Caroline Caradu

Revascularisation dans l’artériopathie oblitérante des membres inférieurs au stade des troubles trophiques

L’ischemie critique chronique (ICC) represente le stade ultime de l’arteriopathie obliterante des membres inferieurs (AOMI), associe a un risque eleve d’evenements cardiovasculaires. Pour assurer le sauvetage de membre et la cicatrisation des troubles trophiques, la restauration d’un flux sanguin direct dans le pied est necessaire. Le pontage distal est le traitement de reference mais ces dernieres annees, la strategie de revascularisation a ete bouleversee par les resultats du traitement endovasculaire. L’apparition de nouvelles techniques et de materiel dedie ont permis d’obtenir des taux de sauvetage de membre a long terme equivalents a ceux des pontages, tout en limitant la morbi-mortalite peri-operatoire. Trois nouveaux essais randomises controles sont actuellement en cours aux Etats-Unis et en Europe (BEST-CLI, BASIL-2 et -3). Les deux premiers visent a comparer traitement endovasculaire et pontage tandis que le dernier comparera l’angioplastie par ballon simple, l’angioplastie par ballon actif et l’utilisation de stents actifs. Ces essais fourniront des informations essentielles sur les caracteristiques et le pronostic de l’ICC et des preuves plus recentes pour guider le traitement dans cette pathologie difficile.

Combination of Chimneys and Fenestrated Endografts in the Treatment of Complex Aortic Aneurysms.

Purpose: To present early results of fenestrated endovascular aneurysm repair (FEVAR) combined with chimney grafts in a high-volume center. Methods: From July 2011 to July 2016, 45 patients (mean age 73.0±8.8 years; 39 men) with complex aneurysms who were poor candidates for open repair and anatomically ineligible for standard or custom-made FEVAR were treated with chimney FEVAR (chFEVAR). Eight (18%) cases were treated in emergency. In all, 130 target vessels (2.9/patient) were addressed using 21 scallops, 42 open/18 covered chimneys, and 27 custom-made/22 homemade fenestrations. Results: Successful aneurysm exclusion, successful reconstruction, and technical success rates were 97.8% (44/45), 98.2% (107/109 vessels excluding the scallops), and 93.3% (42/45). Six (13.3%) patients died within 30 days (5 in hospital). Estimated overall survival, freedom from aneurysm-related death, and freedom from aneurysm-related reintervention were 85.9%, 88.5%, and 59.2%, respectively, at 12 months. The target vessel patency rate was 96.0%. At latest follow-up, 1 type Ia and 3 type II endoleaks were present. Sac shrinkage occurred in 18 (54%) patients. Conclusion: Combined chFEVAR showed good technical feasibility and could be an effective approach in emergent settings and highly selective cases when FEVAR is not feasible. Thirty-day mortality, target vessel patency, and type Ia endoleak rates were acceptable.

Monocentric Evaluation of Endovascular Repair of Juxta-renal Abdominal Aortic Aneurysms by the “Chimney” Technique vs. “Fenestrated” Stentgrafts

implantation of an aortic fenestrated (FEVAR) or branched (BEVAR) stentgraft to treat aortic aneurysms. Materials and Methods: Eighty-two patients were operated for aortic aneurism by FEVAR or BEVAR between January 2008 and December 2014 in two French university hospitals. The data were collected prospectively. The principal criterion of judgment was a postoperative degradation of the renal function at D15. It was defined using the Risk Injury Failure Loss and End Stage criteria by a reduction of more than 25% of the preoperative glomerular filtration rate (GFR) and a threshold value of GFR<60mL/min/1.73m. Univariate then multivariate analysis were carried out in order to determine the variables associated with an early degradation with the postoperative renal function. Results: Seventy-seven patients were included with a total of 145 target renal arteries. Preoperatively, 16 (20.8%) patients had a GFR<60mL/min/1.73m. At D15, 8 (10.4%) patients presented a degradation of the renal function and 21 (27.3%) patients had a GFR<60mL/min/1,73m. Only one patient needed immediate postoperative hemodialysis during 10 days. The average follow-up was 14.2 (0.1-76.4) months. Mortality was 1.3% (n1⁄41) at D30. At the end of the follow-up it was 22.4% (n1⁄417). The variables ‘‘perirenal hematoma’’ and ‘‘preoperative kidney size <100mm’’ were significantly associated with the occurrence of a degradation of the renal function at D15 after mutual adjustment in multivariate analysis (p<0.001 and p1⁄40.01, respectively). There was no significant link between the preoperative impaired renal function, any stage confused, and the occurrence of an early degradation of the postoperative renal function (p1⁄40.096). Conclusion: The presence of a preoperative reduced renal size and the occurrence of a postoperative perirenal hematoma are predictive factors of degradation of the postoperative renal function at D15 after FEVAR or BEVAR.

