Modalités et résultats du traitement endovasculaire du syndrome cave supérieur d origine bénigne

Objectifs : Évaluer les modalités et les résultats du traitement endovasculaire des syndromes caves supérieurs (SCS) d origine bénigne. Matériel et méthodes : Étude rétrospective monocentrique de 90 patients entre 1995 et 2010 présentant un SCS d origine bénigne et traités par voie endovasculaire. Les principales étiologies sont une complication d un cathéter veineux central (CVC) (n=46) ou d une fistule artério-veineuse (FAV) (n=39). Une angioplastie (ATP) seule (n=20) ou complétée d une endoprothèse (ATP+EP) (n=61) a été pratiquée. Le critère de jugement principal est la survenue d une récidive clinique confirmée par un examen morphologique. Les critères de jugements secondaires sont les taux de perméabilité primaire, assistée et secondaire ainsi que le devenir des patients ayant une atteinte de la veine sous-clavière (VSC) dans le défilé thoraco-brachial. Résultats : Les taux de succès technique et clinique sont de 91.1% et de 87.6 %. Une récidive clinique survient chez 38% des patients, plus fréquente en cas de FAV (p=0.001) ou d atteinte de la VSC dans le défilé thoraco-brachial (p=0.007). Elle est plus fréquente en cas d ATP seule par rapport à une ATP+EP (p=0.06). Les taux de perméabilité primaire, primaire assistée et secondaire sont de 76%, 83% et 93% à un an. La perméabilité primaire est en moyenne de 20.3 mois (+/-2.8 DS). Les antiagrégants plaquettaires ne sont pas associés à une diminution significative du taux de récurrence (p=0.7). Conclusion : Le traitement endovasculaire des SCS d origine bénigne est efficace et peu invasif. Les récidives restent fréquentes, surtout chez les patients ayant une FAV, sans qu une modalité de traitement ne montre de supériorité.Purpose: Evaluate endovascular modalities and results to treat benign superior vena cava syndrome (SCS). Material and methods: From 1995 to 2010, 90 patients with SCS from non malignant cause and treated by endovascular approach at the CHU of Grenoble were retrospectively included. Central venous catheters (CVC) (n=46) or arterio-venous fistulae (AVF) for hemodialysis (n=39) are the most frequent etiologies. Endovascular procedure consists in angioplasty (PTA) (n=20) or angioplasty with stenting (PTS) (n=61). Primary end-point is clinical recurrence confirmed by a morphological exam. Secondary end-points are primary, assisted primary and secondary patency. We isolated patients becoming in case of subclavian vein lesion in thoracic outlet. Results: Technical and clinical success rates are 91.1% and 87.6 %. Recurrence occurs in 38% of patients and are more frequent (p=0.001) in patients with AVF or subclavian vein lesion in thoracic outlet (p=0.007). PTA is associated with higher recurrence rate than PTS, but without significative difference (p=0.06). Primary, assisted primary and secondary patency rates are 76%, 83% and 93% at one year. Mean primary patency is 20.3 months (+/- 2.8 SD). Antiplatelets after procedure are not associated with lower recurrences and could be responsible of hemorrhagic complications (p=0.7). Conclusion: Endovascular treatment of benign SCS is safe and efficient. No modality between angioplasty and stenting is better to prevent clinical recurrence. These are more frequent on AVF dialysed patients, who needed multiple re-interventions.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Occlusion par voie endoluminale des dissections résiduelles circulantes après chirurgie de l'aorte ascendante dans les dissections aortiques de type A

Notre travail concerne le traitement par voie endoluminale des dissections résiduelles circulantes après chirurgie des dissections aortiques de type A. Notre étude préliminaire, portant sur 13 cas, a montré que l'embolisation percutanée des différentes portes d'entrées des dissections résiduelles permet d'obtenir leur thrombose avec un taux de 77% et un taux de morbidité mineure de 17%. L'évolution à moyen terme après embolisation, montre la stabilité du diamètre aortique et une re-expansion du vrai chenal. Ces données n'ont pas de valeur statistique étant donné la faible taille de l'échantillon et un suivi trop court. Un protocole d'étude prospective multicentrique nationale (OCCLUDISS) ayant pour but d'évaluer ce traitement a été élaboré en collaboration avec le CIC. Il s'agissait d'une étude randomisée, prévoyant l'inclusion sur 2 ans et le suivi sur 5 ans de 100 patients. Malheureusement, nous n'avons pu obtenir le financement nécessaire à la réalisation de l'étude.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Dissection of a Renal Artery Originating in the Thorax and Coursing Through the Diaphragm: A Complication of Renal Artery Entrapment

International audienc

Endovascular stent-graft management of aortic intramural hematomas.

