Serge Declemy

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.

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.

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.

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.

Thrombophlebitis of the Ovarian Vein With Free-Floating Thrombus in the Inferior Vena Cava

Two cases of thrombophlebitis of the right ovarian vein, one occurring after cesarean section and the other after natural childbirth, are reported. The clinical diagnosis was based on the symptoms of postpartum fever in association with right flank pain and confirmed by abdominal CT scans. In both cases the thrombosis extended into the inferior vena cava and was associated with a free-floating thrombus extending up to the renal veins. Thrombectomy of the inferior vena cava and ligation of the right ovarian vein were performed with good results in both cases, as shown by late follow-up CT scans. This and alternative therapeutic strategies are discussed.

Prognostic Value of Preoperative Border-zone (Watershed) Infarcts on the Early Postoperative Outcomes of Carotid Endarterectomy after Acute Ischemic Stroke☆

OBJECTIVES To evaluate the prognostic value of cerebral border-zone infarctions (watershed infarctions) on the early postoperative outcomes of patients undergoing carotid endarterectomy (CEA) after acute ischemic stroke (AIS). METHODS Sixty-six (66) patients with symptomatic carotid stenosis (SCS) that underwent ipsilateral CEA after AIS from January 2007 to March 2012 were included in this study. They were divided into two groups according to the topographic patterns of the stroke: group 1, Territorial Cerebral Ischemic Strokes (TCIS) caused by emboli of carotid origin; group 2, cerebral border-zone infarctions (CBZI) related to an SCS associated with hemodynamic impairment. All data was collected in a prospective database and analyzed. Outcome measures included postoperative neurological morbidity and 30-day mortality. RESULTS Forty-three (43) patients (65.15%) experienced TCIS and were included in group 1, 23 patients (34.85%) had a CBZI and were included in group 2. There were no postoperative deaths. The postoperative neurologic morbidity rate was significantly higher in the CBZI group (22% vs. 2%, p = 0.02). Multivariate analysis demonstrates that CBZI was the only independent predictive factor of neurologic morbidity after CEA for AIS related to an SCS. Furthermore, the risk of postoperative neurologic morbidity remained significantly higher for patients with CBZI after adjustment for age, sex, initial NHISS scores, and associated contralateral carotid occlusion (HR: 0.059, 95% CI 0.004-0.85; p = 0.03). CONCLUSION CBZIs, compared to TCIS, were associated with a higher neurological complication rate during the postoperative period after CEA for SCS in cases of AIS. Further studies are required to better define the timing and the best treatment modality for patients with CBZI related to an SCS in order to reduce associated procedural complications.

Spontaneous Dissecting Aneurysm of the Common Iliac Artery

A 52-year-old man sought medical advice for sudden onset of intermittent claudication of the left lower limb after 50 meters walking. Aortography documented a dissecting aneurysm limited to the left common iliac artery. After resection, a prosthetic graft was inserted. Pathology showed that the cause of the dissection was atheroma. Spontaneous dissecting aneurysm of the common iliac artery is rare. Rupture represents the principal hazard. A high index of suspicion should lead to diagnosis as soon as signs of lower limb ischemia, occasionally transient, appear.

Blunt abdominal aortic trauma in paediatric patients.

BACKGROUND Blunt abdominal aortic trauma (BAAT) is a very rare occurrence in children, with significant morbidity and mortality. Varied clinical presentations and sparse literature evidence make it difficult to define the proper management policy for paediatric patients. METHOD We report our centres data on three consecutive children with BAAT managed between 2006 and 2010. A Medline search was also performed for relevant publications since 1966, together with a review of references in retrieved publications. RESULTS Forty children (range 1-16 years) were included in our final analysis. Motor vehicle crashes (MVC) were the leading cause of injury (65%). The in-hospital mortality rate was 7.5% (3/40). Nine patients (22.5%) ended up with residual sequelae. Main primary aortic lesions were complete wall rupture (12.5%), intimal transection (70%) and pseudoaneurysm (15%). Twenty-eight children underwent aortic surgical repair (70%). Among the 12 non-operatively managed patients, 41.6% had complications, including one death. CONCLUSION Symptomatic lesions and complete ruptures should undergo immediate surgical repair. Circumferential intimal transections are at high risk of complication and should also receive intervention. Partial intimal transections and delayed pseudoaneurysms can be initially observed by clinical examination and imaging. Patients with these latter pathologies should be operated on at any sign of deterioration.