Yannick Georg

Long-Term Outcomes of Direct and Indirect Below-The-Knee Open Revascularization Based on the Angiosome Concept in Diabetic Patients with Critical Limb Ischemia

BACKGROUND We compared long-term outcomes of isolated below-the-knee (BTK) bypass revascularization in diabetic patients presenting with critical limb ischemia (CLI) with and without achieving the bypass on the artery corresponding to the territory of the lesion based on the angiosome concept. MATERIALS We analyzed outcomes of 58 consecutive CLI limbs of 54 diabetic patients presenting with tissue loss who underwent isolated BTK bypasses from 2003 to 2009 for crural occlusive arterial disease. Bypasses were classified into direct and indirect groups based on the angiosome concept, whether feeding artery flow to the site of ischemic tissue loss was achieved or not. We compared median ulcer-healing time, survival, primary patency, and limb salvage rates between both groups by Kaplan-Meier analysis and log-rank test. Independent factors of major amputations were explored by univariate analysis. Variables with P < 0.2 in univariate analysis were submitted to multivariable analysis. RESULTS Median ulcer-healing time was 56 ± 18 days in direct group (n = 36) and 112 ± 45 days in indirect group (n = 22, P = 0.01). There was no difference between both groups in terms of survival or primary patency. Limb salvage rate was significantly higher in direct group than in indirect group: 91% vs. 66% at 1 year, 65% vs. 24% at 3 years, and 58% vs. 18% at 5 years, respectively (P = 0.03). After multivariable Cox proportional analysis, independent factors associated with major amputation were end-stage renal disease (P = 0.030) and C-reactive protein level (P = 0.025). CONCLUSIONS Achieving a direct arterial flow based on angiosome concept in CLI diabetic patients presenting with tissue loss appears to be important for ulcer healing and limb salvage.

Endothelial Microparticles from Acute Coronary Syndrome Patients Induce Premature Coronary Artery Endothelial Cells Ageing and Thrombogenicity: Role of the Ang II/AT1 Receptor/NADPH Oxidase-mediated Activation of MAPKs and PI3-kinase Pathways.

Background: Microparticles (MPs) have emerged as a surrogate marker of endothelial dysfunction and cardiovascular risk. This study examined the potential of MPs from senescent endothelial cells (ECs) or from patients with acute coronary syndrome (ACS) to promote premature EC aging and thrombogenicity. Methods: Primary porcine coronary ECs were isolated from the left circumflex coronary artery. MPs were prepared from ECs and venous blood from patients with ACS (n=30) and from healthy volunteers (n=4) by sequential centrifugation. The level of endothelial senescence was assessed as senescence-associated &bgr;-galactosidase activity using flow cytometry, oxidative stress using the redox-sensitive probe dihydroethidium, tissue factor activity using an enzymatic Tenase assay, the level of target protein expression by Western blot analysis, platelet aggregation using an aggregometer, and shear stress using a cone-and-plate viscometer. Results: Senescence, as assessed by senescence-associated &bgr;-galactosidase activity, was induced by the passaging of porcine coronary artery ECs from passage P1 to P4, and was associated with a progressive shedding of procoagulant MPs. Exposure of P1 ECs to MPs shed from senescent P3 cells or circulating MPs from ACS patients induced increased senescence-associated &bgr;-galactosidase activity, oxidative stress, early phosphorylation of mitogen-activated protein kinases and Akt, and upregulation of p53, p21, and p16. Ex vivo, the prosenescent effect of circulating MPs from ACS patients was evidenced only under conditions of low shear stress. Depletion of endothelial-derived MPs from ACS patients reduced the induction of senescence. Prosenescent MPs promoted EC thrombogenicity through tissue factor upregulation, shedding of procoagulant MPs, endothelial nitric oxide synthase downregulation, and reduced nitric oxide–mediated inhibition of platelet aggregation. These MPs exhibited angiotensin-converting enzyme activity and upregulated AT1 receptors and angiotensin-converting enzyme in P1 ECs. Losartan, an AT1 receptor antagonist, and inhibitors of either mitogen-activated protein kinases or phosphoinositide 3-kinase prevented the MP-induced endothelial senescence. Conclusions: These findings indicate that endothelial-derived MPs from ACS patients induce premature endothelial senescence under atheroprone low shear stress and thrombogenicity through angiotensin II–induced redox-sensitive activation of mitogen-activated protein kinases and phosphoinositide 3-kinase/Akt. They further suggest that targeting endothelial-derived MP shedding and their bioactivity may be a promising therapeutic strategy to limit the development of an endothelial dysfunction post-ACS.

