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We assessed the impact of raising the upper section of the bed, and patient positioning, on ultrasound assessment of gastric fluid contents. We performed ultrasound examinations in 25 subjects lying on their back, left and right sides at bed angles of 0°, 30°, 45° and 90°; this was carried out while the subjects were fasted, and repeated 10 min after drinking ≥ 50 ml water. After drinking, gastric contents were detected more frequently in the 45° semirecumbent position compared with the supine and 30° positions. The diagnostic performance of the Perlas qualitative grading scale to detect gastric fluid volume > 1.5 ml.kg-1 was improved at 45°, compared with 0° and 30° angles. The use of a composite ultrasound grading scale at a 45° angle was associated with the best performance, with a sensitivity and specificity of 82%. Antral cross-sectional area was significantly increased when measured in the right lateral position, but there was no effect of raising the bed. In conclusion, raising the upper section of the bed significantly affected qualitative assessment of gastric fluid contents. Further studies are required to determine the most appropriate composite ultrasound grading scale and bed angle for fast and reliable qualitative ultrasound detection of fluid volumes > 1.5 ml.kg-1 .

To retrospectively assess immediate and 1-year success rate of type 2 endoleak (T2E) treatment with ethylene-vinyl-alcohol-polymer using three-dimensional (3D) image fusion guidance with cone beam computed tomography via trans-arterial embolization (TAE) or direct percutaneous sac injection (DPSI).A total of 37 patients with T2E who were treated either using TAE (34/37; 92%) or DPSI (9/37; 8%) were included. There were 34 men and 3 women with a mean age of 86±9 (SD) years (range: 67-104years). Mean aneurysm diameter was 67±14 (SD) mm (range: 42-101mm) at pre-procedure evaluation. Immediate success was complete embolization of the sac and feeding artery. 1-year success was reduction or stability of the aneurysmal sac diameter based on pre-procedure and 12-month follow-up examinations. Safety (treatment-related complications), patient demographics, duration of procedure and contrast volume were reported.Immediate and 1-year successful outcomes were reported in 94% (n=32) and 88% (n=28) of patients after TAE and 100% (n=9) and 89% (n=8) after DPSI. T2E treatments were immediately successful for 95% of the procedures (41/43) and for 88% (36/41) at 1year. Overall, T2E treatment was effective in 33 patients (89%). No major complications occurred. Mean procedure time and contrast volume were significantly different between the 2 techniques with respectively 87±16 (SD) min (range: 65-120min) and 75±26 (SD) mL (range: 40-130mL) for TAE and 32±10 (SD) min (range: 20-50min) (P0.01) and 6±6 (SD) mL (range: 2-22mL) (P0.01) for DPSI. Mean aneurysm diameter at 1-year was 68±17 (SD) mm (range: 43-101mm). No significant differences in the pre-procedure sac diameter were found at long-term follow-up between patients without T2E and those with persistent T2E (P=0.1) in the successful embolization group (n=33).TAE or DPSI treatments of T2E with ethylene-vinyl-alcohol-polymer using 3D-image fusion guidance were immediately successful for 95% of the procedures and remained effective for 88%. Longer follow-up is necessary to assess sac stability in the case of persistent endoleak.

BACKGROUND Pulse pressure variation (PPV) and plethysmographic variability index (PVI), dynamic indicators of preload dependence based on heart-lung interactions, are used to predict fluid responsiveness in mechanically ventilated patients in the supine position. The sitting position for neurosurgery, by changing intrathoracic blood volume, could affect the capacity of PPV and PVI to predict fluid responsiveness. The aim of the study was to assess the ability of PPV and PVI to predict fluid responsiveness during general anesthesia in the sitting position. METHODS In total, 31 patients were included after settling in the sitting position but before surgery began. PPV, PVI with a finger sensor (PVI finger), and PVI with an ear sensor (PVI ear) were recorded before and after a fluid challenge of hydroxylethylstarch 250 mL over 10 minute. Esophageal Doppler was used to record stroke volume. Patients were defined as fluid responders if stroke volume increased by more than 10% after the fluid challenge. RESULTS In total, 13 (42%) patients were fluid responders. PPV and PVI ear were higher in responders than in nonresponders before the fluid challenge (12±5 vs. 7±3; P=0.0005 and 14±5 vs. 8±3; P=0.001, respectively). Areas under the receiver-operating curves to predict fluid responsiveness were 0.87 for PPV (P

