[Thrombosis caused by active rapamycin stents]. / Thrombose de stents actifs à la rapamycine.

We report the case history of a patient aged 68 years presenting with a recurrence of anterior myocardial infarction complicated by cardiogenic shock with a thrombosis of an active rapamycin stent 77 days following the angioplasty procedure. This was provoked by stopping platelet anti-aggregant treatment, a diabetic background and in the context of scheduled surgery for cancer recurrence. Recent data in the literature combined with our observations prompt the continuation of anti-aggregant bi therapy for at least 9 months after endoprosthesis insertion even if an active stent is used. In the case where surgery is envisaged, it is necessary to wait at least 6 months after the rapamycin stent revascularisation procedure. If an extra-cardiac procedure is envisaged during the angioplasty, it would be preferable to not use an active stent.

[Non cardiac surgery in patient with coronary stenting: think sirolimus now!]. / Chirurgie générale et endoprothèse coronaire: pensez au sirolimus!

We describe a severe preoperative cardiogenic shock in a patient scheduled for a breast surgery. The cardiogenic shock was in relation with thrombosis of two sirolimus-eluting stents received 3 months ago. A percutaneous transluminal coronary angioplasty was successfully performed. The patient recovered well after a 1-day treatment including intraaortic balloon counter pulsation and dobutamine infusion. We discuss about the ideal timing to plan surgery and how to manage the shift of antiplatelet agents.

[Subdural haemorrhage following lumbar spinal drainage during repair of thoraco-abdominal aneurysm]. / Hématome sous-dural aigu après soustraction-drainage du LCR par voie lombaire chez deux patients opérés d'anévrismes thoraco-abdominaux.

Physicians in charge of patients undergoing thoracic or thoraco-abdominal aneurysmectomy, frequently use lumbar spinal drainage of the cerebrospinal fluid (CSF) to prevent paraplegia. Whereas the profit of this technique is a much debated question, we report 2 case reports of delayed sub-dural hemorrhage, after lumbar spinal drainage of CSF. Cross clamping of the aorta decreases the spinal cord artery pressure, increases the cerebral pressure and by alterations of distribution of the venous return, is responsible for an increase of the CSF pressure. This increase of the CSF pressure decreases the spinal cord driving pressure. Lumbar spinal drainage of CSF aims to improve the spinal cord driving pressure close to the normal (where driving pressure = aortic pressure - CSF pressure). The two case reports have to be added to the liability of a method of prevention that, as attractive that it is, did not give the proof of its efficiency to decrease the frequency and/or the severity of paraplegia after thoracic or thoraco-abdominal aneurysmectomy. At this time, this technique should be reserved to the patients with documented risk, as it is possible using preoperative spinal cord arteriography. The insertion and the withdrawal of the catheter must be done in the usual conditions of medullar puncture with regard to anticoagulant and antiplatelet agents

Endovascular treatment of abdominal aortic aneurysms: is there a benefit regarding postoperative outcome?

BACKGROUND AND OBJECTIVE: The endovascular treatment of abdominal aortic aneurysms has raised great interest amongst vascular surgeons. The aim of this study was to compare the postoperative morbidity and mortality rates of endovascular treatment with those of open surgery, from the anaesthesiologist's standpoint. METHODS: From January 1997 to June 2000, 425 consecutive patients with abdominal aortic aneurysms were referred for regular surgery. Thirty-nine patients who needed a visceral or renal artery revascularization, or a nephrectomy were excluded. The remaining 386 patients were studied in a prospective manner. Aneurysms were evaluated with spiral computerized tomography scanning and calibrated aortography. After informed consent, only those patients with a suitable vascular anatomy underwent endovascular treatment (n = 193). All other patients underwent open surgery and are considered as a control group (n = 193). Endovascular treatment was performed by a femoral or an iliac retroperitoneal route. All stent-grafts were made to measure using auto-expandable stainless-steel stents covered with a standard polyester prosthetic graft. RESULTS: Six patients in the endovascular treatment group needed to be converted to the open surgical technique (during the same operation) because of rupture of the iliac bifurcation (1 patient), a large endoleak (2 patients), or technical problems (3 patients). CONCLUSION: The amount of bleeding and the need for blood products were significantly lower in the endovascular treatment group. Despite the absence of significant differences regarding cardiac complications and mortality, there was a lesser incidence of pneumonia, acute respiratory and renal failure. Patients in the endovascular treatment group spent less time in the intensive care unit and in the Hospital.

