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International audience; Objective: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed.Methods: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation.Results: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019).Conclusion: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.

La cirugia hibrida de los aneurismas toracoabdominales (ATA) es una alternativa a la cirugia abierta tradicional y a las endoprotesis ramificadas/fenestradas. Combina la transposicion de las arterias viscerales mediante derivacion con la colocacion de una endoprotesis en la porcion toracoabdominal de la aorta. La transposicion de las arterias viscerales suele realizarse a partir de los ejes iliacos, de la aorta abdominal o, en menos ocasiones, de la aorta ascendente. La etapa endovascular puede realizarse en el mismo tiempo quirurgico o en un segundo tiempo. Ninguna endoprotesis ha demostrado su superioridad en esta indicacion. La cirugia hibrida presenta ciertas ventajas teoricas respecto a la cirugia abierta convencional. No requiere un pinzamiento aortico alto. Ademas, permite prescindir de la circulacion extracorporea y, en ocasiones, reducir la duracion de la isquemia cervical. Se han publicado algunas series retrospectivas monocentricas con resultados alentadores, lo que para algunos equipos justifica utilizar la cirugia hibrida como primera eleccion para el tratamiento de los ATA. Sin embargo, se trata de una intervencion compleja y ningun estudio comparativo ha demostrado con claridad que reduzca significativamente la mortalidad y las complicaciones postoperatorias respecto a la cirugia abierta convencional. En la era endovascular, y dada la ausencia de consenso sobre sus indicaciones, la cirugia hibrida para los ATA es una solucion interesante en los pacientes de alto riesgo, que presenten contraindicaciones anatomicas para la colocacion de una endoprotesis ramificada o fenestrada.

Objectif L’exclusion endovasculaire des anevrysmes de l’aorte abdominale est associee a une reduction de la mortalite et morbidite precoces. En vue d’une reduction supplementaire du risque, notamment celui lie a l’anesthesie generale (AG), l’hypnose semble representer une alternative, chez les patients a haut risque. L’objectif de cette etude est d’evaluer la contribution de l’hypnose associee a l’anesthesie locale (AL) dans cette chirurgie. Patients Tous les patients ayant beneficie d’une implantation d’endoprothese aortique sous-renale ou fenetree/branchee sous hypnose + AL de janvier 2013 a decembre 2015 ont ete inclus retrospectivement (n = 28). Une cohorte-controle de patients sous AG ayant ete operee durant la meme periode (n = 43) a ete constituee. Les donnees peri-operatoires ont ete collectees dans une base de donnees renseignee prospectivement. Resultats Vingt-huit patients (âge moyen 70,9 ans) ont ete inclus dans le groupe hypnose, versus 43 patients (âge moyen 75 ans) dans le groupe controle. Le suivi median etait de 2,8 ± 1,9 ans. Les caracteristiques des groupes (demographie, comorbidites, anatomie) etaient comparables. Huit (28 %) endoprotheses dans le groupe hypnose et 14 (32 %) dans le groupe AG etaient supra renales. Aucune difference significative n’a ete retrouvee en termes de duree de sejour en soins intensifs (p = 06), de survenue d’endofuites, de reintervention, ou de mortalite a 30 jours (p = 1,00, p = 0,73, et 0,24, respectivement). Le groupe hypnose a beneficie d’un usage significativement moindre de noradrenaline (0,04 ± 0,1 mg.h-1 vs 1,2 ± 4,0, p Conclusion L’hypnose pendant le traitement endovasculaire des anevrysmes de l’aorte n’a pas d’impact negatif sur les resultats cliniques. Elle semble reduire la necessite de recours aux vasopresseurs, ainsi que la duree operatoire et de sejour hospitalier.

Objectifs Les objectifs sont de decrire les principes et problematiques de surveillance des techniques endovasculaires pour les patients presentant des anevrismes aortiques complexes traites en semi-urgence. Methode Actuellement, les endoprotheses fenetrees/branchees sur mesure representent l’alternative endovasculaire la plus frequemment utilisee pour le traitement des anevrismes complexes. En raison des delais de fabrication, ces techniques ne sont pas applicables chez les patients necessitant un traitement urgent ou semi-urgent. Un modele d’endoprothese branchee prefabriquee (dispositif T-branch, Cook Medical) a ete developpe mais n’est applicable que dans un nombre limite de cas. La technique de la cheminee est soumise aux risques de stenoses des stents dedies aux arteres cibles et d’endofuite de type I. Les re-interventions sont frequentes. Nous avons developpe une technique d’endoprotheses fenetrees avec fenetres sur mesure confectionnees sur table operatoire par le chirurgien. Les resultats preliminaires portant sur 11 patients ont deja ete publies. Des evolutions techniques ont dernierement ete mises au point. Resultats Entre 2012 et 2017, 28 patients ont beneficie de la mise en place d’une endoprothese fenetree modifiee par le chirurgien, chez des patients a haut risque chirurgical, voire compassionnels (18 anevrismes thoraco-abdominaux, 8 anevrismes para-renaux, 2 endofuites sur endoprotheses deja en place). Le taux de mortalite hospitaliere a ete de 14 % (n = 4), le taux d’ischemie medullaire de 7 % (n = 2). Avec un suivi median de 16 mois (0–70 mois), le taux de permeabilite primaire estime a 2 ans des arteres cibles stentees etait de 98 %. Le taux estime de survie a deux 2 ans etait de 68 % (95 % CI : 83–45). Le talon d’Achille de cette technique etait le taux de reinterventions (50 % a 1 an), en majorite endovasculaires, necessitant la realisation d’angioscanners repetes. Ce taux eleve est en partie lie a la courbe d’apprentissage mais souligne la necessaire mise au point de nouveaux protocoles de surveillance, optimisant les caracteristiques qualitatives et de frequence du suivi par echo–Doppler. Conclusion Pour limiter les irradiations iteratives liees aux angioscanners, l’instauration de protocoles de surveillance echo–Doppler specifiques est necessaire pour le suivi des patients beneficiant en semi-urgence d’une technique parallele ou d’une endoprothese fenetree modifiee par le chirurgien.

