial Periférica , Arteria Poplítea , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Arteria Femoral/cirugía , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/cirugía , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Arteria Poplítea/cirugía , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Obesity is a chronic disease that increases cardiovascular and metabolic morbidity and mortality, decreases quality of life, and increases health care costs. While the role of lifestyle behavioral factors in the development of obesity is well established, the role of traumatic life events, including violence, is unclear. The purpose of this study was to describe situations of traumatic life events reported by patients undergoing a bariatric surgery program, with a particular focus on sexual violence and its clinical correlates. METHODS: In this cross-sectional study, patients with grade II or III obesity, admitted to our digestive surgery department for bariatric surgery from August 01, 2019, to December 31, 2020, underwent a structured interview by a trained psychologist to describe the history of traumatic life events self-reported by the patients. The primary endpoint was the presence of a history of sexual violence (SV). Multivariate logistic regressions were applied to identify independent risk factors for SV. RESULTS: Of the 408 patients interviewed, 87.1% reported at least one traumatic life event and 33.1% reported having had an SV in the past. Female gender (aOR = 7.44, 95% confidence interval: 3.85-15.73; p < 0.001) and higher body mass index (1.05, 1.02-1.08; p = 0.002) were associated with an increased risk of SV. Male gender was associated with a higher risk of difficulties including sports cessation, depression, and work-related distress. CONCLUSION: In the context of obesity, psychosocial trauma is characterized by a high frequency and several gender specificities that must be taken into account in the management of these patients.
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Cirugía Bariátrica , Obesidad , Delitos Sexuales , Humanos , Estudios Transversales , Femenino , Masculino , Adulto , Persona de Mediana Edad , Obesidad/cirugía , Obesidad/psicología , Delitos Sexuales/psicología , Delitos Sexuales/estadística & datos numéricos , Factores de Riesgo , Índice de Masa Corporal , Violencia/psicología , Calidad de Vida , Acontecimientos que Cambian la VidaRESUMEN
To improve the current treatment for vascular diseases, such as vascular grafts, intravascular stents, and balloon angioplasty intervention, the evaluation of the native blood vessel microstructure in full 3D could be beneficial. For this purpose, we used contrast-enhanced X-ray microfocus computed tomography (CECT): a combination of X-ray microfocus computed tomography (microCT) and contrast-enhancing staining agents (CESAs) containing high atomic number elements. In this work, we performed a comparative study based on staining time and contrast-enhancement of 2 CESAs: Monolacunary and 1:2 Hafnium-substituted Wells-Dawson polyoxometalate (Mono-WD POM and Hf-WD POM, respectively) for imaging of the porcine aorta. After showing the advantages of Hf-WD POM in terms of contrast enhancement, we expanded our imaging to other species (rat, porcine, and human) and other types of blood vessels (porcine aorta, femoral artery, and vena cava), clearly indicating microstructural differences between different types of blood vessels and different species. We then showed the possibility to extract useful 3D quantitative information from the rat and porcine aortic wall, potentially to be used for computational modeling or for future design optimization of graft materials. Finally, a structural comparison with existing synthetic vascular grafts was made. This information will allow to better understand the in vivo functioning of native blood vessels and to improve the current disease treatments. STATEMENT OF SIGNIFICANCE: Synthetic vascular grafts, used as treatment for some cardiovascular diseases, still often fail clinically, potentially because of a mismatch in mechanical behaviour between the native blood vessel and the graft. To better understand the causes of this mismatch, we studied the full 3D microstructure of blood vessels. For this, we identified Hafnium-substituted Wells-Dawson polyoxometalate as contrast-enhancing staining agent to perform contrast-enhanced X-ray microfocus computed tomography. This technique allowed to show important differences in the microstructure of different types of blood vessels and in different species, as well as with that of synthetic grafts. This information can lead to a better understanding of the functioning of blood vessels and will allow to improve current disease treatments, such as vascular grafts.
