Publications by authors named "Pierre Alric"

98 Publications

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine.

Interact Cardiovasc Thorac Surg 2021 Jul 30. Epub 2021 Jul 30.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objectives: This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC).

Methods: Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10.

Results: There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence.

Conclusions: VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.
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http://dx.doi.org/10.1093/icvts/ivab215DOI Listing
July 2021

Endovascular aortic arch repair with a pre-cannulated double-fenestrated physician-modified stent graft: a benchtop experiment.

Interact Cardiovasc Thorac Surg 2021 05;32(6):942-949

Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objectives: The critical step in total endovascular aortic arch repair is to ensure alignment of fenestrations with, and thus maintenance of flow to, supra-aortic trunks. This experimental study evaluates the feasibility and accuracy of a double-fenestrated physician-modified endovascular graft [single common large fenestration for the brachiocephalic trunk and left common carotid artery and a distal small fenestration for left subclavian artery (LSA) with a preloaded guidewire for the LSA] for total endovascular aortic arch repair.

Methods: Eight fresh human cadaveric thoracic aortas were harvested. Thoracic endografts with a physician-modified double fenestration were deployed for total endovascular aortic arch repair in a bench test model. A guidewire was preloaded through the distal fenestration for the LSA. All experiments were undertaken in a hybrid room under fluoroscopic guidance with subsequent angioscopy and open evaluation for assessment.

Results: Mean aortic diameter in zone 0 was 31.3 ± 3.33 mm. Mean duration for stent graft modification was 20.1 ± 5.8 min. Mean duration of the procedure was 24 ± 8.6 min. The Medtronic Valiant Captivia stent graft was used in 6 and the Cook Alpha Zenith thoracic stent graft in 2 cases. LSA catheterization was technically successful with supra-aortic trunk patency in 100% of cases.

Conclusions: The use of a double-fenestrated stent graft with a preloaded guidewire appears to be a useful technical addition to facilitate easy and correct alignment of stent graft fenestrations with supra-aortic trunk origins.
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http://dx.doi.org/10.1093/icvts/ivab023DOI Listing
May 2021

Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients.

J Vasc Surg 2021 Jun 20;73(6):1898-1905.e1. Epub 2020 Nov 20.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objective: Our aim was to evaluate the early- and medium-term outcomes of using double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular aortic arch repair.

Methods: The present single-center retrospective analysis of prospectively collected data included 50 patients from January 2017 through October 2019, who had undergone thoracic endovascular aortic repair (TEVAR). The fenestrations were a proximal larger fenestration that incorporated the brachiocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented.

Results: The median duration for stent graft modification was 26 ± 6 minutes. Of the 50 patients, 41 were men. The mean patient age was 68 ± 11.5 years. The indications for treatment included degenerative aortic arch aneurysm (n = 17), dissecting aortic arch aneurysm after type A dissection (n = 13), type B dissection (n = 13), aortic ulcer (n = 3), and other pathologies (n = 4). The technical success rate was 94% (47 of 50) overall, and 100% (28 of 28) after a technical modification incorporating a preloaded guide wire for the LSA fenestration (P < .05). The 30-day mortality was 2% (n = 1). Two patients (4%) had a minor stroke with full recovery. One patient (2%) had a type IB and two patients (4%) had a type II endoleak from the LSA. Four patients (8%) required reintervention: one because of a type IB endoleak and three because of access-related complications. All supra-aortic trunks were patent. During a mean follow-up of 16 ± 8.3 months, no conversions to open surgical repair were required and no aortic rupture, paraplegia, or retrograde dissection occurred.

Conclusions: Using double fenestrated PMEGs for TEVAR is both feasible and effective for total endovascular aortic arch repair, avoiding the need for anatomic and extra-anatomic surgical revascularization. The absence of brachiocephalic trunk stenting was not associated with endoleaks or treatment failure and resulted in a lower stroke risk than alternative strategies. The midterm results suggest that stenting of the brachiocephalic trunk and right common carotid artery might not be necessary for a large proportion of patients undergoing total endovascular aortic arch repair. The persistence of the seal and ongoing durability require assessment in studies with long-term follow-up data available.
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http://dx.doi.org/10.1016/j.jvs.2020.09.041DOI Listing
June 2021

Asymptomatic Internal Carotid Aneurysm: An Uncommon Disease of the Carotid Arteries.

