Impact of donor, recipient and matching on survival after high emergency lung transplantation in France.

INTRODUCTION: Since July 2007, the French high emergency lung transplantation (HELT) allocation procedure prioritises available lung grafts to waiting patients with imminent risk of death. The relative impacts of donor, recipient and matching on the outcome following HELT remain unknown. We aimed at deciphering the relative impacts of donor, recipient and matching on the outcome following HELT in an exhaustive administrative database. METHODS: All lung transplantations performed in France were prospectively registered in an administrative database. We retrospectively reviewed the procedures performed between July 2007 and December 2015, and analysed the impact of donor, recipient and matching on overall survival after the HELT procedure by fitting marginal Cox models. RESULTS: During the study period, 2335 patients underwent lung transplantation in 11 French centres. After exclusion of patients with chronic obstructive pulmonary disease/emphysema, 1544 patients were included: 503 HELT and 1041 standard lung transplantation allocations. HELT was associated with a hazard ratio for death of 1.41 (95% CI 1.22-1.64; p<0.0001) in univariate analysis, decreasing to 1.32 (95% CI 1.10-1.60) after inclusion of recipient characteristics in a multivariate model. A donor score computed to predict long-term survival was significantly different between the HELT and standard lung transplantation groups (p=0.014). However, the addition of donor characteristics to recipient characteristics in the multivariate model did not change the hazard ratio associated with HELT. CONCLUSIONS: This exhaustive French national study suggests that HELT is associated with an adverse outcome compared with regular allocation. This adverse outcome is mainly related to the severity status of the recipients rather than donor or matching characteristics.

Functional Results of Cervical Rib Resection for Thoracic Outlet Syndrome: Impact on Professional Activity.

BACKGROUND: The aim of this study is to report long-term functional results following cervical rib (CR) resection for thoracic outlet syndrome (TOS). METHODS: This monocentric study included all cases of resection of CR for TOS performed between January 2004 and December 2016. Data were retrospectively collected from the hospital electronic database including preoperative symptoms and the evaluation of occupational well-being, intraoperative data, and early clinical evaluation and occupational well-being during the postoperative period. Patients were categorized as neurogenic TOS (NTOS), arterial TOS (ATOS), arterial and neurogenic TOS (ANTOS), venous TOS (VTOS), or asymptomatic according to preoperative evaluation. We evaluated the improvement in work life between the preoperative and the postoperative period. Further assessment was a negative Roos or elevated arm stress test (EAST) during the postoperative period. RESULTS: Thirty-three patients with a median age of 38.5 years (30-46) were included. Thirty-six procedures were performed: 33% to treat ATOS (12/36), 39% for NTOS (14/36), 19% for ANTOS (7/36), 3% for VTOS (1/36), and 6% (2/36) for asymptomatic lesions. There were 9 cases of subclavian artery aneurysms leading to additional arterial repair. Due to distal embolization, a cervical sympathectomy was associated in 5 procedures. First rib resection was associated in 4 procedures (11%) and C7 transverse process resection was performed in 15 procedures (42%). The technical success rate was 100% and intraoperative complications were observed in 4 patients (11%) with favorable postoperative outcomes. During the early postoperative period, 3 Claude Bernard-Horner's syndrome and 1 asymptomatic subclavian dissection were detected. Late complications included 2 bypass thromboses (6%) at 6 weeks and 16 months. Postoperative EAST improved in 16 limbs (44%). Prior to the procedure, only 27% (9/33) patients had normal work lives. After the procedure, 64% (21/33) of patients were able to return to their normal work activity. CONCLUSIONS: CR resection for TOS seems to be a safe procedure leading to good short- and long-term clinical results with a favorable impact on recovering a normal work life in these young patients.

Femoral Bifurcation Endarterectomy with Transection-Eversion of the Superficial Femoral Artery: Technique and Results.

