Treatment of aorto-iliac occlusive lesions by aortic robotic surgery: learning curve and midterm outcome

OBJECTIVES

To evaluate learning curve and midterm results of aorto-iliac occlusive disease (AIOD) revascularization by robot-assisted laparoscopic (RAL) surgery.

DESIGN

A prospective single-center study was conducted.

MATERIALS AND METHODS

Patients with AIOD in the vascular surgery department of Georges Pompidou European Hospital (Paris, France) treated by RAL from February 2014 to February 2019 were included. Demographic characteristics, past medical history, TASC (Trans-Atlantic Inter-Society Consensus) lesions classifications, mortality, primary and secondary patency, as well as complication rates were collected. Safety was analyzed by CUSUM method with a conversion rate of 10%, operative time by cumulative average-time model and primary and secondary patency by Kaplan-Meier method.

RESULTS

Seventy patients were included, 18 (25.7%) with TASC C lesions and 52 (74.3%) with TASC D lesions. Before discharge 14 (24.3%) patients had surgical complications. Among them, 10 (14.3%) required at least one reintervention. One (1.4%) patient died during the hospitalization. The learning curve in terms of safety (conversion rate) was 13 cases with an operating time of 220 minutes after 35 patients. During follow-up (median 37 months [21; 49]), 63 patients (91.3%) improved their symptoms, 53 (76.8%) became asymptomatic and 3 graft limb occlusions occurred. The primary patency at 12, 24, 36 and 48 months was 94%, 92%, 92% and 92% respectively, while the secondary patency for the same intervals was 100%, 98.1%, 98.1% and 98.1% respectively.

CONCLUSION

Robotic surgery in AIOD revascularization seems safe and effective; allowing to treat patients with few comorbidities and severe lesions, in a dedicated center experienced in RAL, with excellent patency. Prospective clinical trials should be performed to confirm safety.

Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit

Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.

Improving clinical suspicion of acute mesenteric ischemia among patients with acute abdomen: a cross-sectional study from an intestinal stroke center

BACKGROUND

Early diagnosis of acute mesenteric ischemia (AMI) is essential for a favorable outcome. Selection of patients requiring a dedicated multiphasic computed tomography (CT) scan remains a clinical challenge.

METHODS

In this cross-sectional diagnostic study conducted from 2016 to 2018, we compared the presentation of AMI patients admitted to an intestinal stroke center to patients with acute abdominal pain of another origin admitted to the emergency room (controls).

RESULTS

We included 137 patients-52 with AMI and 85 controls. Patients with AMI [median age: 65 years (interquartile range 55-74)] had arterial and venous AMI in 65% and 35% of cases, respectively. Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations. On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7-60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2-16, p = 0.002). Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% in controls (p < 0.001). The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77-0.91), depending on the number of factors.

CONCLUSIONS

Sudden onset and the need for morphine are suggestive of AMI in patients with acute abdominal pain and should prompt multiphasic CT scan including arterial and venous phase images for confirmation.

Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification

OBJECTIVE

The aim of this study was to propose computed tomography angiography (CTA) based anatomical segmentation of the superior mesenteric artery (SMA), in order to standardise the reporting of occlusive lesions in acute mesenteric ischaemia (AMI).

METHODS

A retrospective CTA evaluation of patients with occlusive AMI admitted between 2016 and 2021. After the screening of 468 patients, 95 were included. The SMA was segmented into proximal (S1, ostium to the inferior pancreaticoduodenal artery), middle (S2, from the inferior pancreaticoduodenal to the ileocolic artery), and distal (S3, downstream the ileocolic artery) sections. The jejunal arteries were labelled J1 to J6, and the middle, right, and ileocolic arteries C1, C2, and C3. Two radiologists independently applied the proposed segmentation to a cohort of patients with occlusive AMI to describe occlusive lesions. Intra- and inter-rater agreement was assessed with kappa statistics.