Ann Vasc Surg 2021 Jan 22;70:570.e1-570.e5. Epub 2020 Sep 22.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Despite a low-incidence extracranial carotid artery aneurysm (ECAA) disease has important clinical repercussion that obliges understanding and knowledge of correct treatment. The 2 dominant etiologies are atherosclerotic degeneration and pseudoaneurysm. The natural history of ECAAs is understood. Neck pain, a pulsatile mass and central or peripheral neurological manifestations are the most common symptoms. Recommendations for diagnosis and treatment are not uniform and still under discussion, representing a challenge for clinicians. We discuss a case of 2.5 cm asymptomatic saccular atherosclerotic ECAA treated surgically in light of the most recent literature.
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http://dx.doi.org/10.1016/j.avsg.2020.08.127DOI Listing
January 2021

Prevention of Retrograde Ascending Aortic Dissection by Cardiac Pacing During Hybrid Surgery for Zone 0 Aortic Arch Repair.

Ann Vasc Surg 2021 Feb 11;71:48-55. Epub 2020 Sep 11.

Department of Vascular and Thoracic Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Background: Retrograde type A dissection (RTAD) after zone 0 hybrid aortic arch repair is highly lethal and not infrequent complication. The aim of this study was to assess the safety and effectiveness of rapid cardiac pacing as an adjunctive tool to prevent RTAD during or after hybrid procedures for zone 0 disease.

Methods: We performed a retrospective review of 42 consecutive patients with zone 0 hybrid aortic arch repair between November 2004 and January 2018. Right ventricular pacing was carried out through unipolar electrodes attached to the epicardium of the right ventricle through the sternotomy (the indifferent electrode was in the subcutaneous tissue). Pacing was utilised during the clamping of the ascending aorta, release of the aortic clamp, and stent-graft deployment.

Results: Operative indications were aortic arch aneurysm 45% (n = 19), aortic arch dissection 45% (n = 19), traumatic rupture of isthmus 7% (n = 3), and type IA endoleak 2% (n = 1). Urgent procedures 48% (n = 20). The mean proximal aortic diameter was 34.14 ± 2.9 mm. Mean stent-graft oversizing was 12.97 ± 3.4%. The 30-day mortality rate was 14% (n = 6). RTAD was observed in 7% (n = 3). The actuarial survival rate was 74% over a mean follow-up of 50 ± 30.2 months. Since January 2013, rapid right ventricular pacing (overdrive pacing at a rate of 200 beats/min) was systematically used (n = 24). No RTAD was observed in this group of patients. Rapid right ventricular pacing reduced significatively the risk of RTAD (P = 0.038).

Conclusions: Rapid right ventricular pacing is an effective method of inducing hypotension and appears to decrease the risk of retrograde type A dissection after zone 0 hybrid aortic arch repair.
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http://dx.doi.org/10.1016/j.avsg.2020.08.136DOI Listing
February 2021

ASO Author Reflections: Preoperative Embolization or Arterial Reconstruction for Distal Pancreatectomy with Celiac Axis Resection.

Ann Surg Oncol 2020 Dec 7;27(Suppl 3):812-813. Epub 2020 Jul 7.

Department of Surgical Oncology, Institut du Cancer de Montpellier (ICM), Montpellier, France.

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http://dx.doi.org/10.1245/s10434-020-08800-3DOI Listing
December 2020

Distal Pancreatectomy with Celiac Axis Resection (Modified Appleby Procedure) and Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma After FOLFIRINOX Chemotherapy and Chemoradiation Therapy.

Ann Surg Oncol 2021 Feb 25;28(2):1106-1108. Epub 2020 Jun 25.

Department of Surgical Oncology, Institut du Cancer de Montpellier (ICM), Montpellier, France.

Background: Resectability of pancreatic carcinoma (PC) is directly linked to vascular extension (Tempero MA et al. in J Natl Compr Canc Netw 15(8):1028-1061, 2017. https://doi.org/10.6004/jnccn.2017.0131 ; Isaji S et al. in Pancreatology 18(1):2-11, 2018. https://doi.org/10.1016/j.pan.2017.11.011 ). Involvement of the celiac axis (CA) is typically a contraindication to surgery. High postoperative morbidity and subsequent poor prognosis have been observed in this case, especially for contact > 180° requiring arterial resection (Tempero MA et al. 2017). Recent medical advances in PC treatment, such as FOLFIRINOX-based chemotherapy eventually followed by chemoradiation therapy, offer the potential to select tumour for surgery and to obtain a negative-margin resection even in case of unresectable PC at diagnosis (Suker M et al. in Lancet Oncol 17(6):801-10, 2016. https://doi.org/10.1016/s1470-2045(16)00172-8 ; Pietrasz D et al. in Ann Surg Oncol 26(1):109-117, 2019. https://doi.org/10.1245/s10434-018-6931-6 ). A major pathologic response has been observed in more than 20% of patients after this treatment and is associated with an improved survival (Suker M et al. 2016; Pietrasz D et al. 2019). This evolution allows aggressive surgical strategies with the possibility of long-term disease control for patients showing a good response to induction treatment.

