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Guideline Summary: Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: No consensus exists on the optimal strategy for treatment of abdominal aortic aneurysm (AAA) associated with colorectal cancer (CRC). The purpose of this study was to evaluate the results of endovascular treatment of AAA with simultaneous resection of CRC., Methods: Twenty-two consecutive patients presenting with AAA associated with a CRC were treated by endovascular AAA exclusion and simultaneous CRC resection. Median diameter of the aneurysm was 6.5 cm (range, 4.8-8 cm). Two patients (9%) had grade I cancer, 5 patients (23%) grade II, 13 patients (59%) grade III, and 2 patients (9%) grade IV. The 2 surgical procedures were performed under the same general anesthesia. Aneurysm exclusion was achieved using an infrarenal aorto-bi-iliac endoprosthesis (13 patients) and using an aorto-bi-iliac endoprosthesis with suprarenal fixation (9 patients), with 1 patient receiving bilateral renal chimney stent implantation. In all cases, vascularization of the hypogastric arteries was preserved. After AAA exclusion, colic resection was carried out by laparotomy with right colectomy (7 patients) and anterior rectocolic resection (15 patients). In all patients, AAA exclusion was controlled by a computed tomographic angioscan (CTA) at 1 month and duplex ultrasound every 6 months, and at some later stage, it was through inclusion of CTA as part of oncology surveillance. The mean duration of follow-up was 42 months (10-120 months). The primary endpoint was composite and regrouped any death occurring during the first 30 days after procedures, any type I endoleak, any aortic reintervention, and any AAA-related mortality., Results: No patient died during the first 30 postoperative days, and no patient was lost to follow-up. No aortic endoprosthesis infection and no type I endoleak were observed. Five endoleaks arising from the lumbar arteries (n = 4) or from the inferior mesenteric artery (n = 1) were identified. As they were not associated with an increase of the AAA diameter >5 mm, they were not treated. 1 colic anastomotic leak and 2 incisional abscesses were successfully cured by local care only. Nine patients (41%) died of cancer evolution during the follow-up period., Conclusions: In this series, treatment of AAA and CRC during the same operative session yields results comparable to those observed when surgery is performed in 2 distinct operative sessions. Synchronous treatment reduced waiting time of colic resection. It may also shorten total hospitalization duration, although this last hypothesis is not supported by comparison with a control group., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments., Methods: Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft., Results: The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m 2 (range, 23-26.4 kg/m 2 ). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs., Conclusions: Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.

Objectives: The aim of this study was to measure the morphological remodelling of the ascending aorta, aortic arch and thoracic aorta after aortic arch hybrid treatment including debranching and stent graft implantation., Methods: Preoperative, 1-month and 1-year follow-up of computed tomography angiography scans of 22 patients were analysed to compute the lumen centreline from the aortic root to the coeliac trunk, and the following measurements were derived: the total centreline length, distance from the aortic root to the left subclavian artery, distance from the left subclavian artery to the distal landing zone. For both pre- and postoperative centrelines, the pointwise curvature was measured at the proximal and the distal landing zones. The mean curvature values of the whole aortic segment and the endografting region of the ascending and the descending aorta were measured. Surface outerline was computed as well, and curvature values at the endograft landing points were extracted., Results: At the 1-month follow-up, centreline length were already significantly increased (382.66 ± 48.69 to 388.1 ± 50.75 mm; P = 