RESULTS

Occlusions involved one segment in 50 (53%) patients (S1, n = 27 [28%]; S2, n = 12 [13%]; S3, n = 11 [12%]); two segments in 37 (39%) patients (S2/S3, n = 31 [33%]; S1/S2, n = 3 [3%]; S1/S3, n = 3 [3%]); and all three segments in eight patients (S1/S2/S3, 8%). The median number of jejunal arteries was four (interquartile range 3, 4.5). C1 and C2 were present in 93 (98%) and 23 patients (24%), respectively. Almost perfect intra-rater agreement was obtained for S1 (91% agreement, κ = 0.82, 95% confidence interval [CI] 0.72 - 0.92); substantial agreement was obtained for S2 (90% agreement, κ = 0.80, 95% CI 0.68 - 0.92) and S3 (86% agreement, κ = 0.72, 95% CI 0.58 - 0.86). Almost perfect inter-rater agreement (with the second junior reading) was obtained for S1 (97% agreement, κ = 0.95, 95% CI 0.89 - 1.0), S2 (91% agreement, κ = 0.82, 95% CI 0.72 - 0.92), and S3 (agreement 96%, κ = 0.91, 95% CI 0.83 - 0.99).

CONCLUSION

A standardised CTA based anatomical segmental description of SMA occlusive lesions in AMI is proposed; it provided substantial to almost perfect intra- and inter-rater agreement for most anatomical segments.

Impact of Culture-Positive Preservation Fluid on Early Morbidity and Mortality After Lung Transplantation

The prevalence, risk factors and outcomes associated with culture-positive preservation fluid (PF) after lung transplantation (LT) are unknown. From January 2015 to December 2020, the microbiologic analyses of PF used to store the cold ischaemia-placed lung graft(s) of 271 lung transplant patients were retrospectively studied. Culture-positive PF was defined as the growth of any microorganism. Eighty-three (30.6%) patients were transplanted with lung grafts stored in a culture-positive PF. One-third of culture-positive PF were polymicrobial. Staphylococcus aureus and Escherichia coli were the most frequently isolated microorganisms. No risk factors for culture-positive PF based on donor characteristics were identified. Forty (40/83; 48.2%) patients had postoperative pneumonia on Day 0 and 2 (2/83; 2.4%) patients had pleural empyema with at least one identical bacteria isolated in culture-positive PF. The 30-day survival rate was lower for patients with culture-positive PF compared with patients with culture-negative PF (85.5% vs. 94.7%, p = 0.01). Culture-positive PF has a high prevalence and may decrease lung transplant recipient survival. Further studies are required to confirm these results and improve understanding of the pathogenesis of culture-positive PF and their management.

Reperfusion injury on computed tomography following endovascular revascularization of acute mesenteric ischemia: prevalence, risk factors, and patient outcome

BACKGROUND

Data about reperfusion injury (RI) following acute arterial mesenteric ischemia (AAMI) in humans are scarce. We aimed to assess the prevalence and risk factors of RI following endovascular revascularization of AMI and evaluate its impact on patient outcomes.

METHODS

Patients with AAMI who underwent endovascular revascularization (2016-2021) were included in this retrospective cohort. CT performed < 7 days after treatment was reviewed to identify features of RI (bowel wall hypoattenuation, mucosal hyperenhancement). Clinical, laboratory, imaging, and treatments were compared between RI and non-RI patients to identify factors associated with RI. Resection rate and survival were also compared.

RESULTS

Fifty patients (23 men, median 72-yrs [IQR 60-77]) were included, and 22 were diagnosed with RI (44%) after a median 28 h (22-48). Bowel wall hypoattenuation and mucosal hyperenhancement were found in 95% and 91% of patients with post-interventional RI, respectively. Patients with RI had a greater increase of CRP levels after endovascular treatment (p = 0.01). On multivariate analysis, a decreased bowel wall enhancement on baseline CT (HR = 8.2), an embolic cause (HR = 7.4), complete SMA occlusion (HR = 7.0), and higher serum lactate levels (HR = 1.4) were associated with RI. The three-month survival rate was 78%, with no difference between subgroups (p = 0.99). However, the resection rate was higher in patients with RI (32% versus 7%; p = 0.03).

