LISTA LUCRARILOR PUBLICATE :
1. Lucian Stoica MD, PhD, Sidney Chocron MD, PhD, Pierre-Emmanuel Falcoz MD, Djamel Kaili MD, Joseph-Philipe Etievent MD - How to tailor a “π” graft for complex myocardial revascularization - a variant of the mammary loop technique - Annals of Thoracic Surgery, 2005;79:1068-9.
2. Lucian Stoica, Sidney Chocron, Pierre-Emmanuel Falcoz, Djamel Kaili, Joseph-Philippe Etievent; La technique de la "boucle mammaire" et ses applications dans les revascularisations myocardiques multiples; Journal de Chirurgie Thoracique et Cardio-Vasculaire, Vol. IX, no 1, 2005, p 61-64.
3. Lucian Stoica, SidneyChocron, Pierre-Emmanuel Falcoz, Djamel Kaili, Joseph-Philippe Etievent: - Optimizing use of the internal thoracic arteries for total arterial myocardial revascularization, Annals of Thoracic Surgery, 2005;79:753.
4. Lucian Stoica MD, PhD, Sidney Chocron MD, PhD, Pierre-Emmanuel Falcoz MD, Djamel Kaili MD, Joseph-Philipe Etievent MD.- The mammary loop - how to do an adjustable "Y" graft with the left internal thoracic artery.- Annals of Thoracic Surgery, 2004, Vol 78/3:1103-1104
5. Lucian Stoica MD, PhD, Sidney Chocron MD, PhD, Pierre-Emmanuel Falcoz MD, Jean-François Bonneville MD*, Joseph-Philippe Etievent MD - Surgical pitfalls during explantation of a thoracic aortic endoprosthesis – J Thorac Cardiovasc Surg, 2004, 127:1815-1817.
6. Lucian Stoica, Sidney Chocron, Pierre-Emmanuel Falcoz, Joseph-Philippe Etievent.- Endovascular stent grafting for contained rupture of the descending thoracic aorta; European Journal of Cardio-Thoracic Surgery; 23 (2003) 1068-1070.
7. Lucian Stoica, Claude Laurian - Dissection de lîaorte thoracique descendante et portes dîentrée ; STV sang, thrombose, vaisseaux, 2001, no. 3 ; 13 ; 181-182 ;
8. Lucian Stoica M.D., Ph.D., Sidney Chocron M.D., Ph.D., Pierre-Emmanuel Falcoz M.D., Djamel Kaili M.D., JF. Boneville* M.D., Joseph-Philippe Etievent M.D. - Endovascular treatment of the traumatic rupture of the aortic isthmus; Rev. Med. Chir. Soc. Med. Nat. Iasi - 2003 - vol. 107, nr. 3, 822-825.
9. Lucian Stoica – (en roumain) : Morfologia surselor de flux pulmonar in atreziile pulmonare cu defect septal ventricular, review, Revista Romana de Anatomie functionala si clinica, macro- si microscopica si de Antropologie, 2003, vol 2, 101-104.
10. Lucian Stoica MD, Ph.D., Djamel Kaili MD, Sidney Chocron MD, Ph.D., Pierre-Emmanuel Falcoz MD, Joseph-Philippe Etievent MD. - Magnetic resonance imaging of a right atrial cardiac mass; J Cardiovas Dis 2004; 2(1):51.
11. Lucian Stoica MD, PhD, Sidney Chocron MD, PhD, Jean-François Bonneville MD*, Pierre-Emmanuel Falcoz MD, Joseph-Philipe Etievent MD - Explantation of an aortic endoprosthesis for failure of endovascular treatment - Revista Romana de Anatomie functionala si clinica, macro- si microscopica si de Antropologie, vol.II-Nr.3-2003.
12. Lucian Stoica, Loic Mace, Patrice Dervanian, Jean-Yves Neveux : Les resultats du traitement chirurgical des atresies pulmonaires avec septum ouvert – Rom J Cardiovasc Surg, 2004,vol 3, nr 3, 129-136.
13. Lucian Stoica, Sidney Chocron, Djamel Kaili, Pierre-Emmanuel Falcoz, Joseph-Philippe Etievent – Resultats preliminaires avec la technique de la « boucle mammaire » dans les revascularisations myocardiques multiples, Rom J Cardiovasc Surg, 2004,vol 3, no.2, 99-102.
