[Superior vena cava thrombosis or stricture secondary to implanted central venous access: Six cases of endovascular and direct surgical treatment in cancer patients]. / Thromboses ou sténoses de la veine cave supérieure sur chambres implantables. Six cas traités par voie endovasculaire ou chirurgie directe dans un contexte de cancer.

Superior vena cava (SVC) stenosis or thrombosis is a well-known complication of central venous catheterization for endocavitary treatments, hemodialysis, or chemotherapy. In cancer patients, these SVC lesions are often symptomatic due to intimal damage and chemotherapy toxicity. We report our experience with six patients treated between 2007 and 2012 via an endovascular approach (n=5) or a direct surgical approach (n=1). All patients had SVC syndrome with facial edema, headache and upper limb edema. In three cases, the catheter was in place when the clinical symptoms occurred. Duplex Doppler and computed tomography (CT)-angiography identified the following lesions: isolated SVC stenosis (n=2); SVC stenosis with right Pirogoff confluence stenosis (n=1); SVC stenosis associated with left innominate vein thrombosis and right Pirogoff confluence stenosis (n=1); SVC thrombosis affecting azygos flow (n=2). In one patient, the thrombus extended into the right atrium. Five patients underwent endovascular repair via a right jugular approach (n=2) or a double jugular approach (n=3). Treatment involved: SVC angioplasty with stent (n=2); right Pirogoff angioplasty and SVC stent (n=1); kissing angioplasty of both innominate trunks with a SVC stent (n=1); and SVC angioplasty without stent because of an incomplete result with a residual lumen less than 8mm (n=1). One patient had a complete SVC occlusion with extension of thrombus into the right atrium. She was treated via a median sternotomy for open surgical control of both innominate trunks and lateral clamping of the right atrium. A long cavotomy prolonged on the right atrium allowed thrombo-intimectomy and pericardial patch angioplasty. Postoperative follow-up was uneventful in five cases. However, postoperative hemorrhage required pericardial drainage in one patient. The CT scan showed a good morphological aspect in five patients and an incomplete result in one case. Patients have been followed up annually with a duplex scan from two to six years. One patient had a restenosis at 7 months treated by a new angioplasty via a femoral approach. A new catheter was positioned via a cervical approach. Two patients died of metastatic diffusion at 8 and 32 months. The other four patients have remained asymptomatic, with a satisfactory duplex scan. In conclusion, VCS lesions after implanted central access for chemotherapy can often be treated endovascularly. Conventional surgery still has indications when lesions extend into the right atrium.

Open Conversion After Endovascular Abdominal Aneurysm Repair: An 8 year Single Centre Experience.

OBJECTIVE: To report experience with open conversion (OC) after previous failed EVAR and to compare outcomes of patients undergoing elective OC with those operated on in an urgent setting. METHODS: Patients undergoing OC after EVAR between August 2008 and September 2016 were included in this retrospective and observational single institution study. Indications, demographic, anatomical, intra-operative and post-operative data were collected prospectively. Primary endpoints were 30 day and in hospital mortality. Secondary endpoints included moderate to severe complications, secondary interventions, length of intensive care unit, and hospital stay. RESULTS: OC was performed in 31 patients over the study period: 19 elective and 12 emergency OC, including six ruptures. Median time from index EVAR to delayed OC was 35 months (0-228 months). The most common indications for OC were endoleaks (n = 24, 77%), followed by stent graft infection (n = 3, 10%), thrombosis (n = 3, 10%) and kinking (n = 1, 3%). Eight of the removed stent grafts were Endurant, two were Talent, five Excluder, six Nellix, two AFX, five Zenith, one Vanguard, one Anaconda, and one Seta. Overall in hospital mortality was 10%, with significantly increased in hospital mortality in the emergency group compared with the elective group (25% vs. 0%, p = .049). Renal and pulmonary complications were significantly higher in the emergency group (42% vs. 5%, p = .02 and 42% vs. 0%, p = .005, respectively). No late complication or death was recorded after a mean follow-up of 18 ± 13 months. CONCLUSIONS: Emergency OC is associated with significantly increased in hospital mortality and morbidity compared with elective OC. Elective OC appears to be safer and effective, and should be considered as the best option in cases of EVAR failure to avoid further emergency OC procedures.

