Background Our objective was to assess potential contributing factors to implant failure (displacement or rupture) after titanium chest wall osteosynthesis. Methods We retrospectively reviewed the ...clinical data and preoperative and postoperative computed tomographic scans of patients undergoing chest wall osteosynthesis with titanium implants: the Stratos or the Matrix Fixation System in two European departments of thoracic surgery. The indications for titanium chest wall osteosynthesis, the type and number of implants, the topography of the reconstruction, surgical site infection, and role of associated flap and mesh were assessed. Results Between January 2009 and January 2013, 54 patients underwent osteosynthesis after surgical correction of chest wall deformities (n = 25, 46.2%) or to bridge the defect after tumor removal (n = 29, 53.7%). The topography of osteosynthesis was anterior (n = 20), lateral (n = 3), or posterior (n = 1), an average of 1.9 ± 0.9 implants (range, 1 to 5 implants) being used. A combined mesh restored continuity of the chest wall in 15 patients, and muscle flap coverage was performed in 20. The mean follow-up time was 20.2 ± 8.4 months (range, 3 to 48 months). Among these 54 patients, 24 (44%) experienced an implant failure. Seven (29%) were symptomatic. Broken (n = 20, 83.3%) or displaced (n = 4, 16.7%) implants were removed with or without replacement. In patients with broken or displaced implants, the mean duration without implant failure was 6.6 ± 3.1 months (range, 1 to 12 months). There was a significant relationship between the anterior topography of osteosynthesis and implant failure ( p = 0.02). Conclusions Long-term follow-up after chest wall osteosynthesis using titanium implants is required, especially in anteriorly placed implants. The high rate of implant failure at 1 year advocates for early removal whenever possible and suggests the need for improvements in design.
Objective The aim of this study was to assess the short- and midterm results after endovascular repair of the aortic arch in high-risk patients or after previous aortic surgery. Methods From November ...1998 to November 2008, 57 thoracic stent grafts were implanted in 44 patients (sex ratio, 4.5; mean age, 66.5 ± 16.5 years) for aortic arch repair (zone 0 to 2 according to the arch map proposed by Ishimaru) of 19 degenerative aneurysms, 12 traumatic transections of the aorta, 8 complicated aortic dissections, 4 postcoarctectomy aortic pseudoaneurysms, and 1 penetrating atheromatous ulcer. All patients were considered to be at high surgical risk owing to serious comorbidities (American Society of Anesthesiologists score ≥ III 79.5 %) or previous aortic surgery. Endovascular repair was performed in an emergency setting in 27.3% (n = 12) of the patients. Thirty-four underwent a hybrid technique with supra-aortic debranching and simultaneous or staged endovascular stent grafting. Debranching was performed to provide an adequate proximal aortic landing zone, in 28 patients by a cervical approach and in 6 patients by a sternotomy approach. Results The technical success rates for aortic zone 0 patients (n = 6), zone 1 patients (n = 4), and zone 2 patients (n = 34) were, respectively, 100%, 100%, and 97%. The 30-day mortality rate was 20.4%. The actuarial survival was 70% over a mean follow-up of 29.9 months. The rate of stroke was 6.8%. Two (4.5%) cases of paraplegia were observed, 1 of which was reversible after cerebrospinal fluid drainage. The rate of endoleak was 15.9% (n = 7): 3 type I, 3 type II, and 1 type III. There were no cases of device migration, but 1 stent-graft collapse occurred 20 days after exclusion of an aortic traumatic transection. Conclusion Hybrid endovascular aortic arch reconstructions, although some of these adjunctive procedures remain major operations, provide attractive alternatives for treating aortic arch lesions in high-risk patients who would otherwise be unsuitable for open repair, with acceptable primary results and encouraging midterm efficacy to prevent rupture.