14. Sidney Chocron, MD, PhD, Lucian Stoica, MD, Stephane Koch, MD, Jean-François Bonneville, MD, Djamel Kaili, MD, Bruno Heyd, MD, PhD, and Joseph-Philippe Etievent, MD. - Is endovascular stent grafting for descending thoracic aortic disease recommendable in patients with dysphagia?- J Thoracic Cardiovasc Surg 2002; 124:1239-41.
15. Frédéric Gigou, Lucian Stoica, Claude Laurian – Allogreffe artérielle et sepsis prothétique ; STV sang, thrombose, vaisseaux, 2001, nr. 7 ; 13 ; 437-438 ;
16. Sumio Fukui, Christine Cheval, Lucian Stoica – Rupture sous-adventicielle de lîartère fémorale commune ; STV sang, thrombose, vaisseaux, 2001, nr. 6, 13 ; 378-379.
17. Pierre-Emmanuel Falcoz, MD, Sidney Chocron, MD, PhD, Lucian Stoica, MD, Djamel Kaili, MD, Marc Puyraveau, Mariette Mercier, MD, PhD, and Joseph-Philippe Etievent, MD: Open heart surgery: One year self-assesment of quality of life and functional outcome - Ann Thorac Surg 2003; 76:1598-604.
18. Chocron S, Stoica L, Cattin F, Quantin N, Schiele F, Etievent JPh, Bonneville JF . Traitement en urgence dîun anevrysme rompu de lîaorte thoracique par mise en place dîendoprothèse couverte (cas clinique). Repères 2003, 3:8-9.
19. Pierre-Emmanuel Falcoz, Sidney Chocron, Christine Binquet, Lucian Stoica, Djamel Kaili, Catherine Quantin, and Joseph-Philippe Etievent :Revascularization of the Right Coronary Artery: Grafting or Percutaneous Coronary Intervention?
Ann. Thorac. Surg., Apr 2005; 79: 1232 - 1239.
Ann. Thorac. Surg., Apr 2005; 79: 1232 - 1239.
Ann Thorac Surg 2004;78:1103-1104
© 2004 The Society of Thoracic Surgeons
© 2004 The Society of Thoracic Surgeons
How to do it
The mammary loop: How to do an adjustable "Y" graft with the left internal thoracic artery
Lucian Stoica, MD, PhD*,a, Sidney Chocron, MD, PhDa, Pierre-Emmanuel Falcoz, MDa, Djamel Kaili, MDa, Joseph-Philippe Etievent, MDa
a Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, Besançon, France
* Address reprint requests to Dr Stoica, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, 3 Bd Fleming, Besançon, France 25000
l.stoica@voila.fr
, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, 3 Bd Fleming, Besançon, France 25000l.stoica@voila.fr
Abstract
We present a technique that permits the grafting of two vesselswith the left internal thoracic artery when a sequential graftcannot be performed. The left internal mammary artery is anastomosedto itself resulting in a loop that will be cut open at the timeof the coronary anastomosis.
We present a technique that permits the grafting of two vesselswith the left internal thoracic artery when a sequential graftcannot be performed. The left internal mammary artery is anastomosedto itself resulting in a loop that will be cut open at the timeof the coronary anastomosis.
Introduction
Sequential grafting permits the use of one conduit to bypasstwo vessels. Anatomical features restrict the use of this technique.We present here the mammary loop technique as an alternativeto sequential graft when the topography of the arteries is notfavorable. The end of the left internal thoracic artery (LITA)is anastomosed to the proximal LITA into a loop. The latteris then cut open into a "Y" graft in order to bypass two vessels.This technique enables the accurate determination of the lengthsof the two "Y" branches just before anastomosis [1].
Sequential grafting permits the use of one conduit to bypasstwo vessels. Anatomical features restrict the use of this technique.We present here the mammary loop technique as an alternativeto sequential graft when the topography of the arteries is notfavorable. The end of the left internal thoracic artery (LITA)is anastomosed to the proximal LITA into a loop. The latteris then cut open into a "Y" graft in order to bypass two vessels.This technique enables the accurate determination of the lengthsof the two "Y" branches just before anastomosis [1].
