Search

Objective/background: This study aimed to describe an arch morphology protocol in a healthy population, and to assess the impact of age and sex., Methods: A retrospective morphology evaluation was conducted in a population with no personal history of thoracic aorta surgery or pathology, through computed tomography (CT) imaging analysis, using a standardised protocol. Based on centreline three dimensional coordinates, a single investigator calculated a series of parameters in the arch zones and in the total arch, using Matlab scripts. These were categorized as: (i) morphometric data: diameter, length and aortic angle of each zone, total arch angle, and length; (ii) geometric data: tortuosity index (TI), arch width, assimilated curvature radius (CR i ), and attachment zone angles. Student or Mann-Whitney tests were used to compare parameter means. Their variability with age and sex was assessed through univariate and multivariate regression analysis., Results: CT images from 123 subjects (mean ± SD age 53 ± 19 years) were reviewed. Significant correlation between age and morphology was found. The aorta expanded homogeneously and stretched heterogeneously with age because of posterior arch elongation. TI decrease, CR i , and attachment zone angle increase were also observed with aging. Age remained significantly associated with these morphological parameters, independently of body surface area and hypertension. Sex also affected morphology: longer total arch length and higher CR arch in men; lower zone 3 attachment angle in women CONCLUSION: Using mathematical algorithms, and with a view to improving endovascular arch treatment, this study provides a standardised arch morphology protocol and objectively identifies both age related evolution and sex related variation in the different zones., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The present study aimed at quantifying mal-positioning during thoracic endovascular aortic repair and analysing the extent to which anatomical factors influence the exact stent graft positioning., Methods: A retrospective review was conducted of patients treated between 2007 and 2014 with a stent graft for whom proximal landing zones (LZ) could be precisely located by anatomical fixed landmarks, that is LZ 1, 2, or 3. The study included 66 patients (54 men; mean age 51 years, range 17-83 years) treated for traumatic aortic rupture (n = 27), type B aortic dissection (n = 21), thoracic aortic aneurysm (n = 8), penetrating aortic ulcer (n = 5), intramural hematoma (n = 1), and floating aortic thrombus (n = 4). Pharmacologic hemodynamic control was systematically obtained during stent graft deployment. Pre- and post-operative computed tomographic angiography was reviewed to quantify the distance between planned and achieved LZ and to analyze different anatomical factors: iliac diameter, calcification degree, aortic angulation at the proximal deployment zone, and tortuosity index (TI)., Results: Primary endoleak was noted in seven cases (10%): five type I (7%) and two type II (3%). Over a mean 35 month follow up (range 3-95 months), secondary endoleak was detected in two patients (3%), both type I, and stent graft migration was seen in three patients. Mal-positioning varied from 2 to 15 mm. A cutoff value of 11 mm was identified as an adverse event risk. Univariate analysis showed that TI and LZ were significantly associated with mal-positioning (p = .01, p = .04 respectively), and that aortic angulation tends to reach significance (p = .08). No influence of deployment mechanism (p = .50) or stent graft generation (p = .71) or access-related factors was observed. Multivariate analysis identified TI as the unique independent risk factor of mal-positioning (OR 241, 95% CI 1-6,149, p = .05). A TI >1.68 was optimal for inaccurate deployment prediction., Conclusion: TI calculation can be useful to anticipate difficulties during stent graft deployment and to reduce mal-positioning., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

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., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to assess the effects of operative indication, anatomy, and stent graft on type I endoleak occurrence after thoracic endovascular aortic repair., Methods: A retrospective review was conducted of patients admitted for thoracic endovascular aortic repair between 2007 and 2013. All computed tomography angiography imaging was analyzed for the presence of endoleak and measurement of diameters and lengths. Variables studied included underlying disease, emergency, achieved aortic neck length, difference between proximal and distal neck diameters, landing zone 2, and stent graft characteristics (diameter, number, type of device, oversizing degree, and covered aorta length)., Results: The study population involved 84 patients (mean age, 56 years; range, 17-94 years) who were treated for thoracic aortic aneurysm (TAA) (n = 29; 34.5%), traumatic aortic rupture (n = 27; 32%), type B aortic dissection (n = 19; 22.5%), intramural hematoma (n = 2; 2%), penetrating aortic ulcer (n = 5; 6%), and aortoesophageal fistula (n = 2; 2%). Of these, 60 patients (71.5%) were treated emergently and 24 (28.5%) electively. Primary type I endoleak was noted in eight patients (9.5%), of which two resolved spontaneously. After a mean follow-up of 32 months (range, 3-76 months), secondary type I endoleak was detected in four patients (4.5%). All of them occurred after emergent TAA treatment. Comparison between emergent and elective groups revealed no significant differences in neck length (19.5 mm vs 26.5 mm; P = .197), oversizing degree (11.1% vs 10.9%; P = .811), or endoleak rates (13.3% vs 8.3%; P = .518). Hemorrhagic shock was not predictive of endoleak (P = .483). Cox regression analysis of the different anatomic and stent graft-related factors revealed short proximal landing zone as the unique independent predictor of type I endoleak (hazard ratio, 0.89; 95% confidence interval, 0.81-0.99; P = .032)., Conclusions: Endoleak risk seems not to be increased by an emergency setting. However, the relatively high rate of late endoleak observed after emergent TAA repair advocates for close follow-up, contrary to traumatic aortic rupture. Furthermore, regardless of the pathologic process, a longer proximal landing zone is likely to guarantee early and late success., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

