Nicla Settembre

Early Experience of Endovascular Repair of Post-dissection Aneurysms Involving the Thoraco-abdominal Aorta and the Arch

OBJECTIVES Outcomes are reported in management of post-dissection aneurysms involving the aortic arch and/or thoraco-abdominal segment (TAAA) treated with fenestrated and branched (complex) endografts. METHODS This report includes all patients with chronic post-dissection aneurysms >55 mm in diameter, deemed unfit for open surgery, treated using complex endografts between October 2011 and March 2015. When appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration or tear enlargement, and other endovascular procedures were performed at least 3 weeks prior to definitive complex endovascular repair. The following outcome data were collected prospectively at discharge, 12 months and annually thereafter: technical success, endoleaks, target vessel patency, false lumen patency, aneurysm diameter, major and minor complications, re-interventions, and mortality. RESULTS The cohort comprised 23 patients with a median age of 65 years. Staged procedures were performed in 14 patients (61%). Seven patients with dissections involving the arch were treated with inner branched endografts, and 16 TAAA patients were treated with fenestrated or branched endografts. The technical success rate was 71% following arch repair and 100% following TAAA repair. During early follow up, one of the arch group patients died and one in the TAAA group suffered spinal cord ischemia. The median follow up was 12 months (range 3-48), during which time one patient died of causes unrelated to aneurysm or treatment. Two early re-interventions were performed in the arch group to correct access vessel complications and there were a further two late re-interventions in the TAAA group to treat endoleaks. All target vessels (n = 72) remained patent. CONCLUSIONS This experience indicates that complex endovascular repair of post-dissection aneurysms is a viable alternative to open repair in patients deemed unfit for open surgery. There are insufficient data to allow comparison with the outcome of open surgery in anatomically similar, but fit, patients.

Dramatic Response to Tocilizumab Before Emergency Surgery in Severe Active Takayasu Disease

A 19-year-old man was admitted in our tertiary care center in August 2014 for a 10-kg weight loss in a few months (48 kg, 1.80 m, and body mass index, 14.8 kg/m2), claudication in the lower limbs after a 500-m distance and a postprandial abdominal pain associated with mild renal insufficiency and proteinuria with no hypertension (100/80 mm Hg). The patient had no medical history and was an active smoker (tobacco and cannabis, estimated consumption: 2 pack-years). Laboratory parameters were elevated leukocyte count (13×109/L), C-reactive protein level (55 mg/L), creatinine (14 mg/L), and B-natriuretic peptide (4246 pg/mL). No thrombophilia, autoimmune disorders, or viral infections were identified. The patient underwent a B-mode Doppler ultrasound that showed multiple proximal arterial occlusions and stenoses of large vessels confirmed by a computed tomographic angiography: occlusions of bilateral subclavian arteries, superior and inferior mesenteric arteries, and right renal artery with kidney atrophy were found (Figure 1A). Furthermore, significant stenoses of celiac artery, left renal artery (Figure 1B), right internal iliac artery, and bilateral superficial femoral arteries were identified. A discrete circumferential thickening of the abdominal aorta was suggestive of aortitis. Cervical magnetic resonance angiography showed a complete occlusion of both subclavian and vertebral arteries (Figure 2). Transthoracic echocardiography revealed a severe left ventricular (LV) systolic dysfunction (LV ejection fraction …

Epiploic Bypass Flap: A New Method of Limb Salvage. Anatomic Basis and Clinical Application

