Video fluoroscopy for pulmonary artery catheter insertion in high-risk situation of knotting or misplacement.

Pulmonary artery catheter (PAC) insertion in patients with severe pulmonary hypertension, right heart dilation and failure, is very challenging. Misplacement and knotting are rare but could be serious complications leading to a delay of the monitoring and sometimes an emergent not expected intervention. Here we report a case of a patient admitted to Intensive Care Unit (ICU) with an acute hypoxemic respiratory failure. She had a history of chronic respiratory failure with pulmonary hypertension and right heart failure. We decided to monitor her cardiac output and pulmonary pressure with a PAC. Repeated attempts to reach the pulmonary artery (PA) were unsuccessful and the PAC was knotted and blocked at the distal tip of the introducer. Under fluoroscopy the knot was released by radiologist. Few days later, a monitoring of PA pressure was needed to guide a PA vasodilator treatment. Under fluoroscopic guidance with the supervision of radiologist, the catheter was successfully placed in the PA at the first attempt. Despite some limitations (patient displacement and radiation), this technique is more accurate than waveform guidance. We suggest in specific situations (low cardiac output, severe pulmonary hypertension, and severe tricuspid regurgitation) to consider first fluoroscopy.

Pulmonary embolism in patients with COVID-19: Time to change the paradigm of computed tomography.

OBJECTIVE: To raise awareness for possible benefits of examining known COVID-19 patients presenting sudden clinical worsening with CT pulmonary angiography instead of standard non-contrast chest CT.

Safety of elective percutaneous peripheral revascularization in outpatients: A 10-year single-center experience.

PURPOSE: To evaluate the safety and feasibility of peripheral percutaneous endovascular procedures in a large group of outpatients with peripheral arterial disease (PAD). MATERIALS AND METHODS: We retrospectively evaluated all consecutive patients who underwent peripheral transluminal angioplasty (PTA) for PAD of the lower extremities as "Out-Patient Admission Protocol" (OPAP) from January 2005 until December 2015. A total of 498 consecutive patients (305 men and 193 women) with mean age of 66±10 (SD) years (range: 37-90 years) were evaluated. By protocol, patients were expected to be discharged 6hours after the procedure. Clinical profile, procedure details and technical success were reviewed. Complications, conversion rate, readmission rate and long-term follow-up were evaluated. RESULTS: Ninety one percent of patients (454/498) suffered from claudication. Unilateral femoral access was performed in 75.4% (493/654) of procedures with a 6-French sheath in 80.7% (528/654) of procedures. Balloon PTA alone was performed in 17.3% (148/857) and stent placement in 82.7% (709/857) of treated segments. Technical success of lesion treatment was 98.2% (857/873). Closure devices were used in 55.4% (362/654) of procedures. Conversion and readmission rates were 1.8% (12/654) and 0.6% (4/654), respectively. Long-term follow-up was obtained in 386 target lesions, 5-year restenosis of lesion was 20.5% (79/386). CONCLUSION: As designed, the OPAP was feasible, safe and effective with very low conversion and complications rates. These results strongly support a larger use of such approaches as routine practice.

[Treatment of critical lower limb ischemia]. / Traitement de l'ischémie critique chronique des membres inférieurs en 2014.

Critical limb ischemia is a major public health problem in our western countries due to the epidemia of (diabesity). The outcome of patients suffering from critical limb ischemia reains poor with an amputation free survival rate at one year of about 50%. The treatment should be multidiciplinary and done in emergency in specialized centers to ensure the limb salvage: this management should be centered aroud 3 axis: the screening of the cardiovascular risk factors, the best medical treatment and the invasive approaches. Due to multiple endovascular technical innovations, more frail patients with com plex diseases can be treated with good results. Therefore, the endovascular treatment is essential in the management of such patients by vascular surgeons.

[Vascular follow up in patients suffering from peripheral arterial disease and undergoing revascularization]. / Suivi angiologique des patients artériopathes après geste de revascularisation.