Patient: This video presents the case of a 66-year-old man diagnosed with a locally advanced ductal adenocarcinoma of the pancreatic body with a 360° involvement of the CA and the hepatic artery. After eight courses of FOLFIRINOX chemotherapy and a capecitabin-based chemoradiation, a surgical exploration was planned for potential resection.

Technique: The key steps of the procedure are presented, i.e. surgical exposition, assessment of resectability with frozen sections of peri-arterial tissues, en bloc resection (Strasberg SM et al. in Surgery 133(5):521-527, 2003. https://doi.org/10.1067/msy.2003.146 ), and primary end-to-end arterial reconstruction.

Conclusion: A modified Appleby operation for locally advanced PC is a technically challenging but feasible procedure in experienced teams. It offers the possibility of en bloc R0 resection of a locally advanced PC with the potential of long-term disease local control. This video may help surgeons to perform this complex intervention.
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http://dx.doi.org/10.1245/s10434-020-08740-yDOI Listing
February 2021

Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair.

J Endovasc Ther 2020 Oct 4;27(5):785-791. Epub 2020 Jun 4.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a "universal double fenestration" design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.
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http://dx.doi.org/10.1177/1526602820931787DOI Listing
October 2020

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms.

J Vasc Surg 2021 02 27;73(2):502-509.e1. Epub 2020 May 27.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objective: Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported.

Methods: This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival.

Results: Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively.

Conclusions: Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.
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http://dx.doi.org/10.1016/j.jvs.2020.05.033DOI Listing
February 2021

Early outcomes of native and graft-related abdominal aortic infection managed with orthotopic xenopericardial grafts.

J Vasc Surg 2021 01 20;73(1):222-231. Epub 2020 May 20.

Department of Thoracic and Vascular Surgery, Hôpital A de Villeneuve, Montpellier, France.

Objective: Reconstruction of infected aortic cases has shifted from extra-anatomic to in situ. This study reports the surgical strategy and early outcomes of abdominal aortic reconstruction in both native and graft-related aortic infection with in situ xenopericardial grafts.

Methods: Included in the analysis are 21 consecutive patients (mean age, 69 years; 20 male) who underwent abdominal xenopericardial in situ reconstruction of native aortic infection (4) and endovascular (4) or open (13) graft aortic infection between July 2017 and September 2019. All repairs were performed on an urgent basis, but none were ruptured. All patients were followed up with clinical and biologic evaluation, ultrasound at 3 months, and computed tomography scan at 6 months and 1 year.

Results: Technical success was 100%; 8 patients were treated with xenopericardial tubes and 13 with bifurcated grafts. Thirty-day mortality was 4.7% (one death due to pneumonia with respiratory hypoxic failure in critical care.). Six patients (28%) developed acute kidney injury, four (19%) requiring temporary dialysis; five fully recovered and one died. Four patients (19%) required a return to the operating room. After a median follow-up of 14 months (range, 1-26 months), overall mortality was 19% (n = 4). Two patients presented with recurrent sepsis after reconstruction, leading to death due to multiorgan failure. Other patients (17/21) have discontinued antibiotics with no evidence of recurrence of infection clinically, radiologically, or on blood tests. Computed tomography scans at 1 year demonstrated no stenosis or graft dilation and one asymptomatic left graft branch thrombosis. Primary patency is 95%.

Conclusions: In situ xenopericardial aortic reconstruction is a safe and effective management strategy for both native and graft-related abdominal aortic infection with good short-term results. The graft demonstrates appropriate resistance to infection such that reliable eradication of infection in this vascular bed is possible. Longer follow-up is required in future studies to determine the durability of the reconstruction and need for reinterventions.
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http://dx.doi.org/10.1016/j.jvs.2020.04.513DOI Listing
January 2021

Short- and Long-Term Outcomes Following Biological Pericardium Patches Versus Prosthetic Patches for Carotid Endarterectomy: A Retrospective Bicentric Study.

