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Recommandations actuelles Il existe un consensus entre francais et anglosaxons concernant la definition d’un anevrisme, son augmentation annuelle, les cas urgents et le traitement pour un diametre inferieur a 55 mm chez la femme. Si la rupture existe pour des diametres inferieurs a 50 mm, le risque selon le diametre varie beaucoup d’une serie a l’autre. 50 ou 55 mm ? Dans les etudes concernant les « petits » anevrismes, les diametres sont compris entre 40 et 59 mm. Le groupe entre 50 et 54 mm n’a pas ete etudie isolement. La marge d’incertitude pour la mesure du diametre d’un anevrisme peut atteindre 4 mm. En France, un anevrisme est traite des 50 mm de diametre car : – sans campagne de depistage et de suivi, l’anevrisme est souvent un diagnostic de rencontre ; – 90 % des anevrismes de 50 mm depasseront 55 mm dans les 3 ans et le patient aura vieilli d’autant. – qu’il s’agisse de chirurgie ouverte ou de traitement endovasculaire (EVAR), un anevrisme plus petit est plus facile a traiter ; – l’elargissement des indications EVAR a tout anevrisme eligible pour cette technique n’a ete autorise en France qu’en 2009. Avant cette periode, d’importants progres ont ete realises, concernant le depistage et le traitement preoperatoire des facteurs de risque coronaires, la preparation respiratoire, la protection renale et les techniques d’anesthesie ; – en France, la prise en charge des anevrismes de l’aorte est effectuee par des chirurgiens vasculaires exclusifs, entraines et beneficiant d’une formation de qualite. Ceci explique peut-etre les excellents resultats de l’etude prospective multicentrique francaise ACE (anevrisme de l’aorte abdominale : chirurgie versus endoprothese) notamment apres chirurgie ouverte, avec 0,6 % de mortalite operatoire. Conclusion Malgre l’absence d’argument indiscutable, il apparait legitime d’envisager en France une indication chirurgicale des 50 mm de diametre. La qualite de la formation des chirurgiens vasculaires, en particulier en chirurgie ouverte, doit permettre de maintenir ces bons resultats et d’offrir a nos patients un reel choix therapeutique.

Objectives. To investigate mechanisms of textile failure in explanted human aortic endoprostheses. Materials and methods. Endoprostheses ( n =31) underwent optical and scanning electron microscopy, filament dynamometry, and saturation index measurement. Results. The macroscopic lesions observed in the Stentor and Vanguard devices were holes at the extremities of the stents and slipping of the warp yarns at the level of sutures or of the longitudinal seams. The macroscopic lesions observed in AneurX endoprostheses were holes, slipping of the warp yarns and ruptures of the ligatures. The macroscopic lesions observed in the two Talent endoprostheses were sections of fibers at the level of the suture holes and few areas lesions of wear, with sometimes holes at the contact of the stent extremities. Stentor, Vanguard and AneurX all demonstrated low saturation indexes of the fabric (44–59%) with an important anisotropy. Whereas the Talent endograft demonstrated a high index of saturation (124–131%) with a low anisotropy. We did not demonstrate significant polymer degradation in any of the endoprostheses. Conclusions. It is essential to take into account the saturation index to optimally choose a woven textile for the construction of an endoprosthesis since this property of the textile may contribute to explain the macroscopic lesions observed. We did not observe significant polymer degradation by filament dynamometry but further studies are needed to confirm these data.

and five windows (four standard and one home-made), the left renal arteries by five chimneys (one open and our covered) and 13 windows (eight standard and five homemade). Two polar renal arteries profited from two open chimneys. Technical success was 100%. Death rate at one month was 5.9%. The postoperative morbidity rate was 6%. An early deterioration of the renal function was found in 15% of the cases. At 3 months, the primary patency of the target arteries was 100% and the rate of endoleaks was 16.5% including 5% of type 1. No death was related to the aneurysm during the follow-up. No secondary need for dialysis was observed. Conclusion: The association of a fenestrated stentgraft with one or more chimneys is an effective alternative in the short term in the endovascular treatment of complex aneurysms of the abdominal aorta which do not allow the easy deployment of a fenestrated stentgraft for technical reasons of making the stentgraft, anatomy and/or access. It also facilitates the deployment of this type of prosthesis and increases the number of patients treated.