Technique
The LITA is mobilized in a skeletonized way from the left subclavianvein to its bifurcated end in order to get maximum length. Theloop is performed by anastomosing "end-to-side," the spatulateddistal end of the LITA on an arteriotomy made on the proximalpart of the LITA at the level of the pericardial reflectionon the left side of the aorta. This loop will be cut open toobtain an adjustable "Y" graft at the time of the coronary anastomosis(Fig 1, Fig 2). We put a textile pad under the LITA at thetime of the loop anastomosis for making the operating fieldmore stable. All the time we preserve the branch made with theproximal part of the LITA for the left anterior descending artery,and we use the other branch for the other left coronary vessel.This technique permits us to bypass the left anterior descendingartery and a distant diagonal artery or the left anterior descendingartery and an intermediate branch or an upper obtuse marginalartery. However, in the case of a distal obtuse marginal orthe circumflex arteries, the use of the right internal mammaryartery is still required [2, 3].
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Fig 1. The right internal mammary artery (dotted arrow) is skeletonized to bypass the right coronary artery; the left mammary loop (solid arrow) is prepared to bypass the left anterior descending artery and an upper obtuse marginal artery.
Fig 2. The construction of the mammary loop and the "Y" graft made only with the left internal thoracic artery (LITA). The LITA clamped at the origin with an atraumatic clamp that is not represented. (1) Arteriotomy on the proximal part of the LITA at the level of the pericardial reflection on the left side of the aorta. (2) 45° spatulated LITA end. (3) End-to-side anastomosis. (4) The loop is cut at the desirable level. (5) Proximal LITA branch to left anterior descending artery. (6) Distal LITA branch to diagonal, intermediate branch or upper marginal artery.
Results
We started to use this technique in April 2003 and we performedit for five patients with triple-vessel disease. In all of thecases we grafted the right coronary artery with the skeletonizedright internal thoracic artery and the left anterior descendingartery and the intermediate branch or the left anterior descendingartery and an upper obtuse marginal artery with an adjustable"Y" graft made with the mammary loop technique. One patientalso had an aortic valve replacement. There were three proceduresperformed with cardiopulmonary bypass and two off-pump procedures.All of the patients had an uneventful early postoperative recovery.The troponin I levels at 6 and 24 postoperative hours were studiedas for all the others patients in our center; we found similarlevels with the other coronary revascularized patients.
Comments
The two goals of this technique are (1) to make a "Y" graftusing only LITA for the patients who need a two-vessel leftcoronary bypass and in whom the coronary vessel topography isinappropriate for a sequential graft with LITA; and (2) to sparethe right internal thoracic artery for grafting other vessel(s).
The two goals of this technique are (1) to make a "Y" graftusing only LITA for the patients who need a two-vessel leftcoronary bypass and in whom the coronary vessel topography isinappropriate for a sequential graft with LITA; and (2) to sparethe right internal thoracic artery for grafting other vessel(s).
The advantages of this technique are (1) only one arterial conduitis needed to finally make a "Y" graft; (2) the "Y" anastomosisis much easier to perform before the distal anastomoses aredone; (3) the two legs of the graft have the right length, whichprevents tractions or distortions of the "Y" graft; and (4)the technique can also be performed for beating heart surgery.
The two technical features that can be used to obtain the maximallength available are (1) harvesting the LITA in a skeletonizedfashion from the second rib down to its bifurcation, and (2)the division of the mediastinal tissue of the left pleura andthe pericardial reflection on the left side of the aorta toimprove the LITA's entrance into the surgical field.
We do not have angiographic follow-up with our first 5 patients.Our policy is to control the grafts only when ischemic symptomatologyis present or when the troponin I level is postoperatively high.We have been performing this technique for 3 months and furtherevaluation is required.