BACKGROUND: We evaluated the results of femoral bifurcation endarterectomy using the eversion technique with transection of the superficial femoral artery (femoral bifurcation endarterectomy with eversion [FBEE]). METHODS: We included all patients who underwent a femoral revascularization using the eversion technique, with or without antegrade or retrograde revascularization, from January 2006 to December 2015. Data were retrospectively collected. Primary and primary assisted patency (PAP) of the femoral bifurcation were analyzed. Secondary outcomes were 30-day postoperative complications. RESULTS: A total of 129 patients (143 limbs) underwent consecutive FBEE (86.8% men, with a mean age of 69.7 years). Patients presented with claudication (93, 65%) and critical ischemia (46, 32.2%). Primary patency was 96.3%, 94.6%, and 93% at 1, 2, and 5 years, respectively. PAP was 99% at 3 time points. Reintervention was necessary in 8 patients during follow-up. The 30-day mortality was 0.7% (1 patient), and the access complication rate was 18.8% (n = 27), of which only 2.8% (n = 4) were major complications. CONCLUSIONS: This retrospective study confirmed the efficiency and the reproducibility of this technique for the treatment of femoral bifurcation lesions. This technique allowed treating extensive atherosclerotic lesions of the deep femoral artery and may be associated with antegrade and retrograde revascularizations.

Uretero-arterial fistula due to a hypogastric aneurysm.

Uretero-arterial fistula is a rare condition that can result in life-threatening haematuria, which should be diagnosed and treated immediately. We report a case of uretero-arterial fistula due to a hypogastric aneurysm. The patient underwent an endovascular treatment of the hypogastric aneurysm associated with a percutaneous nephrostomy. Most fistulae are not identified on computed tomography (CT) and a high degree of suspicion is needed. Presence of unexplained haematuria with CT diagnosis of hypogastric aneurysm should raise suspicions of uretero-arterial fistula as a possible cause.

Aortic bypass surgery for asymptomatic patients awaiting a kidney transplant: A word of caution.

INTRODUCTION: In the presence of severe aorto-iliac calcification, aortic bypass surgery can be mandatory to allow kidney transplantation. The aim of our study was to evaluate the safety and outcomes of this strategy among asymptomatic patients. MATERIALS AND METHODS: We retrospectively reviewed the files of all patients that had undergone vascular bypass surgery prior to kidney transplantation between November 2004 and March 2016. All patients undergoing aortic bypass surgery prior to kidney transplantation without any vascular-related symptoms were included. RESULTS: Twenty-one asymptomatic patients were included. Ten patients (48%) have not received a kidney transplant. Four patients died before kidney transplantation, including 2 deaths related to the bypass surgery (9.5%). Early post-operative morbidity involved 11 cases. Eleven patients (52%) were transplanted. Transplanted patients were significantly younger (median age 60 [56-61] vs 67 [60-72] years, P = .04) at the time of bypass and were less frequently treated for coronary heart disease (9% vs 50%, P = .06). CONCLUSION: Aortic bypass surgery performed prior to kidney transplantation among asymptomatic patients has significant mortality and morbidity rates. When transplantation is possible, the results are satisfying. Larger studies are required to define the selection criteria, such as age and coronary heart disease.

Operation and Chemotherapy: Prognostic Factors for Lung Cancer With One Synchronous Metastasis.

