Michel Bartoli

Critical role of dipeptidyl peptidase I in neutrophil recruitment during the development of experimental abdominal aortic aneurysms

Dipeptidyl peptidase I (DPPI) is a lysosomal cysteine protease critical for the activation of granule-associated serine proteases, including neutrophil elastase, cathepsin G, and proteinase 3. DPPI and granule-associated serine proteases have been shown to play a key role in regulating neutrophil recruitment at sites of inflammation. It has recently been suggested that neutrophils and neutrophil-associated proteases may also be important in the development and progression of abdominal aortic aneurysms (AAAs), a common vascular disease associated with chronic inflammation and destructive remodeling of aortic wall connective tissue. Here we show that mice with a loss-of-function mutation in DPPI are resistant to the development of elastase-induced experimental AAAs. This is in part because of diminished recruitment of neutrophils to the elastase-injured aortic wall and impaired local production of CXC-chemokine ligand (CXCL) 2. Furthermore, adoptive transfer of wild-type neutrophils is sufficient to restore susceptibility to AAAs in DPPI-deficient mice, as well as aortic wall expression of CXCL2. In addition, in vivo blockade of CXCL2 by using neutralizing antibodies directed against its cognate receptor leads to a significant reduction in aortic dilatation. These findings suggest that DPPI and/or granule-associated serine proteases are necessary for neutrophil recruitment into the diseased aorta and that these proteases act to amplify vascular wall inflammation that leads to AAAs.

Pelvic ischemia and quality of life scores after interventional occlusion of the hypogastric artery in patients undergoing endovascular aortic aneurysm repair

OBJECTIVEnThe aim of this study was to analyze the pelvic ischemic complications and their impact on quality of life after interventional occlusion of the hypogastric artery (IOHA) in patients undergoing endovascular aortic aneurysm repair (EVAR).nnnMETHODSnBetween January 2004 and April 2012, 638 consecutive patients with aortoiliac aneurysm treated by EVAR were prospectively registered in two teaching hospitals. We identified all EVAR patients who underwent IOHA. Demographic, clinical, and radiologic data were extracted from electronic databases and patient records as requested. All patients who survived the postoperative period took part in a quality of life survey, the Walking Impairment Questionnaire (WIQ), which included four items: pain, distance, walking speed, and stair climbing. Outcome measures included the 30-day rate of pelvic ischemic complications, the buttock claudication (BC) rate at 30 days and during follow-up, and the comparative WIQ scores between patients with persistent BC, those with regressive BC, and those who never had BC after the IOHA procedure.nnnRESULTSnA total of 71 patients (97% men; mean age, 76 years ± 7.69) required 75 IOHA procedures. These were deemed proximal in 44 cases and distal in 31, with use of coil embolization in 64%, Amplatzer plug in 24%, or a combination of coils and plugs in 12%. The technical success rate was 100%. Two patients (2.8%) experienced fatal acute pelvic ischemic complications in the postoperative period after EVAR. Another patient died of iliac rupture during EVAR, leading to an operative mortality rate of 4.3%. Eighteen patients (25.3%) suffered BC, among whom 11 cases resolved at a median follow-up of 42 months. Young age (odds ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03) and distal IOHA (odds ratio, 3.5; 95% confidence interval, 1.01-11.51; P = .04) were independent predictors of BC occurrence. The actuarial rate of persistent BC was 85% at 18 months. The WIQ scores were lower for patients with persistent BC (median score, 35.04; interquartile range, 16.36; P = .001) compared with patients with regressive BC (median score, 76.5; interquartile range, 36.66; P = .02) or those who never experienced BC after the IOHA procedure (median score, 65.34; interquartile range, 10.94; P < .0003).nnnCONCLUSIONSnPelvic ischemia associated with IOHA may be severe and lead to fatality after EVAR. Our data show that BC may lead to severe quality of life impairment when it does not regress during follow-up.