Background Though pulmonary aspiration of gastric contents occurs mainly in the setting of emergency surgery, it may also occur in children scheduled for elective surgery without any obvious clinical risk factor. Increased gastric content volume is one the predisposing factors for pulmonary aspiration that could affect such children and may be identified using ultrasound examination of the gastric antrum. Aims We aimed to assess the prevalence of "at-risk stomach" defined by ultrasound visualization of any solid content in the antrum and/or by calculated gastric fluid volume > 1.25 mL/kg, in children scheduled for elective surgery. Methods Children scheduled for elective surgery were consecutively included into this prospective cohort study. Preoperative ultrasound examination of the antrum was performed in both the supine and the right lateral decubitus positions. Gastric fluid content was assessed using a 0-2 qualitative grading scale. The antral cross-sectional area was also measured in both the supine and the right lateral decubitus positions, allowing the calculation of the gastric fluid volume according to a formula previously described. Results We analyzed 200 elective children. Median duration of fasting was 4 hours for liquids and >13 hours for solids. None of the children included in this study had evidence of solid content. Six (3%) children had a Grade 2 antrum (fluid content seen in both the supine and the right lateral decubitus positions). Two children had a gastric fluid volume >1.25 mL/kg. The prevalence of "at-risk stomach" was 1% (95% confidence interval: 0.2%-3.9%). Conclusion According to our results, only 1% of elective children had potentially increased risk for pulmonary aspiration. Further studies should be performed in order to define the target population of elective children for which ultrasound assessment of gastric content should be performed prior to general anesthesia.

Medication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university paediatric hospital, and to identify their characteristics and potential predictive factors.This prospective incident monitoring study was conducted between November 2015 and January 2016 in an exclusively paediatric surgical centre. Children18 yr undergoing general anaesthesia were consecutively included. For each procedure, an incident form was completed by the attending anaesthetist on an anonymous and voluntary basis.Incident forms were completed in 1400 (73%) of the 1925 general anaesthetics performed during the study period with 37 reporting at least one medication error (2.6%). Drugs most commonly involved in medication errors were opioids and antibiotics. Incorrect dose was the most frequently reported type of error (n=27, 67.5%), with dilution error involved in 7/27 (26%) cases of incorrect dose. Duration of procedure120 min was the only factor independently associated with medication error [adjusted odds ratio: 4 (95% confidence interval: 2-8); P=0.0001].Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies.

Ultrasound examination of the gastric antrum allows reliable assessment of gastric contents and volume. Postoperative assessment of gastric contents before recovery from anaesthesia could help the physician to choose the most appropriate extubation technique after surgery in children. In this prospective observational study, we assessed whether significant changes occurred in gastric contents during the intra-operative period in children undergoing elective ear, nose and throat (ENT) surgery. Children aged between six months and 16 years were recruited consecutively. Ultrasound examination of the antrum was performed before induction of anaesthesia and at the end of surgery before tracheal extubation, and included quantitative and qualitative assessment of gastric contents. The mean (SD) gastric volume was 0.28 (0.30) ml.kg-1 before surgery and 0.27 (0.30) ml.kg-1 after surgery, p = 0.82. No solid contents were identified in the antrum, and the gastric volume was < 1.5 ml.kg-1 in all patients during both ultrasound examinations. Our results suggest that, after elective ENT surgery, children are not at risk of a full stomach before tracheal extubation, and that pulmonary aspiration of blood that may occur after elective ENT surgery is probably not related to regurgitation of ingested blood from the stomach.

Although perioperative hypothermia may increase maternal morbidity, active warming is infrequently performed to maintain normothermia during Cesarean delivery (CD). The aim of this prospective observational study was to determine the factors associated with maternal hypothermia in this setting.Women scheduled for elective or emergency CD were consecutively included in this study from November 2014 to October 2015. Maternal temperature was measured using an infrared tympanic thermometer on the patient's arrival in the operating room, at skin incision, and at the end of skin suture. Maternal hypothermia was defined by tympanic temperature36°C at the end of skin suture. Univariate analysis was performed, followed by multivariate logistic regression analysis, in order to determine the factors associated with maternal hypothermia at the end of the surgery.Three hundred fifty-nine women were included and analyzed during this study. The incidence of hypothermia was 23% (95% confidence interval, 18 to 27) among the total population included. According to multivariate analysis, obesity, oxytocin augmentation of labour, and use of active forced-air warming were associated with a decreased risk of maternal hypothermia, while maternal temperature37.1°C on arrival in the operating room, maternal temperature36.6°C at skin incision, and an infused volume of fluids650 mL were significantly associated with maternal hypothermia. Both goodness of fit and predictive value of multivariate analysis were high.Several predictive factors for maternal hypothermia during CD were identified. These factors should be taken into account to help prevent maternal hypothermia during CD.

