Arterial Sleeve Lobectomy: Does Pulmonary Artery Reconstruction Type Impact Lung Function?

BACKGROUND: The aim of this single-center retrospective cohort study was to assess the impact of arterial reconstruction technique on lung perfusion. The second objective was to ascertain the functional validity of arterial sleeve lobectomy. METHOD: Between January 2001 and December 2020, a total of 81 patients underwent lobectomy with pulmonary artery (PA) reconstruction for lung cancer at the University Hospital of Montpellier. After excluding patients with an incomplete postoperative pulmonary function test, we conducted a comparative analysis of the preoperative and postoperative functional outcomes (FEV1) of 48 patients, as well as the preoperative and postoperative Technetium99m scintigraphic pulmonary perfusion results of 28 patients. Then, we analyzed postoperative perfusion results according to the pulmonary artery reconstruction techniques use. RESULTS: PA reconstruction types were as follows: 9 direct angioplasties (19%), 14 patch angioplasties (29%), 7 end-to-end anastomoses (15%), 6 prosthetic bypasses (12%), 11 arterial allograft bypasses (23%), and 1 custom-made xenopericardial conduit bypass. Regardless of the type of vascular reconstruction performed, the comparative analysis of lung perfusion revealed no significant difference between the preoperative and postoperative perfusion ratio of the remaining parenchyma (median = 29.5% versus 32.5%, respectively; p = 0.47). Regarding the pulmonary functional test, postoperative predicted FEV1 significantly underestimated the actual postoperative measured FEV1 by about 260 mL (11.4%) of the preoperative value. The patency rate was 96% and the 5-year overall survival was 49% for a mean follow up period of 34 months. CONCLUSION: Lobectomy with PA reconstruction is a valid parenchymal-sparing technique in terms of perfusion and respiratory function.

Medico-economic impact of thoracoscopy versus thoracotomy in lung cancer: multicentre randomised controlled trial (Lungsco01).

BACKGROUND: Lungsco01 is the first study assessing the real benefits and the medico-economic impact of video-thoracoscopy versus open thoracotomy for non-small cell lung cancer in the French context. METHODS: Two hundred and fifty nine adult patients from 10 French centres were randomised in this prospective multicentre randomised controlled trial, between July 29, 2016, and November 24, 2020. Survival from surgical intervention to day 30 and later was compared with the log-rank test. Total quality-adjusted-life-years (QALYs) were calculated using the EQ-5D-3L®. For medico-economic analyses at 30 days and at 3 months after surgery, resources consumed were valorised (€ 2018) from a hospital perspective. First, since mortality was infrequent and not different between the two arms, cost-minimisation analyses were performed considering only the cost differential. Second, based on complete cases on QALYs, cost-utility analyses were performed taking into account cost and QALY differential. Acceptability curves and the 95% confidence intervals for the incremental ratios were then obtained using the non-parametric bootstrap method (10,000 replications). Sensitivity analyses were performed using multiple imputations with the chained equation method. RESULTS: The average cumulative costs of thoracotomy were lower than those of video-thoracoscopy at 30 days (€9,730 (SD = 3,597) vs. €11,290 (SD = 4,729)) and at 3 months (€9,863 (SD = 3,508) vs. €11,912 (SD = 5,159)). In the cost-utility analyses, the incremental cost-utility ratio was €19,162 per additional QALY gained at 30 days (€36,733 at 3 months). The acceptability curve revealed a 64% probability of efficiency at 30 days for video-thoracoscopy, at a widely-accepted willingness-to-pay threshold of €25,000 (34% at 3 months). Ratios increased after multiple imputations, implying a higher cost for video-thoracoscopy for an additional QALY gain (ratios: €26,015 at 30 days, €42,779 at 3 months). CONCLUSIONS: Given our results, the economic efficiency of video-thoracoscopy at 30 days remains fragile at a willingness-to-pay threshold of €25,000/QALY. The economic efficiency is not established beyond that time horizon. The acceptability curves given will allow decision-makers to judge the probability of efficiency of this technology at other willingness-to-pay thresholds. TRIAL REGISTRATION: NCT02502318.

VATS versus Open Lobectomy following Induction Therapy for Stage III NSCLC: A Propensity Score-Matched Analysis.