Nouvelles techniques de traitement endovasculaire pour la prise en charge des anévrismes de l’aorte abdominale juxta-rénaux

Sur les 15 dernieres annees, la prise en charge des anevrismes de l’aorte abdominale (AAA) s’est considerablement modifiee. Le traitement de reference, la chirurgie ouverte, a peu a peu ete supplante par la reparation endovasculaire des AAA (EVAR), permettant ainsi d’etendre les indications a des patients plus âges, avec plus de comorbidites. Au debut, EVAR etait reserve aux AAA sous-renaux et 40 % des patients ne pouvaient pas en beneficier en raison des contraintes anatomiques au niveau du collet proximal. Pour y pallier, des techniques hybrides sont apparues, proposant un « debranching » des vaisseaux visceraux associe a une couverture par EVAR, suivies de techniques exclusivement endovasculaires, permettant d’elargir les indications en maintenant une zone d’etancheite suffisante, a savoir les endoprotheses fenestrees (f-EVAR), branchees, les cheminees (c-EVAR), les techniques sandwich ou des methodes combinees f-EVAR et c-EVAR. Ainsi 58 % des patients sont traites en dehors des conditions d’utilisation des endoprotheses. Les indications doivent etre rigoureuses car le benefice a long terme sur la survie apres EVAR reste discutable pour les AAA juxta-renaux, laissant une place a la chirurgie ouverte chez les patients avec une esperance de vie et un risque operatoire acceptables. De plus, le taux plus eleve de reinterventions necessaires a la perennite du montage justifie une surveillance reguliere par imagerie, avec un cout a long terme plus eleve. Il est donc primordial de selectionner attentivement les patients pouvant beneficier de ce type de procedure.

Comparison of Homemade and Standard Renal Fenestrations of Stentgrafts

determine the rates of postoperative patency and endoleaks. The median follow-up was 24 months [1-58]. Results: The technical success rate, defined by the implantation of the ZBIS stentgraft without type I or III endoleaks, was 96% (n1⁄425). The preoperative occlusion of one internal iliac artery was related to the conflict between the aortic bifurcatedmodule and the ZBISmodule. Themedian duration of hospitalization was five days [3-10]. Postoperative mortality at 30 days was null. Two secondary endovascular procedures were necessary at three and six months. In the first case, a type IA endoleak associated with a type II lumbar endoleak was treated successfully by lumbar embolization and a Palmaz stent. In the second case, a type III endoleak on the internal iliac limb was treated successfully by the implantation of an additional internal iliac covered stent through an axillar approach. The mean rate of patency of the ZBIS stentgrafts at 29 months was 96%. No patient presented symptoms of pelvic ischemia or aneurysm rupture, and only one patient presented a buttock claudication in connection with the embolization of the IIA. Four patients died during the follow-up without relationship with the aneurysmal pathology. Conclusion: The preservation of at least one IIA during endovascular exclusion of the aorto-bi-iliac aneurysms appears essential to us. The branched ZBIS stentgraft allows the maintenance of the vascularization of the IIA by an endovascular procedure. The medium-term results are very satisfactory if the preoperative anatomical criteria are strictly respected.