Common carotid artery medialization and fracture dislocation of the cervical spine.

PURPOSE: To describe the management of the discovery of a retropharyngeal carotid artery in the context of a cervical dislocation. DESCRIPTION OF THE CASE: A 68-year-old female presented acute neck pain and incomplete tetraplegia following a fall on the stairs. Radiographs, contrast-enhanced computed tomography scan and magnetic resonance of the cervical spine revealed a C5-C6 bi-articular dislocation. A detailed preoperative assessment of the images discovered a medialization of the left common carotid artery. An external reduction and a left anterior cervical approach allowed a careful management of the vascular variation and an anterior C5-C6 arthrodesis. At six months, a full neurological recovery was assessed and radiographs demonstrated successful fusion of the cervical arthrodesis. DISCUSSION/CONCLUSION: Anatomical features such as medialization of the common carotid artery may affect patients with traumatic cervical spine injuries. The severity of the traumatic bone lesions should not overshadow the preoperative analysis of the adjacent anatomical structures encountered during the surgical approach, even in an emergency situation.

Post-EVAR Thrombus Density on Late Non-Contrast CT Scans Predicts Successful Aneurysm Exclusion.

PURPOSE: The incidence of type II endoleaks (ELII) after endovascular aneurysm repair (EVAR) ranges from 10-44%. Aneurysm thrombus density after EVAR could predict successful aneurysm exclusion. MATERIALS AND METHODS: Twenty-seven patients with an abdominal aortic aneurysm (AAA) who had a CT scan within the first 45 days (early group) post-surgery or after 7 months (late group) were included. Thrombus density was analyzed on non-contrast enhanced CT scans. RESULTS: A total of 5/13 (38%) patients in the early group had an ELII and 9/14 (64.3%) in the late group had a persistent ELII since surgery. In the early group, thrombus density was similar in patients with or without an ELII (mean: 39.9 ± 4.8 vs. 41.9 ± 3.4, p = 0.7; median: 38.7 ± 4.8 vs. 39.7 ± 3.1, p = 0.8). In patients with an ELII, there was no difference in thrombus density at 45 days and after 7 months (mean: 39.9 ± 4.8 vs. 40.2 ± 2.1, p = 0.9; median: 38.7 ± 4.8 vs. 38 ± 2.6, p = 0.9). In patients without an ELII, thrombus density was significantly higher at 45 days than after 7 months (mean: 41.9 ± 3.44 vs. 25.7 ± 2.0, p = 0.005; median: 39.7 ± 3.11 vs. 24.4 ± 1.5, p = 0.004). In patients with an ELII, thrombus density was significantly higher after 7 months than in patients without an ELII (mean: 40.2 ± 2.1 vs. 25.7 ± 2.0. p = 0.001; median: 38 ± 2.6 vs. 24.4 ± 1.5, p = 0.003). CONCLUSION: Low thrombus density after EVAR on late unenhanced CT scans predicts aneurysm exclusion.

Early Postoperative Renal Dysfunction Predicts Long-Term Renal Function Degradation after Type IV Thoracoabdominal Aortic Aneurysm Surgical Repair.

BACKGROUND: Type IV thoracoabdominal aortic aneurysm surgical repair is often complicated by postoperative acute kidney injury. The aim was to evaluate early renal injury influence on long-term renal function. METHODS: All type IV thoracoabdominal surgical repair performed between January 2000 and January 2014 in our tertiary hospital were included in this retrospective observational study. All procedures were performed through a retroperitoneal approach with at least suprarenal aortic cross-clamping. Cold Ringer Lactate was used to perfuse the kidneys. Serum creatinine (Scr.) and glomerular filtration rate (GFR) were recorded preoperatively, daily until discharge and at least annually during follow-up. Postoperative renal dysfunction was classified using the RIFLE score. Predictors of long-term renal decline were identified by logistic regression and a Cox model. RESULTS: Of total, 80 patients were included. Aortic clamping level was suprarenal (10%), supramesenteric (37%) or supracoeliac (53%). Ischemic durations were 29 ± 9 min for the gastrointestinal tract and the right kidney, 54 ± 28 min for the left kidney. Three patients died postoperatively. At discharge, 31 (38.8%) patients did not have a postoperative renal impairment (RIFLE-), compared with 49 (61.2%) who had a renal dysfunction (RIFLE+). GFR was 89 ± 29 ml/min vs 68 ± 37 ml/min, respectively (P < 0.01). In the RIFLE + group, Scr. was increased by x1.5 (Risk) for 22 patients, x2 (Injury) for 19 patients, and ×3 (Failure) for 8 patients. Mean follow-up was 59 months. Eighteen patients died, and 2 patients started permanent dialysis at 46 and 118 months during follow-up. The only predictive factor of long-term GFR degradation was a postoperative GFR below 45 ml/min (OR: 16.5; 95%; P < 0.001). CONCLUSIONS: Postoperative renal dysfunction was a frequent complication, associated with long-term renal function degradation.