Dynamics of Parascaris and Strongylus spp. parasites in untreated juvenile horses.

Parasite control in foals is of utmost importance due to the high susceptibility to parasitic infection and disease in this age group. Foals are commonly co-infected with strongyle and ascarid parasites, which complicate parasite control strategies. The present study retrospectively investigated necropsy records of foals born into a university herd kept without anthelmintic treatment since 1979. The aims were to statistically analyze the relationship between fecal egg counts, worm burdens, foal age, sex, and season with specific focus on Parascaris and Strongylus spp. A total of 83 foals born between 1999 and 2015 were included. Foals were born between January and September within the given year and age at necropsy ranged between 27 and 563 days of age with a mean and median of 202 and 204 days, respectively. One set of multivariate mixed linear models was constructed analyzing strongyle and ascarid fecal egg counts as outcome variables, and another set of analyses investigated the following worm counts as outcome variables: Intestinal Parascaris spp. counts (immatures and adults), S. vulgaris (migrating and intestinal stages), S. edentatus (migrating and intestinal stages). Both ascarid and strongyle egg counts were influenced significantly by differences between study years (p<0.05). In addition, total ascarid egg counts were statistically influenced by age (p=0.020) exhibiting a peak at four months of age and fillies had significantly higher ascarid worm burdens (p=0.043). Foal age had significant influences on intestinal counts of immature Parascaris spp. (p=0.034) and adult S. edentatus counts (p=0.028). Larval counts of S. edentatus were significantly associated with birth month (p=0.023), whereas counts of migrating S. vulgaris larvae were not statistically associated with any of the investigated covariates. This study provides novel information on the dynamics of important parasites in naturally infected foals.

Proximal Scallop in Thoracic Endovascular Aortic Aneurysm Repair to Overcome Neck Issues in the Arch.

OBJECTIVE: To evaluate initial experience with a custom made proximal scalloped stent graft for thoracic endovascular aortic repair (TEVAR) of aortic aneurysms involving the arch. METHODS: Between September 2012 and November 2014, patients presenting with a thoracic aortic aneurysm (TAA) with short or angulated neck were selected for treatment by custom made proximal scalloped Relay Plus stent grafts (ABS Bolton Medical, Barcelona, Spain). Prospectively acquired data relating to patient demographics, procedure details, clinical outcomes, and complications were analyzed retrospectively. RESULTS: Ten selected patients (50% male, mean age 77 ± 8 years) were treated using a thoracic custom made Relay Plus stent graft, three of whom underwent additional cervical supra-aortic trunk revascularizations. TAA were fusiform in four cases, saccular in three, and three patients were treated for proximal type I endoleaks after previous standard TEVAR. The graft was landed in zone 2 in 3 cases, in zone 1 in 4 cases, and in zone 0 in 3 cases. The custom made scallop was designed to preserve flow in the left subclavian artery in three patients, in the left common carotid artery in four, and in the innominate artery in three. No proximal type I endoleak occurred and proximal sealing was achieved in all cases, with a technical success rate of 100%. All targeted vessels were patent. During a mean follow up of 12 ± 5 months, no conversion to open surgical repair and no aortic rupture occurred. One patient died post-operatively from myocardial infarction and one patient suffered a stroke with complete recovery. One patient had a distal type I endoleak on the 6 month CT scan and is scheduled for distal extension. No paraplegia, retrograde dissection and no other aortic related complications were recorded. CONCLUSIONS: Proximal scalloped stent grafts appear to be an effective additional tool for TEVAR of TAA when dealing with short or angulated proximal necks.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.

OBJECTIVES: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

[Massive hemoptysis following thoracic aortic rupture: an advancing field]. / Hémoptysie massive survenue après traitement endovasculaire d'un anévrisme aortique. Une prise en charge en pleine évolution.