BACKGROUND The incidence of critical limb ischemia increases with the aging of the population. Two-thirds of patients with critical limb ischemia present with trophic disorders. Revascularization decreases the rate of amputation. Infected wounds with exposure of the tendons, bones, or points of articulation cannot heal in spite of bridging and local debridement. Surgery associated with a distal venous bypass or recanalization and a free flap makes it possible to cover major tissue loss and offers a hemodynamic advantage by increasing the flow of the bypass, thanks to the vascular bed added by the flap. It is a complex surgery because of the multiplicity of anastomoses on the same arterial axis, with a risk of thrombosis and complications related to the venous autograft. To mitigate these disadvantages, we propose a new surgical method based on the use of a single anatomic unit, the epiploic bypass flap (BF), based on the gastroepiploic artery (GEA) as the inflow for a bypass and a free flap. The objective of this work was to analyze the anatomic feasibility of an epiploic BF and to determine its limits. METHODS One hundred anatomic preparations were conducted with a measure of the internal and external diameters and the lengths of GEA and its branches and a radiograph after injection of a radiopaque product. A first clinical application was carried out. RESULTS According to the data, our study confirms the anatomic feasibility of a BF. The average available length of GEA is 245 mm (range: 210-280 mm). The average proximal diameter is 3 mm, and the distal diameter is 1.5 mm. The most distal epiploic branch that feeds the bypass is approximately 180 mm (range: 161-195 mm) of the origin of the GEA. The anatomic unit based on the GEA provides an arterial graft that is relatively long and a large flap that is both malleable and resistant to infection. CONCLUSIONS Epiploic BF is a surgical technique that allows for distal revascularization and a simultaneous cover of the limb extremity. This technique can be useful in patients requiring a distal revascularization associated with a cutaneous cover.

Infected Abdominal Aortic Aneurysm Attributable to Haemophilus influenzae Rapid Changes of Imaging Findings

A 57-year-old man presented to the emergency department with an 8-day history of abdominal and suprapubic pain radiating in the back associated with fever (38.6°C), myalgia, and a painful rectal examination. A treatment with ofloxacin had been prescribed for a suspected prostatitis. His past medical history included overweight and current cigarette smoking (30 pack-year). Clinical examination found a tense and nondepressible abdomen without nausea or vomiting. On auscultation, he had an abdominal vascular murmur. Computed tomography angiography performed on day 1 revealed a moderate aneurysmal dilation of the infrarenal abdominal aorta with a maximal diameter of 25 mm along with a thickened wall, a periaortic infiltration, and thrombus (Figure 1A). Biological investigations revealed an elevated leukocyte count (14 780/mm3 with 92.5% neutrophils) and a high C-reactive protein level (256.4 mg/L), but no serological evidence for syphilis, HIV, hepatitis B or C infections, and negative standard bacterial and mycobacterial blood cultures. The persistence of abdominal pain and biological inflammation led to that performance of a new computed tomography angiography on day 4. It …

The Influence of Heating on Toe pressure in Patients with Peripheral Arterial Disease

Background and Aim: The toe skin temperature in vascular patients can be low, making reliable toe pressure measurements difficult to obtain. The aim of this study was to evaluate the effect of heating on the toe pressure measurements. Materials and Methods: A total of 86 legs were examined. Brachial pressure and toe pressure were measured at rest in a supine position using a laser Doppler device that also measured skin temperature. After heating the toes for 5 min with a heating pad, we re-measured the toe pressure. Furthermore, after heating the skin to 40° with the probe, toe pressures were measured a third time. Results: The mean toe skin temperature at the baseline measurement was 24.0 °C (standard deviation: 2.8). After heating the toes for 5 min with a warm heating pad, the skin temperature rose to a mean 27.8 °C (standard deviation: 2.8; p = 0.000). The mean toe pressure rose from 58.5 (standard deviation: 32) to 62 (standard deviation: 32) mmHg (p = 0.029). Furthermore, after the skin was heated up to 40 °C with the probe, the mean toe pressure in the third measurement was 71 (standard deviation: 34) mmHg (p = 0.000). The response to the heating varied greatly between the patients after the first heating—from −34 mmHg (toe pressure decreased from 74 to 40 mmHg) to +91 mmHg. When the toes were heated to 40 °C, the change in to toe pressure from the baseline varied between −28 and +103 mmHg. Conclusion: Our data indicate that there is a different response to the heating in different clinical situations and in patients with a different comorbidity.