Open surgical reconstruction of the internal carotid artery aneurysm at the base of the skull

OBJECTIVESnAneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report a standardized surgical technique of ICA reconstruction with long-term results.nnnMETHODSnBetween 1988 and 2005, 13 patients (11 men; age 18 to 76 years, mean 42.6 years) underwent lateral skull base approach with cervical-to-petrous carotid artery bypass for repair of ICA aneurysms. Principal elements of the technique were: partial resection of the parotid gland without rerouting of the facial nerve; luxation of mandibula; drilling of the bone.nnnRESULTSnThe 13 patients had unilateral aneurysm of the ICA at the base of the skull. Four aneurysms were of atherosclerotic origin; six fibromuscular dysplasia; two post-traumatic; one cause was undetermined. The mean diameter of the aneurysms was 12 mm (range, 7-21 mm). Twelve patients were symptomatic: six presented neurological events (four strokes, two transient ischemic attack [TIA]); two retinal events; three compressive symptoms (two Horners syndrome and one paralysis of the glossopharyngeal nerve); one patient presented a visible pulsatile mass in the neck. One patient was asymptomatic. There were no post-operative deaths, one TIA, 13 transient palsies of the lower facial nerve, and one transient palsy of accessory nerve. Palsy of cranial nerves was partial and disappeared within a mean of 5.6 months (range, 1-10 months). The postoperative angiogram showed patency in all but one case (one asymptomatic thrombosis). During follow-up (mean, 152 months), there was one unrelated death, one focal epileptic seizure, and one controlateral TIA. In November 2008, duplex showed patency of all 11 grafts (one death, one thrombosis). At 10 years, the survival, cumulative stroke-free survival, ipsilateral stroke-free, and patency rates was were 90.9%, 100%, 100%, and 92.3%.nnnCONCLUSIONnVenous graft bypass from the cervical-to-petrous ICA can be performed safely with such an approach and produces durable satisfactory results.

Secondary Procedures After Infrarenal Abdominal Aortic Aneurysms Endovascular Repair With Second-Generation Endografts

BACKGROUNDnTo study the incidence, the types, and the results of secondary procedures performed after endovascular treatment of infrarenal abdominal aortic aneurysm (AAA). To compare the population of patients who underwent secondary procedure (P2) with the population of those who did not require it.nnnMATERIAL AND METHODSnBetween 1998 and 2008, this study included all the patients electively treated for AAA with stentgrafts that were still available on the market on January 1, 2009. Data were prospectively collected and retrospectively analyzed. The postoperative follow-up included at least a systematic computed tomography scan at 6, 12, 18, and 24 months and then every year. P2 were defined as any additionnal procedures performed to treat aneurysm related complications after initial stentgraft implantation.nnnRESULTSnWe studied 162 patients with a mean 40 ± 31 months follow-up. In 32 patients (19.7%), there were 46 P2, 3 of them were surgical conversion and 1 with endovascular conversion. Thirty-nine P2 were scheduled, and seven were performed in emergency. Nine patients underwent more than one P2. P2 was indicated for type II endoleak in 17 cases, 13 of them with a diameter increase; for type I endoleak in 10 cases; for AAA rupture in 3 cases; for occlusion or stentgraft stenosis in 13 cases; and for 1 type III endoleak, 1 endotension, and 1 femoro-femoral crossover bypass infection. Two ruptures occurred in patients who had undergone P2. The immediate technical success was 89.1%. At 30 days, morbidity was 10.9%, and there was no mortality. Survival rates at 3 and 5 years were respectively 85.2% and 71.9% in patients with secondary procedure and 70.6% and 47.5% in the others (p = 0.046).nnnCONCLUSIONSnIn patients treated for AAA with second generation stentgrafts, in the long term, secondary procedure rate was 19.7%. Survival rate for patients who underwent a secondary procedure was better, which was probably related to the fact that they were younger at the time of stentgraft implantation. Large AAA diameter was a secondary-procedure risk factor.

Perioperative evaluation of iliac ZBIS branch devices: a French multicenter study.

BACKGROUNDnThe purpose of this study was to evaluate short-term results of endovascular treatment of common iliac artery (CIA) aneurysms without a distal neck by using iliac branch devices (IBDs), which enable maintenance of antegrade perfusion to the internal iliac arteryxa0(IIA).nnnMETHODSnOur investigation was done in a prospective, multicenter, nonrandomized manner. IBD were implanted to exclude CIA aneurysms with a diameter >25 mm in patients unfit for open repair. The stent grafts were designed based on preoperative angio-CT findings. A covered stent implantation between the IBD and the target IIA was performed during the same surgical procedure. Angio-CT was performed within the 30 days after the procedure. From January 2009 to April 2010, 39 patients were included in our study (38 men and 1 woman, mean age 73 years).nnnRESULTSnThe CIA aneurysm (mean diameter 32.3 mm) was isolated in 15 patients and associated with an abdominal aorta aneurysm (mean diameter 66 mm) in 24 patients. The IBD was systematically connected to a bifurcated aortobiiliac stent graft. The bifurcated stent graft was implanted during the same procedure in all patients, except for two who had a bifurcated stent graft history. Median surgery time, fluoroscopy time, and volume of contrast product were 192 (range 90-360) minutes, 32 (10-120) minutes, and 150 (60-352) mL, respectively. In 37 patients (95%), the internal iliac branch was patent at the end of the surgery. In two patients (5%), it was occluded, entailing a subischemic colic episode and buttock claudication in one of them. To treat a type I endoleak, a proximal extension partially covering a renal artery was implanted during the same surgery. A type III endoleak was diagnosed on the postoperative angio-CT. In three patients, a cross-over femorofemoral bypass was performed for an external iliac leg thrombosis (and for an internal iliac branch thrombosis in one case). In all, at 30 days, no death was reported and the success rate was 90% (three leg stenoses and a type III endoleak).nnnCONCLUSIONSnIBD implantation to maintain an antegrade internal iliac perfusion is possible and has shown promising early success. Our results can be compared with those in the published literature. A learning curve will be needed to improve the technical success rate.

