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The techniques of video-assisted surgery have been recently applied to aortoiliac surgery. The choices between first the retroperitoneal approach or the transperitoneal approach and the place of video-assisted surgery in relation to totally laparoscopic surgery are at the centre of debates. The aim of this clarification is to relate the evolution of laparoscopic aortoiliac surgery for occlusive disease and aneuvrysms through a review of the literature on this subject. [Copyright &y& Elsevier]

Objectives: Percutaneous old balloon angioplasty is still the preferred treatment for the treatment of below-the-knee (BTK) arteries in chronic limb-threatening ischemia (CLTI). In the case of a suboptimal angioplasty result, a bailout stenting is required. So far, few data are available to assess the outcomes of bailout stenting after BTK angioplasty. This study aims to investigate the 1-year efficacy and safety after implantation of a polymer everolimus-eluting stent (PEES) as bailout stenting for BTK repair in patients with CLTI in a real-world setting., Design: This was a national multicenter prospective observational study., Methods: Patients with CLTI (Rutherford 4 to 6) BTK lesions (including P3) and requiring a bailout PEES due to dissection, thrombosis, or residual stenosis ≥30% after angioplasty were included. The freedom of a major adverse limb event at 12 months of the target limb was the primary endpoint., Results: XIENCE assessed 106 limbs (CLTI, 96.2%; chronic total occlusion, 2.8%) in 106 patients (mean age 77.1 years; males, 71.7%; diabetes mellitus, 66.9%; chronic kidney failure, 36.8%) with CLTI undergoing PEES stenting as a bailout for BTK lesions. Bailout stenting was required after 75.5% and 26.4% of residual stenosis and dissection, respectively. The mean diameter and length of the PEES were 3 mm and 3.4 ± 0.5 cm, respectively. At 1 year, the freedom of a major adverse limb event was 79.6% (95% CI, 71.5%-88.7%), the major amputation rate was 6.2% (95% CI, 1.3%-11%), and the target revascularization rate was 14.9% (95% CI, 6.5%-22.5%)., Conclusions: In CLTI patients with BTK lesions, PEES stenting showed safety and efficacy as bailout stenting for BTK arterial lesions. This confirms the need for PEES stenting in a real-world practice., Clinical Impact: The XIENCE study introduces the PEES as an effective bailout stenting option for patients with CLTI undergoing BTK revascularization, particularly for lesions under 4 cm. The study focuses on real-world cases where POBA alone is insufficient, demonstrating that PEES significantly improves outcomes by enhancing limb salvage and reducing the need for major amputations. For clinicians, this innovation offers a precise, size-adaptable solution, especially in cases where bailout stenting is required for short, focal lesions, improving both clinical and procedural results., Competing Interests: Declaration of Conflicting InterestsWilliam Sebbag, Antoine Sauguet, Serge Declemy, Tom Lecorvec, Jérôme Brunet, Nellie Della Schiava, Jonathan Sobocinski, and Eric Steinmetz have no conflict of interest to disclose. Yann Gouëffic reports research funding from Abbott, Boston Scientific, Cook, General Electric, and WL Gore and personnal fees and grants from Abbott, Biotronik, Boston Scientific, Medtronic, Penumbra, Terumo, and WL Gore (medical advisory board, educational course, speaking).

