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Background Despite promising early results, mid-term failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. Methods We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. Results We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques—2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non–aortic-related causes. Conclusions The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.

Summary Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding UK Medical Research Council and Health Technology Assessment Programme.

Background Acute lower limb ischemia (ALLI) poses a major threat to limb survival. For many years, surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution to the management of ALLI. It seems that the newly designed endovascular thrombectomy devices may shift treatment recommendations toward endovascular options. This protocol study aims to collect evidence supporting the latest hypothesis. Objective The devices under investigation are the Penumbra/Indigo Systems (Penumbra Inc). The objective of this clinical investigation is to evaluate, in a controlled setting, the early safety and effectiveness of the devices and to define the optimal technique for the use of these systems in patients with confirmed peripheral acute occlusions. Methods This study will be an interventional prospective trial of patients with a diagnosis of ALLI treated with Penumbra/Indigo devices. This project is intended to be a national platform where every physician invited to participate could register his or her own data procedure. The primary outcome is the technical success of thromboaspiration with the Indigo System. Assessment of vessel patency will be recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications before and after use of the device. Clinical success at follow-up is defined as an improvement of Rutherford classification at 1-month follow-up of one class or more as compared to the preprocedure Rutherford classification. Secondary endpoints include the following: (1) safety rate at discharge, defined as the absence of any serious adverse events; (2) primary patency at 1 month, defined as a target lesion without a hemodynamically significant stenosis or reocclusion on duplex ultrasound (>50%) and without target lesion reintervention within 1 month; and (3) limb salvage at 1 month. Results The study is currently in the recruitment phase and the final patient is expected to be treated by the end of March 2019. A total of 150 patients will be recruited. Analyses will focus on primary and secondary endpoints. Conclusions These new endovascular thrombectomy devices that are specifically designed for peripheral intervention in this difficult set of patients, as those under investigation in the proposed registry, may offer improved clinical outcomes with lower rates of major systemic and local complications. Following completion of this study, it is expected that the value of the Indigo Thrombectomy System in the treatment of ALLI will be better defined. As a result, a shift of treatment recommendations toward endovascular options may be observed in the near future. International Registered Report Identifier (IRRID) DERR1-10.2196/9972

Despite the improvement in diagnostic and therapeutic strategies, the treatment of thoracoabdominal aneurysms is still burdened with a high incidence of peri/postoperative morbidity and mortality. The multilayer flow modulator is a new and promising technique for the treatment of such disease; however, some limits are still evident. We report the case of a 76-year-old woman affected by a symptomatic thoracoabdominal aneurysm treated with multiple Cardiatis multilayer flow modulators complicated by aortic arch rupture on the fifth postoperative day, with subsequent patient death.

Background The endovascular treatment of an abdominal aortic aneurysm (AAA) is a treatment with low risk and good reported results. This retrospective study analyzed experience with patients requiring surgical conversion after endovascular abdominal aortic aneurysm repair (EVAR). Methods A total of 26 patients underwent open conversion (OC) after EVAR (18 endografts implanted at the authors' center and 8 in other centers). Patients were divided into 2 groups: early conversion if OC was performed within 30 days from the primary EVAR, and late conversion if OC was performed at least 30 days after EVAR. The authors analyzed all data on OC and the postoperative course. Results In this series, OC was performed for 22 endoleaks (13 type I, 5 type II, 2 type III, and 2 type V, which in 5 cases these were associated with AAA ruptures), 2 renal artery coverages, and 2 endograft infections. Six (23%) patients underwent early conversion with a mortality rate of 50%, and 20 (77%) had late conversion with a mortality rate of 20%. The overall mortality rate after OC, occurring before hospital discharge or within 30 days, was 26.9% (7 of 26). Conclusions Endoleaks remain the weak point of endografts and can result in aneurysm rupture/death. Urgent OC and infections engender a high mortality. Elective OC can be performed with very low mortality and acceptable morbidity. Lifelong surveillance is necessary to detect and treat endoleaks.

To report midterm failure of tandem peripheral multilayer stents used to treat a common hepatic artery aneurysm (HAA) that had a good early result.A 71-year-old man with multiple comorbidities had a 3.4-cm HAA treated with 2 Cardiatis peripheral multilayer stents (8×100 and 9×60 mm) that overlapped by 3 cm. At the 12-month follow-up, the stents were patent, with signs of collateral patency and full thrombosis of the aneurysm sac without expansion. At the 18-month visit, the sac had expanded to 4.5 cm without signs of revascularization, but there was an initial stent dislocation; a wait and watch approach was elected. On the 24-month imaging, the HAA had enlarged to 6 cm, with disconnection of the 2 stents. A new multilayer stent (9×100 mm) was positioned to "bridge" the gap; however, the proximal part of the new stent did not correctly expand despite multiple attempts to overcome the infolding. The 3 stents became completely thrombosed, but thanks to rich mesenteric collaterals, perfusion of the proper hepatic artery was adequate.The multilayer peripheral stent appears to be an alternative for the treatment of visceral aneurysms in patients with a high surgical risk, but it is not a conventional stent. There are unknowns about its function, behavior, and application. Therefore, more experience is needed to validate the effectiveness of the multilayer stent.

