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Objectives: Fungal prosthetic vascular graft infections are rare and mainly supra-inguinal. Current guidelines are based on the few studies that have specifically investigated this population, with few risk factors described. The objective of this study is to compare fungal and non-fungal supra-inguinal prosthetic vascular graft infections (PVGI), describing their specificities, identifying risk factors, and evaluating outcomes., Patients and Methods: This is a single-center retrospective cohort study carried out at the Pitié-Salpêtrière Hospital in Paris, including all patients who were treated for a supra-inguinal PVGI between January 1st, 2009 and February 28th, 2021. Preoperative, intraoperative and postoperative data were compared between fungal and non-fungal PVGI., Results: Out of the 475 patients screened, 148 developed a supra-inguinal PVGI: 32 fungal and 116 non-fungal. Factors independently associated with fungal PVGI were presence of a prostheto-digestive fistula (OR 5.98; 95% CI 2.29-15.62) and preoperative antibiotic therapy of seven days or more (OR 2.87; 95% CI 1.12-7.38). Mortality rate at 180 days was significantly higher for fungal as compared to non-fungal PVGIs (38% vs. 16% p = 0.009) and for fungal PVGI with prostheto-digestive fistula. However, there was no statistically significant relation between mortality due to prostheto-digestive fistula in contrast with fungal PVGI alone (p = 0.21)., Conclusion: Prostheto-digestive fistula was strongly associated with fungal PVGI, which leads us to suggest that in such cases, an anti-fungal agent should be prescribed., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

The optimal surgical treatment for extended thoracoabdominal aortic aneurysms (TAAAs) is still a matter of debate. The historical treatment is open repair (OR), but over the past fifteen years, endovascular strategies have gained widespread acceptance. Although several endovascular techniques have been described for the treatment of TAAAs, fenestrated and branched stent grafts (F/BEVARs) are the most frequently used and best documented. They have become the first-line treatment for both high- and moderate-risk surgical patients in most vascular centers. However, no randomized study comparing OR and F/BEVAR has been published, and decision-making is mainly based on the physician's preference and/or hospital expertise. The objective of this manuscript is to provide an overview of current comparative data for OR and F/BEVAR.

Pelvic schwannomas are rare tumors that may occur either sporadically or in the context of schwannomatosis. We retrospectively reviewed the charts of patients harboring a pelvic schwannoma under conservative management or operated at our reference center between 2016 and 2023. All patients were operated by a multidisciplinary team, combining a vascular surgeon and a neurosurgeon. Twenty-four patients harboring 33 pelvic tumors were included in the cohort, including 12 patients with sporadic lesions, 2 patients with NF2-related schwannomatosis, and 10 patients with NF2-independent schwannomatosis. Multi-nodular tumors were more frequent in schwannomatosis compared to sporadic cases (p = 0.005). The mean age at diagnosis was 41 years old. Schwannomas were located on branches of the sciatic nerve (23/33, 70%), the femoral nerve (6/33, 18%), and the obturator nerve (4/33, 12%). Over the course of the study, 16 patients were operated, including 11 sporadic cases. The indication for surgery was pain (12/16, 75%) or tumor growth (4/16, 25%). Complete resection was achieved in 14 of 16 patients (87%). The mean post-operative follow-up was 37 months (range: 2-168 months). At last-follow-up, complete pain relief was achieved in all 12 patients with pre-operative pain. Post-operative morbidity included 3 long-term localized numbness and one MRC class 4 motor deficit in a multi-nodular tumor in a schwannomatosis patient. Despite its limited size, our series suggests that nerve-sparing resection of pelvic schwannomas offers satisfying rates of functional outcome both in sporadic and schwannomatosis cases, except for multi-nodular tumors., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The long-term outcomes of patients undergoing functional assessment of coronary lesions with fractional flow reserve (FFR) while awaiting transcatheter aortic valve implantation (TAVI) are unknown. Data on the safety of intracoronary adenosine use in this setting are scarce. The objectives of this study were to describe (1) the long-term outcomes based on the coronary artery disease (CAD) assessment strategy used and (2) the safety of intracoronary adenosine in patients with severe aortic stenosis (AS)., Methods: 1023 patients with severe AS awaiting TAVI were included. Patients were classified according to their CAD assessment strategy: angiography guided or FFR guided. Patients were further subdivided according to the decision to proceed with percutaneous coronary intervention (PCI): angiography-guided PCI (375/1023), angiography-guided no-PCI (549/1023), FFR-guided PCI (50/1023), and FFR-guided no-PCI (49/1023). Patients were followed up for the occurrence of major adverse cardiac and cerebrovascular events (MACCEs)., Results: At a mean follow-up of 33.7 months, we observed no significant differences in terms of major adverse cardiovascular and cerebrovascular events (MACCE) in the angiography-guided group (42.4%) compared with the FFR-guided group (37.4%) ( p = 0.333). When comparing outcomes of the FFR-guided no-PCI group (32.7%) with the angiography-guided PCI group (46.4%), no significant difference was noted ( p = 0.999). Following intracoronary adenosine, a single adverse event occurred., Conclusions: In this population, intracoronary adenosine is safe and well tolerated. We found no significant benefit to an FFR-guided strategy compared with an angiography-guided strategy with respect to MACCEs. Although clinically compelling, avoiding the procedural risks of PCI by deferring the intervention in functionally insignificant lesions failed to show a statistically significant benefit., Competing Interests: Dr Josep Rodés-Cabau has received research grant support from 10.13039/100006520Edwards Lifesciences, 10.13039/100004374Medtronic, and 10.13039/100006279St. Jude Medical. The other authors had no conflicts to declare., (© 2023 The Author(s).)