Background The reconstruction of large full-thickness chest wall defects after resection of T3/T4 non-small cell lung carcinomas or primary chest wall tumors presents a technical challenge for ...thoracic surgeons and plays a central role in determining postoperative morbidity. The objective is to evaluate our results in chest wall reconstruction using a combination of expanded polytetrafluoroethylene (ePTFE) mesh and titanium plates. Methods Since 2006, 19 patients underwent reconstruction for wide chest wall defects using a combination of ePTFE mesh and titanium plates. The chest wall reconstruction was achieved by using a layer of 2-mm thickness ePTFE shaped to match the chest wall defect and sewed under maximum tension. The ePTFE is placed close to the lung and fixed onto the bony framework and onto the titanium plate, which is inserted on the ribs. Results Seventeen patients underwent a complete R0 resection with the removal of 3 to 9 ribs (mean, 4.8 ribs), including the sternum in 7 cases. Reconstruction required 1 to 4 horizontal titanium bars (mean, 1.7 bars). In 1 patient, a vertical titanium device was implanted for a large posterolateral defect. There were 2 cases of infection, which required explantation of the osteosynthesis system in 1 patient. One patient had partial skin necrosis that required prompt debridement. One patient had a major complication in the form of respiratory failure. Conclusions Our experience and initial results show that titanium rib osteosynthesis in combination with Dualmesh can easily and safely be used in a one-stage procedure for major chest wall defects.
Background During lobectomy, resection of pulmonary artery, followed by reconstruction or replacement with or without concomitant sleeve bronchial resection, is feasible in selected cases. We report ...morbidity, mortality, and technical issues in pulmonary artery replacement using a cryopreserved arterial allograft after sleeve resection for centrally located non–small cell lung carcinoma (NSCLC). Methods We reviewed clinical and pathologic data of patients who underwent arterial sleeve lobectomy with pulmonary artery replacement in our institution from 2007 to 2012. Results Of 178 centrally located NSCLCs, sleeve resections were performed in 92 (51%), pneumonectomies in 33 (18%), and lobectomies in 53 (31%). Of the 32 (34.7%) pulmonary) reconstructions (excluding tangential suture), 20 (21.7%) were end-to-end anastomosis, 2 (2.1%) were pericardial patch reconstructions, and 10 (11%) were PA replacements. Clinical T staging was cT2a in 4 patients, cT2b in 3, cT3 in 2, and cT4 in 1. Four patients received concurrent induction chemoradiotherapy. Three patients underwent a double-sleeve right lobectomy. Cryopreserved allografts used were descending thoracic aorta (n = 3) and pulmonary arteries (n = 7). Complete resection (R0) was achieved in all patients. Final N staging was pN0 (n = 4), pN1 (n = 5), and pN2 (n = 1). There was no operative mortality. Four patients had major morbidity, including 1 early conduit thrombosis treated by pneumonectomy completion. Graft patency, assessed by contrast-enhanced computed tomography scan, was 90%. Mean follow-up was 25 ± 14 (range, 8-47) months (30% for >36 months). Overall 5-year survival was 66.7%, and the estimated median disease-free survival was 42 months. Conclusions In central NSCLCs, conservative surgery using a cryopreserved arterial allograft to replace the pulmonary artery after extended segmental resection could avoid pneumonectomy in selected patients.
The aim of this study was to evaluate outcomes of left subclavian artery (LSA) revascularization for hybrid aortic arch debranching.
Between 1998 and 2015, 68 patients (41 men; mean age, 67 ± ...16 years) underwent thoracic endovascular aortic repair (TEVAR) with LSA coverage, 19.2% (n = 13) were never revascularized, and the remaining patients underwent LSA revascularization (n = 55; 80.8%). Revascularization was achieved by LSA-carotid transposition via a medial approach in 81.8% (n = 45) and a lateral approach in 18.2% (n = 10). The indication for TEVAR was aneurysmal disease in 30.9% (n = 17), dissection in 29% (n = 16; acute, n = 5), traumatic aortic injury in 21.8% (n = 12), pseudoaneurysm in 10.9% (n = 6), aortobronchial fistula in 5.5% (n = 3), and penetrating atherosclerotic ulcer in 1.9% (n = 1). Elective cases accounted for 52.7% (n = 29). Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter.