Impact of Relative Change in Temperature and Atmospheric Pressure on Acute Aortic Syndrome Occurrence in France.

Acute aortic syndromes (AAS) have been related to significant circadian and seasonal conditions. We used time series analyses to study the impact of meteorological variations on AAS occurrence. We retrospectively assessed 140 patients presenting with AAS over a 6-year period in a French university hospital. Average daily temperature (T) and atmospheric pressure (AP) at the location of the event were collected within the previous 10 days, and their association with AAS investigated with generalized additive models. A decrease in temperature of more than 5 °C within the previous seven days was significantly associated with an increased risk of AAS occurrence (OR equal to 1.86 [1.06; 3.44]). Subgroup analysis revealed that the risk was only significant among normotensive individuals (n = 41) free from blood pressure lowering medication (OR equal to 2.3 [1.05; 5.37]), but not among hypertensive individuals under blood pressure lowering medication despite a larger patient number (n = 99). Similarly, only among the subgroup of normotensive individuals a decrease of AP between 2 and 4 kPa within the previous 3 days was associated with an increased risk of AAS (OR equal to 2.93 [1.1; 8.15]) and an increased between 2 and 4 kPa was associated with a decreased risk (OR equal to 0.59 [0.36; 1.00]). Variations of meteorological conditions (temperature and AP) within the previous week seem to have effects on triggering AAS especially among the population free from blood pressure lowering medication.

Long-term Outcomes after Transplant Renal Artery Stenosis Surgery.

The occurrence of transplant renal artery stenosis (TRAS) ranges from 1 to 23% and is associated with resistant hypertension, volume overload, graft dysfunction, and poor long-term graft and patient survival. Enhancing graft availability with expanded criteria donors results in the transplantation of kidneys with atherosclerotic arteries, increasing the risk of vascular complications. Although endovascular management is the first-line strategy in this context, in some patients, surgery has to be considered. We report the experience and long-term follow-up of TRAS surgery in a French kidney transplantation center. Between 2004 and 2009, 10 patients with postoperative TRAS, considered unfit for an endovascular procedure by a multidisciplinary team, were addressed for surgery. Mean time from transplantation to surgery was 139.8 ± 136.4 days. Clinical indications were oliguria, anuria, or acute decrease in urine output (n = 5), resistant hypertension (n = 4), and persistence of a decreased allograft function (n = 1). Imaging-revealed ostial stenosis is associated with external iliac artery stenosis (n = 3) or early bifurcation (n = 2), and kinking (n = 5). Revascularization techniques consisted in a great saphenous vein bypass (n = 5) and internal iliac artery anastomosis (n = 5). In the postoperative period, there was no graft loss, but 2 patients required hemodialysis during the first week. Mean follow-up was 9.8 ± 2.1 years. One patient lost his graft 10.3 years after transplantation due to chronic rejection, and 1 patient needed endovascular dilation. There was no graft loss at 5 years. Blood pressure was controlled in all patients. Surgical intervention for TRAS is safe and effective on graft survival and graft function and has to be considered for patients unsuitable for endovascular repair.

Operated descending thoracic and thoracoabdominal atherosclerotic aortic aneurysm prognosis.

