J.-B. Ricco

Editor's Choice – Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

Editors Choice - Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).

Mycotic aneurysm of the left subclavian artery presented with hemoptysis in an immunosuppressed man: Case report and review of literature

We report the case of a 32-year-old man with a mycotic aneurysm of the left subclavian artery. This patient had immunosuppression caused by chemotherapy administered for treatment of leukemia. This aneurysm was revealed by two episodes of hemoptysis caused by a lung parenchyma fistulization. The patient was treated successfully by simple ligation and exclusion via a thoracotomy with partial lung resection. Histologic examination confirmed the presence of aspergilloma filaments in the false aneurysm. We suspect that aspergilloma could have been the cause of the mycotic aneurysm in this particular case. The literature on subclavian artery mycotic aneurysms is reviewed.

Role of Thrombophilia in Premature Peripheral Arterial Obstructive Disease – Experience of a Vascular Centre in China

OBJECTIVE To evaluate aetiology profile and role of thrombophilia in patients with premature peripheral arterial obstructive disease (PAOD) in China. METHODS Between January 2000 and January 2010, among 368 patients presenting with PAOD, but not Buergers disease, at an age of less than 45 years, 150 patients have been screened for thrombophilia and the data analysed retrospectively. Aetiologies of thrombophilia which involved in premature PAOD were assessed and surgical outcomes were stratified for presence of thrombophilia. RESULTS In 57 of 150 patients (38%), laboratory assay results suggested thrombophilia, and the rest of them presented with other aetiology (62%). A total of 108 patients, including 38 patients with thrombophilia (35%), needed some type of revascularisation. At 30 days, recurrent thrombosis (29% vs. 9%; p = 0.005) and major amputations (11% vs. 1%; p = 0.032) were more common in patients with thrombophilia. At 1 year, primary patency (56% vs. 75%, p = 0.043), secondary patency (68% vs. 92%, p = 0.036) and limb salvage (74% vs. 96%, p = 0.038) were significantly lower in patients with thrombophilia. CONCLUSION Thrombophilia is frequently diagnosed among premature PAOD in China and adversely affects outcome after revascularisation. Clinicians should be aware of its high prevalence and aim at screening and sustained thrombophilia treatment.

Total laparoscopic renal artery bypass for restenosis after failed percutaneous transluminal renal stenting

OBJECTIVE The purpose of this article was to report our experience of the repair of renal artery restenosis after percutaneous transluminal renal angioplasty (PTRA) using a total laparoscopic technique without robotic assistance. METHODS Between February 2005 and October 2009, we performed six total laparoscopic aortorenal artery bypasses for restenosis after failed PTRA. All these patients had recurrent hypertension with renal insufficiency. RESULTS The mean operative time was 246 minutes (range, 200-310 minutes). The mean warm renal ischemic time was 28 minutes (range, 22-35 minutes). All patients received a prosthetic graft interposition. The estimated surgical blood loss was 980 mL (range, 500-1400 mL). No conversion was observed and no in-hospital deaths occurred. There was no severe postoperative morbidity. Postoperative serum creatinine levels raised in all patients but all returned to baseline before discharge. Median length of postoperative hospital stay was 6 days (range, 4-8 days). Median follow-up was 13 months (range, 7-19 months). Color Doppler ultrasound scan examination and computed tomography (CT) with injection of contrast media showed patency of all bypasses. Hypertension was improved in all patients but renal insufficiency remained unchanged. CONCLUSION Total laparoscopic renal artery bypass is feasible and safe in patients after failed PTRA. This approach may reduce the morbidity of open repair but is technically demanding and necessitates a large previous experience in total laparoscopic aortic surgery.

Part Two: Against the Motion. Young Patients with Good Risk Factors Should not be Treated with EVAR

Surgical repair is indicated for large asymptomatic abdominal aortic aneurysms (AAA) in patients with an acceptable operative risk. Following Parodi’s landmark paper, early results of randomized controlled trials (RCTs) have demonstrated lower peri-operative mortality after endovascular aortic aneurysm repair (EVAR) compared with open surgical repair (OSR). Next to these results, the number of patients receiving EVAR exceeded those treated by OR. However, some years later, the mid-term results of these RCTs have shown equivalent mortality after either EVAR or OSR, with a significantly higher re-intervention rate after EVAR, failing to support evidence favoring its use as firstline therapy, especially in young and/or fit patients. The goal of this debate is to compare early and late outcomes in patients younger than 65 years receiving OSR or EVAR.

Commentary on 'Thirty Day Outcomes and Costs of Fenestrated and Branched Stent Grafts Versus Open Repair for Complex Aortic Aneurysms' An Innovative but Expensive Tool Requiring Further Evaluation

The benefits of standard endovascular grafts (EVAR) for abdominal aortic aneurysm (AAA) have been well documented in terms of 30 day mortality, length of stay, and early cost-effectiveness compared with open surgical repair (OSR). However, these standard stent grafts are not well adapted to complex aortic aneurysms with a short neck or involving the visceral arteries. In this issue of the European Journal of Vascular and Endovascular Surgery, Michel et al. present an interesting study comparing outcomes and costs of f/b EVAR and OSR for complex AAA. The study design is that of the WINDOW registry, which has previously been published. In this registry the control group of patients (OSR) was extracted from the French National Hospital Discharge Database (PMSI). Therefore, the study compares a group of patients at high risk for OSR receiving f/b EVAR in selected centres (the cases, n 1⁄4 268) with a large group of patients at acceptable risk for OSR (controls, n 1⁄4 1,678). Although risk adjustments using the Charlson index improved the comparison between these two groups, most of the comorbidities could not be adjusted, resulting in an analysis comparing two different techniques in two different populations. Furthermore, clinical outcomes and costs were not evaluated in the same way in the two groups. The data for f/b EVAR cases were extracted from a complete case report file (CRF), compared with the cases where data were issued from the coding of the national discharge administrative database. As an example, matches corresponding to thoracoabdominal aneurysms versus juxtarenal aortic aneurysms in the infra-diaphragmatic area were identified in “cases” by reviewing pre-operative CT scans, whereas for “controls,” the matches relied on the coding system alone with no access to the patients’ charts. As suggested by the authors, the data available from the control group are subject to coding incentives and more likely to contain comorbidities that impact the level of reimbursement.

