Bernard Segers

Isolated supradiaphragmatic descending thoracic aorta stenosis in a Takayasu's disease: surgical cure.

A 21-year-old male patient presented with a typical middle aortic syndrome. Echography disclosed a severe narrowing of the lower thoracic aorta with parietal thickening. The isolated character of the lesion was confirmed by magnetic resonance imaging and aortography. The surgical cure was realized by a Dacron bypass between the upper thoracic descending aorta and the juxta-diaphragmatic thoracic aorta. Aortic biopsy confirmed Takayasus disease. Postoperative course was uneventful with normalized blood pressure. The therapeutic options, surgery versus percutaneous dilatation and stent, are discussed.

Totally retroperitoneal laparoscopic aortobifemoral bypass

Abstract The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves-Marie Dion, laparoscopy has been accepted by several authors as a possible minimally invasive alternative for aorto-iliac occlusive disease. The transperitoneal left retrocolic and retrorenal ways are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. We report here a totally laparoscopic retroperitoneal approach to performing aortobifemoral bypass. This approach was proposed to a 51-year-old man with aorto-iliac occlusive disease. There was no indication for endovascular revascularization. The patient suffered from 10 metres of bilateral intermittent claudication and lower limb ulcers. During the surgical procedure our patient was placed in a 30-degree right lateral decubitus position. The optical system was first placed in an intra-abdominal position to check the positioning of the trocars in the left retroperitoneal space. The dissection of the retroperitoneal space was performed by CO2 insufflation and by blunt dissection using laparoscopic forceps. The infrarenal aorta was exposed and clamped by laparoscopic clamps. A bifurcated graft was sutured on the left-hand side of the aorta by a running suture. Both prosthetic limbs were tunnelized retroperitoneally to the groin under optical control. The femoral anastomoses were performed by classic open surgery.

Preliminary Results from a Prospective Study of Laparoscopic Aortobifemoral Bypass Using a Clampless and Sutureless Aortic Anastomotic Technique

OBJECTIVE This prospective study describes the feasibility and safety of a new clampless and sutureless aortic anastomotic technique used during retroperitoneal laparoscopic aortobifemoral bypass in extensive aortoiliac occlusive lesions. This is a case series of a previously published technique, demonstrating wider applicability of the technique. MATERIALS AND METHODS Twelve patients underwent a clampless and sutureless laparoscopic bypass for TASC D aortoiliac occlusive lesions using the EndoVascular REtroperitoneoScopic Technique (EVREST). Dissection of the retroperitoneal space and the infrarenal aorta was performed laparoscopically. A bifurcated graft was inserted into the retroperitoneal space. The main body of the graft was connected on the left side of the aorta by an intra- and extra-aortic covered stent-graft. An aortic clamp was used temporarily on four patients because of excessive bleeding when the connector was deployed. The femoral anastomoses were performed by classic open surgery. Initial technical success, complications, and bypass patency were assessed. RESULTS Median follow-up was 9.3 months. Median operative time was 265 minutes. Median duration of aorto-prosthetic connection was 60 seconds. Thirty-day postoperative mortality was 0%. No major postoperative complications were observed. All grafts were patent at the end of follow-up and there was no early or late disruption of the proximal assembly. CONCLUSIONS EVREST greatly facilitates laparoscopic aortic surgery in occlusive disease with no need for suture or clamping of the aorta. This technique performed in a single center on 12 patients, seems to be feasible and safe. It offers the advantages of laparoscopy and those of endovascular surgery, especially in the challenging conditions encountered during aortic laparoscopic surgery. Early experience supports procedural and initial postprocedural safety and demonstrates proof-of-concept for EVREST.

Retroperitoneal laparoscopic bilateral lumbar sympathectomy.