Ann Vasc Surg 2021 Apr 24;72:66-71. Epub 2020 Apr 24.

Department of Vascular and Thoracic Surgery, CHU de Nîmes, Nîmes, France.

Background: Currently, there are various types of patches available on the market for carotid endarterectomy (CEA) with enlargement angioplasty, prosthetic, and biological patches including bovine pericardial patches. Despite the increasing use of these biological patches, there are little data in the literature comparing the results of these 2 types of patch. The purpose of this study is to compare the short- and long-term results of bovine pericardium patches (BPPs) with prosthetic patches (PPs) in carotid thromboendarterectomy.

Methods: This study presents a retrospective analysis of all CEAs performed at Montpellier and Nîmes University Hospitals (France) in 2014 and 2015. Patients who underwent eversion were excluded. Preoperative, peroperative, and postoperative clinical and Doppler ultrasound results were collected and analyzed. The primary end point was the comparison of the restenosis rate between the BPP and the PP group. Secondary end points were the analysis of restenosis risk factors (type of patch, gender, renal failure, smoking, diabetes, arterial hypertension, dyslipidemia, and redo surgery were analyzed); the comparison of morbidity-mortality and infection between the BPP and the PP group and the comparison of morbidity-mortality between symptomatic and asymptomatic stenosis.

Results: In total, 342 CEAs were performed: 168 (49%) with BPP and 174 (51%) with PP. Median follow-up was 30 months (interquartile range = 24). The stroke rate at day 30 was 3.22% and mortality at day 30 was 1.86%. There was no significant difference between groups concerning anyone of the variables of interest. At the end of follow-up, the restenosis rate >50% was 7.31% (6.45% for the BPP group vs. 8.22% for the PP group, P = 0.55). The severe restenosis rate (>70%) was 4.65% (5.16% for the BPP group vs. 4.11% for the PP group, P = 0.79). The univariate analysis identified renal failure (odds ratio = 2.69) as the main risk factor. The postoperative infection rate was 1.17% (0.59% for the BPP group vs. 1.75% for the PP group, P = 0.62).

Conclusions: The rates of stroke and postoperative death, bleeding, infection, and restenosis are comparable between BPPs and PPs in our study. The use of prosthetic or biological patches seems to deliver comparable outcomes. Further studies on larger samples are required.
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http://dx.doi.org/10.1016/j.avsg.2020.04.010DOI Listing
April 2021

Commentary: Chimneys and Physician Stent-Graft Modifications: A Chaotic Process or a Glimpse of the Future?

J Endovasc Ther 2020 02;27(1):143-144

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

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http://dx.doi.org/10.1177/1526602819896758DOI Listing
February 2020

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR.

J Endovasc Ther 2020 Jun 24;27(3):377-384. Epub 2019 Oct 24.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.
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http://dx.doi.org/10.1177/1526602819881128DOI Listing
June 2020

Homemade Fenestrated Stent-Grafts for Complete Endovascular Repair of Aortic Arch Dissections.

J Endovasc Ther 2019 10 26;26(5):645-651. Epub 2019 Jun 26.

Department of Thoracic and Cardio-Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

To evaluate outcomes of homemade fenestrated stent-grafts for complete endovascular aortic repair of aortic arch dissections. From July 2014 through September 2018, 35 patients (mean age 66±11 years; 25 men) underwent homemade fenestrated stent-graft repair of acute (n=16) or chronic (n=10) complicated type B aortic dissections (n=16) and dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n=9). Nineteen (54%) procedures were emergent. Zone 2 single-fenestrated stent-grafts were used in 25 cases; the remaining 10 were double-fenestrated stent-grafts deployed in zone 0. Median time for stent-graft modification was 18 minutes (range 16-20). Technical success was achieved in all cases. An immediate distal type I endoleak was treated intraoperatively. Among the double-fenestrated stent-graft cases, the left subclavian artery fenestration could not be cannulated in 2 patients and revascularization was required. Partial coverage of the left common carotid artery necessitated placement of a covered stent in 3 cases. One (3%) patient had a stroke without permanent sequelae. Two type II endoleaks required additional covered stent placement at 5 and 7 days postoperatively, respectively. The 30-day mortality was 6% (2 patients with ruptured aortic arch aneurysm). During a mean follow-up of 17.6±13 months, there was no aortic rupture or retrograde dissection. One late type I endoleak was treated with additional proximal fenestrated stent-graft placement. One type II endoleak is currently under observation. One additional patient died (unrelated to the aorta); overall mortality was 9%. All supra-aortic trunks were patent. The use of homemade fenestrated stent-grafts for endovascular repair of aortic arch dissections is feasible and effective for total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.
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http://dx.doi.org/10.1177/1526602819858578DOI Listing
October 2019

Commentary: Endovascular Repair of the Ascending Aorta: Have We Reached the Moon?