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., (Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Literature series that include visceral artery pseudoaneurysms rarely separate them from true aneurysms, although they address different issues. Guidelines for optimal management of these lesions are lacking. We report our experience of stent graft treatment of these lesions with midterm results., Methods: We retrospectively reviewed all patients with a visceral pseudoaneurysm who were treated with a stent graft in our institution. Patient history, clinical characteristics, procedure details, and outcome were recorded and analyzed., Results: From March 2004 to June 2009, 10 consecutive patients (9 men), who were a mean age of 59 years, were treated for symptomatic visceral artery pseudoaneurysm, with hemorrhagic shock in 8 patients (80%), after pancreaticoduodenectomy in 8, gastrectomy in 1, and abdominal trauma in 1. A mean of 24 days (range, 7-60 days) passed between the initial surgery or trauma and pseudoaneurysm diagnosis. Septic complications were associated in six patients (60%). The pseudoaneurysm was in the hepatic artery in 8 patients, the splenic artery in 1, and the superior mesenteric artery in 1. Technical and clinical success was achieved in 80% of patients. Two failures of catheterization were followed by redo surgery and death (20%). No patients died postoperatively, and no complications among the patients who were treated successfully. Mean follow-up was 37 months (range, 10-63 months). All stent grafts were patent, with no signs of infection. Two patients died secondary to neoplasm. No rebleeding or recurrent aneurysms were noted., Conclusion: Stent graft exclusion of visceral artery pseudoaneurysm seems to be a valid therapeutic approach regardless of the patient's septic or hemodynamic status., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To assess the potential benefit of the addition of a covered stent to a subintimal recanalized artery in patients with femoro-popliteal occlusions., Methods: From September 2003 to October 2005, we retrospectively analyzed all patients admitted for severe claudication or critical limb ischemia related to long femoro-popliteal occlusions and treated with subintimal recanalization. Patients were divided into two groups depending on whether they received a stent or not. All patients in the group treated with stent received a stent graft, and the entire length of the recanalized artery was covered in each case. Demographic data, indications, procedure, and outcomes were examined using survival analysis statistical techniques., Results: Fifty-three patients (54 limbs) were treated consecutively for severe claudication (n=19) or critical limb ischemia (n=34). Thirty-four (64%) had a stent placed, while 19 (35.8%) did not. The mean length of the lesions treated was 20.11 cm (range, 5-35 cm). Statistically, there was no significant difference in lesion length, Rutherford stage of peripheral-artery disease, Transatlantic Inter-Society Consensus classification, and distal run-off between the two groups. The technical success rate was 94.5%, and two out of the three failures were treated with surgical bypass in one case and major amputation in the other. The third patient received only medical treatment. Combined procedures were required in the treatment of 68.2% of limbs in the no-stent group and 55.8% in the stent group. Mean follow up was 16.9 months (range, 1-35 months). At 1 year, primary, primary-assisted, and secondary patency for the stent vs no-stent groups was, respectively, 61.8% vs 78.9% (P=.49), 70.6% vs 78.9% (P=.78), and 88.2% vs 78.9% (P=.22). The 1-year limb salvage rate for the stent vs no-stent group was 94.1% vs 100% (P=.7)., Conclusion: Combining subintimal angioplasty with a stent graft in femoro-popliteal lesions does not improve patency. The limb salvage rate remains high after addition of a stent graft. Rigorous monitoring is recommended to diagnose and treat restenosis early in order to improve patency., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Reimplantation of the left renal vein into the infrarenal inferior vena cava is the standard surgical procedure for nutcracker syndrome. A 40-year-old woman with a solitary left kidney suffered from left lumbar pain and hematuria. Imaging techniques found a large kidney with nutcracker syndrome. A totally laparoscopic transposition of the left renal vein was performed. Twelve months later, the patient is improved and has no more hematuria. Duplex scan showed no residual stenosis. Laparoscopic transposition of the left renal vein into the inferior vena cava is feasible with short length of stay and good short-term result.