References
- Athanasiou T, Casula R, Glenville B, Stanbridge R. A new method of grafting the circumflex through lateral MIDCAB with the use of the radial loop technique. Inter Cardiovasc Thorac Surg. 2003;2:97–98
- Chocron S, Etievent JP, Schiele F. The Y graft: myocardial revascularization with both internal thoracic arteries. Evaluation of eighty cases with coronary angiographic assessment. J Thorac Cardiovasc Surg. 1994;108(4):736–740[Abstract/Free Full Text]
- Tector AJ, Kress DC, Schmahl TM, Amundsen S. T-graft: a new method of coronary arterial revascularization. J Cardiovasc Surg (Torino). 1994;35(6 Suppl 1):19–23[Medline]
Ann Thorac Surg 2005;79:1068-1069
© 2005 The Society of Thoracic Surgeons
© 2005 The Society of Thoracic Surgeons
How to do it
How to Tailor A " " Graft for Complex Myocardial Revascularization: A Variant of the Mammary Loop Technique
Lucian Stoica, MD, PhD*,a, Sidney Chocron, MD, PhDa, Pierre-Emmanuel Falcoz, MDa, Djamel Kaili, MDa, Joseph-Philippe Etievent, MDa
a Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, Besançon, France
Accepted for publication December 2, 2003.
* Address reprint requests to Dr Stoica, Department of Thoracic and Cardiovascular, Surgery, Hôpital Jean Minjoz, 3 Bd. Fleming, Besançon 25000, France
l.stoica@voila.fr
, Department of Thoracic and Cardiovascular, Surgery, Hôpital Jean Minjoz, 3 Bd. Fleming, Besançon 25000, France
Abstract
We present a new pattern for tailoring the " " graft that usesthe advantages of the mammary loop technique. The two internalthoracic mammary arteries are skeletonized. The free right mammaryartery is anastomosed end-to-side to the proximal part of thein situ left mammary artery to make a "Y" graft. The distalend of the left mammary artery is anastomosed end-to-side tothe middle portion of the right one to form a loop with thetwo arteries. The loop is severed at the appropriate level atthe time of the coronary anastomosis to form a " " graft. Thistechnique allows a more rational use of the length of the twomammary arteries, because the branch leading to the left anteriordescending artery is measured and cut precisely at the timeof the anastomosis.
We present a new pattern for tailoring the " " graft that usesthe advantages of the mammary loop technique. The two internalthoracic mammary arteries are skeletonized. The free right mammaryartery is anastomosed end-to-side to the proximal part of thein situ left mammary artery to make a "Y" graft. The distalend of the left mammary artery is anastomosed end-to-side tothe middle portion of the right one to form a loop with thetwo arteries. The loop is severed at the appropriate level atthe time of the coronary anastomosis to form a " " graft. Thistechnique allows a more rational use of the length of the twomammary arteries, because the branch leading to the left anteriordescending artery is measured and cut precisely at the timeof the anastomosis.
Introduction
Complex use of the two internal thoracic arteries (ITAs) allowscomplete arterial revascularization of the heart. Differenttechniques offer a rational use of the length of the two ITAs:the "Y" graft [1] or the "T" graft [2], and more recently the" " graft [3]. The latter is a complex technique used to constructa composite conduit with only the two skeletonized ITAs. Thistechnique allows complete left-heart revascularization, butrequires additional extension with the radial artery to bypassthe right heart as well. In the original technique [3], thelower two-thirds of the right ITA is anastomosed end-to-sideto the proximal part of the left ITA to obtain a "Y" or "T"graft. The left ITA is divided at the level of the anastomosison the left anterior descending artery and the distal remnantpart of the left ITA is anastomosed end-to-side to the rightITA at a level that allows the obtaining of a branch that canbypass the diagonal artery, the intermediate branch, or theobtuse marginal arteries. If a right-heart bypass is required,the proximal third of the in situ right ITA is extended withthe free radial artery [3].
We recently reported the left mammary loop technique [4] thatallows the making of an adjustable "Y" graft using only theleft ITA. The distal end of the left ITA is anastomosed end-to-sideto the proximal part of the left ITA to make a loop, which issevered at the appropriate level at the time of coronary anastomosis.We used the advantages of the mammary loop technique to constructa " " graft. The first step was to construct a "Y" graft by anastomosingthe free right ITA to the left ITA. The distal end of the leftITA was then anastomosed to the proximal part of the right ITAto make a loop between the two ITAs. When the left anteriordescending artery was anastomosed, the loop was severed at therequired level.