The objective of this study was to evaluate the results of the off-label use of the Nellix endograft (Endologix, Irvine, Calif) for the treatment of short-neck aneurysms and juxtarenal aortic aneurysms (JAAs) compared with the outcomes of patients with infrarenal abdominal aortic aneurysms treated in accordance with the manufacturer's instructions for use.Data available from patients treated with the Nellix endograft from September 2013 to January 2016 were reviewed to create a case-control analysis (1:2). Fourteen elective patients with a short-neck aneurysm or JAA (10 mm) and mild aortic neck angulation (35 degrees) were included. As a control group, 28 elective patients who had been treated in accordance with instructions for use were included. Patients were matched for age, sex, aortic diameter, and aortic neck angulation. The final cohort group included 42 patients: 14 in the JAA off-label group (5 with aortic neck length ≤4 mm and 9 with necks of 5 to 10 mm) and 28 in the control group. Technical and clinical success, freedom from any secondary intervention, any type of endoleak, and aneurysm-related death were evaluated.There were no significant differences between the two groups in terms of comorbidity, intraoperative time, radiation time, contrast agent volume, and perioperative mortality and morbidity. Two patients of the JAA group subsequently underwent open repair (14%), both with aortic neck length 4 mm (2/5; 40%), for type Ia endoleak. Two of the control group also subsequently underwent open repair (7%). At a mean follow-up of 22 ± 3.9 months, freedom from any reintervention was 85% for the JAA off-label group vs 92% for the control group (log-rank test, P = .33).The off-label use of the Nellix endograft for the treatment of JAA showed a higher rate of subsequent conversion to open repair for JAA patients (aortic neck length ≤4 mm), underlining the need for a proximal sealing zone. Longer term data are needed to verify the possible use of the Nellix endograft in selected short-neck aneurysms with aortic neck length5 mm.

Objective Because of advances in technology and experience of the operator, endovascular aneurysm repair (EVAR) has supplanted open repair to treat abdominal aortic aneurysm (AAA). The low 30-day mortality and morbidity of EVAR make the endovascular approach particularly suitable for patients at high surgical risk. However, endoleak or endograft migration requiring secondary intervention or open surgical conversion is a limitation of EVAR. The Nellix system (Endologix, Inc, Irvine, Calif) has been designed to seal the entire AAA to overcome these limitations with EVAR. We report the results of a retrospective, multicenter study with endovascular aneurysm sealing (EVAS) aimed to assess technical success, procedure-related mortality, complications, and reinterventions. Methods This study included patients selected for elective treatment with the Nellix device per the endovascular repair protocol at 16 Italian vascular centers. All patients were enrolled in a postoperative surveillance imaging program including duplex ultrasound investigations, computed tomography, and magnetic resonance controls following local standards of care. Results From 2013 to 2015, there were 335 patients (age, 75.5 ± 7.4 years; 316 men) who underwent elective EVAS. In 295 cases (88.0%), EVAS was performed under standard instructions for use of the Nellix system. Preoperative aneurysm diameter was 55.5 ± 9.4 mm (range, 46-65 mm). The inferior mesenteric artery and lumbar arteries emerging from the AAA were patent in 61.8% and 81.3% of cases, respectively. Chimney grafts were electively carried out in eight cases (2.4%). One (0.3%) intraprocedural type IB endoleak was observed and promptly corrected. Device deployment was successful in all patients, with no perioperative mortality. Early (≤30 days) complications included 1 (0.3%) type IA endoleak, 2 (0.6%) type II endoleaks (0.6%), 2 (0.6%) stent occlusions (0.6%), 3 (0.9%) distal embolizations, and 2 (0.2%) femoral artery dissections. Six (2.9%) patients underwent reinterventions. At 1-year follow-up, complications included 3 (1.1%) type II endoleaks, 4 (1.4%) type IA endoleaks, 1 (0.3%) type IB endoleak, 2 (0.7%) distal stent migrations, 5 (1.8%) distal embolizations, and 1 (0.3%) stent occlusion. Twelve patients (3.7%) underwent reinterventions, including four (1.4%) surgical conversions due to aortoduodenal fistula (1), endograft infection (1), and type IA endoleak that was unsuccessfully treated percutaneously (2). Two AAA-related deaths occurred. Freedom from aneurysm-related reintervention was 98.3% at 1-month and 94.7% at 12-month follow-up. Conclusions The preliminary results of this real-world multicenter study showed that EVAS with Nellix for the management of AAAs appears feasible. This device platform is associated with acceptable procedure-related mortality and low overall complication and reintervention rates. Definitive conclusions on the value of this novel device await long-term follow-up data.

Purpose: To report midterm outcomes of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the treatment of abdominal aortic aneurysm (AAA). Methods: Between September 2013 and July 2014, 64 AAA patients (mean age 76.6±6.8 years; 61 men) were treated with the EVAS system at 2 centers (only procedures performed at least 12 months prior to the analysis were included). Most patients were treated for a stable AAA, while 1 patient was treated for a ruptured aneurysm. Mean aneurysm diameter was 57.3±9.3 mm. The proximal neck measured a mean 21.5±3.3 mm in diameter and 27.0±12.1 mm long; the neck angle was 16.9°±19.3°. Eleven (17.2%) patients were treated outside the instructions for use (IFU). Results: Technical success was achieved in 63 (98.4%) of 64 patients; 1 type Ia endoleak was treated intraoperatively. One (1.6%) aneurysm-related death occurred at 4 months due to a secondary aortoenteric fistula. Overall, endoleaks occurred in 3 (4.7%) patients (2 type Ia, 1 type II). The estimated rates for 18-month overall survival, freedom from aneurysm-related death, and freedom from secondary interventions were 92.7%, 98.4%, and 95.0%, respectively. Patients treated outside the IFU had a significantly higher incidence of device-related complications (p=0.03). Conclusion: The use of the Nellix device in everyday clinical practice is safe and offers promising midterm results. The risk of secondary aortoenteric fistula requires further analysis. Longer follow-up is needed to assess the actual efficacy of the device, although the risk of migration with late endoleak seems low.

Entre 2000 et 2010, 32 patients (17 hommes ; âge moyen : 64,7 [extremes 18-85 ans) avec des anevrysmes d’arteres viscerales (AAVs) ont ete traites dans notre centre. Le site de la maladie anevrismale etait : l’artere splenique (18), l’artere hepatique (5), l’artere mesenterique superieure (3), l’artere pancreatico-duodenale (3), le tronc cœliaque (2), et (1) l’artere gastroduodenale. Six patients (18,75%) se sont presentes avec une rupture anevrysmale. Neuf cas ont recu un traitement endovasculaire. Le succes technique primaire etait obtenu chez six patients. Les echecs incluaient un cas d'occlusion de stent immediate, une migration de stent, et une tentative d'embolisation. Dans 24 cas, le traitement chirurgical etait realise avec succes. Le taux de survie global etait de 90,6% (en urgence : 75% ; electif : 95,8%). Les resultats etait corrects apres une periode de suivi de 34,7 mois (extremes : 2-117 mois). En raison du risque potentiel de rupture, les AAVs devraient etre traite. Une nouvelle technologie endovasculaire basee sur un stent multicouche a pu nous fournir une alternative au traitement des AAVs, garantissant la thrombose du sac anevrysmal et la perfusion correcte des organes. Cependant, cette nouvelle technologie n'est pas adaptee a tous les anevrysmes et necessite une formation specifique et une courbe d'apprentissage. Chez les sujets avec un faible risque chirurgical, la chirurgie garantit une reparation definitive et durable avec une bonne perfusion d'organe.

