Publications by authors named "Pascal Chabrot"

43 Publications

Optimized radiological alert thresholds based on device dosimetric information and peak skin dose in vascular fluoroscopically guided intervention.

Eur Radiol 2021 May 6;31(5):3027-3034. Epub 2020 Nov 6.

Pôle Interhospitalier d'Imagerie Diagnostique et de Radiologie Interventionnelle, CHU, 63003, Clermont-Ferrand, France.

Objectives: The National Council on Radiation Protection (NCRP) report no. 168 recommended that during fluoroscopically guided interventions (FGIs), each patient should be monitored when one of the following thresholds is reached: an air kerma > 5 Gy, a kerma area product (KAP) > 500 Gy.cm, a fluoroscopy time > 60 min, or a peak skin dose (PSD) > 3 Gy. Whereas PSD is the most accurate metric regarding the prevention of radiological risks, it remains the most difficult parameter to assess. We aimed to evaluate the relevance of the other, more accessible metrics and propose new optimized threshold (OT) for improved patient follow-up.

Methods: Overall, 108 patients who underwent FGI in which at least one NCRP threshold was reached and PSD was measured were considered. The correlation between all metrics was assessed using principal component analysis (PCA). ROC curves and the sensitivity/specificity of both NCRP and OT to predict PSD > 3 Gy were evaluated.

Results: The PCA shows that FGI can be decomposed with two components based on time and dose variables. Only KAP and kerma were correlated with PSD. The overall sensitivity and specificity of the new OT regarding KAP (67.6/93.0), kerma (97.3/81.7), and time (62.2/62.0) were better compared with NCRP thresholds (97.3/16.9, 40.5/95.4, and 21.6/74.7).

Conclusions: This study shows that fluoroscopy time is not a relevant metric when used to predict PSDs > 3 Gy. By adapting KAP and kerma thresholds to predict PSD over 3 Gy, patient follow-ups following vascular FGI can be improved.

Key Points: • In vascular fluoroscopically guided interventions, principal component analysis demonstrates that between fluoroscopy time, KAP, and kerma, only the two last were correlated to the peak skin dose. • Optimized thresholds replacing NRCP ones obtained with ROC curves analysis were 85,451 μGy.cm, 2938 mGy, and 41 min for KAP, kerma, and fluoroscopy time respectively. • Improvements to trigger patient follow-up after vascular fluoroscopically guided interventions may be obtained by using the optimized thresholds.
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http://dx.doi.org/10.1007/s00330-020-07422-3DOI Listing
May 2021

Renal artery thrombosis induced by COVID-19.

Clin Kidney J 2020 Aug 5;13(4):713. Epub 2020 Aug 5.

Nephrology, Dialysis and Transplantation Department, University Hospital, Clermont Ferrand, France.

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http://dx.doi.org/10.1093/ckj/sfaa141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454478PMC
August 2020

Systematic Review of Atrial Vascular Access for Dialysis Catheter.

Kidney Int Rep 2020 Jul 17;5(7):1000-1006. Epub 2020 Apr 17.

Medical Intensive Care Unit, UMR CNRS 6023, CHU Clermont-Ferrand, Clermont-Ferrand, France.

Introduction: The last decade has seen a steady increase worldwide in the prevalence of end-stage renal disease (ESRD). Hemodialysis is the major modality of renal replacement therapy (RRT) in 70% to 90% of patients, who require well-functioning vascular access for this procedure. The recommended access for hemodialysis is an arteriovenous fistula or a vascular graft. However, recourse to central venous catheters remains essential for patients whose chronic renal disease is diagnosed at the end stage or in whom an arteriovenous fistula cannot be created or maintained. Tunneled dialysis catheter (TDC) exposure can induce venous stenosis and occlusions and can result in superior vena cava syndrome and/or vascular access loss. Exhaustion of conventional vascular accesses is 1 of the greatest challenges that nephrologists and patients have to face. Several unconventional salvage-therapy routes for TDC placement in patients with exhausted upper body venous access have been reported in the literature.

Methods: We report 2 new cases of intra-atrial TDC placement for patients with exhausted vascular access and perform a meta-analysis of cases from the literature.

Results: A total of 51 patients were included. The TDC was inserted by a cardiovascular surgeon in all cases. At the end of follow-up, 75% patients were alive. The median survival time was 25 months. Survival time of hemodialysis patients with intra-atrial TDC was lower than that observed with conventional TDC.

Conclusions: This unconventional technique is safe and functional for hemodialysis patients with exhausted venous access. Atrial vascular access for TDC placement is salvage therapy and is therefore potentially lifesaving.
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http://dx.doi.org/10.1016/j.ekir.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335951PMC
July 2020

Fluoroscopy guided electrode-array insertion for cochlear implantation with straight electrode-arrays: a valuable tool in most cases.

Eur Arch Otorhinolaryngol 2021 Apr 25;278(4):965-975. Epub 2020 Jun 25.

Department of Otolaryngology-Head Neck Surgery, University Hospital Center, CHU Gabriel Montpied, 58 rue Montalembert, 63000, Clermont-Ferrand, France.

Purpose: To highlight the advantages of real time fluoroscopy guided electrode-array (EA) insertion (FGI) during cochlear implants surgery.

Methods: All surgical procedures were performed in a dedicated operating room equipped with a robotic C-arm cone beam device, allowing for intraoperative real time 2D FGI and postoperative 3D imaging. Only straight EAs were used. Patients were sorted out in three groups: ANAT, with anatomical concerns; HP, with residual hearing; NPR: patients with no particular reason for FGI. In all cases the angle of EA-insertion was measured. In the HP group pre and postoperative hearing were compared. The radiation delivered to the patient was recorded.