We report the case of a 57-year-old woman who presented with massive hemoptysis and thoracic pain 3 years after the endovascular treatment of a thoracic aortic aneurysm. Emergency work up revealed the presence of an endoleak, leading to the pressurization of the aneurysm sac and its subsequent rupture into the lung parenchyma. The discussion includes presentation, clinical course, diagnosis, complications and new therapeutic options in the management of a massive hemoptysis secondary to aortic rupture. All together, the case and discussion highlight the classical rules of critical care and the recent advances in endovascular treatment of thoracic aortic rupture.

[Pediatric lung transplantation in Broussais-HEGP: a 23-year experience (1990-2013)]. / Transplantation pulmonaire pédiatrique : expérience de l'équipe Broussais-HEGP de 1990 à 2013.

INTRODUCTION: Pediatric lung transplantations (LTx) remains a small part of LTx performed worldwide. The majority of these Tx concerns young adolescents, transplantations in infants being anecdotic. We conducted a retrospective study of LTx in children and adolescents in one center in Paris from the beginning of the 90's to 2013. METHODS: Data from Broussais then HEGP were collected retrospectively from 1990 to 2013: 380 LTx were reported in 368 patients including 111 LTx performed among children from 5 to 18 years of age (30%). RESULTS: One hundred and eleven patients received 121 LTx: 86 bilateral LTx, 13 combined lung-liver, 3 monopulmonary, 5 heart-lung and 4 combined heart-lung-liver Tx. Eighty-eight percent of the patients had cystic fibrosis. Median age was 14 years, weight 34 kg and height 144 cm. Median age of donors was 27 years, weight 60 kg and height 167 cm. Conditional survival for children was not different than adults: 72% at one year, 42% at 5 years, 37% at 10 years and 26% at 15 years. There was not overall early mortality after transplantation. Era graft survival was significantly higher after year 2000 (53% at 5 years vs 32% P=0.03). CONCLUSION: Lung transplantation among children under 18 years have similar outcome to those of adult patients.

Efficacy and safety of recombinant human C1-inhibitor for the treatment of attacks of hereditary angioedema: European open-label extension study.

BACKGROUND: Hereditary angioedema (HAE) owing to C1 inhibitor deficiency is an autosomal dominant disorder, characterized by recurrent, potentially life-threatening, localized attacks of tissue swelling. Current treatment involves the infusion of C1 inhibitor protein (C1-INH) isolated from human plasma. OBJECTIVES: This open-label extension to a European, Israeli and Argentinean randomized study (NCT00262301) aimed to investigate the efficacy and safety of recombinant human C1 inhibitor (rhC1-INH) as a first-line treatment following an HAE attack, together with its effect on subsequent attacks. METHODS: An HAE-specific visual analogue scale (VAS) 0-100 mm was used by patients to assess the severity of attack at four anatomical locations. Patients were treated with one, single-vial, fixed-dose of rhC1-INH (2100 U), followed by up to two further vials at the investigators discretion. The primary end-point was the time from first rhC1-INH injection to first onset of relief of symptoms (≥ 20 mm decrease on VAS). Response to treatment was defined as the onset of relief within 4 h. RESULTS: A total of 57 patients were treated for 194 HAE attacks. Overall, sustained relief of symptoms was achieved in 87% of rhC1-INH-treated patients within 4 h of treatment, with 57% of attacks requiring only one vial of rhC1-INH. When categorized by successive attacks experienced by individual patients, the response rate to rhC1-INH treatment was 96%, 83%, 87%, 80% and 80% for attacks 1-5 respectively. Treatment with rhC1-INH was well tolerated, with no discontinuations owing to treatment-emergent adverse events and no adverse events relating to immunogenicity. CONCLUSIONS AND CLINICAL RELEVANCE: Treatment with rhC1-INH provides fast-onset relief for an HAE attack, with a high rate of therapeutic response maintained throughout subsequent attacks.

Very late heart transplant rejection is associated with microvascular injury, complement deposition and progression to cardiac allograft vasculopathy.