La tecnica endovascolare di trattamento delle stenosi carotidee ha dimostrato la sua fattibilita e l’analisi degli studi clinici che la confrontano con la chirurgia tradizionale permette di precisare le rispettive indicazioni di queste due tecniche, a seconda dei sintomi, dell’anatomia dell’arco aortico e della lesione e dello stato del paziente. La tecnica e ormai ben codificata: la via d’accesso piu spesso utilizzata e quella femorale, dei cateteri guida limitano i rischi e le difficolta di superamento dell’arco aortico e i sistemi di protezione cerebrale e lo stenting limitano il rischio embolico. L’angioplastica carotidea offre gli stessi risultati immediati e tardivi della chirurgia, quando realizzata in pazienti giovani che presentano una stenosi stabile e un’anatomia favorevole e quando eseguita da un operatore esperto. I pazienti piu anziani, con una stenosi sintomatica instabile e un’anatomia complessa, vanno, piuttosto, trattati chirurgicamente.

Objectifs Decrire les principes et rapporter les resultats a moyen terme d’une technique hybride associant endopontage iliaque utilisant un stent couvert deploye par voie endovasculaire et chirurgie de reconstruction du trepied femoral pour le traitement des lesions aorto-ilio-femorales complexes. Methode Entre 2012 et 2017, les donnees des patients ayant beneficie de la mise en place d’un stent couvert de type Viabahn (Gore) associee a une chirurgie de reconstruction du trepied femoral ont ete collectees prospectivement sur logiciel dedie et analysees retrospectivement. L’avantage de cette technique est de proposer une alternative mini-invasive aux techniques de chirurgie ouverte traditionnelles. Resultats Un total de 36 membres inferieurs ont ete traites chez 32 patients, pour ischemie critique (n = 23) ou claudication (n = 13). Les indications etaient : lesions atherosclerotiques Tasc C ou D (n = 29), lesions iatrogenes (n = 5), persistance de thrombus apres embolectomie (n = 2), dissection aorto-iliaque (n = 1). Deux (6 %) patients âges et en ischemie critique sont decedes durant l’hospitalisation. Une complication est survenue chez 5 (14 %) des patients. Une amputation precoce a ete necessaire chez un patient (lit d’aval altere). Avec un suivi median de 24 mois (etendue : 0–63 mois), les taux estimes de permeabilites primaire et secondaire etaient de 97 % et 97 % respectivement. Conclusion La chirurgie hybride offre une alternative valide aux techniques de chirurgie ouverte sur le moyen terme pour le traitement des lesions aorto-ililio-femorales complexes. Les resultats a long terme sont encore inconnus.

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Background and Purpose— Randomized clinical trials show higher 30-day risk of stroke or death after carotid artery stenting compared with surgery. We examined whether operator experience is associated with 30-day risk of stroke or death in the Carotid Stenting Trialists’ Collaboration database. Methods— The Carotid Stenting Trialists’ Collaboration is a pooled individual patient database including all patients recruited in 3 randomized trials of stenting versus endarterectomy for symptomatic carotid stenosis (Endarterectomy Versus Angioplasty in patients with Symptomatic Severe Carotid Stenosis trial, Stent-Protected Angioplasty versus Carotid Endarterectomy trial, and International Carotid Stenting Study). Lifetime carotid artery stenting experience, lifetime experience in stenting procedures excluding the carotid, and annual number of procedures performed within the trial (in-trial volume), divided into tertiles, were used to measure operator experience. The outcome event was the occurrence of any stroke or death within 30 days of the procedure. The analysis was done per protocol. Results— Among 1546 patients who underwent carotid artery stenting, 120 (7.8%) had a stroke or death within 30 days of the procedure. The 30-day risk of stroke or death did not differ according to operator lifetime carotid artery stenting experience ( P =0.8) or operator lifetime stenting experience excluding the carotid ( P =0.7). In contrast, the 30-day risk of stroke or death was significantly higher in patients treated by operators with low (mean ≤3.2 procedures/y; risk 10.1%; adjusted risk ratio=2.30 [1.36–3.87]) and intermediate annual in-trial volumes (3.2–5.6 procedures/y; 8.4%; adjusted risk ratio=1.93 [1.14–3.27]) compared with patients treated by high annual in-trial volume operators (>5.6 procedures/y; 5.1%). Conclusions— Carotid stenting should only be performed by operators with annual procedure volume ≥6 cases per year.