BACKGROUND: Stage IV non-small cell lung cancer (NSCLC) is considered incurable; however, some patients with only few metastases may benefit from treatment with a curative intent. We aimed to identify the prognostic factors for stage IV NSCLC with synchronous solitary M1. METHODS: A database constructed from our weekly multidisciplinary thoracic oncology meetings was retrospectively screened from 1993 to 2012. Consecutive patients with NSCLC stages I to IV were included. RESULTS: Of the 6,760 patients found, 4,832 patients were studied. Among the 1,592 patients (33%) with stage IV NSCLC, 109 (7%) had a synchronous solitary M1. Metastasis involved the brain in 64% of patients. Median overall survival was significantly longer in synchronous solitary M1 than in other stage IV (18.9 months, interquartile range [IQR]: 9.9 to 34.6 months versus 6.1 months, IQR: 2.3 to 13.7 months], respectively, p < 10-4). Among patients with synchronous solitary M1, 90 (83%) received a local treatment with curative intent at the primary and metastatic sites. Factors independently associated with survival were age older than 63 years (hazard ratio [HR] 1.63, 95% confidence interval [CI]: 1.01 to 2.63), Performance status of 3 or 4 (HR 7.91, 95% CI: 2.23 to 28.03), use of chemotherapy (HR 0.38, 95% CI: 0.23 to 0.64), and operation conducted at both sites (HR 0.35, 95% CI: 0.19 to 0.65). CONCLUSIONS: Synchronous solitary M1 treated with chemotherapy and operation at both sites resulted in better survival. Survival of NSCLC with synchronous solitary M1 was more similar to stage III than other stage IV NSCLCs. The eighth TNM classification takes this into account by distinguishing between stages M1b and M1c.

Vascular access-induced hand ischemia: risks and safe management.

Hand ischemia is rare but complex and multifactorial. Distal arteriopathy below the vascular access (VA) is responsible in the vast majority of patients and not a problem of high flow of the VA. Therefore, surgical technique should focus on improving blood flow and pressure instead of reducing blood flow. We present an overview of the standard techniques which are recommended to treat VA-induced hand ischemia. The banding techniques, most of which empirical and not codified, have been abandoned by the majority of the authors because of a high rate of failure and reintervention. Ligation may be necessary in patients with severe ischemia and diffuse arterial lesions and in case of ischemic monomelic neuropathy.

Atypical response to erlotinib in a patient with metastatic lung adenocarcinoma: a case report.

INTRODUCTION: Tyrosine kinase inhibitors are widely prescribed in thoracic oncology and have excellent responses as a first-line treatment for locally advanced or metastatic lung cancer with epidermal growth factor receptor mutations. The side effects of tyrosine kinase inhibitors are mostly gastrointestinal and dermatological, and are usually resolved after symptomatic treatment. However, new complications have now arisen due to increased use of these drugs. Here we report a side effect of erlotinib that has not been described previously: that is, metastatic lung tumor nodules were transformed into cysts, which ruptured the pleura and were responsible for bilateral life-threatening pneumothorax. CASE PRESENTATION: We report the case of a 35-year-old Caucasian woman with metastatic adenocarcinoma and a deletion in epidermal growth factor receptor exon 19 (del E746-A750). She was treated with erlotinib for metastatic lung adenocarcinoma. Treatment with erlotinib resulted in the replacement of pulmonary tumor nodules with air-containing cysts. These cysts ruptured in the pleura causing a life-threatening bilateral pneumothorax. To the best of our knowledge, this tumor-cystic response after erlotinib therapy has not been previously described. CONCLUSIONS: Tyrosine kinase inhibitors are widely prescribed in thoracic oncology, and managing toxicities must be optimal in order to improve adherence. Transformation of pulmonary nodules into cysts must be known and clinicians should be aware of this potential complication, which can lead to life-threatening pneumothorax.

Post-traumatic injury of the brachiocephalic artery: on-pump beating heart repair.

We report the case of 54 year-old man who presented with an injury of the brachiocephalic artery secondary to a violent blunt chest trauma. The patient underwent urgent open surgical repair. The procedure was achieved on on-pump beating heart approach. The subsequent course was uneventful.

Is adrenal venous sampling mandatory before surgical decision in case of primary hyperaldosteronism?