Objectives: A feasibility study., Methods: Eight pigs (all females; mean weight: 29 kg) underwent a conventional transperitoneal aortic approach with implantation of an aorto-prosthetic end-to-side anastomosis using a Clampless device and deployment of a 5-mm polytetrafluoroethylene (PTFE) graft. After proximal ligature, a conventional end-to-end anastomosis was then performed between the graft and the left iliac artery., Results: The first pig died during the procedure due to graft misplacement. The seven other procedures were successful with a mean operative and anastomosis time of 101 min (range: 81-115 min) and 3.35 min (range: 2.25-4.25 min), respectively; mean blood loss was 152 ml (range: 30-235 ml). Another pig with a patent graft died at day 4 as a result of a severe unrelated pneumonopathy. The angiogram performed during the procedure and before sacrifice, at 2 (n=2), 4 (n=2) and 6 weeks (n=2), showed no graft stenosis or thrombosis. Microscopic examination revealed a tissue covering the intraluminal stent, which evolved over time, with no visible endothelial proliferation or inflammation., Conclusion: An aorto-prosthetic anastomosis can be performed safely and efficiently with our new clampless and sutureless device. The next step will be a laparoscopic Clampless implantation.

Background: Ilio-caval stenting now represents the first line treatment for disabling obstructive ilio-caval lesions. Most patients are young women of child-bearing age. We herein report our experience of pregnancy in women who have a history of ilio-caval stenting., Materials and Methods: From November 1995 to April 2008, 119 patients had ilio-caval stenting for obstructive venous disease in our department. Of these, 62 women were able to become pregnant. When pregnancy occurred, they received preventive treatment with low molecular weight heparin (LMWH) from the 3rd month of pregnancy to 1 month after delivery and had to wear elastic stockings. Patients also had to sleep on their right side if possible. They were followed during the pregnancy by duplex scanning at 3, 6, and 8 months, and then 1 month after delivery., Results: Eight pregnancies occurred in 6 patients (mean age 26.5 years) who had a patent self-expanding stent (1 patient had 3 pregnancies). They had stenting for May-Thurner disease in 3 patients, for post-deep venous thrombosis (DVT) left common iliac vein occlusion in 1 patient, and during venous thrombectomy in 2 patients. All stents were self-expanding metallic stents located on the left common iliac vein. One patient had unrelated spontaneous abortion after 2 months of pregnancy. No DVT or symptomatic pulmonary embolism occurred during pregnancy, delivery, or during the postpartum period. Four patients needed cesarean delivery and none had hemorrhagic complications. None of the patients had adverse effects from the treatment. Duplex scan showed compression of the stent(s) at 8 months in 4 patients with inflow obstruction in 3 patients. Postpartum duplex-scan showed no remaining stenosis in all patients. No stents had structural damage., Conclusion: Ilio-caval stent compression can occur during pregnancy but does not lead to structural damage to the self-expanding stents. Despite this, no cases of DVT occurred with preventive LMWH treatment.

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.

Objectives: The aim of this study was to assess the feasibility and efficacy of a new laparoscopic vascular suturing device., Methods: Animal study: six pigs underwent surgery using a retroperitoneal laparoscopic approach. Aorto-prosthetic side-to-end and end-to-end anastomoses were performed laparoscopically on each pig using SuDyn. Clamping and anastomosis times, as well as the properties of the anastomoses, were recorded. Study on cadavers: four aorto-prosthetic end-to-end anastomoses were performed using the direct transperitoneal laparoscopic approach to assess the feasibility of the SuDyn device on atherosclerotic aortas., Results: Animal study: No pigs died and 12 patent and impermeable anastomoses were obtained. Mean anastomosis time was 38(+/-8)min for end-to-side anastomoses and 37(+/-5)min for end-to-end anastomoses. Study on cadavers: Totally laparoscopic anastomoses were performed in 4 human cadavers with a mean anastomosis time of 37(+/-3)min., Conclusions: SuDyn makes laparoscopic aorto-prosthetic anastomoses easier to perform, produces good results and does not require a learning curve.

Purpose: To evaluate superficial femoral artery (SFA) occlusive disease treatment by means of covered stents., Study Design: retrospective., Method: From 2000 to 2005, a Hemobahn/Viabahn endoprosthesis was implanted in 102 limbs (95 patients; mean age: 72.1 years, 52-94) for intermittent claudication (group I, n=50 limbs), critical (group II, n=32) or acute ischemia (group III, n=20). Lesions treated were Trans-Atlantic Inter-Society Consensus (TASC) A (n=9) B (n=42), C (n=28) or D (n=23), associated with a good (2 or 3 leg arteries, n=60) or a poor (1 or 0 artery, n=42) runoff., Results: The endograft was placed successfully in all cases, but 3 early deaths (3.2%) (1 in group II and 2 in group III), and 4 acute thromboses (4%) occurred. Primary and secondary actuarial patency rates were 97+/-1.7%, and 99+/-1% at 1 month, 74+/-4.8% & 84+/-4.1% at 1 year,and 71+/-9.5% & 79+/-8.5% at 3 years, after a mean follow-up of 30.2 months (1-60). Long-term primary and secondary patencies were significantly different between TASC Cand TASC D lesions (P<.004 & .001)., Conclusion: Severity of lesions, rather than preoperative symptoms or runoff, is mainly to be considered before using Hemobahn/Viabahn endoprosthesis in severe SFA occlusive lesions.

