Objective This study assessed predictive factors for reintervention after thoracic endovascular aortic repair (TEVAR) for complicated aortic dissection (C-AD). Methods An institutional review of ...consecutive TEVAR for C-AD was performed. Results Between 2000 and 2011, 41 patients underwent TEVAR for a C-AD involving the descending thoracic aorta. Primary indications included aneurysm >55 mm in 24, rapid aneurysmal enlargement or impending rupture in 6, saccular aneurysm >20 mm in 1, malperfusion in 1, intractable chest pain in 3, and rupture in 6. Technical success was achieved in 100%. The 30-day mortality rate was 5% (n = 2). Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing ≥20% (odds ratio OR, 16; P = .011), bare-spring stent in the proximal landing zone of the stent graft (OR, 12; P = .032), and anticoagulant therapy (OR, 78; P = .03) were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention ( P = .002), whereas complete false lumen thrombosis at the stent graft level was protective ( P < .05). Conclusions This study confirms the feasibility of TEVAR for C-AD, although the rate of reintervention is high. Excessive oversizing, a bare-spring stent graft in the proximal landing zone, large aortic dilatation, and anticoagulant therapy were factors associated with reintervention. Complete false lumen thrombosis at the stent graft level was protective.
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.
OBJECTIVES
The reconstruction of large full thickness chest wall defect after resection of T3/T4 non-small cell lung cancer (NSCLC) or primary chest wall tumours presents a technical challenge for ...thoracic surgeons and is a critical factor in determining post-operative outcome. When the defect is large, complications are common with a 27% mean rate of respiratory morbidity.
METHODS
Since 2006, 31 patients underwent reconstruction for wide chest wall defects using titanium implants and strong mesh. The reconstruction was achieved using a layer of polytetrafluoroethylene or a XCM biologic tissue mesh shaped to match the defect and sutured under maximum tension to re-establish the skeletal continuity. The mesh was placed close to the lung and was fixed onto the bony framework and onto the titanium plate. In one case, we used XCM biologic tissue because of a large infected T3 NSCLC. A horizontal titanium rib osteosynthesis system was used to reestablish the rigidity of the thoracic wall by bridging the defect except for one case in which we use a vertical rib osteosynthesis system.
RESULTS
Twenty-six patients underwent a complete R0 resection with the removal of a mean of 4.67 ± 1.5 3-9 ribs, including the sternum in 14 cases. The mean defect area was 198 ± 91.2 95-400 cm². Reconstruction required a mean of 2.06 ± 1.1 1-4 titanium plates. There were two cases of deep wound infection that required surgical removal of the osteosynthesis system in one patient. Only one patient developed a major complication in the form of respiratory failure. There were two postoperative deaths neither of which was directly related to the surgical procedure.
CONCLUSIONS
Our experience and initial results show that titanium rib osteosynthesis in combination with strong biologic or synthetic mesh can easily and safely be used in a one-stage procedure for the reconstruction of major chest wall defects.
OBJECTIVES
Evaluation of the feasibility, safety and oncological validity of video-assisted thoracic lobectomy (VATS). The VATS study exclusion criteria included T3 or T4 tumours, central hilar ...tumours, tumours visible on bronchoscopy requiring sleeve resection, hilar lymphadenopathy, N2 disease, history of neoadjuvant chemotherapy or radiation, previous thoracic surgery or pleurodesis.
METHODS
A retrospective study of 410 patients (143 women, mean age 61.5 ± 13.1 years (84-15) treated by VATS lobectomy between 1996 and 2011 was performed at our institution. VATS lobectomy was performed for lung cancer (n = 364, 88.9%), pulmonary metastasis (n = 25, 5.8%) and non-neoplastic diseases (n = 21, 5.1%). In lung cancer, a systematic radical lymph node dissection was performed.
RESULTS
There was no intraoperative death. The conversion rate was 6.1% (n = 25): bleeding (n = 4), extended pleural adhesion (n = 6, 1.4%), technical difficulty (n = 6, 1.4%), tumour extension to the fissure or mediastinum or adenopathy (n = 7, 1.7%) and intolerance to one-lung ventilation (n = 2, 0.4%). The postoperative mortality rate was 1.2% (n = 5). Major complications occurred in 21 patients (5.1%). The mean number of mediastinal nodes removed was 14.6 (5-44) and 42 patients (10.2%) presented N2 disease at the definitive staging. The mean operating time was 152 (85-315) min. The mean drainage duration was 3.2 days (1-15). Mean postoperative length of hospital stay before return at home was 6.8 days (3-75) and 5.5 days in patients without major complications. There was no port site recurrence. Kaplan-Meier 3-year survival rates were 76.5% for Stage I and 87.3% for Stage IA, 58% for Stage II and 61% for Stage III.
CONCLUSIONS
VATS lobectomy is an acceptable alternative and seems equivalent to open lobectomy in terms of complications and oncological value. Our experience prompts us to consider VATS lobectomy for early stage NSCLC as the first surgical approach in view of the improvement in outcome, provided that the procedure is performed by a surgeon with adequate experience with this approach.