The rapid evolution of revascularization techniques has allowed an improvement in quality of life of patients with peripheral artery disease. The angiological follow-up aims to insure durable results of revascularization, to diminish risk of amputation and to limit progression of atheroma plaques. The patient history and physical examination are essential in evaluating impact of peripheral artery disease upon quality of life and insuring the appropriate control of cardiovascular risk factors.

[Cardiac imaging: specific clinical role of newly developed non invasive techniques. Part 1: Morphological evaluation]. / Imagerie cardiaque non invasive: apport spécifique en clinique des nouvelles modalités (I). Evaluation morphologique.

Echocardiography is the preferred initial test to assess cardiac morphology and ventricular function. Cardiac MRI enables an optimal visualisation of heart muscle without contrast injection, and precise measurement of the ventricular volumes and systolic function. It is therefore an ideal test for patients with poor echocardiographic windows or for the specific evaluation of right heart chambers. Heart CT also remarkably images heart muscle and precisely measures ventricular systolic function after intravenous injection of iodinated contrast. Coronary CT may also, in selected cases, avoid the need for diagnostic coronary angiography. Although very accurate, these imaging modalities are expensive and may be contra-indicated for a particular patient. Their use in clinical practice has to follow the accepted guidelines.

[Cardiac imaging: specific clinical role of newly developed non invasive techniques. Part II: functional evaluation]. / Imagerie cardiaque non invasive: apport spécifique en clinique des nouvelles modalités (II). Evaluation fonctionnelle.

The non-invasive evaluation of myocardial ischemia is a priority in cardiology. The preferred initial non-invasive test is exercise ECG, because of its high accessibility and its low cost. Stress radionuclide myocardial perfusion imaging or stress echocardiography are now routinely performed, and new non-invasive techniques such as perfusion-MRI, dobutamine stress-MRI or 82rubidium perfusion PET have recently gained acceptance in clinical practice. In the same time, an increasing attention has been accorded to the concept of myocardial viability in the decisional processes in case of ischemic heart failure. In this indication, MRI with late enhancement after intravenous injection of gadolinium and 18F-FDG PET showed an excellent diagnostic accuracy. This article will present these new imaging modalities and their accepted indications.

[Non invasive cardiac imaging: clinical role of newly developed modalities. Part III: non ischemic cardiac diseases]. / Imagerie cardiaque non invasive: rôle des nouvelles modalités en pratique clinique (III). Pathologies cardiaques non ischemiques.

Echocardiography is the preferred initial noninvasive test to assess heart muscle and heart valves. Cardiac MRI has a unique capacity to directly characterise myocardial tissue with specific imaging sequences and late enhancement pattern after gadolinium injection, and has a specific role in the diagnosis of cardiomyopathies. In valvular heart diseases, cardiac MRI precisely measures the severity of aortic or pulmonary regurgitation. In pericardial heart diseases, and specifically when constrictive pericarditis is suspected, cardiac MRI and/or CT are useful to look for pericardial thickening. Cardiac CT and MRI are very rapidly developing techniques in cardiology; the use of these expensive techniques must follow the currently accepted indications in order to be integrated in a rational diagnosis process in clinical practice.

[Hybrid treatment of aortic aneurysms]. / Les cures hybrides des lésions anévrismales.

The hybrid treatment of aortic aneurysms is indicated in patients having the ostia of supra aortic or visceral branches taken in to the aneurysm. Indeed, these lesions are not eligible for classic endovascular treatment because the existing endoprostheses cannot provide perfusion of the side branches without inducing major endoleaks. The surgical technique consists of 2 steps: firstly, a by-pass between normal aorta and the major aortic branches involved in the aneurysm is performed to guarantee the perfusion of the organs such as brain, bowel, and after endoprosthesis deployment. Secondly, the endoprosthesis is deployed using the classical technique to isolate the aneurysm. The hybrid approach provides safe and reliable treatment of complex aortic aneurysms with mortality and morbidity rate far below the classical open surgery.