Background The aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined. Methods Preoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component 25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed. Results Of 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4 ± 4.9% and 34.5 ± 6% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1 ± 2.1% vs. 4.2 ± 3.2%, P = 0.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 n = 0, group 2 n = 2; P = 0.48). Conclusions In our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.

Las rupturas de aneurisma de la aorta abdominal son una urgencia quirurgica cuyo tratamiento sigue teniendo una gran mortalidad. Las modificaciones recientes de la estrategia terapeutica y de los tratamientos deben permitir mejorar estos resultados: la tomografia computarizada (TC) siempre que sea posible permite a algunos equipos aumentar la precision de la decision quirurgica; en anestesia-reanimacion y en reanimacion prehospitalaria se ha adoptado el principio de la hipotension controlada. Desde el punto de vista quirurgico, el pinzamiento rapido mediante cirugia tiende a sustituirse por la oclusion endovascular mediante balon intraaortico y el uso de endoprotesis (EVAR) es cada vez mas frecuente en los pacientes que tengan una anatomia compatible.

Las indicaciones de la cirugia endovascular en el tramo aortoiliaco han cambiado en pocos anos: disminucion del numero de derivaciones aortofemorales, ayuda en el mantenimiento de la permeabilidad de las revascularizaciones extraanatomicas y, sobre todo, ampliacion de las indicaciones en la que paso a ser de primera eleccion gracias a las endoprotesis. Los resultados a largo plazo de las tecnicas endoluminales llevan a plantear las revascularizaciones endoluminales respecto a la cirugia clasica en la mayor parte de las situaciones clinicas y de las lesiones anatomicas, estenosis y oclusiones. Aunque es indispensable que el cirujano vascular actual tenga un conocimiento adecuado de las modalidades tecnicas (cateteres y guias, balones y endoprotesis, vias de acceso homo y contralaterales), tambien debe conocer las complicaciones y los limites de esta tecnica.

Resume Introduction Le syndrome des anticorps antiphospholipides peut etre associe a la survenue d’AVC. Observation Nous rapportons le cas d’une occlusion symptomatique du tronc arteriel brachio-cephalique chez une patiente de 37 ans, associee a un syndrome des anticorps antiphospholipides. Cette association n’a, a notre connaissance, pas encore ete rapportee dans la litterature. L’occlusion du tronc arteriel brachio-cephalique a ete traitee par angioplastie et stenting primaire. Une anti-coagulation efficace au long cours a ete instauree au decours pour prevenir une recidive thrombotique due au syndrome des antiphospholipides. Conclusion La recherche des anticorps antiphospholipides doit etre systematique dans le bilan etiologique de tout AVC du sujet jeune.

Objectives The aim was to determine whether physician modified stent grafts (PMSGs) are safe and effective for the treatment of high risk patients with thoraco-abdominal aortic aneurysms (TAAAs). Design This was a retrospective single institution study. Material Consecutive patients with TAAA undergoing endovascular repair using a PMSG between January 2012 and June 2014 were evaluated. Methods Fenestrations to preserve branch vessels were created in TX2 thoracic (Cook Medical) stent grafts. Pre- intra- and post-operative data were recorded by means of a prospectively maintained database. Results Eleven high risk patients with TAAA (type I, n = 4; type III, n = 3; type IV, n = 3; type V, n = 1) underwent fenestrated endovascular repair using PMSGs. Indications were painful aneurysm ( n = 5), >70 mm rapidly enlarging aneurysm ( n = 4), saccular aneurysm ( n = 1), and visceral patch false aneurysm after open repair of a type IV TAAA ( n = 1). In four asymptomatic patients, an additional fenestration was created for temporary selective sac perfusion and occluded 2–4 weeks later. Median duration for stent graft modifications was 2 hours (range 1–3 hours). The median number of fenestrations was three (range 2–4). One patient died during the post-operative period from colonic ischemia, giving a 9% in hospital mortality rate. Four (36%) patients presented with moderate to severe complications. One (9%) patient presented with a paraparesis that resolved completely after spinal fluid drainage. Among surviving patients, four required early endovascular re-intervention for type III endoleak ( n = 2), type Ia endoleak ( n = 1), or target vessel cannulation failure ( n = 1). The median follow up time was 6 months (range 3–20 months). During follow up, no other complications occurred and all target vessels remained patent. One patient presented with a persistent type II endoleak. Conclusion PMSGs provided acceptable short-term results and may be a management option for the treatment of TAAA in selected high risk patients. Durability concerns need to be assessed in additional studies with long-term follow up.

