Y.S. Alimi

Endovascular Management of Chronic Disabling Ilio-caval Obstructive Lesions: Long-Term Results

OBJECTIVE To report the long-term results of stenting for chronic ilio-caval obstructive lesions. MATERIAL AND METHODS From January 1996 to January 2008, 89 patients (72 women, 17 men; median age 43 years) were admitted for endovascular treatment of chronic disabling non-malignant obstructive ilio-caval lesions. Patients were classified as C2 in 15 cases, C3 in 59, C4 in seven, C5 in two and C6 in six. Median preoperative venous disability score (VDS) and venous clinical severity score (VCSS) were 2 and 9, respectively. Aetiology was primary in 52 patients, secondary in 35 and congenital in two. Lesions were bilateral in seven cases, eight patients had inferior vena cava (IVC) involvement and 18 had common femoral vein (CFV) obstructive lesions. Complete occlusion was found in 30 cases. RESULTS Technical success was achieved in 98%. The median hospital stay was 2 days. During a median follow-up of 38 months (range: 1-144 months), one patient died and five cases of thromboses occurred. Iterative stenting was performed for restenosis in six cases. Primary, assisted-primary and secondary patency rates, in terms of intention to treat, were 83%, 89% and 93%, respectively, at 3 and 10 years, with a median VDS of 1. Univariate analysis found that significant factors affecting patency were CFV involvement for primary patency and history of deep venous thrombosis (DVT) and CFV involvement for secondary patency. The last 46 patients had statistically more severe lesions than the first 43 (higher VDS, more secondary lesions, more occlusions, more stented segments, higher length of stented vein), and in spite of which patency rates are not different. CONCLUSION Endovenous angioplasty, combined with stenting, is a sure, safe, effective and very minimally invasive technique which provides good long-term patency rates. Currently, it is recognised as the technique of choice for the treatment of ilio-caval obstructive lesions. Surgery should be proposed only in case of failure.

Fibromuscular Disease of the Renal Artery: A New Histopathologic Classification

To evaluate the relationship between clinical, radiologic, and histopathologic features in various types of renal artery fibromuscular disease, the records of 37 patients operated upon for a total of 44 lesions of the renal artery (30 unilateral and seven bilateral) were retrospectively reviewed. Of these, 36 had hypertension associated with stenosis or aneurysm of the trunk or branches of the renal artery; one had aneurysm of the renal artery without hypertension. The histopathologic study included 38 arterial segments retrieved from 33 patients and underscored the difficulties in using topographic criteria to classify lesions. While all arterial aneurysms were associated with involvement of the media, more than one layer of the artery was involved in 65.7% of cases. Topographic forms, such as the perimedial type, were difficult to classify. Based on the study results, it appears essential to distinguish patients with fibrosis and smooth muscular hyperplasia (type I: 19 patients, 23 arteries) from patients with isolated fibrosis (type II: 14 patients, 15 arteries). In group II, preoperative hypertension was more long-standing (p<0.04), more lesions were extended distally (p<0.05), and the probability of recovery from hypertension at 52 months follow-up was lower. We have distinguished two different evolutive stages of fibromuscular disease of the renal artery, one characterized by fibrosis with smooth muscle hyperplasia and the second, associated with more severe prognosis, characterized by isolated fibrosis.

Elective Stent-graft Treatment for the Management of Thoracic Aorta Mural Thrombus

