Kim Daenens

Nitinol stent implantation in long superficial femoral artery lesions: 12-month results of the DURABILITY I study.

Purpose: To evaluate the long-term efficacy and integrity of the PROTÉGÉ EverFlex stent in superficial femoral artery (SFA) lesions in symptomatic patients with peripheral artery disease (PAD). Methods: A prospective, multicenter, nonrandomized study enrolled 151 subjects (111 men; mean age 67.8 years, range 42–93) undergoing percutaneous treatment of de novo, restenotic, or reoccluded SFA lesions between August 11, 2006, and June 26, 2007. Subjects were scheduled to receive a single stent and be evaluated through 12 months following the implant procedure. Occlusions were present in 40% of the patients. Mean lesion length was 96.4 mm (range 10–150). Results: A total of 161 stents (158 EverFlex) were implanted in the 151 patients: single stents in 93.4% (141/151) and a second stent in 6.6% (10/151). One-year follow-up information was available for 88.7% (134/151) of the study participants; of the remaining 17 subjects, 6 subjects withdrew from the study, 2 were lost to follow-up, and 9 died. Freedom from restenosis data were available for 99.3% (133/134) of the subjects who completed a 12-month follow-up visit. The mean Rutherford classification fell from 2.8±0.8 (range 1–5) at baseline to 0.6±1.1 (range 0–5) at 12 months. The mean ankle-brachial index rose from 0.6±0.2 (range 0–1.4) at baseline to 0.9±0.2 (range 0–1.2) at 12 months. The rates for freedom from >50% restenosis at 6 and 12 months were 91.3% (95% CI 84.9% to 95.2%) and 72.2% (95% CI 63.8% to 79.6%), respectively. The freedom from target lesion revascularization rate at 12 months was 79.1% (95% CI 71.2% to 85.6%). The 1-year stent fracture rate was 8.1% (95% CI 4.0% to 14.4%). Conclusion: The high freedom from >50% restenosis and low fracture rate at 12 months suggests that the PROTÉGÉ EverFlex stent offers a safe and acceptably efficacious means of treating SFA lesions in symptomatic subjects with PAD.

Treatment of mycotic aneurysms with involvement of the abdominal aorta: single-centre experience in 44 consecutive cases

OBJECTIVE To review our management of mycotic aneurysms involving the abdominal aorta over the past 2 decades to assess the safety and efficacy of in-situ and extra-anatomic repair combined with antibiotic treatment. MATERIALS AND METHODS From March 1990 to August 2008, 44 patients with a mycotic aneurysm involving the abdominal aorta were treated at our University Hospital. For all patients, we recorded the aetiology, clinical findings and anatomic location of the aneurysm, as well as bacteriology results, surgical and antibiotic therapy and morbidity and mortality. RESULTS Twenty-one (47.7%) of the mycotic aneurysms had already ruptured at the time of surgery. Free rupture was present in nine patients (20.5%). Contained rupture was observed in 12 patients (27.3%). Urgent surgery was performed in 18 cases (40.9%). Revascularisation was achieved by in-situ reconstruction in 37 patients (84.1%), while extra-anatomic reconstruction was performed in six patients (13.6%). One patient (2.3%) was treated with a combined in-situ and extra-anatomic reconstruction. In one case (2.3%), endovascular aneurysm repair (EVAR) was performed. In-hospital mortality was 22.7%, 50% in the extra-anatomic reconstruction group and 18.9% in the in-situ repair group. One-third (33.3%) of our patients, who presented with a ruptured mycotic aneurysm died in the peri-operative period. This mortality was 13% in the patient-group presenting with an intact aneurysm. Of the 34 surviving patients, 12 patients (27.3% of surviving patients died after discharge from our hospital. In half of these patients, an acute cardiac event was to blame. Three patients (8%) showed re-infection after in-situ reconstruction. CONCLUSION Management of mycotic aortic aneurysms remains a challenging problem. The results of surgery depend on many factors. In our experience, in-situ repair remains a feasible and safe treatment option for patients who are in good general condition at the time of surgery.