The indication for use of drug-eluting stents (DES) in lower limb arteries is still undefined. We report our series of patients treated with Zilver PTS DES, in treating in-stent restenosis (ISR) and Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) C/D femoropopliteal lesions.The Zilver PTX DES is a self-expanding nitinol stent with a polymer-free Paclitaxel coating. Patients with symptomatic de novo TASC C/D lesions or IRS lesions of femoropopliteal segment were eligible for enrollment. We evaluated patients at one month, six months and one year after treatment. We used clinical evaluation criteria and US Doppler for primary and secondary patency-free rates.From November 2010 to November 2012, we treated 69 patients with DES Zilver PTX. Indication to treat was given in 36 lesions (52%) by an ISR and in 33 cases (48%) by a TASC C/D lesion. Lesions were staged in the superficial femoral artery (SFA) level in 59 patients (85.6%), in the popliteal artery in 6 patients (8.7%), in a femoropopliteal bypass in 4 patients (5.7%). The mean follow-up was 5.3 months (range 1-24). At 12 months the overall primary patency was 85.5%, secondary patency 89.8% and limb salvage 100%.Zilver PTX DES seems to be effective in treating TASC C/D lesions and ISR in femoropopliteal lesions at short term. Therefore DES should be recommended when treating those complex lesions.

To present results and to identify predictive factors of early outcome after fenestrated and/or branched endovascular repair (f/b-EVAR) for complex aortic aneurysms, abdominal (AAA) and thoracoabdominal (TAAA).Feasibility of f/b-EVAR for complex aneurysms is now established, but little is known about which patients will benefit from this technique.Univariate and multivariate analysis of preoperative and intraoperative factors on postoperative mortality and complications was performed on 268 patients (group 1: juxta- and pararenal AAA; group 2: suprarenal and TAAA IV; group 3: TAAA I, II, III) enrolled in a prospective multicenter trial of f/b-EVAR.Thirty-day mortality, in-hospital mortality (IM), and combined mortality and severe complications (CMSC) rates were 6.7%, 10.1%, and 22.0%, respectively. Group belonging (2 or 3 vs 1) was the only preoperative predictive factor of CMSC [hazard ratio (HR) = 2.10; 95% confidence interval (CI): 1.26-3.48; P = 0.0043]. Occurrence of a technical complication and duration of intervention significantly influenced both IM (HR = 4.39; 95% CI: 2.05-9.38; P = 0.0001) and CMSC (HR = 3.07; 95% CI: 1.84-5.11; P0.0001). Postoperative events associated with increased IM were spinal cord ischemia (HR = 9.46; 95% CI: 3.98-22.47; P0.0001), hemodialysis (HR = 27.44; 95% CI: 12.63-59.61; P0.0001), and reintervention (HR = 4.45; 95% CI: 2.03-9.73; P = 0.0002).Although promising, f/b-EVAR still carries a significant rate of mortality and complications, mostly related to the complexity of the procedure. In these complex cases, new strategies should be investigated to improve outcomes.

Pendant pres d’un demi-siecle, la mise a plat-greffe a ete le traitement de reference des anevrismes rompus (AR) de l’aorte abdominale avec un taux de mortalite estime aux alentours de 50 % a 1 mois. Depuis 1994, le traitement endovasculaire est apparu dans l’arsenal therapeutique. Dans les registres et les etudes observationnelles, il semble associe a une diminution de la mortalite (divisee par 2) ainsi qu’a une diminution des complications peri-operatoires. Neanmoins, 4 essais randomises n’ont pas confirme de superiorite du traitement endovasculaire sur le traitement chirurgical en termes de diminution de la mortalite. Dans l’essai francais ECAR (endovasculaire ou chirurgie dans les anevrysmes rompus), 107 patients avec une anatomie favorable et une hemodynamique stable et pouvant recevoir l’une ou l’autre technique ont ete inclus. Les taux de mortalite a 1 mois et 1 an ont ete de 17 et 35 % pour le traitement endovasculaire versus 25 et 40 % pour le traitement chirurgical (non significatif). Par contre, le traitement endovasculaire a ete associe a une diminution des transfusions postoperatoires, de la duree en reanimation et des complications. Le traitement endovasculaire a l’aide d’une endoprothese standard est realisable chez environ 50 % des AR satisfaisant a des criteres hemodynamiques et morphologiques. Chez les malades ayant une instabilite hemodynamique severe, un endoclampage aortique a l’aide d’un ballon permet d’envisager ensuite un traitement endovasculaire ou chirurgical. Chez les malades ayant une anatomie defavorable (collet court), une revascularisation des arteres renales par la mise en place de stents concomitants a la mise en place d’une endoprothese standard peut etre effectuee selon la technique de la cheminee. L’ajout du traitement endovasculaire dans l’arsenal therapeutique du chirurgien a une place qui commence a etre bien definie dans les centres experimentes. Il devrait permettre pour la premiere fois depuis un demi-siecle de reduire la mortalite/morbidite postoperatoire des AR et aussi d’economiser les ressources hospitalieres.