Objectifs Le thrombus libre flottant de l'artere carotide interne (TLF-ACI) est rare et sa vraie incidence est inconnue. L'etiologie la plus commune est la complication d'une plaque atheromateuse, mais plusieurs conditions medicales peuvent etre responsables. Le but de cette etude etait d'analyser retrospectivement notre experience de l'endarteriectomie carotidienne dans la gestion des TLF-ACI et d'analyser les resultats. Methodes Une revue retrospective a ete faite sur tous les patients admis pendant les 9 dernieres annees avec un diagnostic de TLF-ACI. La demographie, les manifestations cliniques, les modalites diagnostiques, les indications chirurgicales, les details operatoires, les suites postoperatoires, et le suivi ont ete enregistres dans la base de donnees de l'hopital. Resultats Entre janvier 2000 et decembre 2008, dans notre unite, 2.572 endarteriectomies carotidiennes ont ete faites pour lesion de l'artere carotide. Un total de 16 patients (16 sur 2.572 ; 0,62%) ont ete traites pour un TLF-ACI. En tout, 87,5% (14 sur 16) patients avaient eu des symptomes neurologiques. Tous les patients ont eu un examen duplex. Dans 75% (12 de 16) de cas, des examens diagnostiques additionnels ont ete faits : angiographie numerique en soustraction (ANS), angiographie par resonance magnetique, ou scanner. Le duplex et l'ANS ont detecte le TLF-ACI dans 62,5% et 100% des cas, respectivement. Le scanner et l'angiographie par resonance magnetique n'ont pas fourni de diagnostic chez la majorite des patients (33,4% et 66,7%, respectivement). La presence d'un TLF-ACI a ete confirmee en peroperatoire dans tous les cas. Le taux cumulatif d'AVC apres chirurgie etait de 6,3% (un sur 16). Parmi tous les patients sortis, 68,75% montraient une amelioration des symptomes neurologiques, 12,5% etaient asymptomatiques, 12,5% n'avaient aucun changement des symptomes, et 6,25% des cas etaient aggraves. Au suivi de 30 jours, le taux de survie etait de 93,7% et 75% des patients avaient une amelioration des symptomes neurologiques, 12,5% etaient asymptomatiques, et 6,25% etaient morts. En tout, 6,25% des patients ont ete perdus de vue. Conclusion Les patients avec TLF-ACI sont habituellement symptomatiques et se presentent en urgence. Le duplex demeure l'examen diagnostic de reference pour detecter les TLF-ACI. Nous ne pouvons pas affirmer que la chirurgie precoce est superieure a l'anticoagulation provisoire et/ou a l'intervention differee en raison de l'absence d'un groupe controle. Cependant, nos resultats retrospectifs suggerent que l'intervention rapide est une alternative sure dans le traitement des TLF-ACI.

Introduction Cette etude retrospective unicentrique sequentielle comparait les resultats de l’endarteriectomie carotidienne (EAC) sous anesthesie generale a l’EAC sous anesthesie generale. Methodes De Novembre 2002 a Octobre 2004, 428 EACs etaient realisees dans notre unite vasculaire. Deux groupes etaient formes : groupe AG (anesthesie generale) : 219 patients operes sous anesthesie generale ; groupe AL (anesthesie locale) : 209 patients operes sous anesthesie locale. Resultats Il n’y avait aucun deces dans les deux groupes. Apres chirurgie, trois accidents vasculaires constitues etaient notes dans le groupe AG et trois dans le groupe AL (AG 1,36% vs. AL 1,43%, p = 0,9540) ; Apres EAC, il y avait trois AITs dans le groupe AG et aucun dans le groupe AL (AG 0,42% vs. AL 0%, p = 0,2634). Conclusion La morbi-mortalite n’etait pas influencee par le type d’anesthesie utilisee en chirurgie carotidienne. Aucune difference statistique n’etait detectee en termes de taux de complications neurologiques et cardio-pulmonaires entre l’AG et l’AL.

The early risk of stroke after transient ischemic attack (TIA)/stroke is of the order of 5-10% at 1 week and 10-20% at 3 months. Even if carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery stenosis, the timing of carotid intervention after acute stroke is not yet codified. The authors want to determinate whether early CEA is safely carried out in the first few hours (48 hours) successive to the nondebilitating neurological event and whether the outcome (TIA/stroke/death) in these cases is comparable with the results of those treated by delayed/deferred surgery (range, 48 hours-24 weeks).In 4 years, the authors performed 1,184 CEA (285 symptomatic). Five groups were formed from 285 symptomatic patients, according to interval between TIA/stroke onset and performance of CEA: G1, less than 48 hours; G2, 48 hours-2 weeks; G3, 2-4 weeks; G4, 4-8 weeks; G5, 8-24 weeks. Surgery was never performed on patients with disabling neurological deficit (modified Rankin Scale, 5) at the time of admittance, cerebral lesions greater than 3 cm at magnetic resonance/computed tomography scan, presence or suspect of parenchymal hemorrhage associated with ischemic damage, condition considered unfit for surgery (American Society of Anesthesiology classification grade V), and occlusion of the cerebral middle artery. Neurological and diagnostic examinations (duplex-scanning and computed tomography/magnetic resonance scan) were used in determining the selection for early CEA.Cumulative TIA/stroke/death rate after CEA was 3.8% (11/285) and at 30 days was 2.8% (8/285). The cumulative TIA rate after CEA and at 30 days was 0% (0/285). The cumulative stroke rate after CEA was 3.5% (10/285) and at 30 days was 2.4% (7/285). The cumulative death rate after CEA and at 30 days was 0.3% (1/285). Stroke rate after CEA in each group was: G1 4.2% (3/70); G2 3.2% (2/61); G3 0% (0/22); G4 3.4% (1/29); G5 3.8% (4/103). Any statistically significant difference between G1 and the other four groups was not detected with regard to postoperative stroke: G1 (4.2%) versus G2 (3.2%), p = 0.7641; G1 (4.2%) versus G3 (0%), p = 0.7648; G1 (4.2%) versus G4 (3.4%), p = 0.8473; G1 (4.2%) versus G5 (3.8%), p = 0.8952. No hemorrhagic stroke was detected after early CEA. The type of anesthesia and the use of a shunt didn't show any significant difference between the five groups.The analysis of these records suggests that early CEA in the acute post stroke phase, for patients clinically selected, does not result in greater complications than when performed delayed or deferred . Furthermore, the advantage of early CEA is the reduction of recurrent strokes, as untreated patients present a higher incidence of neurological events.

