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BACKGROUND: Acute popliteal artery occlusion is a frequent clinical entity with a risk of major amputation. Several attitudes are possible and treatment is not standardized. The purpose of this study is to demonstrate safety and effectiveness of intra-arterial thrombolysis in acute popliteal artery occlusion. METHODS: This is a retrospective analysis of a prospective database of patients treated by intra-arterial thrombolysis for acute lower-limb ischemia due to popliteal artery occlusion between 2001 and 2014.The primary endpoint was technical and clinical success. Etiologies and etiologic treatment, amputation-free survival, in-hospital mortality and bleeding complications rates were secondary endpoints. RESULTS: Seventy-one patients, with a mean 6-day-old ischemic time before thrombolysis, were analyzed. Technical and clinical success was 90% and 87% respectively. Etiology was embolic in 33 patients (cardiac n = 14, aortic = 6, unknown = 13) and thrombotic in 38 (atheromatous n = 19, entrapment n= 4, popliteal aneurysm n = 11, Buerger n = 2, thrombophilia n = 1, hyperhomocysteinemia n = 1). Survival and amputation-free survival at 30 days were 97% and 94% respectively. There were no major bleeding complications. CONCLUSIONS: Intra-arterial thrombolysis of acute popliteal artery occlusion is an effective technique which reduces the rate of open surgery. The risk of bleeding complications is very low.

International audience; BACKGROUND AND AIMS: To evaluate if features of occlusion analyzable on preoperative computed tomography scan could predict risks of technical failure or iliac rupture of endovascular treatment of TransAtlantic InterSociety Consensus C-D aortoiliac chronic total occlusion. METHODS AND RESULTS: All patients treated by endovascular techniques for a TransAtlantic InterSociety Consensus C-D aortoiliac chronic total occlusion between 2009 and 2016 were included (107 patients, 148 iliac arteries). We evaluated the location of the occlusion and the importance of the arterial calcifications. For this factor, patients were divided into 3 groups: the Black occlusion group with mild or no calcifications, the white occlusion group with moderate no protrusive calcifications, and the white protrusive occlusion group with heavy endoluminal calcifications. Technical failure occurred in 11 iliac arteries and peroperative iliac rupture in 6. The location in the external iliac artery is the most significate risk factor of technical failure in univariate (OR = 9.93; P = 0.0012) and multivariate analysis (OR = 15.26; P = 0.0006). The presence of heavy endoluminal calcifications is a further significate risk factor (OR = 13.88; P = 0.0365). Rupture rate was comparable between the 3 groups. CONCLUSIONS: Preoperative computed tomography scan can predict risk of technical failure but not of iliac rupture.

Forty percent of the abdominal aortic aneurysms present an extension to the iliac axes. The access to a distal neck requiring an embolization of the internal iliac artery (IIA) may cause buttock claudication, colic ischemia, perineal necrosis, erectile dysfunction, and spinal cord ischemia. The aim of the branched iliac stent grafts is to preserve pelvic vascularization while adapting to the constraints of arterial tortuosity which generate type Ib endoleaks, plications, and limb thromboses. The objective was to analyze and compare the in vivo anatomical conformability of the Gore ExcluderThis was a monocentric retrospective therapeutic study including 13 IBE and 9 ZBIS stent grafts. Three indices of tortuosity were measured with EndoSize: common iliac artery, pelvic artery index (PAI), and the double iliac sign (DIS). The centerline lengths of the iliac axes and the iliac axis and the IIA were measured by 2 different operators as a blind fashion.The interoperator correlation of the measurements was r = 0.841 (P 0.0001). Twenty-two patients had a high iliac tortuosity: PAI ≥ 1.14 (mean PAI 1.43 [1.16-2.09]). The IBE stent graft modified neither the ipsilateral length nor tortuosity of the common iliac axis or the PAI (P ≤ 0.17, P ≤ 0.16, and P ≤ 0.23, respectively). The ZBIS stent graft significantly modified (P ≤ 0.02) the length and the tortuosity measured by the PAI compared with the IBE group (P ≤ 0.02). The use of IBE or ZBIS did not modify the postoperative length of the IIA (P ≤ 0.34). Three patients of the IBE group presented one DIS. Postoperatively, they did not present any DIS without significant modification of the postoperative PAI (P ≤ 0.07).In patients with a severe iliac tortuosity, the IBE Gore branched iliac stent graft is more conformable than the ZBIS Cook. IBE, more conformable with the anatomy of the patient, could thus make it possible to decrease the incidence of distal endoleaks without increasing the risk of limb thrombosis related to the anatomical constraints.