Technique
The two ITAs are skeletonized from the subclavian vein to thebifurcated end. The entire length of the right ITA is preservedas a free graft. The mediastinal tissue is separated from theleft pleura, and the pericardial reflection on the left sideof the aorta is divided vertically to improve the access ofthe left ITA into the surgical field. An arteriotomy is doneon the left ITA at the level of the pericardial reflection onthe pulmonary trunk. The proximal part of the free right ITAis anastomosed end-to-side at 45° to obtain a "Y" graft(Fig 1). The distal end of the left ITA is spatulated and anastomosedend-to-side to an arteriotomy done on the right ITA to obtaina loop. The level of this anastomosis is variable (ie, on theproximal third for the intermediate branch and on the middlethird for the obtuse marginal or the circumflex artery). Thisanastomosis is performed extrathoracically. The loop is severedwhen the left anterior descending artery is anastomosed. Theresult is a " " graft with three branches: (1) a left branchmade with the proximal left ITA, (2) a middle branch made withthe distal left ITA, and (3) a right branch made with the rightITA (Fig 2). The proximal part of the loop made with the leftITA is always used to bypass the left anterior descending artery.The middle branch is the distal part of the loop, which becomesa reversed conduit and can bypass one or more lateral wall vessels.The part of the right ITA distal to the loop anastomosis islong enough to bypass the posterior descending artery or theleft ventricular branch of the right coronary artery. Sequentialanastomoses can be performed on the left ventricular vesselsunder the appropriate conditions.
The two ITAs are skeletonized from the subclavian vein to thebifurcated end. The entire length of the right ITA is preservedas a free graft. The mediastinal tissue is separated from theleft pleura, and the pericardial reflection on the left sideof the aorta is divided vertically to improve the access ofthe left ITA into the surgical field. An arteriotomy is doneon the left ITA at the level of the pericardial reflection onthe pulmonary trunk. The proximal part of the free right ITAis anastomosed end-to-side at 45° to obtain a "Y" graft(Fig 1). The distal end of the left ITA is spatulated and anastomosedend-to-side to an arteriotomy done on the right ITA to obtaina loop. The level of this anastomosis is variable (ie, on theproximal third for the intermediate branch and on the middlethird for the obtuse marginal or the circumflex artery). Thisanastomosis is performed extrathoracically. The loop is severedwhen the left anterior descending artery is anastomosed. Theresult is a " " graft with three branches: (1) a left branchmade with the proximal left ITA, (2) a middle branch made withthe distal left ITA, and (3) a right branch made with the rightITA (Fig 2). The proximal part of the loop made with the leftITA is always used to bypass the left anterior descending artery.The middle branch is the distal part of the loop, which becomesa reversed conduit and can bypass one or more lateral wall vessels.The part of the right ITA distal to the loop anastomosis islong enough to bypass the posterior descending artery or theleft ventricular branch of the right coronary artery. Sequentialanastomoses can be performed on the left ventricular vesselsunder the appropriate conditions.
Fig 1. The construction of the " " graft. (Left) The "Y" graft: (1) the left internal thoracic artery (ITA); (2) the right ITA; and (3) the "Y" anastomosis at the level of the pericardial reflection on the
Fig 2. (Left) A drawing of the " " graft construction. (Right) The " " graft after coronary anastomoses (numbers are defined in Fig 1).
Results
We performed this technique in July, 2003 on a patient withtriple-vessel disease. The arteries bypassed were the proximalpart of the left anterior descending artery with the left " "branch, the intermediate branch artery, and an obtuse marginalartery with the middle branch of the " " graft in sequential,and the left ventricular branch of the right coronary arterywith the right " " branch. The patency of the whole constructionwas controlled postoperatively by coronarography (Fig 3).
Fig 3. Angiographic assessment of the whole construction (numbers are defined in Fig 1).
Comment
This modification of the original " " graft technique presentscertain advantages: (1) The mammary loop technique allows thedetermination of the level of the left ITA transection withprecision for a more rational use of the length of the leftITA. (2) The middle branch anastomosis of the " " graft, performedextrathoracically, is much easier with the mammary loop technique.(3) Using the entire length of the right ITA allows a bypassof the right vessels with the " " graft to avoid harvesting theradial artery as in the original " " graft technique.