BACKGROUND: The long-term survival of patients treated from descending thoracic aneurysm (DTA) is well known, more than those treated from a thoracoabdominal aortic aneurysm (TAAA). Moreover, studies are rarely focused on the aneurysmal etiology and include both degenerative and post dissecting aneurysms. The aim of this study is to compare the long-term survival of patients operated from DTA or TAAA due to degenerative atherosclerosis. METHODS: Thirty-nine atherosclerotic aneurysm patients were operated between January 2007 and July 2015 at Rouen University Hospital. Eighteen DTA patients were operated by TEVAR and 21 TAAA patients (8 type I and 13 type III) by open approach. The main endpoint was remote survival patients. RESULTS: Overall, the initial population was similar in the two groups. However, one third of DTA were treated in context of emergency for painful aneurysm versus 9.5% of patients with TAAA (P=0.066). Survival median of 18 DTA was 18 months (1-68). Survival median of 21 TAAA followed was 66 months (1-91). Survival in both groups was statistically different with the log-rank test (P=0.044). CONCLUSIONS: Long-term prognosis of atherosclerotic DTA may be worse than that of TAAA's. This retrospective study reflects experience in the management of DTA and TAAA in a single-center. Prospective data in patients treated with endovascular procedures for DTA or TAAA, with fenesterated or branched endoprosthesis, are warranted to confirm these results.

A 30-Minute Supraceliac Aortic Clamping in the Rat Causes Death Due to an Inflammatory Response and Pulmonary Lesions.

BACKGROUND: The treatment of thoracoabdominal aortic aneurysms through an open approach has general and pulmonary consequences of multiple etiologies. Our assumption was that the supraceliac aortic clamping needed for this operation causes a systemic inflammatory response associated with a pulmonary attack. METHODS: We developed a model of 30-min supraceliac aortic clamping in Wistar rats weighing 300 g. After 90 min of reperfusion, the rats were sacrificed. The effects on the digestive tract wall were analyzed by measurement of the mucosal thickness/total thickness ratio. The effects on the mesenteric endothelial function were determined by an ex situ measurement of the arterial pressure/volume curves (third branch). The systemic consequences of the procedure were analyzed by dosing tumor necrosis factor alpha (TNFα), interleukin (IL)1ß, and IL10 in the blood. The pulmonary consequences were analyzed by the measurement of macrophages, polymorphonuclear neutrophils (PNs), T lymphocyte infiltration, pulmonary apoptosis (TUNEL) and active caspase 3. The experimental scheme included 20 rats with ischemia-reperfusion (IR) and 20 control rats. An analysis of survival was carried out on 20 other rats (10 IR and 10 controls). RESULTS: The results were expressed as average ± standard error of the mean. The statistical tests were Student's t-test and Mann-Whitney test. This visceral IR model decreased the ratio of the thickness of the intestinal mucosa compared with that of the control rats (0.77 ± 0.008 vs. 0.82 ± 0.009 [P < 0.001]). This local effect was not accompanied by any mesenteric endothelial dysfunction (P = 0.91). On a systemic level, IR increased TNFα (37.9 ± 1.5 vs. 28.2 ± 0.6 pg/mL; P < 0.0001), IL1ß (67.1 ± 9.8 vs. 22.5 ± 5.6 pg/mL; P < 0.001), and IL10 (753.3 ± 96 vs. 3.7 ± 1.7 pg/mL; P < 0.0001). As regards the lungs, IR increased the parenchymal cellular infiltration by macrophages (6.8 ± 0.8 vs. 4.5 ± 0.4 cells per field; P < 0.05) and PNs (7.4 ± 0.5 vs. 6.2 ± 03 cells per field; P < 0.05). There was no increase in the pulmonary cellular apoptosis measured by TUNEL (P = 0.77) or in the caspase 3 activity (P = 0.59). The mortality of the visceral IR rats was 100% at 36 hr vs. 0% in the animals without IR. CONCLUSIONS: This work showed that the inflammatory response to visceral IR had systemic and pulmonary effects which always results in the death in the rat.

Pathology of graft and stent-graft infections: Lessons learned from examination of explant materials.

Due to the aging population, the number of patients treated with aortic grafts or endografts continues to increase. Although infection after these procedures is uncommon, aortic graft infection is a life-threatening condition, and refinement of management guidelines based on implant pathophysiology is appropriate. In the early 1990s, our European collaborative retrieval program, European Group for Research on Prostheses Applied for Vascular Surgery (GEPROVAS) was commissioned to analyze the degenerative phenomenon occurring on explanted grafts or endografts. In this review, our observations from the examination of explanted aortic grafts and endografts found that both fabric and structural degradation is present and is greater in the setting of inflammation produced by infection.