BACKGROUND Optimal management of aorta mural thrombus (AMT) continues to be controversial. The aim of this study was to describe the management of AMT in the thoracic aorta with either conservative or stent-graft treatment and to analyze the role of morphological characteristics of thrombus in the selection of suitable candidates for intervention. METHODS A retrospective review was conducted of all patients admitted for thoracic AMT. Clinical data, treatment used, and outcomes were recorded. Patients were divided in two groups according to the treatment used: either conservative or stent-graft. Morphological features of thrombus, including size, sessile or pedunculated aspect and mobility, were compared between the two groups. RESULTS From January 2006 to March 2013, 13 consecutive patients (nine male, mean age 53, range 37-76) were admitted for symptomatic (n = 8) or asymptomatic AMT (n = 5). All patients received unfractionated heparin. Management of primary aortic thrombus required stent-graft in seven patients, aortic thrombectomy in one, and anticoagulation therapy alone in five. Indications for intervention were recurrent embolism (n = 4), occurrence of embolism under heparin (n = 1), or persistent thrombus (n = 2). Endovascular exclusion of AMT was successful in all cases, with no complications or deaths at 30 days and no recurrence at midterm. Analysis of the morphological features of the thrombus identified solely the high degree mobility as associated with adverse outcome (p = .048). CONCLUSION In our experience, stent-graft exclusion of AMT is an effective approach. Systematic evaluation of thrombus mobility by a real-time imaging study can be helpful to better define the indications for radical treatment of the aortic lesion.

Occlusive Disease of the Renal Arteries and Chronic Renal Failure: The Limits of Reconstructive Surgery

In order to investigate the value of renal revascularization in patients with chronic renal failure and associated occlusive lesions of the renal arteries, the long-term results of 48 revascularizations in 43 patients operated upon between January 1980 and May 1988 were analyzed. There were 36 men and 7 women whose mean age was 61.8 years (range 36 to 79 years). The diagnosis of kidney failure was based on serum creatinine levels greater than 120 micromoles/L on two consecutive determinations. Patients were divided into four groups: Group I (23 patients) had a creatininemia between 120 and 200 µmoles/L, Group II (16 patients) between 200 and 350 µmoles/L, Group III (2 patients) between 350 and 800 µmoles/L and Group IV (2 patients) who had chronic renal failure requiring hemodialysis. Hypertension was found in 37 patients. Renal artery restoration was unilateral in 38 patients, 12 of whom had a solitary kidney. Restoration was bilateral in five patients. In 24 patients, renal artery surgery was associated with reconstruction of the infrarenal aorta. Three patients undergoing associated aortic procedures (7%) died after surgery. Thirty-nine patients were followed for a mean of 35.1 months; one patient was lost to follow-up. Improvement or stabilization of renal function was noted in 24 patients (62%). Deterioration was found in 15 patients (38%), six of whom presently required chronic hemodialysis. In Groups I and II, 69.5% of patients stabilized or improved their kidney function. Renal function worsened in all patients in Groups III and IV. We conclude that restorative renal surgery can improve renal function in patients whose preoperative serum creatinine levels are less than 350 µmoles/L. In this population of patients, associated aortic restoration should be performed only when absolutely necessary.

Risk Factor Analysis of Bird Beak Occurrence after Thoracic Endovascular Aortic Repair

OBJECTIVES The aim was to analyze the role played by anatomy and stent graft in the incidence of incomplete apposition to aortic arch. METHODS Between 2007 and 2014 data including available and suitable computed tomographic angiography (CTA) imaging of patients who had undergone thoracic endovascular aortic repair were reviewed. The study included 80 patients (65 men, 54 ± 21 years) treated for traumatic aortic rupture (n = 27), thoracic aortic aneurysm (n = 15), type B aortic dissection (n = 24), penetrating aortic ulcer (n = 5), intramural hematoma (n = 2), aorto-oesophageal fistula (n = 2), and aortic mural thrombus (n = 5). Pre- and post-operative CTA images were analyzed to characterize bird beak in terms of length and angle, and to calculate aortic angulation within a 30 mm range at the proximal deployment zone. RESULTS Bird beak configuration was detected in 46 patients (57%): mean stent protrusion length was 16 mm (range: 8-29 mm) and mean bird beak angle was 20° (range: 7-40°). The bird beak effect was significantly more frequent after traumatic aortic rupture treatment (p = .05) and in landing zone 2 (p = .01). No influence of either stent graft type or generation, or degree of oversizing was observed (p = .29, p = .28, p = .81 respectively). However, the mean aortic angle of patients with bird beak was higher in the Pro-form group than that in the Zenith TX2 group (62° vs. 48°, p = .13). Multivariate analysis identified the aortic angle of the deployment zone as the unique independent risk factor of malapposition (HR = 1.05, 95% CI 1-1.10, p = .005). The cutoff value of 51° was found to be predictive of bird beak occurrence with a sensitivity of 58% and a specificity of 85%. CONCLUSIONS Assessment of proximal landing zone morphology to avoid deployment zones generating an aortic angle of over 50° can be recommended to improve aortic curvature apposition with the current available devices.