0.01). Centreline pointwise curvature increased in the proximal (+29%, P = 0.011) and the distal zones (+63%, P = 0.004). Similarly, pointwise curvature of the outerline significantly increased in the proximal (+77%, P = 0.01) and the distal landing zones (+100%, P = 0.04). The centreline mean curvature increased in the ascending aorta (+7%, P = 0.02) and decreased in the endografting region (-3.3%, P = 0.004). No evidence of a relationship of such a remodelling with the type of endograft and the type of pathology was observed. This remodelling trend was confirmed by the analysis of 1-year computed tomography angiographies., Conclusions: Hybrid arch repair was associated with a significant elongation of the vessel and a significant increase in the curvature on the ascending aorta and the descending aorta and on the endograft proximal and the distal landing zones., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The objective of this study was to collect and critically analyze the current evidence on the modalities and results of treatment of descending thoracic aortic surgical graft (SG) and endograft (EG) infection, which represents a rare but dramatic complication after both surgical and endovascular aortic repair., Methods: A comprehensive electronic health database search (PubMed/MEDLINE, Scopus, Google Scholar, and the Cochrane Library) identified all articles that were published up to October 2017 reporting on thoracic aortic SG or EG infection. Observational studies, multicenter reports, single-center series and case reports, case-control studies, and guidelines were considered eligible if reporting specific results of treatment of descending thoracic aortic SG or EG infection. Comparisons of patients presenting with SG or EG infection and between invasive and conservative treatment were performed. Odds ratio (OR) meta-analyses were run when comparative data were available., Results: Forty-three studies reporting on 233 patients with infected SG (49) or EG (184) were included. Four were multicenter studies including 107 patients, all with EG infection, associated with a fistula in 91% of cases, with a reported overall survival at 2 years of 16% to 39%. The remaining 39 single-center studies included 49 patients with SG infection and 77 with EG infection. Association with aortoesophageal fistula was significantly more common with EG (60% vs 31%; P = .01). In addition, time interval from index procedure to infection was significantly shorter with EG (17 ± 21 months vs 32 ± 61 months; P = .03). Meta-analysis showed a trend of increased 1-year mortality in patients with SG infection compared with EG infection (pooled OR, 3.6; 95% confidence interval, 0.9-14.7; P = .073). Surgical management with infected graft explantation was associated with a trend toward lower 1-year mortality compared with graft preservation (pooled OR, 0.3; 95% confidence interval, 0.1-1.0; P = .056)., Conclusions: Thoracic aortic EG infection is likely to occur more frequently in association with aortoesophageal fistulas and in a shorter time compared with SG infection. Survival is poor in both groups, especially in patients with SG infection. Surgical treatment with graft explantation seems to be the preferable choice in fit patients., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Injury to the popliteal vessels during total knee replacement is rare but can lead to catastrophic outcomes., Report: An 81 year old female presented with Rutherford IIb acute left limb ischaemia (ALI) 13 years after total knee replacement. The polyethylene insert in the knee implant had dislocated from the other components and had moved into the popliteal fossa, leading to popliteal artery compression. She underwent emergency multidisciplinary surgery including removal of the polyethylene component, thrombectomy, and popliteal artery stenting, but major amputation was required. The popliteal artery and the stent were removed and submitted to histological analysis. The stent was well expanded but focal malapposition was observed., Conclusion: Regular follow up is mandatory in order to anticipate malfunction of the prosthesis and avoid long term complications.