Background On November 13, 2015, Paris and Saint-Denis were the targets of terrorist attacks. The Public Hospitals of Paris Organization and the Percy Armed Forces Instruction Hospitals were mobilized to face the mass casualty situation. The objective of this study is to analyze the management of the victims presenting with a nonthoracic vascular trauma (NTVT). Methods All the data relating to the victims of NTVT who required a specific vascular open or endovascular treatment were analyzed retrospectively. A 6-month follow-up was obtained for all the patients. Results Among the 351 wounded, 20 (5.7%) patients had an NTVT and were dispatched in 8 hospitals (11 men of average age 32). NTVTs were gunshots in 17 cases (85%) or due to a handmade bomb in 3 cases (15%). Twelve patients (60%) received cardiopulmonary resuscitation during prehospital care. NTVT affected the limbs (14 cases, 70%) and the abdomen or the small pelvis (6 cases, 30%). All the patients were operated in emergency. Arterial lesions were treated with greater saphenous vein bypasses, by ligation, and/or embolization. Eleven venous lesions were treated by direct repair or ligation. Associated lesions requiring a specific treatment were present in 19 patients (95%) and were primarily osseous, nervous, and abdomino-pelvic. Severe postoperative complications were observed in 9 patients (45%). Fourteen patients (70%) required blood transfusion (6.4 U of packed red blood cells on average, range 0–48). There were no deaths or amputation and all vascular reconstructions were patent at 6 months. Conclusions The effectiveness of the prehospital emergency services and a multisite and multidisciplinary management made it possible to obtain satisfactory results for NTVT casualties. All the departments of vascular surgery must be prepared to receive many wounded victims in the event of terrorist attacks.

Background Evacuation of gastric content through a nasogastric tube, followed by rapid sequence induction, is usually recommended in infants undergoing pyloromyotomy. However, rapid sequence induction may be challenging, and is therefore controversial. Some anaesthetists regularly perform classical non-rapid induction technique, after blind aspiration of the gastric contents, although this aspiration may have been incomplete. This prospective observational study aimed to assess whether the ultrasound monitoring of the aspiration of the stomach contents, may be useful to appropriately guide the choice of the anaesthetic induction technique, in infants undergoing pyloromyotomy. Methods Infants undergoing pyloromyotomy were consecutively included. Ultrasound assessment of the antrum was performed before and after the aspiration of the gastric contents through a 10 French gastric tube. The stomach was defined as empty when no content was seen in both supine and right lateral positions. The correlation between antral area and the aspirated gastric volume was also tested. Results We analysed 34 infants. Ultrasound examination of the antrum failed in three infants. The stomach was empty in 30/34 infants (nine before aspiration, 21 after aspiration), allowing to perform a non-rapid induction technique in 88.2% of the infants. There was a significant correlation between antral area measured in right lateral decubitus and the aspirated gastric volume. Conclusions Our results suggest that the qualitative ultrasound assessment of the antral content may be a simple and useful point-of-care tool, for the choice of the most appropriate anaesthetic technique for pyloromyotomy according to the estimated risk of pulmonary aspiration of gastric contents.

Epidural blood patch is the gold standard treatment for post-dural puncture headache, although hydroxyethyl starch may be a useful alternative to blood if the latter is contraindicated. The aim of this experimental study was to assess whether hydroxyethyl starch given via an indwelling intrathecal catheter resulted in clinical or histopathological changes suggestive of neurotoxicity. The study was conducted in rats that were randomly allocated to receive three 10-μl injections on consecutive days of either saline or hydroxyethyl starch administered via the intrathecal catheter. Eight rats were given injections of saline 0.9% and 11 were given 6% hydroxyethyl starch 130/0.4 derived from thin boiling waxy corn starch in 0.9% sodium chloride (Voluven). Daily clinical evaluation, activity measured by actimetry and neuropathological analysis of the spinal cord were subsequently performed to assess for signs of neurotoxicity. No clinical or actimetric changes were observed in either group following intrathecal saline or hydroxyethyl starch administration. Histopathological examination showed non-specific changes with no differences between the two groups. This experimental study in the rat suggests that repeated intrathecal injection of hydroxyethyl starch is not associated with neurotoxicity.

Objective Epidural blood patch is the procedure of choice to relieve postdural puncture headache. Hydroxyethyl-starch (HES) has been proposed as a patch in some circumstances such as in the case of hematological disease due to the theoretical risk of neoplastic seeding to the central nervous system. Acute neurological HES toxicity has been excluded by a previous animal study, but the long-term neurological toxicity has not been evaluated. Methods Rats were randomly assigned to one of three groups: no intrathecal injection, 20 μL of intrathecal saline, or a 20-μL intrathecal HES (6% hydroxyethyl starch 130/0.4) administered via a cervical puncture. Clinical daily rat activity was measured before and after dural puncture by actinometry. The rats were killed at day 28, and the spinal cord was surgically removed and stained with hematoxylin-phloxine-saffron for gross and microscopic examination. Results Eleven rats underwent dural puncture without injection, 11 were injected with normal saline, and 12 received intrathecal HES. No clinical or actimetric changes (total distance traveled, number of direction changes, and number of rearings) were observed up to one month after injection. Nonspecific histopathological changes were equally observed in all groups. Conclusions The results of the current study indicate that intrathecal injection of HES in rats does not induce any clinical or histopathological evidence of long-term neuronal toxicity. Further safety studies in animals are warranted before HES might be considered a safe alternative to the classic epidural blood patch.