Background The management of acute ischemia due to the thrombosis superficial femoral artery (SFA) stents is complex. In situ arterial fibrinolysis, still not evaluated in this indication, would allow, by lifting the ischemia and uncovering its cause, to avoid thrombectomy, endovascular recanalization, or arterial bypass. The purpose of the study was to evaluate the effectiveness, the complications, and the assisted secondary patency of in situ fibrinolysis for thrombosis of SFA stents. Methods We conducted a retrospective monocentric study with prospective collection of the data. Between October 2011 and December 2014, 86 in situ fibrinolysis procedures were carried out for acute lower limb ischemia. Twelve procedures were carried out for acute ischemia due to the thrombosis of SFA stents. Clinical success was defined by the lifting of acute ischemia. The causes of thromboses, the complications related to the fibrinolysis, and the secondary assisted patency were analyzed. Results The mean age of the patients was 66.3 (55–90) years. The average length of the stents was 119.3 (18–270) mm. In 10 patients, the thrombosis extended in the full length of the artery. The average time between the implantation of the stent and the initiation of the fibrinolysis was 180 (11–369) days. The average time between the beginning of the symptoms and fibrinolysis was 5 (0–12) days. The average duration of treatment was 46 (24–72) hr. Clinical success was obtained in all the patients. Diagnosed isolated or associated lesions were a progression of the atheromatous disease upstream or downstream of the stent in 6 cases, and an isolated intrastent restenosis in 3 cases. In 2 cases, no obvious cause was found. One or more additional endovascular procedures were carried out in 9 cases at the end of the fibrinolysis, and consisted of a transluminal intrastent angioplasty with an active balloon in 5 cases, an additional stenting in 3 cases, and the stenting of upstream or downstream arteries in 5 cases. Secondary assisted patency was 100% at 5 months. No major hemorrhagic complication was observed. Two false aneurysms at the site of femoral puncture were observed. Conclusion Our results suggest that ischemia due to the thrombosis of SFA stents can be dealt with first intention in situ fibrinolysis which allows the endovascular treatment of the causal lesion, thus avoiding thrombectomy or bypass.

Endovascular approach is now a safe and effective technique for the elective treatment of a thoraco-abdominal aneurysm. This technique has significantly reduced the morbi-mortality for elective surgery. Moreover, it can permit to treat patients with a high surgical risk who are not eligible for open surgery. The permanent availability of endovascular material opens the door for treating a complex emergency thoraco-abdominal aneurysm. Here, we present the case of an 81-year-old man who had a rapidly evolving salmonella-infected aortic thoraco-abdominal Type IV pseudoaneurysm. Total endovascular treatment using aortic endoprosthesis, chimneys for coeliac trunk and superior mesenteric artery and periscopes for renal arteries was performed and permitted to obtain the complete exclusion of the pseudoaneurysm. The patient was event free and discharged from hospital after a few days with an antibiotic treatment adapted for salmonella. He was still event free 10 months after surgery. Endovascular technique might be a viable option even for an emergency infected complex thoraco-abdominal aortic aneurysm. Secondary open surgery should be discussed under the benefit-risk balance.

International audience; BACKGROUND:The aim of this study is to assess the safety and the short-term results of endovascular treatment of common iliac artery (CIA) aneurysms using the new GORE EXCLUDER iliac branch endoprosthesis (IBE) device.METHODS:The study is a retrospective with prospective follow-up nonrandomized, single-arm evaluation. Patients with a CIA aneurysm (diameter >30 mm) extending to the iliac bifurcation underwent endovascular treatment with the Gore IBE. Anatomic and procedural data were collected. Computed tomography angiography (CTA) was performed within the 30 days after the procedure and every 6 month. Thirty-day and at least 6-months outcomes were investigated.RESULTS:From February 2014 to December 2014, 10 male patients with aneurysmal CIA (mean age 75 years old) underwent consecutive endovascular treatment with the Gore IBE. The CIA aneurysm (mean diameter 43.2 mm, range 32-49) treated with the Gore IBE was associated with an abdominal aortic aneurysm (AAA) in 5 patients. One patient had a previous AAA open repair. CIA aneurysm was bilateral in 5 patients. Preliminary procedure of internal iliac artery embolization was performed in 3 patients. Technical success rate of the Gore IBE implantation was 100% with a median fluoroscopy time of 35 min (range 12-64, ±16) and median contrast load of 150 mL (range 100-250, ±45). No perioperative complications were observed. Median length of stay was 4 days (range 3-7, ±2). One aortic type Ia endoleak was observed on the postoperative CT scan requiring an aortic extension at day 3. Branch patency was observed in all 10 patients at 1 month and 9 patients at 6 month. All CIA aneurysms were excluded without type Ib or type III endoleak.CONCLUSIONS:The technical success and short-term results demonstrate encouraging results and clinical benefits of the new GORE EXCLUDER IBE. A longer follow-up is needed to assess midterm and long-term results.