CONCLUSION

RI is frequent after endovascular revascularization of AAMI, especially in patients who present with decreased bowel wall enhancement on pre-treatment CT, an embolic cause, and a complete occlusion of the SMA. However, its occurrence does not seem to negatively impact short-term survival.

Case–Control Study of 3D Morphology in Isolated Mesenteric Artery Dissection

INTRODUCTION

Isolated mesenteric artery dissection (IMAD) is uncommon and has not been investigated in detail. This study aimed to accurately identify the morphological differences of IMAD patients with control individuals using a detailed 3D volumetric analysis.

METHODS

In this retrospective case-control study, cases were patients with acute symptomatic IMAD treated in a French intestinal stroke center between January 2016 and November 2019. Case-control matching was (1:3) by age, gender, and body mass index (BMI). The semi-automatic morphological analysis of the mesenteric artery included volumetric measurements of the true and false lumen size, the centerline curvature and the 3D aortomesenteric angles.

RESULTS

Seventeen IMAD cases (mean age 56 ± 4 years, 94% men) were matched with 51 controls. The mean overall lumen (OL) volume was higher in IMAD patients as compared to controls (+ 64%, p < 0.001). In the same way, the mean OL cross-sectional area and diameters were higher in IMAD patients: + 77% for OL area (< 0.001) and + 34% for OL diameters (< 0.001). Meanwhile, no significant difference was found in terms of true lumen (TL) volume (p = 0.16) or cross-sectional area (p = 0.30) between IMAD patients and controls, whereas the mean TL diameter was lower in the IMAD group (p < 0.05). Patients with acute mesenteric ischemia had a lower [TL/OL volume] ratio (45% vs. 59%, p < 0.05) and longer dissections (63 mm vs. 48 mm, p < 0.01). The 3D aortomesenteric angle was significantly higher in IMAD patients at both 2 cm (p < 0.01) and 4 cm (p < 0.05) from the ostium.

CONCLUSION

Using an original 3D semi-automated analysis, this study shows that IMAD induces significant morphological changes compared to control individuals: a larger aortomesenteric 3D angle, an increased overall volume and area. IMAD patients with acute mesenteric ischemia presented with a more severe morphological profile.

Acute Isolated Mesenteric Artery Dissection: Four Year Experience From a French Intestinal Stroke Centre

OBJECTIVE

This study aimed to report outcomes of patients with symptomatic acute isolated mesenteric artery dissection (IMAD) treated within a French intestinal stroke centre (ISC).

METHODS

All patients with symptomatic IMAD referred to the ISC from January 2016 to January 2020 were included prospectively. Patients with aortic dissection and asymptomatic IMAD were not included. The standardised medical protocol included anticoagulation and antiplatelet therapy, gastrointestinal resting, and oral antibiotics. Operations were considered for acute mesenteric ischaemia (AMI).

RESULTS

Among the 453 patients admitted to an ISC during the study period, 34 (median age, 53 years [41 - 67]; 82% men) with acute symptomatic IMAD were included. According to the classification of Yun et al., IMADs were reported as follows: type I (n = 7, 20%), type IIa (n = 6, 18%), type IIb (n = 15, 44%), and type III (i.e., complete superior mesenteric artery [SMA] occlusion; n = 6, 18%). Overall, nine (26%) patients had AMI (type I/II, n = 3; type III, n = 6). On initial computerised tomography angiogram, nine (26%) patients had an associated visceral arterial dissection or pseudoaneurysm. All patients with types I/II (n = 28, 82%) followed a favourable clinical course with conservative therapy, with no need for any operation. All patients with type III (n = 6, 18%) underwent urgent laparotomy with SMA revascularisation (open, n = 4; stenting, n = 1) and or bowel resection (early, n = 3; late, n = 1). Rates of intestinal resection and short bowel syndrome were 12% and 8.8%, respectively. After a median follow up of 26 months [18 - 42], recurrence of symptoms occurred in four (12%) patients and aneurysmal change in 14 (41%), with no re-intervention.