Rupture and migration of an endovascular stent in the brachiocephalic trunk causing a vertebral steal syndrome.

Delayed stent fracture has been observed in many different arteries and may represent a risk factor for restenosis. We describe the case of a delayed rupture of an endovascular brachiocephalic trunk stent. The complete fracture allowed a fragment to migrate distally and tilt, resulting in a hemodynamic pattern similar to that of a prevertebral stenosis with complete inversion of the homolateral vertebral blood flow. The induced vertebral steal syndrome as well as the risk of cerebral embolism was corrected by an aortobrachiocephalic bypass and resection of the ruptured stent.

Assessment of occlusive arterial disease of abdominal aorta and lower extremities arteries: value of multidetector CT angiography using an adaptive acquisition method.

We evaluated 16-detector-row CT in the assessment of occlusive peripheral arterial disease (PAD) of the abdominal aorta and lower extremities using an adaptive method of acquisition to optimise arterial enhancement especially for the distal foot arteries. Thirty-four patients underwent transcatheter angiography (TCA) and CT angiography within 15 days. For each patient, table speed and rotation were selected according to the calculated optimal transit time of contrast material obtained after a single bolus test and two dynamic acquisitions at aorta and popliteal arteries. Analysis included image quality and detection of stenosis equal or greater than 50% on a patient basis and on an arterial segment basis. Sensitivity and specificity of CT were calculated with the TCA considered as the standard of reference. CT was conclusive in all segments with no technical failures even in difficult cases with occluded bypasses and aneurysms. On patient-basis analysis, the overall sensitivity and specificity to detect significant stenosis greater than 50% were both 100%. Segmental analysis shows high values of sensitivity and specificity ranging from 91 to 100% and from 81 to 100%, respectively, including distal pedal arteries. Sixteen-detector-row CT angiography using an adaptive acquisition improves the image quality and provides a reliable non-invasive technique to assess occlusive peripheral arterial disease, including distal foot arteries.

[Spontaneous hemoperitoneum: diagnosis, prognosis and possible therapeutics]. / L'hémopéritoine spontané: diagnostic, pronostic et thérapeutiques possibles.

We report the case of a 58-year-old diabetic man admitted to the hospital in a comatose state due to medicamentous hypoglycemia in a context of hypovolemic acute renal failure. Hypovolemia was due to hemoperitoneum in a alcoholic patient with cirrhotic hepatic failure. CT-scan and arterial angiographies revealed a voluminous isolated hepatic mass with active bleeding suggesting the diagnosis of spontaneous bleeding from a hepatocellular carcinoma. The hemorrhage resolved after selective arterial embolization, but the patient died two weeks later from an infectious cause. The differential diagnosis of a spontaneous hemoperitoneum and possibilities of treatment in the case of ruptured hepatocellular carcinoma are discussed.

[CT-angiography of peripheral arterial diseases: principle and current indications]. / Angio-CT des membres inférieurs: principes et indications.

Recent advances in multi-detector CT technology, improving the spatial resolution and the acquisition time, provide basis for CT-angiography of the abdominal aorta and peripheral vessels of the lower extremities. The objective of this review is to help the clinician to understand principle of CT-angiography of peripheral vessels and to provide an overview of the current clinical applications as well as the futures directions in diagnosis, treatment planning and post-therapeutic surveillance in peripheral vascular diseases.

[Management of critical limb ischemia]. / Prise en charge de l'ischémie critique des membres inférieurs.

Critical limb ischemia (CLI) is the leading cause of major leg amputation. Diabetes, smoking and end stage renal disease are the main risk factors for CLI. Despite their reduced survival rate, most CLI patients should be treated by surgical or endovascular arterial reconstruction, since amputation rate with conservative treatment alone is as high as 95% at 1 year in surviving patients with tissue loss, and can be reduced to 25% with successful reconstruction. When arterial reconstruction is impossible or fails, spinal cord stimulation also allows to avoid major amputation in up to 75% of precisely selected patients. Timely management and multidisciplinary approach are advised to reduce the risk of major amputation.