International audience; BACKGROUND: Technical success rates of endovascular recanalizations for Trans-Atlantic Inter-Society Consensus (TASC) C-D chronic occlusions are highly variable and depend on the characteristics and sites of the lesions as well as on the operator experience. We hypothesized that an antegrade approach via transbrachial access could improve the technical success rate of endovascular treatment of TASC C-D occlusions in case of failed femoral access. METHODS: From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac occlusion were treated with an endovascular-first approach. Recanalization was first attempted using a femoral access. In case of failure, an antegrade approach using a transbrachial access was performed. Patient characteristics, anatomic details, procedural data, and immediate outcomes were prospectively recorded. RESULTS: During the study period, 73 patients (99 arteries) were included. Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery occlusions and 16 external iliac artery (EIA) occlusions involving the common femoral or the internal iliac arteries. Forty-six (63%) patients had TASC D occlusions including 10 aortoiliac occlusions, 31 unilateral occlusions of both common and EIAs, and 5 bilateral EIA occlusions. Technical success with femoral access has been obtained in 53 arteries. An antegrade approach via transbrachial access allowed technical success in the other arteries, except in 7 arteries. Overall technical success rate was 93%, and 2 complications were related to the brachial accesses including 1 thrombosis and 1 pseudoaneurysm both requiring a reintervention. CONCLUSIONS: Brachial access for TASC C-D aortoiliac chronic occlusion improves the technical success rate without the need for reentry devices.

Background Arterial cryopreserved allografts are conduit of choice for arterial bypass in case of infection. They are sometimes submitted to accelerated degeneration: stenosis, thrombosis, or aneurysmal evolution. We hypothesized that ABO group and Rhesus compatibility could play a role in arterial cryopreserved allograft complications. Methods Patients who benefit from allograft bypass from 2006 to 2011 were retrospectively compared, regarding ABO or rhesus compatibility and irregular agglutinins. Results Seventy-two patients were included. Regarding ABO mismatch, there was no difference in terms of death (51% vs. 43%, P = 0.820), thrombosis (25% vs. 32%, P = 0.78), rupture (9% vs. 0%, P = 0.247), stenosis (3% vs. 12%, P = 0.331), aneurysmal degeneration (16% vs. 12%, P = 1), and 5 years of secondary patency rate (34% vs. 39%, P = 0.141). There was also no difference regarding Rhesus mismatch. Conclusions Allograft degeneration does not seem to be related to ABO mismatch. This degeneration could be related to another way of immunogenicity, particularly Human Leukocyte Antigen mismatch, and needs further exploration.

The long-term follow-up of patients with endovascular aneurysm repair (EVAR) and a normal surgical risk was defined by the French National Authority for Health (Haute Autorité de Santé) in 2009. The monitoring of the volume of the aneurysm sac theoretically avoids the bias related to the measurement of its diameter alone. The objective of this study was to evaluate how reliable and reproducible the volumetric measurement of the aneurysm sac by ultrasound was compared with computerized tomography angiography (CTA).We carried out a retrospective diagnosis study of 75 consecutive patients treated with EVAR in our institution who were monitored with 3-dimensional ultrasonography (3DU) and CTA between January 2010 and December 2012. The measurement of the volume (cm(3)) of the aneurysm sac with a Toshiba Aplio XG ultrasound system equipped with a 3-MHz 3-dimensional probe was compared with the volume obtained by CTA. Interoperator reproducibility was studied in the last 45 enrolled patients; 2 different blinded operators made 2 volumetric measurements on the same patients, on the same day. An analysis of a 48-patient subgroup in which at least two 3DU were performed during follow-up was also carried out to determine the threshold value of the increase in the volume of the aneurysm sac, making it possible to suspect the presence of an endoleak.A total of 116 pairs of examinations were compared (the patients who had the longest postoperative follow-up had 4 pairs of compared examinations). The correlation between volumetric ultrasound and CTA measurements was excellent (r = 0.931; P 0.0001) in the 116 pairs of examinations, and so was the reproducibility of volumetric echography (r = 0.949; P 0.0001) in 45 patients. The subgroup study highlighted the fact that a 6.5-cm(3) increase of the aneurysm sac made it possible to suspect the presence of an endoleak in comparison with CTA as the gold standard (sensitivity and specificity were 85.7% and 85.3%, respectively). The area under the curve was 0.854 (95% confidence interval, 0.793-0.915). In the 116 examinations, a good correlation between volume and diameter was calculated with CTA (r = 0.733; P 0.0001) and between ultrasound volumetric and CTA diameter (r = 0.660; P 0.0001).Volumetric echography is comparable with CTA for the evaluation of the aneurysm sac after EVAR, reproducible and inexpensive. When a significant increase of the volume of the sac is detected by ultrasound, the examination can be supplemented by an injection of ultrasound contrast agent or by CTA to visualize an endoleak.

which regressed spontaneously in six months in two cases (66%). Buttock claudication was permanent in one case (38%). We did not find a relation between the buttock claudication and the patency of the contralateral hypogastric artery or the deep femoral artery. No endoleak was observed. The aneurysmal sac decreased in diameter in five cases (25%), it was stable in 75% of the patients. The mean duration of hospitalization was four days. The survival rate was 95% at six months and 70% at five years. Half of the deaths were secondary to cardiovascular causes. No late aneurysm ruptures were observed. Conclusion: Embolization of the internal iliac artery to treat an aneurysm is reliable. Hypogastric embolization involves a significant risk of permanent buttock claudication in more than one third of the cases. Bifurcated stentgrafts should contribute to avoid this complication.