Objectif Le risque precoce de survenue d’un accident vasculaire cerebral apres un accident ischemique transitoire (AIT)/accident vasculaire cerebral (AVC) varie entre 5 et 10% a une semaine et 10 et 20% a trois mois. Bien que l’endarteriectomie carotidienne (EAC) soit le traitement de choix des stenoses symptomatiques de l’artere carotide interne, le delai de realisation des interventions carotidiennes apres un accident vasculaire aigu n’est toujours pas codifie. Les auteurs ont voulu determiner si une EAC precoce pouvait etre realisee de maniere sure au cours des premieres heures ( Methodes En quatre ans, les auteurs ont effectue 1184 EAC (285 symptomatiques). Cinq groupes ont ete formes a partir des 285 patients symptomatiques, selon l’intervalle separant la survenue de l’AIT (accident cerebral) et la realisation de l’EAC : G1, moins de 48 heures ; G2, 48 heures-2 semaines ; G3, 2-4 semaines ; G4, 4-8 semaines ; G5, 8-24 semaines. La chirurgie n’a jamais ete effectuee lorsque les patients presentaient des deficits neurologiques invalidants (echelle de Rankin modifiee, 5) a l’admission, des lesions cerebrales superieures a 3 cm sur l’IRM ou le scanner, presence ou suspicion d’hemorragie parenchymateuse associee aux lesions ischemiques, patients consideres comme mauvais candidats a la chirurgie (classification de l’American Society of Anesthesiology grade V) et en cas d’occlusion de l’artere cerebrale moyenne. Des examens neurologiques et diagnostiques (echographie Doppler et scanner/IRM) ont ete utilises pour selectionner les candidats a l’EAC precoce. Resultats Le taux cumulatif AIT/AVC/deces apres EAC a ete de 3,8% (11/285) et de 2,8% (8/285) a 30 jours. Le taux cumulatif d’AIT apres EAC et a 30 jours a ete de 0% (0/285). Le taux cumulatif d’AVC apres EAC a ete de 3,5% (10/285) et a 30 jours de 2,4% (7/285). Le taux cumulatif de deces apres EAC et a 3 jours a ete de 0,3% (1/285). Le taux d’AVC apres EAC dans chaque groupe a ete : G1 4,2% (3/70) ; G2 3,2% (2/61) ; G3 0% (0/22) ; G4 3,4% (1/29) ; G5 3,8% (4/103). Il n’a pas ete montre de difference statistiquement significative entre les groupes G1 et les quatre autres groupes concernant la survenue d’un AVC post-operatoire : G1 (4,2%) versus G2 (3,2%), p = 0,7641 ; G1 (4,2%) versus G3 (0%), p = 0,7648 ; G1 (4,2%) versus G4 (3,4%), p = 0,8473 ; G1 (4,2%) versus G5 (3,8%), p = 0,8952. Il n’y a eu aucun accident hemorragique compliquant une EAC precoce. Le type d’anesthesie et l’utilisation d’un shunt n’etaient pas significativement differents entre les 5 groupes. Conclusions L’analyse de ces donnees suggere qu’une EAC precoce dans la phase suivant un evenement neurologique aigu, chez les patients cliniquement selectionnes, ne semble pas augmenter le risque de complications comparee a la chirurgie retardee ou differee. De plus, l’avantage de l’EAC precoce est de reduire les taux de recidive d’evenement neurologique, les patients non traites en presentant une plus forte incidence.

We report a case of a metachronous common iliac artery and the internal iliac artery (IIA) aneurysm developed 8 years after an aortobi-femoral bypass for treatment of abdominal aortic aneurysm associated at chronic occlusion of the right iliac axis. To exclude the metachronous aneurysm on the left iliac axis and to maintain the pelvic circulation, an external to IIA endografts were positioned ("U stent-graft technique"). At 6-month follow-up, the computed tomography scan showed patency of the endografts, of the bypass and of the IIA, without endoleak, or other adverse events.

