In Situ Antegrade Laser Fenestrations During Endovascular Aortic Repair.

INTRODUCTION: The technique and preliminary outcomes are reported for laser fenestrated endografting (LfEVAR), developed as an alternative procedure for endovascular repair of thoraco-abdominal aortic aneurysms (TAAAs), type IA endoleaks (T1AELs), and pararenal aortic aneurysms (PAAAs). METHODS: Patients with TAAA, T1AEL, and PAAA considered unfit for open repair by a multidisciplinary team and who could not benefit from a custom made device were selected. LfEVAR is a physician modified technique requiring sequential steps. After preliminary stenting of each target artery, a standard stent graft was deployed in the aorta. Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of each target artery ostium. After progressive dilation of the laser fenestration, bridging stents were placed and flared to insure accurate perfusion of the visceral arteries. RESULTS: Between August 2015 and March 2017, 16 consecutive patients were treated using LfEVAR including two TAAAs, four T1AELs, and 10 PAAAs. Thirty-three laser fenestrations were performed with a 94.3% success rate for visceral artery fenestration. The median ischaemic was 7.5 minutes for the superior mesenteric artery, 48 and 50 minutes for the left and right renal arteries, and 125 minutes for the coeliac trunk. Four secondary procedures were required: two endoleaks (type II and III), and two related to fenestrations: one renal stent dislocation, and one renal artery stent stenosis. During a mean follow up of 17 months, no deaths occurred. Follow up computed tomography (CT) scans performed at 30 days, 6, 12, and 18 months were satisfactory (4 endoleaks and two aneurysm enlargements were observed). The follow up CT scan imaging demonstrated 97% primary patency. CONCLUSION: In situ antegrade LfEVAR is feasible and a safe alternative option for high risk inoperable patients or for those not eligible for custom made device endografting, particularly in emergency cases.

Type II endoleak prevention with coil embolization during endovascular aneurysm repair in high-risk patients.

OBJECTIVE: This study evaluated endoleak level and size decrease of infrarenal abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) with coil embolization in patients at high risk for type II endoleak. METHODS: Between 2009 and 2013, 83 of 187 patients (44.3%) who underwent EVAR for AAA also underwent coil embolization of the aneurysm sac immediately after complete stent graft release because of risk factors for type II endoleak, including absence of a circumferential thrombus, two or more pairs of patent lumbar arteries, or a patent inferior mesenteric artery. Coil embolization was achieved using a 4F catheter with a microcatheter placed between the stent graft and the aneurysm wall. Computed tomography and color duplex ultrasound imaging were performed 1, 6, 12, and 24 months later to look for an endoleak and assess aneurysm sac diameter. RESULTS: Mean follow-up was 24 ± 11 months (range, 6-53 months). A mean of 12 coils (range, 4-23) was used. Technical success was achieved in all patients, with no procedurally related complications. Follow-up computed tomography showed type II endoleak in one patient. Aneurysm sac diameter was significantly decreased after 6 months (P = .001), 12 months (P = .001), and 24 months (P = .001). Surgery was required in one patient for common femoral artery occlusion unrelated to the procedure and in another patient for distal type I endoleak. CONCLUSIONS: Aneurysm sac coil embolization during EVAR for patients at risk for type II endoleak is technically feasible, safe, and effective in preventing type II endoleak. This procedure leads to rapid AAA shrinkage. Thus, coil embolization could be used routinely to improve EVAR outcomes for patients at risk for type II endoleak.

Catheter-based interventions for modified Blalock-Taussig shunt obstruction: a 20-year experience.