Results: Fifty-three cochlear implantation procedures were achieved under fluoroscopy in 50 patients from November 2015 to January 2020 (HP group: n = 10; ANAT group: n = 13; NPR group: n = 27). In the ANAT group, FGI proved to be helpful in 8 cases (61.5%), successfully guiding the surgeon during EA -insertion. On average, the angle of insertion was at 424° ± 55°. In the HP group, a controlled smooth EA-insertion was carried out in all cases but one. The targeted 360° angle of insertion was always reached. Hearing preservation was possible with an eventual average drop of 30 ± 1.5 dB. In the NPR group, FGI helped control the quality of insertion in all cases and appeared very informative in five (17.8%): one EA-misrouting, three stuck EAs, and one case with hidden electrodes out of the cochlea in revision surgery. Final 3D cone beam CT scan double-checked the EA position in all adults. The radiation dose was equivalent to a bit less than four digital subtract radiographs.

Conclusion: The FGI is a very useful adjunct in cochlear implantation in all cases of expected surgical pitfalls, in patients with residual hearing, and even in case without preoperative particular reason, with low irradiation.
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http://dx.doi.org/10.1007/s00405-020-06151-zDOI Listing
April 2021

Impact of take-home messages written into slide presentations delivered during lectures on the retention of messages and the residents' knowledge: a randomized controlled study.

BMC Med Educ 2020 Jun 3;20(1):180. Epub 2020 Jun 3.

Biostatistics unit, Delegation à la Recherche Clinique (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.

Background: Lectures with slide presentations are widely used to teach evidence-based medicine to large groups. Take-home messages (THMs) are poorly identified and recollected by students. We investigated whether an instruction to list THMs in written form on slides would improve the retention thereof by residents, and the residents' level of knowledge, 1 month after lectures.

Methods: Prospective blinded randomized controlled study was conducted. Twelve lectures (6 control and 6 intervention lectures) were delivered to 73 residents. For the intervention lectures, the lecturers were instructed to incorporate clear written THMs into their slide presentations. The outcomes were ability of resident to recollect THMs delivered during a lecture (as assessed by accordance rate between the lecturers' and residents' THMs) and knowledge (as assessed by multiple choice questions (MCQs)).

Results: Data for 3738 residents' THMs and 3410 MCQs were analyzed. The intervention did not significantly increase the number of THMs written on slides (77% (n = 20/26), 95% CI 56-91 vs 64% (n = 18/28), 95% CI 44-81, p = 0.31) nor THMs retention (13% (n = 238/1791), 95% CI 12-15 vs 17% (n = 326/1947), 95% 15-18, p = 0.40) nor knowledge (63.8 ± 26.2 vs 61.1 ± 31.4 /100 points, p = 0.75). In multivariable analyses performed with all THMs written on slides from the two groups, a superior knowledge was associated with notetaking during lectures (OR 1.88, 95% CI 1.41-2.51) and THMs retention (OR 2.17, 95% CI 1.54-3.04); and THMs retention was associated with written THMs (OR 2.94, 95% CI 2.20-3.93).

Conclusions: In lectures delivered to residents, a third of the THMs were not in written form. An intervention based on an explicit instruction to lecturers to provide THMs in written form in their slide presentations did not result in increased use of written THMs into the slide presentation or improvement of the THMs retention or level of knowledge. However, we showed that there was a strong positive association between writing THMs on a slide, retention of THMs and residents' knowledge. Further researches are needed to assess interventions to increase written THMs in lectures by faculty.

Trial Registration: ClinicalTrials.gov NCT01795651 (Fev 21, 2013).
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http://dx.doi.org/10.1186/s12909-020-02092-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7271544PMC
June 2020

Combined biembolization induces higher hypertrophy than portal vein embolization before major liver resection.

HPB (Oxford) 2020 02 31;22(2):298-305. Epub 2019 Aug 31.

Department of Vascular Radiology, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, Place Henri Dunant, 63000 Clermont-Ferrand, France; UMR Auvergne CNRS 6284, Clermont-Ferrand Faculty of Medicine, 28 Place Henri Dunant, 63000 Clermont-Ferrand, France.

Background: Combined preoperative portal and hepatic vein embolization (biembolization, BE) has been recently described and may further enhance preoperative FLR growth. The objective of this study was to compare the efficacy of combined preoperative biembolization and portal vein embolization (PVE).

Methods: This study was performed between 2010 and 2017. From 2010 to 2014, patients only underwent preoperative PVE. After 2014, BE was proposed as an alternative to PVE. Liver volumetry was assessed by a CT-scan before BE or PVE and then three weeks later.

Results: During the study period, 72 patients underwent radiological procedures that included 41 PVE (PVE group) and 31 BE (BE group). The time elapsing between the procedure and surgery was similar (p = 0.760). The mean percentage of FLR ratio hypertrophy in the PVE group was 31.9% (±34), but reached 51.2% (±42) in the BE group (p = 0.018) and this difference remained significant under multivariate analysis that included age, gender, body mass index, diabetes mellitus, cirrhosis and NASH. The kinetic growth rates were 19% (±17%) and 8% (±13%) in the BE and PVE groups, respectively (p = 0.026).

Conclusion: This study shows that BE induces higher hypertrophy than portal vein embolization before major liver resection with no more morbidity.
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http://dx.doi.org/10.1016/j.hpb.2019.08.005DOI Listing
February 2020

Quantification of steatosis in alcoholic and nonalcoholic fatty liver disease: Evaluation of four MR techniques versus biopsy.

Eur J Radiol 2019 Sep 19;118:169-174. Epub 2019 Jul 19.

CHU Estaing, Service de radiologie, Clermont-Ferrand, France.

Purpose: Given the growing prevalence of obesity and metabolic syndrome, the management of hepatic steatosis, especially its quantification, is a major issue. We assessed the quantification of liver steatosis using four different MR methods, in order to determine the one that is best correlated with the reference method which consists of histological measurement by liver biopsy.

Method: Seventy-one successive patients requiring liver biopsy for acute or chronic liver disease were enrolled prospectively between March 2017 and March 2018, 11 were excluded and 60 were reported. Liver MR (1.5 T) was organised in order to be performed the same day, using four different steatosis quantification techniques (3-echo MRI, 6-echo MRI, 11-echo MRI and MR Spectroscopy). Quantitative histological and imaging data were compared. In a secondary analysis, we studied the possible influence of alcohol drinking, hepatic iron overload, and the presence of liver fibrosis.