Objectives: This study aims to evaluate the perioperative and oncologic outcomes of thoracoscopic lobectomy for advanced stage III NSCLC. Methods: We retrospectively reviewed 205 consecutive patients who underwent VATS or open lobectomy for clinical stage III lung cancer between January 2013 and December 2020. The perioperative and oncologic outcomes of the two approaches were compared. Long-term survival was assessed using the Kaplan−Meier estimator. Propensity score-matched (PSM) comparisons were used to obtain a well-balanced cohort of patients undergoing VATS and open lobectomy. Results: VATS lobectomy was performed in 77 (37.6%) patients and open lobectomy in 128 (62.4%) patients. Twelve patients (15.6%) converted from VATS to the open approach. PSM resulted in 64 cases in each group, which were well matched according to twelve potential prognostic factors, including tumor size, histology, and pTNM stage. Between the VATS and the open group, there were no significant differences in unmatched and matched analyses, respectively, of the overall postoperative complications (p = 0.138 vs. p = 0.109), chest tube duration (p = 0.311 vs. p = 0.106), or 30-day mortality (p = 1 vs. p = 1). However, VATS was associated with shorter hospital stays (p < 0.0001). The five-year overall survival (OS) and five-year Recurrence-free survival (RFS) were comparable between the VATS and the open groups. There was no significant difference in the recurrence pattern between the two groups in both the unmatched and matched analyses. Conclusion: For the advanced stage III NSCLC, VATS lobectomy achieved equivalent postoperative and oncologic outcomes when compared with open lobectomy without increasing the risk of procedure-related locoregional recurrence.

Patient risk factors for conversion during video-assisted thoracic surgery-the Epithor conversion score.

OBJECTIVES: Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score. METHODS: We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020. RESULTS: From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients' preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort). CONCLUSIONS: Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS-an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS.

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine.

OBJECTIVES: This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC). METHODS: Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10. RESULTS: There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence. CONCLUSIONS: VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms.

OBJECTIVE: Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS: This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS: Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS: Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

Partial Vertebrectomies without Instrumented Stabilization During En Bloc Resection of Primary Bronchogenic Carcinomas Invading the Spine: Feasibility Study and Results on Spine Balance.

OBJECTIVE: It is unknown whether spinal instrumentation is required to prevent deformity after partial vertebrectomy in the treatment of primary bronchogenic carcinomas invading the spine (PBCIS). In this study, we focus on the postoperative spine deformity in patients who underwent operation for partial vertebrectomies without instrumentation during en bloc PBCIS resection. Our objective was to determine whether deformity depends on the type of vertebral resection and if any vertebral resection threshold can be observed to justify additional spinal instrumentation. METHODS: This is a retrospective study, including all patients with PBCIS operated without spinal instrumentation from 2009 to 2018. Partial vertebrectomies were classified into categories A, B, and C depending on vertebral resection. Patients had long-term radiologic follow-up to assess the spine deformity evolution. RESULTS: Eighteen patients were included. The median follow-up was 27 months. Four patients underwent a secondary posterior instrumentation surgical procedure due to progressive spinal deformity. A low-risk group of deformation was characterized as type A resection and type B resection on less than 3 vertebrae. CONCLUSIONS: There are no validated criteria to justify a systematic spinal instrumentation when performing a partial vertebrectomy during en bloc resection of PBCIS. Performed alone without spine instrumentation, both type A and type B resections on less than 3 resected vertebrae were not subject to sagittal and coronal deformity even after a long follow-up, emphasizing that a systematic stabilization is not needed in this low-risk group. These results could help to reduce the perioperative morbidity of these procedures that are usually long and complex.

Oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate in lung cancer surgery: a randomized clinical trial.