LSA revascularization was achieved in all the cases. Thirty-day mortality rate was 12.7%. Thirty-day mortality related to LSA revascularization was 0%. No patient suffered a stroke. Vocal cord paralysis was detected in 7.2% of patients (n = 4). Hematoma requiring surgical drainage was observed in 3.6% of patients (n = 2). Lymph leak requiring revision surgery was observed in 1.8% of patients (n = 1). Phrenic nerve palsy was not observed. The local complication rate was significantly higher (P = 0.03) in patients with LSA transposition via a lateral approach (20%; n = 2) when compared to patients with LSA revascularization via a medial approach (11.1%; n = 5). After a mean follow-up of 31.5 months (range, 2-171 months), the patency of the LSA revascularization was maintained in all patients.
During TEVAR, when LSA coverage is required, LSA revascularization is a durable procedure associated with a low morbidity rate. LSA transposition via a medial approach would appear to be associated with significantly fewer complications.
Objective The study objective was to compare the outcome between open and endovascular repair of acute traumatic rupture of the thoracic aorta. Methods Seventy-five patients (mean age 38.6 ± 10.7 ...years) with an acute traumatic aortic rupture were referred to the Arnaud de Villeneuve Hospital between January 1990 and January 2010. Between January 1990 and December 2000, 35 patients (33 men, mean age 35.8 ± 11.3 years) underwent surgical repair using cardiopulmonary bypass. From January 2001, an endovascular approach was deliberately chosen; 40 patients (30 male, mean age 41 ± 10.1 years) underwent endovascular repair. The 2 groups were statistically comparable. Results The overall mortality rates for the surgical and endovascular groups were 11.4% (intraoperative mortality: 8.5%) and 2.5% (intraoperative mortality: 0%), respectively. The mortality rates related to aortic repair for the surgical and endovascular groups were 11.4% and 0%, respectively. In the surgical group, the morbidity rate was 14.2%: 4 cases of recurrent nerve palsy and 1 case of false anastomotic aneurysm were diagnosed at 52 months. In the endovascular group, the morbidity rate was 20%: 3 cases of intraoperative inadvertent coverage of supra-aortic trunks (requiring a secondary procedure in 2 cases after 1 and 2 years to revascularize the supra-aortic trunks), 1 proximal type I endoleak (requiring deployment of a second stent-graft at day 2), 2 stent-graft collapses in the first postoperative month (treated by open repair and explantation in 1 case and by the deployment of a second stent-graft in 1 case), 1 vertebrobasilar insufficiency after left subclavian artery coverage, and 1 intraoperative iliac rupture (surgically repaired). No cases of paraplegia or stroke were observed. The median follow-up was 7.7 (range, 0.4–15) years. Conclusions Compared with open repair, endovascular repair of traumatic thoracic aortic rupture is associated with a lower death rate but failed to reach statistical significance, most likely because of underpowering. These results prompt us to consider endovascular repair as the first-line therapy for acute traumatic rupture of the thoracic aorta, except in some rare but challenging anatomic situations. New stent-graft designs, sizes, and deployment systems could improve the results of endovascular repair in these indications.
Objective Improved early and late outcomes of thoracic endovascular aortic repair compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. However, rare but serious ...complications due to device failure or adverse events may occur, requiring conversion to open repair. Methods In our experience, 186 patients underwent thoracic endovascular aortic repair. Seven of these patients (3.7%) required open repair because of 3 retrograde type A dissections, 1 thoracic stent-graft collapse, 1 aneurysm enlargement without endoleak, 1 aortoesophageal fistula, and 1 stent-graft infection. All patients but 1 underwent surgical repair using cardiopulmonary bypass. Four stent-grafts were totally removed, and 3 endografts were left in situ. Three patients underwent supracoronary ascending aorta replacement via a sternotomy. Three patients underwent a descending aortic replacement via a left thoracotomy. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass, and stent-graft explantation. Results Thirty-day mortality was 28%. Four patients had an uneventful postoperative course. One patient was treated for postoperative sternitis. Two patients with stent-graft infections died of multiorgan failure in the early postoperative course. No stroke, paraplegia, or renal failure occurred. With a mean follow-up of 21.4 months (range, 2–60 months), 5 patients had no adverse events. Conclusions Complications due to device failure or adverse events may occur after thoracic endovascular aortic repair, requiring conversion to open repair. Our experience suggests that in some clinical or anatomic situations, caution should be recommended when offering endovascular procedures to patients with thoracic aortic diseases. Open conversion can be performed with encouraging results by a team experienced in the management of thoracic aortic diseases. With the increasing use of thoracic endovascular aortic repair, more patients will present with indications of surgical conversion.