Animal studies are often required to evaluate new cardiovascular medical devices before they reach the market. Moreover, first-generation novel devices including aortic endovascular prostheses and circulatory support devices are often larger than later iterations or tested in a limited range of sizes. One of the challenges in evaluating these devices is finding a model that is both accessible and anatomically similar to humans, as there is a paucity of data on vascular dimensions in large animals. We set out to complete a comprehensive review of available reports on vascular dimensions in swine, ovine, and bovine models, with a particular focus on the descending aorta and ilio-femoral arteries. We searched Embase and MEDLINE databases for reports of descending aorta and peripheral vascular dimension in large animal models. Data from swine, ovine, and bovine models were separated by weight into 3 categories: 40 to 60 kg, 61 to 80 kg, and >80 kg. We also incorporate our computed tomography angiography data from 4 large sheep and 9 calves into this review. Swine, sheep, and calf >80 kg may serve as the best models to maximize aortic diameter resemblance to humans. If device implantation can be achieved in aortas of smaller dimensions, care should be taken to ensure access site suitability such as the common femoral artery in these smaller animals.

Background: When best medical treatment fails to relieve symptoms of aorto-iliac occlusive disease, endovascular treatment or conventional open surgery are the remaining options depending on lesions and patients' characteristics. However, in certain situations both endovascular tools and abdominal aorta to bifemoral bypass (TFB) are not an option and the use of the descending thoracic aorta may be considered as an inflow site for revascularization., Methods: This work is a single-center retrospective study. Between 2008 and 2020, 27 patients were identified who were treated with descending thoracic aorta to TFB for severe aorto-iliac occlusive disease. Primary end point was 30-day postoperative mortality and major cardiovascular events. Secondary end points were primary patency, secondary patency, and all-cause mortality., Results: The mean age of patients was 68 years and the majority (88.9%) presented with severe claudication. Eighteen patients underwent isolated TFB and 9 had TFB and concomitant visceral vessel revascularization. The mean length of stay was 14 days and there was no postoperative death. Complications, mainly pulmonary, occurred in 29.8% of the cases. After a mean of 26 months of follow-up, survival rate was 95% and primary and secondary patency rates were 92.6% and 96.3%, respectively. Mean Rutherford index shifted from 3.1 to 1.2 (P < 0.001)., Conclusions: TFB is an invasive procedure which provides high clinical improvement and patency rates. This procedure should remain part of the vascular surgeon portfolio., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: COVID-19 infection is associated not only with venous thromboses but also with arterial thromboses (COV-ATs) in relation with an endothelial dysfunction, a coagulopathy and rhythm disorders. The incidence, the topography, and the prognosis of COV-ATs remain poorly known. The objective of this study was to report the overall experience of the Greater Paris University Hospitals (Assistance Publique - Hopitaux de Paris, AP-HP) during the first pandemic wave of COVID-19 infection., Methods: After approval by the ethics committee, a study using the AP-HP clinical data warehouse was carried out between March and May 2020. Overall, 124,609 patients had a polymerase chain reaction for COVID-19 in our hospitals, of which 25,345 were positive. From 20,710 exploitable stays, patients tested positive for COVID who presented an episode of acute COV-AT (except coronary and intracranial arteries) were selected on the basis of the French medical classification for clinical procedures codes. The data are presented as absolute values with percentages and/or means with standard deviation., Results: Over the studied period, 60 patients (aged 71±14 years, 42 men) presented a COV-AT at the time of their hospitalization, an incidence of 0.2%. The arterial complication occurred 3±7 days after the COVID infection and was inaugural in 30% of the cases (n = 18). The sites of COV-AT were the lower extremities (n = 35%, 58%), the abdominal aorta (n = 10%, 17%), the thoracic aorta (n = 7%, 12%), the upper limbs (n = 7%, 12%), the cerebral arteries (n = 7%, 12%), the digestive arteries (n = 6%, 10%), the renal arteries (n = 2%, 3%), and the ophthalmic artery (n = 1%, 2%). Multiple COV-ATs were observed in 13 patients (22%). At the time of diagnosis, 20 (33%) patients were in intensive care, including six (10%) patients who were intubated. On computed tomography angiography, COVID lesions were classified as moderate and severe in 25 (42%) and 21 (35%) cases, respectively. Revascularization was attempted in 27 patients (45%), by open surgery in 16 cases, using endovascular techniques in 8 cases and with a hybrid approach in three cases. Six patients (22%) required reinterventions. The duration of hospitalization was 12±9 days. Early mortality (in-hospital or at 30 days) was 30% (n = 18). Nine (15%) patients presented severe nonlethal ischemic complications., Conclusions: Arterial involvement is rare during COVID-19 infection. The aorta and the arteries of the limbs are the privileged sites. The morbi-mortality of these patients is high. Future studies will have to determine if the systematization of anticoagulation therapy decreases the incidence and the severity of the condition., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Mycotic/infective native aortic aneurysms (INAA) are managed heterogeneously. In the context of disparate literature, this study aimed to assess the outcomes of INAA surgical management and provide comprehensive data in alignment