Congenital Anomalies of Inferior Vena Cava in Young Patients with Iliac Deep Venous Thrombosis

Venous thromboembolism (VTE) in young patients is frequently associated with hereditary biological thrombophilia, autoimmune disorders, or neoplasia. Advances in venous ultrasound and contrast-enhanced computed tomography have allowed for the identification of inferior vena cava (IVC) anomalies as newly considered etiologic factor. We present two cases of VTE in young patients: the first case involves left IVC in a 22-year-old man and the second involves IVC atresia in a 39-year-old man. IVC anomalies should be identified in young patients with spontaneous VTE involving the iliac veins because they are at a high risk for thrombotic recurrence and adaptation to long periods of antithrombotic therapy.

Long-Term Results of Large Stent Grafts to Treat Abdominal Aortic Aneurysms

BACKGROUNDnOpen surgery and endovascular treatment are currently the 2 methods of treatment for abdominal aortic aneurysms (AAAs). Although in open surgery, the proximal diameter of the implanted prostheses seldom exceeds 24xa0mm, endovascular aneurysm repair (EVAR) makes it possible to use stent grafts up to 36xa0mm in diameter. The aim of this study was to compare the long-term results of these large stent grafts compared with the others.nnnMETHODSnA total of 908 patients operated between 1998 and 2012 for a nonruptured AAA with an infrarenal stent graft were enrolled in this multicentric retrospective study. The patients in whom the proximal diameter of the principal component of the stent graft was above 32xa0mm belonged to group 1 (nxa0=xa0170) and the others belonged to group 2 (nxa0=xa0738). The qualitative and quantitative data were compared with the chi-squared test and the t-test, respectively. The long-term data were analyzed with the log-rank test and Kaplan-Meier curves.nnnRESULTSnMean age of the patients was 75xa0±xa08.3xa0years, and the average follow-up duration was 38xa0±xa028.2xa0months. There was no difference between the 2 groups regarding demographic data, risk factors except chronic renal insufficiency (30.6% in group 1 vs. 21.2%, Pxa0=xa00.011), and the proportion of obese patients (26.2% vs. 17.7%, Pxa0=xa00.02). Concerning the preoperative anatomic features, there was a significant difference between the groups concerning the length of the neck (25.5xa0±xa010.1 vs. 28.3xa0±xa012.6xa0mm, Pxa0=xa00.008), the maximum diameter of the AAA (58xa0±xa010.1 vs. 56.1xa0±xa010.1xa0mm, Pxa0=xa00.027), and the oversizing (18.1xa0±xa08.3% in group 1 vs. 16.8xa0±xa07.4% in group 2, Pxa0=xa00.043). There was no difference of the postoperative rates of complications, technical failure, endoleaks, and death. In the long run, analyses of survival showed that the rates of proximal endoleaks (13% vs. 3.9%, Pxa0<xa00.0001) and of reintervention (24.1% vs. 14.7%, Pxa0=xa00.009) were higher in group 1. There was no significant difference between the 2 groups regarding the evolution of the aneurysmal sac, the long-term rate of death from all causes or in relation to the aneurysm.nnnCONCLUSIONSnOur results suggest that large stent grafts are more at the risk of proximal endoleak and reintervention in the long run. However, there were no differences observed in mortality or evolution of the aneurysmal sac in the patients treated by EVAR with wide neck during the period of follow-up.

