Spontaneous isolated dissection of the superior mesenteric artery.
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Biomedical subjects
A d'Audiffret
Publications and source records attributed to A d'Audiffret.
Follow-up evaluation of endoluminally treated abdominal aortic aneurysms with duplex ultrasonography: validation with computed tomography.
OBJECTIVE: A growing number of patients with abdominal aortic aneurysms are currently being offered endoluminal treatment. However, the incidence of endoleaks, stenosis, and thrombosis is around 25% to 30%. As a result, a strict post procedure imaging surveillance protocol is necessary. The purpose of this study was to compare duplex ultrasonography (DU) and computed tomography (CT) for the follow-up of endoluminally treated aortic aneurysms. METHODS: A total of 89 patients were followed up with serial CT and DU at 1, 3, 6, 12, and 24 months after endoluminal treatment. Special attention was directed toward the presence of endoleaks and aneurysm diameter evolution. Preoperative CT and DU were also reviewed to assess aneurysm diameter correlation. RESULTS: With DU, 14 type I and 21 type II endoleaks were identified. In one case the DU did not visualize a type II endoleak present on CT, and CT did not confirm three type II leaks identified with DU. There was only one false positive for type I endoleak with DU. The sensitivity of DU was 96% with a specificity of 94%, when compared with CT. A linear regression analysis of the diameters obtained with DU and CT revealed a good correlation. However, variability was high, indicating poor agreement. Regarding diameter evolution, the range was identical in 45%, and the trend was similar in 73%. However, in 9% of the cases, DU showed a decrease in diameter, whereas CT showed a significant increase. CONCLUSION: DU is an accurate tool for the diagnosis of endoleaks, but is less valuable for diameter measurements, when compared with CT. Currently, DU is a useful tool, but CT remains a key part of the postoperative evaluation after endoluminal treatment of abdominal aortic aneurysms. At institutions where DU is used for follow-up, researchers should perform quality control studies to avoid potentially significant errors.
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Technical aspects and current results of carotid stenting.
PURPOSE: We reviewed our experience with carotid stenting (CS), focusing on technical evolution and results. METHODS: From September 1995 to February 2000, 77 patients with 83 internal (n = 68) and common carotid artery lesions (n = 15) were selected for CS. This patient population was categorized into three consecutive periods based on patient selection, material, and technical skills. For internal carotid artery lesions, period I included 11 patients treated by means of direct carotid puncture with balloon expandable stents; period II included 42 patients treated by means of a femoral approach with self-expandable stents; and period III included 15 patients in whom monorail system and cerebral protection devices were used. Common carotid artery lesions were treated by means of carotid puncture in five patients and by means of a femoral approach in 10 patients. In only two of the latter cases, cerebral protection devices were used. RESULTS: The overall immediate success rate, defined as successfully treated stenosis with no neurological events, was 89.7% for internal carotid artery lesions and 100% for common carotid artery lesions. All neurological events, which consisted of reversible events (4.4%), minor stroke (1.5%), and major stroke (2.9%), occurred during periods I and II. In periods I, II, and III, the rate of surgical conversion was 18%, 9.5%, and 0%, respectively, the rate of transient ischemic attack and reversible ischemic neurologic deficit was 0%, 7%, and 0%, respectively, and the rate of minor and major stroke was 0%, 7%, and 0%, respectively. All major strokes were cleared with intra-arterial thrombolysis. At discharge, the success rates defined by means of the absence of conversion and neurological events were 82% during period I, 76% during period II, and 100% during period III. The freedom from neurological deficits rates were 100%, 97.6%, and 100%, respectively. During follow-up, six significant asymptomatic restenoses were detected with duplex scanning; however, only one patient required reintervention. CONCLUSION: Technical skills and technological improvement, including low-profile balloon and catheter, cerebral protection device, and intra-arterial rescue techniques, may reduce the rate of neurological events associated with CS. Technical improvements should be given careful consideration before the initiation of randomized trials comparing CS and carotid endarterectomy.
Adult↗
[Metaplasia of aortic tissue into tracheal tissue. Surgical perspectives].