BACKGROUND: Primary hyperaldosteronism (PHA) is a cause of secondary arterial hypertension potentially curable by laparoscopic unilateral adrenalectomy. We describe the follow-up of these patients according to their medical or surgical treatment. METHODS: We report a retrospective single-center study of 91 patients with PHA from 1998 to 2012. Treatment was guided by computed tomography (CT) scans. Preoperative adrenal vein sampling (AVS) was performed when the CT scan did not show single solitary unilateral nodules on the adrenal glands. During the follow-up, we considered hypertension to be cured in patients with normal blood pressure without antihypertensive medication (AM), and improvement was defined by a decrease in AM. RESULTS: A total of 28 patients received only AM. Of the 62 patients who underwent a unilateral adrenalectomy, 46 (74 %) had an adrenal adenoma, 14 (22 %) a hyperplasia, and the adrenal gland was normal in two cases. Hypertension was cured in 24 cases (38 %), and 28 patients (45 %) showed improvement with a reduction in AM. Predictive factors for a cure were gender, age, number of preoperative AMs, preoperative arterial systolic blood pressure, and plasma renin activity. All patients who presented with hypokalemia were cured postoperatively. We performed 38 AVS and nine of these patients were operated on based on the AVS findings, with an improvement of 100 % of arterial blood pressure after surgery. CONCLUSION: Laparoscopic unilateral adrenalectomy for PHA cured or improved hypertension in 84 % of patients. Preoperative AVS is mandatory for surgical decision making if the CT scan shows bilateral or no lesions associated with PHA.

Mycotic aneurysm of the internal carotid artery.

BACKGROUND: Infected aneurysms of the extracranial carotid arteries are uncommon. This article presents a complete review of the literature on this condition, illustrated with a case report. This case report describes a mycotic aneurysm of carotid bifurcation with proven infection of the arterial wall from Salmonella enteritidis. The treatment consisted of excision of the aneurysm, ligation of the external carotid, and realization of a common to internal carotid artery bypass with the greater saphenous vein. METHODS: In August 2012, the authors searched the PubMed database with the keywords "carotid artery pseudoaneurysm" and "mycotic carotid aneurysm" for the period until 2012. RESULTS: The incidence of extracranial infected carotid artery aneurysm is relatively stable, with approximately 20 cases reported per decade over the past 30 years. The authors analyzed approximately 100 cases reported in the literature and studied the origin of the condition and the evolution of surgical options.

Primary extraosseous Ewing sarcoma of the lung in children.

We report a case of primary extraosseous Ewing sarcoma (EES) of the lung in a four-year-old child. In the literature, there are only a few case reports of EES located in the thorax.

Endovascular treatment of aortic and primitive iliac artery aneurysms associated with Behçet disease.

Behçet disease is a systemic vasculitis that can cause vascular complications. We describe a 42-year-old woman with an aortic aneurysm and common right iliac aneurysm, both saccular and complicating Behçet disease. The patient was successfully treated by an endovascular method, which currently seems to be the best therapeutic choice given the frequent anastomotic complications of conventional surgical treatment.

Unusual foreign body in urinary bladder due to vascular surgery intervention.

Iatrogenic bladder injury in vascular surgery is very rare. We report a case of bladder injury by penetration secondary to the tunneling of a vascular graft through the space of Retzius. The diagnosis of an intravesical graft was made by computed tomography 1 week later. The patient underwent open bladder surgery associated with complete graft resection without immediate vascular reconstruction.

Late revelation of a subphrenic extralobar pulmonary sequestration as a suprarenal mass.

Pulmonary sequestrations are some rare congenital anomalies. The incidence was estimated of 0.15% to 1.7%. They are characterized by a mass of non functioning pulmonary tissue that has no communication to the normal bronchial tree. The vascularisation is supplied by systemic arteries. They are classified further as intralobar and extralobar types. Extralobar sequestration, so-called accessory lung, is separated from the normal lung. We present a rare case of subphrenic extralobar pulmonary sequestration in a 57 years old patient. The lesion was initially presented as a non-typical suprarenal mass discovered on CT scan. The approach by laparatomy permitted the resection and the definitive diagnosis.