Ultrasound examination of the gastric antrum is a non-invasive tool that allows reliable estimation of gastric contents. We performed this prospective cohort study in non-elective paediatric surgery to assess whether gastric ultrasound may help to determine the best anaesthetic induction technique, whether rapid sequence or routine. The primary outcome was the reduction of inappropriate induction technique. A pre-operative clinical assessment was performed by the attending anaesthetist who made a provisional plan for induction. Gastric ultrasound was performed in the semirecumbent and right lateral decubitus positions for a qualitative assessment of gastric contents, using a 0-2 grading scale. A final induction plan was made based on this assessment. Immediately after tracheal intubation, gastric contents were suctioned through a multi-orifice nasogastric tube; these were defined as above risk threshold for regurgitation and aspiration if there was clear fluid > 0.8 ml.kg-1 , and/or the presence of thick fluid and/or solid particles. Gastric ultrasound was feasible in 130 out of 143 (90%) of children, and led to a change in the planned induction technique in 67 patients: 30 from routine to rapid sequence, and 37 from rapid sequence to routine. An appropriate induction technique was therefore performed in 85% of children, vs. 49% planned after pre-operative clinical assessment alone (p < 0.00001). Our results suggest that gastric ultrasound is a useful guide to the general anaesthetic induction technique with respect to the risk of pulmonary aspiration, in comparison with pre-operative clinical assessment alone.

There are no data available on the risk of intraoperative bleeding during decompressive craniectomy (DC) after traumatic brain injury (TBI) in children. The objectives of this study were to assess the risk of intraoperative bleeding during DC for intractable intracranial hypertension after TBI, to identify potential factors associated with the risk of bleeding during DC, and to assess the impact of DC on systemic and cerebral hemodynamics and on coagulation. Twelve children were identified as having undergone DC after TBI from April 2009 to June 2013 in our center. Subjects were allocated into two groups according to the percentage of blood loss (IBL) during the intraoperative period (

Local anesthetic intoxication is an uncommon complication of regional anesthesia. We report the case of a 4-month-old infant who presented with generalized tonic-clonic seizure complicated by cardiac arrest secondary to a severe intoxication to local anesthesia. These complications were observed after a bilateral dorsal penile nerve block with lidocaine for circumcision in a non-hospital setting. This report emphasizes the potential risk of local anesthetic systemic toxicity in such circumstances and describes its treatment.; L'intoxication est une complication rare de l'anesthésie locorégionale. Nous rapportons le cas d'un nourrisson de 4 mois ayant présenté une crise convulsive tonico-clonique généralisée compliquée d'un arrêt respiratoire secondaire à une intoxication grave aux anesthésiques locaux à l'occasion d'un bloc pénien dorsal bilatéral avec de la lidocaïne pour une circoncision réalisée hors du milieu hospitalier. Le but de ce travail est de souligner le risque potentiel de toxicité systémique des anesthésiques locaux utilisés dans ces circonstances particulières et de préciser leur prise en charge. Summary Local anesthetic intoxication is an uncommon complication of regional anesthesia. We report the case of a 4-month-old infant who presented with generalized tonic-clonic seizure complicated by cardiac arrest secondary to a severe intoxication to local anesthesia. These complications were observed after a bilateral dorsal penile nerve block with lidocaine for circumcision in a non-hospital setting. This report emphasizes the potential risk of local anesthetic systemic toxicity in such circumstances and describes its treatment.

Background The aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined. Methods Preoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component 25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed. Results Of 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4 ± 4.9% and 34.5 ± 6% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1 ± 2.1% vs. 4.2 ± 3.2%, P = 0.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 n = 0, group 2 n = 2; P = 0.48). Conclusions In our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.

Ultrasound measurement of the antral cross-sectional area allows a quantitative estimate of gastric contents in non-pregnant adults, but this relationship may be affected by compression of the stomach exerted by the gravid uterus during pregnancy. This study aimed to assess differences in quantitative (Perlas score) and qualitative (antral cross-sectional area) ultrasound assessments of the gastric antrum performed immediately before and after caesarean section. Forty-three women having elective caesarean section performed under spinal anaesthesia were studied in the semirecumbent and semirecumbent-right lateral positions. Thirty-nine women showed no change in stomach contents using the Perlas score between the two measurement periods; four women showed a change, but by one grade only. The median (IQR [range]) antral cross-sectional area was 323 (243-495 [103-908]) mm2 before, and 237 (165-377 [112-762]) mm2 after, caesarean section in the semirecumbent position (p = 0.001); the comparable values in the semirecumbent-right lateral position were 418 (310-640 [161-1238]) mm2 and 362 (280-491 [137-1231]) mm2 (p = 0.09). The distance between the skin and the antrum, and the aorta and the antrum, decreased significantly in both positions after surgery. We suggest that our results indicate that stomach contents remain largely unchanged in women having elective caesarean section, but antral cross-sectional area decreases, especially in the semirecumbent position, related to a change in the position of the stomach within the abdomen. This implies that the relationship of antral cross-sectional area to volume of stomach contents, which has been determined for non-pregnant subjects, may not apply in term pregnant women.