Objective: Type B acute aortic syndrome (AAS) encompasses aortic dissection (AD) and intramural haematoma (IMH), the diagnosis, evolution, and treatment of which are subject to controversies. The aim of this pilot investigation was to assess the ability of specific magnetic resonance imaging (MRI) criteria to differentiate AD from IMH and predict optimal aortic remodeling following AAS., Methods: In this retrospective study, all patients presenting between 2008 and 2015 with type B AAS, who had diagnostic MRI following admission, were included. Three MRI criteria were proposed to identify IMH: (i) no visualised entry tear; (ii) no contrast uptake in the aortic lesion on the first pass angiographic run; (iii) no contrast uptake in the aortic lesion on the equilibrium phase T1 sequence. On each patient's diagnostic and follow up imaging studies, the volume of (i) false lumen/IMH, (ii) total aorta, and (iii) true lumen were calculated. Using the Wilcoxon signed rank test, the evolution of these volumes according to the presence or absence of the aforementioned criteria were compared., Results: Of 39 patients, in seven all MRI criteria were positive (group IMH) and 32 had one or more negative criteria (group AD). Patients with IMH and AD were similar with respect to sex, age, and delay between onset of symptoms and diagnostic and follow up imaging studies. Eighteen patients had a follow up imaging study after a mean period of 11.2 months: six in the IMH group and 12 in the AD group. Lesion volume decrease and relative true lumen volume increase were statistically significant in group IMH (p = .046 and p = .046, respectively), whereas there was a statistically significant increase of lesion volume (p = .008) in the AD group., Conclusion: This pilot study proposed three simple MRI criteria to differentiate between AD and IMH. Once prospectively and clinically validated, this could have substantial therapeutic benefits as IMH are likely to heal spontaneously., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: We report midterm outcomes with the GORE Iliac Branch Endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, Ariz) in the U.S. investigational device exemption (IDE) trial and comparatively assess outcomes in the IDE trial with outcomes in a real-world population of patients treated in the Gore Global Registry for Endovascular Aortic Treatment (GREAT)., Methods: From 2013 to 2016, the IDE trial enrolled 99 patients treated with the IBE for common iliac artery (CIA) aneurysms or aortoiliac aneurysms. Bilateral IBE treatment was allowed only in the continued access phase. From 2013 to 2016, there were 92 patients treated with the IBE in the GREAT registry. Baseline characteristics, procedural variables, and reinterventions through 6 months were compared in the IDE trial and GREAT registry. Clinical and core laboratory-assessed imaging outcomes were assessed in the IDE trial through 2 years., Results: GREAT patients were significantly older (P = .01) and of shorter height (P < .001) and lower weight (P < .001). There were also significantly more women treated in GREAT vs the IDE trial (8% vs 1%; P = .02). Thirteen GREAT patients (14%) and 4 of 35 continued access IDE patients (11%) had bilateral IBE placement (P = .70). IDE patients were more likely to be treated with percutaneous access methods (55% vs 40%; P = .04). Three IDE patients and three GREAT patients underwent 1-month reintervention, with two IDE reinterventions (2.1%) and one GREAT reintervention (1.6%) for thrombotic events. Five additional patients in each study underwent reintervention through 6 months (5% vs 5%; P = .92), all for nonthrombotic events. Internal iliac limb patency was 93.6% (95% confidence interval, 86.4%-97.1%) at 12 and 24 months in the IDE study. Subset analyses of the 10 IDE and GREAT patients with ≤6-month reintervention vs 181 intervention-free patients found that acute myocardial infarction (P = .01), nonpercutaneous access (P = .01), and surgical conduit use (P < .001) were associated with reintervention through 6 months. In the IDE trial, 3.4% and 4.1% of patients underwent reintervention at 12 months and 24 months, respectively, all for treatment of type II endoleaks. At 24 months, 8.7% of IDE patients exhibited abdominal aortic aneurysm sac expansion; 21.7% exhibited abdominal aortic aneurysm sac regression. No patients exhibited CIA aneurysm sac expansion; 45% exhibited CIA aneurysm sac regression., Conclusions: Midterm IDE outcomes and 6-month outcomes in the worldwide GREAT registry suggest that endovascular aortic aneurysm repair with concomitant CIA aneurysm repair with the IBE device is safe and effective. Thrombotic events are uncommon and are concentrated in the first month after the index procedure, and they typically can be resolved with endovascular reintervention., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this paper was to provide recommendations for diagnosis and management in the setting of infection following open or endovascular reconstructions of the supra-aortic trunks., Methods: A review of the Medline database was performed from 1997 to 2017 by a combined strategy of MeSh terms., Results: The literature search identified 49 publications: 36 studies addressing prosthetic material infections and 13 studies addressing stent infections. A total of 140 cases of prosthetic material infections were reported, mostly