Tracheal reconstruction after extensive resection remains an unsolved surgical problem. Numerous attempts have been made using tracheal grafts or prosthetic conduits with disappointing results. In this study, we propose a new alternative using an aortic autograft as tracheal substitute. In a first series of experiments, a half circumference of two rings was replaced with an autologous carotid artery patch. In a second series, a complete segment of trachea was replaced with an autologous aortic graft supported by an endoluminal tracheal stent. No dehiscence or stenosis was observed. Microscopic examinations at 3 and 6 months showed the replacement of the aortic tissue by tracheal tissue comprising neoformation of cartilage and mucociliary or non-keratinizing metaplastic polystratified squamous epithelium. Although these results need to be confirmed by a larger series of experiments, they showed that a vascular tissue placed in a different environment with a different function can be submitted to a metaplastic transformation which tends to restore a normal structure adapted to its new function. These remarkable findings offer new perspectives in tracheal reconstruction in human.
Animals↗
Acute occlusion of popliteal and/or tibial arteries: the value of percutaneous treatment.
OBJECTIVES: to describe early and mid-term results with a percutaneous therapeutic protocol including thromboaspiration, thrombolysis, and correction of the underlying lesion by PTA. METHODS: thirty-three consecutive selected patients with recent (<1 month) reversible acute ischaemia associated with popliteal and/or tibial occlusion were studied. The primary endpoints were technical success (defined as residual mural thrombus less than 20% of the lumen and the presence of at least one tibial artery on angiogram), patient survival and limb salvage at 1 and 12 months. Secondary endpoints included complications, primary, assisted primary and secondary patency determined by duplex scan at 1, 6 and 12 months. RESULTS: technical success was achieved in 27 patients (82%). Twenty patients were treated by thrombo- aspiration+/-thrombolysis only, and seven required additional PTA (26%). In six patients (18%), percutaneous techniques failed, and embolectomy was performed in two, bypass in one and major amputations in three (9%). For the entire series, the survival rate was 100% at 1 month and 94% at 1 year. The limb salvage rate was 91% at 1 month and 1 year. The cumulative primary patency, assisted primary patency and secondary patency rates were 81%, 81% and 86% respectively at 1 month and 66%, 72% and 77%, respectively, at 12 months. Early complications occurred in 10 patients (30%): five groin haematomas (15%), four compartment syndromes (12%) and one haemoglobinuria (3%). CONCLUSION: percutaneous techniques offer excellent early and mid-term results in selected patients presenting with acute ischaemia with popliteal and/or tibial arteries occlusion.
Acute Disease↗
Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair.
PURPOSE: To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter. CASE REPORT: A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year. CONCLUSIONS: latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.
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The role of thrombolytic therapy in the management of paradoxical embolism.
Paradoxical emboli are considered a rare event, representing less than 2% of all arterial emboli. The most common intracardiac defect associated with paradoxical emboli is a patent foramen ovale. Most commonly, a pulmonary embolism is the cause of the acute increase in right atrial pressure leading to a reversal of intracardiac flow and passage of venous embolic material to the left heart. We present a patient with a pulmonary embolism and paradoxical emboli, and discuss therapeutic approach. We suggest that the treatment of choice for the patient with pulmonary embolism and non-limb-threatening acute ischemia due to a paradoxical emboli should be thrombolytic therapy and intracaval filter placement, followed by patent foramen ovale repair.
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Endothelial dysfunction following thrombolysis in vitro.
OBJECTIVES: Thrombolytic therapy is frequently used to manage vascular graft thrombosis. However, long-term patency after thrombolysis remains poor. The purpose of this study was to characterise the morphological and functional response of endothelial cells (EC) exposed to a thrombus and subsequently lytic therapy. METHODS: Human EC were exposed to human whole blood thrombus for 2, 6, 12, and 24 h. The thrombus was lysed with urokinase. Cell morphology was studied with electron microscopy. Northern blot analyses were performed with human c-DNA probes for endothelin-1, thrombomodulin, tissue factor, tissue plasminogen activator, plasminogen activator inhibitor, and triose phosphate isomerase. RESULTS: EC retraction occurred for each period of incubation. Thrombomodulin expression was increased 2.2-fold at 6 h and 2.4-fold at 24 h. t-PA expression was depressed proportionally to the duration of thrombus exposure. PAI and TF expression transiently increased 1.5-fold at 2 h of exposure and returned to baseline at 6 h. Endothelin expression remained unchanged. CONCLUSIONS: Except for a transient increase in TF expression and reversal of the tPA/PAI ratio, EC exposed to thrombus do not appear to become actively procoagulant. The increase in TM expression may reflect enhanced thromboresistance. However, EC retraction may be responsible for an increase thrombogenicity of saphenous vein graft after thrombosis and Urokinase therapy.
Cells, Cultured↗