Thrombotic occlusion of a modified Blalock-Taussig (BT) shunt is rare, leading to life-threatening hypoxemia. Rescue percutaneous interventions may allow recanalization of the systemic-to-pulmonary shunt but data on large patients' scales are lacking. We aimed to describe safety and effectiveness of catheter-based interventions to restore modified BT shunt patency. All patients who attempted transcatheter intervention for thrombotic occlusion of a modified BT shunt at our Institution from 1994 to 2014 were reviewed. Characteristics, management, and outcomes of the 28 identified patients were analyzed. Thirty-three procedures were performed at a median age of 0.6 years old (range 0.03-32.1 years) and a median weight of 5.8 kg (range 2.2-82 kg). Percutaneous intervention consisted in 33 balloon angioplasty (100 %) and 14 stent implantations (42.4 %). Thrombolytic agents were also used in 6.1 % cases. No peri-procedural death occurred but complications were observed in five patients (15.2 %), including one catheter-induced transient complete atrioventricular block, one cardiac tamponade, and one massive thrombo-embolic stroke. Early procedural success was obtained in 28 patients (84.8 %) and remained long-lasting in 26 patients (78.8 %). A young age and a low body-weight at the time of the procedure were significantly associated with procedural failure (p = 0.0364 and p = 0.0247, respectively). Although technically challenging and carrying potential major complications, transcatheter intervention can be considered as an efficient rescue strategy to restore patency in case of thrombotic obstruction of a modified BT shunt.

Non-invasive diagnosis of ischaemic heart failure using 64-slice computed tomography.

AIMS: We evaluated the accuracy of 64-slice computed tomography (CT) to identify ischaemic aetiology of heart failure (IHF). METHODS AND RESULTS: Ninety-three consecutive patients in sinus rhythm with dilated cardiomyopathy but without suspicion of coronary artery disease (CAD) were enrolled when admitted for angiography. Accuracy of CT to detect significant stenosis (>50% lumen narrowing) was compared with quantitative coronary angiography. IHF was defined as a significant stenosis on left main or proximal left anterior descending artery or two or more vessels. Forty-three out of 1395 segments (3%) were heavily calcified and excluded. CT correctly assessed 103 of 142 (73%) significant stenosis and identified 46 of 50 (92%) patients without and 42 of 43 (98%) patients with CAD, 60 of 62 (97%) patients without and 28 of 31 (90%) patients with IHF. Overall, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT for identifying CAD by segment was 96, 73, 99, 92, and 97%, respectively; by patient was 95, 98, 92, 91, and 98%, respectively; and for identifying IHF was 95, 90, 97, 93, and 95%, respectively. CONCLUSION: Non-invasive 64-slice CT assessment of the extent of CAD may offer a valid alternative to angiography for the diagnosis of IHF.

Comparison of 64-slice computed tomography planimetry and Doppler echocardiography in the assessment of aortic valve stenosis.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare, prospectively, the planimetry of aortic stenosis on 64-slice computed tomography (CT), with the area calculated by Doppler transthoracic echocardiography (TTE) in symptomatic patients evaluated before potential aortic valve replacement. METHODS: Fifty-two consecutive patients (27 males, 25 females; mean age 74 +/- 10 years) admitted to the authors' institution during 2005 were evaluated with 64-slice CT and Doppler TTE. The time interval between the two evaluations was 2 +/- 1 weeks. Planimetry of the anatomic orifice area (AOA) drawn on 64-slice CT was compared to the effective area determined by Doppler TTE by Bland and Altman analysis, and the anatomic area threshold value corresponding to a significant effective aortic stenosis (50.75 cm2) was determined by receiver operating characteristic (ROC) analysis. RESULTS: The aortic orifice area measured by 64-slice CT correlated well with the effective area (r = 0.76; p <0.0001), but was significantly greater, with a systematic overestimation (0.132 cm(2)) and a variability of 0.239 cm(2). There was good agreement between planimetry determined by two independent radiologists (difference = 0.002, variability = 0.115 cm(2)). ROC analysis showed that a threshold value of 0.95 cm(2) as measured by 64-slice CT planimetry identifies significant aortic stenosis with sensitivity, specificity, accuracy, positive and negative predictive values of 82%, 77%, 81%, 91% and 59%, respectively. CONCLUSION: 64-slice CT is a reproducible and reliable non-invasive method to evaluate aortic valve stenosis compared to the reference method of Doppler TTE. Indeed, the CT approach could replace the latter evaluation when measurements used in the continuity equation are inadequate.