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Prótesis Vascular , Hafnio , Humanos , Ratas , Animales , Porcinos , Microtomografía por Rayos X , StentsRESUMEN
PURPOSE/BACKGROUND: The aim of this study was to evaluate the short and midterm results of aortic coarctation (AoCo) stenting in an adolescent and adult population. METHODS: All patients with a AoCo older than 14 years treated by stent placement between December 2000 and November 2016 were included in this study. Twenty-eight patients with an invasive peak systolic pressure gradient >20 mmHg were identified. Number of redilations, non-invasive systolic blood pressure, peak systolic pressure gradient, antihypertensive medication intake, claudication status and complications were evaluated. RESULTS: Twenty-two covered and 6 uncovered stents were successfully placed. Peak systolic pressure gradient decreased immediately after stenting from a mean of 32 mmHg to 0 mmHg (± 7 mmHg). Mean AoCo diameter increased from 8 tot 16 mm (± 4 mm). Peripheral arterial injury was seen in 2 patients (7.1%). The mean follow-up time was 60 ± 49 months. Redilation of the stent was required in 4 patients, 2 to accommodate for growth and 2 for restenosis. Six (35%) patients could stop all antihypertensive medication. All claudicants (6/28) became and remained asymptomatic after surgery and during their follow-up. No aneurysms, stent fractures or dissections were noticed. There were 2 stent migrations during the first procedure with only 1 needing additional stent placement. CONCLUSION: Aortic coarctation stenting is a safe and effective treatment that significantly reduces the peak systolic pressure gradient. Antihypertensive medication can be reduced, and increase of walking distance in claudicants can be obtained. Younger patients may need more frequent reinterventions to accommodate for growth.
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Coartación Aórtica , Adulto , Humanos , Adolescente , Coartación Aórtica/diagnóstico por imagen , Coartación Aórtica/cirugía , Resultado del Tratamiento , Antihipertensivos/uso terapéutico , Stents , Factores de TiempoRESUMEN
BACKGROUND: The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery. METHODS AND RESULTS: Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade > or =3+) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI < or =2+ and in 57% of those with AI > or =3+ (P=0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, P<0.001). Overall survival at 8 years was 88+/-8%. Freedom from AV reoperation at 8 years was similar with preoperative AI < or =2+ versus preoperative AI > or =3+ (89+/-11% versus 90+/-7%, P=0.7) and with versus without cusp repair (84+/-17% versus 92+/-8%, P=0.5). Freedom from recurrent AI (grade > or =3+) at 5 years was also similar between groups (90+/-10% versus 89+/-8%, P=0.9, and 90+/-8% versus 89+/-9%, P=0.8, respectively). By multivariate analyses, predictors of recurrent AI > or =2+ were preoperative left ventricle end-diastolic diameter and AI >1+ on discharge echocardiography. CONCLUSIONS: With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair.
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Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Adulto , Anciano , Insuficiencia de la Válvula Aórtica/etiología , Ecocardiografía , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Resultado del TratamientoRESUMEN
A Gore TAG Excluder stent graft was deployed in a 35-year-old woman for an isthmic saccular aneurysm. At 12-hour follow-up, we diagnosed a proximal collapse. A Palmaz stent was used to reopen the proximal segment. Two months later, she presented with a transient ischemic attack (embolic process) related to a suboptimal apposition of the Palmaz stent in the distal aortic arch. This led to open surgical replacement of the ascending aorta and aortic arch with reimplantation of the supraaortic branches. Reopening of a stent graft collapse with a Palmaz stent might be a short-term solution; however, its presence can lead to embolic complications.
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Aneurisma Falso/terapia , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/terapia , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Falla de Prótesis , Stents , Adulto , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/cirugía , Angioplastia de Balón , Aorta Torácica/anomalías , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Embolia Intracraneal/etiología , Ataque Isquémico Transitorio/etiología , Diseño de Prótesis , Tomografía Computarizada por Rayos X , Insuficiencia del TratamientoRESUMEN
Background: Accurate positioning of a right-sided double-lumen tube is essential but challenging due to the location and the potential obstruction of the right upper lobe bronchus. Fiberoptic bronchoscopy is, therefore, necessary but requires a specific training period for the anesthesiologist and might not always be available. Objective: We describe an original backup technique to assess the correct placement of these tubes in cases a fiberopetic bronchoscopy is lacking. Design: Prospective pilot feasibility study with 10 adult patients scheduled for a left thoracic surgery. Setting: Operating theater in a universitary hospital. Materials and Methods: The new technique uses a fluoroscopy and an adult central venous catheter wire. The time needed to perform the new technique, its success rate and its efficacy in properly exclude the left lung were evaluated. Any oxygen desaturation episode (SpO2 <90%) was considered. The technique was performed by two anesthesiologists with different experience in thoracic anesthesia. Results: The success rate of our technique was 90%, which did not depend on the anesthesiologist's experience. The range of time to successfully place the tube in the dorsal decubitus position and subsequently in the right lateral decubitus position was respectively 1 min-6 min and 1 min-15 min. None of the patients presented any desaturation episodes. Conclusions: We describe an original, safe, and acceptable backup technique to properly insert right-sided double-lumen endobronchial tubes, whenever a fiberoptic bronchoscopy is not available. Moreover, this technique is easy enough to be performed by anesthesiologists with limited experience in thoracic anesthesia.