Long-term results after endovascular abdominal aortic aneurysm repair using the Cook Zenith endograft

OBJECTIVE This study assessed the long-term outcome of patients with abdominal aortic and aortoiliac aneurysms treated with the Cook Zenith endovascular graft (Cook Inc, Bloomington, Ind). METHODS Between September 1998 and October 2003, 143 patients underwent elective endovascular aneurysm repair (EVAR) using the Cook Zenith endograft. Data from these patients were reviewed from a prospective database in October 2008. Primary outcome measures were overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary outcome measures were early and late postoperative complications, including endoleaks. RESULTS Mean follow-up was 66.4 months (range, 1.9-121.0 months). Overall survival was 72.1% at the 5-year follow-up and 50.9% at the 8-year follow-up. Intervention-free survival was 77.1% at 5 years and 63.8% at 8 years. There were no reintervention-related deaths. Six patients had a late aneurysm rupture, which was fatal in three. Freedom from aneurysm rupture was 98.1% at 5 years and 91.0% at 8 years. Late complications occurred throughout the follow-up period, with a tendency for aneurysm rupture and surgical conversion to occur at a later stage in the follow-up period. Aneurysm sac enlargement during follow-up was associated with late aneurysm rupture and with the need for reintervention. CONCLUSION Elective EVAR using the Cook Zenith endograft provides excellent results through a mean follow-up of >5 years. There is a low aneurysm-related mortality and an acceptable rate of postoperative complications and reinterventions. The occurrence of late complications throughout the follow-up period stresses the need for continued postoperative surveillance in EVAR patients.

Gallic Acid Antagonizes P-Selectin–Mediated Platelet–Leukocyte Interactions Implications for the French Paradox

Background—Current paradigm attributes the low incidence of cardiovascular disorders in Mediterranean countries despite a high saturated fat intake, the “French paradox,” to the antioxidant capacity of red wine polyphenols. Conceivably, other antiinflammatory pathways may contribute to at least a similar extent to the atheroprotective activity of these polyphenols. We have investigated whether gallic acid (GA), an abundant red wine polyphenol, modulates the activity of P-selectin, an adhesion molecule that is critically involved in the recruitment of inflammatory cells to the vessel wall and thus in atherosclerosis. Methods and Results—GA potently inhibited the binding of a peptide antagonist (IC50, 7.2 &mgr;mol/L) and biotin-PAA-Lea-SO3H, an established high-affinity ligand, to P-selectin (IC50, 85 &mgr;mol/L). Under dynamic flow conditions, GA markedly and dose dependently attenuated the rolling of monocytic HL60 cells over P-selectin-transfected Chinese hamster ovary cells (EC50, 14.5 &mgr;mol/L) while increasing the velocity of P-selectin-dependent rolling of human blood leukocytes over a platelet monolayer. In vivo tests established that GA administration to normolipidemic C57/Bl6 and aged atherosclerotic apolipoprotein E–deficient mice impaired the baseline rolling of conjugates between activated platelets and circulating monocytes over femoral vein endothelium, as judged by online video microscopy (ED50, 1.7±0.3 and 1.5±0.4 mg · kg−1 · h−1, respectively). Conclusions—Our findings provide a solid mechanistic foundation through which GA intervenes in major inflammatory pathobiologies by binding and antagonizing P-selectin.

The learning curve of totally laparoscopic aortobifemoral bypass for occlusive disease. How many cases and how safe

OBJECTIVES Totally laparoscopic aortic surgery is appealing. However, the adoption of this technique in the broad vascular world is hampered by the steep learning curve and the fear of exposing patients to excessive morbidity and mortality. We assessed how many patients should be treated to overcome this learning curve. MATERIALS AND METHODS The first 50 patients treated with totally laparoscopic aortobifemoral bypass for severe aorto-iliac occlusive disease were followed prospectively. Operative variables such as operative time, aortic clamping time, amount of blood loss, conversion to laparotomy etc were recorded (as well as 30-day mortality and morbidity). To discover a turning point we used the technique of sliding averages. These data were compared with the mortality and morbidity as predicted by POSSUM and P-POSSUM. RESULTS A clear turning point, with improved operative variables, was seen after 20-30 patients. Mortality and morbidity were not higher than predicted by POSSUM and P-POSSUM. CONCLUSIONS These data confirm the intuition of most people involved in laparoscopic aortic surgery that the learning curve could be set at 25-30 cases. However, patients are not exposed to excessive morbidity and mortality during this learning curve.

