Romain de Blic

Initial Experience with Percutaneous Angioplasty of the Common Femoral Artery in De Novo Stenotic Lesions

BACKGROUNDnThe aim of this study was to report an initial experience with percutaneous transluminal angioplasty (PTA) in de novo stenotic lesions of the common femoral artery (CFA).nnnMETHODSnA retrospective analysis for 34 consecutive patients was conducted. The follow-up consisted of clinical evaluation and color duplex ultrasound scan (CDU) 1, 6, and 12 months after the procedure.nnnRESULTSnThe symptoms were claudication in 16 patients (47%), critical limb ischemia in 17 (50%), and preservation of an infrainguinal bypass in 1 (3%). PTA was performed in CFA alone in 45.7%, associated to iliac and/or profunda/superficial femoral artery PTA in 54.3%. Stenting was performed in 23 patients (65.7%). All procedures were successful. Two patients required surgery for a local complication. Median hospital stay was 2 days. Mean follow-up was 11 months (range 1-56). Primary and secondary sustained clinical improvement rates were 77% and 85%, and primary, CDU-controlled patency rate was 88%. Four reinterventions were required for symptomatic CFA restenosis. At the end of follow-up, no major amputation had been performed, all patients with claudication remained improved with no restenosis, and the secondary sustained improvement rate was 85%.nnnCONCLUSIONSnPTA for primary CFA lesions is feasible and safe, with acceptable short-term results in claudicants. In patients with tissue loss, frequent reinterventions raise questions about PTA benefit. This approach needs to be compared with open surgery in a randomized trial.

Chimney stent graft for endovascular sealing of a pararenal aortic aneurysm.

Chimney endovascular aneurysm repair is still a controversial treatment of complex aortic aneurysms. Stent-graft patency and type-I endoleaks are the main challenges that temper this bailout technique. Endovascular aneurysm sealing (EVAS) consists of anchoring and sealing the device within the aneurysm sac. The first results are promising, even for adverse anatomy. We describe a case of EVAS for a pararenal aortic aneurysm associated with a chimney stent graft for the right renal artery. Wrapping the chimney stent graft inside endobags filled with polymer is expected to prevent gutters and stent compressions.

Long-Term Preservation of Native Arteriovenous Dialysis Fistulas

Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.

Elective treatment of abdominal aortic aneurysm is reasonable in patients >85 years of age.

BACKGROUNDnThe numbers of patients >85 years of age referred for abdominal aortic aneurysm (AAA) repair have increased in recent decades. With the population aging, increased screening of AAA, and introduction of less invasive surgical techniques, vascular surgeons will be treating more elderly patients. Few data are available for estimating the risks and benefits of prophylactic repair among those with such an advanced age. The aim of this single-center study was to evaluate the short-term to midterm results after AAA repair in patients >85 years of age.nnnMETHODSnBetween 2004 and 2012, data of patients >85 years old who required an elective AAA repair at our institution were collected prospectively. According to the current guidelines, patients underwent endovascular aneurysm repair (EVAR) each time the aortic anatomy was suitable. Open repair (OR) was performed in those patients with hostile proximal neck anatomy and/or severe iliac tortuosity. Type of repair (EVAR or OR) and perioperative and midterm outcomes were analyzed. Primary end points were 30-day mortality and midterm survival.nnnRESULTSnAmong 1016 patients undergoing elective AAA repair during the study period, 59xa0(5.8%) were ≥85 years of age (54 men, mean age 87 ± 2 years), with a mean aneurysm diameter of 61.5 ± 20.3 mm. Thirty-three patients (56%) underwent EVAR and 26 (44%) had an OR. Thirty-day mortality was 6.7% (6% with EVAR and 7.6% with OR, P <0.05). Mean follow-up was 24.7 ± 18 months. Kaplan‒Meier analyses for survival were 85.5%, 64.5%, and 50% at 1, 3, and 5 years, respectively. No aneurysm-related death was observed during follow-up.nnnCONCLUSIONnElective repair may be proposed in patients >85 years of age in cases of threatening AAA, showing acceptable perioperative mortality and reasonable midterm survival results. Even if EVAR did not seem to offer significant benefits in perioperative mortality in our study, it appears reasonable to suggest this less invasive technique as first-line treatment in cases of suitable anatomy in such an advanced-age population.

De Novo Periaortic Fibrosis after Endovascular Aortic Repair

We report a case of a 63-year-old man presenting with abdominal pain and hydronephrosis secondary to periaortic fibrosis (PAF) 8 months after an endovascular aortic repair (EVAR) using a woven polyester bifurcated graft. De novo delayed PAF after open repair is rare and even more infrequent after EVAR. All 3 previously reported cases occurred after woven polyester grafts and no reported cases after polytetrafluorethylene grafts. Management included steroidal anti-inflammatory treatment and bilateral double J tube placement. Satisfactory results were obtained.

Surgical revascularization of the celiac artery for persistent intestinal ischemia in short bowel syndrome

BACKGROUND AND OBJECTIVESnWithout prompt superior mesenteric artery (SMA) revascularization, acute mesenteric ischemia (AMI) frequently leads to death or short bowel syndrome (SBS). In SBS patients, persistent or chronic intestinal ischemia (PII) of the remnant bowel can lead to recurrences of AMI. Since SMA revascularization is sometimes unfeasible, celiac artery (CA) revascularization may improve blood supply to the remnant bowel. The aim of this study was to describe and to assess our experience of the CA revascularization in case of SMA occlusion unsuitable for revascularization in the setting of PII in SBS patients.nnnMETHODSnAll consecutive patients with i) SBS consecutive to AMI, ii) persistent intestinal ischemia (PII), iii) irreversible SMA occlusion, i.e unsuitable for radiological or surgical revascularization and iv) occlusion or severe stenosis of the CA were included.nnnRESULTSnThirteen patients (7 males/6 females, mean ageu202f=u202f47.2u202f±u202f12.1 years) were included. The mean length of remnant small bowel was 47u202f±u202f39u202fcm and 77% of patients had a stoma. The types of revascularization included anterograde aorto-hepatic bypass nu202f=u202f11 (84%), ilio-hepatic bypass nu202f=u202f1 (8%) and endarterectomy nu202f=u202f1 (8%). Major adverse events were observed in 5 cases: bypass graft infection (nu202f=u202f2), hemorrhagic pericarditis (nu202f=u202f2), hemorrhagic shock (nu202f=u202f2) and aortic false aneurysm (nu202f=u202f1). After a mean follow-up of 27.0u202f±u202f25.2 months, symptoms of PII relieved in 12 cases (92%) allowing for digestive surgical rehabilitation with continuity restoration in 7 patients (54%). PN was weaned for 2 patients. One-year and 3-year survival rates were 73.8% and 73.8% respectively. No recurrence of AMI or further need for bowel resection was noticed.nnnCONCLUSIONnFor patients with SBS suffering from PII with CA occlusion or stenosis without possibility of SMA revascularization, the surgical revascularization of the CA allowed digestive rehabilitation with acceptable morbidity and mortality rates.

Impact of Stent-Graft Oversizing on Gutter Areas after Chimney Graft Repair for Complex Abdominal Aortic Aneurysms

BACKGROUNDnThe aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined.nnnMETHODSnPreoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component < 25% (group 1) and >25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed.nnnRESULTSnOf 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4xa0±xa04.9% and 34.5xa0±xa06% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1xa0±xa02.1% vs. 4.2xa0±xa03.2%, Pxa0=xa00.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 nxa0=xa00, group 2 nxa0=xa02; Pxa0=xa00.48).nnnCONCLUSIONSnIn our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.