Réda Hassen-Khodja

Carotid Endarterectomy Plaques: Correlations of Clinical and Anatomic Findings

To establish possible relationships between the structure of carotid plaque and neurologic symptoms, 187 consecutive endarterectomy specimens were studied prospectively. Each specimen was examined for gross and histopathological features. Intraplaque hemorrhage, although found infrequently, was closely correlated with the presence of symptoms. Plaque ulcerations were encountered more often when lesions were symptomatic. Calcifications were more frequently associated with asymptomatic lesions. Consistency of plaque was related to its morphological features (stenosis or ulceration) and symptoms. Soft plaques with predominant atheromatous grumous material and hemorrhage were associated more often with tightiy stenotic, ulcerated, and symptomatic lesions. Consistency of atherosclerotic carotid plaques should be assessed and considered as an important element in the therapeutic decision.

Percutaneous closure devices for endovascular repair of infrarenal abdominal aortic aneurysms: a prospective, non-randomized comparative study.

PURPOSE This study was designed to describe and evaluate our preliminary results with a percutaneous arterial closure device as compared to those obtained with conventional femoral surgical cut down during endovascular repair of abdominal aortic aneurysms (AAA). MATERIAL AND METHODS Between January 2004 and December 2006, 40 of 86 AAA patients selected for endovascular repair met the criteria for inclusion in this study. Nineteen of these patients (Group A) received a bifurcated endograft placed by direct puncture of the femoral arteries (38 femoral triangles) with closure by a Prostar((R)) percutaneous arterial closure device (Abbott). The other 21 patients (control group B) were managed with a bifurcated endograft placed by conventional open surgery (42 femoral triangles). Data concerning all 40 patients were collected prospectively and analyzed. RESULTS The technical success rate was 92% (group A) vs 90% (group B), P=0.79. The incidence of perioperative complications was 16% (3/19) in group A and 14% (3/21) in group B (P=0.89). The mean hospital stay was 5.8 days in group A and 7.8 days in group B (P=0.05). The difference in the length of hospitalisation was associated with reduced cost for the percutaneous group (5579.60 euros vs. 7503.60 euros; P=0.04), that counterbalanced the cost induced by the Prostar XL((R)) suture mediated device. Mean follow-up in both groups was 12 months. The overall incidence of locoregional complications after one year of follow-up was 11% (2/19) in group A and 19% (4/21) in group B (P=0.45). CONCLUSION This study confirms the feasibility and safety of total percutaneous endovascular AAA repair. Our preliminary results suggest that the costs paid by healthcare providers for endovascular AAA repair might not be increased with the selective use of percutaneous closure devices.

In-situ Revascularisation for Patients with Aortic Graft Infection: A Single Centre Experience with Silver Coated Polyester Grafts

OBJECTIVE The aim of this study was to evaluate the early and mid term outcome of patients with aortic graft infection who underwent in-situ revascularisation with a silver coated prosthesis. MATERIAL From January 2000 to December 2006, 24 consecutive patients (22 male, 2 female) with mean age 67 years were prospectively entered in this study of aortic graft infection at our single centre. Infection was managed with either total (n=19) or partial (n=5) excision of the infected graft and in- situ reconstruction with a silver coated prosthesis, Inter Gard Silver (IGSG). METHODS The primary endpoint was recurrence of infection. Secondary endpoints were early and late mortality, peri-operative morbidity, primary graft patency, major amputation rates and patient survival. RESULTS Fourteen patients had a primary graft infection, however 10 of 24 patients had graft infection secondary to aorto digestive (n=9) or aorto urinary (n=1) tract fistulas. Bacteriological cultures were negative in 8 (33%) patients. Most organisms cultivated where virulent and the majority of graft infections were polymicrobial (71%). Silver grafts were placed emergently in 6 (25%) patients. Mean follow up 32.5+/-31.0 months (range 2-78 months). Peri-operative morbidity and mortality were 46% and 21% respectively. Early interventions occurred in 6 (25%) patients and late secondary intervention were required in 3 (15.7%), caused by silver graft reinfection. The late mortality was 26%. CONCLUSION In-situ reconstruction with the silver graft confirms similarity with other modalities. The greatest advantage for the silver graft is its ease of use but the risk of reinfection remains significant.