[Endovascular treatment of aorto-iliac aneurysms. Made-to-measure endoprotheses increase the feasibility]. / Traitement endovasculaire des anévrismes aorto-iliaques. La confection astisanale sur mesure des endoprothèses augmente le taux de faisabilité.

The authors describe their experience of tailoring endoprostheses for endovascular treatment of aorto-iliac aneurysms with components available on the market. Between January 1996 and December 1999, 188 aorto-iliac aneurysms were treated by tailor-made endoprostheses using self-expanding Z stents made of stainless steel compiled with polyester ligatures and covered with standard commercially available polyester prostheses. These endoprostheses were implanted with an 18 to 24 Fr (usually 20 Fr) introducer and positioned by a surgical approach. This method allows construction of tubular, bifurcated, digressive or occlusive endoprostheses associated with an extra-anatomical bypass graft. It increased the number of endovascular procedures for aorto-iliac aneurysms in the authors' department. This number has been further increased by using endoprostheses with an uncovered proximal or distal stent for cases with particularly short or angled necks and by using hybrid endoprostheses with one or more extremities without a stent, allowing surgical suture of the anastomosis. The authors' results show that tailoring endoprostheses considerably increased the feasibility of endovascular treatment of aorto-iliac aneurysms, even in unselected patients whilst providing an effectiveness and safety to justify the continuation of this experience.

[Risk factors for mortality in abdominal aortic surgery]. / Facteurs de risque de mortalité après chirurgie de l'aorte abdominale.

OBJECTIVE: To analyse pre and peroperative variables for predicting mortality after abdominal aortic surgery. STUDY DESIGN: Prospective study. PATIENTS: We prospectively included 658 consecutive patients undergoing abdominal aortic surgery from January 1993 to July 1997. METHODS: Age, gender, hypertension, history of myocardial infarction or coronary revascularization, angina pectoris, diabetes, arrhythmia, cardiac insufficiency, serum creatinine > 150 mumol.L-1, beta-blockers therapy, calcium channel inhibitors, angiotensin converting enzyme inhibitors were preoperative analysed variable. Type of aortic disease (anuerysms versus aortic occlusion), duration of surgery, blood loss, type of laparotomy (medium versus lombotomy) were peroperative analysed variables. Haemoglobinemia was monitored during surgery and patients were transfused if haemoglobinaemia < 80 g.L-1. RESULTS: Thirty-three patients died after aortic surgery (5%). In multivariate analysis, angina pectoris (OR = 5.47, P < 0.001), chronic obstructive bronchopulmonary disease (OR = 2.27, P = 0.05) and duration of surgery (OR = 1.60, P < 0.001) were the independent predictive factors of mortality. Age, blood loss were predictive factors only in univariate analysis. CONCLUSION: Angina pectoris and COBP were the two independent preoperative factors of mortality. The duration of surgery was the only peroperative factor. Well monitored blood loss was not a predictive factor.

Treatment of intraoperative refractory hypotension with terlipressin in patients chronically treated with an antagonist of the renin-angiotensin system.

UNLABELLED: The goal of the present study was to determine whether terlipressin, an agonist of the vasopressin system, could counteract perioperative hypotension refractory to common vasopressor therapy and to analyze its circulatory effects. We enrolled 51 consecutive vascular surgical patients chronically treated with angiotensin-converting enzyme inhibitors or antagonists of the receptor of angiotensin II, who received a standardized opioid-propofol anesthetic. Of these 51 patients, 32 had at least one episode of hypotension, which responded to epinephrine or phenylephrine. In 10 other patients, systolic arterial pressure (SAP) did not remain above 100 mm Hg for 1 min, despite three bolus doses of ephedrine or phenylephrine. In these patients, we injected a bolus of 1 mg of terlipressin, repeated twice if necessary. Hemodynamic and echocardiographic variables were recorded every 30 s over 6 min. In eight patients, arterial pressure was restored with one injection of terlipressin; in two other patients, three injections were necessary. One minute after the last injection of terlipressin, the SAP increased from 88+/-3 to 100+/-4 mm Hg and reached 117+/-5 mm Hg (P = 0.001) 3 min after the injection and remained stable around this value. This increase in SAP was associated with significant changes in left ventricular end-diastolic area (17.9+/-2 vs 20.2+/-2.2 cm2; P = 0.003), end-systolic area (8.1+/-1.3 vs 9.6+/-1.5 cm2; P = 0.004), end-systolic wall stress (45+/-8 vs 66+/-12; P = 0.001), and heart rate (60+/-4 vs 55+/-3 bpm; P = 0.001). Fractional area change and velocity of fiber shortening did not change significantly. No additional injection of vasopressor was required during the perioperative period. No change in ST segment was observed after the injection. IMPLICATIONS: Terlipressin is effective to rapidly correct refractory hypotension in patients chronically treated with antagonists of the renin-angiotensin system without impairing left ventricular function.