CONCLUSION

Although IMAD was associated with a high frequency of AMI, a standardised protocol produced a low rate of intestinal resection. Conservative therapy seems appropriate in types I/II patients, whereas urgent SMA revascularisation should aim to avoid intestinal resection or death in type III patients.

Endovascular revascularization of acute arterial mesenteric ischemia: report of a 3-year experience from an intestinal stroke center unit

OBJECTIVE

To report the 3-year experience of endovascular revascularization of acute arterial mesenteric ischemia (AMI) from an intestinal stroke center unit (ISCU).

METHOD

All data from patients admitted to the ISCU between January 2016 and January 2019 for arterial AMI who underwent endovascular recanalization were prospectively acquired and retrospectively analyzed. Patient demographics, clinical and laboratory characteristics at presentation, and CT scans were reviewed. The type (thrombolysis, thrombectomy, stenting) and the outcome of endovascular procedures (technical success or failure, complications) were noted. Care pathways were described focusing on post-procedural treatments (surgical revascularization, bowel resection) and the mortality rate was evaluated in subgroups.

RESULTS

Fifty-eight patients (34 men [59%], mean 69 ± 29 years) were included. Endovascular revascularization was technically successful in 51/58 (88%) patients, and 10 (17%) patients had post-procedural complications. Stenting and in situ thrombolysis were performed in most patients (n = 33 and n = 19, respectively). Thirty-two patients (55%) were recurrence-free and required no further treatment after the procedure, while 9 (16%), 5 (9%), and 5 (9%) patients underwent 2nd-line bowel resection, surgical revascularization, or both. Overall, 46 (79%), 45 (78%), and 34 patients (63%) were alive at 3 months, 1 year, and 3 years. No significant difference in survival was found in care pathways or baseline characteristics.

CONCLUSION

Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. Results of endovascular revascularization shall only be interpreted as part of a multidisciplinary patient management strategy.

KEY POINTS

• Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. • Several techniques are available to perform endovascular revascularization, and their use depends on the cause, the location, and the quality of underlying arteries of patients. • Results of endovascular revascularization shall only be interpreted in relation to its role in an integrated multidisciplinary and patient management strategy.

[Management of abdominal aortic aneurysms]

MANAGEMENT OF ABDOMINAL AORTIC ANEURYSMS The abdominal aortic aneurysm is a permanent dilation of the aorta with a diameter of more than 30 mm. It can be strictly infra-renal or be located opposite the origin of the digestive and renal arteries (complex aneurysm). Most often fortuitous, the diagnosis must seek a secondary location of the aneurysmal disease (thoracic aorta, popliteal artery) as well as other manifestations of atheromatous disease. The natural course of the aneurysm is rupture, the severity of which is such that preventive and elective surgical treatment is warranted when the aneurysm reaches 55 mm or if it grows rapidly. Regular monitoring of the diameter by Doppler ultrasound is necessary when the diameter is less than 45 mm; beyond this threshold, a CT angiogram and a specialist consultation in vascular surgery are necessary. Flattening - graft and stent exclusion are the two possible surgical options; the anatomy of the aneurysm and the patient's comorbidities determine the choice of surgical technique.

