Quentin Desiron

Isolated Atherosclerotic Aneurysms of the Iliac Arteries

Atherosclerotic aneurysms limited to the iliac arteries are rare and entail a high risk of rupture. To evaluate the efficacy of prophylactic surgery, we retrospectively studied 15 patients (13 men and two women; mean age 69 years) treated for isolated iliac aneurysms in the Department of Cardiovascular Surgery at the University Hospital of Liège over a period of 18 years. They had a total of 25 aneurysms (20 common iliac and five internal iliac). Six patients were treated electively and nine on an emergency basis for rupture. Five of the emergency patients (33%) died in the early postoperative period (< 30 days); in each case the aneurysm had ruptured and an emergency operation was performed (55.5% mortality in the ruptured iliac aneurysm group). On the other hand, all patients treated electively survived. Our study is comparable to other recent series in the literature, which also reported a high incidence of rupture and death in emergency operations. Prophylactic elective surgery is recommended for iliac aneurysms.

Potential benefits of laparoscopic aorto-bifemoral bypass surgery

Abstract Background : This series aims to prove the positive impact of laparoscopic approach in aortofemoral bypass grafting. Methods : It concerns a retrospective non randomized study comparing 58 consecutive patients treated with laparoscopic procedure (n = 30) and with a standard open procedure (n = 28) in a single center. The different operating times, the complications and the follow-up of these two groups are compared Results : The demographics and angiographic data of the two groups were comparable. Operating time was longer in the laparoscopic group. However, we noticed a significant shorter hospitalisation stay (p < 0.0001) after the laparoscopic procedure with a mean 5.1 days. There was no significant difference of morbidity. Conclusion : We suggest that the trans-peritoneal approach is the best way in laparoscopic procedure in term of exposure and ergonomics. Laparoscopic aortofemoral bypass grafting is feasible, safe and effective. Shortening of operating time is observed as surgeon’as experience grows.

Bispectral index profile during carotid cross clamping.

This study aimed at investigating the Bispectral Index (BIS) profile during carotid cross clamping (CXC). The study involved a pilot group of 10 patients undergoing routine carotid endarterectomy with shunt insertion under total intravenous anesthesia, and a study group of 26 additional patients. In all patients, rates of propofol and remifentanil providing a steady-state level of hypnosis (BIS: 40-60) were maintained constant throughout a recording period ranging from 3 minutes before CXC to shunt insertion. BIS was recorded throughout this period and the internal carotid backflow observed at the time of shunt insertion was graded as good, moderate, or poor. In addition, A-Line Autoregressive Index (AAI) and processed electroencephalogram (EEG) parameters were recorded in patients of the study group. All parameters were averaged over 1 minute before CXC, at CXC, 1, 2, and 3 minutes after CXC, and at shunt insertion. Statistical analysis was performed using χ2, Friedman, and Spearman correlation tests. For technical reasons, reliable AAI, BIS monitor-derived, and other processed EEG data were obtained in 24, 25, and 18 patients of the study group, respectively. During the first 3 minutes after CXC, BIS increased over 60 [68.8 (6.1)] in 47%, decreased below 40 [34.9 (4.4)] in 25%, and remained in the 40 to 60 range in 28% of all recruited patients. A BIS increase was more frequently observed in patients with moderate or poor than in those with good internal carotid backflow (78, 67, and 29%, respectively). It was significantly correlated to an increase in AAI and EEG amplitude, a decrease in EEG suppression ratio, and a shorter time between induction of anesthesia and CXC. A BIS decrease was significantly correlated to an increase in suppression ratio and a longer time between induction and CXC. In conclusion, during CXC under a constant level of intravenous anesthesia, BIS may increase, decrease, or remain unchanged. The paradoxical BIS increase could be related to borderline ischemia, a change in brain anesthetic agent concentration, or a change in the nociceptive-antinociceptive balance associated with a CXC-elicited painful stimulation. Caution should be used when interpreting BIS value during CXC.

Comparison of results of carotid artery surgery after either direct closure or use of a vein patch.