IntroductionIn the last decade, video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) has had a major effect on thoracic surgery. Retrospective series have ...reported benefits of VATS when compared with open thoracotomy in terms of postoperative pain, postoperative complications and length of hospital stay. However, no large randomised control trial has been conducted to assess the reality of the potential benefits of VATS lobectomy or its medicoeconomic impact.Methods and analysisThe French National Institute of Health funded Lungsco01 to determine whether VATS for lobectomy is superior to open thoracotomy for the treatment of NSCLC in terms of economic cost to society. This trial will also include an analysis of postoperative outcomes, the length of hospital stay, the quality of life, long-term survival and locoregional recurrence. The study design is a two-arm parallel randomised controlled trial comparing VATS lobectomy with lobectomy using thoracotomy for the treatment of NSCLC. Patients will be eligible if they have proven or suspected lung cancer which could be treated by lobectomy. Patients will be randomised via an independent service. All patients will be monitored according to standard thoracic surgical practices. All patients will be evaluated at day 1, day 30, month 3, month 6, month 12 and then every year for 2 years thereafter. The recruitment target is 600 patients.Ethics and disseminationThe protocol has been approved by the French National Research Ethics Committee (CPP Est I: 09/06/2015) and the French Medicines Agency (09/06/2015). Results will be presented at national and international meetings and conferences and published in peer-reviewed journals.Trial registration numberNCT02502318.
Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing ...for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported.
This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival.
Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively.
Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.
Hybrid aortic arch repair for dissecting aneurysm Faure, Elsa Madeleine, MD; Canaud, Ludovic, MD, PhD; Marty-Ané, Charles, MD, PhD ...
The Journal of thoracic and cardiovascular surgery,
07/2016, Volume:
152, Issue:
1
Journal Article
Peer reviewed
Open access
Abstract Objective This study analyzed the outcome of a combined endovascular and debranching procedure for hybrid aortic arch repair in patients with chronic dissecting aortic aneurysms involving ...the aortic arch. Methods We reviewed all consecutive patients who underwent hybrid aortic arch repair for dissecting aneurysm at the Arnaud de Villeneuve Hospital. Results A total of 33 consecutive patients between March 2005 and September 2015 were included. Patients' mean age was 65.1 ± 12.2 years. Mean aneurysm diameter was 60.3 ± 14.2 mm. Patients were treated for aneurysm diameter 55 mm or greater (n = 28), aortic growth more than 1 cm/year (n = 3), or rupture (n = 2). Eleven complete supra-aortic debranchings were performed in zone 0, with 2 concomitant replacements of the ascending aorta. Partial aortic arch debranching was performed in 22 patients (zone 1 = 8; zone 2 = 14). Technical success was achieved in 97% of patients. There was no in-hospital death. One patient died of decompensated cirrhosis on day 20, resulting in a 30-day mortality of 3%. One patient had major cerebrovascular complications (3%). Spinal cord ischemia was observed in 1 patient (3%), with complete recovery after spinal fluid drainage. Retrograde dissection occurred in 1 patient (3%). After a mean follow-up of 24.3 months (range, 0.6-104.8 months), the overall mortality was 12% (n = 4) with 3 additional deaths. Endoleak was reported in 6 patients (18%), of whom 2 required reintervention. Overall, 8 reinterventions were performed (24%), with a mean time from intervention of 8.7 months (range, 1.2-24.6 months). Conclusions Hybrid aortic arch repair for dissecting aneurysm is associated with acceptable early and midterm major morbidity and mortality, even for patients treated in zone 0. However, given the high rate of reintervention and endoleak, close follow-up is required.
Our objective was to assess potential contributing factors to implant failure (displacement or rupture) after titanium chest wall osteosynthesis.
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.
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).
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 Thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the descending thoracic aorta seems, in the short term, to be associated with better outcomes than open repair, but ...long-term data are lacking. Methods A review was conducted of a prospectively maintained database of patients who underwent TEVAR for traumatic rupture of the descending thoracic aorta in our unit, with a minimum 10-year follow-up. Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter. Particular attention was focused on device-related issues. Results Among the 53 patients, 17 had a minimum 10-year follow-up: mean age was 45.8 ± 17 years (range: 18-78 years); 4 were women. Mean follow-up was 11.6 years (range: 10.1-13.1 years). Technical success was achieved in 100% of cases. The distribution of the proximal landing zone was zone 2 in 4 cases, zone 3 in 13 cases. A case of inadvertent coverage of supra-aortic trunks occurred intraoperatively. An early proximal type I endoleak was successfully treated by proximal implantation of an additional second stent-graft. No perioperative death was observed, and none of the patients suffered transient or permanent paraplegia, or cerebral complication. After a minimum 10-year follow-up, all patients were still alive. Follow-up computed tomography scans did not reveal any stent-graft migration or collapse, or secondary endoleaks. However, we observed that the proximal and distal aortic neck dilated to some extent, as is the natural history of the thoracic aorta. This dilation was more marked in patients aged <30 years. Conclusions Our minimum 10-year follow-up study of endovascular repair for acute traumatic transection of the thoracic aorta demonstrated that the reduction in the operative mortality rate of TEVAR, compared with open repair, lasts over time, without any device-related issues. Longer-term follow-up is necessary to determine whether the thoracic aorta expansion continues and becomes clinically significant.
PDF