PURPOSE: Respiratory complications are the leading causes of morbidity and mortality after lung cancer surgery. We hypothesized that oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate (CHG) would be an effective method to reduce these complications as reported in cardiac surgery. METHODS: In this multicenter parallel-group randomized double-blind placebo-controlled trial, we enrolled consecutive adults scheduled for anatomical pulmonary resection for lung cancer. Perioperative decontamination consisted in oropharyngeal rinse solution (0.12% CHG) and nasopharyngeal soap (4% CHG) or a placebo. The primary outcome measure was the proportion of patients requiring postoperative invasive and/or noninvasive mechanical ventilation (MV). Secondary outcome measures included occurrence of respiratory and non-respiratory healthcare-associated infections (HAIs) and outcomes within 90 days. RESULTS: Between July 2012 and April 2015, 474 patients were randomized. Of them, 24 had their surgical procedure cancelled or withdrew consent. The remaining 450 patients were included in a modified intention-to-treat analysis: 226 were allocated to CHG and 224 to the placebo. Proportions of patients requiring postoperative MV were not significantly different [CHG 14.2%; placebo 15.2%; relative risks (RRs) 0.93; 95% confidence interval (CI) 0.59-1.45; P = 0.76]. Neither of the proportions of patients with respiratory HAIs were different (CHG 13.7%; placebo 12.9%; RRs 1.06; 95% CI 0.66-1.69; P = 0.81). The CHG group had significantly decreased incidence of bacteremia, surgical-site infection and overall Staphylococcus aureus infections. However, there were no significant between-group differences for hospital stay length, change in tracheal microbiota, postoperative antibiotic utilization and outcomes by day 90. CONCLUSIONS: CHG decontamination decreased neither MV requirements nor respiratory infections after lung cancer surgery. Additionally, CHG did not change tracheal microbiota or postoperative antibiotic utilization. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, number NCT01613365.

Medicoeconomic analysis of lobectomy using thoracoscopy versus thoracotomy for lung cancer: a study protocol for a multicentre randomised controlled trial (Lungsco01).

INTRODUCTION: In the last decade, video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) has had a major effect on thoracic surgery. Retrospective series have reported benefits of VATS when compared with open thoracotomy in terms of postoperative pain, postoperative complications and length of hospital stay. However, no large randomised control trial has been conducted to assess the reality of the potential benefits of VATS lobectomy or its medicoeconomic impact. METHODS AND ANALYSIS: The French National Institute of Health funded Lungsco01 to determine whether VATS for lobectomy is superior to open thoracotomy for the treatment of NSCLC in terms of economic cost to society. This trial will also include an analysis of postoperative outcomes, the length of hospital stay, the quality of life, long-term survival and locoregional recurrence. The study design is a two-arm parallel randomised controlled trial comparing VATS lobectomy with lobectomy using thoracotomy for the treatment of NSCLC. Patients will be eligible if they have proven or suspected lung cancer which could be treated by lobectomy. Patients will be randomised via an independent service. All patients will be monitored according to standard thoracic surgical practices. All patients will be evaluated at day 1, day 30, month 3, month 6, month 12 and then every year for 2 years thereafter. The recruitment target is 600 patients. ETHICS AND DISSEMINATION: The protocol has been approved by the French National Research Ethics Committee (CPP Est I: 09/06/2015) and the French Medicines Agency (09/06/2015). Results will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02502318.

Outcomes of Left Subclavian Artery Transposition for Hybrid Aortic Arch Debranching.

BACKGROUND: The aim of this study was to evaluate outcomes of left subclavian artery (LSA) revascularization for hybrid aortic arch debranching. METHODS: Between 1998 and 2015, 68 patients (41 men; mean age, 67 ± 16 years) underwent thoracic endovascular aortic repair (TEVAR) with LSA coverage, 19.2% (n = 13) were never revascularized, and the remaining patients underwent LSA revascularization (n = 55; 80.8%). Revascularization was achieved by LSA-carotid transposition via a medial approach in 81.8% (n = 45) and a lateral approach in 18.2% (n = 10). The indication for TEVAR was aneurysmal disease in 30.9% (n = 17), dissection in 29% (n = 16; acute, n = 5), traumatic aortic injury in 21.8% (n = 12), pseudoaneurysm in 10.9% (n = 6), aortobronchial fistula in 5.5% (n = 3), and penetrating atherosclerotic ulcer in 1.9% (n = 1). Elective cases accounted for 52.7% (n = 29). Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter. RESULTS: LSA revascularization was achieved in all the cases. Thirty-day mortality rate was 12.7%. Thirty-day mortality related to LSA revascularization was 0%. No patient suffered a stroke. Vocal cord paralysis was detected in 7.2% of patients (n = 4). Hematoma requiring surgical drainage was observed in 3.6% of patients (n = 2). Lymph leak requiring revision surgery was observed in 1.8% of patients (n = 1). Phrenic nerve palsy was not observed. The local complication rate was significantly higher (P = 0.03) in patients with LSA transposition via a lateral approach (20%; n = 2) when compared to patients with LSA revascularization via a medial approach (11.1%; n = 5). After a mean follow-up of 31.5 months (range, 2-171 months), the patency of the LSA revascularization was maintained in all patients. CONCLUSIONS: During TEVAR, when LSA coverage is required, LSA revascularization is a durable procedure associated with a low morbidity rate. LSA transposition via a medial approach would appear to be associated with significantly fewer complications.