J Endovasc Ther 2019 08 24;26(4):446-447. Epub 2019 Jun 24.

1 Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

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http://dx.doi.org/10.1177/1526602819857524DOI Listing
August 2019

Is Chimney EVAR an Acceptable Endovascular Technique ?

EJVES Short Rep 2019 30;42:43. Epub 2019 Jan 30.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

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http://dx.doi.org/10.1016/j.ejvssr.2019.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424684PMC
January 2019

Trans-iliac Bypass for Critical Limb Ischaemia with Groin Necrosis: A Case Report.

EJVES Short Rep 2019 20;42:31-33. Epub 2019 Feb 20.

Vascular and Thoracic Surgery, CHRU of Montpellier, France.

Introduction: Infections at the level of the groin involving native or prosthetic vessels are typically bypassed using the obturator canal. However, extensive wounds or infections, particularly those involving the medial compartment of the thigh, can preclude this approach.

Report: A 66 year old male with diabetes mellitus presented after several previous revascularisations of the femoral artery with extensive necrosis of the groin and critical limb ischaemia with necrotic changes in the toes. An iliopopliteal bypass through the iliac wing was planned because of the extent of the infection.

Discussion: The post-operative course was uneventful with complete resolution of tissue loss at one year follow up.
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http://dx.doi.org/10.1016/j.ejvssr.2019.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411489PMC
February 2019

Double homemade fenestrated stent graft for total endovascular aortic arch repair.

J Vasc Surg 2019 10 25;70(4):1031-1038. Epub 2019 Mar 25.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objective: The aim of this retrospective analysis was to evaluate the outcomes of physician-modified double fenestrated stent grafts for total endovascular aortic arch repair: one proximal large fenestration for the brachiocephalic trunk and the left common carotid artery and one distal fenestration for the left subclavian artery (LSA).

Methods: From January 2017 through February 2018, 17 patients (88.2% elective) underwent thoracic endovascular aortic repair (TEVAR) with double homemade fenestrated stent graft for total endovascular aortic arch repair to maintain supra-aortic trunk patency. Indications were degenerative aortic arch aneurysm (n = 7), dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n = 6), chronic complicated type B aortic dissection (n = 3), and acute complicated type B aortic dissection (n = 1). Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and supra-aortic trunks patency and endoleak.

Results: The median time for stent graft modification was 19 minutes (range, 16-20 minutes). Endovascular exclusion of the aortic arch was achieved in all the cases. One LSA catheterization failed and LSA revascularization was performed by carotid axillary bypass and coverage of the LSA fenestration by additional stent graft placement. Additional planned endovascular procedures were required in three patients: closure of supra-aortic trunks re-entry tears in two cases of dissecting aortic arch aneurysms and one transcatheter aortic valve replacement for severe native aortic valve regurgitation. One stroke, with no long-term deficit, was observed. No patients died. All left supra-aortic trunks are patent. No type I endoleak was observed. We only observed one patient with a type II endoleak. During a mean follow up of 7 ± 2 months, there were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde dissection.

Conclusions: Double homemade fenestrated TEVAR is both feasible and effective for maintaining the patency of the supra-aortic trunks and allows total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.
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http://dx.doi.org/10.1016/j.jvs.2018.11.054DOI Listing
October 2019

Physician-Modified Thoracic Stent Grafts for the Arch After Surgical Treatment of Type A Dissection.

Ann Thorac Surg 2019 08 19;108(2):491-498. Epub 2019 Mar 19.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Background: This study evaluated the outcome of physician-modified thoracic stent grafts for the treatment of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection.