This modification of the original " " graft technique presentscertain advantages: (1) The mammary loop technique allows thedetermination of the level of the left ITA transection withprecision for a more rational use of the length of the leftITA. (2) The middle branch anastomosis of the " " graft, performedextrathoracically, is much easier with the mammary loop technique.(3) Using the entire length of the right ITA allows a bypassof the right vessels with the " " graft to avoid harvesting theradial artery as in the original " " graft technique.
The " " graft is a complex technique that should only be usedin selected patients. Our modification of the original " " grafttechnique offers a more rational use of the two ITAs and thepossibility to do a right coronary artery bypass with the ITA.Further experience is needed to determine the long-term patencyof this " " graft.
References
- Chocron S, Etievent JP, Schiele F, et al. The Y graft—myocardial revascularization with both internal thoracic arteries. Evaluation of eighty cases with coronary angiographic assessment. J Thorac Cardiovasc Surg. 1994;108(4):736–740[Abstract/Free Full Text]
- Tector AJ, Kress DC, Schmahl TM, Amundsen S. T-graft: a new method of coronary arterial revascularization. J Cardiovasc Surg (Torino). 1994;35(6 Suppl 1):19–23[Medline]
- Prapas SN, Anagnostopoulos CE, Kotsis VN, et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the " " graft. Ann Thorac Surg. 2002;73:1990–1992[Abstract/Free Full Text]
- Stoica L, Chocron S, Falcoz PE, Kaili D, Etievent JPh. The mammary loop — or how to do an adjustable "Y" graft with the left internal thoracic artery. Ann Thorac Surg 2004;78:1103–4
Eur J Cardiothorac Surg 2003;23:1068-1070
© 2003 Elsevier Science NL
© 2003 Elsevier Science NL
Endovascular stent grafting for contained rupture of the descending thoracic aorta
Lucian Stoica*, Sidney Chocron, Pierre-Emmanuel Falcoz, Joseph-Philippe Etievent
Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, 3 Boulevard Fleming, Besancon 25000, France
Received 17 December 2002; received in revised form 25 January 2003; accepted 3 February 2003.
* Corresponding author. e-mail: l.stoica@voila.fr
Abstract
We report three cases of contained rupture of the descendingthoracic aorta managed by endovascular stent grafting and discussthe possibility of managing this life-threatening complicationin emergency, by endoluminal devices. Further experience isneeded to specify the indications for aortic stenting in descendantthoracic aortic ruptures.
Key Words: Aortic rupture • Endoprosthesis • Aortic salmonellosis • Aortic hematoma • Aorto-esophageal fistula
1. Introduction
The use of endoluminal devices in the treatment of aortic diseasesis progressing [1,2]. We describe three cases of contained aorticruptures treated by endovascular stent grafting. These casesrepresent our initial experience and are described in chronologicalorder. At the time, we had to order the prostheses. We now havea readily available supply of 10-cm prostheses for emergencyuse, in the following diameters: 24, 28, 32,38 and 42 mm.
2. Case reports
2.1. Case 1
A 77-year-old man with a history of smoking and prostate adenomapresented in February 2000 with acute dorsal pain with lumbarirradiation, dyspnea and left limb paresthesia. Trans-esophagealechography revealed a post-subclavian aortic rupture with asmall left pleural effusion confirmed by contrast computer tomography(CT) scan. The patient was managed medically with anti-hypertensivetreatment and drainage of a 1.1-l left hemothorax. One weeklater, the left hemothorax reappeared. Angiography showed threeaortic fissure lesions at different levels of the thoracic aorta.CT scan confirmed the rupture (Fig. 1) .
A 77-year-old man with a history of smoking and prostate adenomapresented in February 2000 with acute dorsal pain with lumbarirradiation, dyspnea and left limb paresthesia. Trans-esophagealechography revealed a post-subclavian aortic rupture with asmall left pleural effusion confirmed by contrast computer tomography(CT) scan. The patient was managed medically with anti-hypertensivetreatment and drainage of a 1.1-l left hemothorax. One weeklater, the left hemothorax reappeared. Angiography showed threeaortic fissure lesions at different levels of the thoracic aorta.CT scan confirmed the rupture (Fig. 1) .