involving carotid patches. Surgical treatment was mostly based on complete removal of the infected material followed by in situ arterial reconstruction (86 cases, 62.3%). Peri-operative complications included cranial nerve injury in 17 cases (12.5%), stroke in eight (6.7%), bleeding in four (2.9%), re-infection in five (3.6%), and cardiac failure in three cases (2.2%). Stent infections were reported in 12 patients: eight carotid stents, three subclavian stents and one tandem brachiocephalic subclavian stent. Treatment was not described for one case, was conservative in one case, consisted of stent removal with venous reconstruction in six cases, stent removal without reconstruction because of carotid thrombosis in two cases, and carotid embolisation in two cases. Complications included intra-operative death in one case (9.1%), stroke in two (18.2%), reinfection in one (9.1%), bleeding in one (9.1%), and cardiac failure in one case (9.1%)., Conclusion: Appropriate pre-operative imaging is mandatory and treatment modality should be determined by patient condition. Complete removal of the infected material, followed by in situ arterial reconstruction with venous material seems advisable, despite high morbidity. However, alternative strategies may be considered for fragile and high risk patients. A multidisciplinary approach is mandatory to ensure optimum results., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective/background: Since the late 1950s, major advances in vascular surgical practice have been closely associated with the introduction of novel vascular implants. These devices have been constructed from a variety of materials and have been designed to be implanted in several different ways. Despite a rigorous regulatory process, regular failures continue to be observed. A systematic review of the literature and of the Geprovas registry was performed in order to improve understanding of the failures., Methods: A systematic review was performed via a search of the MEDLINE and Embase databases. Full text, English, German, or French language studies without any chronological limit were included. The reference lists of included studies, as well as the first 20 related items, were scanned for other potentially relevant studies., Results: Data extraction allowed the evaluation of 184 publications; 72 publications met the inclusion criteria. Only 12 publications reported sufficient data for structural, histopathological, and epidemiological analysis. However, explant analysis allowed the understanding of degenerative phenomena: "warp knitted" replaced "weft knitted" polyethylene terephthalate grafts, decreasing the risk of dilatation or rupture; inter-nodal distance was modified in order to improve polytetrafluoroethylene graft incorporation capacities; and index of saturation, endograft fabric/stent interactions, and stent fatigue phenomena have been extensively studied in an attempt to improve endovascular device durability., Conclusion: A general lack of depth of reporting of explants remains. Dedicated systematic explant analysis programs are the key to improving the performance of future generations of devices., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

We report the case of a 71-year-old man complaining of swollen left limb and progressively worsening pain. He underwent surgery 12 years ago for popliteal artery aneurysm with proximal and distal ligation and venous bypass grafting. The patient was diagnosed as having left peroneal neuropathy caused by a 10.5 cm expanded aneurysmal sac compressing the peroneal nerve in the popliteal fossa. The patient underwent open repair with opening of the aneurysmal sac, removal of the thrombus, and sewing of the left genicular artery responsible for back-bleeding. Postoperative range of motion exercises and physical therapy allowed resolving foot drop 1 year after surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Peripheral artery disease (PAD) is a common circulatory disorder of the lower limb arteries that reduces functional capacity and quality of life of patients. Despite relatively effective available treatments, PAD is a serious public health issue associated with significant morbidity and mortality. Ischemia-reperfusion (I/R) cycles during PAD are responsible for insufficient oxygen supply, mitochondriopathy, free radical production, and inflammation and lead to events that contribute to myocyte death and remote organ failure. However, the chronology of mitochondrial and cellular events during the ischemic period and at the moment of reperfusion in skeletal muscle fibers has been poorly reviewed. Thus, after a review of the basal myocyte state and normal mitochondrial biology, we discuss the physiopathology of ischemia and reperfusion at the mitochondrial and cellular levels. First we describe the chronology of the deleterious biochemical and mitochondrial mechanisms activated by I/R. Then we discuss skeletal muscle I/R injury in the muscle environment, mitochondrial dynamics, and inflammation. A better understanding of the chronology of the events underlying I/R will allow us to identify key factors in the development of this pathology and point to suitable new therapies. Emerging data on mitochondrial dynamics should help identify new molecular and therapeutic targets and develop protective strategies against PAD., (Copyright © 2016 the American Physiological Society.)

