Endovascular management of aortoenteric fistulas with aortic cuff extenders: report of two cases.

Despite immediate open surgery, aortoenteric fistula (AEF) remains a highly lethal condition. Endovascular management is widely employed, although there is no agreement on its role as a definite treatment or, because of a high incidence of recurrent bleeding and sepsis, as a bridge to open repair. Two cases of secondary AEFs after distant elective abdominal aortic aneurysm repair are presented. The first patient was a 76-year-old man and the second one a 70-year-old man. Both patients presented with hematemesis, had no signs of sepsis and were successfully managed with endovascular surgery, using aortic cuff extenders. Postoperative course was uneventful for both patients who were discharged on long-term antibiotics. However, during follow-up the first patient was readmitted four times; twice due to infection (at 2 and 6 months, respectively) and twice due to recurrent bleeding (at 5 and 9 months, respectively). The last episode of bleeding was managed with axillobifemoral bypass grafting, removal of the prostheses and closure of the aortic stump and the duodenal defect, but the patient died on the 5th postoperative day from multiple organ failure. The second patient remained asymptomatic until the 16th postoperative month when he developed lumbar spine osteomyelitis as a direct extension of graft infection and was deemed inoperable due to multiple comorbidities. Endovascular management of AEF can achieve satisfactory short-term results. Due to the high rate of recurrent bleeding and sepsis it should be used as a temporary measure and a bridge to open repair, whenever this is feasible.

[Post-myocardial infarction cardiogenic shock and circulatory assistance]. / Choc cardiogénique post-infarctus et assistance circulatoire.

Post-myocardial infarction cardiogenic shock still carries a very poor prognosis despite the rapid recourse to effective methods of myocardial revascularisation. Circulatory assistance devices allow restoration of adequate haemodynamics with limitation of myocardial work. In the most severe cases, implantation of intra-thoracic devices is associated with a 70% survival rate in the latest series, providing they are used early. However, in many cases, the essential problem is to stabilise the patient's haemodynamic status, sometimes even before myocardial revascularisation. In these situations, implantation of a peripheral femoro-femoral extra corporeal circulation (ECMO: extra corporeal membrane oxygenation) re-establishes an appropriate cardiac output andprovides time to transfer the patient, to perform coronary revascularisation or to assess neurological status, before deciding on the indications for more complicated assist systems. This "bridge to bridge" concept avoids the risk of implanting complicated assist devices in cerebrally dead patients or in those with multi-organ failure beyond treatment. Conversely, it gives some patients with apparent contraindications to complicated assist systems or who are unable to benefit from these systems for geographical reasons, a chance to survive. In early cardiogenic shock, the ECMO which has a low rate of complications, could safely promote myocardial recovery.

Multiple systems organ failure from organophosphate poisoning.

A 68-year-old man was admitted to an intensive care unit after a suicidal ingestion of dimethoate with organophosphate poisoning. Despite temporary improvement, the patient's condition progressively deteriorated with the development of adult respiratory distress syndrome and acute renal failure. Hemodynamic measurements substantiated the evidence of non cardiogenic pulmonary edema, while renal indices the presence of acute tubular necrosis. Despite vigorous organ specific support the patient died on the 12th hospital day. An autopsy confirmed the presence of adult respiratory distress syndrome and acute tubular necrosis. Organophosphate poison can be added to the list of toxins that caused adult respiratory distress syndrome and acute tubular necrosis and provoked the development of multiple systems organ failure.