Methods: From August 2016 through February 2018, 13 patients (8 men and 5 women) underwent thoracic endovascular aortic repair in which physician-modified thoracic stent grafts were used to treat dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. Patients were a mean age of 70.7 ± 10 years (range, 43 to 82 years). Four patients were treated in an emergent setting for a symptomatic aortic arch aneurysm. The aneurysmal disease involved zone 0 in 10 patients and zone 2 in 3. Seven patients (48%) were treated using an aortic arch stent graft with a single fenestration, combined with cervical debranching in 4 patients. Six patients underwent total endovascular aortic arch repair using a double-fenestrated stent graft. Additional planned endovascular procedures were performed in 3 patients.

Results: Median time for stent graft modifications was 18 minutes (range, 14 to 21 minutes). All the proximal entry tears in the arch were successfully excluded. The 30-day mortality rate was 0%. One patient (7.6%) had a stroke without permanent sequelae. The median length of stay was 5 days (range, 1 to 17 days). During follow up of 8 ± 6 months, there were no conversions to open repair, aortic rupture, paraplegia, or retrograde dissection.

Conclusions: The use of physician-modified thoracic stent grafts for the treatment of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection is feasible and effective. Durability concerns will need to be assessed in future studies.
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http://dx.doi.org/10.1016/j.athoracsur.2019.02.026DOI Listing
August 2019

Filter-Associated Inferior Vena Cava Thrombosis with Duodenal Perforation: Case Report and Literature Review.

Ann Vasc Surg 2019 Jul 11;58:383.e1-383.e6. Epub 2019 Feb 11.

Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Background: The aim of this article is to report a case of filter-associated inferior vena cava (IVC) thrombosis with perforation of the duodenum and penetration of a vertebral body by the filter struts.

Case Report: A 37-year-old woman with a medical history of Behcet's disease treated with corticosteroids underwent placement of a retrievable IVC filter because of recurrent iliofemoral venous thrombosis regardless of therapeutic levels of anticoagulation. Despite a correct positioning of the filter, the second follow-up computed tomography scan, performed at 1 year, showed a complete thrombosis of the infrarenal IVC segment, with perforation of the vessel wall by the filter struts and penetration in the duodenum. The patient remained asymptomatic. Open surgical removal of the filter with resection of the affected vena cava without vascular reconstruction was planned. The operation was performed under general anesthesia, surgical exposure was performed through a small midline laparotomy, and a duodenal Kocher maneuver was then performed to expose the IVC. The filter struts were found to have completely passed the cava wall in multiple directions. 2 struts penetrated through the duodenal serosa and 1 strut was embedded in the L3 periosteum. The IVC filter was successfully removed en bloc with the segment of the thrombosed and retracted IVC. The stumps were closed with 3-0 running polypropylene sutures and the duodenal lesions were closed with vicryl seromuscular sutures. No vascular reconstruction was necessary due to the marked development of collateral venous circulation. The patient was discharged home on postoperative day 6 and is doing well 6 months after surgery.

Conclusions: Patients with IVC penetration of filter struts are usually asymptomatic, as was our patient. However, a high level of clinical suspicion for perforation should be maintained when facing nonspecific abdominal or back pain, and in episodes of gastrointestinal bleeding in patients with an IVC filter. We recommend that patients with implanted IVC filters, even those who are asymptomatic, should receive regular imaging follow-up, and retrievable filters should be removed as soon as they are no longer needed.
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http://dx.doi.org/10.1016/j.avsg.2018.11.021DOI Listing
July 2019

Risk factors for distal stent graft-induced new entry tear after endovascular repair of thoracic aortic dissection.

J Vasc Surg 2019 May 3;69(5):1610-1614. Epub 2019 Jan 3.

Department of Thoracic and Cardiovascular Surgery, Hôpital A de Villeneuve, Montpellier, France; CHU Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France.

Objective: A review of the literature was conducted for incidence, outcomes, and risk factors for distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of aortic dissection.

Methods: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: Seven articles reporting on 1415 patients with thoracic aortic dissection undergoing TEVAR without supplemental distal bare stenting were included. In this cohort, 86 patients were treated for a residual type A aortic dissection and 1329 for a complicated type B aortic dissection. Distal SINE occurred in 112 patients (7.9%). The mean time to identification of distal SINE was 19 ± 7 months. The incidence of distal SINE after TEVAR for type B aortic dissection differed on the basis of whether it was a chronic or acute dissection repair and was, respectively, 12.9% (43/331) and 4.3% (12/273). Successful secondary interventions were performed in 54% of the patients. All the studies analyzing the relationship between distal stent graft oversizing and incidence of distal SINE reported a significantly higher rate of SINE with oversizing.