Homemade proximal scalloped stent graft for thoracic endovascular aortic repair of zone 2 acute aortic syndrome.

OBJECTIVE: The aim of this study was to evaluate the outcomes of homemade proximal scalloped stent grafts for thoracic endovascular aortic repair of zone 2 acute aortic syndrome. METHODS: Between May 2015 and December 2015, 10 patients with unremitting symptoms or rupture secondary to an acute aortic syndrome involving zone 2 underwent urgent or emergency thoracic endovascular aortic repair. Among them, 8 were treated using homemade proximal scalloped stent grafts to preserve the patency of the left subclavian artery. Indications included traumatic transection (n = 3) and acute (n = 4) and subacute (n = 1) complicated type B aortic dissection. Follow-up computed tomography scans were performed at 1 week and 3 and 6 months. RESULTS: The median duration for stent graft modification was 15 minutes (range, 14-17 minutes). The technical success rate was 100%; sealing was achieved in all cases with no type I endoleaks. All left subclavian arteries were patent, although 1 case was associated with a 50% stenosis. No deaths occurred as a consequence of the aortic repair, but 1 patient died of a traumatic renal hematoma on postoperative day 5. During a mean follow-up of 7.2 ± 2 months, there were no conversions to open surgical repair, aortic ruptures, paraplegia, retrograde dissection, or other aortic complications. CONCLUSIONS: The use of the homemade proximal scalloped stent graft is both feasible and effective for left subclavian artery revascularization during thoracic endovascular aortic repair involving a spectrum of acute thoracic aortic pathology. This approach provides a rapid, reproducible method of scalloping the endograft. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Hybrid aortic arch repair for dissecting aneurysm.

OBJECTIVE: This study analyzed the outcome of a combined endovascular and debranching procedure for hybrid aortic arch repair in patients with chronic dissecting aortic aneurysms involving the aortic arch. METHODS: We reviewed all consecutive patients who underwent hybrid aortic arch repair for dissecting aneurysm at the Arnaud de Villeneuve Hospital. RESULTS: A total of 33 consecutive patients between March 2005 and September 2015 were included. Patients' mean age was 65.1 ± 12.2 years. Mean aneurysm diameter was 60.3 ± 14.2 mm. Patients were treated for aneurysm diameter 55 mm or greater (n = 28), aortic growth more than 1 cm/year (n = 3), or rupture (n = 2). Eleven complete supra-aortic debranchings were performed in zone 0, with 2 concomitant replacements of the ascending aorta. Partial aortic arch debranching was performed in 22 patients (zone 1 = 8; zone 2 = 14). Technical success was achieved in 97% of patients. There was no in-hospital death. One patient died of decompensated cirrhosis on day 20, resulting in a 30-day mortality of 3%. One patient had major cerebrovascular complications (3%). Spinal cord ischemia was observed in 1 patient (3%), with complete recovery after spinal fluid drainage. Retrograde dissection occurred in 1 patient (3%). After a mean follow-up of 24.3 months (range, 0.6-104.8 months), the overall mortality was 12% (n = 4) with 3 additional deaths. Endoleak was reported in 6 patients (18%), of whom 2 required reintervention. Overall, 8 reinterventions were performed (24%), with a mean time from intervention of 8.7 months (range, 1.2-24.6 months). CONCLUSIONS: Hybrid aortic arch repair for dissecting aneurysm is associated with acceptable early and midterm major morbidity and mortality, even for patients treated in zone 0. However, given the high rate of reintervention and endoleak, close follow-up is required.

Thoracic Endovascular Aortic Repair for Penetrating Aortic Ulcer: Literature Review.