with recent suggestions for reporting standards., Methods: A retrospective review of patients presenting with INAA from September 2002 to March 2020 at two institutions was conducted. In hospital mortality, 90 day mortality, overall mortality, and infection related complications (IRCs) were the study endpoints. Overall survival and IRC free survival were estimated, and predictors of mortality tested using uni- and multivariable analyses., Results: Seventy patients (60 men [86%], median age 68 years [range 59 - 76 years]) were included. Twenty (29%) were ruptured at presentation. INAA location was thoracic in 11 (16%) cases, thoraco-abdominal in seven (10%), and abdominal in 50 (71%). Half of the abdominal INAAs were suprarenal. Two INAAs were concomitantly abdominal and thoracic. Pathogens were identified in 83%. The bacterial spectrum was scattered, with rare Salmonella species (n = 6; 9%). Open surgical repair was performed in 66 (94%) patients, including five conversions of initially attempted endovascular grafts (EVAR), three hybrid procedures, and one palliative EVAR. Vascular substitutes were cryopreserved arterial allografts (n = 67; 96%), prosthesis (n = 2), or femoral veins (n = 1). Kaplan-Meier estimates of overall survival at 30 and 90 days were 87% (95% confidence interval [CI] 76.6 - 93.0) and 71.7% (95% CI 59.2 - 80.9), respectively. The overall in hospital mortality rate was 27.9% (95% CI 1.8 - 66.5). IRCs occurred in seven (10%) patients. The median follow up period was 26.5 months (range 13.0-66.0 months). Chronic kidney disease (CKD) was independently related to in hospital mortality (odds ratio [OR] 20.7, 95% CI 1.8 - 232.7). American Society of Anesthesiologists score of 3 (OR 6.0, 95% CI 1.1 - 33.9), 4 (OR 14.9, 95% CI 1.7 - 129.3), and CKD (OR 32.0, 95% CI 1.2 - 821.5) were related to 90 day mortality., Conclusion: Surgical INAA management has significant mortality and a low re-infection rate. EVAR necessitated secondary open repair, but its limited use in this report did not allow conclusions to be drawn., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The treatment of complex aortic disease has been described with various retrograde visceral bypass techniques. An original technique with a single stem retrograde visceral graft (SSRVG) is presented., Methods: This was a single centre retrospective study including 16 patients between 2015 and 2019. Patients were treated for aortic dissection (AD; type A and acute or chronic type B), thoraco-abdominal aortic aneurysms (TAAAs), and visceral occlusive disease. Surgery consisted of visceral vessel debranching from the native infrarenal aorta or from an aortic graft. In the case of AD, surgical fenestration was performed. Additional thoracic endovascular aneurysm repair (TEVAR) completed the treatment when indicated, during the same procedure or later. Patient outcomes and reconstruction patency were studied., Results: The mean patient age was 64 years (median 68 ± 12.6). Ten (62%) patients were treated for AD, three (19%) for TAAA, and three (19%) for occlusive disease. Sixty-nine target vessels were debranched with this SSRVG technique. Aortic surgical fenestration was performed in eight cases and TEVAR in four. During their hospital stay, three (19%) TAAA patients died, seven cases of renal insufficiency (44%), four cases of pneumonia (25%), and three colonic ischaemia cases (19%) were noted. After a mean follow up of 21 months, no other deaths occurred. All vessels (except two inferior mesenteric arteries) were patent and no endoleak was noted., Conclusion: The SSRVG technique can be offered in various complex aortic diseases. The use of a single graft is feasible and reduces the volume of multiple branch assembly in the retroperitoneal space. The observed patency rate is high., (© 2022 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery.)

Background: Vascular and bleeding complications related to secondary femoral access site are frequent in patients undergoing transcatheter aortic valve replacement (TAVR), and their occurrence is associated to poorer outcomes. We aimed to evaluate the clinical impact of vascular closure devices (VCDs) for secondary femoral access hemostasis in TAVR procedures., Methods: This was a multicenter study including 4031 patients who underwent TAVR (mean age, 81 ± 8 years; mean Society of Thoracic Surgeons [STS] score, 4.9 [interquartile range, 3.3-7.6]), and had a secondary femoral access. The 30-day clinical outcomes were analyzed according to femoral access-site hemostasis (manual compression vs VCD), and according to the type of VCD (Perclose [Abbott Cardiovascular] vs Angio-Seal [Terumo Interventional Systems]) using a propensity-matched, multivariable, logistic regression model., Results: Manual compression was used in 941 patients (23.3%) and VCDs were used in 3090 patients (76.7%; Perclose in 1549 patients [38.4%] and Angio-Seal in 1541 patients [38.2%]) for secondary femoral access hemostasis. Vascular complications related to secondary access site occurred in 162 patients (4%), and were more frequent in patients who underwent manual compression (7.2%) compared with VCD hemostasis (3%; adjusted P<.001). In the VCD group, the use of Angio-Seal (vs Perclose) was associated with a higher rate of vascular complications (3.7% vs 2.4%, respectively; adjusted P=.02), femoral artery pseudoaneurysm (1.3% vs 0.4%, respectively; adjusted P<.01), invasive treatment requirement for treating vascular complications (surgery: 0.8% vs 0.3%, respectively [adjusted P=.03]; and thrombin injection: 0.9% vs 0%, respectively [adjusted P<.001])., Conclusion: VCDs represented a safer and more effective alternative compared with manual compression for secondary femoral access-site hemostasis in patients undergoing TAVR procedures, and the Perclose VCD was associated with the lowest risk of vascular complications. Future randomized studies are warranted.