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.

Aim: The purpose of the study was the characterization of a type of rupture occurring on warp-knitted polyester vascular prostheses. Materials and Methods: We studied 20 cases of warp-knitted polyester vascular prostheses that were explanted from humans that showed a longitudinal rupture as a part of a collaborative retrieval program. All the prostheses were immediately fixed in a 10% formaldehyde solution after their explantation in the operating room. The clinical data of these cases were recorded. The explants were photographed, washed to eliminate the surrounding tissues, and photographed again. The ruptures were characterized with macroscopic examination, optical stereomicroscopy, and scanning electron microscopy. Results: The mean duration of implantation of the prostheses was 16.0 ± 3.3 years (range, 9-20.7 years). The prostheses were Cooley Double Velour (n = 15) and Microvel Double Velour (n = 5). There were 16 aortobifemoral bypass grafts, 1 aorto-biiliac, 1 aorto-aortic, 1 iliofemoral, and 1 axillobifemoral. The longitudinal ruptures occurred on two specific parts of the prostheses: the guide line (6 cases) and the remeshing line (11 cases). In three cases both lines were affected. Scanning electron microscopy showed major degradation of the trilobar filaments of the velour and gradual ruptures of the flat filaments of the remeshing and guide lines. Conclusions: In this study, we have identified a specific mechanism of late (9-20 years) longitudinal rupture of knitted polyester prostheses consisting of degradation of the polyester filaments along the remeshing and guide lines that run the length of the graft. (J Vasc Surg 2001;33:1015-21.)

Im Rahmen der klinischen Nachuntersuchung von 273 in den Jahren 1981 bis 1985 operierten BAA-Patienten beobachteten wir eine Dilatation von Polyesterprothesen, im Mittel um 17,4% in 12 Tagen und 34,8% in 3 Jahren. Bei dieser fruh postoperativen Dilatation handelt es sich um eine Maschenstraffung, die im aortalen Bereich ohne klinische Bedeutung ist. Die spate Dilatation nach ca. lOjahriger Implantation ist Folge einer Materialdegeneration. Die Auswertung von 436 explantierten Gefasprothesen aus 75 Kliniken zeigte, das bei 42 von 255 (16%) explantierten Polyesterprothesen und 2 von 42 (5%) PTFE-Prothesen eine Prothesenruptur oder -aneurysmabildung (anatomosenfern) der Explantationsgrund war. Eine Haufung der Prothesenrupturen war in der Leistenbandregion nach 10 bis 20jahriger Implantationsdauer zu verzeichnen. Verglichen mit modernen endovaskularen Prothesen sind die herkommlichen Polyester und PTFE-Prothesen der Goldstandard in Puncto Materialbestandigkeit.

Background Cyclosporine induces daily renal hypoperfusion in subjects with normal atrial natriuretic peptide (ANP) levels, but its acute effects in heart transplant patients with increased ANP remain to be determined. Methods Cyclosporinemia and creatinine clearance were monitored during 7 hours following cyclosporine administration in 6 heart transplant patients. Results-conclusions No acute cyclosporine-induced decrease in creatinine clearance was observed after heart transplantation. These data suggest that maintenance cyclosporine dose may be less nephrotoxic than suspected and that increased ANP might protect the renal function late after heart transplantation.