Background: Compliance is one of the mechanical features of a vascular prosthesis (VP) that influences its performances. The goal of the present in vitro study was to attempt characterizing textile VP compliance through mechanical tests proposed in the standards., Methods: Three different models of commercially available knitted VP (P1, P2, and P3) were studied using longitudinal and circumferential traction tests on coated and uncoated samples. Five samples of each model were considered for each test. The Young modulus was then calculated to indirectly predict the longitudinal and radial compliance of the VP. Moreover, actual compliance was measured on a specific device that regulates the intraluminal pressure of a fluid maintained in the tested VP at 37°C. VP dilatation under pressure load was measured with a digital camera system., Results: The Young modulus variations from one VP to the other were compared with the differences between effective compliance values at radial, longitudinal, and volume level. Although the presented results show differences among the VP, one can observe that the graft materials' Young modulus and the compliance properties are linked together in general., Conclusions: Although VPs are subjected to multidirectional stresses ex vivo, unidirectional standard mechanical tests, through the measurement of the materials Young modulus, can help predicting their compliance, however, in a limited frame., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Since the first implantation of an endograft in 1991, endovascular aneurysm repair (EVAR) rapidly gained recognition. Historical trials showed lower early mortality rates but these results were not maintained beyond 4 years. Despite newer-generation devices, higher rates of reintervention are associated with EVAR during follow-up. Therefore, the best therapeutic decision relies on many parameters that the physician has to take in consideration. Patient's preferences and characteristics are important, especially age and life expectancy besides health status. Aneurysmal anatomical conditions remain probably the most predictive factor that should be carefully evaluated to offer the best treatment. Unfavorable anatomy has been observed to be associated with more complications especially endoleak, leading to more re-interventions and higher risk of late mortality. Nevertheless, technological advances have made surgeons move forward beyond the set barriers. Thus, more endografts are implanted outside the instructions for use despite excellent results after open repair especially in low-risk patients. When debating about AAA repair, some other crucial points should be analysed. It has been shown that strict surveillance is mandatory after EVAR to offer durable results and prevent late rupture. Such program is associated with additional costs and with increased risk of radiation. Moreover, a risk of loss of renal function exists when repetitive imaging and secondary procedures are required. The aim of this article is to review the data associated with abdominal aortic aneurysm and its treatment in order to establish selection criteria to decide between open or endovascular repair.

Background: Compliance mismatch between native artery and a prosthetic graft used for infrainguinal bypass is said to be a factor for graft failure. The aim of this study was to develop a technique for measuring the compliance of collagen-coated polyethylene terephthalate (PET) vascular prostheses and to analyze the influence of several key properties on the elastic behavior of the grafts., Methods: Compliance testing was performed on 3 prostheses with and without internal compliant membrane (ICM). The principle of this test was to study the dimensional changes of prostheses submitted to internal pressure from 30 to 240 mm Hg at intervals of predetermined values., Results: We demonstrated that the ICM created links with the inner surface of the crimps and considerably modified the graft behavior when submitted to internal pressure. The results showed that compliance properties were dependent on the wall thickness and the crimping geometry of textile vascular prostheses. Mechanical analysis predicts the circumferential tensile behavior of these arterial grafts and validates tests for measuring compliance.