In order to assess the benefit of vein patching versus direct closure after carotid endarterectomy, a series of 2271 carotid operations were analysed retrospectively. Apart from 114 procedures consisting of saphenous vein bypass (n = 29) and eversion endarterectomy (n = 85), 2157 open endarterectomies were performed. They were closed either directly (n = 837) or using a vein patch (n = 1320). The combined mortality-major neurological morbidity rate was 1.7%, i.e. 1% mortality (0.2% neurological) and 0.7% permanent neurological morbidity (0.5% ipsilateral to the operated artery). Early symptomatic internal carotid thrombosis was documented in six cases (four following direct closure and two after vein patching). A total of 827 carotid arteries were followed up by duplex scanning on an annual basis (244 direct closure and 583 vein patching). The mean follow-up was 44 months; 69 months for direct closure and 35 months for vein patching. In direct closure, there were 21 stenoses (9%) and 10 occult thromboses (4%); in vein patching carotids, there were 17 stenoses (3%), nine thromboses (1.8%) [corrected] and six pseudoaneurysms (1%). Annual incidence of poor results was 2.4% in direct closure, and 0.87% in vein patching. The only other factor responsible for a significant difference was gender (3.4% in women versus 2.1% in men). In this retrospective study, vein patching appears to be beneficial for the prevention of acute postoperative thrombosis and late stenosis or thrombosis.

Sequential Successful Surgical Management of Extracranial Internal Carotid Stenosis and Ipsilateral Intracranial Aneurysm Case Reports

The coexistence of extracranial internal carotid stenosis and ipsilateral intracranial aneurysm is a rare event whose management is controversial. Theoretically, the correc tion of a significant stenosis of the extracranial internal carotid may lead to an increase in the downstream pressure in the intracranial carotid and may, consequently, increase the risk of rupture of the ipsilateral aneurysm. Moreover, dramatic increase of blood pressure is not uncommon after carotid endarterectomy and may promote aneurysmal rupture. Intracranial surgical correction of a hypoperfused aneurysm down to an extracra nial carotid stenosis should carry an increased risk of inadequate cerebral flow during the procedure, and unspecific postoperative stimulation of platelets aggregation and coagu lation may complete obstruction of a subtotal carotid stenosis. The authors describe successful treatment of 2 patients by a two-stage surgical procedure. In a first step, the intracerebral aneurysms were controlled and electively excluded by clipping. In a second step, carotid endarterectomies were performed some days later without any neurologic complications. Postoperative recoveries were uneventful, and six months after these surgical procedures, clinical examination of both patients did not reveal any worsening of the preoperative neurologic status.

Hématome intramural aortique de type A : une entité clinique sous-évaluée

Intramural hematoma of the ascending aorta occurs after rupture of the vasa vasorum. Previously considered as a first step of acute aortic dissection, it was later defined as a separate entity that may or may not lead to arterial dissection. The debate about the most appropriate treatment for a 69-year-old patient with intramural hematoma of the ascending aorta, led to this extensive review of the literature demonstrating that intramural hematoma type A is a life-threatening condition requiring urgent surgical support.

Kinking of the internal carotid artery: Clinical significance and surgical management

The authors report on 62 surgical corrections for kinking of the internal carotid artery during a 13-year period (1980-1993). This represents 2.8% of all carotid operative procedures (n = 2188) in the same period. It always concerned a significant (< 60 degrees) angulation of a redundant internal carotid artery, that in all but 3 cases was associated with atherosclerotic involvement of the carotid bifurcation. The indication to surgery included transient hemispheric or ocular ischaemia in 25.5% of cases, a regressive neurologic deficit in 8%, a minor stroke in 3%, a stroke in evolution in 11%, and non-lateralized cerebral ischaemia in 21%. In 19 patients (31%) it concerned an asymptomatic high degree stenosis. The surgical technique consisted in carotid transposition-reimplantation after eversion endarterectomy in 37 cases, in posterior transverse plication with patch angioplasty in 20 cases, and in segmental excision with venous interposition graft in 5 cases. There was one postoperative death. The morbidity include one ipsilateral non-fatal stroke and 3 transient ischaemic attacks. A complete long-term follow-up (mean duration 3.4 years) is available for 57 patients. The late incidence of stroke is 1.5% per year. The 5-year survival attains 67%. These long-term results are comparable to the outcome of standard endarterectomy in the same institution. The authors discuss the indication, techniques, and outcome of surgical correction of kinked internal carotid artery. They recommend a shortening procedure, often associated with endarterectomy for severely kinked vessels (angulation 60 degrees or less), symptomatic or not.