International audiencePURPOSE: To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH). MATERIALS AND METHODS: From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months). RESULTS: The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%. CONCLUSIONS: Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results

Aortic dissection with acute malperfusion syndrome: Endovascular fenestration via the funnel technique

International audienceOBJECTIVE:To analyze the short- and long-term results of an original aortic fenestration method using the funnel technique during aortic dissection complicated by malperfusion syndrome.METHODS:The funnel technique consists of deployment of an uncovered aortic stent graft placed from the false to the right lumen through an intimal flap aortic fenestration made by balloon angioplasty. Twenty-eight patients presenting with an aortic dissection (type A, n = 19; type B, n = 9) were treated for malperfusion syndrome owing to dynamic compression (16 renal, 17 bowel, and 13 lower limb ischemia) using the aforementioned technique, and had follow-up evaluation at short term (30 days) and long term (mean: 55 ± 40 months). Eight patients had severe ischemia on arrival (6 bowel, 7 renal, 3 lower limb).RESULTS:Technical success was achieved in 27 of 28 patients (96%), and ischemic symptoms had disappeared in 25 of 28 patients (89%) at short-term follow up. Five patients presented postprocedure complications: 4 minor and 1 major with arterial thrombosis which caused technical failure (3.6%). The 30-day mortality rate was 7% (n = 2), related to bowel ischemia complications. At long-term follow up, 21 patients had a stable thoracic aortic diameter (91%).CONCLUSIONS:The funnel technique, in cases of malperfusion syndrome after aortic dissection, safely improves short- and long-term clinical outcome, and could represent an interesting alternative in the management of patients. The hemodynamic efficiency of this technique may account for a lower mortality in our series

Resuscitative endovascular balloon occlusion of the aorta for pelvic blunt trauma and life-threatening hemorrhage

International audienceBACKGROUND:Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used as a noninvasive clamp of the aorta after diverse posttraumatic injuries. Balloon inflation in zone 3 (from the lower renal artery to the aortic bifurcation) can be performed to stop ongoing bleeding after severe pelvic trauma with life-threatening hemorrhage. The aim of our study was to describe our 20-year experience with REBOA in terms of efficacy and safety in patients with a suspicion of severe pelvic trauma and extreme hemorrhagic shock.METHODS:We performed a retrospective study from 1996 to 2017 in a French Level I trauma center. All consecutive patients who underwent a REBOA procedure were included. REBOA indication relied on (1) extreme hemodynamic instability (systolic arterial blood pressure [SBP] < 60 mm Hg on admission, SBP < 90 mm Hg despite initial resuscitation in the trauma bay or posttraumatic cardiac arrest) and (2) positive pelvic X-ray. Efficacy endpoints were vital signs and coagulation parameters before and after balloon inflation. Safety endpoints were REBOA-related complications: vascular events, acute renal failure, and rhabdomyolysis.RESULTS:Within the study period, 32 patients underwent a REBOA procedure. Only two patients had technical failure and balloon was not inflated in one patient. Nineteen patients did not survive at day 28. The REBOA significantly improved SBP from 60 (35-73) mm Hg to 115 (91-128) mm Hg (p < 0.001). We also reported a high rate of vascular complications (19%, n = 5 patients) but no amputation. Renal replacement therapy was initiated in 11 patients, and 15 patients had severe rhabdomyolysis.CONCLUSION:The REBOA is safe and effective in improving hemodynamics after severe pelvic trauma and life-threatening hemorrhage. Our study supports the use of REBOA as a bridge to definitive hemostatic treatment after severe pelvic trauma

Arterial Embolization in the Management of Mesenteric Bleeding Secondary to Blunt Abdominal Trauma

International audienceINTRODUCTION:Mesenteric bleeding is a rare but potentially life-threatening complication of blunt abdominal trauma. It can induce active hemorrhage and a compressive hematoma leading to bowel ischemia. Emergency laparotomy remains the gold standard treatment. We aimed to study the effectiveness and complications of embolization in patients with post-traumatic mesenteric bleeding.MATERIALS AND METHODS:The medical records of 7 consecutive patients with active mesenteric bleeding treated by embolization in a level-one trauma center from 2007 to 2014 were retrospectively reviewed. All patients presented with active mesenteric bleeding on CT scans without major signs of intestinal ischemia. We focused on technical success, clinical success, and the complications of embolization.RESULTS:Six endovascular procedures were successful in controlling hemorrhage but 1 patient had surgery to stop associated arterial and venous bleeding. One patient suffered from bowel ischemia, a major complication of embolization, which was confirmed by surgery. No acute renal failure was noted after angiography. For 1 patient we performed combined management as the endovascular approach allowed an easier surgical exploration.CONCLUSION:In mesenteric trauma with active bleeding, embolization is a valuable alternative to surgery and should be considered, taking into account the risk of bowel ischemia

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

International audiencePURPOSE:We aimed to compare clinical outcomes and early adverse events of operative management (OM), nonoperative management (NOM), and NOM with splenic artery embolization (SAE) in blunt splenic injury (BSI) and identify the prognostic factors.METHODS:Medical records of 136 consecutive patients with BSI admitted to a trauma center from 2005 to 2010 were retrospectively reviewed. Patients were separated into three groups: OM, NOM, and SAE. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors.RESULTS:The total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management.CONCLUSION:Patients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury

Know the strengths and weaknesses of ischemia tests to guide the therapeutic strategy of a patient with multi-vessel disease

International audienceno abstrac