Abstract The first retroperitoneal lumbar sympathectomy was performed in 1924 by Julio Diez. The classic procedure for sympathectomy is open surgery. We report a unilateral laparoscopic retroperitoneal approach to perform bilateral lumbar sympathectomy. This approach was performed for a 43-year-old man with distal arterial occlusive disease and no indication for direct revascularization. His predominant symptoms were intermittent claudication at 100 metres and cold legs. The patient was placed in a left lateral decubitus position. The optical system was placed first in an intra-abdominal position to check that the trocars were well positioned in the retroperitoneal space. The dissection of retroperitoneum was performed by CO2 insufflation. The inferior vena cava was reclined and the right sympathetic chain was individualized. Two ganglia (L3-L4) were removed by bipolar electro-coagulation. The aorta was isolated on a vessel loop and careful anterior traction allowed a retro-aortic pre-vertebral approach between the lumbar vessels. The left sympathetic chain was dissected. Two ganglia (L3-L4) were removed by bipolar electro-coagulation.

Endovascular repair of a life-threatening radiation-induced ruptured false aneurysm of the intrathoracic left subclavian artery: case report

Massive hemorrhage in tracheostomy patients is generally described as a result of a tracheoinnominate artery fistula. Other etiologies for rupture of a false aneurysm are rare. The classical procedure for subclavian artery aneurysm is open surgery. Endovascular techniques have been accepted by several authors as a possible minimally invasive alternative. We report a life-threatening radiation-induced ruptured false aneurysm of the intrathoracic subclavian artery successfully treated by endovascular stent graft through left brachial access in a tracheostomy patient.

New development for aorto bifemoral bypass – a clampless and sutureless endovascular and laparoscopic technique

The classic procedure for aortobifemoral bypass is open surgery. Laparoscopy has been accepted by several authors as a minimal invasive alternative for aortoiliac occlusive disease. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. Whatever the approach, the aortoprosthetic anastomosis is a major difficulty making those techniques unpopular despite obvious advantages for the patients. We report a clampless and sutureless approach for the proximal anastomosis of a totally retroperitoneal laparoscopic aortobifemoral bypass using an EndoVascular REtroperitoneoScopic Technique (EVREST). This approach was proposed to a 56-year-old man with severe aortoiliac occlusive disease. There was no indication for endovascular re-vascularization. The patient was placed in a 30° right lateral decubitus position. The dissection of the retroperitoneal space was performed and the infrarenal aorta was exposed. A bifurcated graft was inserted into the retroperitoneal space. Under videoscopic control the prosthetic limbs were brought to the groins. The main body of the graft was connected on the left side of the aorta by an intra and extra aortic covered stent-graft. This connection was performed without the use of an aortic clamp and without suture. The femoral anastomoses were performed by classic open surgery.

Outcome of permanent vascular access for haemodialysis in patients with end-stage renal disease in Cameroon: results from the pilot experience of the Douala general hospital

Abstract Background Chronic Kidney disease is a major health problem in the world. Native arteriovenous Fistula (AVF) is well established as the best vascular access for haemodialysis. Little is known about the outcome of AVF in sub-Saharan Africa. We aim to analyze the outcome of patients undergoing AVF creation during the pilot program established at the Douala general hospital (DGH). Method This was hospital-based, longitudinal study with a retrospective phase (April 2010–January 2014) and a prospective phase (January 2014–April 2014). All consecutive patients operated for AVF creation were included in this study. Socio-demographics data, functionality, and complications were analyzed. Results Eighty-one patients including 52 men were enrolled in this study (49 prospectively and 32 retrospectively). The mean age was 52, 3 years (range 18–81 years). Hypertension (66, 7%), diabetes (17, 3%), and HIV (8, 6%) were the most observed co-morbidities. About 96.3% of AVF were native and 3.7% were prosthetic graft. Radiocephalic AVF was performed at a rate of 77.8%. The primary function rate was 97.7% and the mean follow-up period 43.4 weeks. The overall rate of complications was 44.4% of whom 30.5% were early, 30.5% secondary, and 39% lasted. The treatment of these complications was conservative in 48.7% of cases. Conclusions The results of the pilot program of AVF creation at the DGH are encouraging. However, the sustainability of this project requires human capacity building.