Results: All four MR techniques were found to have excellent correlations with the histological measurements: 3-echo MRI (r = 0.852, p < 0.001), 6-echo MRI (r = 0.819, p < 0.001), 11-echo MRI (r = 0.818, p < 0.001) and MR Spectroscopy (r = 0,812, p < 0,001). Interestingly, we also found that the presence of alcohol consumption, iron overload and fibrosis did not interfere with measurements, whichever technique was used.

Conclusion: In the evaluation of hepatic steatosis, our study showed very good correlations of all four MR techniques with the histological standard. There was no confounding factor in a representative group of patients with associated liver conditions such as alcohol consumption, fibrosis and iron overload, for each technique. All four MR techniques may be used in daily practice.
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http://dx.doi.org/10.1016/j.ejrad.2019.07.025DOI Listing
September 2019

A robust multi-variability model based liver segmentation algorithm for CT-scan and MRI modalities.

Comput Med Imaging Graph 2019 09 28;76:101635. Epub 2019 May 28.

Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, F-63000 Clermont-Ferrand, France.

Developing methods to segment the liver in medical images, study and analyze it remains a significant challenge. The shape of the liver can vary considerably from one patient to another, and adjacent organs are visualized in medical images with similar intensities, making the boundaries of the liver ambiguous. Consequently, automatic or semi-automatic segmentation of liver is a difficult task. Moreover, scanning systems and magnetic resonance imaging have different settings and parameters. Thus the images obtained differ from one machine to another. In this article, we propose an automatic model-based segmentation that allows building a faithful 3-D representation of the liver, with a mean Dice value equal to 90.3% on CT and MRI datasets. We compare our algorithm with a semi-automatic method and with other approaches according to the state of the art. Our method works with different data sources, we use a large quantity of CT and MRI images from machines in various hospitals and multiple DICOM images available from public challenges. Finally, for evaluation of liver segmentation approaches in state of the art, robustness is not adequacy addressed with a precise definition. Another originality of this article is the introduction of a novel measure of robustness, which takes into account the liver variability at different scales.
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http://dx.doi.org/10.1016/j.compmedimag.2019.05.003DOI Listing
September 2019

Automatic segmentation methods for liver and hepatic vessels from CT and MRI volumes, applied to the Couinaud scheme.

Comput Biol Med 2019 07 1;110:42-51. Epub 2019 May 1.

Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, F-63000, Clermont-Ferrand, France.

Background: Proper segmentation of the liver from medical images is critical for computer-assisted diagnosis, therapy and surgical planning. Knowledge of its vascular structure allows division of the liver into eight functionally independent segments, each with its own vascular inflow, known as the Couinaud scheme. Couinaud's description is the most widely used classification, since it is well-suited for surgery and accurate for the localization of lesions. However, automatic segmentation of the liver and its vascular structure to construct the Couinaud scheme remains a challenging task.

Methods: We present a complete framework to obtain Couinaud's classification in three main steps; first, we propose a model-based liver segmentation, then a vascular segmentation based on a skeleton process, and finally, the construction of the eight independent liver segments. Our algorithms are automatic and allow 3D visualizations.

Results: We validate these algorithms on various databases with different imaging modalities (Magnetic Resonance Imaging (MRI) and Computed Tomography (CT)). Experimental results are presented on diseased livers, which pose complex challenges because both the overall organ shape and the vessels can be severely deformed. A mean DICE score of 0.915 is obtained for the liver segmentation, and an average accuracy of 0.98 for the vascular network. Finally, we present an evaluation of our method for performing the Couinaud segmentation thanks to medical reports with promising results.

Conclusions: We were able to automatically reconstruct 3-D volumes of the liver and its vessels on MRI and CT scans. Our goal is to develop an improved method to help radiologists with tumor localization.
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http://dx.doi.org/10.1016/j.compbiomed.2019.04.014DOI Listing
July 2019

Ontology-Based Approach for Liver Cancer Diagnosis and Treatment.

J Digit Imaging 2019 02;32(1):116-130

Institut Pascal, Université Clermont Auvergne, UMR6602 CNRS/UCA/SIGMA, 63171, Aubière, France.

Liver cancer is the third deadliest cancer in the world. It characterizes a malignant tumor that develops through liver cells. The hepatocellular carcinoma (HCC) is one of these tumors. Hepatic primary cancer is the leading cause of cancer deaths. This article deals with the diagnostic process of liver cancers. In order to analyze a large mass of medical data, ontologies are effective; they are efficient to improve medical image analysis used to detect different tumors and other liver lesions. We are interested in the HCC. Hence, the main purpose of this paper is to offer a new ontology-based approach modeling HCC tumors by focusing on two major aspects: the first focuses on tumor detection in medical imaging, and the second focuses on its staging by applying different classification systems. We implemented our approach in Java using Jena API. Also, we developed a prototype OntHCC by the use of semantic aspects and reasoning rules to validate our work. To show the efficiency of our work, we tested the proposed approach on real datasets. The obtained results have showed a reliable system with high accuracies of recall (76%), precision (85%), and F-measure (80%).
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http://dx.doi.org/10.1007/s10278-018-0115-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382636PMC
February 2019

Interventional endoscopic ultrasound: A new promising way for intrahepatic portosystemic shunt with portal pressure gradient.

Endosc Ultrasound 2017 Nov-Dec;6(6):394-401

Department of Digestive and Hepatobiliary Diseases, CHU Estaing; Auvergne University Department/CNRS 6284 Image Sciences for Innovations Techniques, France.

Background And Objectives: Interventional endoscopic ultrasound (EUS) is a promising novel approach for intravascular interventions. The aim of this study was to assess the feasibility and safety of a EUS-guided intrahepatic portosystemic shunt (EGIPS) with portal pressure gradient measurement in a live porcine model.