A 30-mm diameter,101-mm long Talent type endoprosthesis (World Medical Corp.,Sunrise, FL) was deployed 1 cm from the origin of the left subclavianartery. After the procedure, thoracic drainage eliminated a1.8-l left hemothorax. The hemothorax did not reappear and thecontrol CT scan showed no leak. The patient's recovery was uneventfuland he is doing well 34 months after the procedure. Contrastthoraco-abdominal control CT scans done every 6 months haveshown no leak, stent migration or other complication.) . A 30-mm diameter,101-mm long Talent type endoprosthesis (World Medical Corp.,Sunrise, FL) was deployed 1 cm from the origin of the left subclavianartery. After the procedure, thoracic drainage eliminated a1.8-l left hemothorax. The hemothorax did not reappear and thecontrol CT scan showed no leak. The patient's recovery was uneventfuland he is doing well 34 months after the procedure. Contrastthoraco-abdominal control CT scans done every 6 months haveshown no leak, stent migration or other complication.
Fig. 1. Case 1. The aortic rupture is confirmed by the CT scan (1.1); the angiography showed three levels of rupture (1.2), covered by the stent graft (1.3).
2.2. Case 2
A 78-year-old woman with a history of arterial hypertension,appendectomy, salmonellosis and polyarthritis was examined inJanuary 2001 for acute left basithoracic pain, dyspnea and fever.Thoracic radiography showed a left pleural effusion. A contrastthoracic CT scan revealed an aortic hematoma with a contrastleak at the level of the ninth dorsal (D9) vertebra and theangiography also showed the level of the rupture (Fig. 2) .
A 78-year-old woman with a history of arterial hypertension,appendectomy, salmonellosis and polyarthritis was examined inJanuary 2001 for acute left basithoracic pain, dyspnea and fever.Thoracic radiography showed a left pleural effusion. A contrastthoracic CT scan revealed an aortic hematoma with a contrastleak at the level of the ninth dorsal (D9) vertebra and theangiography also showed the level of the rupture (Fig. 2) .
The zone was covered using two 31-mm long Talent type endoprostheses.Control arteriography during the procedure showed a persistentleak between the two stents, so a third one was deployed. Acontrol contrast thoracic CT scan done 3 days later revealedno contrast leak and a regression of the aortic hematoma. Atpostoperative day 8, the patient had a high fever with shiveringand a positive hemoculture for Salmonella enteridis. Antibioticswere given and the fever and inflammatory markers regressed;treatment was stopped 18 months ago and the patient is doingwell. Due to the risk of graft infection, this patient requiresclose supervision.) .The zone was covered using two 31-mm long Talent type endoprostheses.Control arteriography during the procedure showed a persistentleak between the two stents, so a third one was deployed. Acontrol contrast thoracic CT scan done 3 days later revealedno contrast leak and a regression of the aortic hematoma. Atpostoperative day 8, the patient had a high fever with shiveringand a positive hemoculture for . Antibioticswere given and the fever and inflammatory markers regressed;treatment was stopped 18 months ago and the patient is doingwell. Due to the risk of graft infection, this patient requiresclose supervision.
Fig. 2. Case 2. CT scan (2.1) and angiography (2.2) showed the aortic rupture which was covered by the stent graft (2.3).
2.3. Case 3
A 59-year-old woman with a medical history of arterial hypertension,morbid obesity and smoking presented in December 2001 with aleft pleural effusion after 3 weeks of persistent undiagnosedfever, asthenia, and progressive dysphagia. A contrast CT scanrevealed a spontaneous aortic rupture with a peri-aortic hematomacompressing the esophagus and the left atrium (Fig3) .
A 59-year-old woman with a medical history of arterial hypertension,morbid obesity and smoking presented in December 2001 with aleft pleural effusion after 3 weeks of persistent undiagnosedfever, asthenia, and progressive dysphagia. A contrast CT scanrevealed a spontaneous aortic rupture with a peri-aortic hematomacompressing the esophagus and the left atrium (Fig3) .
Fig. 3. Case 3. CT scan (3.1) showed an aortic rupture with a peri-aortic hematoma and the angiography (3.2) showed the contrast leak in the peri-aortic space; after stent deployment, the contrast leak disappeared (3.3).