Purpose: Iliac vein occlusive disease leads to 73% of rethrombosis that occurs after venous thrombectomy when left untreated. The goal of this study is to present our long-term results of stenting of iliocaval occlusive lesions persisting after surgical venous thrombectomy., Methods: From November 1995 to April 2007, 29 patients (19 women), with a median age of 38 years, had surgical venous thrombectomy with creation of an arteriovenous fistula and angioplasty and stenting. All were admitted for acute (<10 days) deep venous thrombosis (DVT) involving the iliocaval segment, of which eight had concomitant acute pulmonary embolism. Six patients had a history of DVT (2 with previous venous thrombectomy), two were pregnant, and three had postpartum DVT. No patients had short- or mid-term life-threatening factors. The underlying lesion was left iliocaval compression (May-Thurner syndrome) in 22 patients, chronic left common iliac vein occlusion in 3, residual clot in 3, and compression of the left external iliac vein by the left internal iliac artery in 1., Results: Neither perioperative death nor pulmonary embolism occurred. Four early complications occurred after stenting (13.8%). Median hospital length of stay was 8 days (range, 5-22 days). Median follow-up was 63 months (range, 2-137 months). Three late complications occurred (10.3 %): one rethrombosis due to stent crushing during pregnancy and two restenosis, which were treated by iterative stenting. At the end of the follow-up, the median venous clinical severity score was 3 (range 1-12) and the venous disability score was 1 (range 0-2). Primary, assisted primary and secondary patency rates were, respectively, 79%, 86%, and 86% at 12, 60, and 120 months. Patients with patent iliocaval segments had significantly fewer infrainguinal obstructive lesions (4% vs 50%) and a higher rate of valvular competence (76% vs 0%) than those who experienced rethrombosis. Venous scores were also worse in patients with rethrombosis., Conclusion: Stenting is a safe, efficient, and durable technique to treat occlusive iliocaval disease after venous thrombectomy. Its use can prevent most of the rethrombosis that occurs after venous thrombectomy without major adverse effects.

We report a case of ruptured abdominal aortic aneurysm emergently treated by endovascular aneurysm repair (EVAR) that developed a primary type II endoleak leading to persistent blood loss and retroperitoneal hematoma increase. Coil embolization resolved this. Although to our knowledge there are no recommendations regarding this, our report suggests that early type II endoleaks occurring after emergency EVAR for ruptured AAA should be treated when it is associated with blood extravasation outside the aneurysm sac.

Background: The goal of this article is to present clinical and patency results of endovascular treatment of nonmalignant, iliocaval venous obstructive disease and to discuss the evolution of technical details., Methods: From November 1995 to June 2004, 44 patients (female-male ratio, 3.9:1; left-right lower limb ratio, 8.6:1; median age, 42 years; range, 21-80 years) had treatment for chronic disabling obstructive venous insufficiency with iliocaval stenosis or occlusion. The clinical class of CEAP was 2 in 11 limbs, 3 in 31, 4 in 4, 5 in 1, and 6 in 1; etiology was primary in 32 patients, secondary in 10, and congenital in 2. Anatomic involvement included superficial veins in 16 patients and perforator veins in 11. Obstruction was associated with superficial reflux in 4 patients, deep reflux in 13, and both in 13. Ten patients had occlusion. All procedures were performed in the operating room with perioperative angiography and angioplasty with or without self-expanding stent implantation. Venous clinical severity and disability scores were obtained before and after treatment. Patency and restenosis were evaluated by duplex Doppler ultrasonography., Results: No perioperative death or pulmonary embolism occurred. The technical success rate was 95.5% (two recanalization failures), and two (4.5%) perioperative stent migrations occurred. One early thrombosis (2.4%) was treated by thrombectomy and creation of an arteriovenous fistula. One late death and one thrombosis occurred. Restenoses were found in five patients and were all treated successfully (four needed iterative stenting). Median follow-up was 27 months (range, 2-103 months). Median venous clinical severity score improved from 8.5 to 2, and median venous disability score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 36 months were 73%, 88%, and 90%, respectively, in intention to treat. The survival rate was 100% at 12 months and 97.3% at 60 months., Conclusions: Endovascular treatment of benign iliocaval occlusive disease is a safe and efficient minimally invasive technique with good mid-term patency rates. Moreover, it improves cases with obstruction only, as well as cases with associated reflux and obstruction. Primary stenting should always be performed by using self-expanding stents deployed under general anesthesia to avoid lumbar pain. In case of failure, the endovascular procedure does not preclude further surgical reconstruction.

Purpose: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease., Method: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001)., Results: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II., Conclusion: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.