Methods: The left hepatic vein (LHV) or the inferior vena cava (IVC) was punctured with a needle that advanced into the portal vein (PV). A guidewire was then inserted into the PV, and a needle knife was used to create an intrahepatic fistula between LHV and PV. Portal pressure was recorded. The fistula was dilated with a balloon and a biliary metal stent was deployed between LHV and PV under sonographic and fluoroscopic observation. A portocavography validated the patency of the stent. Necropsies were realized after euthanasia.

Results: Portosystemic stenting was achieved in 19/21 pigs. Final portocavography confirmed stent patency between PV and LHV or IVC in 17 pigs (efficacy of 81%): Four stents were dysfunctional as two were thrombosed and two were poor positioned. Portal pressure was documented before and after shunting in 20/21 pigs. Necropsies revealed that 19/21 procedures were transesophageal and two were transgastric. Hemoperitoneum and pneumothorax were found in one pig and hemothorax was found in two pigs. Morbidity was 14.2% (3/21 animals).

Conclusion: EGIPS was feasible in 91% of cases, functional in 81%, with 14.2% per procedure morbidity. EGIPS still needs to be assessed in portal hypertension pig models with longer follow-up before being considered as an alternative when the transjugular intrahepatic portosystemic shunt fails.
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http://dx.doi.org/10.4103/eus.eus_42_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752762PMC
December 2017

CT patterns of acute type A aortic arch dissection: longer, higher, more anterior.

Br J Radiol 2017 Oct 22;90(1078):20170417. Epub 2017 Aug 22.

2 Service de Chirurgie cardio-vasculaire, Hôpital Gabriel Montpied, CHU Clermont-Ferrand, Clermont-Ferrand, France.

Objectives: This study analysed CT patterns of the acute dissected aortic arch using original biometric features along with comparison with normal aortas.

Methods: The diagnostic CT scans of 57 patients (42 males, age (mean ± SD: 64.5 ± 13.8 years) admitted with acute Stanford type A dissection involving the aortic arch were analysed by semi-automatic detection protocol of the true lumen of the dissection. We measured the distances from the apex to the ascending and descending aorta, the curvilinear length of the entire arch and of its segments (especially between the brachiocephalic artery trunk and the left subclavian artery), as well as the surface area, angle, height and shift of the arch. These measurements were compared with results previously obtained in a healthy cohort in an analysis adjusted for age, sex and weight. The surface area and rotation of the false lumen were also analysed.

Results: Compared to normal aortic arches (N), dissected aortic arches (D) were longer (D: 155 ± 26  mm, N: 135 ± 25  mm, p = 0.002), higher (D: 51 ± 10  mm, N: 45 ± 9  mm, p = 0.04), and with a more anterior apex (shift: D: 1.19 ± 0.56, N: 1.40 ± 0.62, p = 0.007). False lumen occupied between 47-65% of the aorta, turned preferentially clockwise and its rotation decreased progressively along the arch.

Conclusions: The morphology of the dissected aortic arch differs from that of the normal arch. Thus, our compilation of aortic arch measurements may help improve existing endovascular devices and/or design of new endoprostheses. Advances in knowledge: In this article, we provide a comprehensive set of measurements of the dissected aortic arch, and show that dissected aortic arches are longer, higher, and with a more anterior apex than normal arches.
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http://dx.doi.org/10.1259/bjr.20170417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5853365PMC
October 2017

Combined Preoperative Portal and Hepatic Vein Embolization (Biembolization) to Improve Liver Regeneration Before Major Liver Resection: A Preliminary Report.

World J Surg 2017 07;41(7):1848-1856

Department of Digestive and Hepatobiliary Surgery, Estaing Hospital, CHU Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France.

Background: Insufficient volume of the future liver remnant (FLR) is a major cause of non-resectable disease in patients presenting with primary or metastatic liver tumours. The objective of this study was to evaluate the safety and efficacy of the combined preoperative portal and hepatic vein embolization (biembolization) before extended right liver resections.

Methods: This retrospective study was performed in a tertiary centre between 2014 and 2015. Combined right portal and hepatic vein embolization (biembolization) was proposed, as an alternative to ALPPS procedure, for all patients with primary or metastatic liver tumour, before right extended hepatectomy. CT scan liver volumetry was assessed before biembolization, three weeks after biembolization and one week after surgery.

Results: Seven patients underwent biembolization. All patients had right portal vein embolization (PVE) combined with right hepatic vein embolization (HVE, n = 4), median HVE (n = 2) and right + median HVE (n = 1). Three patients had preoperative liver disease and two received preoperative chemotherapy. No biembolization procedure-related complications occurred. The mean FLR regeneration rate was 52.6% (range: 18.2-187.9) after the biembolization. One patient with gallbladder carcinoma was not operated because of peritoneal carcinomatosis diagnosed after the biembolization. The remnant six patients did not develop postoperative liver failure.

Conclusions: Biembolization seems to induce safe, reproducible and effective FLR growth before extended right hepatectomy, in patients with primary or metastatic liver tumour.
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http://dx.doi.org/10.1007/s00268-017-4016-5DOI Listing
July 2017

Non-lethal Right Liver Atrophy After TIPS Occlusion in A Cirrhotic Patient: Introducing The Hepatic Biembolization.

J Gastrointest Surg 2016 09 25;20(9):1671-2. Epub 2016 Mar 25.

Department of Digestive and Hepatobiliary Surgery, Estaing Hospital, CHU Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France.

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is the standard procedure in the treatment of refractory ascites and variceal bleeding in the setting of portal hypertension. Secondary obstruction of the shunt is a classic but potentially lethal complication.

Methods: We present here the case of a cirrhotic patient that underwent a TIPS for refractory ascites, with early complete thrombosis without lethal complication.

Results: Obstruction of the TIPS led to thrombosis of both the right hepatic and the right portal veins with progressive total atrophy of the right liver and marked hypertrophy of the left liver. Despite initial poor liver function, biological hepatic markers improved slowly until complete recovery.

