Eric Ducasse

Use of the Flixene vascular access graft as an early cannulation solution

OBJECTIVE The primary end points of this study were safety and efficacy of early cannulation of the Flixene graft (Maquet-Atrium Medical, Hudson, NH). Secondary end points were complications and patency. METHODS This is a prospective single-center nonrandomized study. Study data included patient characteristics; history of vascular access; operative technique; interval between implantation and initial cannulation; complications; and patency at 1 month, 3 months, and every 6 months. Patency rates were estimated by the Kaplan-Meier method. RESULTS Between January 2011 and September 2013, a total of 46 Flixene grafts were implanted in 44 patients (27 men) with a mean age of 63 years. The implantation site was the upper arm in 67% of cases, the forearm in 11%, and the thigh in 22%. Seven grafts were never cannulated during the study period. Of the remaining 39 grafts, 32 (82%) were successfully cannulated within the first week after implantation, including 16 (41%) on the first day. The median interval from implantation to initial cannulation was 2 days (interquartile range, 1-3 days). The median follow-up was 223.5 days (interquartile range, 97-600 days). Five hematomas occurred, but only one required surgical revision. Primary assisted and secondary patency rates were 65% and 86%, respectively, at 6 months and 56% and 86%, respectively, at 1 year. CONCLUSIONS This study suggests that cannulation of the Flixene graft within 1 week after implantation is safe and effective. Early cannulation avoids or shortens the need for a temporary catheter. One-year patency rates appeared to be comparable to those achieved with conventional grafts, but long-term follow-up and randomized controlled studies will be needed to confirm this finding.

In-situ revascularisation for secondary aorto-enteric fistulae: the success of silver-coated Dacron is closely linked to a suitable bowel repair.

OBJECTIVES The purpose of this study was to assess short- and mid-term results of in-situ revascularisation (ISR) using silver-coated Dacron prostheses and bowel repair for management of secondary aorto-enteric fistulae (SAEF). DESIGN Single-centre retrospective chart review. MATERIAL AND METHODS This study includes all the patients treated by ISR using silver-coated Dacron for SAEF between 2006 and 2010. Primary end points were mortality and survival rates. Secondary end points were reinfection-free survival and secondary patency rates. RESULTS Eighteen male patients with SAEF with a median age of 64 years were operated by ISR using silver-coated Dacron during the study period without operative death. The 30-day mortality was 22% and the in-hospital mortality rate was 39%. Indeed, during hospitalisation, a duodenal leak was observed in four patients including three who died. Four others patients died due to multi-system organ failure. Median follow-up was 16 months (range 1-66). The survival rate at 12 months was 55%. One duodenal leak was observed leading to death. The reinfection-free survival and the secondary patency rates at 12 months were 60% and 89%, respectively. CONCLUSION In-situ revascularisation with silver-coated Dacron provides acceptable results in terms of mortality. This treatment may be useful for simple vascular reconstruction and allow greater attention to bowel repair that is a determinant in short- and mid-term survival.

Early cannulation of the Flixene™ arteriovenous graft

Purpose The aim of this review was to search for evidence of the efficiency of early cannulation of the Flixene™ (Maquet-Atrium Medical, Hudson, NH, USA) arteriovenous graft (AVG) in the current literature and to assess its patency and complication rates. Methods Searches in Pubmed, Medline, Embase and the Cochrane Library were performed using the following specific search terms: early cannulation AVG and/or Flixene™ graft. The primary outcomes were mean time to first cannulation and patency rates at 12 months. Secondary outcomes were complications. Results Six studies reporting outcomes in a total of 260 procedures were included in this review. The median delay from intervention to first cannulation was documented in four studies and was less than 3 days. Primary assisted patency at 12 months ranged from 45% to 53% in the four documented series. In five studies, documented secondary patency at 12 months ranged from 63% to 92%. Two studies compared outcomes between traditional and Flixene™ grafts: one study reported significantly (p<0.01) improved one-year patency using the Flixene™ graft, the two studies did not report significant differences in complication rates between both groups. The rate of infection and pseudo-aneurysm formation ranged from 0 to 11% and 0 to 6%, respectively. Conclusions This review shows that early cannulation of the Flixene™ graft within 3 days following its implantation is feasible with one-year patency and complication rates equivalent to those of conventional grafts which can be cannulated only after 2 weeks.

Hemodynamic Conditions may Influence the Oversizing of Stent Grafts and the Postoperative Surveillance of Patients with Ruptured Abdominal Aortic Aneurysm Treated by EVAR.