A 25-mm diameter Talent type endoprosthesis was deployed tocover and exclude the aortic rupture area. There were no proceduralcomplications. On the 7th postoperative day, the patient hada moderate hematemesis. An upper fibroscopy revealed an aorto-esophagealfistula 30 cm from the dental arcades and an esophageal ulcercovered with clots. Thoracic CT scan excluded migration or stentkinking. The aorto-esophageal fistula was managed surgicallyby esophageal resection with bilateral exclusion by right thoracotomy,cervical esophagostomy and gastrostomy. The patient recoveredwell in the early postoperative period but developed sepsisand died 2 months later.
3. Discussion
These cases show that acute contained rupture of the thoracicaorta can be treated by endovascular stenting. As this techniqueis new, each team's experience is needed in order to determinethe right indication. In our experience, as described in anotherpaper [3], the compression of the esophagus at the time of diagnosisis a contraindication for an endoluminal procedure. In suchcases, conventional treatment is preferable as it treats notonly the rupture, but also relieves the esophageal compressioncaused by the periaortic hematoma and the intra-aneurysmal thrombosis,which are, in our opinion, responsible for the further aorto-esophagealfistula. Moreover, the fragile ischemic esophageal area maybe subject to mechanical aggression caused by the retractionof the aneurysm or the hematoma after stenting.
In the second case, the rupture is likely to have been causedby infection (salmonella). The risk of sepsis is identical withboth surgical and endoluminal techniques in our opinion. Weshow that endoluminal treatment is possible in such cases, associatedwith antibiotherapy which should be initiated immediately beforethe endovascular treatment.
With experience, the endoluminal technique is being used formore and more patients. In our initial experience we limitedthe use of this technique to fragile patients. We now proposethis kind of treatment to a wider population, i.e. to patientswho could undergo a thoracotomy. As always with new techniques,the initial enthusiasm is tempered by complications which allowto define the right indications. Endoluminal treatment of containedaortic rupture is not the standard treatment. Even if this techniquemay be successful in some cases, more data are needed to determinethe safety of this approach. In the case of aortic containedrupture, esophageal compression by the hematoma is a contraindicationfor endoluminal treatment.
References
- Brittenden J., McBride K., McInnes G., Gillespie I.N., Bradbury A.W. The use of endovascular stents in the treatment of penetrating ulcers of the thoracic aorta. J Vasc Surg 1999;30(5):946-949.[Medline]
- Murgo S., Dussaussois L., Golzarian J., Cavenaile J.C., Abada H.T., Ferreira J., Struyven J. Penetrating atherosclerotic ulcer of the descending thoracic aorta: treatment by endovascular stent-graft. Cardiovasc Intervent Radiol 1998;21(6):454-458.[CrossRef][Medline]
- Chocron S., Stoica L., Koch S., Bonneville J.-F., Heyd B., Etievent J.-P. Is endovascular stent grafting for descending thoracic aortis disease recommendable in patients with dysphagia?. J Thorac Cardiovasc Surg 2002;124:1239-1241.[Free Full Text] L., Koch S., Bonneville J.-F., Heyd B., Etievent J.-P. Is endovascular stent grafting for descending thoracic aortis disease recommendable in patients with dysphagia?. J Thorac Cardiovasc Surg 2002;124:1239-1241.
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Brief communication
Surgical pitfalls during explantation of a thoracic aortic endoprosthesis
Lucian Stoica MD, PhD , , a, Sidney Chocron MD, PhDa, Pierre-Emmanuel Falcoz MDa, Jean-François Bonneville MDb and Joseph-Philippe Etievent MDa
a Department of Thoracic and Cardio-Vascular Surgery, Hôpital Jean Minjoz, Besançon, , France,
b Department of Radiology, Hôpital Jean Minjoz, , Besançon, , France
Received 13 December 2003; accepted 30 December 2003. Available online 25 May 2004.
a Department of Thoracic and Cardio-Vascular Surgery, Hôpital Jean Minjoz, Besançon, , France,
b Department of Radiology, Hôpital Jean Minjoz, , Besançon, , France
Received 13 December 2003; accepted 30 December 2003. Available online 25 May 2004.
Author Keywords: 13; 26
Corresponding author. Address for reprints: Lucian Stoica, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, 3 Blvd Fleming, , Besançon, , France 25000 Corresponding author. Address for reprints: Lucian Stoica, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Hôpital Jean Minjoz, 3 Blvd Fleming, , Besançon, , France 25000