Subintimal Recanalization Plus Stenting or Bypass for Management of Claudicants with Femoro-popliteal Occlusions

OBJECTIVE To assess a practice of claudicant revascularization with either subintimal angioplasty (SIA) plus stenting or femoropopliteal bypass. METHODS All claudicants related to femoropopliteal occlusions treated either with above-the-knee femoropopliteal (AKFP) bypass (group 1) or SIA and stent (group 2) between 2004 and 2011 were reviewed. The two groups were analyzed with regard to patency and freedom from re-intervention. RESULTS One hundred and fifty limbs were consecutively treated with AKFP bypass (n = 82), SIA plus stenting (n = 58), or SIA (n = 10). Bypasses were performed with synthetic grafts in 49 limbs (59.7%). Covered stents were used in 34 limbs (63%) and self-expandable stents in the remainder. Mean follow-up was 26 and 36 months, respectively, in group 1 and 2. At 24 months, primary, primary-assisted, and secondary patency for bypass versus SIA + stent groups was, respectively, 66.6 versus 70.1%, 76.5 versus 90.1%, and 88.2 versus 90.1%. Freedom from re-intervention rates at 12 and 36 months were, respectively, 78.8 and 68.4% for group 2 and 86.4% and 65.2% for group 1. CONCLUSION SIA plus stenting is an effective and useful option for the management of claudicants with femoropopliteal occlusions, and can be considered as complementary to surgical bypass.

Biaxial tensile tests of the porcine ascending aorta

One of the aims of this work is to develop an original custom built biaxial set-up to assess mechanical behavior of soft tissues. Stretch controlled biaxial tensile tests are performed and stereoscopic digital image correlation (SDIC) is implemented to measure the 3D components of the generated displacements. Using this experimental device, the main goal is to investigate the mechanical behavior of porcine ascending aorta in the more general context of human ascending aorta pathologies. The results highlight that (i) SDIC arrangement allows accurate assessment of displacements and so stress strain curves, (ii) porcine ascending aorta has a nearly linear and anisotropic mechanical behavior until 30% of strain, (iii) porcine ascending aorta is stiffer in the circumferential direction than in the longitudinal one, (iv) the material coefficient representing the interaction between the two loading directions is thickness dependent, (v) taking into account the variability of the samples the stress values are independent of the stretch rate in the range of values from 10(-3) to 10(-1)s(-1) and finally, (vi) unlike other segments of the aorta, 4-month-old pigs ascending aorta is definitely not a relevant model to investigate the mechanical behavior of the human ascending aorta.

A voluminous glomus tumor of the leg.

Glomus tumors are uncommon benign neuromyoarterial tumors, classically known to induce incoercible localized pain. Seventy percent of them are located in the hands, particularly in the sub-ungual region.1–3 They usually represent small tumors that do not generally exceed 1 cm in diameter.1–3 We would like to report here a voluminous glomus tumor located in the leg with a delay to diagnosis related to its unusual anatomic location. A 54-year-old woman consulted in 2011 for recurrence of left calf enlargement associated with chronic pain. She initially consulted 4 years ago and was diagnosed with Cockett’s syndrome, as the cause of compression of …

Mechanical characterization of porcine ascending aorta.

Numerous works deal with tensile testing of soft tissue, such as arteries, to characterize their mechanical responses. The objectives of these studies are various but whatever the goal and the used...