Risk factors for acute postoperative renal failure in thoracic or thoracoabdominal aortic surgery: a prospective study.

UNLABELLED: Acute postoperative renal failure is a common complication of thoracic aorta, thoracoabdominal aorta, or aortic arch surgery. To identify variables associated with acute postoperative renal failure, we prospectively studied 475 consecutive patients undergoing thoracoabdominal aortic surgery over a 12-yr period, including those requiring emergent surgery. One hundred twenty-one (25%) patients developed acute postoperative renal failure, and 39 (8%) required hemodialysis. Using multivariate analysis, acute postoperative renal failure was significantly associated with the following variables: age >50 yr (odds ratio [OR] 2.90 [95% confidence interval 1.52-5.53]), preoperative serum creatinine >120 micromol/L (OR 2.76 [1.70-4.48]), duration of left kidney ischemia >30 min (OR 2.01 [1.27-3.17]), packed red cells administration >5 units (OR 2.04 [1.24-3.37]), and Cell-Saver administration >5 units (OR 2.31 [1.34-1.96]). Reimplantation of visceral, renal arteries and the Adamkievicz artery; duration of visceral, spinal, and right kidney ischemia; requirement for fresh frozen plasma; administration of aprotinin; extracorporeal circulation; and procedures with circulatory arrest and profound hypothermia were not predictive of postoperative renal failure. In addition, age >50 yr (OR 5.59 [1.31-23.91]), requirement for packed red blood cells >5 unit (OR 3.91 [1.58-9.67]), and preoperative serum creatinine concentration >120 micromol/L (OR 2.26 [1.13-4.53]) were independent factors for acute renal failure requiring hemodialysis. In conclusion, acute renal failure is often observed after thoracic aortic surgery. Numerous predictive factors must be considered when evaluating the etiology of this complication. IMPLICATIONS: Acute postoperative renal insufficiency is a common complication of thoracic aortic surgery. This study found that age >50 yr, preoperative renal dysfunction, duration of renal ischemia, and amount of blood transfusion are significant predictors of this complication.

Lumbar muscle rhabdomyolysis after abdominal aortic surgery.

Lumbar muscle rhabdomyolysis has been very rarely reported after surgery. The aim of this study was to determine its incidence and main characteristics in a large population undergoing abdominal aortic surgery. Over a 21-mo period, 224 consecutive patients, 209 male and 15 female, mean age 65 +/- 10 yr, underwent abdominal aortic surgery (aortic aneurysm in 142 patients and occlusive aortic degenerative disease in 82 patients). Surgical incision was a midline incision with exaggerated hyperlordosis in 173 patients and a flank incision with a retroperitoneal approach in 51 patients. Postoperative rhabdomyolysis was diagnosed in 20 patients. In these patients, 9 (4%) experienced severe low back pain, and lumbar muscle rhabdomyolysis was confirmed by tomodensitometry (n = 6) or muscle biopsy (n = 3). The remaining 11 patients had lower limb muscle rhabdomyolysis. Rhabdomyolysis occurred after surgery of longer duration, which involved more frequent visceral artery reimplantation, with longer duration of aortic clamping and greater intraoperative bleeding. Lumbar rhabdomyolysis occurred in younger patients who were more frequently obese. On first postoperative day, the mean creatine kinase (CK) value was greater in lumbar rhabdomyolysis than in lower limb rhabdomyolysis (17,082 +/- 15,003 vs 3,313 +/- 3,120 IU/L, P < 0.05). Acute renal failure and postoperative death did not occur in patients with lumbar muscle rhabdomyolysis. Lumbar rhabdomyolysis was not a rare event after abdominal aortic surgery (4%). This syndrome was characterized by postoperative low back pain of unusual severity, which required analgesic therapy, and induced a very high increase in CK with typical findings at tomodensitometry or muscle biopsy but was not associated with postoperative renal failure.