Purpose: The purpose of this study was to assess the feasibility of insertion of endovascular stents and the precision of an open-field interventional magnetic resonance imaging (iMRI) system in an in vivo model. Methods: A feasibility study was undertaken at a university-affiliated hospital. Three male piglets with an average age of 6 months and a weight between 70 and 77 kg and two 3-month-old male piglets that weighed 40 to 44 kg were anesthetized. The five piglets underwent placement of nitinol stents inserted through the right femoral artery, under the guidance of a SIGNA-SP 0.5T open-configuration iMRI unit. With a dedicated high-resolution near–real-time MRI sequence, the stent was guided and deployed onto a predefined target. Results: The main outcome measures were the duration of the procedure from the beginning of positioning to the end of deployment of the stent, the final position of the stent in relation to the target on the iMRI screen, and comparison with autopsy findings. Three stents were deployed within the aorta at the level of the renal arteries, and two were deployed within the right iliac artery just below the aortic trifurcation. The average duration of the endovascular deployment was 13 minutes. There was an agreement of 0.6 mm in the position of the stent as observed on iMR images and found at autopsy. When the piglets were sacrificed, the average distance between the stents and the predefined target was 7.8 mm, mostly because of the migration of one stent. Axial views allowed for accurate determination of stent impaction on the vascular wall. Conclusions: This study confirms the feasibility of stent deployment under near–real-time MRI guidance. It also emphasizes some inherent characteristics that hold promise with regard to other conventional techniques: stents and vascular structures are visualized in near–real-time in any desired plane, and the technique is performed without the potential adverse effects of ionizing radiations and iodinated contrast agents. (J Vasc Surg 2000;32:1006-14.)

Objective: Adrenomedullin (ADM), secreted by the failing human heart, is a newly discovered potent endogenous vasorelaxing and natriuretic peptide that may play a role in cardiorenal regulation. No data are available on ADM in heart-transplant recipients (Htx) and the aim of this study was to determine the short- and long-term responses of ADM after heart transplantation. Methods: Circulating ADM and its relationship with parameters of cardiovascular hemodynamics, humoral factors and renal function were determined in normal subjects and Htx early (1, 2, 4, 8, 15 and 30 days) and late (32±16 months) after transplantation. Additionally, ADM was obtained in matched hypertensive and renal-transplant patients ( n =9 in each group). Results: Plasma ADM, elevated in heart failure patients, further increased transiently at day 1 after transplantation (from 37.9±15.9 to 125.8±15.3 pmol/l, P

Summary A 7 cm diameter tumor of the left atrium is reported in a 78 year-old woman with a past history of pT3N1M0 colonic adenocarcinoma. The histological examination of the atrial tumor disclosed areas of highly vascularized myxoid stroma with cells strongly reactive for vimentin. Multiple mucoid spaces lined by a single layer of goblet cells were scattered among those typical areas of myxoma. No nuclear atypia was observed. Cytoplasm of the glandular cells was immunoreactive for epithelial antisera (keratin, EMA), CEA and CA19.9. Two years later, the patient was doing well, with no local recurrence of the cardiac myxoma and no secondary location of the colonic adenocarcinoma. The histological characteristics, the absence of atypia, the absence of tumoral extension or neoplastic lymphatic vascular thrombi in the pedicle or in the interatrial septum, and the finding of typical myxomatous areas supported the diagnosis of cardiac myxoma with glandular component. To our knowledge, 21 cases of myxoma with glandular mucinous component, focal or prominent, have been previously published in the literature. These myxoma were generally sporadic cases with the same clinical features and prognosis as typical myxoma. Immunoreactivity of these glandular structures was constant for epithelial markers. The positive immunostaining by CEA, and by CA19.9 in our case, reflects the histogenetic endodermal origin.