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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Irrespective of the organ involved, restoration of blood flow to ischemic tissue is vital, although reperfusion per se is deleterious. In the setting of vascular surgery, even subtle skeletal muscle ischemia contributes to remote organ injuries and perioperative and long-term morbidities. Reperfusion-induced injury is thought to participate in up to 40% of muscle damage. Recently, the pathophysiology of lower limb ischemia-reperfusion (IR) has been largely improved, acknowledging a key role for mitochondrial dysfunction mainly characterized by impaired mitochondrial oxidative capacity and premature mitochondrial permeability transition pore opening. Increased oxidative stress triggered by an imbalance between reactive oxygen species (ROS) production and clearance, and facilitated by enhanced inflammation, appears to be both followed and instigated by mitochondrial dysfunction. Mitochondria are both actors and target of IR and therapeutic strategies modulating degree of ROS production could enhance protective signals and allow for mitochondrial protection through a mitohormesis mechanism., (Copyright © 2014. Published by Elsevier Ltd.)

Computational studies of aortic hemodynamics require accurate and reproducible segmentation of the aortic tree from whole body, contrast enhanced CT images. Three methods were vetted for segmentation. A semi-automated approach that utilizes denoising, the extended maxima transform, and a minimal amount of manual segmentation was adopted.

It was previously showed that PLLA nanofiber mesh promoted good endothelial cell proliferation. A new technique was developed to produce nanofibers by air jet spinning inside the tubular shape of vascular prostheses and to characterize this nanofiber mesh. Polymer macromolecule stability was assessed by gel permeation chromatography. Thermal analyses were conducted with differential scanning calorimetry and dynamic mechanical analysis on PLLA nanofibers obtained with 4% and 7% solutions (w/v) in chloroform. Polyethylene terephthalate (PET) was also treated with atmospheric pressure dielectric barrier discharge under air or nitrogen atmosphere to optimize PLLA nanofiber adherence, assessed by peel tests. Air spinning induced a reduction of number-average molecular weight (M(n)) for the 7% PLLA solution but not for the 4% solution. The nanofibers were more crystalline and less sensible to viscoelastic relaxation as a function of aging in the 4% solution than in the 7% solution. Discharge treatment of the PET promoted identical surface modification on PET film and PET textile surfaces. Moreover, the best PLLA nanofibers adhesion results were obtained under nitrogen atmosphere. This study demonstrates that it is possible to coat the internal side of tubular vascular prostheses with PLLA nanofibers, and provides a better understanding of the air spinning process as well as optimizing nanofibers adhesion., ((c) 2010 Wiley Periodicals, Inc.)

Background: The aim of this study was to evaluate the quality of the current treatment of patients presenting with ruptured abdominal aortic aneurysms (RAAAs), from the first symptoms to the operating room with an analysis of preoperative mortality risk factors., Methods: For 3 years, in four vascular surgery departments, we have collected all the consecutive cases of patients operated on for RAAA. We analyzed the initial clinical situation, the means of transportation, the time elapsed before treatment, and the mortality rate at 3 days. Sixty-six RAAAs were operated on. Mean patient age was 76 years (range, 52-93 years)., Results: The initial symptoms were a precisely located pain either abdominal (45.3%), lumbar (17.2%), or both (14.1%) or feeling faint (10.9%). In 22.7% of the cases, an initial hemodynamic instability was observed. In 46.8% of the cases, patients first went to a peripheral hospital before being admitted into a referral centre. In 84.5% of the cases, medical mean of transportation was used. The mean distance covered was 59.8 kilometers (range, <5 km to 213 km). The initial diagnosis was accurate in 67.3% of the cases. The mean intrahospital waiting period between the arrival at a reference center and the admission into an operating room was 127 minutes. Global mortality rate was 44.2%. The main preoperative mortality factor to be noticed was the initial hemodynamic instability (p=0.0031). Among stable patients, only two of them (5.4%) worsened during the preoperative treatment., Conclusion: In our study, hemodynamic instability corresponds to the main prognosis factor of mortality. In most cases, the initial stability persisted and allowed additional evaluation. However, the intrahospital waiting periods appeared to be too long. To be optimal, the adequate treatment should be specifically designed as soon as a diagnosis has been established., (Copyright (c) 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