Endovascular Treatment of Asymptomatic Abdominal Aortic Aneurysms in Octogenarians: Factors Influencing Long-term Survival

BACKGROUNDnBeyond the age of 80xa0years, the preventive treatment of an asymptomatic abdominal aortic aneurysm (AAA) has to be decided in light of the life expectancy which it is difficult to evaluate, but it is important to determine who in this population will benefit from it. The objective of our study was to determine the factors influencing short-term mortality and long-term survival in patients aged 80 years and older after the endovascular treatment of AAAs (EVAR).nnnMATERIAL AND METHODSnWe present a retrospective analysis of the prospective databases of 4 French academic departments of vascular surgery, bringing together the data of all the patients presenting an AAA who were treated by EVAR between 1998 and 2011. Logistic regression and multivariate analysis with a Cox survival model were used to determine the factors influencing perioperative and long-term mortality. The cumulative rate of events for the measurement of survival was calculated with the technique of Kaplan-Meier.nnnRESULTSnWe treated 345 octogenarians and 339 younger patients. The average follow-up was 40xa0months. Average survival was 75% at 36xa0months and 49% at 60xa0months. There was no evidence of any risk factor influencing mortality at 30xa0days in the octogenarians. However, chronic kidney disease (odds ratio [OR]xa0=xa03.95, Pxa0<0.001) and chronic respiratory failure (ORxa0=xa02.62, Pxa0<0.001) proved to be independent factors of a poor long-term prognosis.nnnCONCLUSIONSnThe treatment by stent graft in octogenarians is effective in the long term. The presence of an impaired renal function or respiratory failure in this population could put into question the operative indication.

Anatomical Evolution of the Descending Thoracic Aorta after Endovascular Treatment of a Degenerative Aneurysm

Objectives: The endovascular treatment of aortic aneurysms is less invasive than the conventional surgical treatment. Nevertheless the conjunction of the aortic curvature and the origin of the supra-aortic trunks (SAT) at the level of the arch require an adaptation of the dedicated material. For that reason themorphological study of the aorta arch is necessary. Materials and Methods: The study was carried out from aortic angio-CTs. Four groups were designed: group 1: normal aorta (n1⁄420); group 2: aneurysm of the ascending aorta (n1⁄420); group 3: aneurysm of the posterior arch extending to the descending thoracic aorta (n1⁄413); group 4: aneurysm of the ascending aorta + aortic arch (n1⁄420). The diameters of the aorta aswell as the lengths of the central line and the external curvature were measured using the Endosize software (Therenva). The orientation of the SATs plane was laid down by the line passing by the ostia of the brachio-cephalic trunk and the LSA. Results: The maximum diameter (Dmax) of the ascending aorta was increased by 130%, 55% and 59% in groups 2, 3 and 4 compared to the normal aorta, respectively. Dmax of the horizontal portion of the arch was increased by 44%, 40% and 44% in groups 2, 3 and 4, respectively. Dmax of the descending thoracic aorta was increased by 4%, 70% and 46% in groups 2, 3 and 4, respectively. The average length of the central line of the thoracic aorta was increased by 15%, 25% and 20% for groups 2, 3 and 4 compared to the normal aorta, respectively. The length of the aorta increasedproportionallywith theaorticdiameter.Onaverage, the external line was increased by 17% compared to the central line in each group. The slope of the axis formed by the origin of the SAT was 0.6 in group 1, 0.3 in group 2, 2.3 in group 3, and 1.2 in group 4. Conclusion: Aneurysms generate a centripetal but also longitudinal extension of the aortic tissues. This expansion creates an anterior angulation in the event of an ascending aortic aneurysm and a posterior angulation in the event of an aneurysm of the descending thoracic aorta. This leads to a flattening of the plane of the SATs when the aneurysm reaches the anterior portion of the arch and verticalize it in the event of posterior development of the aneurysm. Moreover the expansion of the aorta is limited to the aneurysmal segment in case of an aneurysm of the ascending aorta whereas the ascending aorta is also widened in the presence of an aneurysm of the descending thoracic aorta.

Monocentric Comparative Study of Conventional Surgery and Endovascular Treatment with Fenestrated Stentgrafts to Treat Juxtarenal and Pararenal Aneurysms of the Abdominal Aorta

Materials and Methods: Between January 2005 and December 2014, we retrospectively included all the patients electively treated in our center for a JRA by excluding the type IV thoraco-abdominal aortic aneurysms. JRAs were classified in three anatomical categories according to a classification described in the literature. We compared the clinical and radiological data of the patients treated by fenestrated stentgraft (ENDO group) with those treated by conventional surgery (OPEN group). Preoperative surgical risk was measured by the ASA score and the clinical score of Lee.We then compared the surgical risk, the morbi-mortality at 30 days, and the survival at 5 years.