Long-term results of surgical treatment of aneurysms of digestive arteries.

BACKGROUND The aim of this study was to document the long-term results of open surgical treatment of aneurysms of the digestive arteries. METHODS Between January 2000 and March 2010, 60 patients were operated on for 78 aneurysms of the digestive arteries at our institution. The mean age of patients was 61 years (31-84 years). The average lesion diameter was 33 mm (range 10-90 mm). Topographic distribution involved the coeliac trunk in 23 cases (30%), hepatic artery in 20 (26%), splenic artery in 19 (24%), superior mesenteric artery in 11 (14%), gastroduodenal artery in 3 (4%), and pancreaticoduodenal arteries in 2 (3%). Twenty patients (33%) were symptomatic, 1 of whom presented with aneurysmal rupture (1.7%). Follow-up was prospective and an actuarial analysis was carried out. Only 3 patients (5%) were lost to follow-up. RESULTS Hospital mortality was 1.7% (upper gastrointestinal bleeding from gastric metastases of a kidney cancer). Postoperative complications were mainly respiratory (18%), digestive (18%), and renal (13%). Five reintervention procedures (8%) were necessary: 2 for colonic ischemia; 1 for intestinal bleeding; 1 for secondary graft infection due to peritonitis; and 1 for drainage of an acute pancreatitis. The average follow-up was 42 months (range 1-120 months). The actuarial survival rates were 98% at 1 month and 1 year, and 97% at 5 and 10 years, respectively. One late death occurred at 22 months (bronchopulmonary cancer). Three late reinterventions were carried out: 2 re-establishments of digestive continuity and 1 embolization for a recurrent aneurysm 7 years after the initial operation. The primary patency rate of the revascularizations was 98% at 1 month and 1 year, and 95% at 5 and 10 years. The rates of indemnity of restenosis or thrombosis were 98% at 1 month and 1 year, and 95% and 93% to 5 and 10 years, respectively. The rates of freedom of reintervention on bypasses were 98% at 1 month and 1 and 5 years, and 97% at 10 years. CONCLUSION Open surgical treatment of aneurysms of the digestive arteries offers excellent long-term results in terms of patency. It is with these late results that endovascular techniques will have to be compared to define the best therapeutic strategy.

Five Year Outcomes of Surgical Treatment for Popliteal Artery Entrapment Syndrome

OBJECTIVE/BACKGROUND The aim of this study was to evaluate long-term outcomes following surgery for popliteal artery entrapment syndrome. METHODS A retrospective study of all patients that underwent surgery for popliteal artery entrapment syndrome between January 2003 and December 2009 was performed. Patient demographic data, clinical features, imaging modalities, and surgical management were recorded. The primary outcome was 5 year patency. RESULTS Eighteen patients (25 limbs) underwent surgery. The mean age at the time of surgical procedure was 35 (median 35 years; range 15-49). Presentation was bilateral in seven patients (39%). Diagnosis was made using various imaging modalities, including position stress test, Duplex ultrasonography, computed tomography angiography, magnetic resonance imaging and conventional angiography. In four limbs the popliteal artery was compressed and undamaged (16%), and treatment consisted of musculo-tendinous division alone. In 16 limbs the popliteal artery was damaged with lesions limited to the popliteal artery (64%) where treatment consisted of venous interposition. In five limbs lesions extended beyond the popliteal artery (20%) and procedures included one below knee femoro-popliteal bypass, three femoro-posterior tibial bypasses, and one popliteo-posterior tibial bypass. Musculo-tendinous division was associated with vascular reconstruction in 19 limbs (90%). Mean follow up was 82 months (median 81 months, range 60-120). Five year patency was 84%. CONCLUSION Long-term outcomes of surgical procedures performed for popliteal artery entrapment syndrome can be considered satisfactory.

Poor long-term stability of the Corvita abdominal stentgraft.

INTRODUCTION The endovascular treatment of abdominal aortic aneurysms was introduced in the early 1990s, with different generations of devices using various options for either the stent skeleton or the membrane. REPORT Corvita generated one of these devices using braided stainless steel and a porous spun polycarbonate urethane membrane. DISCUSSION In this report, we describe a case involving Corvita stentgraft explantation for complete aneurysm reperfusion after 13 years, demonstrating major degradation of the polyurethane membrane.