Stent-Graft Repair of a Mycotic Ascending Aortic Pseudoaneurysm

A 75-year-old woman with a history of coronary artery bypass surgery complicated by mediastinitis presented with hemoptysis and fever. An enlarging pseudoaneurysm of the ascending aorta was found on computed tomography (CT) and magnetic resonance imaging. After a bypass graft procedure for cerebral and cardiac protection, two endoprosthetic cuffs, which are normally used for proximal abdominal aortic stent-graft extension, were positioned over the pseudoaneurysm neck via right carotid artery access. Blood cultures revealed methicillin-sensitive Staphylococcus aureus, and antibiotic therapy was continued for 6 weeks. Follow-up CT images demonstrated exclusion of the pseudoaneurysm with decrease in size over time. Endovascular stent-graft placement combined with antibiotic therapy may offer an alternative to surgery for the management of mycotic ascending aortic pseudoaneurysm.

ERK2 activation in arteriolar and venular murine thrombosis: platelet receptor GPIb vs. P2X1

Summary.  The functional significance of extracellular signal‐regulated kinase 2 (ERK2) activation was investigated during shear induced human platelet aggregation (SIPA) in vitro and during shear controlled thrombosis in vivo in intestinal arterioles and venules of wild type (WT) and transgenic (TG) mice with platelet‐specific overexpression of human P2X1 (TG). In SIPA, ERK2 was rapidly phosphorylated during GPIb stimulation, its activation contributing to SIPA for 50%, independently of P2X1 regulation. Thrombotic occlusion of injured arterioles occurred considerably faster in TG (4.3 ± 2.3 min) than in WT (38 ± 8 min) arterioles, but occlusion times in TG (19 ± 12) and WT (48 ± 4.5 min) venules differed less. Both the αβ‐meATP triggered desensitization of platelet P2X1, as well as P2X1 antagonism by NF279 or NF449 prolonged mean occlusion to about 75 min in WT and 65 min in TG arterioles, but venular occlusion times were less affected. Preventing ERK2 activation by U0126 prolonged occlusion times in TG (41 ± 10 min) and WT (51 ± 17) arterioles more than in TG (46 ± 5 min) and WT (56 ± 6 min) venules, uncovering a role for ERK2 in shear controlled thrombosis. Antagonism of GPIb by a recombinant murine von Willebrand factor (VWF)‐A1 fragment prolonged occlusion times to comparable values, ranging from 55 to 58 min, both in TG and WT arterioles and venules. Further inhibition strategies, combining VWF‐A1, U0126 and NF449 in WT and TG mice and resulting in occlusion in various time windows, identified that inhibition by VWF‐A1 largely abrogated the ERK2 contribution to thrombosis. In conclusion, P2X1 and ERK2 both participate in shear stress controlled thrombosis, but ERK2 activation is initiated predominantly via GPIb–VWF interactions.

Endoprosthetic Treatment of a Mycotic Superficial Femoral Artery Aneurysm

Purpose: To describe the successful stent-graft exclusion of a mycotic aneurysm of the superficial femoral artery. Case Report: A 78-year-old man presented with Salmonella arteritis and the formation of a mycotic false aneurysm of the superficial femoral artery. Antibiotics were administered; the aneurysm was excluded using 2 Hemobahn stent-grafts, and the surrounding hematoma was drained. One year postoperatively, there are no clinical or biochemical signs of infection. Ultrasound examination does not show any fluid around the patent stent-graft. Conclusions: Stent-graft placement might be an alternative to traditional surgery in selected cases of mycotic aneurysm.

Extracranial carotid artery stenting in surgically high-risk patients using the Carotid Wallstent endoprosthesis: midterm clinical and ultrasound follow-up results

AbstractThe purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent® in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients—31.5%) or because of severe comorbidities (37 patients—68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 ± 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres (7.4%), transient ipsilateral facial pain in 1 patient (1.8%), infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic instent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent®, even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or instent restenosis still remain real challenging problems.

Endovascular stent-graft and first rib resection for thoracic outlet syndrome complicated by an aneurysm of the subclavian artery

Abstract Purpose: To report our experience with a combined endovascular and surgical approach for arterial thoracic outlet syndrome (TOS) complicated by an aneurysm of the subclavian artery. Methods: We treated three consecutive patients suffering from arterial thoracic outlet syndrome complicated by an aneurysm of the subclavian artery by the use of a stent-graft and a first rib resection. These patients were reviewed retrospectively. Results: At a mean follow-up of 37.3 months all patients were free of symptoms without late complications. Conclusions: Endovascular stent-grafting followed by decompression of the costoclavicular space is an attractive alternative to the conventional surgical approach of complicated arterial TOS.