[Mesenteric arterial ischemia: from diagnosis to decision]

FROM DIAGNOSIS TO MULTIDISCIPLINARY TREATMENT IN INTESTINAL STOKE UNIT Acute mesenteric ischemia (AMI) is a severe vascular and intestinal emergency, most commonly related to the occlusion (mesenteric occlusive disease or emboli) of the superior mesenteric artery (SMA). Such as myocardial infarction or stroke, SMA occlusion is responsible of an intestinal infarction. In case of an early revascularization of the SMA, AMI can be reversible with no need for bowel resection. However, when left untreated, AMI fatally leads to irreversible intestinal necrosis and death following multiple organ failure. Considering its poor prognosis, AMI might be systematically suspected in case of a sudden, unusual and intense abdominal pain. Because AMI has a nonspecific clinical presentation, delayed diagnosis are frequent and unfortunately associated with poor outcomes. Therefore, general and emergency doctors, along with gastroenterologists, have a key role to play in the recognition of early AMI. In any case of clinically suspected AMI, an abdominal computed tomography angiogram might be urgently performed. Chronic mesenteric ischemia can also be revealed by postprandial abdominal pain associated with food fear and weight loss. In recent years, there has been a major improvement in the treatment of AMI following the creation of a French intestinal stroke center, gathering the expertise of specialized gastroentorologists, vascular and digestive surgeons, radiologists and intensivists. A multimodal and multidisciplinary approach combining the use of a systematic medical protocol, early revascularization of viable bowel and resection of non viable bowel when needed, has dramatically improved the prognosis of AMI, with current survival rates of 80 % and bowel resection being avoided in nearly two thirds of patients.

Retrograde Open Mesenteric Stenting for Acute and Chronic Mesenteric Ischaemia: Results from an Intestinal Stroke Centre

OBJECTIVE

To report the intra-operative adverse events (IOAEs) and the initial and one year outcomes of retrograde open mesenteric stenting (ROMS) using balloon expandable covered stents for acute and chronic mesenteric ischaemia.

METHODS

Clinical data and outcomes of all consecutive patients treated with ROMS for acute and chronic mesenteric ischaemia at an intestinal stroke centre between November 2012 and September 2019 were reviewed. ROMS was performed using balloon expandable covered stents. Endpoints included IOAEs, in hospital mortality, post-operative complications, and re-interventions. One year overall survival, freedom from re-intervention, primary patency and assisted primary patency rates were analysed using the Kaplan-Meier time to event method.

RESULTS

During the study period, 379 patients were referred to the centre for acute or chronic mesenteric ischaemia. Thirty-seven patients who underwent the ROMS procedure were included. All the patients had severe atherosclerotic mesenteric lesions. The ROMS technical success rate was 89% in this cohort. The rate of IOAEs was 19% and included four cases of retrograde recanalisation failure. All ROMS failures occurred in patients presenting with flush superior mesenteric artery occlusion and they were treated by mesenteric bypass. Ten patients (27%) underwent bowel resection, four of which resulted in a short bowel syndrome (11%). The in hospital mortality rate was 27%. Post-operative complications and re-intervention rates were 67% (n = 25) and 32% (n = 12), respectively. The median follow up was 20.2 months (interquartile range 29). The estimated one year overall survival for the cohort was 70.1% (95% confidence interval [CI] 52.5% - 82.2%). The estimated freedom from re-intervention at one year was 61.1% (95% CI 42.3 - 75.4). The one year primary patency and assisted primary patency rates were 84.54% (95% CI 63.34 - 94) and 92.4% (95% CI 72.8 - 98), respectively.

CONCLUSION

ROMS procedures offer acceptable one year outcomes for mesenteric ischaemia but are associated with frequent stent related complications. Precise pre-operative planning, high quality imaging, and meticulous stent placement techniques may limit the occurrence of such events.

D-dimer at hospital admission for COVID-19 are associated with in-hospital mortality, independent of venous thromboembolism: Insights from a French multicenter cohort study

Background

Coronavirus disease 2019 (COVID-19) has been associated with coagulation disorders, in particular high concentrations of D-dimer, and increased frequency of venous thromboembolism.

Aim

To explore the association between D-dimer at admission and in-hospital mortality in patients hospitalised for COVID-19, with or without symptomatic venous thromboembolism.