BACKGROUND: The aim of the study was to provide a literature review of thoracic endovascular aortic repair (TEVAR) outcomes for penetrating ulcer of the aorta. METHODS: Relevant articles in the Embase, Medline, and Cochrane databases reporting the results of endovascular repair for penetrating ulcers of the thoracic aorta were systematically searched and reviewed. RESULTS: Thirty-one articles were integrated after a literature review, and 310 patients treated by TEVAR for penetrating ulcers of the aorta were identified. In this cohort, most patients were male (65.8%), had a history of smoking (60.4%), and systemic hypertension (90%). Only 9% were asymptomatic at initial presentation. Most cases (76%) occurred among patients with a single ulcer, located in the descending thoracic aorta (81%), with associated intramural hematoma in 45%. The technical success of TEVAR was 98.3%. Surgical conversion during the postoperative period with stent-graft explantation was required in 1 patient. The overall 30-day mortality was 4.8% (15 of 310). The most frequent complications were endoleaks (8%, 25 of 310) and access problems (16.1%, 26 of 161). After a mean follow-up of 17.7 months (range, 1 to 52), the all-cause mortality was 22.9% (71 of 310), and the aortic-related mortality was 4.1% (13 of 310). During follow-up, new endoleak and ulcer recurrence were observed in 5.4% (n = 15 of 274) and 4.5% (n = 5 of 110), respectively, requiring a new aortic endovascular procedure in 50% (n = 10). CONCLUSIONS: Thoracic endovascular aortic repair of penetrating ulcer has excellent short-term and midterms results. The endovascular approach should be the first line management for aortic ulcer when intervention is indicated.

Thoracic endovascular aortic repair: A single center's 15-year experience.

OBJECTIVE: Specific complications of thoracic endovascular aortic repair (TEVAR) exist and long-term data are lacking. The purpose of this study was to evaluate our long-term TEVAR results. METHODS: This is a single-center retrospective study of 223 patients undergoing TEVAR from 1998 to 2013. Indication was aneurysm (45%), traumatic (26%), dissection (23%), and septic (6%). RESULTS: Patients' mean age was 62.7 ± 17.9 years, 84% of them had an American Society of Anesthesiologists score ≥3, and 42% had an aortic rupture. TEVAR was performed in zone 0 (n = 17), 1 (n = 17), or 2 (n = 59) in 42% of patients. Technical success rate was 96.4%. Overall 30-day mortality was 11.7% (elective aneurysm, 11.6%; emergent aneurysm, 34.3%; acute type B dissection, 14.8%; chronic dissection, 4.2%; septic, 8.3%; and traumatic, 1.7%). Major adverse events included stroke in 4.5%, spinal cord ischemia in 1.8%, and retrograde aortic dissection in 2.7%. Mean follow-up was 43.4 ± 38 months. Estimated aortic complications-free survivals at 12, 36, 60, and 120 months were (% ± standard error) 73% ± 3%, 64% ± 4%, 62% ± 4% and 57% ± 5%, respectively. Multivariate analysis showed that patients treated for a chronic aortic dissection had a significant risk of late reintervention (P = .001) CONCLUSIONS: Because of its simplicity and low morbimortality rate, TEVAR has become the first-line approach for thoracic aortic diseases. Mortality outcomes are related to aortic pathology, emergent status, and proximal landing zone. To improve long-term results, rigorous patient selection and follow-up, development of referral centers, and technologic evolution of materials have to be reached.

Staged Hybrid Repair to Reduce the Risk of Spinal Cord Ischemia After Extensive Thoracic Aortic Aneurysm Repair.

We hypothesized that staged repair of extensive thoracic aneurysms might mitigate the incidence and severity of spinal ischemia by facilitating structural remodeling of the spinal cord vasculature. Staged hybrid repair (in two or three stages) was undertaken in 7 patients with extensive thoracic aortic aneurysms. The 30-day mortality and spinal ischemia rates were 0%. The conceptual basis of staging extensive aortic repairs is the maintenance of adequate flow to a sufficient number of spinal arteries and that spinal perfusion is preserved during the early postoperative period when the patient is most vulnerable to hypotension, by deliberately allowing interval distal type I endoleak.

Hybrid Aortic Repair of Dissecting Aortic Arch Aneurysm after Surgical Treatment of Acute Type A Dissection.