In heart transplants, the significance of very late rejection (after 7 years post-transplant, VLR) detected by routine endomyocardial biopsies (EMB) remains uncertain. Here, we assessed the prevalence, histopathological and immunological phenotype, and outcome of VLR in clinically stable patients. Between 1985 and 2009, 10 662 protocol EMB were performed at our institution in 398 consecutive heart transplants recipients. Among the 196 patients with >7-year follow-up, 20 (10.2%) presented subclinical ≥3A/2R-ISHLT rejection. The VLR group was compared to a matched control group of patients without rejection. All biopsies were stained for C4d/C3d/CD68 with sera screened for the presence of donor-specific antibodies (DSAs). In addition to cellular infiltrates with myocyte damage, 60% of VLR patients had evidence of intravascular macrophages. C4d and/or C3d-capillary deposition was found in 55% VLR EMB. All cases of VLR associated with microcirculation injury had DSAs (mean DSA(max) -MFI = 1751 ± 583). This entity was absent from the control group (p < 0.0001). Finally, after a similar follow-up postreference EMB of 6.4 ± 1 years, the mean of CAV grade was 0.76 ± 0.18 in the control group compared to 2.06 ± 0.26 in the VLR group respectively, p = 0.001). There was no difference in patient survival between study and control groups. In conclusion, VLR is frequently associated with complement-cascade activation, microvascular injury and DSA, suggesting an antibody-mediated process. VLR is associated with a dramatic progression to severe CAV in long-term follow-up.

Downregulation of remodelling enzymatic activity induced by an angiotensin-converting enzyme inhibitor (perindopril) reduces the degeneration of experimental abdominal aortic aneurysms in a rat model.

AIMS: Angiotensin-converting enzyme (ACE) inhibitors have proven their ability to affect vascular wall remodelling, in addition to their anti-hypertensive effects. The aim of this study was to assess the impact of perindopril on the development of abdominal aortic aneurysm (AAA) in a rat model, and its correlation to enzyme activities involved in vascular wall remodelling. METHODS: The model of the decellularised aortic xenograft in Lewis rat was chosen. Rats were randomised to two groups: group P fed with 3 mg kg(-1) of perindopril daily during 30 days, or control group C (n = 15 per group)). Rats were euthanised at 30 days for analysis. AAA growth and histological changes in the aortic wall were measured by histomorphometry. Proteolytic activities were measured by gelatin zymography of conditioned medium for activematrix metalloproteinase 9/pro-matrix metalloproteinase 9 (MMP9/pro-MMP9) and activeMMP2/pro-MMP2, and by quantitative immunofluorescence tissue for elastase and plasmin. RESULTS: The mean maximal diameter of AAAs at 30 days was significantly lower in the treated group P compared with the control group C (2.5 ± 1.0 vs. 4.9 ± 2.1 mm; P < 0.01). The expansion rate of AAAs after 30 days was significantly reduced in group P compared with group C (36 ± 14% vs. 67 ± 23%; P < 0.01). Pro-MMP9 and MMP9 activities were significantly decreased in relative intensity (RI) in group P compared with group C (0.43 ± 0.64 RI vs. 1.02 ± 0.61 RI, P = 0.01; 0.18 ± 0.57 RI vs. 0.66 ± 1.19 RI, P = 0.004). The activation rate of MMP2 was also significantly lower in group P compared with group C (1.27 ± 0.42 vs. 1.67 ± 0.44; P = 0.002). Elastase and plasmin tissue activities were significantly lower in group P compared with group C, respectively (3.9 ± 3.3 vs. 5.8 ± 3.7 IF min(-1) g(-1),and 25.9 ± 23.9 vs. 49.1 ± 38.7 IF min(-1) g(-1); P < 0.05). CONCLUSION: After 30 days of treatment by perindopril, a significant decrease in aneurysmal degeneration of the decellularised aortic xenograft AAA model was observed. This phenomenon appears to be induced by a downregulation of enzymes involved in the aortic wall remodelling during aneurysmal degeneration.

[Stenting or coronary artery bypass surgery for triple vessel disease?]. / Maladie coronaire tritronculaire : angioplastie/stent ou pontages aortocoronaires ? Etat actuel et revue de la littérature.