The absence of neoendothelium covering the intimal surface of small-diameter PET vascular prostheses is known to be one cause of failure following implantation in humans. Protein coatings currently used to seal porous textile structures have not shown evidence of in vivo neoendothelium formation. In this study, we covered the inner wall of textile prostheses with a biodegradable synthetic scaffold made of poly(l-lactic) acid (PLLA) nanofibres obtained by an air-spinning process we developed that produces nanofibres by stretching a solution of polymer with a high-speed compressed air jet. The air spinning was designed to process a scaffold that would support good endothelial cell proliferation. Our innovative process enabled us to very rapidly cover textile samples with PLLA nanofibres to determine the influence of air pressure, polymer solution flow rate and polymer concentration on fibre quality. High air pressure was shown to induce a significant number of ruptures. High polymer flow rate stimulated the formation of polymer droplets, and the fibre diameter mean increased for the 4% and 7% polymer concentrations. The adherence and proliferation of bovine aortic endothelial cells was assessed to compare prosthesis samples with or without the PLLA nanofibre scaffold and PET film. The PLLA nanofibres displayed a significantly better proliferation rate, and enabled endothelial cells to proliferate in the monolayer. Our novel approach therefore opens the door to the development of partially degradable textile prostheses with a blood/textile interface that supports endothelial cell proliferation.

Background: Renal transplantation is an excellent therapeutic alternative for end-stage renal diseases. Nevertheless, the cardiac function is often impaired in renal-transplant patients (RTR) and importantly determines their prognosis. Adrenomedullin (ADM), a peptide involved in cardiovascular homeostasis, is believed to protect both cardiac and renal functions - by increasing local blood flows, attenuating the progression of vascular damage and remodelling and by reducing glomerular injury - and might be involved in renal-transplantation physiopathology. This work was performed to investigate whether an increase in circulating ADM might be related to RTR cardiac function., Methods: Twenty-nine subjects, 19 RTR and 10 healthy subjects, participated in the study. After 15 min rest in supine position, heart rate and systemic blood pressure were measured together with cyclosporine through levels, creatinine and ADM. Systolic and diastolic cardiac functions were assessed, using Doppler echocardiography., Results: Subjects were similar concerning age, weight, heart rate and blood pressure. Creatinine and ADM (53.8 +/- 6.9 vs. 27.2 +/- 4.1 pmol/L, p = 0.02) were significantly increased in RTR (73 +/- 10 months after transplantation). Cardiac systolic function was normal, but a reduced mitral E:A ratio was observed in RTR (0.90 +/- 0.06 vs. 1.38 +/- 0.10, p < 0.001), reflecting their impaired left ventricular relaxation. Such a ratio was negatively correlated with ADM (r = -0.55, p = 0.002)., Conclusions: RTR present with an increased ADM is likely related to cardiac diastolic dysfunction. In view of its protective effect on the cardiovascular system, these data support further studies to better define the role and the therapeutic potential of ADM after renal transplantation.

The outcome of conventional elective open repair for infrarenal abdominal aortic aneurysm (AAA) has improved mainly as a result of screening to detect coronary artery disease, the main risk factor for morbidity and mortality. Our group's policy is to perform routine coronary angiography in patients scheduled to undergo elective AAA repair. The purpose of this study was to evaluate morbidity and mortality in our department using this work-up strategy. From January 1990 to December 2000 we performed elective open repair on 632 patients, including 580 men (92%) and 52 women (8%). Preoperative coronary angiography performed in 607 cases (96%) revealed significant coronary disease in 53% of patients and led to the decision to propose prior myocardial revascularization in 12.5% of cases. Mortality and morbidity in the first 30 days after AAA repair were 1.4% and 15%, respectively. Analysis with the Cox model showed that the only risk factor for mortality was chronic renal insufficiency. Our data support routine use of coronary angiography prior to AAA repair. Screening and, if necessary, treatment of coronary artery disease that is commonly associated with AAA enhances the outcome of open AAA repair.