Serguei Malikov

Open surgical reconstruction of the internal carotid artery aneurysm at the base of the skull

OBJECTIVES Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report a standardized surgical technique of ICA reconstruction with long-term results. METHODS Between 1988 and 2005, 13 patients (11 men; age 18 to 76 years, mean 42.6 years) underwent lateral skull base approach with cervical-to-petrous carotid artery bypass for repair of ICA aneurysms. Principal elements of the technique were: partial resection of the parotid gland without rerouting of the facial nerve; luxation of mandibula; drilling of the bone. RESULTS The 13 patients had unilateral aneurysm of the ICA at the base of the skull. Four aneurysms were of atherosclerotic origin; six fibromuscular dysplasia; two post-traumatic; one cause was undetermined. The mean diameter of the aneurysms was 12 mm (range, 7-21 mm). Twelve patients were symptomatic: six presented neurological events (four strokes, two transient ischemic attack [TIA]); two retinal events; three compressive symptoms (two Horners syndrome and one paralysis of the glossopharyngeal nerve); one patient presented a visible pulsatile mass in the neck. One patient was asymptomatic. There were no post-operative deaths, one TIA, 13 transient palsies of the lower facial nerve, and one transient palsy of accessory nerve. Palsy of cranial nerves was partial and disappeared within a mean of 5.6 months (range, 1-10 months). The postoperative angiogram showed patency in all but one case (one asymptomatic thrombosis). During follow-up (mean, 152 months), there was one unrelated death, one focal epileptic seizure, and one controlateral TIA. In November 2008, duplex showed patency of all 11 grafts (one death, one thrombosis). At 10 years, the survival, cumulative stroke-free survival, ipsilateral stroke-free, and patency rates was were 90.9%, 100%, 100%, and 92.3%. CONCLUSION Venous graft bypass from the cervical-to-petrous ICA can be performed safely with such an approach and produces durable satisfactory results.

Subscapular artery Y-shaped flow-through muscle flap: A novel one-stage limb salvage procedure

OBJECTIVES Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage. METHODS Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally. RESULTS One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg. CONCLUSION We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.

Bypass flap reconstruction, a novel technique for distal revascularization: outcome of first 10 clinical cases.

Combined distal venous bypass grafting and free flap transfer can achieve successful treatment of soft tissue defects due to advanced leg ischemia. However, this combined approach is a complex technique involving multiple anastomoses on the same arterial axis with an increased risk of thrombosis. To reduce this risk, we have proposed a new bypass-flap (BF) reconstruction technique using an arterial graft and a free flap supplied by a collateral branch of the graft. The purpose of this report is to document the outcome in the first 10 patients treated using the BF reconstruction technique. From 2002 to 2004, a total of 10 patients with a mean age of 67 years (range 55-78) were treated using a BF. All patients presented critical ischemia with soft tissue defects resulting in exposure of tendons and muscles on the foot or ankle. Distal anastomosis was made between the distal branch of the BF and the pedal artery in five cases, the posterior tibial artery or plantar artery in four cases, and the peroneal artery in one case. In six cases proximal anastomosis was performed between the leg artery and arterial autograft. In the remaining four cases proximal anastomosis required extension of the bypass using a venous graft. The mean duration of hospitalization was 25 days. During the postoperative period, one patient died due to stercoral peritonitis and one patient required major amputation due to unrelenting sepsis. Bypass occlusion was not observed. Mean follow-up was 24 months (range 14-36). No patient was lost to follow-up and no patient died after the first 30 postoperative days. Follow-up examinations including clinical assessment and Doppler ultrasound imaging were performed at 3 months and every 6 months thereafter. Findings demonstrated bypass patency and healing of the covered defect in all cases. Outcome in this initial series demonstrates the clinical feasibility of the new BF reconstruction technique, which allows revascularization and coverage of tissue defects using a one-piece anatomic unit.

Dramatic Response to Tocilizumab Before Emergency Surgery in Severe Active Takayasu Disease