Ascending Aorta Stenting After Off-Pump Aortic Wrapping in Stanford A Retrograde Aortic Dissection.

We report 4 cases of off-pump ascending aorta wrapping combined with ascending aorta stenting in retrograde Stanford A acute aortic dissection (SAAD). Since 2008, 18 patients have undergone wrapping of the ascending aorta at our institution. Four patients had a persistent circulating false lumen in the ascending aorta after wrapping, with a threat to the aortic root. We chose an endovascular approach with ascending aorta stenting. Follow-up computed tomography showed a reapplication of the intimal flap in the reinforced aorta. Ascending aorta stenting after aortic wrapping for retrograde SAAD is a safe and efficient technique to prevent proximal progression of the dissection.

Coronary stenosis detection by 16-slice computed tomography in heart transplant patients: comparison with conventional angiography and impact on clinical management.

OBJECTIVES: We sought to find a non-invasive alternative to conventional coronary angiography (CCA) for serial detection and follow-up of coronary stenosis due to cardiac allograft vasculopathy in heart transplant patients. BACKGROUND: Cardiac allograft vasculopathy is the main factor limiting long-term success of heart transplantation. It is usually detected by CCA. Multislice computed tomography (MSCT) coronary angiography has recently proven effective for the diagnosis of coronary stenosis in non-transplant patients. METHODS: Fifty-three consecutive heart transplant patients underwent MSCT within 24 h before or after their annual routine CCA. Only angiographic segments >1.5 mm were considered for analysis; the coronary arterial tree was divided into nine segments. Three patients were excluded because of technical failure. RESULTS: Of the 450 angiographic coronary segments, 432 (96%) were evaluable by MSCT. Of the nine coronary stents in seven patients, only three, including one intrastent restenosis, were correctly evaluated by MSCT, and two intrastent restenoses were missed. Complete analysis of the coronary tree was possible for 44 (88%) of the 50 patients. For detection of coronary stenosis >50%, sensitivity was 83%, specificity 95%, positive predictive value 71%, negative predictive value 95%, and accuracy 93%. In the 22 patients with strictly normal MSCT, no stenosis was found by CCA. CONCLUSIONS: Our study suggests the following guidelines already applied in our institution: 16-slice MSCT can replace CCA in de novo heart transplant patients and patients with strictly normal MSCT at follow-up. Significant wall or lumen changes observed on annual MSCT or stents require further investigation by CCA.

Comparison of coronary minimal lumen area quantification by sixty-four-slice computed tomography versus intravascular ultrasound for intermediate stenosis.

The present study assessed 64-slice computed tomographic accuracy to quantify minimal lumen area (MLA) and determine lesion severity in intermediate stenosis by angiography compared with intravascular ultrasound (IVUS). Sixty-four-slice computed tomography (CT) has been shown to be effective in coronary stenotic assessment by visual estimation compared with angiography. However, angiography is not an accurate gold standard for intermediate stenotic quantification compared with IVUS. Forty patients (54 lesions) with 30% to 70% coronary stenosis by angiography in a major coronary branch were included. All patients underwent quantitative angiography, retrospective electrocardiographically gated 64-slice CT (Siemens), and IVUS (40-MHz Atlantis; Boston Scientific). MLA was manually traced by 2 blinded and independent operators on 64-slice computed tomographic cross-sectional reconstruction and compared with IVUS MLA. A lesion was considered significant if the MLA was

Comparison of lumens of intermediate coronary stenosis using 16-slice computed tomography versus intravascular ultrasound.

We aimed to quantify ambiguous coronary stenosis using the minimal lumen area with 16-slice computed tomography compared with intravascular ultrasound. The sensitivity, specificity, and accuracy for significant lesion classification was 68%, 86%, and 78%, respectively. The correlation between intravascular ultrasound and CT minimal lumen area was r = 0.73 (p <0.001), and the 95% confidence interval for CT measurement was -72% to +56%.