Passive Temporary Visceral Shunt from the Axillar Artery as an Adjunct Method during the Open Treatment of Thoracoabdominal Aortic Aneurysm.

BACKGROUND: Distal aortic retrograde perfusion systems like the left heart bypass or femoro-femoral extracorporeal circulation are the methods of reference for organ protection during direct approaches to thoracoabdominal aortic aneurysms. The aim of this work was to evaluate the use of a passive arterial shunt to reduce visceral ischemia during aortic operations when occlusive diseases of the iliac arteries make distal aortic retrograde perfusion inappropriate. METHODS: Ten patients affected by a Crawford type III thoracoabdominal aneurysm (TAA) were operated on between January 2013 and January 2015 with the use of a temporary shunt inserted onto the left axillar artery that allows visceral perfusion immediately after the aorta is opened. The operation was performed after a single dose of heparin (50 UI/kg). The sera lactate levels were measured 2 hr after the last aortic clamp was removed and compared with those obtained from a group of 19 patients operated on for a Crawford type IV TAA during the same period without any arterial shunt. RESULTS: Neither mortality nor paraplegia occurred. The sera lactate levels were lower in the group of patients operated on for a type III TAA (2.57 ± 1) than for a type IV TAA (3.68 ± 1) (P < 0.01, Student's t-test). CONCLUSION: This method was effective for low mesenteric ischemia, easy to perform, and did not require high doses of anticoagulants.

Thoracic aorta to femoral artery bypass allows secondary kidney transplantation in case of major iliac artery disease.

Iliac artery major calcifications can compromise kidney graft. First-performed prosthetic arterial bypass from the thoracic aorta to the femoral artery allows secondary kidney transplantation. Four patients were submitted to this procedure. No patient died during the postoperative period or the follow-up. The median time to receive a kidney graft after the arterial surgery was 24 months (4-52). The normalization of the sera creatinine level was 6.4 days (2-15). The median follow-up was 38 months (7-79). In our experience, using lateral side clamping of the descendant thoracic aorta during the proximal implantation of the arterial graft avoids bleeding and visceral abdominal ischemia. The secondary performed kidney graft is safe on a very available arterial conduit.

Axillofemoral bypass for kidney transplant protection during open repair of abdominal aortic aneurysm.

The need to treat an abdominal aortic aneurysm (AAA) in kidney transplanted patient is a rare event. To date, no method to protect the kidney during the aneurysm treatment has been identified as undeniably relevant. On the other hand, the advantage of endovascular treatment of the aneurysm (EVAR) is to avoid transplanted kidney injury. Unfortunately, EVAR is not always available leading to open repair and then aortic cross clamping. We report here 3 cases of AAA open repair in kidney transplanted patients using a temporary axillofemoral bypass to protect the renal function.

Open aortic repair up to previous abdominal aortic surgery.

BACKGROUND: To determine whether direct open repair of thoracoabdominal aortic aneurysms after previous abdominal aortic surgery is a safe option. METHODS: Ten patients were operated between January 2006 and January 2012. Mean age was 70 years (62-78 years). Four aneurysms (Crawford type III) were treated by firstly performed bypasses from the upper thoracic aorta to the celiac trunk, the superior mesenteric artery, and the left renal artery. Secondly performed aortic repair included revascularization of intercostal arteries identified as critical for spinal cord and the right renal artery. Similarly, the 6 aneurysms (Crawford type IV) were treated by firstly performed bypass from the upper thoracic aorta to the left renal artery before aortic repair. RESULTS: The overall mortality and paraplegia rates were nil. The maximal creatinin sera variation was 48 ± 16% with return to the baseline level before discharge. Five patients presented with pulmonary complications. The duration of stay was 9.3 days (2-29) in the intensive care unit and 24 days (10-40) in the surgical unit. The mean follow-up was 35 months. No patient died during the follow-up. CONCLUSIONS: In our experience, open redo aortic surgery appears to be safe. The main relevant point is the sequential reconstruction of the aorta including bypasses of the visceral branches that lowered the visceral ischemic damage because of high level aortic cross-clamping.