Background: Preoperative anticoagulant therapy is known to have a positive impact on the prognosis of patients with acute limb ischemia (ALI). However, little is known about its efficacy in elderly patients. We aimed to investigate the potential effect of anticoagulation in nonagenarian patients managed for ALI., Methods: Between January 2015 and December 2021, we identified all nonagenarian patients managed for ALI at a single center. Long-term anticoagulation and hemostasis parameters (prothrombin rate, activated partial thromboplastin time [APTT], platelet count) measured on admission were reviewed. The primary end point was mortality at 30-day mortality (D30) in patients with or without long-term anticoagulation therapy. We also studied the effect of these factors on the occurrence of revascularization failure in operated patients (initial failure, ischemic recurrence during hospitalization, necrosis requiring major amputation)., Results: A total of 68 nonagenarian patients were managed for ALI, with a mean age of 93.8 years (from 90-107 years), 76.5% of whom were women. Of these patients, 47 (69%) were managed surgically. Long-term anticoagulation therapy was associated with better survival at D30, both in nonoperated (P < 0.01) and operated (P < 0.05) patients. In operated patients, the absence of long-term anticoagulation therapy was associated with the occurrence of revascularization failure (P < 0.05). In operated patients, survival to D30 and successful revascularization were associated with a longer APTT (P < 0,05). We were able to observe the survival of 4 patients contraindicated for surgery and treated with a single medical therapy (intravenous unfractionated heparin)., Conclusions: Anticoagulation appears to have an impact on the survival and postoperative prognosis of nonagenarian patients with ALI. In addition, curative anticoagulation therapy may be an alternative treatment when surgery is contraindicated in this frail population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Aims: Despite close follow-up of patients with native arteriovenous fistulas (AVFs), up to 10% experience thrombosis each year. The OSMOSIS Study (Osteopontin as a Marker of Stenosis) tested the hypothesis that the systemic osteopontin level, a pro-inflammatory mediator related to vascular remodelling and intimal hyperplasia, increases in AVF stenosis, and may be used in clinical surveillance., Methods: Our cross-sectional study compared the level of plasmatic osteopontin (pOPN) between patients with a well-functioning AVF (control group) and patients who required revision of their AVF due to stenosis (stenosis group). Blood samples were collected before dialysis (control group) or before intervention (stenosis group) from the AVF arm, and from the opposite arm as a within-subject control. pOPN level was measured by enzyme-linked immunosorbent assay., Results: A total of 76 patients were included in the study. Baseline characteristics were similar between the groups (mean age, 70 years; men, 63%; AVF duration, 39 months), apart from prevalence of type 2 diabetes (T2D) (control group, 33%; stenosis group, 57%; p = 0.04). pOPN levels were similar between the AVF arm and the contralateral arm (551 ± 42 ng/mL vs. 521 ± 41 ng/mL, respectively, p = 0.11, paired t-test). Patients in the stenosis group displayed a higher pOPN level than patients in the control group (650.2 ± 59.8 ng/mL vs. 460.5 ± 61.2, respectively, p = 0.03; two-way ANOVA). T2D was not identified as an associated factor in a multivariate analysis (p = 0.50)., Conclusions: The level of pOPN in hemodialysis patients was associated with the presence of AVF stenosis requiring intervention. Thus, its potential as a diagnostic biomarker should be assessed in a vascular access surveillance program., (© 2021. Italian Society of Nephrology.)

Key Points: Patients with end-stage renal failure need arteriovenous fistulas (AVF) to undergo dialysis. However, AVFs present a high rate of failure as a result of excessive venous thickness. Excessive venous thickness may be a consequence of surgical dissection and change in oxygen concentration within the venous wall. We show that venous cells adapt their metabolism and growth depending on oxygen concentration, and drugs targeting the hypoxic response pathway modulate this response in vitro. We used the same drugs on a mouse model of AVF and show that direct or indirect inhibition of the hypoxia-inducible factors (HIFs) help decrease excessive venous thickness. Hypoxia and HIFs can be targets of therapeutic drugs to prevent excessive venous thickness in patients undergoing AVF surgical creation., Abstract: Because the oxygen concentration changes in the venous wall, surrounding tissue and the blood during surgical creation of arteriovenous fistula (AVF), we hypothesized that hypoxia could contribute to AVF failure as a result of neointimal hyperplasia. We postulated that modulation of the hypoxia-inducible factors (HIF) with pharmacological compounds could promote AVF maturation. Fibroblasts [normal human fibroblasts (NHF)], smooth muscle cells [human umbilical vein smooth muscle cells (HUVSMC)] and endothelial cells [human umbilical vein endothelial cells (HUVEC)], representing the three layers of the venous wall, were tested in vitro for proliferation, cell death, metabolism, reactive oxygen species production and migration after silencing of HIF1/2-α or after treatment with deferioxamine (DFO), everolimus (Eve), metformin (Met), N-acetyl-l-cysteine (NAC) and topoisomerase I (TOPO), which modulate HIF-α stability or activity. Compounds that were considered to most probably modify intimal hyperplasia were applied locally to the vessels in a mouse model of aortocaval fistula. We showed, in vitro, that NHF and HUVSMC can adapt their metabolism and thus their growth depending on oxygen concentration, whereas HUVEC appears to be less flexible. siHIF1/2α, DFO, Eve, Met, NAC and TOPO can modulate metabolism and proliferation depending on the cell type and the oxygen concentration. In vivo, siHIF1/2α, Eve and TOPO decreased neointimal hyperplasia by 32%-50%, 7 days after treatment. Within the vascular wall, hypoxia and HIF-1/2 mediate early failure of AVF. Local delivery of drugs targeting HIF-1/2 could inhibit neointimal hyperplasia in a mouse model of AVF. Such compounds may be delivered during the surgical procedure for AVF creation to prevent early AVF failure., (© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society.)

Arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access, but 60% of conventional [vein-to-artery (V-A)] AVF fail to mature, and only 50% remain patent at 1 year. We previously showed improved maturation and patency in a pilot study of the radial artery deviation and reimplantation (RADAR) technique that uses an artery-to-vein (A-V) configuration. Here, we show that RADAR exhibits higher rates of maturation, as well as increased primary and secondary long-term patencies. RADAR is also protective in female patients, where it is associated with decreased reintervention rates and improved secondary patency. RADAR and conventional geometries were compared further in a rat bilateral carotid artery-internal jugular vein fistula model. There was decreased cell proliferation and neointimal hyperplasia in the A-V configuration in male and female animals, but no difference in hypoxia between the A-V and V-A configurations. Similar trends were seen in uremic male rats. The A-V configuration also associated with increased peak systolic velocity and expression of Kruppel-like factor 2 and phosphorylated endothelial nitric oxide synthase, consistent with improved hemodynamics. Computed tomography and ultrasound-informed computational modeling showed different hemodynamics in the A-V and V-A configurations, and improving the hemodynamics in the V-A configuration was protective against neointimal hyperplasia. These findings collectively demonstrate that RADAR is a durable surgical option for patients requiring radial-cephalic AVF for hemodialysis access., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Descending necrotizing mediastinitis (DNM) is a life-threatening disease which often develops from a purulent infection of the oral cavity and is associated with high rates of mortality. Here we report the case of a young patient who died from an aortic arch rupture in context of DNM developed from an odontogenic infection caused by Prevotella buccae. Based on the current knowledge on this very rare vascular complication, we discuss factors that may have contributed to this fatal issue and future issues to optimize care provided to patients.

Background: To assess subclavian vein (SCV) patency and long-term functional outcomes following surgical decompression of the thoracic outlet (SDTO) for Paget-Schroetter Syndrome (PSS)., Methods: Between January 1978 and January 2013, we identified 33 patients with PSS who underwent SDTO. Demographic, clinical and radiological data were extracted from electronic databases and patient records. All patients were invited to update their follow-up data during dedicated outpatient visits between October and December 2013. Outcome measures included long-term SCV patency and clinical success rates during follow-up. Clinical success was defined as the combined absence of functional symptoms and patient's ability to maintain normal professional activities at final follow-up. The QuickDASH score was also determined., Results: The study population comprised 17 men and 16 women (mean age 34 years; range: 14-53 years) with PSS. Diagnosis was reached by venography (29 cases) or duplex scan (4 cases). SDTO was performed via the transaxillary route (25 cases) or using the combined supra-infraclavicular approach (8 cases). The procedure was carried out within 10 days in 13 patients (early-group), and between 30 to 120 days in the remaining 20 patients (late-group). The former had SCV recanalization obtained actively by thrombolysis (3 cases), thrombectomy (9 cases) or endovenectomy followed by patch venoplasty (1 case). The latter were maintained under chronic oral anticoagulation to allow SCV recanalization. There was neither postoperative death nor major bleeding complications. At a median follow-up of 240 months, 11 SCV remained patent in the early group, while in the other there was 3 re-occlusions, 4 residual stenoses and 5 chronic SCV occlusions. Clinical success was achieved in 73% of patients for the whole cohort, but was significantly better in patients operated on in the early stages (100% vs. 55%; P=0.005). The mean Quick Disabilities of the Arm, Shoulder, and Hand Score was 3.5 (95% CI: 1.5-5.4) in the early-group and 17.3 (95% CI: 8.4-26.2) in the late-group (P=0.01)., Conclusions: Our data shows that long-term functional outcomes and SCV patency remained better in PSS patients who underwent early SDTO and active SCV recanalization techniques.