BACKGROUND To report the causes of second rupture in patients treated with a stent graft for ruptured abdominal aortic aneurysm (rAAA). CASE REPORT A 69-year-old man was admitted for abdominal pain and hypovolemic shock 22 months after endovascular exclusion of an rAAA with an aortomonoiliac stent graft and a crossover bypass despite normal duplex ultrasound and sac shrinkage at 1 year. During emergent laparotomy, a type IA endoleak was discovered and the aortomonoiliac stent graft was explanted. A Dacron bypass was interposed between the infrarenal aorta and the iliac extension stent graft. CONCLUSIONS Considering the literature, this report has 3 implications for the endovascular treatment of rAAA. First, 30% oversizing is preferable to 15% when treating an rAAA assessed by computed tomography angiography (CTA) performed during permissive hypotension. Second, the surveillance program should rely on CTA and not on a duplex examination to detect any endoleaks or migration. Finally, partial stent graft explantation is a valid option for decreasing aortic clamping time.

Re: How to do it: use of the Alexis wound protector as a laparostomy device: Letters to the Editor

We read with great interest the article by Rutledge et al. published in a recent issue of ANZ Journal of Surgery. As commercial dressings used for temporary abdominal closure of the open abdomen are expensive, every simple, effective and cheap device deserves all our interest. More than cost effective, the ideal temporary abdominal closure method has to be readily available, easy to apply and remove, allowing straightforward re-explorations and easy nursing maintenance while decreasing abdominal pressure, maintaining abdominal domain and protecting abdominal contents to limit tissue damage, contamination and hypothermia. The system suggested by Rutledge et al. seems to fit to those specifications. Nevertheless, the dressing has to avoid adhesions and prevent fascial retraction, thus increasing primary fascial closure rates and also limiting the risk of enteroatmospheric fistulas. It is the reason why it is such important to use a protective layer as large as possible. This goal is very easy to reach using commercial devices or ‘home-made’ Barker’s vacuum pack. Furthermore, this might facilitate suction and removal of exudate and infectious material. The Alexis retractor used as suggested in the article does not cover the abdominal contents as well as a large plastic layer, keeping bowel and parietal peritoneum in contact, causing adhesions and then restricting fascial mobilization that might delay fascial closure and increase the risk of enteroatmospheric fistula. Furthermore, because it cannot reach the deepest areas of the abdomen, it is doubtful that the system provides such a good suction as alternative systems. This might be harmful because it has been suggested that the quality of suction improves the clearance of cytokines and inflammatory mediators, thus increasing survival and primary fascial closure rates. However, this clever system might be of great interest for the first dressing when the outcome seems uncertain or in poor situations such as mass causalities events.

Lower extremity arterial disease in patients with diabetes: a contemporary narrative review

Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.

Laparoscopic Resection of a Middle Colic Artery Aneurysm

We report herein the successful laparoscopic resection of an asymptomatic 3-cm middle colic artery aneurysm in a young woman. Endovascular treatment represents nowadays the first-line option facing visceral artery aneurysm, but in this case, embolization was excluded because of hostile anatomy. Advantages of laparoscopic approach were the safe resection of the aneurysm with immediate evaluation of the bowel tolerance and the possibility of a histological examination of the arterial wall, without the disadvantages of laparotomy.

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.

Les techniques endovasculaires très distales chez le patient diabétique

Mots clés : Angioplastie ; Diabétique Jusqu’à récemment, le traitement endovasculaire des artères sousgonales était considéré comme « la région oubliée » de la chirurgie endovasculaire. Pourtant, avec un nombre croissant de patients diabétiques présentant une forte incidence d’artériopathie infrapoplitéale, l’option endovasculaire a été largement préférée depuis avec des résultats encourageants, devenant le traitement de première intention dans les dernières recommendations de la Société de chirurgie vasculaire. Chez cette population de patients diabétiques, il est fréquent que la présentation initiale soit déjà très avancée au stade du trouble trophique distal, justifiant une attitude agressive et recherchant une revascularisation directe des artères de jambes et de l’arche plantaire. En cas d’atteinte multiple, une revascularisation endovasculaire de plusieurs angiosomes est possible dans le même temps opératoire, tout en privilégiant l’angiosome atteint du trouble trophique. Grâce aux progrès du matériel et à l’introduction de ballons et stents dédiés de petit diamètre, il est dorénavant possible de réaliser des angioplasties transluminales ou sous-intimales dans l’intention de traiter des sténoses longues et/ou des occlusions très distales. Ces techniques peuvent s’effectuer par voie antérograde homolatérale sans oublier la possibilité d’un recours à une approche rétrograde distale où à une loop technique dans l’arche plantaire en cas d’échec. Elles permettent d’obtenir un taux de sauvetage de membre à court terme comparable à celui obtenu lors de la chirurgie conventionnelle au prix d’une morbi-mortalité moindre. Enfin, ces techniques endovasculaires n’empêchent pas, en cas d’échec, un recours à un pontage distal secondaire grâce à la cartographie du pied réalisée lors de l’artériographie peropératoire. Nous présenterons ces différentes techniques de recanalisation d’artères jambières tout en détaillant les abords et ponctions possibles, et en expliquant nos choix de matériels utilisés au cours de leur réalisation.