Resume Objectif Etudier les risques d’instabilite hemodynamique et la survenue eventuelle d’hematome perimedullaire, de meningite et d’abces perimedullaire lors de l’utilisation de l’analgesie peridurale pour la chirurgie de cytoreduction tumorale et chimiohyperthermie intraperitoneale (CHIP). Methode Il s’agit d’une etude retrospective portant sur 35 patients traites par CHIP a l’oxaliplatine ou au cisplatine. Un catheter peridural etait introduit avant induction de l’anesthesie generale. En postoperatoire, une administration peridurale continue de ropivacaine, puis une analgesie peridurale autocontrolee par le patient etaient instaurees. Resultats Le catheter peridural a ete utilise en peroperatoire avant la CHIP chez 12 patients (34 %) et apres la CHIP chez 23 patients (66 %). La dose mediane de ropivacaine administree en peridural en peroperatoire etait de 40 mg (30–75). Deux patients (6 %) beneficiaient de noradrenaline en peroperatoire (debit median de 0,325 μg/kg par minute [0,32–0,33]) et quatre patients (11 %) pendant les premieres 24 heures postoperatoires. Aucun cas d’hematome perimedullaire, de meningite ou d’abces perimedullaire n’etait constate. Cinq patients (14 %) presentaient une thrombopenie ou un taux de prothrombine inferieur a 60 % avant ablation du catheter peridural. Deux patients (6 %) presentaient une leucopenie avant ablation du catheter. Aucun cas de thrombopenie ou de trouble d’hemostase significatif n’etait note le jour d’ablation du catheter. Conclusion Dans cette serie limitee de 35 patients, l’utilisation de l’analgesie peridurale pour la CHIP n’a pas ete responsable d’instabilite hemodynamique majeure, d’hematome perimedullaire, de meningite et d’abces perimedullaire. La realisation d’une CHIP aux sels de platine n’est pas incompatible avec une bonne tolerance de l’analgesie peridurale, avec un remplissage vasculaire optimise en peroperatoire et un respect strict des bonnes pratiques de l’anesthesie perimedullaire.

This prospective observational study sought to assess the rate of full and empty stomach in elective and emergency patients and to determine the factors associated with full stomach.Non-premedicated patients were consecutively included between May 2014 and October 2014. Ultrasound examination of the gastric antrum was performed by an operator blinded to the history of the patient. It included measurement of the antral cross-sectional area, performed in the supine position with the head of the bed elevated to 45°, and qualitative assessment of the gastric antrum, performed in both semirecumbent and right lateral decubitus positions. Full stomach was defined by the appearance of any gastric content in both positions (Grade 2). Empty stomach was defined either by empty antrum in both positions (Grade 0) or by empty antrum in the semirecumbent position only (Grade 1) with measured antral area 340 mm2. The combination of Grade 1 and antral area 340 mm2 defined intermediate stomach. Logistic regression analyses were performed for the identification of factors associated with full stomach.Four hundred and forty patients were analysed. The prevalence of full stomach was 5% (95% confidence interval: 2–9) in elective patients and 56% (95% confidence interval: 50–62) in emergency patients (P0.0001). Obesity, diabetes mellitus, emergency surgery, and preoperative consumption of opiates were independent factors predictive of full stomach.The results suggest that preoperative ultrasound assessment of gastric content should be performed in all emergency patients, and in elective patients with identified predictive factors for full stomach.

The incidence of non-Hodgkin lymphoma has increased over the past 10 years, particularly in association with human immunodeficiency virus (HIV) infection. Burkitt lymphoma is a highly aggressive non-Hodgkin lymphoma that involves the heart in up to a third of cases. This case describes an HIV-positive patient with cardiac involvement of Burkitt lymphoma who presented with atrial flutter and heart failure with pulmonary edema. Transthoracic echocardiography showed extensive heterogeneous lymphomatous infiltration of the heart (including the right atrium), with associated wall motion abnormalities. Within a day of starting chemotherapy, the patient had converted to normal sinus rhythm. His heart failure rapidly improved, and a repeat echocardiogram performed on day 5 of chemotherapy showed a significant reduction in myocardial tumor burden and improved cardiac function. This case demonstrates how echocardiography plays a significant role in diagnosis, management, and follow-up of lymphoma (in this case Burkitt) with cardiac involvement.