Objective We compared the outcomes and the durability of endovascular recanalization (EVR) with the Viabahn (W. L. Gore and Associates, Flagstaff, Ariz) covered stent graft vs traditional aortobifemoral or aortofemoral bypass grafting for complex aortoiliac occlusions. Methods Between 2008 and 2014, 11 unilateral iliac occlusions and 11 aortobiiliac occlusions were treated by EVR. Also collected were data from the last 21 consecutive patients treated in the same period by aortofemoral (n = 6) or aortobifemoral (n = 15) bypass grafting. In accordance with the TransAtlantic Inter-Society Consensus II (TASC II) document, only patients with type D lesions were considered. Kaplan-Meier estimates for patency were calculated, and Cox proportional hazard modeling was performed. Results The difference in risk factors between the groups was not significant. General anesthesia was required in 100% of the surgical group, and local or locoregional anesthesia was used for EVR. Suprarenal aortic cross-clamping was required in nine of the open surgical procedures (41%). A brachial percutaneous approach was performed in all patients undergoing EVR, and technical success was 100% in both groups. All of the attempts at EVR were successful. At the 2-year follow-up, primary patency did not differ significantly between the endovascular (91%) and surgical (95%) groups. This was seen in the univariate model (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.02-2.95; P = .28) and in the multivariate model (HR, 0.77; 95% CI, 0.06-10.07; P = .84) for group (HR, 0.58; 95% CI, 0.04-7.72; P = .68), age (HR, 0.89; 95% CI, 0.73-1.08; P = .24), symptoms (HR, 1.98; 95% CI, 0.42-9.46; P = .39), and occlusion (HR, 3.22; 95% CI, 0.51-20.35; P = .21). The average hospital length of stay was shorter for patients treated with ERV than for those treated with open surgery (3.9 ± 2.2 vs 5.8 ± 3.1 days, respectively; P = .03). The complication rate was 4% for EVR vs 18% in the surgical group (P = .32). Conclusions At 2 years of follow-up, the results of endoluminal bypass grafting with the Viabahn stent to treat complex aortoiliac disease are promising. Longer-term results are needed to fully evaluate the potential benefits and longer-term patency.

Introduction Intravascular ultrasound (IVUS) can be used as a quality control technique following carotid artery stenting (CAS). Report An asymptomatic 79-year-old female, with 70% right internal carotid artery (ICA) stenosis, underwent CAS. ICA IVUS evaluation was performed before and after CAS. Angiogram post-CAS showed good results while IVUS detected a flap protrusion across the stent. We treated the flap protrusion with another stent placement. A second IVUS evaluation did not show any further procedural defects. Discussion IVUS can be a useful tool to perform quality control following CAS.

We wished to analyze our initial experience with the Cardiatis Multilayer Stent for visceral artery aneurysms. Two males with a hepatic artery aneurysm (34 mm and 48 mm in diameter, respectively) were treated, via a percutaneous femoral approach, with multilayer stents. We deployed the stent in front of the aneurysm neck, covering the hepatic artery branches. At 12 months, a computed tomography scan showed thrombosis of the aneurysmal sac and patency of all the branches of the hepatic artery. The Multilayer Stent appears to be a viable alternative for the treatment of visceral artery aneurysms in patients at high surgical risk, but long-term follow-up is needed.

Percutaneous closure of an atrial septal defect has been increasingly used, and complications have been rare. We report the case of a 63-year-old man who had undergone endovascular closure of a secundum atrial septal defect months earlier. The occluder was later found in the abdominal aorta.

OBJECTIVE: Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections. METHOD: We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients. RESULTS: The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1–56), and the survival rate was 77.8%. The endoleaks’ rate was 3.7% (1/27), due to a stent-graft migration. CONCLUSION: Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.

Atherosclerosis can be thought of as a complex process involving many aspects of the patient’s life, ranging from sex, age, and genetics to lifestyle and nutrition. In the last 10 years, there has been a wide expansion of the “-omics” sciences. Such sciences have proven very effective and accurate in the analysis of complex systems, where the analysis of many factors might help a better understanding of the system itself. Among all the “-omics” sciences, metabolomic and metabonomic are gaining increasing interest. Metabonomics quantitatively measures living systems undergoing the effects of diseases. Unlike genomics and proteomics, metabonomics focuses on the multiparameter evaluation of a living complex system by studying its overall physiological profile. Metabonomics can be thought of as a multiparameter profiling technique of each individual.

A 69-year-old man was referred to our facility owing to the sudden onset of a compression-like pain in the right leg, without limb-threatening acute ischemia. The duplex scan examination, followed by a selective leg angiography, showed the presence of a peroneal artery aneurysm. A diagnosis of mycotic aneurysm was made on the basis of the patient’s clinical condition, positive blood cultures, and the unusual location of the lesion. Endovascular repair was performed by using a coil embolization and covered stent release. The patient was discharged in good general condition with complete pain relief. In previously published data, only four cases of peroneal artery aneurysm with a mycotic etiology have been reported. In this case, the endovascular treatment was safe and resolutive.

Surgical treatment for steno-obstructive pathology of the extracranial carotid artery is today the gold standard for the prevention of cerebral ischemic disease associated to the manifestation of atherosclerosis. During the 1990s, a number of randomised trials incontrovertibly demonstrated the advantages which are derived from carotid endarterectomy with respect to medical therapy alone, in patients with symptomatic or asymptomatic stenosis. As a whole, these ­trials ­indicated a perioperative rate of major adverse events (stroke, mortality and MACE) of about 9%. Many projects have since been conducted in the field of carotid surgery, and today the reported complication rates are lower than 3%, with excellent long-term results (North American Symptomatic Carotid Endarterectomy Trial Collaborators, N Engl J Med 325(7):445–534, 1991; Mayberg et al., JAMA 266(23):3289–945, 1991). The results of new arising techniques, such as carotid stenting, must be compared with these complication rates in order to have a clear benchmark for a more objective future dissemination.

Five patients were treated for ruptured visceral artery aneurysms during the last 9 years, including two splenic and three pancreaticoduodenal aneurysms. The average size of aneurysm was 2.6 cm (range: 1.5-5 cm). All patients underwent open surgical treatment. There was one operative death. After a mean follow-up of 46.6 months, there were no cases of mortality or secondary complications. The authors conclude that operative treatment of ruptured visceral artery aneurysms is durable.

Congenital vascular malformations represent a wide number of diseases with a great variability of clinical features. The association between congenital vascular malformations and peripheral aneurysms is very rare. The present study reports a case of giant superficial femoral artery aneurysm (7-cm-long) associated with Parkes-Weber syndrome (capillary malformation, multiple arteriovenous fistulas [AVFs], skeletal hypertrophy of the affected limb) treated by positioning two covered self-expandable endoprostheses after embolization of AVFs with Gianturco coils. The peri- and postoperative course was uneventful and the postprocedural angiography showed the complete exclusion of the aneurysm sac. At last follow-up, after 87 months, the duplex scan and computed tomography scan showed regular patency of the vessels with thrombosis of the aneurysm sac and the presence of a large number of AVFs. The association between Parkes-Weber syndrome and peripheral aneurysms represents a very unusual entity. The lack of evidence does not allow the establishment of the most suitable treatment for this disease. Endovascular approach associated with previous embolization of AVFs may represent a valid alternative to traditional surgical repair, which is still burdened by a high percentage of complications and failures.