Objectives to understand the cause, and propose a mechanism for frame dislocation in endovascular grafts. Materials and methods five tube grafts were explanted due to secondary distal leakage 15–21 months after operation. One bifurcated graft was removed during emergency operation after aortic rupture caused by secondary leakage. A second bifurcated graft was harvested from a patient with thrombotic occlusion of one limb, who died after transurethral prostatic resection. The inside of the grafts were examined endoscopically. The stent was inspected after removal of the fabric, broken ligatures were counted and examined by scanning electron microscopy. The fabric strength was tested by probe puncture. Results we found 17–44% of the stent ligatures of the body middle rings to be loose. The knots were intact. Degradation of the polyester textile was not observed. Conclusions continuous movements in the grafted aorta and blood pressure impose permanent stress to the stent frame and the polyester fabric resulting in morphological changes in the body middle ring of grafts. The clinical implications of the suture breakages are unknown although they may be related to distal secondary leakage in tube grafts.

Introduction capillary microscopy disclosed few signs of aspecific microangiopathy. No angiography was performed. Bleomycin treatment was discontinued and the Raynaud’s syndrome may be observed in HIV infected patient was treated with topical trinitrate which patients, mainly in patients treated with bleomycin resulted in a slow improvement after 1 year of followfor acquired immune deficiency syndrome-related up. Thereafter, his treatment included consecutive Kaposi’s sarcoma. This complication has been preinterferon (March–April 1994), adriamycin and velbe viously reported to occur in 10% of these patients. (two cycles in June and July 1994), radiotherapy of It may lead to disabling digital ischaemia with necrosis the proximal left thigh where several Kaposi’s lesions which may be difficult to treat in weakened patients. appeared with significant oedema (October 1994), We successfully treated such a patient with thoracodaunoxome (from May 1996 to January 1997), VP scopic sympathectomy. 16 (August 1996 to January 1997), velbe and oncovin (from January 1997) and triple antiretroviral combination. The patient was readmitted in October 1996 Case Report after he suffered an acute onset of coldness with cyanosis and pain involving all fingers of the right A 41-year-old homosexual man was admitted in hand. The radial pulse was palpable but ulnar pulse October 1996 for severe ischaemia of the right hand. was absent. Arteriography of the right upper limb He had been found HIV-1 positive in 1986, and had showed a segmental occlusion of the radial artery developed a cutaneous Kaposi’s sarcoma in July at the level of the wrist, occlusion of the ulnar artery 1992. After failure of zidovudine and interferon at the forearm, and multiple occlusions of the therapy, he had been treated with bleomycin in interdigital arteries with a lack of vascularisation of January 1993 and developed after three cycles (cumuthe index (Fig. 1). The symptoms did not regress lative dose of bleomycin: 120 mg) a typical Raynaud’s after 6 days of treatment with daily infusions phenomenon on both hands occurring every day, of 2.5 mg/kg heparin and 6 mg piribedil. A right mainly after cold exposure. All pulses were palpable. thorascopic dorsal sympathectomy extended from T2 Coagulation tests including antiphospholipid antito T4 was performed. The patient immediately bodies, protein C and protein S were normal. Nailfold improved after the operation with rewarming of the fingers, and was discharged on the third post∗ Please address all correspondence to: D. N. Chakfe, Department operative day. Six months later, the patient remained of Cardiovascular Surgery, Les Hopitaux Universitaires de Strasasymptomatic but described compensatory sweating bourg, 1, place de l’Hopital, BP n 426, 67091 Strasbourg Cedex, France. of the right shoulder.

Myxomas rarely are located on the mitral valve. We report the case of a 44-year-old man operated on successfully with mitral valve conservation, which is the 21st case of mitral valve myxoma reported in the western literature. Among the cases reported in the literature, the diagnosis was made at the time of autopsy in 6 cases, with premortem heart failure in 1 case. A clinical diagnosis was made in 15 cases on the basis of the following symptoms: peripheral embolism in 9 cases, cardiac signs in 4 cases, and constitutional manifestations in 2 cases. The clinical presentation of mitral valve myxoma differs slightly from that of other cardiac myxomas in that it has a lower incidence of constitutional manifestations. The gold standard for noninvasive diagnosis and localization of cardiac myxomas is transesophageal echocardiography. It allows for the detection of early, small valvular tumors and may help to characterize better their location and echostructure, facilitating the choice of an optimal surgical approach through preoperative study of the integrity and mobility of the valve. Conservative operative treatment by resection of the area of implantation of the myxoma followed by suture repair of the valve and annuloplasty may be recommended as the most appropriate treatment option for this rare condition.