Preoperative and postoperative evaluation of airways compression in pediatric patients with 3-dimensional multislice computed tomographic scanning: effect on surgical management.

OBJECTIVES: Surgical management of airway compression of vascular origin requires an accurate analysis of anatomy and various mechanisms of compression. This study assessed the usefulness of 3-dimensional computed tomographic scanning in the preoperative and postoperative evaluation of airways compression in a pediatric population. METHODS: Thirty-seven consecutive patients (median age, 4 months) were examined with multislice 3-dimensional computed tomographic scanning: 18 patients before surgical treatment of anomalies of vascular rings, 2 patients because of respiratory symptoms after repair of esophageal atresia, and 17 patients because of persisting respiratory symptoms or prolonged mechanical ventilation after cardiac surgery for congenital heart disease. RESULTS: The procedure was successful, with high-quality diagnostic imaging obtained in all cases without any complications. The anatomy and relationship between the vascular arches and airways was analyzed in all referred patients with vascular arch anomalies confirmed on the basis of the surgical findings, and this helped the surgeon to plan the procedure and choose the best approach. After cardiac surgery, the airway and vascular structures involved and the mechanism of compression were specified in all but one case, and the 3-dimensional computed tomographic scan serves as an important tool for deciding whether to perform reoperation on patients requiring prolonged mechanical ventilation. CONCLUSION: Three-dimensional computed tomographic scanning is a safe, fast, and noninvasive method useful for accurately analyzing the mechanisms of airway compression of vascular origin and thus possible improving the surgical management of pediatric patients.

Hybrid treatment of an aortic pseudoaneurysm arising at the innominate artery junction secondary to superior vena cava stenting.

Pseudoaneurysm of the innominate artery secondary to superior vena cava stenting has never been reported. We report the case of a 42-year-old woman previously treated for a Masaoka stage III thymoma with superior vena cava replacement through median sternotomy followed by adjuvant radiation therapy. Four years later, the patient came back with a large pseudoaneurysm at the junction of the innominate artery and ascending aorta. To avoid resternotomy, endovascular deployment of a stent graft in the ascending aorta with a periscope stenting in the left common carotid artery after axilloaxillary bypass was performed to treat this aortic pseudoaneurysm.

Closure of tubular patent ductus arteriosus with the Amplatzer Vascular Plug IV: feasibility and safety.

BACKGROUND: Closure of tubular patent ductus arteriosus remains a challenging procedure. Anecdotal use of Amplatzer Vascular Plug IV for tubular ductus closure has been reported but feasibility and safety in a consecutive patients' series remain unknown. METHODS: We performed a monocenter prospective study at the Marie Lannelongue Hospital in Paris, France. From 2009 to 2014, a total of 47 patients (39 infants, 3 children, and 5 adults) underwent ductus closure with the Plug IV. RESULTS: Ductus morphology was a type E in 34 (72.3%) patients and a type C in 13 (27.7%) patients. Ductus closure occurred in 39 (83.0%) infants at a median age of seven months (range: 3-23 months) and a median weight of 6.9 kg (range: 4.1-17.0 kg). A past history of prematurity and very low birth weight was found in 33 (70.2%) of them. Twelve (25.5%) patients had pulmonary hypertension. Mean Plug IV diameter was 1.9 ± 0.1 mm larger than the mean maximal ductus diameter. Early complete closure of the ductus was obtained in all patients. Early migration of an undersized Plug IV occurred in one (2.1%) patient and was suitable for percutaneous device retrieval. After a mean follow-up of 3.4 ± 1.4 years, all patients are alive and asymptomatic, no late complication occurred. CONCLUSION: Transcatheter closure of tubular ductus with the Amplatzer Vascular Plug IV can be safe and effective, with a 100% early occlusion rate. This device, suitable for a 4F sheath, is a new alternative for tubular ductus closure in low-body-weight infants.

[Management of the traumatic aortic blunt injury in 2014]. / Traitement des ruptures traumatiques de l'isthme aortique en 2014.