Background Free-floating thrombus in the internal carotid artery (FFT-ICA) is a rare condition and its real incidence is unknown. The most common etiology is a complication of an atherosclerotic plaque, but several medical conditions can be responsible. The purpose of this study was to retrospectively analyze our experience with carotid endarterectomy in the management of FFT-ICA and also to analyze the patient outcome. Methods A retrospective review was performed of all patients admitted during the past 9 years with a diagnosis of FFT-ICA. Patient demographics, clinical manifestations, diagnostic modalities, surgical indications, operative details, postoperative courses, and follow-up information were recorded from the hospital database. Results Between January 2000 and December 2008, in our Unit, 2,572 carotid endarterectomies were performed for carotid artery disease. A total of 16 patients (16 of 2,572; 0.62%) were treated for an FFT-ICA. In all, 87.5% (14 of 16) of patients had neurological symptoms. All patients underwent a duplex scan. In 75% (12 of 16) of cases, additional diagnostic tests were performed: digital subtraction angiography (DSA), magnetic resonance angiography, or computed tomographic scan. Duplex scan and DSA detected the FFT-ICA in 62.5% and 100% of cases, respectively. Computed tomographic scan and magnetic resonance angiography failed to provide a diagnosis in majority of the patients (33.4% and 66.7%, respectively). The presence of FFT-ICA was confirmed intraoperatively in all cases. The cumulative stroke rate after surgery was 6.3% (one of 16). Of the total number of patients discharged, 68.75% showed an improvement of neurological symptoms, 12.5% were asymptomatic, 12.5% had no changes in symptoms, and 6.25% of cases worsened. At 30-day follow-up, the survival rate was 93.7% and 75% of patients showed an improvement of neurological symptoms, 12.5% were asymptomatic, and 6.25% died. In all, 6.25% of patients were lost to follow-up. Conclusion Patients with FFT-ICA are usually symptomatic and present with an acute emergency. DSA remains the gold standard diagnostic test in FFT-ICA detection. We cannot assert that early surgery is superior to temporary anticoagulation and/or delayed intervention because of the absence of a comparison group. However, our retrospective results suggest that prompt intervention seems to be a safe alternative in FFT-ICA treatment.

Between 2000 and 2010, 32 patients (17 males; mean age: 64.7 [range: 18-85] years) with visceral artery aneurysms (VAAs) were treated in our center. The site of aneurysmal disease was: splenic artery (18), hepatic artery (5), superior mesenteric artery (3), pancreaticoduodenal artery (3), celiac axis (2), and gastroduodenal (1). Six patients (18.75%) presented with an aneurysm rupture. Nine cases received an endovascular treatment. Primary technical success was achieved in six patients. Failures included one case of immediate stent occlusion, one stent migration, and one failed attempt of embolization. In 24 cases, the surgical treatment was performed successfully. The total survival rate was 90.6% (in urgency: 75%; in election: 95.8%). A follow-up period of 34.7 months (range: 2-117 months) showed good results. Because of the potential risk of rupture, VAAs should be treated. A new endovascular technology based on a multilayer stent could provide us with a new alternative to VAA treatment, guaranteeing both aneurysmatic sac thrombosis and the correct perfusion of the organs. However, this new technology is not suitable for all aneurysms and requires a specific training and learning curve. In subjects with a low surgical risk, surgery guarantees a definitive and long-lasting repair with a good organ perfusion.

True aneurysms of tibial artery are rare occurrences and their rupture is really rare. We report the case of a 59-year-old man who, after an episode of bacterial endocarditis, presented a posterior tibial aneurysm formation evolved in rupture. To our knowledge, this is the first case of a true giant aneurysm rupture of the posterior tibial artery (diameter, 6 cm). The treatment consisted of aneurysmectomy and surgical arterial ligation. A follow-up of 24 months was performed with good results.

We report the case of a 54-year-old man with acute stroke caused by left internal carotid artery (ICA) occlusion secondary to pleural mesothelioma, discovered later. The cranial computed tomography scan revealed a left hemisphere ischemic lesion. At neurological examination, the modified National Institutes of Health Stroke Scale (mNIHSS) score was 9. The carotid duplex scan (DS) showed a complete thrombotic occlusion of the left ICA. The patient underwent emergency carotid thrombectomy. The screening tests revealed thrombocytosis, hyperfibrinogenemia, increased C-reactive protein values, and multiple left pleural mesothelioma nodularity confirmed at the immunohistochemical investigation. After surgery, the patient's neurological symptoms improved, with an mNIHSS score of 3. At 30 and 120 days, the DS follow-up showed regular patency of the ICA.

Background This sequential retrospective monocentric study compares the results between general and local anesthesia for carotid endarterectomy (CEA). Methods Between November 2002 and October 2004, 428 CEAs were performed in our vascular unit. Two groups were formed: group GA (general anesthesia): 219 patients operated under general anesthesia; group LA (local anesthesia): 209 patients operated under local anesthesia. Results No mortality was found in both groups. After surgery, three strokes were detected in group GA and three in group LA (GA 1.36% vs. LA 1.43%, p = .9540); After CEA, there were three TIAs in GA group and none in LA group (GA 0.42% vs. LA 0%, p = .2634). Conclusion The morbi-mortality was not influenced by the type of anesthesia used for carotid surgery. No statistical difference was detected in the perioperative neurological and cardiopulmonary complication rates between GA and LA.

The Nellix device (Endologix, Irvine, CA), has been designed with a brand new concept to seal the abdominal aortic aneurysms, minimizing endoleaks and reducing reinterventions. We present the first open conversion of a Nellix endograft due to aortoduodenal fistula of a 74-year-old male patient treated for an abdominal aortic aneurysms of 62-mm diameter.