A Comparison of the Mid-term Results Following the use of Bifurcated and Aorto-uni-iliac Devices in the Treatment of Abdominal Aortic Aneurysms

PURPOSE To compare the mid-term results following the use of bifurcated (ABIS) and aorto-uniiliac (AUIS) endovascular devices in the treatment of abdominal aortic aneurysms (AAA) in a population of patients deemed to be at high risk for open surgery. MATERIAL AND METHODS Over a 4 year period (January 2003 to December 2007), 447 underwent elective endovascular aneurysm repair (EVAR) using ZENITH) stent-grafts. Group I comprised patients treated using the AUIS (n=124), and group II those receiving ABIS (n=323). Outcome measures included the assisted technical success rate, perioperative mortality, major complications, freedom from reintervention, and primary and secondary patencies. Factors associated with mid-term clinical failures were determined using univariate and multivariate analyses. RESULTS The assisted primary technical success rate was 94% and 99% in groups I and II respectively (p=.002). Major perioperative complications occurred in 13 group I patients (10%) vs. 12 group II patients (4%) (p=.005). The 30-day mortality rate was 3.2% vs.1.5% (p=0.2). TASC C and D iliac lesions significantly increased the risk of major perioperative complications (35% vs. 3%; OR=14.94; 95% CI: 5.75 to 38.78; p<.0001). During the follow-up period (median 24 months), secondary procedures were required in 11% and 5% of group I and group II patients respectively (p=.01). Freedom from reintervention at 12, 24 and 36 months was 98%, 90%, and 85% in group I vs. 96%, 92%, and 92% in group II (P<0.005). The primary and secondary patency rates at 3 years were 92% vs. 98% (p=.003) and 97% vs. 99% (p=.04) for groups I and II respectively. In group I, the Crossover Femoro-Femoral Bypass (CFFB) was responsible for 3 major complications (2.4%) which occurred at 7, 12 and 57 months of follow-up. However, the use of AUIS with CFFB did not independently increase the risk of major complications during follow-up (HR=0.108; 95% CI: 0.007 to 1.637; p=.11, Cox proportion model). In both univariate and multivariate analysis, concomitant iliac arterial occlusive disease (IAOD) was the only significant predictor of clinical failure in study population as a whole (OR=3.996; 95% CI: 1.996 to 7.921; p<.0001). CONCLUSION This study demonstrates that ABIS is associated with better results than AUIS in the management of patients with AAA. Iliac artery occlusive disease was more frequently diagnosed in the AUIS group and this was significantly associated with a higher risk of complications, while the crossover graft itself was not. Nevertheless, the outcomes for both groups are encouraging in this high risk population.

Revascularization of Internal Iliac Arteries during Aortoiliac Surgery: A Multicenter Study

p < 0.001). Associated revascularization of the inferior mesenteric artery was performed in 9% of patients (11.5% with aneurysms vs. 5.5% with occlusive lesions, p < 0.001). Postoperative colonic ischemia was observed in 21 patients (1.2%) (1.2% with aneurysms vs. 1.2% with occlusive lesions) and claudication in the gluteal region was observed in 31 patients (1.7%) (1.5% with aneurysms vs. 2.1% with occlusive lesions). Revascularization of the internal iliac artery, regardless of the technique, had no significant effect on the incidence of postoperative colonic ischemia and claudication in the gluteal region—neither after surgery for aneurysm (0.6% vs. 2.1% and 1.2% vs. 1.9%, respectively) nor after surgery for occlusive lesions (0.9% vs. 0.4% and 1.5% vs. 2.6%, respectively). Whether performed routinely or not, revascularization of the mesenteric artery has no significant effect on the incidence of postoperative colonic ischemia (1.1% vs. 1.3%).

Visceral artery aneurysms in Von Recklinghausen's neurofibromatosis

We report the case of a patient with Von Recklinghausens neurofibromatosis in whom two visceral artery aneurysms were diagnosed: a 4 cm aneurysm originating from the common hepatic artery and a smaller aneurysm originating from the superior mesenteric artery. The hepatic artery aneurysm underwent successful embolization. Because of the patients poor general condition, the superior mesenteric aneurysm was considered inoperable and has been kept under surveillance by ultrasonography. Arterial involvement in Von Recklinghausens neurofibromatosis is a well-known but infrequent occurrence. Stenotic lesions predominate, with the renal arteries being the site of predilection. Aneurysmal defects are less common, and involvement of the visceral arteries is exceptional. Only three reports of superior mesenteric artery aneurysm in patients with Von Recklinghausens neurofibromatosis were found in the literature, and hepatic artery aneurysm has never previously been described in this disease.