Objectives: To characterise the morphologic behaviour of infrainguinal vascular grafts during flexion of the knee. Design: A prospective angiographic study. Materials and methods: In 64 infrainguinal bypass grafts, intravenous digital subtraction angiography was performed within the first postoperative week. Frontal and lateral projection angiograms with the knee joint extended and with a 80–90° flexion were taken. The distal anastomosis of the bypass was performed below-knee in 49 cases (18 in situ veins, 8 reversed veins with an anatomic course, 2 reversed veins with an extra-anatomic course, 4 composite grafts, 15 synthetic grafts with an anatomic course (14 polytetrafluoroethylene (ePTFE), 1 polyurethane), and two synthetic grafts with an extra-anatomic course. Fifteen ePTFE prostheses were implanted in the above-knee position. Results: Out of 64 cases a total of 16 grafts showed stenotic kinking during flexion: two of the 18 in situ vein grafts, four of the 12 reversed vein grafts implanted with an anatomic course, one of the two reversed vein grafts implanted in an extra-anatomic site, eight of the 15 synthetic grafts crossing the knee, 0 of the two extra-anatomic ePTFE grafts, and one of the 15 cases of above-knee femoropopliteal ePTFE grafts. Conclusions: Stenotic kinking due to knee flexion can affect all kinds of bypass grafts including vein grafts placed anatomically and above-knee prostheses.

In order to replace failing human heart valves, there are mainly two types of valve prostheses that currently fulfill the surgeons need. Mechanical prostheses proved good durability but require lon...

Eight patients with femoro-popliteal or sural DVT, confirmed by phlebography, were treated with intravenous Desmin (LMW-dermatan sulphate): on the first day, after an initial i.v. injection of 400 mg, all patients received an infusion of 800 mg in 500 ml of saline, during 24 hours; this infusion was repeated in each of the subsequent 9 days (global treatment period: 10 days). To monitor efficacy of the antithrombotic treatment a phlebography, with calculation of Marder score, was repeated at the end of treatment. Laboratory tests monitoring blood coagulation were carried out: aPTT, TT, PT. Factor Xa inhibition (by chronometric and chromogenic method), Stachrom DS, fibrinogen, prothrombin fragments F1 + 2 and TAT. Seven patients completed the ten-day treatment: 6 patients evidenced good improvement of the phlebographic patterns, 1 remained stationary and 1 patient was withdrawn due to adverse events. During the ten days treatment we did not observe any variation of blood coagulation tests. Desmin tolerability was good and no haemorrhagic episodes were registered. The collected results point to a good antithrombotic activity of the new LMW-dermatan sulphate, that deserves to be further evaluated with controlled investigations on larger number of patients.

A collagen impregnated graft and its parent preclotted prosthesis were implanted as thoraco-abdominal bypasses in dogs for periods ranging from 4 hr to 6 months and evaluated for their ease of handling, imperviousness, and healing behavior in terms of luminal surface thrombogenicity using labeled platelets and fibrinogen, prostacyclin (PGI 2 ) secretion, histomorphometric determination of internal capsule thickness, and histopathologic and scanning electron microscopic studies. The collagen impregnated graft was impervious to blood and both grafts showed excellent handling characteristics. Fibrin uptake was negligible on both grafts; however, platelet uptake was higher on the collagen impregnated graft than on the control graft at 4 and 24 hr. The healing behavior of the collagen impregnated graft was also found to be different than that of the control graft between 1 and 6 months post implantation. The development of a host collagenous internal capsule at the anastomoses, and a confluent endothelial lining, was observed in both grafts at 1 month; in later implantation periods, the healing of the medial region was found to be more irregular in the collagen impregnated grafts, showing a lower mean PGI 2 secretion than the preclotted control grafts. Histomorphometric analysis showed the internal capsule on the collagen impregnated grafts to be thicker than on the control grafts for most periods of implantation. The current study illustrates that the healing process of collagen impregnated grafts is delayed and that bovine collagen has a stimulating effect on tissue encapsulation. Current impregnated polyester arterial prostheses therefore cannot be recommended as small diameter blood conduits.