Conclusion: Hence, we suggest the concept of combined right portal and hepatic vein embolization as a new procedure to induce partial liver hypertrophy before major liver resection, even in cirrhotic patients.
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http://dx.doi.org/10.1007/s11605-016-3133-zDOI Listing
September 2016

Comparison of two transarterial chemoembolization strategies for hepatocellular carcinoma.

Anticancer Res 2014 Dec;34(12):7247-53

Department of Pharmacy, University Hospital, Dijon, France EA 4184, Burgundy University, Dijon, France

Aim: This retrospective study aimed to compare the efficacy of and tolerance to two center-related conventional transarterial chemoembolization (TACE) strategies in the management of unresectable hepatocellular carcinoma (HCC).

Patients And Methods: All HCC patients in whom TACE was initiated in the two centers from June 2008 to July 2011 were included. The TACE strategy performed in center 1 was "on demand" with selective injections of idarubicin, whereas the TACE strategy in center 2 was based "on scheduled" non-selective injections of epirubicin. Toxicity was evaluated using the National Cancer Institute Common Terminology Criteria for Adverse Events v4.0.

Results: One hundred and fifty HCC patients were included. Median time to treatment failure was significantly higher in center 1, 13.1 months vs. 7.9 months in center 2 (hazard ratio, 2.32; p<10-3 in multivariate analysis). Median overall survival was 21.1 months in center 1 vs. 18.4 months in center 2 (p=NS). The proportion of grade ≥ 3 adverse events and mean hospitalisation duration for the overall TACE treatment were significantly greater in center 2 than in center 1: 56% vs. 32% (p<0.01) and 14.2 ± 7.2 days vs. 10.3 ± 7.0 days (p<0.01), respectively.

Conclusion: Our results failed to show any significant survival differences between two center-related TACE strategies but showed a significantly smaller proportion of grade ≥ 3 adverse events and shorter hospitalisation for the overall treatment when the "on-demand" strategy was used.
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December 2014

Ovarian thrombosis and uterine synechiae after arterial embolization for a late postpartum haemorrhage.

Case Rep Womens Health 2015 Jan 22;5:1-4. Epub 2014 Nov 22.

Department of Obstetrics and Gynaecology, Academic Medical Centre, France.

Background: We report two unusual separate complications after uterine artery embolization for a late postpartum haemorrhage. This report appeared important to us in view of the apparent absence of any other publications on this topic.

Case Presentation: We report the case of a 25-year-old woman, gravida 3, para 1, admitted for uterine bleeding 7 days after a spontaneous delivery at term, in our university hospital. A suction curettage and then, after persistent bleeding, uterine artery embolization were necessary. Immediately after the embolization, a bilateral ovarian thrombosis occurred, subsequently followed by amenorrhea, due to uterine synechiae, and depression. Hysteroscopic surgery was performed to remove the adhesions. A complete work-up for thrombophilia showed a heterozygous mutation of the factor V gene R506Q. The pathology examination found subinvolution of the placental bed. One month after treatment of the synechiae (and insertion of a copper IUD for contraception), the woman's menstrual cycle returned to normal. Her clinical examination 19 months later was normal.

Conclusions: This case teaches us that one rare complication can hide another! It is important to consider the diagnosis of subinvolution of the placental bed in cases of late PPH and to know the complications associated with vascular artery embolization in order to provide the most rapid and least invasive treatment.
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http://dx.doi.org/10.1016/j.crwh.2014.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5863026PMC
January 2015

Comparison between three types of stented pericardial aortic valves (Trivalve trial): study protocol for a randomized controlled trial.

Trials 2013 Dec 3;14:413. Epub 2013 Dec 3.

Heart Surgery Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France.

Background: Aortic valve stenosis is one of the most common heart diseases in older patients. Nowadays, surgical aortic valve replacement is the 'gold standard' treatment for this pathology and the most implanted prostheses are biological ones. The three most implanted bovine bioprostheses are the Trifecta valve (St. Jude Medical, Minneapolis, MN, USA), the Mitroflow valve (Sorin Group, Saluggia, Italy), and the Carpentier-Edwards Magna Ease valve (Edwards Lifesciences, Irvine, CA, USA). We propose a randomized trial to objectively assess the hemodynamic performances of these bioprostheses.

Methods And Design: First, we will measure the aortic annulus diameter using CT-scan, echocardiography and by direct sizing in the operating room after native aortic valve resection. The accuracy of information, in terms of size and spatial dimensions of each bioprosthesis provided by manufacturers, will be checked. Their hemodynamic performances will be assessed postoperatively at the seventh day and the sixth month after surgery.

Discussion: This prospective controlled randomized trial aims to verify and compare the hemodynamic performances and the sizing of these three bioprostheses. The data obtained may help surgeons to choose the best suitable bioprosthesis according to each patient's morphological characteristics.

Trial Registration: ClinicalTrials.gov Identifier: NCT01522352.
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http://dx.doi.org/10.1186/1745-6215-14-413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4220818PMC
December 2013

Distortion of the CoreValve during transcatheter aortic valve-in-valve implantation due to valve dislocation.

Cardiovasc Revasc Med 2013 Sep-Oct;14(5):294-8. Epub 2013 Aug 9.

Department of Cardiology, Gabriel Montpied Hospital, CHU Clermont-Ferrand, Clermont-Ferrand, France; ERIM-EA3295, University of Auvergne, Clermont-Ferrand, France. Electronic address:

Nowadays transcatheter aortic valve implantation (TAVI) is an accepted alternative to surgical aortic valve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position.
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http://dx.doi.org/10.1016/j.carrev.2013.05.004DOI Listing
April 2014

Unenhanced 3D turbo spin-echo MR angiography of lower limbs in peripheral arterial disease: a comparative study with gadolinium-enhanced MR angiography.

AJR Am J Roentgenol 2013 May;200(5):1145-50

Department of Radiology B, CHU Gabriel Montpied, Clermont-Ferrand, France.