This review was undertaken to objectively analyse the cumulated medical literature on techniques of myocardial revascularization (angioplasty, bare metal stenting, drug eluting stenting, coronary artery surgery) in multivessel coronary artery disease. Randomized trials, meta analyses and registries comparing these treatment modalities show a short and long term advantage of surgery over percutaneous techniques for angina recurrence and need for repeat revascularization, although mortality and myocardial infarction rate do not seem statistically different. Diabetes mellitus, chronic renal failure and female gender represent high risk subgroups. Data on drug eluting stents are to date limited to the short term; however, it does not seem that drug eluting stents have resolved the need for repeat revascularization. Stenting addresses focal lesion whereas future revascularization occurs on other coronary sites by progression of coronary disease. Cardiologists should objectively inform the consenting coronary multivessel disease patient on the risk of repeat revascularization inherent to percutaneous techniques and on the weight of actual data favouring surgery in multivessel disease.

[Systolic anterior motion (SAM): a rare cause of late failure in mitral valve repair]. / Le SAM: une cause exceptionnelle d'echec tardif de plastie mitrale.

Systolic anterior motion (SAM) of the mitral valve is a rare complication of mitral valve repair. The treatment of the large majority of cases is purely medical. Nevertheless, an early degradation may require reoperation (revision of the repair or valve replacement). The authors report two cases of post-repair SAM with a poor outcome with medical therapy which required reoperation after several years. In both cases, an excess of bivalvular tissue with respect to the size of the mitral orifice was observed. A second repair was possible (sliding valvuloplasty associated with an oval resection of the anterior leaflet) with satisfactory long-term results. The identification of the risk factors and careful analysis of the lesions in cases of SAM after mitral valve repair may lead to a repeat repair and the avoidance of mitral valve replacement.

[Five years experience with non-pulsatile flow]. / Enseignement de 5 années d'expérience avec les assistances circulatoires à flux non pulsé.

Mechanical circulatory assistances now belong to the therapeutic stock in case of advanced heart failure. Their mainspring lays on the substitution of the failing left and/or right ventricle function with a pump. The goal being to maintain or restore the system main functions. Their main indication is a bridge to transplant mechanical circulatory assistance, allowing the patient to await transplantation. However, indications for definitive implantation appear in case of transplantation counter indication, mechanical circulatory assistances already emerging as a possible alternative to transplantation. For over 10 years, we have used pulsatile flow assistances, either with pneumatic ventricles or electro-mechanic implantable left ventricles. We henceforth observe the development of a new generation of implantable assistance providing a non-pulsatile flow. These are axial pumps. We evaluated the first model, the DeBakey axial pump which became the most used axial pump worldwide. We now observe the development of other axial pumps as well as the development of new implantable centrifugal pumps.

[Prevention and treatment of atrial fibrillation after cardiac surgery]. / Prevention et traitement de la fibrillation atriale après chirurgie cardiaque.

The incidence of postoperative atrial fibrillation in cardiac surgery is still high despite major advances in anesthetic, pharmacological and surgical techniques. Its precise mechanism is still totally unknown. Postoperative atrial fibrillation increases length of stay as well as hospital costs. Rate of postoperative atrial fibrillation spontaneous conversion is high. Several protocols have been developed for prevention and/or treatment of postoperative atrial fibrillation. Beta-blockers, amiodarone and atrial pacing reduce.atrial fibrillation incidence as compared to placebo. On the other hand, amiodarone and propafenone achieve a high conversion rate of installed postoperative atrial fibrillation. However, among many pharmacological options, the best treatment is still to be defined.

[Pediatric mechanical circulatory assistance. Biventricular assistance for fulminant myocarditis in a 5 year old child]. / Assistance circulatoire mécanique pédiatrique. A propos d'une assistance biventriculaire pour une myocardite fulminante chez un enfant de 5 ans.

The authors report the case of a 5 years old infant with cardiogenic shock due to a fulminant myocarditis. The severity of the shock which was refractory to conventional therapies necessitated to require to a cardiopulmonary bypass on emergency, followed by an external pneumatic bi-ventricular assistance. After 10 days (3 days with cardioplumonary bypass and 7 days of bi-ventricular assistance), the patient had been able to be disconnected of any mechanical circulatory supply with total recovery of the cardiac function.