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Broncoscopía , Catéteres Venosos Centrales , Intubación Intratraqueal/instrumentación , Errores Médicos/prevención & control , Diseño de Equipo , Estudios de Factibilidad , Femenino , Tecnología de Fibra Óptica , Fluoroscopía , Humanos , Masculino , Proyectos Piloto , Estudios ProspectivosRESUMEN
BACKGROUND: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified. METHODS AND RESULTS: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist's supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99). CONCLUSIONS: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Arterias Mamarias/trasplante , Anciano , Angiografía Coronaria , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Factores de Tiempo , Grado de Desobstrucción VascularRESUMEN
We suggest a new approach to peripheral vascular bypass surgery planning based on solving the one-dimensional (1D) governing equations of blood flow in patient-specific models. The aim of the present paper is twofold. First, we present the coupled 1D-0D model based on a discontinuous Galerkin method in a comprehensive manner, such as it becomes accessible to a wider community than the one of mathematicians and engineers. Then we show how this model can be applied to predict hemodynamic parameters and help therefore clinicians to choose for the best surgical option bettering the hemodynamics of a bypass. After presenting some benchmark problems, we apply our model to a real-life clinical application, i.e. a femoro-popliteal bypass surgery. Our model shows good agreement with preoperative and intraoperative measurements of velocity and pressure and post-surgical reports.
Asunto(s)
Hemodinámica , Modelos Biológicos , Procedimientos Quirúrgicos Vasculares/métodos , Arterias/fisiopatología , Circulación Sanguínea , Puente de Arteria Coronaria , Trasplante de Corazón , Humanos , Modelos Anatómicos , Vena Safena/fisiopatología , Vena Safena/cirugíaRESUMEN
AIMS:: Stenting of the popliteal artery (PA) is generally considered inappropriate due to the high mechanical stress and bending of the artery during knee flexion. Nevertheless, vessel recoil remains problematic following angioplasty procedure for chronic total occlusions (CTOs) and adjunctive stenting may be required. The purpose of this study is to compare balloon angioplasty alone versus bailout stenting for isolated CTO of the PA. MATERIALS AND METHODS:: Between March 2012 and October 2016, 43 patients were treated with percutaneous transluminal angioplasty with balloon alone (PTA, n = 16) or bailout stenting percutaneous transluminal angioplasty and stenting (PTAS, n = 27) for de novo CTO of PA. There was no statistically significant difference between both groups with regard to patient demographics and lesions characteristics (calcification severity and lesion length). The median lesion lengths were 67 mm (39.5-78.5) in the PTA group and 94 mm (50-114) in the PTAS group ( p = 0.14). The primary outcome measure was primary patency; secondary outcomes were technical success, primary assisted patency, major amputation, and increased Rutherford classification. RESULTS:: Technical success rate was 37% and 96.3% in the PTA and PTAS groups, respectively. There was no statistical difference in 12-month primary patency rate (65.8% versus 58.7%; p = 0.15) and primary assisted patency at 12 months (75.2 versus 69.2; p = 0.47) between the 2 groups. Freedom from target lesion revascularization at 12 months was not significantly different, with 85.7% and 81.6% ( p = 0.2) in the PTA and PTAS groups, respectively. One amputation occurred in the PTA group. CONCLUSION:: This small cohort suggests that stenting as a bailout procedure in CTO of the PA provides similar results to successful balloon angioplasty. Stenting should only be performed after suboptimal balloon angioplasty with vessel recoil. Due to the large lost to follow-up, strong evidence of a therapy over the other cannot be formulated. Larger studies with longer and stronger follow-up are needed to confirm those results.