Jean-Luc Magne

In situ revascularization with silver-coated polyester grafts to treat aortic infection: early and midterm results

PURPOSE In this prospective study we analyzed the immediate and midterm outcome in patients with abdominal aorta infection (mycotic aneurysm, prosthetic graft infection) managed by excision of the aneurysm or the infected vascular prosthesis and in situ replacement with a silver-coated polyester prosthesis. METHODS From January 2000 to December 2001, 27 consecutive patients (25 men, 2 women; mean age, 69 years) with an abdominal aortic infection were entered in the study at seven participating centers. Infection was managed with either total (n = 18) or partial (n = 6) excision of the infected aorta and in situ reconstruction with an InterGard Silver (IGS) collagen and silver acetate-coated polyester graft. Assessment of outcome was based on survival, limb salvage, persistent or recurrent infection, and prosthetic graft patency. RESULTS Twenty-four patients had prosthetic graft infections, graft-duodenal fistula in 12 and graft-colonic fistula in 1; and the remaining 3 patients had primary aortic infections. Most organisms cultured were of low virulence. The IGS prosthesis was placed emergently in 11 patients (41%). Mean follow-up was 16.5 months (range, 3-30 months). Perioperative mortality was 15%; all four patients who died had a prosthetic graft infection. Actuarial survival at 24 months was 85%. No major amputations were noted in this series. Recurrent infection developed in only one patient (3.7%). Postoperative antibiotic therapy did not exceed 3 months, except in one patient. No incidence of prosthetic graft thrombosis was noted during follow-up. CONCLUSION Preliminary results in this small series demonstrate favorable outcome with IGS grafts used to treat infection in abdominal aortic grafts and aneurysms caused by organisms with low virulence. Larger series and longer follow-up will be required to compare the role of IGS grafts with other treatment options in infected fields.

Functional assessment of human femoral arteries after cryopreservation

PURPOSE An established method of cryostorage that might preserve the vascular and endothelial responses of human femoral arteries (HFAs) to be transplanted as allografts was studied. METHODS HFAs were harvested from multiorgan donors and stored at 4 degrees C in Belzer solution before cryostorage. One hundred eleven HFA rings were isolated and randomly assigned to 1 control group of unfrozen HFAs and 2 groups of HFAs cryopreserved for 7 and 30 days, respectively. Cryopreservation was performed in Elohes solution containing dimethyl sulfoxide (1.8 mmol/L), and the rate of cooling was 1.6 degrees C/min, until -141 degrees C was reached. The contractile and relaxant responses of unfrozen and frozen/thawed arteries were assessed in organ bath by measurement of isometric force generated by the HFAs. RESULTS After thawing, the maximal contractile responses to all the contracting agonists tested (KCl, U46619 [a thromboxane A2-mimetic], norepinephrine, serotonin, and endothelin-1) were in the range of 7% to 34% of the responses in unfrozen HFAs. The endothelium-independent relaxant responses to forskolin and verapamil were weakly altered, whereas the endothelium-independent relaxant responses to sodium nitroprusside were markedly reduced. Cryostorage of HFAs also resulted in a loss of the endothelium-dependent relaxant response to acetylcholine. The vascular and endothelial responses were similarly altered in the HFAs cryopreserved for 7 and 30 days. CONCLUSION The cryopreservation method used provided a limited preservation of HFAs contractility, a good preservation of the endothelium-independent relaxant responses, but no apparent preservation of the endothelium-dependent relaxation. It is possible that further refinements of the cryopreservation protocol, such as a slower rate of cooling and a more controlled stepwise addition of dimethyl sulfoxide, might allow better post-thaw functional recovery of HFAs.

Furosemide inhibits thromboxane A2-Induced contraction in isolated human internal mammary artery and saphenous vein

Evidence suggests that, in addition to its diuretic property, furosemide also may exert direct vascular effects. Because thromboxane A2 (TXA2) has a role in the control of vascular tone, we investigated the effect of furosemide on the contraction induced by U46619 (a stable TXA2 mimetic) on isolated human internal mammary artery (IMA) and saphenous vein (SV). Concentration-response curves to U46619 were performed in the absence (vehicle) or the presence of furosemide (0.1-1 mM) on rings of IMA and SV. In addition, the relaxant effect of furosemide (0.1 microM-1 mM) also was evaluated on U46619-precontracted IMA and SV. The participation of cyclooxygenase derivatives was studied by pretreatment with indomethacin. Furosemide (0.1-1.0 mM) caused parallel rightward shifts of U46619 concentration-response curves without affecting the maximal responses in both IMA and SV. Treatment with indomethacin (1 microM) modified neither the inhibitory effect of furosemide on U46619-induced contractions, nor the relaxant effect of furosemide on U46619-induced contractions, nor the relaxant effect of furosemide on U46619-precontracted IMA and SV. In conclusion, furosemide at high concentrations inhibited U46619-induced contraction in human isolated IMA and SV and relaxed U46619-precontracted IMA and SV by mechanisms independent of the release of relaxant prostaglandins. These results suggest that blockade of TXA2 receptors by furosemide may contribute to explaining the therapeutic effects of furosemide in the treatment of severe heart failure.