Background: Compression of the left renal vein between the aorta and the superior mesenteric artery is a rare but possibly underestimated condition. Surgical correction (42 cases reported in the literature) can be performed by means of a variety of different techniques. Although endovascular stenting is well accepted for iliocaval occlusive disease, it has been poorly evaluated in this indication. We describe five patients who were treated for nutcracker syndrome by using stenting and analyze the nine cases previously reported., Methods: From November 2002 to September 2004, five women (mean age, 34.7 years) were admitted for endovascular treatment of a nutcracker syndrome. They all had incapacitating pelvic congestion syndrome, including two with a history of left ovarian vein embolization; moreover, two had left lumbar pain, and three had hematuria. The mean preoperative venous disability score was 2.4. The patients underwent a gynecologic examination and laparoscopy to eliminate other causes of pelvic pain. The laparoscopy revealed large pelvic varicose veins and no signs of endometriosis. Duplex scan, computed tomographic scan, and iliocavography revealed left renal vein compression, with proximal distention and collateral pathways, with dilatation and permanent reflux in the left ovarian vein in the three patients who had not had prior embolization. The mean renocaval pullback gradient was 4.3 mm Hg. A percutaneous endovascular procedure, during in which a self-expanding metallic stent was implanted, was performed under general anaesthesia., Results: Technical success was achieved in all cases. One case of stent migration occurred: the stent was pulled down in the inferior vena cava, with uneventful follow-up (mean, 14.3 months). One month later, patients were all improved and stents were patent at the duplex scan examination, without restenosis. The mean venous disability score was 1. No further left ovarian vein reflux was evident at duplex scan in patients who did not have prior embolization. Pelvic pain recurred in one patient who had initially improved, and endometriosis was diagnosed 15 months after the procedure. Two other patients, who received 40-mm-long stents, had a secondary recurrence of the symptoms caused by stent dislodgement. The two other patients were asymptomatic., Conclusions: This study shows that stenting is feasible, but some guidelines should be followed, mainly the use of long stents protruding into the inferior vena cava. Stenting can eliminate the symptoms of the condition, and the technique is only very slightly invasive. Further experience and follow-up are needed before accepting such a procedure for treatment of the nutcracker syndrome.

Objective: Review of a 10 year-experience, to evaluate the efficacy of pre-operative investigations in the detection of external iliac artery (EIA) endofibrosis in top endurance athletes., Design: Retrospective study., Materials: From September 1995 to March 2004, 13 highly-trained athletes (all men, mean age 32.3 years) underwent surgery for disease involving 14 lower limbs (11 left, one right, one bilateral)., Methods: We compared ultrasound scan (US) and digital subtraction angiography (DSA) data, at rest and at hip flexion with intra-operative findings for all 14 lower limbs. We analyzed the presence of stenosis in the external and common iliac arteries, the presence of psoas muscle arteries and the presence of excessive EIA length., Results: In the affected limbs, before treatment, the mean ankle brachial index (ABI) at rest was 0.98 compared with 0.56 after exercise, p=0.0001. The sensitivities of the US vs DSA examination in the detection of external and common iliac artery stenosis were, respectively, 84.6 and 53.8% vs 53.8 and 12.5%. The muscle psoas artery was detected by DSA with a sensitivity of 57.1 and 100% specificity. For the detection of excessive EIA length, the sensitivity of US was 85.7% with 57.1% specificity., Conclusions: A fall of ABI after exercise proves the presence of a significant stenosis in symptomatic athletes. Color coded duplex ultrasonography is recommended for non-invasive imaging of suspected endofibrotic stenosis in young athletes, since it detects reliably both stenosis and elongation of iliacal arteries.

Objectives: To evaluate ligation of aortoiliac arteries with laparoscopic staplers in order to develop specifically designed staplers., Methods: Cadaveric study. Seven human cadaver aortas were stapled using EndoGIA60 staplers. Efficiency was evaluated macroscopically and on a hydrodynamic bench. Clinical study. Twelve patients had ligation of 14 large abdominal arteries (aorta: nine, iliac artery: four, hepatic artery: one) using a laparoscopic stapler. Stapling efficiency was judged on peroperative clinical and postoperative CT scan criteria., Results: Cadaveric study. Stapling was performed perfectly on four moderately calcified aortas, without leakage with a pulsatile pressure of >250 mmHg. For three aortas with severe calcification, stapling was not efficient and major leakage occurred. Clinical study. Stapling appeared clinically efficient on all arteries but one aorta: this severely calcified aorta was ligated conventionally. The staplers are not easy to use due to their shape and their lack of articulation. After a mean follow-up of 31.3 months, all the other stapled arteries were effectively ligated., Conclusion: The commercially available staplers can be used securely on moderately calcified arteries but stapling of severely calcified arteries should be avoided. These devices should be redesigned to facilitate their use in vascular surgery.