[Radiofrequency tumor ablation: from the liver to the lung passing by the kidney]. / Destruction tumorale par radiofréquence: du foie au poumon en passant par le rein.

Tumor ablation using radiofrequency technique is an interventional radiology method for the treatment of liver renal or pulmonary tumors. The size of the lesion is the limiting factor of this technique. Tumors below 3 cm are treated with a 90% efficacy in one session. Complications are variable according to the organ treated.

[Non invasive multidetector CT angiography of coronary arteries: when and how should I do?]. / Angiographie non invasive des coronaires en scanner multibarrette: comment, quand et pour qui?

Recent advances in multi-detector computed tomography technology offer a reliable tool for coronary arteries visualization and atherosclerotic plaque assessment. The objective of this article is to describe the principle of coronary angiography using multi-detector computed tomography, review the current diagnostic performances and help the reader to understand current applications and future challenges of multi-detector computed tomography in coronary artery disease diagnosis and management.

An accurate and reproducible scheme for quantification of coronary artery calcification in CT scans.

The coronary artery disease is a major cause of deaths in the western world. One indicator for coronary artery disease (CAD) is coronary artery calcification (CAC). An accurate and reproducible scheme is desired to monitor the progression of patient's coronary calcification in follow-up studies. Traditional approaches for CAC estimation lack to provide accurate and reproducible results. In This work, a new adaptive and stochastic 3D method has been proposed by employing a modified expectation-maximisation (MEM) algorithm. It is less sensitive to partial volume effects, motion effects, slice thickness and low dose. Accuracy of the proposed method was measured by a cardiac CT stationary phantom containing 6 calcium inserts of predetermined size and density that were scanned 90 times using 15 different protocols based on slice thickness and radiation. Reproducibility was measured in 35 patients who were each scanned twice with the patient being repositioned before the second scan. Compared with the Agatston based method, it is shown that the proposed algorithm gives better results in terms of accuracy and reproducibility.

[Incidence of acute cor pulmonale and deep venous thrombosis in acute pulmonary embolism]. / Incidence du coeur pulmonaire aigu et de la thrombose veineuse profonde dans l'embolie pulmonaire aiguë.

OBJECTIVE: Ultrasounds are a useful tool when looking for indirect evidence in favor of pulmonary embolism. The aim of this study was to determine the incidence of acute cor pulmonale and deep venous thrombosis revealed by ultrasonographic techniques in a population of patients presenting with pulmonary embolism. METHODS: 96 consecutive patients with a mean (+/- SD) age of 65 +/- 15 years, admitted to our hospital for pulmonary embolism were included in this study. The diagnosis of pulmonary embolism was made either by spiral computed tomography or selective pulmonary angiography. Each patient subsequently underwent both trans-thoracic echocardiography and venous ultrasonography. The diagnostic criterion used for defining acute cor pulmonale by echocardiography was the right to left ventricular end-diastolic area ratio over (or equal to) 0.6. Diagnosis of deep venous thrombosis was supported by the visualization of thrombi or vein incompressibility and/or the absence of venous flow or loss of flow variability by venous ultrasonography. RESULTS: Using ultrasounds, an acute cor pulmonale was found in 63% of our patients while 79% were found to have deep venous thrombosis and 92% of the patients had either acute cor pulmonale or deep venous thrombosis or both. All of the patients with proximal pulmonary embolism had acute cor pulmonale and/or deep venous thrombosis. The presence of acute cor pulmonale on echocardiography was significantly higher in patients with proximal pulmonary embolism (p < 0.0001). CONCLUSION: This study emphasizes the potential value of ultrasonographic techniques in the diagnosis of acute pulmonary embolism.