BACKGROUND: The aim of this study was to evaluate the short-term and midterm results of hybrid repair of dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections. METHODS: Between 2003 and 2014, 7 consecutive patients, previously operated for acute type A dissection, underwent hybrid repair of their aortic arch for a dissecting aortic arch aneurysm (6 men, mean age 62 ± 11 years). Aneurysm formation requiring treatment in these aortic arches was observed from 2 to 20 years after the initial aortic dissection repair. A hybrid technique was used in all patients, with supra-aortic debranching through a redo sternotomy and either simultaneous (6 patients) or staged endovascular stent grafting (1 patient). Two patients were treated in an emergent setting (1 ruptured and 1 symptomatic aneurysm). Two patients required a more extensive aortic repair of either the thoracic aorta (n, 1) or of the thoracoabdominal aorta (n, 1). One patient underwent, saphenous vein bypass from the ascending aorta to the anterior descending coronary artery on full cardiopulmonary bypass. Follow-up computed tomography scans were performed at 1 week, 3, and 6 months, and annually thereafter. RESULTS: Technical success was achieved in all the cases. One transient ischemic attack, 1 stroke, and 1 episode of transient spinal cord ischemia were observed. Thirty-day mortality was not observed. A type I endoleak at 6 months was successfully treated with deployment of a second stent graft. After a mean follow-up of 3.5 ± 3.1 years (range, 0.4-9.6 years), no aortic-related mortality was observed. No cases of stent-graft migration or secondary rupture were observed. CONCLUSIONS: Our experience demonstrates the promising potential of endovascular repair of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. The potential to diminish the magnitude of the surgical procedure and the consequences of aortic arch exposure, and above all avoiding the need for circulatory arrest are promising and mandate further investigation to determine the efficacy and durability of this technique.

Saccular Thoracoabdominal Aneurysms in Systemic Lupus Erythematosus.

Aortic aneurysm is a rare but a serious complication of systemic lupus erythematosus. We report the case of a 59-year-old man with systemic lupus erythematosus disease who presented with symptomatic saccular thoracoabdominal aneurysms. The 2 aneurysms were resected and 2 silver-coated tube grafts were interposed. Surgical pathology revealed lymphoplasmacytic aortitis, without pathogenic agents. This is the first case of a double localization of saccular thoracoabdominal aneurysms with inflammatory aortitis caused by lupus. In patients with a history of systemic lupus erythematosus, with or without active inflammation, screening for aortic disease should be selectively performed if other risk factors for aortic aneurysm are present.

Titanium Implant Failure After Chest Wall Osteosynthesis.

BACKGROUND: Our objective was to assess potential contributing factors to implant failure (displacement or rupture) after titanium chest wall osteosynthesis. METHODS: We retrospectively reviewed the clinical data and preoperative and postoperative computed tomographic scans of patients undergoing chest wall osteosynthesis with titanium implants: the Stratos or the Matrix Fixation System in two European departments of thoracic surgery. The indications for titanium chest wall osteosynthesis, the type and number of implants, the topography of the reconstruction, surgical site infection, and role of associated flap and mesh were assessed. RESULTS: Between January 2009 and January 2013, 54 patients underwent osteosynthesis after surgical correction of chest wall deformities (n = 25, 46.2%) or to bridge the defect after tumor removal (n = 29, 53.7%). The topography of osteosynthesis was anterior (n = 20), lateral (n = 3), or posterior (n = 1), an average of 1.9 ± 0.9 implants (range, 1 to 5 implants) being used. A combined mesh restored continuity of the chest wall in 15 patients, and muscle flap coverage was performed in 20. The mean follow-up time was 20.2 ± 8.4 months (range, 3 to 48 months). Among these 54 patients, 24 (44%) experienced an implant failure. Seven (29%) were symptomatic. Broken (n = 20, 83.3%) or displaced (n = 4, 16.7%) implants were removed with or without replacement. In patients with broken or displaced implants, the mean duration without implant failure was 6.6 ± 3.1 months (range, 1 to 12 months). There was a significant relationship between the anterior topography of osteosynthesis and implant failure (p = 0.02). CONCLUSIONS: Long-term follow-up after chest wall osteosynthesis using titanium implants is required, especially in anteriorly placed implants. The high rate of implant failure at 1 year advocates for early removal whenever possible and suggests the need for improvements in design.