Diagnosis of blunt thoracic aortic injury (BAI) should be considered in any serious polytrauma. The diagnosis is mainly based on the CT scan at baseline. Life-threatening lesions are often associated with BAI. Hospital mortality is mainly due to associated lesions. Except the complete rupture of the aorta, treatment should be initiated after hemodynamic and respiratory stabilization of the patient and after the treatment of a lesion involving the immediate prognosis. Endovascular treatment of BAI became the treatment of choice, especially for patients with severe associated injuries and bleeding risk. Additional data on the long-term stents are necessary in these young patients. Conventional surgical treatment is always indicated for young subjects with stable hemodynamic, low risk of bleeding and when surgery may be delayed several hours.

Coronary plaque burden detected by multislice computed tomography after acute myocardial infarction with near-normal coronary arteries by angiography.

Nonsignificant coronary artery plaque rupture or erosion may be the origin of acute myocardial infarction (AMI). The aim of our study was to assess the ability of multislice computed tomography (MSCT) to detect coronary plaques responsible for near normal coronary angiography AMI. Eight patients with presentation of AMI and no significant coronary narrowing by angiography were enrolled. Two groups were defined: (1) true AMI and (2) myocarditis. MSCT was able to detect nonsignificant coronary soft plaques responsible for AMI and has provided information on plaque volume, eccentricity, and density. In patients with myocarditis, there was no evidence of plaque.

Characterization of vulnerable nonstenotic plaque with 16-slice computed tomography compared with intravascular ultrasound.

We compared 16-slice computed tomography with intravascular ultrasound in the detection of unstable component characteristics of nonstenotic plaque responsible for acute coronary syndrome. Computed tomography accurately assessed plaque eccentricity, calcification, and remodeling, and intraplaque hypodensity correlated with intravascular ultrasound echolucent area.

Aortic wrapping for stanford type A acute aortic dissection: short and midterm outcome.

BACKGROUND: Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement. METHODS: We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B). RESULTS: Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p=0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47]. CONCLUSIONS: The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative.

Transcatheter closure of patent ductus arteriosus: past, present and future.

This review aims to describe the past history, present techniques and future directions in transcatheter treatment of patent ductus arteriosus (PDA). Transcatheter PDA closure is the standard of care in most cases and PDA closure is indicated in any patient with signs of left ventricular volume overload due to a ductus. In cases of left-to-right PDA with severe pulmonary arterial hypertension, closure may be performed under specific conditions. The management of clinically silent or very tiny PDAs remains highly controversial. Techniques have evolved and the transcatheter approach to PDA closure is now feasible and safe with current devices. Coils and the Amplatzer Duct Occluder are used most frequently for PDA closure worldwide, with a high occlusion rate and few complications. Transcatheter PDA closure in preterm or low-bodyweight infants remains a highly challenging procedure and further device and catheter design development is indicated before transcatheter closure is the treatment of choice in this delicate patient population. The evolution of transcatheter PDA closure from just 40 years ago with 18F sheaths to device delivery via a 3F sheath is remarkable and it is anticipated that further improvements will result in better safety and efficacy of transcatheter PDA closure techniques.

Transcatheter closure of large atrial septal defects: feasibility and safety in a large adult and pediatric population.