The endovascular treatment of abdominal aortic aneurysm (EVAR - EndoVascular Aneurism Repair) has become an alternative therapy to conventional open surgery. The objective of Angiovision project was to contribute to the improvement of EVAR procedures in terms of accuracy and customization of the interventional strategy. Our approach was mainly based on the use of patient-specific data, computer-aided endovascular navigation and numerical simulation. We proposed a new FEM-based patient-specific simulation solution to estimate the deformations caused by the introduction of stiff endovascular devices. We developed and implemented an original endovascular navigation system to augment the intraoperative fluoroscopy with the visualization of deformed preoperative aorto-iliac structure, and related information concerning vessel wall (calcifications), as well as stent-graft virtual deployment. The proposed solution, that requires only lightweight computer equipment, can be used in a standard operating room in order to optimize device placement (from a single angle of incidence). Evaluation is currently under way.

Grâce aux extraordinaires progres technologiques de ces dernieres annees, le scanner et l’IRM sont devenus la base de l’imagerie pour le diagnostic des maladies de l’aorte, le planning preoperatoire et le suivi. L’arteriographie qui, jusque dans les annees 1990, representait l’unique moyen d’exploration des affections vasculaires n’est maintenant utilisee qu’au cours des gestes endovasculaires et pour une periode probablement limitee du fait de l’evolution de l’imagerie interventionnelle dans les salles dediees dites « hybrides ».

L’histoire naturelle des anevrysmes de l’aorte abdominale sous-renale (AAA) est marquee par une augmentation progressive de taille (environ 4 mm par an). Le risque de rupture depend principalement du diametre anevrysmal. Lorsque le diametre est compris entre 5 et 5,9 cm, le risque de rupture est de 11% par an et il s’eleve a plus de 25% au-dela de 6 cm (1). Ainsi, la rupture d’AAA est actuellement responsable de 1 a 2% des deces des hommes âges de plus de 65 ans dans les pays industrialises (2).

La rupture d’un anevrysme de l’aorte abdominale ou de l’artere iliaque (AAIR) est grevee d’un taux de mortalite spontane de plus de 80% (1). La «mise a plat greffe chirurgicale» de l’anevrysme est le traitement de reference des AAIR mais le taux de mortalite de cette intervention rapporte par une meta-analyse sur 171 etudes compilees depuis 1955 est de 48% (2).

Le pontage femoro-poplite-jambier en veine saphene a longtemps ete le gold standard du traitement de la pathologie atheromateuse occlusive femoro-poplitee tibiale ainsi que des anevrismes poplites. Ces interventions necessitent le plus souvent une anesthesie generale ont une morbi/mortalite non nulle et necessitent des incisions etagees des veines saphenes. Les taux de permeabilite peuvent atteindre plus de 70 % a 5 ans. Ces interventions sont depuis les annees 1990 concurrencees par les therapeutiques endovasculaires qui ont les avantages de pouvoir traiter les patients sous anesthesie locale en percutane au prix d’une morbi/mortalite quasi nulle mais avec des taux de permeabilite plus faibles a long terme. Dans les maladies occlusives, les essais controles proposent d’utiliser la veine saphene preferentiellement si celle-ci est de bonne qualite, chez les patients ayant une ischemie critique et une esperance de vie superieure a 2 ans. Le prelevement veineux peut etre effectue sous videoscopie, ce qui pourrait diminuer le traumatisme local lie au prelevement. Dans les anevrismes poplites, la plupart des equipes favorisent l’utilisation de la veine saphene par rapport au stent couvert ou a la prothese ce d’autant que le malade est jeune et la veine de bonne qualite. Le traitement medical par antiagregant plaquettaire doit etre systematiquement debute et poursuivi en association avec le pontage saphene.

Les anevrismes des arteres renales et digestives (AARD) ont une prevalence de 0,1 a 1 %. La localisation renale est la plus frequente (35 %) suivie de l’artere splenique (11 %-22 %), hepatique (8 %), mesenterique superieure (5 %-12 %), pancreatico-duodenale, gastrique gauche, gastroduodenale et mesenterique inferieure. L’etiologie dominante est l’atherosclerose pour les arteres digestives (51 %) et la dysplasie fibro-musculaire (DFM) pour les arteres renales (68 %). Les autres causes sont post-traumatiques (12 %) liees a une pancreatite (7 %), une vascularite (4 %), une dissection (3 %) ou une infection. Dans 2/3 des cas, le diagnostic est fortuit et etabli par l’imagerie. Dans 1/3 des cas, la rupture est le mode de decouverte. L’indication operatoire est evidente pour les AARD rompus, symptomatiques ou infectieux. Pour les AARD asymptomatiques, il n’existe pas de correlation entre diametre et rupture et pas de consensus sur un diametre-seuil. En general, ceux dont le diametre n’excede pas 20 mm sont a faible risque de rupture. Les femmes en âge de procreer doivent etre traitees du fait d’un risque de rupture majeur pendant le 3 e trimestre de grossesse. L’association a une periarterite noueuse, une DFM ou une hypertension mal controlee sont aussi des facteurs qui doivent inciter a intervenir. Il existe deux options therapeutiques : le traitement par chirurgie ouverte (anevrysmorraphie, anevrysmectomie avec ou sans reconstruction, ligature) ou par technique endovasculaire (embolisation par coils ± Onyx ® , stent couvert). Ces techniques beneficient de l’apport du Robot Magellan de navigation endovasculaire. Dans notre serie portant sur 40 patients de 1995 a 2010, comme dans la litterature, il n’existe pas entre ces options de difference significative en termes de complications ou de mortalite post-operatoires (15,5 % pour les rompus, 1,1 % pour les asymptomatiques). Le traitement endovasculaire semble plus adapte en situation de rupture, s’accompagne d’une duree mediane d’hospitalisation courte de 4 jours mais comporte un risque de reperfusion de l’anevrisme de 8 % imposant une surveillance prolongee.