CREST: the twilight zone between (mis)interpretation and deception.

What is the main message of Parakesvas and co-authors almost three years after publication of the “carotid revascularization endarterectomy versus stent trial” (CREST) main results? Was CREST a bad trial? Without hesitation, the answer should be “No”. CREST was designed in the late 1990s and started in 2000. At the time, there had been no adequate randomized comparison of carotid endarterectomy (CEA) and protected carotid angioplasty (CAS). The reason for CREST was self-evident: compare protected CAS and CEA in low-surgical-risk but symptomatic patients. It was the first trial implementing a lead-in-phase to guide interventionalist experience. CREST added substantially to the body of data comparing CEA with CAS, with the lowest death/stroke rates ever achieved in a randomized trial on carotid revascularization independent of indicative symptoms and type of intervention. So far so good, but where did it go wrong? CREST was set-up to randomize symptomatic patients, but inclusion of asymptomatics was necessary to maintain enrollment. Although this is not a flaw per se, publicity of main results uncritically on differentiation between asymptomatics and symptomatic patients is a serious FLAW! CREST data were initially presented as showing that there were no differences in outcomes between the two procedures. The primary endpoint which included death stroke and myocardial infarction (MI) within 30 days was 4.5% for CEA and 5.2% for stenting (NS), leading the interventionists to claim equivalence of the two procedures. Subsequent “subgroup” analyses showed that CAS was associated with higher stroke and death rates in symptomatic patients, females, and patients >65 years. By that time, the general public opinion already had been influenced and molded, and CREST and subsequent guidelines were used to “promote wider use of CAS in standard and low risk symptomatic patients”. Headlines in national newspapers concluded that “CAS and CEA were equally as safe and effective in terms of stroke prevention”. This statement was factually incorrect because CREST, as in all trials on CAS versus CEA, showed that CAS was associated with a significantly higher risk (almost twofold excess) of procedural stroke. Uncritical interpretation of the CREST data (and initially incompletely reported data) could fatally

Editor's Choice – Management of Descending Thoracic Aorta Diseases

Editors Choice - Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).

Commentary on ‘Comparison of the Antimicrobial Properties of Silver Impregnated Vascular Grafts with and without Triclosan’

In this interesting study, Berard and colleagues compared the antimicrobial properties of two antimicrobial grafts containing silver or a combination of silver and triclosan using an in vitro model. Vascular grafts were inoculated separately by four microorganisms: overall, the silver vascular graft combined with triclosan demonstrated better short-term antimicrobial activity for all investigated test organisms. Essentially, these experiments repeat a previous study conducted by Ricco et al., who explored the time to kill kinetics of silver/triclosan vascular grafts against MRSA in 2012. The present study expands on Gram positive and Gram negative organisms, and Candida, and closes a hitherto unexplored and important gap. Interestingly, the authors highlight that the newly obtained time to kill curves confirm the efficacy of a silver/triclosan impregnated vascular graft even after 24 hours, with the exception of MRSA, where the combined antimicrobial vascular graft failed to achieve a >3 logRF after 8 hours. On a first note, the results for MRSA seem to stand in conflict with the previously reported results by Ricco et al. in 2012. However, it is a common misconception to set the 3 logRF as the ultimate test for being “effective”. On close analysis it becomes apparent that the shape of the MRSA time to kill kinetics of both studies are very similar. Trendwise, both studies demonstrate that adding triclosan to a silver based vascular graft achieves faster kill of MRSA, which supports the concept of antimicrobial combination. The authors identify two aspects that may have explained the difference of MRSA activity within 8 hours of incubation. While it is correct that the inoculum of the recent study was almost double the study conducted by Ricco et al., which explains missing a 3 logRF at 8 hours by Berard et al., the different origin of the two MRSA strains used requires further attention. Ricco et al. investigated the efficacy of silver/triclosan impregnated grafts against a well described laboratory

Chirurgia delle arterie dell’arto inferiore: tecniche

Le rivascolarizzazioni arteriose degli arti inferiori sono tra le procedure piu frequentemente eseguite nei pazienti con malattia arteriosa ateromatosa occlusiva. Sono, qui, definite come qualunque ricostruzione arteriosa che utilizza un bypass autogeno, una protesi o una tecnica di endoarteriectomia al di sotto del legamento inguinale. Spesso riguardano pazienti con grave ischemia degli arti. Sono trattate solo le procedure chirurgiche convenzionali o ibride, mentre le tecniche endovascolari sono state descritte altrove. Inoltre, non e trattata qui la chirurgia degli aneurismi della femorale e degli aneurismi poplitei (cfr. “Chirurgia degli aneurismi arteriosi degli arti”). Negli ultimi due decenni, i progressi nella valutazione, nella selezione dei pazienti e nella realizzazione tecnica dei bypass sottoinguinali hanno permesso di sviluppare un approccio piu aggressivo con ricostruzioni arteriose piu distali nei pazienti con un’ischemia cronica severa per i quali l’alternativa e un’amputazione maggiore. Gli studi pubblicati in questi ultimi anni hanno confermato il miglioramento parallelo della pervieta del bypass e dei tassi di salvataggio dell’arto, a condizione che il paziente abbia una vena grande safena (VGS) utilizzabile.