Objectives: The purpose of this study was to evaluate the consequences on patient selection and on early and midterm results of the learning curve of a surgical team performing laparoscopy-assisted surgery in the treatment of severe aortoiliac occlusive disease (AIOD)., Patients and Method: Between January 1998 and June 2003, 58 patients (53 men, 5 women; mean age, 59.5 years [range, 37-76 years]) were included in a prospective study and underwent a laparoscopy-assisted aortofemoral reconstruction with graft implantation through a 5-cm to 8-cm minilaparotomy. Fifty-one patients (88%) had claudication (category 2 or 3, Rutherford classification), and seven patients (12%) had tissue loss; at presentation they had TransAtlantic Inter-Society Consensus C (n=24, 41.4 %) or D (n=32, 55.2%) iliac lesions, and the last 2 patients (3.4%) had severe aortic lesions. Perioperative data for the first 29 patients, obtained during the first 34 months of the study (group 1), were compared with data for the last 29 patients, obtained during the last 32 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomography before discharge and then every 2 years., Results: One intraoperative surgical conversion (1.7%) was necessary, and two other patients (3.4%) died in the immediate postoperative period. With experience, initial contraindications such as obesity or suprarenal artery aortic clamping were eliminated, making it possible to increase the percentage of patients included, from 53.7% during the first 34 months to 90.6% during the last 32 months (P=.003). The mean duration of the operative procedure decreased from 285 minutes in group 1 to 192 minutes in group 2 (P<.001), and the mean duration of aortic clamping decreased from 76.4 minutes in group 1 to 31.8 minutes in group 2 (P<.001). The number of early repeat interventions was reduced from three (10.3%) in group 1 to 2 (6.9%) in group 2 (P=NS), and the clinical recovery period decreased from 7 days to 4.5 days (P=.05). During a mean follow-up of 26.7 months (range, 1-66 months) there were 5 repeat surgeries (9%) to treat late graft occlusion, establishing midterm primary and secondary patency rates of 89.3% and 91%, respectively. No aortic false aneurysms were detected, and no major amputations were performed., Conclusion: These preliminary results assess the feasability and the safety of this minimally invasive video-assisted technique. A short period of postoperative recovery and good midterm patency rate are the two main benefits of this new surgical option.

Long-standing arteriovenous fistula (AVF) can lead after closure to late arterial aneurysm formation. We report the case of an extensive iliofemoral aneurysm extending from the aorta to a left venous above-knee to below-knee popliteal bypass occurring 14 years after closure of a post-traumatic popliteal AVF. While the arterial axis, which was not dilated at closure, became aneurysmal, it is remarkable that the vein bypass performed at the same time was not altered. The pathophysiologic mechanism of such a complication could be morphologic modification of the arterial wall while the AVF is open and hemodynamic change after its closure.

Lesions of the internal carotid artery involving the bifurcation and the intrapetrous portion represent a challenging therapeutic situation. We herein report the first case of a patient suffering from tinnitus which was treated by simultaneous carotid endarterectomy of the bifurcation and transluminal angioplasty and stenting of the intrapetrous portion with a good mid-term angiographic result.

Objectives: This study was undertaken to evaluate the consequences on patient selection and on early and mid-term results during the learning curve of a surgical team performing laparoscopy-assisted surgery to treat abdominal aortic aneurysm (AAA)., Patients and Methods: Between December 1998 and January 2002, 24 patients (22 men, 2 women; mean age, 68.2 years [range, 57-82 years]) were included in a prospective study and underwent laparoscopic transperitoneal AAA dissection followed by graft implantation through a 6 to 9 cm minilaparotomy. Perioperative data for the first 10 patients, obtained during the first 25 months of the study (group 1), were compared with data for the last 14 patients, obtained during the last 13 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomographic scanning before discharge and yearly thereafter., Results: One patient (4.3%) died in the immediate postoperative period. In this patient and two others (12.5%), the minilaparotomy was extended intraoperatively, from 12 cm to 16 cm. With experience, initial contraindications such as obesity and short proximal or calcified aortic neck were eliminated, enabling increase in rate of patients included, from 27.7% during the first 25 first months to 56% during the last 13 months (P =.063). Mean duration of operative clamping decreased from 275 minutes in group 1 to 195 minutes in group 2 (P <.0001), and mean duration of aortic clamping decreased from 101 minutes in group 1 to 52 minutes in group 2 (P <.0001). The number of early repeat interventions was reduced from 3 (30%) in group 1 to 2 (14.3%) in group 2 (P =.61), and clinical recovery period decreased from 6.8 days to 4.3 days (P <.005). During mean follow-up of 17.1 months (range, 3-38 months), no late aortoiliac procedures were necessary and no prosthetic abnormality was detected., Conclusion: This minimally invasive video-assisted technique provides good postoperative comfort and excellent mid-term results. Developments in experience and instrumentation have enabled us to include a growing number of patients and to reduce the duration of the procedure.

We report two cases of iliocaval occlusion caused by retroperitoneal fibrosis; one presented acute symptoms and one chronic. Both were treated by use of transluminal angioplasty and stenting with excellent clinical, hemodynamic, and imaging results at 36 and 51 months. These cases confirm the benefit of endovascular techniques in the treatment of nonmalignant obstructive disease of large veins, and specifically in the case of retroperitoneal fibrosis.