The reduced physiological impact of endovascular aneurysm repair (EVAR) compared with conventional open repair has been demonstrated. If this technique could be used routinely in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. This review of the literature identified the current experience with EVAR of ruptured AAA. Only a small number of case series with selected patients are reported. These patients were selected for their haemodynamic stability, and their suitable aneurysm morphology. The overall anatomic suitability rates for EVAR reported, suggest an applicability of 58% to 80% from an intent-to-treat experience. The average post-operative mortality rate was 24%, ranging from 9 to 45% and may reflect increasing experience and patient selection. Important lessons have been learned from these first experiences that help to define a clear position of EVAR as an additional therapeutic option for ruptured AAA.

The aim of this retrospective study was to evaluate the patency and limb salvage rates after prosthetics or venous bypasses for asymptomatic or mildly symptomatic popliteal aneurysms, in order to determine if small uncomplicated aneurysms (caliber300%) should be operated or periodically controlled when a venous conduit is not available.During a 18 years period, 100 popliteal aneurysms, including 85 asymptomatic and 15 associated with intermittent claudication, were operated on: group I consisted of 80 venous bypasses, and group II consisted of 20 prosthetic bypasses.Demographics and risks factors were similar in both groups. Local complications were more frequent in group I (17% vs 10% p=NS). Early vascular complications were rare in both groups. Late arterial complications were more frequent in group II. Primary patency, assisted primary patency, and secondary patency rates at 2 years were 94.3%, 97.3% and 98.7% in group I, and 61.5%, 89% and 88.4% in group II (p0.05). In contrast, the limbs salvage rates were not significantly different for each type of graft (98.7% vs 100% p=NS).Our data shows that aneurysms treated with a prosthetic graft are at higher risk of late occlusion than those operated with a vein graft. This should be taken into account when facing a small uncomplicated aneurysm without available venous conduit. The presence of a suitable vein should be checked before deciding to operate a small uncomplicated popliteal aneurysm.

Antiphospholipid syndrome may be associated with stroke.We report a case of a symptomatic occlusion of the innominate artery in a 37-year-old patient, who developed primary anti-phospholipid syndrome. This association, to our knowledge, has not been reported in the literature. Occlusion of the innominate artery was treated by angioplasty-stenting. Effective oral anticoagulation was given to prevent a new thrombotic event.Systematic search for antiphospholipid antibodies is needed as part of the etiology work-up in young stroke victims.

Current treatment of aortic abdominal aneurysms by conventional surgery or endoprosthesis is flawed by high post-operative mortality and unpredictable durability of haemodynamic exclusion, respectively. We have developed endovascular approaches with cell and gene transfer, aimed at controlling further diameter expansion in an animal model of already-developed aneurysms in rats. Preliminary results suggest that both cell and gene endovascular therapy can be used to control expansion of aneurysms generated by inflammation and proteolytic destruction of the aortic wall.

In addition to its role in hematopoiesis, bone marrow appears to be a reservoir of stem cells that can differentiate into components of vessel wall. Upon stimulation by factors such as tissue ischemia, bone marrow stem cells can enter into circulating blood, and incorporate into areas of vascular development. Animal models suggest that bone marrow is a cellular source for tissue repair and/or regeneration. Data from humans, and clinical trials using bone marrow stem cells for the treatment of chronic ischemia in limbs and myocardium, support the view that stem cells may represent a new tool for the treatment of ischemia.

Acute pancreatitis after surgical treatment of non ruptured aneurysm of abdominal aorta is a rare complication, considered to be due to pancreatic ischemia or peroperative trauma of pancreas. The aim of this study is to describe 4 new cases of this complication and to discuss its etiology.From January 1995 to November 2000, 365 patients underwent elective surgery for a non ruptured abdominal aorta aneurysm. Four (1.1%) men, aged 66 to 79 years and operated for an aneurysm which diameter ranged from 60 to 77 mm, developed postoperative acute pancreatitis. The abdominal approach was a midline incision in 3 cases and a retroperitoneal lombotomy in one case. Superior pole of the aneurysm always adjoined or involved the right renal artery. The aortic clamping was supra-renal in 3 cases and celiac in one case. Diagnosis of acute pancreatitis was established at days 2, 4, 12, and 23 after surgery on abdominal computed tomography in 3 cases and at reoperation in one case.Three patients died, including 2 from early multiple organ failure and one peroperatively during surgical attempt to treat a prostheto-digestive fistula. One patient was alive and asymptomatic with a 2-years follow-up.Acute pancreatitis is a rare and serious complication after surgical treatment of abdominal aorta aneurysm. Its diagnosis is often delayed. The main etiological factor of this complication could be trauma of pancreas during supra-renal clamping through a midline incision.