Methods

From 26 February to 20 April 2020, D-dimer concentration at admission and outcomes (in-hospital mortality and venous thromboembolism) of patients hospitalised for COVID-19 in medical wards were retrospectively analysed in a multicenter study in 24 French hospitals.

Results

Among 2878 patients enrolled in the study, 1154 (40.1%) patients had D-dimer measurement at admission. Receiver operating characteristic curve analysis identified a D-dimer concentration > 1128 ng/mL as the best cut-off value for in-hospital mortality (area under the curve 64.9%, 95% confidence interval [CI] 60–69), with a sensitivity of 71.1% (95% CI 62–78) and a specificity of 55.6% (95% CI 52–58), which did not differ in the subgroup of patients with venous thromboembolism during hospitalisation. Among 545 (47.2%) patients with D-dimer concentration > 1128 ng/mL at admission, 86 (15.8%) deaths occurred during hospitalisation. After adjustment, in Cox proportional hazards and logistic regression models, D-dimer concentration > 1128 ng/mL at admission was also associated with a worse prognosis, with an odds ratio of 3.07 (95% CI 2.05–4.69; P < 0.001) and an adjusted hazard ratio of 2.11 (95% CI 1.31–3.4; P < 0.01).

Conclusions

D-dimer concentration > 1128 ng/mL is a relevant predictive factor for in-hospital mortality in patients hospitalised for COVID-19 in a medical ward, regardless of the occurrence of venous thromboembolism during hospitalisation.

Midterm results after covered stenting of the superior mesenteric artery

OBJECTIVE

Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery.

METHODS

Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency.

RESULTS

During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively.

CONCLUSIONS

Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.

Anticoagulation Before Hospitalization Is a Potential Protective Factor for COVID-19: Insight From a French Multicenter Cohort Study

Background

Coronavirus disease 2019 (COVID‐19) is a respiratory disease associated with thrombotic outcomes with coagulation and endothelial disorders. Based on that, several anticoagulation guidelines have been proposed. We aimed to determine whether anticoagulation therapy modifies the risk of developing severe COVID‐19.

Methods and Results

Patients with COVID‐19 initially admitted in medical wards of 24 French hospitals were included prospectively from February 26 to April 20, 2020. We used a Poisson regression model, Cox proportional hazard model, and matched propensity score to assess the effect of anticoagulation on outcomes (intensive care unit admission or in‐hospital mortality). The study enrolled 2878 patients with COVID‐19, among whom 382 (13.2%) were treated with oral anticoagulation therapy before hospitalization. After adjustment, anticoagulation therapy before hospitalization was associated with a better prognosis with an adjusted hazard ratio of 0.70 (95% CI, 0.55–0.88). Analyses performed using propensity score matching confirmed that anticoagulation therapy before hospitalization was associated with a better prognosis, with an adjusted hazard ratio of 0.43 (95% CI, 0.29–0.63) for intensive care unit admission and adjusted hazard ratio of 0.76 (95% CI, 0.61–0.98) for composite criteria intensive care unit admission or death. In contrast, therapeutic or prophylactic low‐ or high‐dose anticoagulation started during hospitalization were not associated with any of the outcomes.

Conclusions

Anticoagulation therapy used before hospitalization in medical wards was associated with a better prognosis in contrast with anticoagulation initiated during hospitalization. Anticoagulation therapy introduced in early disease could better prevent COVID‐19–associated coagulopathy and endotheliopathy, and lead to a better prognosis.