Objective: To investigate the use of cryopreserved arterial allografts (CAA) as a substitute for infected infrarenal aortic prostheses, and its outcomes., Methods: A single centre retrospective study of consecutive patients receiving an abdominal aortic CAA after removal of an infected graft was conducted between January 1997 and December 2013. The primary outcome was the rate of allograft related revision surgery. Secondary outcomes were the 30 day mortality rate, survival, primary patency, limb salvage, and infection recurrence. Allograft ruptures secondary to infection and risk factors for allograft failure were also investigated., Results: Two hundred patients (mean age 64.2 ± 9.4 years) were included. In 56 (28%) cases, infection was related to an enteric fistula. The mean follow up duration was 4.1 years. The 30 day mortality rate was 11%. Early revision surgery was needed in 59 patients (29.5%). Among them, 15 (7.5%) were allograft related and led to the death of three patients (1.5%), corresponding to a 7.5% 30 day allograft related revision surgery rate. During the first six months, 17 (8.5%) patients experienced 21 events with complete or partial rupture (pseudo-aneurysm) of the allograft responsible for five (2.5%) deaths, corresponding to a re-infection rate of 8.5%. The multivariable analysis showed that diabetes and pseudo-aneurysm of the native aorta on presentation were predictive factors for short term allograft rupture. After six months, 25 (12.5%) patients experienced long term allograft complications (rupture, n = 2, 1%; pseudo-aneurysm, n = 6, 3%; aneurysm, n = 2, 1%; thrombosis, n = 11, 5.5%; stenosis, n = 4, 2%;) requiring revision surgery resulting in one death. The five year rates of survival, allograft related revision surgery, limb salvage, primary patency, and infection recurrence were 56%, 30%, 89%, 80%, and 12%, respectively., Conclusion: CAAs provide acceptable results to treat aortic graft infection with few early graft related fatal complications. Long term allograft related complications are quite common but are associated with low mortality and amputation rates., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To describe the rates of healing, major amputation and mortality after 12 months in patients with a new diabetic foot ulcer (DFU) and their care in a French diabetic foot service (DFS)., Method: A prospective single-centre study including patients from March 2009 to December 2010. The length of time to healing, minor amputation, major amputation and mortality rate after inclusion were analysed using the Kaplan-Meier method., Results: Some 347 patients were included (3% lost to follow-up), with a median follow-up (IQR) of 19 (12-24) months. The mean (SD) age was 65±12 years, 68% were male, and the median duration of the ulcer was 49 (19-120) days. Complications of the DFU were ischaemia (70%), infection (55%) and osteomyelitis (47%). Of the patients, 50% were inpatients in the DFS at inclusion (median duration of hospitalisation 26 (15-41) days). The rate of healing at one year was 67% (95% confidence interval (CI): 61-72); of major amputation 10% (95% CI: 7-17); of minor amputation 19% (95% CI: 14-25), and the death rate was 9% (95% CI: 7-13). Using an adjusted hazard ratio, the predictive factors of healing were perfusion and the area of the wound. The risk factors for a major amputation were active smoking and osteomyelitis. The risk factors for mortality were perfusion and age., Conclusion: This study confirms the need to treat DFUs rapidly, in a multidisciplinary DFS.

Objectives: To determine the occurrence of vascular complications (VCs) following transfemoral transcatheter aortic valve replacement (TAVR) with new-generation devices according to the use of a crossover technique (COT)., Background: The use of a COT (with/without balloon) has been associated with a reduction of VCs in TAVR patients. However, scarce data support its use with second-generation devices. Also, its potential benefit in obese patients (at high-risk of VCs) has not been elucidated., Methods: A multicenter study including 2214 patients who underwent full percutaneous transfemoral TAVR (COT, 1522 patients; no COT, 692 patients). Thirty-day events were evaluated according to the use of a COT using a multivariate logistic regression model. A subanalysis was performed in obese patients., Results: Primary access major VCs (3.5% COT vs 3.9% no COT; P=.19), major/life-threatening bleeding (3.4% COT vs 2.0% no COT; P=.33), and mortality rates (2.4% COT vs 2.6% no COT; P=.23) were similar between groups. However, minor VCs (11.7% COT vs 5.9% no COT; P<.001) and postprocedural acute renal failure (8.9% COT vs 3.9% no COT; P<.001) were higher in patients undergoing the COT. In the overall cohort, percutaneous closure device failure was more frequent in obese patients (4.0% in the obese group vs 1.9% in the non-obese group; P<.01), but these differences were no longer significant in those undergoing a COT (3.4% in the obese group vs 2.0% in the non-obese group; P=.12). Indeed, in the subset of obese patients, the COT tended to be associated with fewer VCs (3.4% COT vs 5.9% no COT; P=.09)., Conclusions: The use of a COT was not associated with a reduction of major VCs or improved outcomes. However, some patient subsets, such as those with higher body mass index, may benefit from the use of a COT. These findings would suggest the application of a tailored strategy, following a risk-benefit assessment in each TAVR candidate.