Purpose: The purpose of this study was to determine the benefits and the indications of performing a minilaparotomy during laparoscopic abdominal aortoiliac reconstructions., Methods: This prospective study was approved by the Commission Consultative de Protection des Personnes dans la Recherche Biomédicale of the University of Marseilles, and all patients gave their informed consent. Between January 1998 and March 2000, 27 patients (23 men; 4 women) with a mean age of 58.2 years (range, 42-76 years) underwent aortoaortic (n = 3), aortounifemoral (n = 4), or aortobifemoral (n = 20) bypass graft for aortoiliac occlusive disease (n = 20), emboligenic aortitis (n = 1), or abdominal aortic aneurysm (AAA) (n = 6). At the beginning of the trial, the decision was made to perform an intraoperative conversion to open surgery in case of bleeding (group 0), when a totally laparoscopic procedure was possible (group I), or when a 6- to 8-cm supraumbilical minilaparotomy was needed in case of technical difficulty (group II). In each case of AAA, the remaining lumbar arteries were controlled (group III); and for the last six patients of this series (group IV), a minilaparotomy was systematically performed., Results: One patient was admitted with multiple organ failure and died on day 12 (3.7%) with a patent graft. One intraoperative conversion to open surgery (3.7%, group 0) was performed for bleeding; recovery was uneventful. Seven postoperative surgical procedures (26%) were necessary, including two cases of aortic bleeding because of hypertensive access. Seven procedures were totally laparoscopic (group I), and a minilaparotomy was performed in the other 19 cases, including seven cases of technical difficulty (group II). The mean operative and clamping times and the mean postoperative hospital stay were globally (P =.021) and individually (P < or =.016) significantly shorter in group IV when compared with those of the other three groups. Twenty patients (74%) had a postoperative hospital stay of 6 days or less (3-6 days), with minimal complaints of pain, tolerance of oral feeding on day 2, and mobilization on day 2 or 3. All bypass grafts remained patent after a mean follow-up of 11 months (1-26 months)., Conclusion: With regard to the instrumentation presently available, this study shows the benefit of a minilaparotomy when performing a laparoscopic aortoaortic or aortofemoral bypass graft for the treatment of aortoiliac occlusive disease and AAA.

Objective: to define the respective advantages and pitfalls of the trans- or retroperitoneal approaches in laparoscopic abdominal aortic reconstruction (LAOR)., Design: prospective study., Material: ten patients (8 males; average age 58) underwent an aortouni- (n=2) or bifemoral bypass (n=8) to treat aortoiliac occlusive disease (n=8) or an aortic aneurysm (n=2)., Methods: a retroperitoneal approach (the "apron" technique) was used in the first 5 cases (Group I) and a transperitoneal approach in the last 5 cases (Group II)., Results: no early or late death occurred, and all bypasses remain patent after a mean follow-up of 5.7 months. Mean surgical and clamping times are similar in both groups (370 and 126 min in Group I; 324 and 137 min in Group II). One intraoperative conversion to open surgery and two postoperative surgical complications occurred in Group I. Four minilaparotomies of 8-10 cm were necessary in Group II. Two patients were discharged on postoperative day 6 in Group I and five in Group II., Conclusion: this preliminary study shows the feasibility of LAOR through both approaches. In Group II, a better exposure of the right aortic wall and of the right iliac axis was noted and division of the inferior mesenteric artery was not always necessary., (Copyright 2000 Harcourt Publishers Ltd.)

Reduction in aneurysm size during the months after an endovascular graft placement generally is considered one of the criteria of success. We report the case of a patient with an abdominal aortic aneurysm rupture occurring 9 months after a bifurcated endovascular graft placement despite a greater than 45% reduction in size noted on contrast-enhanced computed tomography scan performed at 7 months. Biomaterial modifications of the stent and of the Dacron explanted stent-graft are analyzed.

Purpose: Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown., Methods: During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted., Results: No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively., Conclusion: Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts.

Purpose: The treatment of permanent and benign iliac vein occlusion responsible for acute vein thrombosis or chronic symptoms remains controversial. Different methods of reconstruction using a reinforced expanded polytetrafluoroethylene bypass graft associated with an arteriovenous fistula and their intermediate-term results are analyzed., Methods: Eight consecutive patients (six men, two women; mean age, 45.6 years; range, 29 to 70 years) were treated over a period of 38 months for iliac vein obstruction. Three short bypass procedures between the left iliac vein and the right common iliac vein with temporary arteriovenous fistulas were carried out after an iliofemoral (and caval in two cases) venous thrombectomy, which revealed May-Thurner syndrome (n = 1) and a compression of the left common iliac vein by the left hypogastric artery (n = 2). Five long bypass procedures (one femorofemoral, two left common femoral-vena caval, one right superficial femoral-common iliac, and one bifemorocaval) with a definitive arteriovenous fistula were performed for long chronic venous occlusion in four cases (responsible for venous claudication [n = 3], recurrent ulcers [n = 1] and after iatrogenic ligature of the left external iliac vein during total cystectomy with double ureterostomy in one case., Results: There was no evidence of pulmonary embolism, and no deaths were recorded in the perioperative period. Two patients had an early bypass thrombectomy, but one returned with a further graft occlusion. Seven grafts remained patent after a mean follow-up of 19.5 months (range, 10 to 45 months). One successful thrombectomy was necessary during the twenty-third postoperative month., Conclusions: Reconstruction of iliac veins in case of permanent compression, mostly discovered after venous thrombectomy, or for selected patients with symptomatic benign iliac vein occlusion, is safe and provides good intermediate-term results.