Introduction Chronic mesenteric ischemia (CMI) is a challenging problem, with revascularization the mainstay of treatment. Management of CMI is especially challenging in the patient with superior mesenteric artery (SMA) and celiac artery (CA) occlusions. Report We report a case series of four patients with chronic mesenteric ischemia who were not candidates for CA or SMA revascularization who were successfully treated with inferior mesenteric artery (IMA) angioplasty and stent placement to improve collateral circulation and palliate symptoms. Discussion To our knowledge, this is the largest case series to date reporting the use of an IMA stent to improve collateral circulation in patients with CMI.

Massive haemoptysis are rare in pregnant woman. Besides usual causes of haemoptysis, cases of idiopathic haemoptysis have been described during pregnancy, probably with a hormonal role. A pregnant woman at 22 weeks amenorrhoea was admitted in intensive care unit for massive and recurrent haemoptysis, enhanced by bouts of hypertension in a context of preeclampsia. Arteriography showed bronchial hypervascularisation, with abnormally dilated bronchial arteries, and a lot of collateral arteries. Three sessions of bronchial artery embolization have been performed with success. The management of idiopathic haemoptysis in pregnant woman seems to be based on the usual algorithm of management, emphasizing on the control of blood pressure, and the key role of interventional radiology.

Purpose Anatomy of the aortic arch is highly variable and can be drastically altered by surgical or endovascular procedures. Detailed analysis of computed tomography (CT) scans is facilitated by reconstruction techniques such as virtual angioscopy (VA). In the present study, we have evaluated the benefit of VA for the assessment of aortic arch abnormalities in patients with prior surgical or endovascular procedures. Material and methods We analysed post-procedural CT scans available in 103 patients who underwent thoracic aortic procedures between 2006 and 2009 at our institution. Patients were classified into three groups: surgical (group A, n = 26), hybrid (group B, n = 27) and endovascular (group C, n = 50), procedures. A 64 LightSpeed ® volume computed tomography (VCT) multidetector-row computed tomography was used, allowing maximal intensity projection, maximal projection rendering imaging and three-dimensional (3D) rendering of images. VA reconstruction was performed by applying volume-rendered thresholds and spatial rendering to generate endoluminal views. Results Multiplanar reformations (MPRs) detected 46 abnormalities in 39 patients: inadequate apposition of the proximal rim of a stent-graft ( n = 21), abnormalities of the stent-graft itself ( n = 11), aortic aneurysm ( n = 6), residual intimal tears ( n = 5) and secondary dissection ( n = 3). VA provided additional information in 76% of cases (35/46) and was more contributive after endovascular repair than after open repair (group A: 54% (7/14), group B: 75% (9/12), group C: 95% (19/20)). VA improved localisation of abnormalities with respect to supra-aortic vessels, measured inadequate stent-graft apposition in relation to the aortic wall and precisely analysed kinking or inadequate apposition of overlapping stent grafts. VA diagnosed three additional abnormalities: two false aneurysms and one retrograde dissection developed on a suture line. Conclusions VA conceptualises planar images by 3D reconstruction. It provides additional information in comparison with conventional CT scans by allowing precise localisation of abnormalities with respect to the aortic wall itself and supra-aortic vessels. Furthermore, it facilitates analysis of abnormalities in case of overlapping stent grafts.

Management of anastomotic stenosis after lower extremity bypass surgery with cutting balloon angioplasty Purpose. Conventional balloon angioplasty of anastomotic stenosis following bypass surgery is insufficient at mid- and long-term. However, short-term results with cutting balloon angioplasty (CBA) are satisfactory. The purpose of this study is to determine the long-term results using this technique. Materials and methods. Between January 2002 and January 2006, all patients with anastomotic stenosis more than one month after bypass surgery, shorter than 2 cm and > 50%, were referred without randomisation to CBA. Results. A total of 19 patients with mean age of 63.5 years (55-82 years), 14 males and 5 females, were included. Twenty stenoses (femoral n=15, popliteal n=4 and calf n=1) managed with CBA affected 17 infrainguinal and 2 suprainguinal bypasses. One patient had anastomotic stenoses at both extremities. The rate of technical success aws 100%. Mean follow-up was 32 months (12-42). Three deaths occurred during follow-up. One patient presented with restenosis at 3 months, successfully treated with repeat CBA. No thrombosis or infection was observed. Conclusion. The results with CBA appear persistent and compete favorably with results from surgical repair. A randomized trial would be necessary to confirm these results.