Background The management of occult lung lesions, particularly subsolid opacities, is a new challenge because they are difficult to localize during surgery and the number of lesions detected by ...computed tomography (CT) is increasing. Methods Between February 2008 and December 2011, preoperative CT-guided marking with coils was systematically carried out to localize presumed impalpable nodules before video-assisted thoracoscopic surgery (VATS). The procedure feasibility, reliability, and safety as well as its impact on the resection volume and on the pathologic examination strategy were examined. Results This preoperative marking procedure was used for 68 nodules in 60 consecutive patients. The mean procedural time was 25 minutes/patient and complications included minimal asymptomatic pneumothorax (42 cases, 70%) and hemorrhagic suffusion (21 patients, 35%). Patients with non-retrieved coils during VATS required larger resection volumes (94.88 mm3 vs 20.65 mm3 ; p = 0.008). The presence of a coil loop in the pleural space was not statistically associated with higher resected lung volume. Primary pulmonary adenocarcinoma was found in 42 patients (71.2%). Five nodules were associated with atypical adenomatous hyperplasia. Pathologic examination was considered to be improved by the presence of a coil next to the lesion but not within it. Coil placement modified the pathology practices for intraoperative analysis, as tissue sampling in the immediate vicinity of the coil was preferred to systematic sampling. Conclusions Impalpable lung nodules can be safely marked with coils preoperatively to improve their surgical and pathologic management.
Objective To report a new human ex vivo model of type B aortic dissection (TBAD) and to assess if the locations of the primary entry tear determine the patterns of dissection propagation. Methods ...Twenty fresh human aortas were harvested. TBADs were surgically initiated 2 cm below the left subclavian artery at four different locations (lateral, n = 5; medial, n = 5; anterior, n = 5; posterior, n = 5). Aortas were thereafter connected to a bench-top pulsatile flow model to induce antegrade propagation of the dissection. Results Antegrade propagation of the dissection was achieved and reached at least the celiac trunk (CT) in all the cases. Dissection was propagated to the renal aorta in 16 (80%) and infrarenal aorta in seven cases (35%). Left renal artery with or without the CT originated more often from the false channel when primary entry tear was lateral. Right renal artery and the CT most often originated from the false channel when primary entry tear was medial. When the CT was the only one originating from the false channel, primary entry tear was more often anterior, whereas when it originated from the true channel, it was more often posterior. Conclusions This human ex vivo model of TBAD is reproducible, since, in all the aortas, extended dissection was achieved and provides the first model of human aortic dissection with infrarenal aorta extension allowing future assessment of endovascular devices developed for human use. Furthermore, it allows clarification of the patterns of aortic dissection propagation and visceral and renal artery involvement according to the site of the primary entry tear.
Abstract Study objective Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. ...The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly. Design This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 μ g of sufentanyl). Intervention Patients were randomized to group P (100- μ g/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case. Measurements Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute. Main results Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P < .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 0-39 vs 1 0-10, median extremes, P < .01), but the number of hypotensive patients was similar between groups (19 73% vs 20 71%, P = 1). The time to onset of the first hypotension was shorter in group C (3 1-13 vs 15 1-95 minutes, P = .004). The proportion of patients without hypotension (cumulative survival) was better in group P ( P = .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups ( P = not significant). Conclusion Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.
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