A 19-year-old man was admitted in our tertiary care center in August 2014 for a 10-kg weight loss in a few months (48 kg, 1.80 m, and body mass index, 14.8 kg/m2), claudication in the lower limbs after a 500-m distance and a postprandial abdominal pain associated with mild renal insufficiency and proteinuria with no hypertension (100/80 mm Hg). The patient had no medical history and was an active smoker (tobacco and cannabis, estimated consumption: 2 pack-years). Laboratory parameters were elevated leukocyte count (13×109/L), C-reactive protein level (55 mg/L), creatinine (14 mg/L), and B-natriuretic peptide (4246 pg/mL). No thrombophilia, autoimmune disorders, or viral infections were identified. The patient underwent a B-mode Doppler ultrasound that showed multiple proximal arterial occlusions and stenoses of large vessels confirmed by a computed tomographic angiography: occlusions of bilateral subclavian arteries, superior and inferior mesenteric arteries, and right renal artery with kidney atrophy were found (Figure 1A). Furthermore, significant stenoses of celiac artery, left renal artery (Figure 1B), right internal iliac artery, and bilateral superficial femoral arteries were identified. A discrete circumferential thickening of the abdominal aorta was suggestive of aortitis. Cervical magnetic resonance angiography showed a complete occlusion of both subclavian and vertebral arteries (Figure 2). Transthoracic echocardiography revealed a severe left ventricular (LV) systolic dysfunction (LV ejection fraction …

Epiploic Bypass Flap: A New Method of Limb Salvage. Anatomic Basis and Clinical Application

BACKGROUND The incidence of critical limb ischemia increases with the aging of the population. Two-thirds of patients with critical limb ischemia present with trophic disorders. Revascularization decreases the rate of amputation. Infected wounds with exposure of the tendons, bones, or points of articulation cannot heal in spite of bridging and local debridement. Surgery associated with a distal venous bypass or recanalization and a free flap makes it possible to cover major tissue loss and offers a hemodynamic advantage by increasing the flow of the bypass, thanks to the vascular bed added by the flap. It is a complex surgery because of the multiplicity of anastomoses on the same arterial axis, with a risk of thrombosis and complications related to the venous autograft. To mitigate these disadvantages, we propose a new surgical method based on the use of a single anatomic unit, the epiploic bypass flap (BF), based on the gastroepiploic artery (GEA) as the inflow for a bypass and a free flap. The objective of this work was to analyze the anatomic feasibility of an epiploic BF and to determine its limits. METHODS One hundred anatomic preparations were conducted with a measure of the internal and external diameters and the lengths of GEA and its branches and a radiograph after injection of a radiopaque product. A first clinical application was carried out. RESULTS According to the data, our study confirms the anatomic feasibility of a BF. The average available length of GEA is 245 mm (range: 210-280 mm). The average proximal diameter is 3 mm, and the distal diameter is 1.5 mm. The most distal epiploic branch that feeds the bypass is approximately 180 mm (range: 161-195 mm) of the origin of the GEA. The anatomic unit based on the GEA provides an arterial graft that is relatively long and a large flap that is both malleable and resistant to infection. CONCLUSIONS Epiploic BF is a surgical technique that allows for distal revascularization and a simultaneous cover of the limb extremity. This technique can be useful in patients requiring a distal revascularization associated with a cutaneous cover.

Anatomical repair of a congenital aneurysm of the distal abdominal aorta in a newborn

Congenital (primary) neonatal abdominal aortic aneurysm (AAA) is an extremely rare truncular arterial abnormality among numerous congenital vascular malformations. Only seven cases have been reported as congenital origin in newborns. This report presents the case of a male infant in whom a 33-mm congenital AAA was diagnosed prenatally and was successfully treated 10 days after birth without exogenous graft material or aneurysmorrhaphy. Follow-up study at 39 months demonstrated excellent clinical, ultrasound scan, and computed tomography scan findings. Anatomic reconstruction with native vessels is the preferred surgical technique to ensure the childs potential for harmonious growth.

Infected Abdominal Aortic Aneurysm Attributable to Haemophilus influenzae Rapid Changes of Imaging Findings

A 57-year-old man presented to the emergency department with an 8-day history of abdominal and suprapubic pain radiating in the back associated with fever (38.6°C), myalgia, and a painful rectal examination. A treatment with ofloxacin had been prescribed for a suspected prostatitis. His past medical history included overweight and current cigarette smoking (30 pack-year). Clinical examination found a tense and nondepressible abdomen without nausea or vomiting. On auscultation, he had an abdominal vascular murmur. Computed tomography angiography performed on day 1 revealed a moderate aneurysmal dilation of the infrarenal abdominal aorta with a maximal diameter of 25 mm along with a thickened wall, a periaortic infiltration, and thrombus (Figure 1A). Biological investigations revealed an elevated leukocyte count (14 780/mm3 with 92.5% neutrophils) and a high C-reactive protein level (256.4 mg/L), but no serological evidence for syphilis, HIV, hepatitis B or C infections, and negative standard bacterial and mycobacterial blood cultures. The persistence of abdominal pain and biological inflammation led to that performance of a new computed tomography angiography on day 4. It …