Background: Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts., Methods: Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity., Results: Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively., Conclusions: Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to determine, in patients undergoing percutaneous coronary intervention (PCI) during the work-up pre-transcatheter aortic valve replacement (TAVR): 1) the clinical and peri-procedural PCI characteristics; 2) the long-term outcomes; and 3) the clinical events in those patients with complex coronary features., Background: A PCI is performed in about 25% of TAVR candidates, but procedural features and late outcomes of pre-TAVR PCI remain largely unknown., Methods: Multicenter study including 1197 consecutive patients who had PCI in the work-up pre-TAVR. A total of 1,705 lesions (1.5 ± 0.7 lesions per patient) were included. Death, stroke, myocardial infarction, and major adverse cardiovascular and cerebrovascular events (MACCE) were recorded, as well as target lesion failure (TLF) and target vessel failure (TVF)., Results: One-half of patients exhibited a multivessel disease and the mean SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) score was 12.1 ± 9.1. The lesions were of B2/C type, calcified, bifurcation, and ostial in 49.9%, 45.8%, 21.4%, and 19.3% of cases, respectively. After a median follow-up of 2 (interquartile range: 1 to 3) years, a total of 444 (37.1%) patients presented an MACCE. Forty patients exhibited TVF (3.3%), with TLF identified in 32 (2.7%) patients. By multivariable analysis, previous peripheral artery disease (p < 0.001), chronic obstructive pulmonary disease (p = 0.002), atrial fibrillation (p = 0.003), diabetes mellitus (p = 0.012), and incomplete revascularization (p = 0.014) determined an increased risk of MACCE. In patients with unprotected left main or SYNTAX score >32 (n = 128), TLF, TVF, and MACCE rates were 3.9%, 6.3%, and 35.9%, respectively (p = 0.378; p = 0.065, and p = 0.847, respectively, vs. the rest of the population)., Conclusions: Patients undergoing PCI in the work-up pre-TAVR frequently exhibited complex coronary lesions and multivessel disease. PCI was successful in most cases, and TLF and TVF rates at 2-year follow-up were low, also among patients with high-risk coronary features. However, overall MACCE occurred in about one-third of patients, with incomplete revascularization determining an increased risk. These results should inform future studies to better determine the optimal revascularization strategy pre-TAVR., Competing Interests: Author Relationship With Industry Dr. Faroux has received fellowship support from Institut Servier and the Association Régionale de Cardiologie de Champagne-Ardenne; and has received research grant support from Biotronik, Edwards Lifesciences, and Medtronic. Dr.Rodés-Cabau has received institutional research grants from Edwards Lifesciences, Medtronic, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Arterial involvement in Behçet disease (BD) is rare, and its surgical management is a major concern because of its high recurrence rate. This study evaluated the influence of the surgical technique, device, and immunosuppressive treatment used on the postoperative recurrence in patients with non-pulmonary arterial BD., Methods: A single-center, retrospective study was conducted of 23 patients meeting the international criteria for BD who underwent surgery for arterial involvement between May 1996 and September 2015. Recurrence was defined as the occurrence of arterial aneurysm or thrombosis during follow-up. Perioperative medical treatment and surgical technique used were reported., Results: There were 47 surgical procedures performed in 23 patients. Mean follow-up was 8.4 ± 7.5 years. Initial arterial lesions were aneurysms and thrombosis in 85% and 15% of cases, respectively. Arterial lesions were aortic and peripheral in 48% and 52% of cases. Recurrence rate was 51%. Recurrences developed within <1 year in 24% of cases and at the same anatomic site in 92% of cases. Among the 24 recurrences, 17 were false aneurysms, 6 were thrombosis, and 1 was a true aneurysm in a different arterial site. To treat the arterial lesion, direct anastomosis was performed in 6 cases; bypass using the saphenous vein, graft, or allograft was performed in 6, 27, and 5 cases, respectively; and stent graft was used in 3 cases. Vascular lesions involved the aorta in 19 cases and a peripheral artery in 28 cases. Preoperative medical treatments, including colchicine, steroids, and immunosuppressants, significantly decreased recurrence rate: 28% (7/25) vs 75% (15/20) in untreated patients (P = .002). The recurrence rate was 42.5% (17/40) in patients treated postoperatively vs 80% (4/5) in untreated patients. The nature of the device used (vein, prosthetic graft, allograft, stent graft, or direct anastomosis) did not change the risk of recurrence. When anastomoses were protected using the prosthetic sleeving technique, the recurrence rate was three times lower (P = .08)., Conclusions: Relapse is a main concern after surgical repair of arterial BD. This study suggests the need for targeted perioperative medical management to reduce the risk of arterial recurrence in BD patients. To this end, a multidisciplinary approach is mandatory. The use of sleeve anastomosis is associated with a numerically lower risk of recurrence. However, further studies are needed to confirm this efficacy., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Carotid