Purpose: Although anticoagulation therapy for iliofemoral venous thrombosis prevents pulmonary embolism, it is not designed to avoid the postthrombotic syndrome. Mechanical removal of the thrombus in the form of venous thrombectomy should yield better long-term results. The purpose of our study was to analyze the clinical outcome and venous valvular function of limbs 5 to 13 years after iliofemoral venous thrombectomy., Methods: Seventy-seven lower extremities underwent venous thrombectomy for acute iliofemoral venous thrombosis and were monitored for a mean follow-up of 8 1/2 years (range, 5 to 13 years). Patency of the iliofemoral venous system, competence of the femoral popliteal valves, and clinical signs and symptoms of chronic venous insufficiency were evaluated in each case., Results: Subsequent to early perioperative failure, patency remained stable over time at 84%. Valvular competence was preserved in 80% at 5 years; however, it decreased to 56% at 10 years. It is important that more than 90% of the limbs had no symptoms or mild symptoms of chronic venous insufficiency., Conclusions: Venous thrombectomy should be considered for primary treatment in selected cases of early iliofemoral venous thrombosis.

Purpose: Blunt injuries to the internal carotid artery (ICA) at the base of the skull are uncommon but potentially dangerous lesions whose management remains unclear. We report a new surgical approach of the intrapetrosal portion of the ICA that was used in six patients with the help of an ear, nose, and throat surgeon., Methods: During a 70-month period, seven consecutive patients (four women, three men; mean age, 35.7 years; range, 21 to 59 years) were admitted, six after a motor vehicle accident and one after a cervical manipulation. All patients had a neurologic deficit. An arteriographic scan revealed four unilateral ICA lesions: two false aneurysms, one tight stenosis, and one dissection; two cases of bilateral ICA dissection were mentioned, and one case of ICA dissection was associated with a contralateral ICA thrombosis., Results: One patient died before surgery, and six patients underwent a unilateral venous graft restoration, reaching the vertical portion of the intrapetrosal ICA in two patients and the horizontal portion in four. A shunt was used in one patient. Failure to recognize the end of the ICA lesion was responsible for one postoperative asymptomatic graft thrombosis (17%), but this difficulty was overcome by using intraoperative angioscopy in the other patients. No deaths and no new strokes were noted during postoperative and midterm follow-up (mean follow-up, 34 months). Five postoperative facial pareses occurred and were totally regressive within 3 to 6 months in four patients; one total deafness was recorded., Conclusion: Venous graft restoration of traumatic ICA lesions at the base of the skull can safely be performed with such an approach, thus producing highly satisfactory results. Before undergoing surgery, the patient must be aware of the risk of facial and auditive disorders, which are generally temporary.

Purpose: Little data are available concerning the relation between the muscular pumping mechanism and the variation of superficial and deep venous pressure during normal action of the calf pump; therefore we undertook this study to determine the pressure values in three compartments of the calf and in the deep and the superficial venous system and to establish correlation between muscular and venous pressure., Methods: Nine healthy young women with a mean age of 23 years (range 19 to 28 years) were examined. In the same calf, a muscular catheter was placed in the deep posterior compartment (DPC), in the superficial posterior compartment (SPC), and in the anterior tibial compartment (ATC), and a vascular catheter was placed in the popliteal vein and in the greater saphenous vein (GSV). The five lines of pressure were simultaneously recorded in the following situations: at rest, during Valsalva maneuver, foot flexion, and foot extension. The situation was studied with the patient in the following positions: decubitus, sitting, standing, and squatting. A final continuous recording was carried out after the patient had been walking for 5 minutes., Results: Mean values with standard errors of muscular and venous pressure were established in each situation. At rest and during Valsalva maneuver, the muscular pressures did not vary, whereas venous pressures increased significantly when the patient was sitting and standing. On the other hand, squatting was associated with a rise in the muscular and vein pressures. Foot flexion entailed a significant increase in the ATC pressure and a rise in the GSV pressure, whereas foot extension caused the DPC pressure to rise without venous pressure modifications. Walking was associated with an alternating increase in the DPC, SPC, GSV and popliteal vein pressures when the foot was compressed to floor followed by a significant decrease when the foot pressure was released., Conclusions: The variations in the deep and superficial venous pressures when the patient is sitting and standing both at rest and during Valsalva maneuver are not associated with an increase in the muscular pressure. On the contrary, during foot movements, the ATC and the DPC are responsible for superficial vein pressure variations without modifications of the SPC pressure.