Carotid Artery Revascularisation Following Neck Irradiation: Immediate and Long-Term Results

OBJECTIVE Carotid artery stenosis is a complication of neck irradiation. We describe the immediate and long-term results of surgical treatment. METHODS This was a retrospective single centre study. From 1996 to 2009, 24 consecutive patients who had in the past received neck radiation therapy (mean 12 years, 1-41 years) underwent 27 primary carotid artery revascularisation procedures. Six patients (23%) had previous radical neck dissection, three permanent tracheostomies and one cervicoplasty with pectoral muscle flap. Indications for surgery included symptomatic (five transient ischaemic attacks (TIAs), four strokes; 34%) and asymptomatic (18 patients, 66%) stenosis. Four patients had occlusion of the contralateral carotid. General anaesthesia without shunting was used with measurement of stump pressure. Carotid interposition bypass grafting included 23 vein grafts and three polytetrafluoroethylene (PTFE) grafts. RESULTS No perioperative deaths or central neurological events occurred. Three patients suffered transient cranial nerve injuries. Eleven patients died during follow-up, mean interval of 28 months (range 6-120 months), of causes unrelated to surgery. Five patients had recurrent bypass stenosis with one TIA and one stroke. All other surviving patients remained asymptomatic. CONCLUSION Despite no comparative study as evidence, we think that the perioperative risk of stroke is at least comparable with the risk encountered for angioplasty procedures.

Popliteal venous aneurysms: A two center experience with 21 cases and review of the literature

Popliteal venous aneurysms (PVA) are an uncommon but potentially life-threatening disease as they can be a source for pulmonary emboli (PE). We reviewed 21 patients (5 males, 16 females aged 33–79 years, mean age 60 years) with popliteal venous aneurysms treated between 1985 and 1998 in two centers. Nine aneurysms were discovered in patients with varicose veins, and 12 aneurysms were symptomatic: 50% presented with PE and 50% had thrombotic symptoms. The diagnosis of PVA was achieved by venous duplex imaging and phlebography: 85% (18/21) of the aneurysms were saccular and 43% (9/21) had an intraluminal thrombus. Surgical repair was performed by aneurysmectomy with venorrhaphy in 16 patients. Five patients had various procedures, including vein transposition (n=1), resection and end-to-end anastomosis (n=2), resection with interposition vein grafting using the greater saphenous vein (n=1) or superficial femoral vein (n=1). Two patients had a concomitant inferior vena cava filter placement. Mean follow-up was 53 months (range: 2 to 136 months). No operative deaths occured, and no patient had evidence of a recurrent PE. Postoperative thrombosis of the surgical repair developed in 3 cases. Patency was restored with anticoagulation therapy. Four complications (19%) included transistory nerve injury (n=2) and postoperative hematoma (n=2). Despite its rarity PVA should be ruled out in patients with PE and no other obvious embolic source or thromboembolic risk factors. Based on our experience and a review of the literature: (1) Surgical treatment is indicated in all symptomatic patients and tangential aneurysmectomy with lateral venorraphy is the recommended procedure; (2) Asymptomatic patients with saccular or large fusiform PVA should also undergo surgery because of the unpredictable risk of thromboembolic complications; (3) Asymptomatic patients with small fusiform and thrombus-free PVA may remain under close surveillance and surgery should be performed if thrombus is detected in the aneurysm and if thromboembolic complications occur. Although this policy has been advocated by some authors, it will have to be supported by other long-term observations.

Endovascular Treatment of Aortic and Primitive Iliac Artery Aneurysms Associated With Behçet Disease

Behçet disease is a systemic vasculitis that can cause vascular complications. We describe a 42-year-old woman with an aortic aneurysm and common right iliac aneurysm, both saccular and complicating Behçet disease. The patient was successfully treated by an endovascular method, which currently seems to be the best therapeutic choice given the frequent anastomotic complications of conventional surgical treatment.

Midterm results of internal iliac artery aneurysm embolization

OBJECTIVE We describe the immediate and midterm results of endovascular treatment of isolated internal iliac artery aneurysms (IIAA). METHODS This was a retrospective single center study. From 2005 to 2014, data from 20 consecutive patients who had an embolisation for an isolated atherosclerotic internal iliac artery aneurysm underwent an endovascular treatment. We retrospectively evaluated the technical aspects and outcomes. RESULTS The mean aneurysm diameter was 42mm (range 30-97mm). No perioperative deaths or treatment failures occurred. No endoleaks or secondary aneurysm ruptures were observed during the follow-up. Three patients experienced disabling buttock claudication, which was spontaneously remissive in two cases. No relationship was found between buttock claudication and the patency of the contralateral internal iliac artery and the deep femoral artery. Six patients (30%) died during follow-up. Among these, three patients died due to cardiovascular events. The mean follow-up interval was 24 months (range 6-96 months). CONCLUSION The endovascular treatment of isolated internal iliac artery aneurysm is safe in the short-term and could prevent secondary aneurysm rupture at midterm.