Objective: The purpose of this study was to assess the feasibility and diagnostic performance of an unenhanced MR angiography sequence (Syngo Native Space, Siemens Healthcare) to detect and quantify lower-limb peripheral arterial disease (PAD), with gadolinium-enhanced MR angiography (CE-MRA) as the reference standard.

Subjects And Methods: Fifty-one patients known to have lower-limb arteriopathy were included in this prospective study. For every patient, we performed Native sequence and CE-MRA on a 1.5-T system. We evaluated examination duration, image quality, and location, number, and severity of lesions.

Results: Examination duration was longer for Native sequence (mean, 39.6 min, vs 10 min for CE-MRA). Image quality was significantly better for CE-MRA, with 92% of images listed as good to excellent for CE-MRA, compared to 53% for Native. Sensitivity, specificity, negative predictive value (NPV), and accuracy of Native were respectively 75%, 95%, 89%, and 88% for all mixed levels; 52%, 97%, 88%, and 87% for aortoiliac level; 87%, 99%, 95%, and 92% for femoropopliteal level; and 82%, 87%, 87%, and 85% for subpopliteal level. If we considered only patients with Leriche and Fontaine stage II arteriopathy, Native results were slightly better, with respective specificities and NPVs of 96% and 91% for all mixed levels; 98% and 90% for aortoiliac level; 98% and 93% for femoropopliteal level; and 91% and 90% for subpopliteal level.

Conclusion: Unenhanced MR angiography, cheaper than CE-MRA, showed in our study a good NPV, which suggests its utility as first-line test to screen for PAD, especially in patients at risk of nephrogenic systemic fibrosis.
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http://dx.doi.org/10.2214/AJR.12.8730DOI Listing
May 2013

Unenhanced MR angiography of renal arteries: 51 patients.

AJR Am J Roentgenol 2012 Nov;199(5):W629-37

Department of Radiology B, Centre Hospitalier Universitaire Gabriel Montpied, 58 rue Montalembert, 63003, Clermont-Ferrand, France.

Objective: The purpose of this research was to assess the feasibility and performance of an unenhanced 3D balanced steady-state free precession (SSFP) sequence, compared with contrast-enhanced MR angiography (CEMRA), which is the reference standard to detect and quantify renal artery stenoses (RAS).

Subjects And Methods: Fifty-one patients were included in this prospective study. Balanced SSFP sequence (Native) and CEMRA were performed using a 1.5-T magnet. Signal quality and stenosis grade were assessed per segment for renal arteries and for ostia of celiac trunk and superior mesenteric artery (SMA). We compared signal quality of Native and CEMRA. Sensitivity, specificity, negative predictive value (NPV), and accuracy were also calculated.

Results: Evaluation involved 114 renal arteries, 51 celiac trunks, and 51 SMAs. By use of CEMRA, 20 significant stenoses were found for renal arteries, 10 stenoses and three occlusions for celiac trunk, and three stenoses for SMA. At artery-by-artery analysis, sensitivity, specificity, accuracy, and NPV of the balanced SSFP sequence in detecting stenosis were respectively 85%, 96%, 94%, and 96% for renal arteries; 100%, 97%, 98%, and 100% for celiac trunk; and 100%, 100%, 100%, and 100% for SMA. No significant difference of signal quality was found for the entire examination and for the different segments evaluated except for hilar and intrarenal branches, which showed better signal quality on balanced SSFP sequence.

Conclusion: The NPV results in our study suggest that unenhanced balanced SSFP MR angiography can be the first-choice imaging method to exclude RAS in patients at high risk of nephrogenic systemic fibrosis. However, when stenosis is found, other imaging modalities are necessary for better estimation.
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http://dx.doi.org/10.2214/AJR.12.8513DOI Listing
November 2012

Embolization and endothelial ablation with chitosan and sodium sotradecol sulfate: preliminary results in an animal model.

J Endovasc Ther 2012 Jun;19(3):439-49

Service de Radiologie, CHU Clermont-Ferrand, France.

Purpose: To investigate whether embolization with chitosan hydrogel (CH) with or without a sclerosant (sodium tetradecyl sulphate, STS) can induce chemical endothelial ablation and prevent endothelial recanalization in a rabbit model.

Methods: Chitosan radiopaque thermogels were prepared using chitosan, β-glycerophosphate, iopamidol, and different STS concentrations. Each auricular artery of 14 New Zealand White rabbits was cannulated and injected with 0.6 mL of chitosan (CH0; n = 14) on one side and either saline (n = 3), chitosan and 1% STS (CH1; n = 6), or chitosan and 3% STS (CH3; n = 6) in the contralateral side. Immediately after embolization and at 1, 7, 14, and 30 days, auricular artery patency and percentage of recanalization were assessed by visual inspection; microcirculation was evaluated using laser Doppler imaging (LDI). The rabbits were sacrificed at 30 days to assess endothelial ablation and inflammatory response by histological analyses.

Results: All arteries were catheterized and embolized with success. All saline-injected arteries rapidly recovered normal flow. The length of embolization was greater with CH3 than CH1 or CH0, regardless of the time observed (p<0.001). No difference in recanalization length was found among the gels (p = 0.07). Destruction of arterial wall was frequently observed independent of embolizing agent. Foreign body reaction was more frequent with CH3 as compared with CH1 and CH0 (p = 0.0070 and 0.0058, respectively). After 30 days, hypervascularization was observed on LDI only with CH0; it was attributed to intra- or perivascular neovessels and inflammatory response on pathological analysis. The vascular modifications appeared to be more homogenous across the length of embolization with CH3 than the other formulations.

Conclusion: The viscosity obtained with chitosan and 3% STS permits better control during injection and longer vascular occlusion. These findings, combined with the intravascular neovascularization observed with CH0, led us to prefer the combination with STS.
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http://dx.doi.org/10.1583/11-3745R.1DOI Listing
June 2012

Cisplatin pharmacokinetics in nontumoral pig liver treated with intravenous or transarterial hepatic chemoembolization.