Extra-Anatomical Revascularization of the Adamkiewicz Artery Using the Internal Mammary Artery: Preliminary Anatomical Study

Ischemic spinal cord injury remains a major complication of both open and endovascular repairs of extensive lesions of the thoracic or thoracoabdominal aorta. Patients undergoing endovascular treatment cannot benefit from direct revascularization of the Adamkiewicz artery (AA). Primary revascularization of the intercostal artery (ICA) giving rise to the AA using the internal mammary artery (IMA) could ensure uninterrupted flow in the AA even if the origin of the feeding ICA was obstructed. The purpose of this study was to assess the anatomical feasibility of revascularization of the ICA giving rise to the AA using the IMA. Twenty-four dissections were carried out on 12 cadavers (eight men, four women) with a mean age of 76 at the time of death. Preparation consisted of intra-arterial injection of polymethylsiloxane (Rhodorsil, Rhodia, France). For each IMA, the following parameters were determined: diameter in relation to the ICA in the paravertebral region before division, length, and level of the intercostal space in which direct anastomosis was possible. Dissection showed that the mean diameter at the end of the IMA was 1.8mm (range 1.2-2.4). The mean diameter of the ICA in the paravertebral region was compatible with that of the IMA, i.e., 1.6mm (range 0.9-2.5). The mean length of the IMA was 185 mm (range 165-230). The lowest intercostal space available in the paravertebral region for direct anastomosis between the IMA and ICA was the seventh space in one case, the eighth in 12, the ninth in eight, and the tenth in three. The findings of this preliminary study document the feasibility of using the IMA to revascularize the ICA in the paravertebral region. This technique could provide a means of preserving spinal cord vascularization during endovascular treatment of thoracic or thoracoabdominal aortic lesions.

Cerebral Infarct Topography and Early Outcome after Surgery for Symptomatic Carotid Stenosis: A Multicentre Study

Introduction: Although carotid stenosis can cause both territorial and border-zone (BZ) cerebral infarcts (CI), the influence of CI topography on postoperative complications after surgery remains unclear. We compared early outcomes after endarterectomy on the basis of CI location: territorial (T group) or BZ group. Material and Methods: During the period between 2009 and 2013, ischaemic stroke patients who had undergone surgery for symptomatic carotid stenosis were identified from prospective databases from 3 French centres. The outcome was the identification of a combined stroke/death rate 30 days after endarterectomy. Results: Two hundred and eighty-nine patients were included, 216 (74.7%) in the T group and 73 (25.3%) in the BZ group. The mean degree of stenosis was comparable in the 2 groups (78 ± 12% in the T group vs. 80 ± 12% in the BZ group, p = 0.105), with, however, more sub-occlusions (stenosis >90%) in the BZ group (38.4 vs. 23.1%, p = 0.012). The mean time between the time CI developed and the time surgery was performed was 19.6 ± 24.8 days, with a majority of patients being operated upon within 2 weeks following the formation of CI (66.7% in the T group vs. 60.3% in the BZ group, p = 0.322). The combined endpoint was significantly more frequent in the BZ group (9.6 vs. 1.9%, p = 0.003), with 4 ischaemic strokes and 3 deaths. In multivariate analysis, BZ CI was an independent predictor of postoperative stroke or death at 30 days (HR 4.91-95% CI [1.3-18.9], p = 0.020). Conclusion: BZ infarcts carry a greater risk of postoperative complications after carotid surgery, thus suggesting that topography of the CI should be considered in the decision-making process regarding surgery.

Alternative Accesses for Aortic Devices - Postoperative Feasibility and Complications

defects of hemostasis and the dissections at the level of the femoral access as well as the failures of implantation. Results: In 217 percutaneous femoral accesses, 23 (10.6%) complications were directly attributed to the procedure of percutaneous arterial closure: 14 (61%) stenoses, six (26%) defects of hemostasis, one (4.3%) dissection, one (4.3%) failure of use and one (4.3%) malposition. This malposition, above the inguinal ligament, was at the origin of the only major complication presenting as a retroperitoneal hematoma which imposed a femoral surgical access and a transfusion of two globular units. The other complications were treated by contralateral endovascular route and crossover maneuver allowing the placement of covered stents. Conclusion: Percutaneous arterial closure with Prostar is effective. Indeed, an arterial restoration of quality is ensured in 90% of the cases, whichever the quality of the femoral artery. Moreover, 95% complications are managed by endovascular route without recourse to a direct surgical access. The use of such a device makes it possible to systematically consider a percutaneous access of first intention for all the endovascular aortic reconstructions.