Dissection of a Renal Artery Originating in the Thorax and Coursing Through the Diaphragm: A Complication of Renal Artery Entrapment

To the Editor, Renal arteries originate mostly from the abdominal aorta. However, about 30% of patients have anatomic variations in renal arteries. Among them, less than a dozen cases of aberrant renal arteries originating from the thoracic aorta have been reported in the literature [1], all on the right side. It is important to report this anatomical variant, particularly on examinations prior to organ removal so as to avoid intraoperative vascular lesions [2]. To our best knowledge, no other complication has been reported to this ectopic origin. We describe herein a case of spontaneous dissection of an ectopic renal artery originating from the lower thoracic aorta and occurring at the level of its trans-diaphragmatic passage. A 50-year-old man was admitted to the emergency room of our academic hospital for brutal and intense pains in the right lumbar fossa. His main antecedents were an episode of left nephritic colic in 2010, and active smoking at 30-pack-years. His blood pressure was 220/110 mmHg. The urinary dipstick revealed hematuria. Laboratory analyses showed a discrete inflammatory syndrome: CRP = 20 mg/L, leucocytes = 11.6 G/L, serum creatinine = 156 micromol/L, urea = 5.4 mmol/L, and lactates = 3.5 mmol/L. A non-injected abdomino-pelvic CT scan showed no obstruction of the urinary tract. The complementary scan, after injection of contrast media, showed an ectopic right renal artery, originating from the descending thoracic aorta (Fig. 1A) and crossing the diaphragm at the level of the right vertebral groove (Fig. 1B). The right kidney was small in size, measuring 8.4 cm along the long axis, versus 10.8 cm on the left side, with a parenchymal delay and multiple ischaemic plaques (Fig. 1C). The trunk of the renal artery was aneurysmal in its supradiaphragmatic segment and a circumferential parietal hematoma was present in its subdiaphragmatic segment extending into the right retropyleal branch (Fig. 1D). No traumatic context was reported. The diagnosis of spontaneous renal artery dissection was made. The patient was initially treated by anticoagulants at a curative dose for 6 months and by a combination of two antihypertensives. As the dissecting hematoma extended into the dividing branches of the renal artery, emergency reimplantation surgery was contraindicated. During the follow-up, the blood pressure was well controlled with the dual therapy, at 137/85 mmHg at rest, and the creatininemia remained stable at 140 micromol/L. A CT scan showed the regression of the hematoma along with ischemic sequelae in the right kidney. A renal scintigraphy with DMSA revealed right renal function at only 16%. Despite this poorly functioning kidney but well controlled blood pressure under dual therapy, no invasive & Julien Ghelfi JGhelfi@chu-grenoble.fr

Carotid glomectomy: A treatment for syncope?

MOTS CLÉS Glomus carotidien ; Pression artérielle ; Syncope A 44-year-old woman was hospitalized with syncope involving a serious fall. Twentyeight years earlier, she had undergone cervical radiotherapy for Hodgkin’s lymphoma. For 6 months, she had presented numerous episodes of syncope, always during daytime after getting up and all preceded by significant clinical vasoplegia. On examination, her blood pressure was 112/77 mmHg lying down with a regular pulse of 62/minute and no orthostatic hypotension. Massage of the carotid sinuses did not cause bradycardia but massage of the left carotid sinus, just before the patient got up, led to severe vasoplegia with generalized redness, a pulse that could not be taken and syncope followed by a sudden fall. Blood pressure and heart rate values during this period are shown in Fig. 1. Syncope was reproduced in the same way by rotating the head to the left. The electrocardiogram, 24-hour rhythm recording, cardiac ultrasound and cerebral magnetic resonance imaging were normal. Owing to the cervical antecedents and clinical history, we decided to perform a left carotid glomectomy. Surgery went ahead without any complications and the anatomopathological examination showed a normal carotid body. Since the glomectomy, and after a 4-year follow-up period, the patient has been totally asymptomatic. The cells of the carotid body, a small vasculonervous formation containing chemoreceptors, are essential to cardiovascular and respiratory homeostasis [1]. Although these cells do not directly control the baroreflex, their proximity to the carotid sinus explains why a carotid body tumour compressing the sinus leads to a feeling of faintness and even syncope due to sinus hypersensitivity. This carotid sinus hypersensitivity is common in patients with syncope and falls, particularly in elderly subjects [2,3]. In 1933, the first treatment for carotid sinus hypersensitivity was denervation of the sinus [4]. In the 1990s, a team suggested performing a glomectomy in combination with a presinusoidal lymphadenectomy [5]. In our patient, the presence of syncope could have indicated carotid