Cardiovasc Intervent Radiol 2012 Dec 24;35(6):1467-74. Epub 2012 Apr 24.

Pôle de Radiologie, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.

Purpose: To evaluate cisplatin (CDDP) pharmacokinetics after its intravenous (IV) or intrahepatic arterial administration (IHA) in healthy pigs with or without embolization by absorbable gelatine.

Material And Methods: We analysed plasmatic and hepatic drug concentration in four groups of six mini-pigs each according to the modality of administration of CDDP (1 mg/kg): IV, IHA, IHA with partial embolization using absorbable gelatine (IHA-Pe), and IHA with complete embolization (IHA-Te). Unbounded plasmatic and hepatic platinum concentrations were measured. Concentration and pharmacokinetics parameters were compared using analysis of variance.

Results: For all groups, there was a rapid and biexponential decrease in free platinum concentration. Plasmatic terminal half-life (T(1/2)) was significantly decreased after embolization at 191, 178, 42, and 41 min after IV, IHA, IHA-Pe, and IHA-Te administration, respectively. Maximal plasmatic concentration and systemic exposure to CDDP (AUC(24)) values were significantly decreased after embolization (C(max) p = 0.0075; AUC(24) p = 0.0053). Hepatic CDDP concentration rapidly peaked and then decreased progressively. After 24 h, the residual concentration represented 45, 47, 60, and 63 % of C(max), respectively, after IV, IHA, IHA-Pe, and IHA-Te. Hepatic T(1/2) and AUC(∞) values were increased after embolization, but the differences were not statistically significant.

Conclusion: This preliminary study confirms the feasibility of a pig model to study systemic and hepatic CDDP pharmacokinetics. Systemic exposure is lower after embolization, which could minimize systemic toxicity. Hepatic T(1/2) elimination and hepatic exposition values are increased with IHA compared with IV administration.
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http://dx.doi.org/10.1007/s00270-012-0386-0DOI Listing
December 2012

Management of isolated non-traumatic renal artery dissection: report of four cases.

Acta Radiol 2012 May 19;53(4):401-5. Epub 2012 Apr 19.

Department of Radiology, Clermont Ferrand University Hospital, Université D'Auvergne, France.

Background: Isolated non-traumatic renal artery dissection (RAD) is a rare disorder with uncertain natural history. The management may be surgical reconstruction, endovascular repair, or conservative medical treatment, yet no official consensus had been established.

Purpose: To report the management of four cases of isolated non-traumatic RAD, emphasizing the beneficial role of conservative medical treatment.

Material And Methods: From the year 2000 till 2011, four male patients with mean age of 42.5 years (range 34-48 years) presented with isolated non-traumatic RAD and were initially treated with medical therapy. Transcatheter in situ thrombolysis was performed in a case with thrombotic occlusion.

Results: Isolated non-traumatic RAD in four patients involving at least seven branches progressed to thrombotic occlusion in two branches, luminal narrowing in five, dual lumens in two, and aneurysmal dilatation in three. Medical treatment was efficacious in three patients, who showed persistent preserved renal function, controlled blood pressure, and favorable arterial remodeling. After failure of medical therapy, the fourth patient was referred to surgery. Thrombolysis was successful to dissolute an occluding thrombotic dissection.

Conclusion: Conservative therapy is safe and effective when the renal artery is patent and blood pressure is controlled: we propose it as the first line of treatment, reserving interventional management for refractory cases.
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http://dx.doi.org/10.1258/ar.2012.110303DOI Listing
May 2012

A new injectable radiopaque chitosan-based sclerosing embolizing hydrogel for endovascular therapies.

Acta Biomater 2012 Jul 7;8(7):2712-21. Epub 2012 Apr 7.

École de technologie supérieure, Department of Mechanical Engineering, Montréal, Québec, Canada.

Endovascular repair of abdominal aortic aneurysms with a stent graft is limited by the persistence or recurrence of endoleaks. These are believed to be related to the recanalization of the aneurismal sac by endothelialized neochannels, which could lead to late type I and II endoleaks. Embolization has been proposed to treat or prevent endoleaks, but presently commercialized embolizing materials have several drawbacks and do not fully prevent endoleak recurrence. A novel chitosan hydrogel that is injectable, radiopaque and contains sodium tetradecyl sulfate (STS), a well-known sclerosing agent, was developed in order to combine blood flow occlusion and endothelium ablation properties. chitosan/STS hydrogels were characterized and optimized using rheometry, scanning electron microscopy, swelling and ex vivo embolization assay. They were shown to exhibit rapid gelation and good mechanical properties, as well as sclerosing properties. Their potential for the embolization of aneurysms was subjected to preliminary in vivo evaluation in a bilateral iliac aneurysm model (three dogs) reproducing persistent endoleaks after endovascular aneurysm repair (EVAR). At 3 months no endoleak was detected in any of the three aneurysms treated with chitosan/STS hydrogels. In contrast, type I endoleaks were detected in two of the three aneurysms treated with chitosan hydrogels. Generally, chitosan/STS hydrogels have great potential as embolizing and sclerosing agents for EVAR and possibly other endovascular therapies.
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http://dx.doi.org/10.1016/j.actbio.2012.04.006DOI Listing
July 2012

Endovascular treatment of eight renal artery aneurysms.

Acta Radiol 2012 May 20;53(4):430-4. Epub 2012 Mar 20.

Department of Radiology, Clermont Ferrand University Hospital, Université D'Auvergne, France.

Background: Renal artery aneurysms (RAA) are a relatively rare vascular entity. Treatment could be either surgical or via an endovascular route. The main aim of therapy is to prevent lethal rupture.

Purpose: To evaluate the angiographic and clinical results after endovascular treatment (EVT) of eight renal artery aneurysms.