Open Repair of Mycotic Abdominal Aortic Aneurysms With Biological Grafts: An International Multicenter Study

Background The treatment of mycotic abdominal aortic aneurysm requires surgery and antimicrobial therapy. Since prosthetic reconstructions carry a considerable risk of reinfection, biological grafts are noteworthy alternatives. The current study evaluated the durability, infection resistance, and midterm outcome of biological grafts in treatment of mycotic abdominal aortic aneurysm. Methods and Results All patients treated with biological graft in 6 countries between 2006 and 2016 were included. Primary outcome measures were 30‐ and 90‐day survival, treatment‐related mortality, and reinfection rate. Secondary outcome measures were overall mortality and graft patency. Fifty‐six patients (46 males) with median age of 69 years (range 35–85) were included. Sixteen patients were immunocompromised (29%), 24 (43%) had concomitant infection, and 12 (21%) presented with rupture. Bacterial culture was isolated from 43 (77%). In‐situ aortic reconstruction was performed using autologous femoral veins in 30 patients (54%), xenopericardial tube‐grafts in 12 (21%), cryopreserved arterial/venous allografts in 9 (16%), and fresh arterial allografts in 5 (9%) patients. During a median follow‐up of 26 months (range 3 weeks–172 months) there were no reinfections and only 3 patients (5%) required assistance with graft patency. Thirty‐day survival was 95% (n=53) and 90‐day survival was 91% (n=51). Treatment‐related mortality was 9% (n=5). Kaplan–Meier estimation of survival at 1 year was 83% (95% confidence interval, 73%–94%) and at 5 years was 71% (52%–89%). Conclusions Mycotic abdominal aortic aneurysm repair with biological grafts is a durable option for patients fit for surgery presenting an excellent infection resistance and good overall survival.

Cerebral Infarct Topography and Early Outcome after Surgery for Symptomatic Carotid Stenosis: A Multicentre Study

Introduction: Although carotid stenosis can cause both territorial and border-zone (BZ) cerebral infarcts (CI), the influence of CI topography on postoperative complications after surgery remains unclear. We compared early outcomes after endarterectomy on the basis of CI location: territorial (T group) or BZ group. Material and Methods: During the period between 2009 and 2013, ischaemic stroke patients who had undergone surgery for symptomatic carotid stenosis were identified from prospective databases from 3 French centres. The outcome was the identification of a combined stroke/death rate 30 days after endarterectomy. Results: Two hundred and eighty-nine patients were included, 216 (74.7%) in the T group and 73 (25.3%) in the BZ group. The mean degree of stenosis was comparable in the 2 groups (78 ± 12% in the T group vs. 80 ± 12% in the BZ group, p = 0.105), with, however, more sub-occlusions (stenosis >90%) in the BZ group (38.4 vs. 23.1%, p = 0.012). The mean time between the time CI developed and the time surgery was performed was 19.6 ± 24.8 days, with a majority of patients being operated upon within 2 weeks following the formation of CI (66.7% in the T group vs. 60.3% in the BZ group, p = 0.322). The combined endpoint was significantly more frequent in the BZ group (9.6 vs. 1.9%, p = 0.003), with 4 ischaemic strokes and 3 deaths. In multivariate analysis, BZ CI was an independent predictor of postoperative stroke or death at 30 days (HR 4.91-95% CI [1.3-18.9], p = 0.020). Conclusion: BZ infarcts carry a greater risk of postoperative complications after carotid surgery, thus suggesting that topography of the CI should be considered in the decision-making process regarding surgery.

Alternative Accesses for Aortic Devices - Postoperative Feasibility and Complications

defects of hemostasis and the dissections at the level of the femoral access as well as the failures of implantation. Results: In 217 percutaneous femoral accesses, 23 (10.6%) complications were directly attributed to the procedure of percutaneous arterial closure: 14 (61%) stenoses, six (26%) defects of hemostasis, one (4.3%) dissection, one (4.3%) failure of use and one (4.3%) malposition. This malposition, above the inguinal ligament, was at the origin of the only major complication presenting as a retroperitoneal hematoma which imposed a femoral surgical access and a transfusion of two globular units. The other complications were treated by contralateral endovascular route and crossover maneuver allowing the placement of covered stents. Conclusion: Percutaneous arterial closure with Prostar is effective. Indeed, an arterial restoration of quality is ensured in 90% of the cases, whichever the quality of the femoral artery. Moreover, 95% complications are managed by endovascular route without recourse to a direct surgical access. The use of such a device makes it possible to systematically consider a percutaneous access of first intention for all the endovascular aortic reconstructions.