Buttock claudication from isolated stenosis of the gluteal artery.

Buttock claudication is usually caused by proximal arterial obstruction in the aorta or the common iliac artery. We report an unusual case of buttock claudication caused by isolated stenosis of the superior gluteal artery diagnosed by angiography. Both physical examination and noninvasive vascular explorations had been unremarkable. Twenty-six months after undergoing treatment by percutaneous transluminal angioplasty, the patient has no symptoms. Buttock claudication related to unilateral stenosis of the superior gluteal artery as observed in this case can be successfully managed by percutaneous transluminal angioplasty.

Axillary loop grafts for hemodialysis access : Midterm results from a single-center study

PURPOSE This study reports our midterm results with arteriovenous axillary loop grafts (AVALG) and evaluates their role in construction of vascular access for patients on chronic hemodialysis. METHODS The clinical data of 27 patients who underwent construction of an AVALG for hemodialysis access at our institution between July 2002 and December 2006 were analyzed retrospectively. Outcome measures included graft patency, the complication rate, and the frequency and morbidity of secondary procedures after AVALG creation. The Kaplan-Meier method was used to calculate the primary and secondary patency curves. RESULTS AVALG was constructed as the first access procedure in eight patients: five patients with no suitable vein to construct an adequate angioaccess on the upper limbs, and three patients with elbow and forearm arteritis. The 19 other patients had all had two to five failed prior vascular accesses leading to exhaustion of venous access sites on the upper extremities (18 cases), or a steal syndrome (one case). No postoperative death occurred, but four patients died of causes unrelated to the intervention between the second and the tenth postoperative months. The mean follow-up was 15 months (range, 2-48 months). The primary patency rate at 12 months and the secondary patency rate at 18 months were 51% and 80%, respectively. Infection (three cases), thrombosis (seven cases), and stenosis of the outflow vein (two cases) were the main complications, occurring in 10 of the 27 patients (41%). Twelve secondary procedures were performed in these 10 patients with little additional morbidity. Five of the 27 patients developed irreversible AVALG occlusion leading to access loss: two patients with concomitant graft infection and three patients with a history of subclavian vein catheterization. CONCLUSION AVALG may represent a supplementary option for chronic hemodialysis patients with vascular steal or inadequate upper extremity venous access sites.

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

OBJECTIVE The 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). METHODS Between 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. RESULTS A 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). CONCLUSIONS Pelvic 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.

Early surgical thrombectomy improves salvage of thrombosed vascular accesses

OBJECTIVE The timing and urgency of salvage attempts for acutely thrombosed hemodialysis vascular accesses remain poorly defined. We examined the outcome of early surgical thrombectomy after acute access thrombosis to assess the influence of expedited timing on access salvage. METHODS Between January 2007 and October 2012, 114 surgical thrombectomy attempts were performed on 82 patients to salvage 89 accesses. The time between the diagnosis of thrombosis and admission to the operative suite (T1), the time between diagnosis and the following dialysis session (T2), and clinical and biologic parameters were collected prospectively. Data were retrospectively compared between the early (T1 <6 hours) and later (T1 >6 hours) treatment groups. The main outcome measure was technical success. Kaplan-Meier survival analysis was used to estimate functional patency rates. RESULTS Mean patient follow-up was 22 ± 18 months. The mean time from referral to procedure (T1) was 5.7 ± 4.5 hours. The mean time T1 was 3.6 ± 1.2 hours in the early group and 10.3 ± 5.4 hours in the later group. The mean time to dialysis (T2) was 14.3 ± 6.5 hours in the early group and 23.9 ± 9.4 hours in the later group. Thrombectomy performed ≤ 6 hours after diagnosis (T1 <6 hours) had significantly higher technical success of 86% compared with 69% for thrombectomy performed later (T1 >6 hours; P = .04). The two groups did not differ significantly in patient comorbidities, type of access, or adjunctive procedures performed (P ≥ .1). At 12 months, the primary patency rate for all index cases, including technical failures, was 55% ± 7.1% in the early group and 33% ± 9.7% in the later group (P = .13). The secondary patency rate was 67% ± 6.8% in the early group and 50% ± 9.9% in the later group (P = .05). CONCLUSIONS After acute access thrombosis, early surgical thrombectomy was associated with higher technical success and potentially improved midterm patency.