We report a case of abdominal endograft proximal collapse due to acute type B aortic dissection in a patient previously treated with endovascular repair (EVAR) for an infrarenal abdominal aortic aneurysm. Patient underwent axillobifemoral bypass grafting, in emergency. The postoperative computed tomography scan showed reexpansion of the occluded endograft. The patient died after 2 days with evidence of progression of the thrombosis of the false lumen and with involvement of renal, visceral, and medullar artery. EVAR collapse associated to acute type B aortic dissection is a challenging condition, which requires aggressive approach.

A 59-year-old male, referred to our center with a ruptured aortic aneurysm, underwent urgent endovascular repair and femoro-femoral crossover bypass. An endograft infection because of Aspergillus fumigatus occurred about 20 days after surgery. We removed the endograft and femoral prosthesis and we then performed an aorto-bi-iliac bypass with autogenous reversed superficial femoral veins. Five days after surgery, the patient died. Microbiological examination and postmortem examination showed the presence of A. fumigatus in femoral prosthesis, aortic wall, and periaortic exudate.

A 48-year-old woman was referred to us for a pulsatile and painful mass on the right leg after a trauma occurred 2 months earlier. The duplex scan revealed the presence of an aneurysm of the perforating peroneal artery. The patient underwent an endovascular coil embolization of the aneurysm. The duplex-scan follow-up showed the patency of the peroneal vessel and the complete aneurysm thrombosis. The patient was discharged in good condition without pain. In literature, only four cases of aneurysm of perforating peroneal artery aneurysm, all with a clear traumatic etiology, are reported. In this case, the endovascular treatment was safe and effective.

Les fistules aorto-esophagiennes sont rares mais mortelles si non traitees. La chirurgie thoracique ouverte est associe a une mortalite et a une morbidite operatoires elevees. Nous rapportons le cas d'un homme de 77 ans qui, traite par reparation aortique endovasculaire thoracique (TEVAR) pour anevrysme thoracique descendant dans un autre centre, apres un episode aigu d'hematemese et de moelena avait ete transfere dans notre centre. Le scanner corps entier montrait la re-perfusion du sac anevrysmal thoracique descendant (8,8 cm de diametre) au niveau de la zone proximale et distale d'ancrage de TEVAR (endofuite de type I) sans signes clairs de fistule avec la lumiere oesophagienne. Le malade a eu un nouveau TEVAR a travers l'implantation precedente avec ancrage proximal tres proche de l'artere sous-claviere gauche et ancrage distal juste au-dessus du tronc coeliaque. En raison de la presence d'une fistule tracheo-esophagienne, une endoprothese oesophagienne a ete implantee peu apres, et une jejunostomie a ete faite. A 30 jours, le malade etait en bonne etat general, mais il est mort a 3 mois. Les fistules aorto-oesophagiennes sont rares et habituellement mortelles ; l'identification precoce et le traitement par TEVAR empechent l'exsanguination immediate des malades, mais apres deploiement de l'endoprothese, la plupart des malades sont a risque de complications infectieuses. L'arret du saignement et la restauration de la circulation sont l'urgence primordiale, mais les complications infectieuses et la reparation oesophagienne demeurent des problemes non resolus.

Aortoesophageal fistula is rare but fatal if untreated. Open thoracic surgery is associated with high operative mortality and morbidity. We report a case of a 77-year-old man who, treated with thoracic endovascular aortic repair (TEVAR) for descending thoracic aneurysm in another center, after an acute episode of hematemesis and melena was referred to our center. The total body computed tomography scan showed the presence of reperfusion of the descending thoracic aneurysm sac (8.8 cm in diameter) in the proximal and distal TEVAR landing zone (endoleak type I) without clear signs of fistulous tract with the esophageal lumen. The patient underwent new TEVAR inside previous implantation with proximal landing very close to left subclavian artery and distal landing just above celiac trunk. For the presence of a tracheoesophageal fistula, an esophageal endoprosthesis was implanted few days later, and a jejunostomy was performed. At 30 days, patient was in good general condition, but he died at 3 months' follow-up. Aortoesophageal fistula is a rare and usually fatal condition; early recognition and TEVAR treatment prevent immediate exsanguination in patients, but after deployment of the endograft, most patients are at risk for infectious complications. Cessation of bleeding and restoration of circulation is of paramount urgency, but infectious diseases and esophageal repair remain open problems.

Un homme de 69 ans etait transfere dans notre service pour le debut soudain d'une douleur a type de compression de la jambe droite, sans ischemie aigue menacante. L'examen duplex, suivi d'une angiographie selective de jambe, montrait un anevrysme peronier. Un diagnostic d'anevrysme mycotique etait fait sur la base de l'etat clinique du patient, des hemocultures positives, et du site inhabituel de la lesion. La reparation endovasculaire etait faite en employant une embolisation par spires un stent couvert. Le patient est sorti en bon etat general sans douleur. Dans les donnees precedemment publiees, seulement quatre cas d'anevrysmes peroniers mycotiques ont ete rapportes. Dans ce cas, le traitement endovasculaire a ete sur et efficace.

Cinq patients ont ete traites pour des anevrysmes des arteres viscerales rompus pendant les 9 dernieres annees, dont deux anevrysmes spleniques et trois pancreatico-duodenaux. La taille moyenne de l'anevrysme etait de 2,6 cm (extremes : 1,5-5 cm). Tous les patients ont eu un traitement chirurgical ouvert. Il y a eu un deces operatoire. Apres un suivi moyen de 46,6 mois, il n'y avait aucun cas de mortalite ou de complication secondaire. Les auteurs concluent que le traitement chirurgical des anevrysmes des arteres viscerales rompus est durable.

