Reprinted article "Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms".

INTRODUCTION: Acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. METHODS: Twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. RESULTS: Median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n = 3), or retroperitoneal access (n = 2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascular re-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. DISCUSSION: Our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.

Aortic stent-grafting: successful introduction into the combined procedure for coronary artery bypass grafting and aortic aneurysm repair.

OBJECTIVES: Coronary artery bypass grafting (CABG) and combined stent-grafting (SG) were evaluated to reduce morbidity and mortality of patients with descending or infrarenal aortic aneurysm. METHODS: CABG and SG (thoracic n=6, infrarenal n=36) were performed during the same hospitalization in 42 patients (mean age of 73+/-14 years). In 29 patients (mean Euroscore: 9), SG was performed under local anesthesia 9+/-3 days after coronary surgery (simultaneous) and in 13 patients (mean Euroscore: 7) during the same anesthesia (synchronous). In the latter group, 11 out of 13 patients underwent off-pump CABG. All aneurysms were treated by implantation of commercially available self-expanding grafts. RESULTS: CABG was successful in all, but one patient with left internal mammary artery hypoperfusion syndrome, requiring an additional distal saphenous graft to the left anterior descending coronary artery. SG was uneventful in 98% (41/42 patients). Postoperative computerized tomography showed incomplete sealing in seven patients (17%), but only the two attachment endoleaks had to be treated by one proximal and one distal SG extension. Overall hospital stay for the synchronous repair was 12.5+/-6 days and that of the simultaneous group 17.5+/-7 days. Thirty-day mortality was 5% (2/42) as one patient of the simultaneous group experienced a lethal cerebral embolism during SG and one patient of the synchronous group developed an untreatable infection. In the follow-up of 4 years, there were two vascular reinterventions but no additional procedure-related morbidity or mortality. CONCLUSIONS: This experience shows that combined CABG and SG of thoracic or infrarenal aortic aneurysm is a safe and less-invasive alternative to the open graft repair, especially in the older patients or patients with severe comorbidities.

Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.

INTRODUCTION: acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. METHODS: twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. RESULTS: median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n=3), or retroperitoneal access (n=2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascularre-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. DISCUSSION: our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.

Acute traumatic aortic rupture: early stent-graft repair.

OBJECTIVE: Prospective evaluation of early stent-graft repair of acute traumatic aortic rupture. METHODS: Twelve patients with acute traumatic aortic rupture of the descending aorta, out of a series of 337 endovascular aortic procedures, were treated by implantation of self-expanding stent-grafts. The procedures were performed within a mean post-injury time-period of 5+/-7 days (median: 1 day). The feasibility of stent-grafting was assessed by CT scanning and echography. Implantation was performed under local (n=6), or general anesthesia (n=6) if patients were already intubated (n=5) or required a common iliac artery access (n=1). RESULTS: The immediate technical success rate was 100%. There were no post-procedure complications in all but one patient, who died 12 h postoperatively (8% mortality). Complete sealing of the aortic rupture in the remaining 11 patients was confirmed by postoperative CT scans. There were no intervention-related morbidity or mortality during the mean follow-up of 17 months. One patient with peri-graft leakage was successfully repaired with an additional stent-graft 12 months postoperatively. CONCLUSION: Non-delayed or early stent-grafting in acute traumatic rupture of the descending aorta is feasible. This technique seems to be a valuable option, in particular when associated lesions may interfere with the surgical outcome. Immediate post-procedural CT scanning and/or echography should be performed, in order to rule out residual leakage.

Contrast media triggering cutaneous graft-versus-host disease.

Adverse reactions to iodinated contrast media are varied and known to develop in patients with asthma and a history of allergy. We describe three successful allogeneic bone marrow transplantation (BMT) patients, who all developed dermal graft-versus-host disease (GVHD) after receiving contrast media. Cutaneous GVHD triggered by contrast media has not been reported to date and has implications for the assessment, monitoring and treatment of patients during the post-transplant period.

Development of bladder and bowel control: significance of prematurity, perinatal risk factors, psychomotor development and gender.

UNLABELLED: Development of bladder and bowel control from 6 months to 6 years was investigated in 140 preterm children and a control group of 349 healthy term children. Structured parental interviews and neurodevelopmental assessments were carried out when the child was 1, 3, 6, 9, 12, 18 and 24 months, and at yearly intervals thereafter. Even though preterm children were put on the potty at significantly earlier ages and significantly more frequently than term children, they expressed their need for evacuation and attained day and night bladder and bowel control at the same corrected age as term children. Initiation and intensity of toilet-training were not significantly correlated with the development of bladder and bowel control. Gestational age, being too small for gestational age, adverse perinatal conditions and mild to moderate neurological impairment did not affect the occurrence of the child's initiative and the development of bladder and bowel control. Neither developmental and intelligence quotients at the age of 1 to 3 years nor the socioeconomic status of the families influenced the age at which the child became clean and dry. Girls were significantly more advanced in expressing their needs and gaining bladder and bowel control than boys in both the preterm and term groups. CONCLUSION: Development of bladder and bowel control is largely a maturational process which cannot be accelerated by an early onset or a high intensity of training. It is not affected by prematurity, adverse perinatal events or mild to moderate neurological impairment, nor is it related to psychomotor development or actual Swiss socioeconomic conditions.

Does a profound change in toilet-training affect development of bowel and bladder control?

A major change in toilet-training was observed in two successive generations. The median onset of toilet-training was postponed by 13 months between the First Zürich Longitudinal Study (320 children born between 1954 and 1956) and the Second Zürich Longitudinal Study (309 children born between 1974 and 1984). Bladder control, both day and night, was not affected, but bowel control was delayed by 16 months, due not to a lack of training, but to the abandonment of maternal control. The results strongly confirm earlier findings that the development of bowel and bladder control is a maturational process which cannot be accelerated by early onset and high intensity of potty-training. The child's initiative proved to be a reliable indicator that the child was developmentally capable of being clean and dry. Girls were consistently earlier than boys, indicating different maturation rates. No significant correlations were noted between the socioeconomic status and start and intensity of toilet-training, onset of the child's initiative or development of bladder and bowel control.