Aprotinin to decrease bleeding and intraoperative blood transfusion requirements during descending thoracic and thoracoabdominal aortic aneurysmectomy using cardiopulmonary bypass.

The purpose of this retrospective study was to assess the efficacy of aprotinin, an antifibrinolytic agent, in reducing bleeding and blood transfusion requirements in patients undergoing descending thoracic or thoracoabdominal aortic aneurysmectomy using cardiopulmonary bypass (CPB). Sixty-nine consecutive patients underwent thoracic or thoracoabdominal aneurysmectomy using CPB in a 2-year period. None of the 29 patients operated on in 1990 (group 1) received aprotinin, whereas all 40 patients operated on in 1991 (group 2) were placed on a high-dose regimen of aprotinin. There were no significant differences between the two groups. Administration of aprotinin was associated with a decrease in CPB time (p = 0.02), surgical duration (p = 0.05) and intraoperative blood loss (p = 0.008) as well as a reduction in intraoperative packed red cells (p = 0.01), Cell-Saver units (p = 0.05), fresh-frozen plasma units (p = 0.002), and platelet concentrate (p = 0.01) requirements. These data suggest that aprotinin is effective in reducing bleeding and blood transfusion requirements during descending thoracic or thoracoabdominal aortic aneurysmectomy using CPB.

Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy.

PURPOSE: In an attempt to clarify the role of hypothermic circulatory arrest (HCA) in the management of complex aortic aneurysms operated on through the left thoracotomy, our technique of HCA and outcome were reviewed. METHODS: During a 21-month period, 15 (17%) of 87 aneurysms of the descending thoracic or thoracoabdominal aorta were operated on by HCA. Eleven patients had chronic aortic dissections (four type A and seven type B), two patients had atherosclerotic aneurysms, and one each had congenital or infected postoperative aneurysms. The use of HCA was planned before surgery in 14 patients. Indications included proximal aortic disease in 12 patients, making either clamping of the transverse aortic arch unsafe (eight patients) or necessitating replacement of the arch with a graft (four patients). Preoperative decision to use HCA was made in two additional patients, one with a ruptured aneurysm and another patient for spinal cord and visceral protection because of anticipated prolonged ischemia as a result of reoperation. Intraoperative technical difficulties prompted the use of HCA in only one patient. Deep hypothermia (15 degrees to 24 degrees C) was induced through partial cardiopulmonary bypass. Left-sided heart venting was necessary in five patients. Aortic replacement was limited to the descending thoracic aorta in five patients, whereas it involved the thoracoabdominal aorta in 10 patients. Four patients had associated replacement of the aortic arch. RESULTS: Three patients died (one of a ruptured aneurysm) during surgery or early after surgery (two of bleeding and one of left ventricular failure). All other patients awoke neurologically intact, but one patient had delayed onset of paraplegia. Another patient died 4 days after surgery of rupture of the ascending aorta. Eleven patients were perioperative survivors without significant morbidity. CONCLUSIONS: Hypothermic circulatory arrest is a valuable adjunct in the management of complex aortic aneurysms through left-sided thoracotomy. Its results warrant consideration of its selective use for spinal cord/visceral protection.

Cutaneous nerve stimulation and motoneuronal excitability: I, soleus and tibialis anterior excitability after ipsilateral and contralateral sural nerve stimulation.

Modification of soleus and anterior tibial anterior horn cell excitability following ipsilateral and contralateral stimulations of the sural nerve was studied by either the H reflex (for the soleus and anterior tibial muscles) or the F response (for the anterior tibial muscles). Several intensities of stimulation were employed. In every instance the recovery curves showed two distinct peaks of facilitation, which appeared with the same delay in muscles with antagonist functions. Also, reciprocal facilitation and inhibition phenomena which occurred after a 25 ms delay and which lasted more than 1000 ms were observed. The intervention of suprasegmentary neuronal mechanisms is proposed to explain the facilitation peaks, while the longer lasting phenomena are probably dependent on spinal processes.