endarterectomy and carotid artery stenting are both valid therapeutic options for the treatment of radiation-induced carotid stenosis (RICS). The second has the advantage of being less invasive, although it seems to result in more restenosis than the first. Meanwhile, progress in radiation therapy and head and neck surgery has significantly increased the survival of these patients. As a result, treatment of RICS should be considered from a long-term perspective. This works presents perioperative and follow-up outcomes of surgical treatment of RICS., Methods: This single-center retrospective study included all patients who underwent carotid endarterectomy for RICS from January 1998 to June 2017. Clinical and duplex ultrasound examination-based follow-up was performed postoperatively, at 1 month, 6 months, 12 months, and yearly thereafter. Kaplan-Meier curves were used for survival plots based on a log-rank test. Any abnormal finding led to angio-computed tomography scan and specialized neurovascular examination., Results: Between 1998 and 2017, 128 patients (162 lesions) were treated. The median interval between radiation therapy and surgery was 16 years. Forty-five patients (35%) were symptomatic. The eversion technique was performed in 79 cases (49%), and the patch was favored in 24 cases (15%), prosthetic bypass graft in 51 cases (31%), and a venous bypass graft in 8 cases (5%). Two postoperative deaths (1.5%) (one secondary to massive stroke) were noted. The primary end point of early postoperative cerebrovascular event was 2.5%. Two cervical hematomas (1.2%) required surgical revision and seven cases of permanent cranial nerve injury were recorded. The median follow-up was 29 months (range, 2-199 months). There were no additional strokes. The 3-year primary patency rate was 96% and the 3-year freedom from neurologic event was 98%., Conclusions: Open surgical treatment of RICS lesions is a safe and durable option. Our results suggest that the outcomes of such treatment are good and in particular that rates of cerebrovascular event and restenosis are low and that cranial nerve injury should not be a concern. As a result, we consider that open surgery for RICS lesions should be offered as a first-line treatment. However, comparative data are mandated to address this issue., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the rates of healing, major amputation and mortality after 12 months in patients with a new diabetic foot ulcer (DFU) and their care in a French diabetic foot service (DFS)., Method: A prospective single-centre study including patients from March 2009 to December 2010. The length of time to healing, minor amputation, major amputation and mortality rate after inclusion were analysed using the Kaplan-Meier method., Results: Some 347 patients were included (3% lost to follow-up), with a median follow-up (IQR) of 19 (12-24) months. The mean (SD) age was 65±12 years, 68% were male, and the median duration of the ulcer was 49 (19-120) days. Complications of the DFU were ischaemia (70%), infection (55%) and osteomyelitis (47%). Of the patients, 50% were inpatients in the DFS at inclusion (median duration of hospitalisation 26 (15-41) days). The rate of healing at one year was 67% (95% confidence interval (CI): 61-72); of major amputation 10% (95% CI: 7-17); of minor amputation 19% (95% CI: 14-25), and the death rate was 9% (95% CI: 7-13). Using an adjusted hazard ratio, the predictive factors of healing were perfusion and the area of the wound. The risk factors for a major amputation were active smoking and osteomyelitis. The risk factors for mortality were perfusion and age., Conclusion: This study confirms the need to treat DFUs rapidly, in a multidisciplinary DFS.

Background: Currently, 2 third-generation transcatheter valves, 29-mm Sapien-3 and 34-mm Evolut-R (ER), are indicated for large sized aortic annuli. We analyzed short and 1-year performance of these valves in patients with large (area ≥575 mm 2 or perimeter ≥85 mm) and extra-large (≥683 mm 2 or ≥94.2 mm) aortic annuli undergoing transcatheter aortic valve replacement., Methods: A total of 833 patients across 12 centers with symptomatic aortic stenosis and large aortic annuli underwent transcatheter aortic valve replacement with 29-mm Sapien-3 (n=640) or 34-mm ER (n=193). Clinical, anatomic, and procedural characteristics were collected, and Valve Academic Research Consortium-2 outcomes were reported., Results: Median aortic annulus area and perimeter were 617 mm 2 (591-657) and 89.1 mm (87.0-92.1), respectively (704 mm 2 [689-743] and 96.0 mm [94.5-97.9] in the subgroup of 124 patients with extra-large annuli). Overall device success was 94.3% (Sapien-3, 95.8% and ER, 89.3%; P =0.001), with a higher rate of significant paravalvular leak ( P =0.004), second valve implantation ( P =0.013), and valve embolization ( P =0.009) in the ER group. Thirty-day and 1-year mortality was 2.4% and 9.2%, respectively, without differences between groups. Valve hemodynamics were excellent (mean gradient, 8.8±3.6 mm Hg; 3.3% rate of moderate-severe paravalvular leak) in the extra-large annulus, without differences compared with the large annulus group., Conclusions: In patients with large and extra-large aortic annuli, transcatheter aortic valve replacement using 29-mm Sapien-3 and 34-mm ER is safe and feasible. Observed differences in clinical outcomes and hemodynamic performance may guide valve choice in this cohort of patients undergoing transcatheter aortic valve replacement.

