Raphael Soler

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.

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.

Results of EVAR in patients Followed up for at Least eight Years

favorable for FBS had an elective intervention. Two (14%) patients had emergency surgery (acute rupture and painful aneurysm with covered rupture). The data are expressed in medians and range. Results: The series included 13 men (93%) and one woman (7%), with a median age of 85 years (65-90). The diameter of the JRAAA was of 61 mm (58-80). Twenty-six target arteries were treated (1.9 with patient; 19 renal arteries, six superior mesenteric arteries and one celiac artery) revascularized by 22 (85%) chimneys and 4 (15%) periscopes. Intraoperatively, an ilio-renal bridging was carried out to recover an occluded chimney. Three type Ia endoleaks were noted and followed up. The operative time was 280 min (180-580) and 120 mL (20240) of contrast medium were used. Postoperatively, the two patients operated in emergency died (multivisceral failure [MVF]) and major stroke). The mortality of the elective CHIMPS was 8% (1/12): one patient with end stage renal failure died of MVF due to cholesterol embolisms. Another patient presented a partially regressive acute renal failure and a limb was stented at D13. With a 12 months (2-37) follow-up, one patient died of a non-vascular cause. No JRAAA increased in diameter. The type Ia endoleaks had regressed and three patients (27%) presented a type II endoleak. The primary patency of the target arteries was 81% (three renal occlusions) and four patients (36%) had a decrease> 20% in glomerular filtration rate. Conclusion: The CHIMPS can be proposed in patients accessible to FBS but they remain debatable in emergency. The deterioration of the renal function during the follow-up is alarming. This problem being also observed in the literature after FBS, a comparative study with more patients should be conducted.

In-situ Revascularization with Silver Coated Grafts Soaked in Rifampin for Infection of the Abdominal Aorta: A Single Center Experience

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

Repermeation Without Pharmacological Thrombolysis of the Extracranial Symptomatic Occlusions of the Internal Carotid Artery: Results of the Early Carotid Endarterectomy

Objectives: Two types of carotid endarterectomies (CE) are currently practiced, longitudinal CE with patch (CEP) or by eversion. We propose a new technique, the ‘‘carotidoplasty’’ (CP), which is freed from an excess length of the carotid bifurcation (sometimes problematic for the CEP) and of the stop of plaque (sometimes problematic for eversion). The objective of our study was to evaluate the results of CP in the short and long term. Materials and Methods: Technique: CP consists in a skeletonization of the carotid bifurcation to mobilize it, divide the internal carotid obliquely, and carry out a longitudinal arteriotomy of the carotid bulb then an endarterectomy of the bulb and external carotid. The internal carotid is endarterectomized a minima under visual control then obliquely reimplanted in the bulb by a circular running suture, which makes it possible to secure an atherosclerotic plaque if necessary, to correct a possible excess of length, and to obtain a quasi-anatomical restitution of the carotid bifurcation. From a prospective database, we studied the CE (n1⁄4748) carried out in our unit by CEP (n1⁄4624, 83.4%) and by CP (n1⁄4 73.9.8%) between January 1st, 2007 and December 31st, 2011. We analyzed the demographic criteria (sex, age, cardiovascular risk factors, and comorbidities), the degree of stenosis, the symptomatic character and the type of symptoms of the carotid stenoses, the status of the contralateral carotid, the type of anesthesia, the cross clamp time, the need for a shunt, the early reinterventions, and the longterm follow-up. The principal criterion of judgment was the CRMM (rate of stroke or death at 30 days). The secondary criteria of judgment were the rates of residual stenosis, of postoperative thrombosis, of restenosis, and of long term survival. Results: The average time of follow-up was 30.5 months (1 to 72 months). The significantly different elements between CP and CEP were: the age (75.8 years ± 8.9 vs 72.9 years ± 9.6, p1⁄4 0.015), the cross clamp time (36 min ± 7.6 vs 40.3 min ± 11.0, p1⁄40.005), and the rate of restenosis (0 vs 5.3%, p1⁄40.039), respectively. The CRMM were 0% vs 3.4%, respectively, without significance (p1⁄40.153). The other analyzed parameters were not different. Conclusion: The carotidoplasty, a new surgical technique, showed satisfactory results in the short and long term, in this monocentric experience. Its interest must be confirmed in more patients with a multicentric evaluation.