A revolutionary technology has totally renovated the treatment of aneurysms of the abdominal aorta. Classical "dissection-graft" procedures require a wide abdominal incision with clamping and declamping times, and often major blood loss. Perioperative mortality varies from 3% to 7% depending on the team's experience and the presence of comorbidities. Complications occur in 30% of the patients; often benign they can be quite serious. As direct consequence of the development of peripheral stents, endoprostheses can now be introduced via the femoral route through a short inguinal incision. Operative trauma is considerably reduced, greatly shortening the recovery time. Mortality is low, of around 1%, and postoperative complications are much less frequent and much less severe. There is also a 3-fold reduction in the duration of the hospital stay.All aneurysms cannot be treated with this method. The anatomy of the aneurysm and the iliac arteries is a determining factor. The iliac vessels must be large enough and devoid of important obstruction (kinks, atheromatous plaques) in order to access the aorta. The subrenal collar must measure at least 1 cm and be free of severe calcifications or thrombi. A rigorous preoperative exploration, using CT-scan with 3D reconstruction and graduated arteriography, is necessary. The length and diameter of the prosthesis is calculated from the results and must be perfectly adapted to avoid failure.Long-term outcome remains unknown. The endoprosthesis excluded the aneurysm from the blood stream, depressurizing the aneurysmal sac. Endoprosthetic leakage can occur in case of defective application or by reflux from lumbar or inferior mesenteric arteries or due to leakage of the endoprosthesis itself. In such cases, the aneurysm can continue to progress. This explains the need for careful follow-up with duplex Doppler and/or CT-scan in treated patients. If the treatment is incomplete, complementary procedures may be necessary, often via an endovascular route or in some cases with conversion to conventional surgery.Improved prosthetic design and durability is an important point. Randomized studies organized in France, as well as in England and Holland and the United States, are currently assessing the contribution of this new technique and its relative role compared with conventional surgery.

Intimal hyperplasia is extensively studied in order to improve arterial reconstruction outcome. The mechanisms leading to stenosis or restenosis may vary according to the technique used for arterial reconstruction. Lesions are mostly made of an accumulation of smooth muscle cells and fibroblasts, with only sparse inflammatory cells. The accumulated material reduces the graft lumen and ultimately induces thrombosis. Intimal hyperplasia with smooth muscle cell and matrix accumulation is the prominent feature in all these situations with evidences of intense cell proliferation and cell death. The purpose of this review is to present the biology of intimal hyperplastic response based on the recently published data. Experiments in the rabbits have shown that the vein wall thickening is mainly regulated by the tangential wall stress which is applied transversely to the vein wall as a blood pressure. Experiments in the rat carotid artery balloon injury suggested that heparin could be used as a treatment to prevent intimal hyperplasia. Treatments for preventing restenosis after angioplasty or stenoses development in bypasses have been disappointing clinical evaluation suffers from insufficient prospective randomized studies. Intimal hyperplasia is the major cause of failure after arterial reconstruction. The biology of intimal hyperplasia is complex, and treatment disappointing. Some types of hyperplasia may need to be preserved in order to prevent functional atrophy and aneurysmal dilatation of vein grafts.

To assess long-term outcome after surgical cure of radiation-induced aorto-ilio-femoral arterial occlusion and to deduce therapeutic indications.Over a 20-year period, 15 patients were treated for occlusion of the aorto-ilio-femoral vessels 4 to 28 years after receiving radiotherapy. Primary treatment was medical (n=1), balloon dilatation (n=5), anatomic revascularization (n=5), and extra-anatomic bypass (n=4). Mean follow-up was 6.8 years.Among the 5 balloon dilatations, there was one failure requiring right axillofemoral bypass that was followed shortly by fatal septic shock; the 4 others have remained patent at 2 to 15 years, one having required stent dilatation at 6 months. Among the 5 patients who had anatomic revascularization, excepting on patient who died shortly after surgery from her cancer, all have required revision; 2 patients died of infection at 9 and 10 years; the two others are alive at 5 and 18 years. Among the 4 patients with extra-anatomic bypass (one aortothoracic-bifemoral bypass, two axillofemoral bypasses and one cross-over bypass), 2 died with prosthetic sepsis at 3 and 7 years and 2 others have had a bypass replacement. Overall, at last follow-up, half of the operated patients have died from infection (n=5) or cancer (n=2).In reports in the literature, revision and infection after conventional surgery is frequent. There is less risk with the endovascular approach, but it can be only applied for short occlusions.Excepting easily accessible occlusions with an apparent minimal risk for percutaneous balloon dilatation, irradiated arteries should be operated on only in case of severe ischemia. Patients with claudication should be treated conservatively because of the high risk of complications for prosthesis implantation with irradiated arteries.