Objective: Treatment of renal artery aneurysms (RAA) remains controversial. Endovascular treatment has increased for main trunk and for very distal aneurysms, whereas for lesions located at the bifurcation surgical treatment seems to be a valid option. The goal of this study was to describe the technique of direct reconstruction of RAA and to report on outcomes., Methods: This study comprised single centre prospective collection of data with retrospective analysis (January 2015 to August 2018) of patients operated on for distal RAA using direct reconstruction., Results: A total of 24 RAA in 21 patients (seven men and 14 women, mean age 59 ± 13 years) was included. History of hypertension was found in 15 patients and renal insufficiency was present in one. Mean pre-operative systolic and diastolic blood pressures were 134 ± 21 mmHg and 74 ± 10 mmHg, and mean pre-operative rates of creatinine and glomerular filtration rate were 67 ± 13 μmol/L and 93 ± 49 mL/min/1.73 m 2 , respectively. Indications for repair were a diameter >20 mm in seven cases (mean diameter = 25 ± 2 mm) or rapid growth in one case, symptomatic aneurysm in 12 cases (hypertension, haematuria, pain), and a concomitant lesion in four cases (splenic aneurysm, abdominal aortic aneurysm, occlusive visceral artery lesions). All lesions were distal, main artery bifurcation in 22 cases and hilar in two cases. The main aetiology was fibromuscular dysplasia (16 cases) followed by atherosclerosis (seven cases) and one case of Ehlers Danlos Syndrome. In situ reconstruction was possible for 22 RAA, while two cases required kidney autotransplantation. The mean renal ischaemia time was 18 ± 5 min. At two years, the patency rate was 100%, and mean systolic blood pressure decreased (134 mmHg-122 mmHg, p = .047). Renal function was stable from 93 ± 49 pre-operatively to 95 ± 35 mL/min/1.73 m 2 in the post-operative course (p = .56)., Conclusion: Direct reconstruction appears to be efficient for most RAA. This technique is complementary to ex vivo autotransplantation and endovascular treatment., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: In the endovascular era, angioplasty has grown a large place in the treatment of peripheral artery disease. Few studies have been focused in short atherosclerotic lesions of the popliteal artery itself, which remain for many surgeons a critical zone for the technical approach decision. We herein describe simple techniques of popliteal endarterectomy for the treatment of short popliteal occlusive disease., Methods: Between January 2011 and June 2019, patients with isolated popliteal artery atherosclerotic lesions were included in this retrospective study. Indication for intervention was either disabling lower limb claudication or critical limb ischemia. We performed either endarterectomy by eversion of the popliteal artery or a simple endarterectomy with a patch angioplasty. We then studied the procedural data, the thirty-day outcomes, and the mid-term follow-up., Results: A total of 17 patients were included in the study, and 18 limbs were revascularized with the endarterectomy technique. Total duration of the procedure was 100 ± 46 min. Overall technical success was 100%. Median hospital stay was 4 days. Complete clinical success, that is, freedom from claudication or rest pain, was achieved in all cases. No early additional procedure was needed. After a mean follow-up of 34 ± 32 months with no patient lost to follow-up, all patients were alive, and a 100% primary patency and limb salvage was observed., Conclusions: At 3 years' follow-up, endarterectomy of the popliteal artery appears to be a valid option for isolated and short atherosclerotic lesions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: We sought to evaluate the position of balloon-expandable valves in relation to the coronary ostia using an angiographic- and computed tomography (CT)-based analysis, and to determine the impact of valve position on coronary angiography (CA)/percutaneous coronary intervention (PCI) feasibility and results., Methods: A total of 533 patients who received a Sapien XT or Sapien 3 valve were included in the angiographic analysis. Of these, 49 benefited from an opportunistic electrocardiography-gated CT after transcatheter aortic valve replacement (TAVR) and were included in the CT analysis., Results: Regarding the left coronary artery (LCA) ostium, the top of the transcatheter heart valve (THV) frame was infraostial in 49% of cases, and the valve totally covered the LCA ostium in 27% of patients. The stent frame of the Sapien 3 valve completely covered the LCA ostium more frequently than the Sapien XT valve (43% vs 12%, respectively; P<.001) and the relative implantation depth was significantly less ventricular in the Sapien 3 group than in the Sapien XT group (28.0 ± 12.3% vs 36.8 ± 12.6%, respectively; P<.001). The CT evaluation found similar results to angiographic evaluation. A total of 53 patients (10%) underwent CA (± PCI) following TAVR, and valve position did not influence CA performance/quality and PCI results., Conclusions: The stent frame of balloon-expandable Sapien valves exceeded the coronary ostia in about one-fourth of patients, and this percentage was >40% with the new-generation Sapien 3 valve. However, THV position did not affect the feasibility, quality, and results of CA/PCI post TAVR.

Objectives: This study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of late cerebrovascular events (LCVEs) (>30 days post-procedure) following transcatheter aortic valve replacement (TAVR)., Background: Scarce data exist on LCVEs following TAVR., Methods: This was a multicenter study including 3,750 consecutive patients (mean age, 80 ± 8 years; 50.5% of women) who underwent TAVR and survived beyond 30 days. LCVEs were defined according to the Valve Academic Research Consortium 2 (VARC 2) criteria., Results: LCVEs occurred in 192 (5.1%) patients (stroke, 80.2%; transient ischemic attack, 19.8%) after a median follow-up of 2 (1 to 4) years. Late stroke was of ischemic, hemorrhagic, and undetermined origin in 80.5%, 18.8%, and 0.7% of patients, respectively. Older age, previous cerebrovascular disease, higher mean aortic gradient at baseline, the occurrence of stroke during the periprocedural TAVR period, and the lack of anticoagulation (novel oral anticoagulants or vitamin K antagonists) post-TAVR were independent factors associated with late ischemic stroke/transient ischemic attack (p < 0.05 for all). Echocardiographic data at the time of the LCVE showed no signs of valve thrombosis or degeneration in the vast majority (97%) patients. Late stroke was disabling in 107 (69.5%) patients (ischemic, 68%; hemorrhagic, 79%), and associated with an in-hospital mortality rate of 29.2%., Conclusions: LCVEs occurred in 5.1% of TAVR recipients after a median follow-up of 2 years. LCVEs were ischemic in most cases, with older age, previous cerebrovascular events, higher mean aortic gradient at baseline, the occurrence during the periprocedural TAVR period, and lack of anticoagulation (but not valve thrombosis/degeneration) determining an increased risk. Late stroke was disabling in most cases and associated with dreadful early and midterm outcomes., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to assess the position of the CoreValve Evolut R/Pro (Medtronic) with respect to the left coronary artery (LCA) ostium and evaluate the impact of implantation depth on this relationship., Methods: One hundred consecutive patients who received an Evolut R/Pro valve and had an adequate angiography following valve implantation were included. Angiographic measurements included valve implantation depth, the position of the Evolut R/Pro with respect to the LCA, and the distance between the neo-valve cusp and the LCA ostium. Coronary access issues following TAVR were also recorded., Results: Regarding the LCA ostium, the neo-valve of the Evolut R/Pro was supraostial, at the ostial level, and infraostial in 3%, 12%, and 85% of cases, respectively. When beneath the LCA ostium, the mean distance between the neo-valve and the floor of the LCA ostium was 4.1 ± 5.2 mm. An implantation depth ≤6 mm was associated with a higher rate of neo-valve at the ostial level or above (25% vs 4% for implantation depth >6 mm; P=.01). Accessing the coronary arteries was required in 10% of the patients at 12 ± 8 months post TAVR, and selective coronary angiography of the left and right coronary arteries was achieved in 60% and 40% of the cases, respectively., Conclusions: The Evolut R/Pro neo-valve was positioned below the LCA ostium in the vast majority of cases (85%), but an implantation depth ≤6mm was associated with a higher rate of neo-valve positioning at or above the coronary ostia level. Considering the current tendency of very high (aortic) valve implants to avoid conduction disturbances, future studies should determine the impact of high Evolut R/Pro positioning on coronary access issues post TAVR.