The aberrant right subclavian artery (ARSA) aneurysm is rare; however, the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. In this report, we have described two cases of this anomaly. In the first case, a 62-year-old male patient presented with a symptomatic aneurysm of ARSA (maximum diameter of 4 cm) causing chest pain with dyspnea during moderate physical effort. Surgical treatment was performed with aneurysmal exclusion and direct anastomosis of the two heads of the subclavian artery. In the second case, a 72-year-old male patient presented with a symptomatic aneurysm (maximum diameter of 5.1 cm) of ARSA causing dysphagia and dysphonia. In this case, a one-stage hybrid treatment was performed: a bilateral carotid-subclavian bypass was associated with intentional occlusion of both subclavian arteries (by plug positioning) during thoracic endovascular stent-grafting procedures. In both cases, the peri/postoperative course was uneventful and the technical results in our series were excellent at long-term follow-up. Surgical treatment can be safely performed in patients with low operative risk or whenever endovascular technique is not suitable. The ARSA aneurysm, with appropriate anatomy, can be successfully treated by hybrid treatment (combined surgical and endovascular approach). We reckon that this minimally invasive technique helps avoid thoracotomy and could be the treatment of choice in high-risk patients.

Les anevrysmes de l'artere sous-claviere droite aberrante (ARSA) sont rares ; cependant, les risques de rupture et thromboembolique sont eleves, avec un taux de mortalite post-rupture de 50%. Dans ce travail, nous decrivons deux cas de cette anomalie. Dans le premier cas, un homme de 62 ans s'est presente avec un anevrysme symptomatique de l'ARSA (diametre maximum de 4 cm) causant une douleur thoracique avec dyspnee pendant un effort physique modere. Le traitement chirurgical a ete fait avec exclusion anevrismale et anastomose directe des deux extremites de l'artere sous-claviere. Dans le deuxieme cas, un homme de 72 ans s'est presente avec un anevrysme symptomatique (diametre maximum de 5,1 cm) de l'ARSA causant une dysphagie et une dysphonie. Dans ce cas, un traitement hybride en un temps a ete fait : un pontage carotido-sous-clavier bilateral a ete associe a l'occlusion intentionnelle des deux arteres sous-clavieres (par plug) pendant des procedures de stentgraft endovasculaire thoraciques. Dans les deux cas, les suites postoperatoires etaient simples et les resultats techniques de nos cas etaient excellents au suivi a long terme. Le traitement chirurgical peut etre effectue sans risque chez les patients avec un faible risque operatoire ou toutes les fois que la technique endovasculaire n'est pas adaptee. L'anevrysme de l'ARSA, avec une anatomie appropriee, peut etre traite avec succes par traitement hybride (approche chirurgicale et endovasculaire combinees). Nous soulignons que cette technique miniinvasive evite la thoracotomie et pourrait etre le traitement de choix chez les patients a haut risque.

Les malformations vasculaires congenitales representent un grand nombre de maladies avec une grande variabilite de presentation clinique. L’association entre des malformations vasculaires congenitales et des anevrysmes peripheriques est tres rare. La presente etude presente un cas d’anevrysme geant de l’artere femorale superficielle (7-cm de long) lie au syndrome de Parkes-Weber (malformation capillaire, fistules arterioveineuses multiples [AVFs], hypertrophie squelettique du membre affecte) traite en placant deux endoprotheses couvertes auto-expansibles apres embolisation de l’AVF avec des coils de Gianturco. Les suites peri et postoperatoires etaient simples et l’angiographie post procedurale montrait l’exclusion complete du sac de l’anevrysme. Apres 87 mois, le balayage duplex et la tomodensitometrie montraient la permeabilite arterielle avec thrombose du sac de l’anevrysme et la presence d’un grand nombre de AVFs. L’association entre le syndrome de Parkes-Weber et les anevrysmes peripheriques represente une entite tres rare. Le manque d’evidence ne permet pas l’etablissement du traitement le plus approprie de cette maladie. L’approche endovasculaire avec embolisation prealable des AVFs peut representer une alternative valide a la reparation chirurgicale traditionnelle, qui est encore grevee par un pourcentage eleve de complications et d’echecs.

Les anevrysmes vrais de l’artere tibiale sont rares et leur rupture est tres rare. Nous rapportons le cas d’un homme de 59 ans qui, apres un episode d’endocardite bacterienne, a presente un anevrysme tibial posterieur rompu. A notre connaissance, c’est le premier cas d’une veritable rupture d’un anevrysme geant de l’artere tibiale posterieure (diametre, 6 cm). Le traitement s’est compose de l’anevrysmectomie avec ligature arterielle. Un ulterieur de 24 mois a ete fait avec de bons resultats.

Nous rapportons le cas d’un homme de 54 ans ayant presente un accident vasculaire cerebral (AVC) aigu provoque par l’occlusion de l’artere carotide interne (ACI) gauche secondaire a un mesotheliome pleural, decouvert plus tard. Le scanner cerebral indiquait une lesion ischemique de l’hemisphere gauche. A l’examen neurologique, le score de NIHSS modifie (NIHSSm) etaient de 9. L’echodoppler (ED) carotidien montrait une occlusion thrombotique complete de l’ACI gauche. Le patient a subi une thrombectomie carotidienne de sauvetage. Les tests de depistage ont indique une thrombocytemie, une hyperfibrinogenemie, des valeurs accrues de C-reactive proteine, et de multiples nodules pleuraux gauche de mesotheliome confirme par analyse immunohistochimique. Apres chirurgie, les symptomes neurologiques du patient se sont ameliores, avec un score NIHSSm a 3. A 30 et 120 jours, le suivi ED montrait une permeabilite normale de l’ACI.

We treated two patients with asymptomatic high grade internal carotid artery stenosis, by carotid artery stenting (CAS) with embolus protection filters 75% and 70%, respectively (North American Symptomatic Carotid Endarterectomy criteria). The immediate cranial and carotid angiogram showed a good result with regular patency of carotid and cerebral vessels. In both cases, the CAS procedure was complicated with symptomatic embolism, in one case 6 h after CAS and the other one occurring after seven days. The duplex scan (DS) control revealed the presence of plaque protrusion intra-stent in both cases. An early treatment with stent removal and carotid surgery was performed