Objectives to evaluate an alternative and simple technique which consists in impregnation of a synthetic prosthesis with either autogenic omental fat or bone marrow. These tissues have been selected based on previous works and because they contain multiple cellular and extracellular compounds with biological healing properties (i.e. angiogenesis, endothelialisation, etc.). Design PTFE grafts of Group 1 were impregnated with fatty tissue, those of Group 2 with bone marrow and those of Group 3 served as controls. Materials nine mongrel dogs divided among these three groups. PTFE grafts are 3 mm in diameter. Methods in each animal, both iliac arteries were submitted to an end-to-side ilio-iliac bypass. At 3 months, pathology assessment was performed. Results group 1: all grafts were thrombosed and intimal hyperplasia was found occluding the anastomotic sites. Group 2: 4/6 grafts were patent and their mid-portion presented a thin neointima which did not totally cover the anastomotic sites. Group 3: 2/5 grafts were patent and their mid-portion as well as the anastomotic sites were covered with neointima which was hyperplastic in some areas. Conclusions addition of bone marrow cells may contribute to improve the quality of the healing process.

In their paper, Gernigon et al. 1 evaluated the test-retest reliability of Global Positioning System (GPS) derived measurements in patients with claudication under community walking conditions. They showed that the reliability of greatest walking distance and average of walking speeds are high, despite the variability of the different measured distances between two symptom limited stops during a 1 hour stroll. This suggests that GPS technology offers new perspectives in the individual evaluation of walking ability and that it might help in objectively evaluating the severity and the impact of claudication in a patient in his daily life. However, we would like to make some points on the paper. The first point isthatthe methodology suffers from several limitations. Twenty patients were included over a 30 month periodandthreeofthemwereexcludedbecauseofsomeGPS issues. Moreover, there was no standardization between the two series of evaluations, with the second test being performed within 30 days of the first, under potentially different environmental conditions. Total time walking duration was sometimes longer than 1 hour and it is possible that walking 25% longer could change the results. The small sample size, thelong duration ofthestudy,the outdoorstroll, andthe lack of standardization could have influenced biased the results. The second point is the logistics of these measurements. The authors mentioned that the potential advantages of GPS technology in the setting of claudication include price of the test and the time saving. However, the cost of the GPS device, the time needed to equip the patient and explain the procedures, and the time to learn how to analyze the GPS recording were not taken into consideration. The authors also described some adjunctive procedures that could help in improving GPS data interpretation (heart rate, near infrared spectroscopy, temperature), but it is expected that the cost of GPS devices able to record such physiological parameters would be high. Finally, it has already been demonstrated that exercise therapy with hospital or community based training under the supervision of a physical therapist or other trained medical personnel is superior to other forms of exercise therapy, and that increased supervision tends to lead to a greater improvement in walking distance. 2 As a result, supervised exercise has been given a class I, level of evidence A recommendation by the American College of Cardiology/American Heart Association. 3 Moreover, supervised exercise therapy is more cost-effective. 4 In any case, this paper opens the door towards remote evaluation of multiple variables associated with physical activity in claudicants and could help to objectively measure the impact of a given treatment in the patient’s specific daily life conditions. Patients merely have to remember not to leave their smartphone at home!