Covered Stents as a First-Line Treatment for Vascular Access Complications During Transfemoral Transcatheter Aortic Valve Implantation: Eight-Year Experience From a Single Center

We report 8-year experience with vascular access complications (VACs) after percutaneous transfemoral transcatheter aortic valve implantation (TAVI). From January 2010 to January 2018, patients with iliofemoral VAC treated by an intervention following percutaneous transfemoral TAVI were included. Major VAC was defined according to the Valve Academic Research Consortium 2 classification. As first-line strategy, VACs were treated using covered nitinol stents (CS). Among 795 percutaneous transfemoral TAVI, 74 (9.3%) patients (female, 57%; 82 ± 8 years) with VAC treated by CS and/or open repair were included in this study: 59 CS cases and 15 open repair cases. Two CS patients were converted to open repair. Technical success for stent implantation was 97%. The main VAC was a persistent bleeding related to percutaneous closure device failure (72%). Thirty-day mortality in the study cohort was 5.4% (4/74), including 1 VAC-related death. One patient had postoperative lower limb ischemia successfully treated by open repair. No amputation, new-onset claudication or in-stent occlusion was recorded. Endovascular intervention using self-expandable nitinol covered stent is safe and effective as a first-line strategy for the treatment of VAC in percutaneous transfemoral TAVI. However, open repair is needed in case of unfeasibility or failure of endovascular therapy.

Using the OUTBACK Catheter to Overcome Aortic Reentry Issues in Retrograde Open Mesenteric Stenting

BACKGROUND

The purpose of this study was to describe the use of the OUTBACK catheter to overcome aortic reentry issues in acute mesenteric ischemia (AMI) treated by retrograde open mesenteric stenting (ROMS).

TECHNIQUE

The technique is demonstrated in two female patients presenting with late AMI related to flush occlusion of the superior mesenteric artery (SMA). In such cases of thrombotic AMI with clear preoperative evidence of intestinal necrosis, ROMS is the first-line revascularization technique in our intestinal stroke center. Following an open approach of the SMA through laparotomy, the SMA was punctured in a retrograde fashion. Retrograde mesenteric subintimal recanalization was initiated. In case of aortic reentry issue, the OUTBACK Elite (Cordis, Hialeah, Fl) catheter was advanced through the occlusion over a 0.014 guidewire. The aortic reentry was created by puncture of the aortic wall with the OUTBACK needle, positioned in the desired position. After low-profile balloon angioplasty of the reentry site and 0.035 guidewire exchange, ROMS was performed using balloon-expandable covered stent.

CONCLUSIONS

The OUTBACK catheter appears to be a safe and effective tool to overcome aortic reentry issues in ROMS. This technical tip might therefore increase the technical success rate of challenging ROMS and decrease the need for bailout bypass in the septic context of AMI.

Arterial vascularization of the right colon with implications for surgery

PURPOSE

During right-sided colectomies, surgeons encounter major anatomical variations at the level of the right colon, leading to morbidity. Due to the confusion surrounding the colonic arterial vessels emerging from the superior mesenteric artery (SMA) to vascularize the right part of the colon, this review aimed to describe the arterial vessels found in the mesocolic structures of the ascending colon, the hepatic flexure and the right transverse colon.

METHODS

A review of the literature was performed using the MEDLINE database. Only human studies were included. All dissection, angiographic, arterial cast and corrosion studies were analyzed.

RESULTS

This review demonstrates that the right colon, the hepatic flexure and the right transverse colon are vascularized by three significant arteries emerging from the SMA and forming one peripheral paracolic arc: (1) the ileocolic artery (ICA), the most constant vessel (99.8%) with low variability; (2) the right colic artery (RCA), the most inconstant vessel (2/3 of cases) with high variability in its origin; and (3) the middle colic artery (MCA), a constant vessel (95%) with variation in its origin and its number. The marginal artery is almost constant (100%) and represents the only peripheral arterial arc at the level of the right side of the colon.

CONCLUSIONS

Three arteries emerging from the superior mesenteric artery exist: the ICA, the RCA and the MCA. The ICA and the MCA are the most constant. Knowledge of this vascular anatomy is essential for performing right-sided colectomies.

False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up

OBJECTIVE

Failure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections.

METHODS

Between June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs.

RESULTS

The technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001).

CONCLUSIONS

Embolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.

False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up

OBJECTIVE

Failure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections.

METHODS

Between June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs.

RESULTS

The technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001).

CONCLUSIONS

Embolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.