Background: The poor clinical results that are frequently reported for arteriovenous fistulae (AVF) for hemodialysis are typically due to failure of AVF maturation. We hypothesized that early AVF maturation is associated with generation of reactive oxygen species and activation of the hypoxia-inducible factor-1 (HIF-1) pathway, potentially promoting neointimal hyperplasia. We tested this hypothesis using a previously reported mouse AVF model that recapitulates human AVF maturation., Methods: Aortocaval fistulae were created in C57Bl/6 mice and compared with sham-operated mice. AVFs or inferior vena cavas were analyzed using a microarray, Amplex Red for extracellular H 2 O 2 , quantitative polymerase chain reaction, immunohistochemistry, and immunoblotting for HIF-1α and immunofluorescence for NOX-2, nitrotyrosine, heme oxygenase-1 (HO-1), and vascular endothelial growth factor (VEGF)-A., Results: Oxidative stress was higher in AVF than that in control veins, with more H 2 O 2 (P = 0.007) and enhanced nitrotyrosine immunostaining (P = 0.005). Immunohistochemistry and immunoblot showed increased HIF-1α immunoreactivity in the AVF endothelium; HIF-1 targets NOX-2, HO-1 and VEGF-A were overexpressed in the AVF (P < 0.01). AVF expressed increased numbers of HIF-1α (P < 0.0001) and HO-1 (P < 0.0001) messenger RNA transcripts., Conclusions: Oxidative stress increases in mouse AVF during early maturation, with increased expression of HIF-1α and its target genes NOX-2, HO-1, and VEGF-A. These results suggest that clinical strategies to improve AVF maturation could target the HIF-1 pathway., (Published by Elsevier Inc.)

Objective: Although the end cephalic vein-to-side radial artery arteriovenous fistula is the "gold standard" procedure for primary hemodialysis access, it is associated with high rates of primary failure because of the development of neointimal hyperplasia and juxta-anastomotic stenosis. We report initial results of a new approach to perform radial-cephalic fistulas, radial artery deviation and reimplantation (RADAR), designed to avoid juxta-anastomotic stenosis., Methods: RADAR patients' data were prospectively maintained and retrospectively reviewed and compared with a historical control group of traditional radial-cephalic fistulas created in the same center. Duplex ultrasound was used to monitor maturation (flow ≥500 mL/min and venous diameter ≥5 mm) and to diagnose juxta-anastomotic stenosis. Study end points were rates of maturation, juxta-anastomotic stenosis, reintervention, and primary and secondary patency., Results: There were 53 RADAR fistulas performed (follow-up, 10.5 ± 2.6 months) and compared with 73 control fistulas (follow-up, 12.0 ± 6.6 months). RADAR fistulas had increased rates of maturation compared with control fistulas (75% vs 45% at 6 weeks, P = .001; 92% vs 71% at 3 months, P = .003) and decreased incidence of juxta-anastomotic venous stenoses (2% vs 41%; P = .001). At 6 months, RADAR fistulas had increased primary patency (93% vs 53%; P < .0001) and secondary patency (100% vs 89%; P = .0003) and decreased incidence of reinterventions (10% vs 74%; P = .001) compared with control fistulas. No RADAR fistulas caused ischemic symptoms., Conclusions: The RADAR technique is associated with less juxta-anastomotic stenosis, increased maturation and patency, and fewer secondary interventions. These improved outcomes suggest that RADAR may be the preferred surgical technique to perform radial-cephalic arteriovenous fistula., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Although radial-cephalic (RC) and brachial-cephalic (BC) fistulas are the recommended primary accesses for hemodialysis, access failure is frequently due to juxta-anastomotic stenosis (JAS). Because increased turbulence at the anastomosis may lead to JAS, we hypothesized that an acute angle at the arteriovenous anastomosis is associated with JAS, reduced fistula patency, and increased reinterventions., Methods: Between February 2013 and September 2014, the anastomotic angle and vessel diameters were prospectively collected for all patients who underwent RC or BC fistula creation. The primary end point was reintervention on the juxta-anastomotic segment. Secondary end points were primary and secondary patency of the fistula., Results: A total of 149 patients (median age, 72 years) received 73 RC and 76 BC fistulas; the median follow-up was 7 months (range, 1-22 months) for RC and 12 months (range, 2-24 months) for BC fistulas. The median anastomotic angle in RC fistulas, was 30°. Anastomotic angles of <30° were associated with reduced primary patency (38% vs 66%, P = .003) and secondary patency (84% vs 97%, P = .02) and increased numbers of reinterventions (67% vs 34%, P = .001). Cox analysis showed that an anastomotic angle of <30° was an independent factor predicting decreased primary patency (P = .009) and secondary patency (P = .03) as well as increased reinterventions (P = .004). In BC fistulas, the median anastomotic angle was 90°. Patients with anastomotic angles <90° and ≥90° had similar rates of primary patency (67% vs 67%, P = .39) and secondary patency (93% vs 94%, P = .89) at 6 months, with a similar reintervention rate at 12 months (31% vs 32%, P = .56). Vein diameter was the only factor that predicted reintervention (P < .0001)., Conclusions: RC fistulas with anastomotic angles of <30° have reduced primary and secondary patency and increased numbers of reinterventions, suggesting that, if possible, surgeons should avoid an anastomotic angle of <30° when creating RC fistulas. Anastomotic angles of <90° or ≥90° may not play a role in outcome of BC fistulas., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: We compared outcomes of transposed brachio-basilic arteriovenous fistulas (BBAVF) with brachio-axillary prosthetic grafts (BAPG) for hemodialysis., Methods: All consecutive patients who underwent creation of a BBAVF or a BAPG, in one of the two institutions, between January 2008 and December 2013 were retrospectively identified. We assessed functional patency and compared complication rates. Patency was also compared between one-stage and two-stage creation procedures for the BBAVF group., Results: Two hundred and thirty-eight patients underwent the creation of a BBAVF (N = 136) or a BAPG (N = 102). Median follow-up was 17 months (range, 1-79). At 6, 12 and 24 months, patients in the BBAVF group had significantly higher primary patency (80%, 69%, 56% vs. 77%, 56%, 37%, respectively; p = 0.005), assisted primary patency (90%, 80%, 71% vs. 80%, 66%, 48%; p&lt;0.0001) and secondary patency (93%, 84%, 72% vs. 94%, 87%, 62%; p = 0.006). Two-stage BBAVF had a significantly higher secondary patency (98%, 92%, 78% vs. 90%, 80%, 68%; p = 0.04) than one-stage BBAVF. The rate of infectious complications was significantly lower in the BBAVF group than in the BAPG group (0.8% vs. 6.9%; p = 0.03)., Conclusions: In this large cohort, BBAVF had a higher functional patency and lower rate of infectious complications than BAPG. After exhaustion of cephalic veins, we suggest creation of a BBAVF instead of BAPG, whenever anatomically feasible. The superiority of one-stage or two-stage BBAVF creation procedure must be further investigated.

Although radiocephalic fistulae are the preferred hemodialysis access, juxta-anastomotic stenosis is often responsible for early fistula failure. We hypothesized that wall ischemia from surgical manipulation leads to early juxta-anastomotic neointimal hyperplasia and failure of maturation and that minimal venous dissection will improve surgical salvage, increasing fistula maturation rates. For failing-to-mature radiocephalic fistulae that develop early juxta-anastomotic stenosis, we describe 3 variations to perform a new proximal anastomosis with a minimal dissection technique on the forearm cephalic vein: (1) side-to-side anastomosis, (2) radial artery deviation and reimplantation, or (3) radial artery deviation and loop reimplantation. Minimal dissection of the cephalic vein achieves fistula salvage without needing a more proximal site for access., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Vascular access thrombosis lacks the implementation of a treatment algorithm at large scale, involving all the actors. We aimed to determine a better understanding of the current practice patterns around vascular access thrombosis in France, with 4 axes: incidence, surveillance protocol, treatment, and time to treatment., Methods: A comprehensive survey of all the nephrologists staffing all hemodialysis centers in France during April 2013 included 266 of 269 (99%) centers, treating 27,798 patients with arteriovenous fistula or graft., Results: In 104 centers treating 11,088 patients, there were 905 documented episodes of vascular access thrombosis (8.8%) in 1 year; in the other 162 centers that supplied a range of events, the mean incidence was 8.4%. Use of in-line access flow monitoring as part of surveillance program was not correlated with better outcome compared with Doppler ultrasound (thrombosis: 7.9% vs. 10%, respectively, P = 0.09). Fifty-three percent of centers referred the patients to a vascular surgeon and 32% to an interventional radiologist (2% to urologist and 13% variable referral depending on the case complexity). Time to treatment was <24 hr in 58% and <48 hr in 91% of the centers; treatment >48 hr (9%) occurred mainly in rural zones (P = 0.04). The specialty of the treating physician did not influence time to treatment (P > 0.05)., Conclusions: In France, vascular access thrombosis rate is low and not influenced by surveillance protocol type. Most patients can receive timely treatment by vascular surgeons or interventional radiologists., (Copyright © 2015 Elsevier Inc. All rights reserved.)