Midterm failure after endovascular treatment of a persistent sciatic artery aneurysm.

Persistent sciatic artery (PSA) is a rare arterial embryologic malformation that tends to present early atherosclerotic degeneration such as aneurysmal formation. Open surgical treatment of PSA aneurysms has been considered as the gold standard but endovascular techniques have been recently proposed in the literature. We report the case of a 65-year-old man, diagnosed with a PSA aneurysm on peripheral thromboembolic complications. We achieved an endovascular repair with a covered stent. Despite an uneventful postoperative course, the covered stent demonstrated fracture and thrombosis 6 months after implantation without any symptoms.

Current aortic endografts for the treatment of abdominal aortic aneurysms

ABSTRACT Endovascular Aneurysm Repair is a widely adopted method of treatment for patients with abdominal aortic aneurysms. The minimally invasive approach offered with EVAR has become popular not only among physicians and patients, but in the medical device industry as well. Over the past 25 years the global market for aortic endografts has increased rapidly, resulting in a wide range of devices from various companies. Currently, there are seven endografts approved by the FDA for the treatment of abdominal aortic aneurysms. These devices offer a wide range of designs intended to increase inclusion criteria while decreasing technical complications such as endoleak and migration. Despite advances in device design, secondary interventions and follow-up requirements remain a significant issue. New devices are currently being studied in the U.S. and abroad and may significantly reduce complications and secondary interventions.

Gender Related Long-Term Differences After Open Infrainguinal Surgery for Critical Limb Ischemia

OBJECTIVE The role of gender on long-term infrainguinal open surgery outcomes still remains uncertain in critical limb ischemia patients. The aim of this study is to evaluate the gender-specific differences in patient characteristics and long-term clinical outcomes in terms of survival, primary patency and limb salvage among patients undergoing infrainguinal open surgery for CLI. MATERIAL AND METHODS All consecutive patients undergoing infrainguinal open surgery for critical limb ischemia between 2003 and 2012 were included. Survival, limb salvage and primary patency rates were assessed. Independent outcome determinants were identified by the Cox proportional hazard ratio using age and gender as adjustment factors. RESULTS 584 patients (269 women and 315 men, mean age 76 and 71 years respectively) underwent 658 infrainguinal open surgery (313 in women and 345 in men). Survival rate at 6 years was lower among women compared to men with 53.5% vs 70.9% (p < 0.001). The same applied to primary patency (35.9% vs 52.4%, p < 0.001) and limb salvage (54.3% vs 81.1%, p < 0.001) at 6 years. Female-gender was an independent factor predicting death (hazard ratio 1.50), thrombosis (hazard ratio 2.37) and limb loss (hazard ratio 7.05) in age and gender-adjusted analysis. CONCLUSION Gender-related disparity in critical limb ischemia open surgical revascularization outcomes still remains.

Pathology of graft and stent-graft infections: Lessons learned from examination of explant materials

Due to the aging population, the number of patients treated with aortic grafts or endografts continues to increase. Although infection after these procedures is uncommon, aortic graft infection is a life-threatening condition, and refinement of management guidelines based on implant pathophysiology is appropriate. In the early 1990s, our European collaborative retrieval program, European Group for Research on Prostheses Applied for Vascular Surgery (GEPROVAS) was commissioned to analyze the degenerative phenomenon occurring on explanted grafts or endografts. In this review, our observations from the examination of explanted aortic grafts and endografts found that both fabric and structural degradation is present and is greater in the setting of inflammation produced by infection.

Treatment of Aneurysmal Aberrant Right Subclavian Artery with Triple-Barrel Stent Graft

Aneurysmal evolution of an aberrant right subclavian artery (ARSA) is an operative indication. Endovascular treatment is a minimally invasive procedure, which offers good short-term and midterm results. We describe a case of a 9-cm diameter ARSA aneurysm in a symptomatic man, treated with the triple-barrel technique using a thoracic aortic stent graft combined with surgical and endovascular revascularization of the supra-aortic trunks. Postoperatively, the patient developed a type III endoleak which was covered. The triple-barrel technique has been a proposed treatment approach for complex aortic arch pathologies and remains a less invasive option when compared with open surgery.