Conclusions: The successful management of complicated descending thoracic aortic dissections by TEVAR is well established. Whereas distal SINE is relatively frequent, if it does occur, the complication can generally be treated with additional TEVAR without a poor outcome. The main determinant of SINE seems to be excessive distal oversizing.
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http://dx.doi.org/10.1016/j.jvs.2018.07.086DOI Listing
May 2019

Systematic review of native and graft-related aortic infection outcome managed with orthotopic xenopericardial grafts.

J Vasc Surg 2019 02 24;69(2):614-618. Epub 2018 Oct 24.

Department of Thoracic and Vascular Surgery, Hôpital A de Villeneuve, Montpellier, France. Electronic address:

Objective: Limited data are available on the use of xenopericardium in the treatment of native and graft-related aortic infections. The aim of this review was to assess outcomes of neoaortic reconstruction using xenopericardium in this challenging group of patients.

Methods: Studies involving xenopericardial graft reconstruction to treat native and aortic graft infections were systematically searched and reviewed (Embase, Medline, and Cochrane databases) for the period of January 2007 to December 2017.

Results: A total of 4 studies describing 71 patients treated for aortic graft (n = 54) and native aortic (n = 17) infections were included; 25 patients (35%) were operated on in an acute setting. The technical success rate was 100%. The mean 30-day mortality was 25% (range, 7.7%-31%). Only one death (1.4%) was linked to the operator-made pericardial tube graft (acute postoperative bleeding from proximal anastomosis). Septic multiorgan failure was the most common cause of perioperative death (72% [13/18]). Among the 53 patients who survived, only 3 presented with recurrent infection (5.7%), so 70.4% of patients were alive after intervention without evidence of infection (50/71). During follow-up, 2 false aneurysms (3.7% [2/53]), 1 early rupture (1.4% [1/71]), and 2 cases (3.7% [2/53]) of late rupture were reported. Other causes of late deaths unrelated to the aortic xenopericardial repair were not reported in the different series. The early reintervention rate was 1.4% (1/71), treated by open repair for rupture. The late reintervention rate was 7.5% (4/53) with thoracic endovascular aortic repair in three patients (one false aneurysm and two ruptures) and open repair in one patient (one false aneurysm). There were no cases of early or late graft thrombosis. One-year mortality rate was 38% but only 4.2% were related to the aortic repair using orthotopic xenopericardium (one early and two late ruptures).

Conclusions: These data confirm the high morbidity of native and graft-related aortic infections and provide insight into the results of orthotopic xenografts as a treatment alternative. Larger series and longer follow-up will be required to compare the role of operator-made pericardial tube graft with other treatment options in infected fields.
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http://dx.doi.org/10.1016/j.jvs.2018.07.072DOI Listing
February 2019

Commentary: Custom Fenestration Templates for Endovascular Repair of the Aortic Arch.

J Endovasc Ther 2018 10 30;25(5):559-560. Epub 2018 Jul 30.

1 Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

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http://dx.doi.org/10.1177/1526602818792345DOI Listing
October 2018

Reverse extra-anatomic aortic arch debranching procedure allowing thoracic endovascular aortic repair of a chronic ascending aortic aneurysm.

J Vasc Surg Cases Innov Tech 2018 Jun 25;4(2):102-105. Epub 2018 Apr 25.

Department of Thoracic and Cardiovascular Surgery, Hôpital A de Villeneuve, Montpellier, France.

A 79-year-old woman was admitted with a large chronic dissecting ascending aortic aneurysm starting 5 mm distal to the ostia of the left coronary artery and ending immediately proximal to the innominate artery. A reverse extra-anatomic aortic arch debranching procedure was performed. During the same operative time, through a transapical approach, a thoracic stent graft was deployed with the proximal landing zone just distal to the coronary ostia and the distal landing zone excluding the origin of the left common carotid artery. The postoperative course was uneventful. Computed tomography at 12 months documented patent extra-anatomic aortic arch debranching and no evidence of endoleak.
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http://dx.doi.org/10.1016/j.jvscit.2018.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6012997PMC
June 2018

Commentary: Physician-Modified Thoracic Stent-Graft: To Break the Rules You Must First Master Them.

J Endovasc Ther 2018 08 31;25(4):464-465. Epub 2018 May 31.

1 Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

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http://dx.doi.org/10.1177/1526602818779394DOI Listing
August 2018

Experimental evaluation of homemade distal stent graft fenestration for thoracic endovascular aortic repair of type A dissection by a transapical approach.