Objective : To compare management of injured children in an adult trauma center (TC) with competencies in pediatric trauma care (2005-2007) and in a pediatric-only trauma center (2010-2012). Study design. A before-after retrospective study. Patients and methods. Fifty-nine children between 1and 15years of age admitted to the adult TC (2005-2007) were compared to 56 children admitted to the pediatric TC (2010-2012). Epidemio-logical data, severity scores, early outcome, and care duration in trauma resuscitation before whole-body CT were collected and compared between the two periods. Results : This study found no significant differences between the two periods interms of care duration before the whole-body CT scan (28 min [18-40] vs 26.5 min [21-36], P = 0.89) and early mortality (eight children [13.5%] vs ten children [17.8%], P = 0.35). Conclusion: With no differences in early management to injured children demonstrated, this study validates the organization within our pediatric trauma center. The effectiveness of management of children between 1 and 15 years of age with severe trauma seems to be similar in the two contexts.; L'objectif était, dans le cadre d'une évaluation des pratiques professionnelles, de comparer la prise en charge en salle d'accueil des urgences vitales (SAUV) d'enfants gravement traumatisés dans un centre de traumatologie pour adultes à compétence pédiatrique et un centre exclusivement pédiatrique. Type d'étude. Etude rétrospective mono centrique comparative sur un modèle avant-après. Patients et méthodes. Cinquante-neuf enfants âgés de1 à 15 ans, gravement traumatisés, admis dans le centre pour adultes (2005-2007) ont été comparés à 56 enfants admis dans le centre pédiatrique (2010-2012). Les données épidémiologiques et accidentologiques, les scores de gravité, le devenir et la durée en SAUV ont été recueillis et comparés. Résultats, Il n'y avait pas de différence de prise en charge des enfants entre le centre pédiatrique et le centre pour adultes ayant un haut volume d'activité et une compétence pédiatrique en termes de durée en SAUV (28min [18-40]vs26, 5min[21-36], p = 0,89)et de mortalité précoce (8 enfants [13,5%] vs 10 enfants [17,8%], p = 0,35).

Transplant renal artery stenosis (TRAS) is a common complication of kidney transplantation but attempts to identify predisposing risk factors for TRAS have yielded conflicting results. In order to determine the predisposing factors for transplant (TRAS), we retrospectively reviewed the records of 29 renal allograft recipients with TRAS treated with percutaneous transluminal angioplasty (PTA). The TRAS group was compared with a case-control group of 58 patients. Predisposing factors for TRAS included CMV infection (41.4% vs. 12.1% p = 0.0018) and initial delayed graft function (DGF) (48.3% vs. 15.5% p = 0.0018), respectively in the TRAS and the control group. Acute rejection occurred more frequently in patients from the TRAS group (48.3%) compared with the control group (27.6%), although the difference was not significant (p = 0.06). In a multivariate analysis, only CMV infection (p = 0.005) and DGF (p = 0.009) appear to be significantly and independently associated with TRAS. The long-term graft survival was significantly higher in the control group, compared with the TRAS group (p = 0.03). Our study suggests that CMV infection and DGF are two reliable risk factors for TRAS. Despite treatment by PTA with primary successful results, TRAS significantly affects long-term graft outcome.

PurposeTo assess the feasibility of endovascular aortic repair (EVAR) on patients presenting with a ruptured abdominal aortic aneurysm (AAA) in a teaching hospital, and to compare there post-operative outcomes with contemporaneous patients treated with open repair (OR).MethodsA series of consecutive of patients presenting ruptured AAA with retro/intraperitoneal haematoma were included in the study. EVAR was attempted whenever possible. In all other cases (severe haemodynamic instability, adverse anatomy, device unavailability), ruptured AAA were treated by OR.ResultsThirty-seven patients were enrolled between January 2001 and July 2004. Seventeen (46%) patients were treated using adapted designed aortoiliac endografts (eight bifurcated, eight aorto-uniiliac, one iliac extension). Twenty (54%) patients unfit for EVAR because of severe haemodynamic instability (n=8), adverse anatomical configuration (n=7), or unavailability of an appropriate endograft (n=5) were treated by OR. Twenty-seven (73%) had a retrospective suitable anatomy for EVAR. Three early conversions from EVAR to OR were performed. Blood loss, operating time, and intensive care stay were significantly decreased in EVAR patients (respectively: 156min±60, 1520ml±1175, 3 days for EVAR; vs. 222min±82, 3075ml±1750, 13 days for OS; P

The reduced physiological impact of endovascular aneurysm repair (EVAR) compared with conventional open repair has been demonstrated. If this technique could be used routinely in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. This review of the literature identified the current experience with EVAR of ruptured AAA. Only a small number of case series with selected patients are reported. These patients were selected for their haemodynamic stability, and their suitable aneurysm morphology. The overall anatomic suitability rates for EVAR reported, suggest an applicability of 58% to 80% from an intent-to-treat experience. The average post-operative mortality rate was 24%, ranging from 9 to 45% and may reflect increasing experience and patient selection. Important lessons have been learned from these first experiences that help to define a clear position of EVAR as an additional therapeutic option for ruptured AAA.