The EUROSTAR (European Collaborators on Stent/graft techniques for aortic aneurysm repair) Registry was established in 1996 to collect data on the outcome of treatment of patients with infrarenal aortic aneurysms with endovascular repair. To date, 88 European centers of vascular surgery have contributed. The purpose of the study was to evaluate the results of this treatment in the medium term (up to 4 years) according to the analysis of "hard" or primary end points of rupture, late conversion, and death.Patients with aortic aneurysms suitable for endovascular aneurysm repair were notified to the EUROSTAR Data Registry Centre before treatment to eliminate bias due to selective reporting. The following information was collected on all patients: (1) demographic details and the anatomic characteristics of their aneurysms, (2) details of the endovascular device used, (3) complications encountered during the procedure and the immediate outcome, (4) results of contrast enhanced computed tomographic imaging at 3, 6, 12, and 18 months after operation and at yearly intervals thereafter, and (5) all adverse events. Life table analysis was performed to determine the cumulative rates of (1) death from all causes, (2) rupture, and (3) late conversion to open repair. Risk factors for rupture and late conversion were identified through regression analysis.By March 2000, 2464 patients had been registered, and their mean duration of follow-up was 12.19 months (SD, 12.3 months). There were 14 patients with confirmed rupture of their aneurysms. The cumulative rate (risk) of rupture was approximately 1% per year. Emergency surgery was undertaken in 12 (86%) patients, of whom five (41.6%) survived. Two patients who were not treated surgically also died, which resulted in an overall death rate of 64.5% (9/14) of the patients. Significant risk factors for rupture were proximal type I endoleak (P =.001), midgraft (type III) endoleak (P =.001), graft migration (P =.001), and postoperative kinking of the endograft (P =.001). Forty-one patients underwent late conversion to open repair with a perioperative mortality rate of 24.4% (10/41). The cumulative rate (risk) of late conversion was approximately 2.1% per year. Risk factors (indications) for late conversion were proximal type I endoleak (P =. 001), midgraft (type III) endoleak (P =.001), type II endoleak (P =. 003), graft migration (P =.001), graft kinking (P =.001), and distal type I endoleak (P =.001).Endovascular repair of infrarenal aortic aneurysms with the first- and second-generation devices that predominated in this study was associated with a risk of late failure, according to an analysis of observed hard end points of 3% per year. Action taken to address the risk factors identified by the study may improve results in the future.

The aim of this retrospective study was to assess the advantages of regional anesthesia over general anesthesia in carotid artery surgery.From January 1989 to December 1998, 670 patients with severe internal carotid artery stenosis were operated in the same center and were classified into two groups according to the type of anesthesia: group I, general anesthesia (n = 312) and group II, regional anesthesia (n = 358). Characteristics of the two groups were almost similar except for a higher rate of unstable heart disease in group I and bypass grafts in group II.A shunt was used in 16.3% of cases in group I and in 8.4% in group II. Complications resulting from the use of a shunt and intraoperative complications observed with regional anesthesia were reported. There was a conversion from regional to general anesthesia in 6 patients. Median duration of clamping was longer in group II (30 min vs 25 min). Cardiac complication rates were similar in the two groups, particularly cardiac mortality (0.6%). There were more pulmonary and miscellaneous complications in group I. Neurological complications were more frequent in group I, particularly fatal strokes (1% versus 0%). Neurological mortality and morbidity cumulative rates were 3.1% and 1.5%, respectively, not significantly different.These results, in agreement with those of the literature, confirm that carotid artery endarterectomy is associated with a low rate of neurological mortality and morbidity. Although regional anesthesia was associated with a lower rate of complications, we are not allowed to conclude to its superiority, as the present study was retrospective and the difference was not statistically significant.

To report the results of a multicenter safety trial of percutaneous carotid stenting performed by vascular surgeons.Symptomatic or asymptomatic patientsor = 65 years of age with internal carotid artery (ICA) stenosesor = 70% andor = 2-cm long were eligible for enrollment. The procedures were performed in an operating room with the choice of anesthesia and the percutaneous access site at the discretion of the surgeon. Only Palmaz stents were used.From January 1, 1996 to December 31, 1997, 99 patients (74 men, mean age 70 years, range 51 to 94) were enrolled in the study. More than half (57 of 99 patients) were asymptomatic. The direct cervical approach was used predominantly (97%). Three (3%) cases were converted to surgery for inability to access the artery or deploy the stent (technical success 97%). No perioperative death or myocardial infarction was reported. Six (6%) procedural complications included 1 reversible arterial spasm, 2 dissections, 1 cervical hematoma, and 2 residual stenoses. One neurological event reversed within 7 days (1% minor stroke rate) and 4 (4%) transient ischemic attacks resolved within 24 hours. One (1%) asymptomatic early occlusion occurred 2 days postoperatively. No neurological event was observed in the 1- to 24-month follow-up (mean 13 months). Two (2%) patients died of nonprocedurally related causes. No stent compression was seen, but 1 asymptomatic occlusion and 3 asymptomatic, non-flow-limiting restenoses (240%, 1 at 60%) were found within 1 year (3% restenosis rate on an intention-to-treat basis). Patency was 98% at 1 year.The results of this trial support the contention that carotid stenting of short ICA lesions can be performed with a low neurological complication rate.