J Vasc Surg 2018 10 19;68(4):1217-1224. Epub 2018 Apr 19.

Department of Cardiac and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.

Objective: The use of off-the-shelf stent grafts for thoracic endovascular aortic repair of type A dissections is limited by variability in both the length of the ascending aorta and the location of the proximal intimal tear. This experimental study aimed to assess the feasibility of using a physician-modified thoracic aortic stent graft to treat acute type A dissection by a transapical cardiac approach.

Methods: The experiments were performed on six cadaveric human heart, ascending aorta, aortic arch, and descending aorta specimens. Fenestration was fashioned in each standard tubular Valiant thoracic stent graft (Valiant Captivia; Medtronic Vascular, Santa Rosa, Calif) to match the anatomy of each specimen. Stent grafts of sufficient length were selected to cover the entire ascending aorta and aortic arch. Stent graft diameters in proximal sealing zones were oversized by 5% to 10%. The length of the fenestration was the distance between the left subclavian artery and the proximal edge of the origin of the brachiocephalic trunk with an additional 10 mm. The diameter of the scallop was that of the brachiocephalic trunk with an additional 5 mm on all sides. The length of the covered portion of the stent graft was the distance between coronary arteries and the proximal edge of the origin of the brachiocephalic trunk. Two lateral radiopaque markers were positioned to delineate the distal and lateral edge of the scallop. Another 3-cm radiopaque marker was sutured onto the sheath to ensure accurate radiologic positioning of the scallop on the outer curve of the aorta. The left ventricle and the thoracic aorta were connected to a benchtop aortic pulsatile flow model. A 5-mm 30-degree lens was introduced through the left subclavian artery to monitor the procedure. The customized stent graft was deployed by a transapical approach under fluoroscopic control.

Results: Median duration of stent graft modification was 21 minutes (range, 17-40 minutes). All attempts to deploy the homemade proximal scalloped stent graft by a transapical approach were successful. Completion angiography demonstrated patency of the supra-aortic trunks and of the coronary arteries in all cases. Macroscopic evaluation did not identify any deterioration of the customized stent graft.

Conclusions: The use of physician-modified stent grafts is feasible for thoracic endovascular aortic repair of type A dissection by a transapical approach in this model.
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http://dx.doi.org/10.1016/j.jvs.2017.08.095DOI Listing
October 2018

[Endovascular repair of the thoracic aorta].

Presse Med 2018 Feb 23;47(2):153-160. Epub 2018 Feb 23.

CHU de Montpellier, hôpital Arnaud-de-Villeneuve, service de chirurgie thoracique et vasculaire, 191, avenue Doyen-Gaston-Giraud, 34090 Montpellier, France.

Degenerative aneurysms of the thoracic aorta are increasing in prevalence. The recognition of the decreased morbidity of this approach compared with open repair was readily apparent, as it avoided left thoracotomy, aortic cross-clamping, and left heart bypass. Repair of isolated descending thoracic aortic aneurysms using stent grafts was introduced in 1995, and in an anatomically suitable subgroup of patients with thoracic aortic aneurysm, repair with endovascular stent graft provides favorable outcomes, with decreased perioperative morbidity and mortality relative to open repair. The cornerstones of successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough preprocedural planning, and cautious procedural execution. Since then, TEVAR is increasingly being used for other aortic pathologies such as complicated type B dissection, traumatic aortic transection, and aneurysmal disease extending into the arch or visceral segment, requiring debranching procedures.
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http://dx.doi.org/10.1016/j.lpm.2017.12.004DOI Listing
February 2018

Factors Favoring Retrograde Type A Aortic Dissection After Endovascular Aortic Repair.

Ann Thorac Surg 2018 02;105(2):668

Service de Chirurgie Vasculaire et Thoracique, Hôpital Arnaud de Villeneuve, 191 av Doyen Gaston Giraud, 34090 Montpellier, France.

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http://dx.doi.org/10.1016/j.athoracsur.2017.04.006DOI Listing
February 2018

Endovascular aortic repair of a chronic ascending and arch aortic aneurysm.

J Thorac Cardiovasc Surg 2018 03 15;155(3):e79-e83. Epub 2017 Sep 15.

Department of Thoracic and Cardiovascular Surgery, Hospital Arnaud de Villeneuve, Montpellier, France. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2017.09.017DOI Listing
March 2018
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