M.-A. Bartoli

Plasmatic Level of Leukocyte-Derived Microparticles Is Associated With Unstable Plaque in Asymptomatic Patients With High-Grade Carotid Stenosis

OBJECTIVES This study sought to analyze whether the plasmatic level of leukocyte-derived microparticles (LMP) is associated with unstable plaques in patients with high-grade carotid stenosis. BACKGROUND Preventive carotid surgery in asymptomatic patients is currently debated given the improvement of medical therapy. Therefore, noninvasive biomarkers that can predict plaque instability are needed. The LMPs, originating from activated or apoptotic leukocytes, are the major microparticle (MP) subset in human carotid plaque extracts. METHODS Forty-two patients with >70% carotid stenosis were enrolled. Using a new standardized high-sensitivity flow cytometry assay, LMPs were measured before thromboendarterectomy. The removed plaques were characterized as stable or unstable using histological analysis according to the American Heart Association criteria. The LMP levels were analyzed according to the plaque morphology. RESULTS The median LMP levels were significantly higher in patients with unstable plaque (n = 28; CD11bCD66b+ MP/μl 240 [25th to 75th percentile: 147 to 394], and CD15+ MP/μl 147 [60 to 335]) compared to patients with stable plaque (16 [0 to 234] and 55 [36 to 157]; p < 0.001 and p < 0.01, respectively). The increase in LMP levels was also significant when considering only the group of asymptomatic patients with unstable plaque (n = 10; CD11bCD66b+ MP/μl 199 [153 to 410] and CD15+ MP/μl 78 [56 to 258] compared with patients with stable plaque (n = 14; 20 [0 to 251] and 55 [34 to 102]; p < 0.05 and p < 0.05, respectively). After logistic regression, the neurologic symptoms (odds ratio: 48.7, 95% confidence interval: 3.0 to 788, p < 0.01) and the level of CD11bCD66b+ MPs (odds ratio: 24.4, 95% confidence interval: 2.4 to 245, p < 0.01) independently predicted plaque instability. CONCLUSIONS LMP constitute a promising biomarker associated with plaque vulnerability in patients with high-grade carotid stenosis. These data provide clues for identifying asymptomatic subjects that are most at risk of neurologic events.

Surveillance des endoprothèses aortiques abdominales : intérêt de l’échographie-doppler standard et avec contraste

OBJECTIVE Long-term surveillance is needed after endovascular aneurysm repair to monitor the aneurysm and search for persistent endoleaks. Our aim was to compare follow-up with duplex ultrasound, with and without a new contrast agent to track endoleaks, versus computed tomography angiography taken as the gold standard. MATERIAL AND METHOD Patients treated with endograft were included prospectively from December 2005 to July 2006. Aortic duplex ultrasound and computed tomography were used to measure maximal aneurysm diameter and detect endoleaks. Patients with a high risk of endoleaks had a contrast-enhanced ultrasound with Sonovue (Bracco, Milan, Italy). We compared echographic and tomographic diameter and studied the sensitivity of ultrasound endoleak diagnosis. RESULTS Sixty-seven patients were included. There was a good correlation between maximum anteroposterior diameters (CCI=0.98) measured by ultrasound and tomography, as well as mean maximum cross section diameters (CCI=0.96). Compared to tomography, the sensitivity of ultrasound endoleaks diagnosis was 44% (kappa=0.58). Contrast injection improved this sensitivity significantly (p<0.001) (sensitivity=88%; kappa=0.72). CONCLUSION These findings confirmed the performance of our ultrasound method for endograft surveillance. Contrast-enhanced ultrasound significantly improves the sensitivity of detection of endoleaks. We suggest alternating ultrasound and tomographic exams. A unique report chart for use nationwide would be useful for standardizing follow-up.

Brown-Sequard-type myelopathy due to cervical disc herniation associated with severe carotid stenosis prompting rapid combined corpectomy and carotid endarterectomy under deep anticoagulant therapy

BACKGROUND CONTEXT The risk of stroke because of carotid retraction during an anterior cervical spine surgery as well as the risk of bleeding complications after an anterior cervical corpectomy under deep anticoagulation and antiplatelet therapy is a surgical issue poorly addressed in the literature. PURPOSE To describe the feasibility and safety of a simultaneous carotid endarterectomy and anterior corpectomy and fusion under deep anticoagulation in a patient with a cervical spinal cord compression and a severe carotid artery stenosis. STUDY DESIGN Case report. METHODS The authors describe the case of a 79-year-old man who had a 1-month history of progressive pain in the neck and left arm, associated with progressive weakness in the left arm and leg. He also presented a history of coronaropathy and bilateral severe carotid stenosis for which he was receiving a regimen of antiplatelet therapy. RESULTS The cervical magnetic resonance imaging demonstrated a C4-C5 disc herniation migrating down to C5. His condition worsened rapidly during hospitalization prompting a rapid decompression. Given the necessity of a C5 corpectomy and the risk of stroke during anterior cervical spine surgery, it was therefore decided to undertake the surgical procedure under efficient anticoagulant and antiplatelet therapy. A combined endarterectomy and spinal decompression and fusion were then performed. The postoperative course was uneventful, and the patient recovered neurologically. CONCLUSIONS This case suggests that such a combined carotid endarterectomy and cervical corpectomy with fusion under anticoagulant and antiplatelet therapy is feasible. However, even if the unique clinical presentation of our patient led us to undertake such a surgical strategy, therapeutic decision in patients presenting with both severe carotid stenosis and cervical spinal cord compression should rely on a case-by-case analysis.

False aneurysm at the origin of the anterior tibial artery after opening wedge osteotomy.

We report the case of a false aneurysm at the origin of the anterior tibial artery complicating upper tibial osteotomy. The proximally located lesion compressed the posterior tibial nerve, and despite successful decompression, the patient suffers from probably irreversible neurologic after-effects. Even though it is rare, this complication must be considered when faced with leg pain consecutive to upper tibial osteotomy without deep venous thrombosis.

Dissection artérielle : un même nom, plusieurs entités

Spontaneous arterial dissection is a disease whose prevalence is difficult to know and which varies according to the affected artery territory. It can affect the aorta and all medium caliber peripheral arteries including cerebrovascular arteries, coronary arteries and renal arteries. The pathophysiology is common, it is a bleeding in the media. The causes are diverse and vary by territory. Affected patients have few cardiovascular risk factors. Fibromuscular dysplasia is the condition to look for in these few presentations. The vital and functional prognosis may be engaged. Treatment varies depending on territory, severity, and etiology. Conservative treatment is the first-line treatment.

Emergency Embolization of a Ruptured Aneurysm of the Internal Iliac Artery by Direct Ultrasound-Guided Puncture: Report of a Case.

We report the emergency embolization of a ruptured aneurysm of the internal iliac artery in a patient at high surgical risk. Admission computed tomography scan showed that the ostium of the aneurysmal internal iliac artery was covered by a covered stent. In this patient, we chose to carry out an embolization of the aneurysm and its efferent arteries by direct puncture of the aneurysmal sac using an antero-external abdominal approach under ultrasound guidance. Short-term results were favorable and we consider that this technique is one of the therapeutic options to discuss in such situation.

Endovascular Management of a Significantly Kinked Aortomonoiliac Stent Graft

We report our endovascular management of a highly kinked aortomonoiliac stent graft. This complication is unusual because kinks generally occur in bifurcated stent grafts and they are managed with extra-anatomic bypass. We will then expose the possible reasons for such complication. With long term follow-up severe kink might be reported more often.