BACKGROUND: Data are needed on the safety and efficacy of device closure of large atrial septal defects. METHODS AND RESULTS: Between 1998 and 2013, 336 patients (161 children <15 years) with large, isolated, secundum atrial septal defects (balloon-stretched diameter ≥34 mm in adults or echocardiographic diameter >15 mm/m(2) in children) were managed using the Amplatzer device, at the Marie Lannelongue Hospital. Transthoracic echocardiographic guidance was used starting in 2005 (n=219; 65.2%). Balloon-stretched diameter was >40 mm in 36 adults; mean values were 37.6±3.3 mm in other adults and 26.3±6.3 mm/m(2) in children. Amplatzer closure was successful in 311 (92.6%; 95% confidence interval, 89%-95%) patients. Superior and posterior rim deficiencies were more common in failed than in successful procedures (superior, 24.0% versus 4.8%; P=0.002; and posterior, 32.0% versus 4.2%; P<0.001). Device migration occurred in 4 adults (2 cases each of surgical and transcatheter retrieval); in the 21 remaining failures, the device was unreleased and withdrawn. After a median follow-up of 10.0 years (2.5-17 years), all patients were alive with no history of late complications. CONCLUSIONS: Closure of large atrial septal defects using the Amplatzer device is safe and effective in both adults and children. Superior and posterior rim deficiencies are associated with procedural failure. Closure can be performed under transthoracic echocardiographic guidance in experienced centers. Early device migration is rare and can be safely managed by device extraction. Long-term follow-up showed no deaths or major late complications in our population of 311 patients.

[Surgical treatment of chronic thromboembolic pulmonary hypertension]. / Traitement chirurgical de l'hypertension pulmonaire post-embolique.

Chronic thromboembolic pulmonary hypertension is a rare but underdiagnosed disease. The development of imaging played a crucial role for the screening and the decision of operability over the past few years. Indeed, chronic thromboembolic pulmonary hypertension is the only type of pulmonary hypertension with a potential curative treatment: pulmonary endarterectomy. It is a complexe surgical procedure performed under cardiopulmonary bypass with deep hypothermia and circulatory arrest. The aim of the procedure is to completely remove the scar tissue inside the pulmonary arteries down to the segmental and sub-segmental levels. Compared to lung transplantation, which carries a postoperative mortality of 15-20% and a 5-year survival of 50%, pulmonary endarterectomy is a curative treatment with a postoperative mortality of less than 3%. However, lung transplantation remains an option for young patients with inoperable distal disease or after pulmonary endarterectomy failure. Considering that medical history of deep venous thrombosis or pulmonary embolism is lacking in 25 to 50%, the diagnosis of chronic thromboembolic pulmonary hypertension remains challenging. The lung V/Q scan is useful for the diagnosis showing ventilation and perfusion mismatches. Lesions located at the level of the pulmonary artery, the lobar or segmental arteries may be accessible to surgical removal. The pulmonary angiogram with the lateral view and the pulmonary CT scan help to determine the level of the intravascular lesions. If there is a correlation between the vascular obstruction assessed by imaging and the pulmonary resistance, pulmonary endarterectomy carries a postoperative mortality of less than 3% and has a high rate of success. If the surgery is performed at a later stage of the disease, pulmonary arteriolitis developed mainly in unobstructed territories and participated in the elevated vascular resistance. At this stage, postoperative risk is higher.

Coronary aorto-ostial stenosis analysed by multislice computed tomography: a new tool for percutaneous coronary intervention?

AIMS: Conventional quantitative coronary angiography approaches are limited to quantify complex aorto-ostial stenosis. Multislice CT was able to detect and classify coronary plaques, compared with intravascular ultrasound (IVUS). The aim of the present study was to determine the accuracy of multislice computed tomography (CT) in addition to conventional angiography to identify aorto-ostial coronary stenosis characteristics before revascularisation. METHODS AND RESULTS: Patients with coronary ostial stenosis were selected for the study. All patients had selective coronary angiography and retrospectively ECG-gated multislice CT (Siemens AG, Munich, Germany). IVUS was performed in patients with ambiguous ostial stenosis revealed by angiography. Forty significant aorto-ostial lesions (38 patients) were analysed by two independent observers in comparison with an expert consensus blinded or not to the coronary CT data sets. Using CT in addition to angiography permitted observers to obtain a strong agreement for assessment of calcified lesions (kappa value 0.75), a good agreement for aortic plaques location and ideal stent position in aorto-ostial coronary stenosis. CONCLUSIONS: This study shows that CT associated with an angiogram allows a better identification of aorto-ostial plaques morphology and ideal stent position in aorto-ostial coronary stenosis before angioplasty.