The Topography of Cerebral Ischemic Accidents Influences the Results of the Surgery of the Symptomatic Carotid Stenoses

Objectives: Carotid stenoses can be at the origin of two types of cerebral ischemic accidents (CIA), the territorial CIAs due to an embolic mechanism starting from an unstable plaque, and the junctional CIAs, of rather hemodynamic origin, which occur in between two contiguous arterial territories. The topography of the CIA could play a role in the occurrence of postoperative complications after surgery for symptomatic carotid stenoses? The objective of this study was to compare the CRMM (combined rate of morbi-mortality within the 30 postoperative days) after endarterectomy for a symptomatic carotid stenosis, according to whether the initial CIA was territorial (group T) or junctional (group J). Materials and Methods: It was a tricentric, retrospective, continuous and consecutive study, carried out starting from prospective databases and including the patients operated between January 1st, 2009 and December 31st, 2013. Results: Two hundred and eighty-nine patients were included, 216 (74.7%) in the T group and 73 (25.3%) in the J group. The degree of stenosis of the operated carotid was comparable in the two groups (78±12% in the T group vs 80±12% in the J group, p1⁄40.106), with however more subocclusions (stenosis > 90%) in the J group (19.2% vs. 9.7%, p1⁄40.032). The other clinical and preoperative data were comparable, except for dyslipidemia, more frequent in the J group (61.6% vs. 42.6%, p1⁄40.005). The majority of the patients were operated in the first 15 days following the CIA (66.7% in the T group vs. 60.3% in the J group, p1⁄40.322). The CRMM was significantly higher in the J group, 9.6% vs. 1.9%, p1⁄40.003. In multivariate analysis, the junctional topography of the CIA remained a predictive independent factor of CVA or death in the 30 postoperative days. Conclusion: This study shows that junctional CIAs increase the risk of postoperative complications after carotid surgery. The topography of CIAs will have to be taken into account in the operative indications for symptomatic carotid stenoses.

Preoperative 3D/3D MRI Fusion of Image in the Hybrid Room: Treatment of Aorto-Iliac Aneurysms in Patients with Renal Insufficiency

Objectives: Severe chronic renal insufficiency is a major limitation for the endovascular treatment of aorto-iliac aneurysms (EVAR). MRI imaging can bring an important alternative to angio-CT. The aim of this study was to evaluate the feasibility of preoperative MRI and computer processing to minimize the use of iodized contrast during EVAR. Materials and Methods: From October 2013 to November 2014, each patient requiring EVAR and presenting a severely chronic impaired renal function was submitted to a specific preoperative imaging protocol. Preoperative MRI was carried out according to a protocol adapted with a reinforcement of the osseous relief. Preoperative 3D imaging was linked with the rotational radiographic imaging (3D) obtained on the operating table by using the Artis zeego Fusion program (Siemens AG, Forchheim, Germany). The fused image was applied for the vascular cartography for EVAR and the associated procedures (angioplasties, embolization). The correction of the positioning of the ‘‘target’’ arteries was carried out by the positioning of the guidewire or the injection of a minimal volume of contrast medium. The distances of correction were analyzed. Final control was carried out by ultrasound. Results: Eleven patients (six women, 73±8 years) were treated by applying this technique. The filtration rate (eGFR) was 16.5 mL/min/1.73 m. The mean volume of contrast medium used during the procedure was 7mL (15-5). The implantation of the abdominal stentgraft guided by the MRI fusion of image was feasible in all the patients. No peroperative type I endoleak was observed on ultrasound scanning. A wound of a branch of a renal artery required a selective embolization. Except for this last patient, no deterioration of the renal function was observed after one month of follow-up. The average error of positioning of the mapping cartography was 3 mm for the renal artery and 8.5 mm for the hypogastric artery. Conclusion: The feasibility and the precision of endovascular guiding based on fused MRI images are good in the