Background: Transfemoral approach has been commonly used as secondary access in transcatheter aortic valve replacement (TAVR). Scarce data exist on the use and potential clinical benefits of the transradial approach as secondary access during TAVR procedures. The objective of the study is to determine the occurrence of vascular complications (VC) and clinical outcomes according to secondary access (transfemoral versus transradial) in patients undergoing TAVR., Methods: This was a multicenter study including 4949 patients who underwent TAVR (mean age, 81±8 years, mean Society of Thoracic Surgeons score, 4.9 [3.3-7.5]). Transfemoral and transradial approaches were used as secondary access in 4016 (81.1%) and 933 (18.9%) patients, respectively. The 30-day clinical events (vascular and bleeding complications, stroke, acute kidney injury, and mortality) were evaluated and defined according to Valve Academic Research Consortium-2 criteria. Clinical outcomes were analyzed according to the secondary access (transfemoral versus transradial) in the overall population and in a propensity score-matched population involving 2978 transfemoral and 928 transradial patients., Results: Related-access VC occurred in 834 (16.9%) patients (major VC, 5.7%) and were related to the secondary access in 172 (3.5%) patients (major VC, 1.3%). The rate of VC related to the secondary access was higher in the transfemoral group (VC, 4.1% versus 0.9%, P <0.001; major VC, 1.6% versus 0%, P <0.001). In the propensity score-matched population, VC related to the secondary access remained higher in the transfemoral group (4.7% versus 0.9%, P <0.001; major VC, 1.8% versus 0%, P <0.001), which also exhibited a higher rate of major/life-threatening bleeding events (1.0% versus 0%, P <0.001). Significant differences between secondary access groups were observed regarding the rates of 30-day stroke (transfemoral: 3.1%, transradial: 1.6%; P =0.043), acute kidney injury (transfemoral: 9.9%, transradial: 5.7%; P <0.001), and mortality (transfemoral: 4.0%, transradial: 2.4%, P =0.047)., Conclusions: The use of transradial approach as secondary access in TAVR procedures was associated with a significant reduction in vascular and bleeding complications and improved 30-day outcomes. Future randomized studies are warranted.

This study sought to determine, in patients with new-onset persistent left bundle branch block (NOP-LBBB) after transcatheter aortic valve implantation (TAVI), the incidence and factors associated with (i) LBBB recovery and (ii) permanent pacemaker implantation (PPI) at 1-year follow-up. This was a multicenter study including 153 patients (mean age: 81 ± 5 years, 56% of women) with NOP-LBBB post-TAVI (balloon-expandable valve in 112 patients). Delta PR (ΔPR) and delta QRS (ΔQRS) were defined as the difference in PR and QRS length between baseline and hospital discharge ECG, and the relative ΔPR and ΔQRS as absolute ΔPR and ΔQRS divided by baseline PR and QRS length, respectively. The patients had a clinical visit and 12-lead ECG at 1-year follow-up. LBBB recovery was observed in 50 patients (33%), and 14 patients (9%) had advanced conduction disturbances requiring PPI during the follow-up period. No clinical or ECG variables were associated with LBBB recovery, including prosthesis type (self- or balloon-expandable valve, p = 0.563), QRS width at baseline/discharge or absolute/relative ΔQRS (p >0.10 for all). The presence of atrial fibrillation at baseline (0.026), a longer PR interval at discharge (0.009), and a longer absolute and relative ΔPR (p = 0.002 and p = 0.004, respectively) were associated with an increased risk of PPI at 1-year follow-up. In conclusion, NOP-LBBB post-TAVI resolved in one-third of patients at 1-year follow-up, but no clinical or ECG variables were associated with LBBB recovery. Conversely, a nonsinus rhythm at baseline and a longer ΔPR were associated with an increased risk of PPI within the year after TAVI., (Copyright © 2019 Elsevier Inc. All rights reserved.)