Radio-frequency ablation of atrial flutter: long-term results and predictive value of cavo-tricuspid isthmus bidirectional block as determined by a simplified technique.

OBJECTIVES: Complete bidirectional cavo-tricuspid isthmus (CTI) block is mandatory for radio-frequency (RF) ablation of typical atrial flutter (AF). CTI block can be assessed by a simplified method using two catheters and the technique of differential pacing, but long-term results in large series are poorly known. METHODS: CTI RF ablation was performed in 255 consecutive patients with typical AF, using one quadripolar catheter, and the ablation catheter, in association with the technique of differential pacing. RESULTS: Procedural success, as defined by documentation of complete bidirectional CTI block using limited activation mapping, positive differential pacing together with termination of ongoing AF, was achieved in 80% of patients. AF recurred in 37 patients (14%) over a mean follow-up period of 15 +/- 9 months. Two hundred and forty-one patients (94%) were finally cured, with 1.1 procedures/patient. The recurrence rate was related to the achievement of complete CTI bidirectional block (12% vs. 29%, p = 0.01). CONCLUSIONS: Long-term results of CTI ablation, employing a simplified method using the differential pacing technique, are similar to those for the standard methods using multipolar catheters. Therefore, this technique compares favorably to other established methods for such common RF procedures, especially due to its lower cost.

Midterm results of endovascular treatment of atherosclerotic aneurysms of the descending thoracic aorta.

OBJECTIVE: We sought to determine the midterm results of endovascular repair of atherosclerotic aneurysms of the thoracic descending aorta by using second-generation, commercially available stent grafts. METHODS: Between 1996 and 2005, 45 patients (mean age, 68 +/- 11 years) with aneurysms of the descending thoracic aorta underwent endovascular repair. Aortic dissections, penetrating ulcers, and traumatisms were excluded. The mean follow-up was 24.7 +/- 21.6 months (maximum, 6.7 years). RESULTS: No patients died, and no conversion to surgical intervention was required during the procedures. Three (6.7%) patients died during the first month, and 6 (14.7%) died later on. The main complications were strokes (13.3%), vascular access complications (8.9%), aortic complications (6.6%), paraplegia (4.4%), and sudden deaths (4.4%). Nineteen (42%) primary endoleaks were encountered: 3 required reinterventions, 15 spontaneously thrombosed, and 1 patient died. Except for 2 sudden unexplained deaths, no aortic complications were observed after 1 month. Actuarial survival estimates at 1, 3, and 5 years were 87.6% +/- 5.3%, 76.9% +/- 7.4%, and 70.6% +/- 9.2%, respectively. Actuarial freedom from death related to the treated aortic disease was 94.3% +/- 4.0%, 94.3% +/- 4.0%, and 86.4% +/- 8.4% at 1, 3, and 5 years, respectively. Aspirin status of greater than 3 (P = .005), high aortic diameter (P = .007), and long covered lengths (P = .02) were determinant for mortality. Actuarial freedom from complication was 62.6% +/- 7.7%, 58.9% +/- 8.1%, and 58.9% +/- 8.1% at 1, 3, and 5 years, respectively. The location of the aneurysm (P = .05) and a high aortic diameter (P = .04) were both determinants for endoleaks. CONCLUSIONS: Stent grafting of atherosclerotic aneurysm of the thoracic descending aorta is safe and effective. Further studies are mandatory to determine the most relevant indications and the long-term efficacy of such treatment.

Endovascular repair of traumatic rupture of the aortic isthmus: midterm results.

OBJECTIVE: The endovascular management of aortic traumatic ruptures has been proposed as an alternative to classical surgical procedures. The aim of this work was to report the midterm results of the endovascular treatment of traumatic ruptures of the isthmic aorta. METHODS: Between January 1996 and July 2005, endovascular repair of blunt traumatic aortic ruptures was performed in 33 patients (mean age, 40 +/- 17 years). The stent grafts used were either Talent Medtronic (n = 27), Gore Excluder (n = 4), or Boston Vanguard (n = 2) grafts. Follow-up was 94.9% complete and averaged 32.4 +/- 28.8 months (maximum, 8 years). RESULTS: Stent graft deployment was successful in all cases without need for surgical conversion. Except for one iliac rupture, which was treated with an iliofemoral bypass during the same procedure, there was no major perioperative complication. The early complications consisted of 3 primary endoleaks (1 type I and 2 type IV), 1 transient paraparesis, 1 occlusion of the main left bronchus, 1 thrombosis, and 2 pseudoaneurysms of the brachial artery. All the primary endoleaks healed within the first month. No patient died, and no aortic reinterventions were performed. The midterm complications were a mild circumferential thrombus at the distal part of the stent graft and a fracture of the nitinol stent. Both complications were asymptomatic and were discovered on systematic computed tomographic scan examination. Actuarial freedom from complication at 1 year was 96.1% +/- 3.8% and 85.5% +/- 10.6% at 3 and 5 years, respectively. CONCLUSION: This study demonstrates that the endovascular treatment of blunt thoracic aortic traumatisms is a safe and effective therapeutic method without increased midterm morbidity and mortality rates.

Pulmonary angiomyolipoma.

Extrarenal angiomyolipoma are benign lesions that have rarely been described in the thorax. We present the clinical, radiographic, and pathologic findings of a pulmonary angiomyolipoma in a 63-year-old woman who had no diagnosis of tuberous sclerosis or lymphangioleiomyomatosis. We believe that this report is one of the first descriptions of angiomyolipoma of the lung.

Transection of the brachial artery after closed posterior elbow dislocation.

Although elbow dislocations are common orthopaedic lesions, vascular complications remain rare. We report the cases of three patients who presented with a rupture of the brachial artery after closed posterior dislocation, which is even more uncommon. Arteriograms were performed in all cases because of the persistent absence of pulses at the wrist after emergency reduction. In each patient, the treatment consisted of the insertion of reversed end-to-end saphenous bridges. None of them presented mid-term vascular complications (mean follow-up, 17 months). Brachial artery disruption can result from closed posterior elbow dislocation and responds well to vascular repair.

Surgical treatment of an aortic arch aneurysm without cardio-pulmonary bypass: endovascular stent-grafting after extra-anatomic bypass of supra-aortic vessels.

A 70-year-old patient presented a large saccular aneurysm involving the whole aortic arch. Because of a past history of left thoracotomy and a high co-morbidity profile, we opted for a combined strategy, consisting of an extra-anatomic bypass of the supra-aortic vessels, followed by the endovascular implantation of a covered thoracic stent-graft. Endovascular stent grafting of aortic arch aneurysm, after extra anatomic bypass of supra-aortic vessels, appears as an attractive alternative strategy for high surgical risk patients.