Material And Methods: From January 2000 to June 2011, 18 patients presented with 18 renal artery aneurysms. One was classified as Rundback type I, 15 were type II, and two aneurysms were type III. Endovascular treatment was considered unsafe in 10 cases (all were Rundback type II), and were referred to surgery. The remaining eight aneurysms were treated endovascularly during altogether nine sessions. Among these, four patients were asymptomatic, three were hypertensive, and one presented with ipsilateral flank pains. Aneurysmal sac diameter varied between 12 and 50 mm. EVT included selective coil embolization in five cases, covered stents in two cases, and parent artery occlusion in one.

Results: Follow-up with CT angiography was obtained in all endovascularly treated aneurysms (range 6-54 months, mean 15 months). Complete durable occlusion was achieved in all aneurysms except one, which showed re-expansion after 20 months and was retreated with covered stent implantation. Clinically silent, branch occlusion occurred after four procedures with subsequent limited (less than 25%) ischemic parenchymal loss. All patients were discharged with preserved renal function. Clinical improvement was noted in all symptomatic patients.

Conclusion: Endovascular treatment of renal artery aneurysms is an adequate treatment and can be proposed, if feasible, as first step.
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http://dx.doi.org/10.1258/ar.2012.110458DOI Listing
May 2012

Acute thrombotic mesenteric ischemia: primary endovascular treatment in eight patients.

Cardiovasc Intervent Radiol 2011 Oct 30;34(5):942-8. Epub 2011 Jun 30.

Digestive Surgery Department, CHU Estaing, 1 Place Lucie Aubrac, 63003 Clermont Ferrand Cedex 1, France.

Introduction: The purpose of this study was to evaluate our experience with initial percutaneous transluminal angioplasty (PTA) ± stenting as valuable options in the acute setting.

Methods: Between 2003 and 2008, eight patients with abdominal angio-MDCT-scan proven thrombotic AMI benefited from initial PTA ± stenting. We retrospectively assessed clinical and radiological findings and their management. Seven patients presented thrombosis of the superior mesenteric artery, and in one patient both mesenteric arteries were occluded. All patients underwent initial PTA and stenting, except one who had balloon PTA alone. One patient was treated by additional in situ thrombolysis.

Results: Technical success was obtained in all patients. Three patients required subsequent surgery (37.5%), two of whom had severe radiological findings (pneumatosis intestinalis and/or portal venous gas). Two patients (25%) died: both had NIDD, an ASA score ≥4, and severe radiologic findings. Satisfactory arterial patency was observed after a follow-up of 15 (range, 11-17) months in five patients who did not require subsequent surgery, four of whom had abdominal guarding but no severe CT scan findings. One patient had an ileocecal stenosis 60 days after the procedure.

Conclusions: Initial PTA ± stenting is a valuable alternative to surgery for patients with thrombotic AMI even for those with clinical peritoneal irritation signs and/or severe radiologic findings. Early surgery is indicated if clinical condition does not improve after PTA. The decision of a subsequent surgery must be lead by early clinical status reevaluation. In case of underlying atherosclerotic lesion, stenting should be performed after initial balloon dilatation.
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http://dx.doi.org/10.1007/s00270-011-0212-0DOI Listing
October 2011

Recurrent bleeding within 24 hours after uterine artery embolization for severe postpartum hemorrhage: are there predictive factors?

Cardiovasc Intervent Radiol 2012 Jun 26;35(3):508-14. Epub 2011 May 26.

Department of Radiology, Gabriel Montpied Hospital, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.

Purpose: To retrospectively identify predictive factors of recurrent bleeding within 24 h after uterine artery embolization (UAE) for postpartum hemorrhage (PPH).

Materials And Methods: A total of 194 patients underwent UAE for PPH between August 1999 and April 2009 at our institution. Twelve patients experienced recurrent bleeding within the next 24 h; a second attempt at UAE was thus necessary, which was successful in 10 cases. In two cases, hemostatic hysterectomy was performed. Epidemiological, gynecological-obstetrical, anatomic, and biological data were analyzed.

Results: Complete data were available for 148 of the 194 (76%) included patients. Sixty-four (43%) were primiparous, 18 (12.2%) had a placenta accreta, 21 (14%) had a coagulopathy, and 28 (18.9%) had an anatomic variant of the uterine arterial vasculature. Mean age and pregnancy term were similar in both recurring and nonrecurrent bleeding groups. After multivariate analysis, three criteria emerged as risk factors of recurrent bleeding: primiparity (10 patients, 83%; odds ratio [OR]=18.84; P=0.014), coagulation disorders (6 patients, 50%; OR=12.08; P=0.006), and anatomic variant of the uterine arterial vasculature (28 patients; OR=9.83; P=0.003).

Conclusion: Search for uterine collaterals must be performed before UAE for PPH. Primiparity and coagulation disorders increase the risk of recurrent bleeding after UAE for PPH.
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http://dx.doi.org/10.1007/s00270-011-0181-3DOI Listing
June 2012

Arterial injury complicating subclavian central venous catheter insertion.

J Cardiothorac Vasc Anesth 2012 Feb 18;26(1):101-3. Epub 2011 Feb 18.

Department of Radiology, Gabriel Montpied Hospital, Clermont-Ferrand, France.

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http://dx.doi.org/10.1053/j.jvca.2010.11.024DOI Listing
February 2012

[Acute aortic syndrome and endovascular treatment: good indications of stent-graft, stent and aortic fenestration].

Presse Med 2011 Jan 3;40(1 Pt 1):62-71. Epub 2010 Dec 3.

Centre hospitalier universitaire, pôle d'imagerie, service de radiologie B, Université d'Auvergne Clermont 1, faculté de médecine, EA 3295, BP 38, 63001 Clermont-Ferrand cedex 1, France.

Acute aortic syndrome of the descending aorta can be treated with stent-graft thanks to technical and material development. Ruptured aneurysms, aortic dissection, wall hematoma and penetrating ulcers can be treated with stent-graft. According to the type of initial lesion, and the clinical tolerance, the emergency of treatment can be different. Non covered stent and aortic fenestration are used in case of visceral ischemia in aortic dissection, according to the type of ischemia.
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http://dx.doi.org/10.1016/j.lpm.2010.10.013DOI Listing
January 2011