Objectives: to evaluate the rate of late reoperations after primary lower limb revascularisation. Methods: a prospectively collected database of 639 consecutive patients, undergoing 763 primary arterial reconstruction for lower limb occlusive disease during the five-year period 1989 through 1993, was analysed with regard to the rates and locations of late (after 30 days) re-operation. The reconstruction was supra-inguinal in 527 (69%) cases, surgical in 391 (Group IA) and endovascular in 136 (Group IB). Infra-inguinal reconstruction had been performed in 236 (31%) cases, surgical in 160 (Group IIA) and endovascular in 76 (Group IIB). The 499 men and 140 women were followed during an average of 32 (range 1–122) months. Results: the 5-year cumulative reoperation rates were 25% after supra-inguinal surgery and 28% after supra-inguinal angioplasty, respectively (NS). The rates were 47% and 33% after infra-inguinal surgery and angioplasty, respectively ( p =0.04). Conclusion: limbs treated for occlusive arterial disease carry a high risk of late reoperation whether the initial procedure is open surgery or angioplasty. Reoperations were twice as common for infra-inguinal procedures.

Objectives The aim was to determine whether physician modified stent grafts (PMSGs) are safe and effective for the treatment of high risk patients with thoraco-abdominal aortic aneurysms (TAAAs). Design This was a retrospective single institution study. Material Consecutive patients with TAAA undergoing endovascular repair using a PMSG between January 2012 and June 2014 were evaluated. Methods Fenestrations to preserve branch vessels were created in TX2 thoracic (Cook Medical) stent grafts. Pre- intra- and post-operative data were recorded by means of a prospectively maintained database. Results Eleven high risk patients with TAAA (type I, n = 4; type III, n = 3; type IV, n = 3; type V, n = 1) underwent fenestrated endovascular repair using PMSGs. Indications were painful aneurysm ( n = 5), >70 mm rapidly enlarging aneurysm ( n = 4), saccular aneurysm ( n = 1), and visceral patch false aneurysm after open repair of a type IV TAAA ( n = 1). In four asymptomatic patients, an additional fenestration was created for temporary selective sac perfusion and occluded 2–4 weeks later. Median duration for stent graft modifications was 2 hours (range 1–3 hours). The median number of fenestrations was three (range 2–4). One patient died during the post-operative period from colonic ischemia, giving a 9% in hospital mortality rate. Four (36%) patients presented with moderate to severe complications. One (9%) patient presented with a paraparesis that resolved completely after spinal fluid drainage. Among surviving patients, four required early endovascular re-intervention for type III endoleak ( n = 2), type Ia endoleak ( n = 1), or target vessel cannulation failure ( n = 1). The median follow up time was 6 months (range 3–20 months). During follow up, no other complications occurred and all target vessels remained patent. One patient presented with a persistent type II endoleak. Conclusion PMSGs provided acceptable short-term results and may be a management option for the treatment of TAAA in selected high risk patients. Durability concerns need to be assessed in additional studies with long-term follow up.

Objectives to investigate the feasibility of placing stents across renal arteries.Design we have studied in pigs: (i) the feasibility of accurately placing a fenestrated stent in front of one renal ostium; (ii) the short-term effects on renal arteries and function after the placement of such a fenestrated stent. Materials and methods eight fenestrated Palmaz stents were placed over pigs» renal ostia under fluoroscopy. Five weeks later, angiograms were performed and the animals were sacrificed. Proliferation of the healing tissues over the ostia was measured and analysed by microscopy. Serum creatinine was measured prior to all angiograms and at 5 weeks. Results all eight stents were correctly placed. One stent later migrated and was excluded from the study. One pig died at day 1. Gross examination confirmed the correct placement of the fenestrations in four pigs out of seven (57%). In the six remaining pigs, at 5 weeks, there was no angiographic evidence of stent misplacement and all the kidneys were fully perfused. Nine renal ostia were covered by struts and neointima with a mean area of coverage of 38±5% altogether. No tissue proliferation was observed over the three renal ostia located in front of the fenestration. Serum creatinine did not significantly increase at 5 weeks. Conclusion creating a fenestration in a stent for renal arteries may be worth while in order to avoid neointimal covering of the renal ostia. However, accurate placement of such a fenestrated stent remains a difficult task.

Object: to evaluate the influence of diabetes mellitus on the therapeutic indications and the one-month results in patients with occlusive disease of the aorta and/or lower limbs arteries. Material: a retrospective study of fully computerised data of 1003 patients (753 men, 250 women) admitted consecutively to our vascular surgery unit over a 5-year period (1992–1996). Of the total, 169 were diabetics (group I) and 834 were non-diabetics (group II). Sixty-two per cent of patients in group I vs. 40% in group II presented with critical ischaemia or trophic changes (p

Indirect damages to activities are at first lost production; it is a major part of global damages, so it has to be precisely assessed. It must be made out a typology fonction of the flood vulnerability. For the great plants, an exhaustive inquiry is necessary to quantify the risks. The action during the crisis is important for the determination of damages amount. Risk evaluation goes through the making out of a damages curve which shows threshold effects. But not all the consequences of a great flood can be developed.