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Summary Objective The persistent sciatic artery (PSA) is a rare congenital anomaly with a high rate of aneurysm formation, occlusion and stenosis. It may lead to severe complications including thrombosis, distal embolisation, or aneurysm rupture. We reported herein our experience in the management of PSA and its complications, and discuss the therapeutic options. Methods Eight patients with 10 PSA were managed in our institutions between 1985 and 2017. An analysis was done for the clinical data, surgical technique, and results. Results The series included six women and two men. The median age of the patients was 66,5 years (37–80 years). Physical examination found a pulsatile gluteal mass in five patients, sciatic neuropathy in two cases. Four patients had an acute ischemia of the lower limb. Cowie's sign was described in only two patients (diminished or absent femoral pulse but presence of popliteal pulse). Digital subtraction angiography was performed in all patients, and was completed with a computed tomography angiography (CTA) with a diagnosis of PSA, associated with a symptomatic aneurysmal lesion in seven cases and with an occlusion in one case. The treatment was surgical in all cases: bipolar exclusion of the aneurysm and bypass between the iliac artery and the PSA distal to the aneurysm was performed in four cases, only proximal and distal ligation was done in 2 other cases. A Chopart amputation was necessary in 2 cases. Conclusion We consider that the treatment of PSA is usually surgical in symptomatic cases. Surgical techniques depend on symptoms and classification describing anatomy of the PSA. However, future studies should compare the open versus the endovascular approach to optimize patient selection criteria and identify the most safe and effective strategy. In an asymptomatic patient, PSA does not require any intervention; continued follow-up is required because of the high incidence of aneurysmal formation and the risk of thromboembolic events.

International audience; OBJECTIVE: Nutcracker syndrome can cause disabling chronic pain requiring surgical intervention. At present, data describing a straightforward management approach are lacking. Transposition of the left gonadal vein is one of the surgical therapeutic alternatives. The aim of the present study was to describe our clinical results with gonadal vein transposition. METHODS: All 11 patients from three centers who had undergone left gonadal vein transposition for nutcracker syndrome from 2016 to 2019 were retrospectively included. The surgical cases were mainly selected according to the morphologic criteria of the left gonadal vein. The diameter and length dictated the type of approach (laparotomy or retroperitoneal) and the transposition level. A minimally invasive retroperitoneal approach was preferred. Pain was assessed using a numeric rating scale. RESULTS: We included 11 patients (10 women) with a median age of 35 years (range, 25-69). Preoperative computed tomography angiography showed anterior nutcracker syndrome in 10 patients (91%). All 11 patients had experienced lower back and/or pelvic pain, which was associated with pelvic congestion syndrome in 6 patients (55%) and hematuria in 5 patients (45%). The median preoperative numeric rating scale score for pain was 7.0 (range, 3.5-10.0) and 6.0 (range, 3.5-8.0) for lower back pain and pelvic pain, respectively. At the level of the iliac vein crossing (external or common), the median diameter of the left gonadal vein was 7.87 mm (range, 6.45-11.28). The left gonadal vein was transposed to the inferior vena cava in one case (9%), the left external iliac vein in five (45%), and the left common iliac vein in five cases (45%). The median in-hospital stay was 4 days (range, 2-20 days). Two early complications (18%) requiring surgical revision occurred: one of active bleeding and one hematoma. The median follow-up was 15 months (range, 6-44 months). The median postoperative pain score was 1.0 (range, 0.0-4.0) and 0.0 (range, 0.0-6.0) for lower back and pelvic pain, respectively. Incisional and/or neuropathic pain was noted, with a median score of 3.5 (range, 1.0-6.0) in seven patients (64%). Two late complications (18%) were observed: one case of thrombosis and one case of anastomotic stenosis. The hematuria had disappeared in all patients who had presented with it initially. CONCLUSIONS: Left gonadal vein transposition can be proposed as a first approach if the diameter of the left gonadal vein is sufficient to perform the anastomosis. It is an easily achievable, minimally invasive alternative that achieves satisfactory results without the use of foreign material.

Pelvic venous insufficiency can cause pelvic pain but can also contribute to lower limb varicose veins. This condition is certainly underdiagnosed. It is mainly due to pelvic vein incompetence, but obstructive lesions must also be recognized as they need specific treatments. Embolization is the gold standard treatment of PVI and gives good results while being minimally invasive.

International audience; Objectives: The aim was to analyze the role played by anatomy and stent graft in the incidence of incomplete apposition to aortic arch.Methods: Between 2007 and 2014 data including available and suitable computed tomographic angiography (CIA) imaging of patients who had undergone thoracic endovascular aortic repair were reviewed. The study included 80 patients (65 men, 54 +/- 21 years) treated for traumatic aortic rupture (n = 27), thoracic aortic aneurysm (n = 15), type B aortic dissection (n = 24), penetrating aortic ulcer (n = 5), intramural hematoma (n = 2), aorto-oesophageal fistula (n = 2), and aortic mural thrombus (n = 5). Pre- and post-operative CIA images were analyzed to characterize bird beak in terms of length and angle, and to calculate aortic angulation within a 30 mm range at the proximal deployment zone.Results: Bird beak configuration was detected in 46 patients (57%): mean stent protrusion length was 16 mm (range: 8-29 mm) and mean bird beak angle was 20 degrees (range: 7-40 degrees). The bird beak effect was significantly more frequent after traumatic aortic rupture treatment (p = .05) and in landing zone 2 (p = .01). No influence of either stent graft type or generation, or degree of oversizing was observed (p = .29, p = .28, p = .81 respectively). However, the mean aortic angle of patients with bird beak was higher in the Pro-form group than that in the Zenith TX2 group (62 degrees vs. 48 degrees, p = .13). Multivariate analysis identified the aortic angle of the deployment zone as the unique independent risk factor of malapposition (HR = 1.05, 95% Cl 1-1.10, p = .005). The cutoff value of 51 degrees was found to be predictive of bird beak occurrence with a sensitivity of 58% and a specificity of 85%.Conclusions: Assessment of proximal landing zone morphology to avoid deployment zones generating an aortic angle of over 50 degrees can be recommended to improve aortic curvature apposition with the current available device

Background Because of its location, the popliteal artery is exposed to important biomechanical constraints, inducing a specific risk of thrombosis of stents, little studied in the literature. The objective of this monocentric retrospective study was to evaluate the patency of stents implanted in the popliteal artery to treat atheromatous lesions and the risk factors predisposing to thrombosis. Methods Between January 2009 and July 2013, all the patients receiving stents for a residual stenosis or a complication of angioplasty in the popliteal artery or the distal anastomosis of a femoropopliteal bypass were included retrospectively and in an intention to treat. Forty-six patients (17 women), with a 71.5 years median age (range, 45–90 years), including 17 diabetic patients (37%) and 7 hemodialysis patients (15%), were operated in 51 limbs for claudication (n = 25, 49%), critical ischemia (n = 18, 35%), or acute ischemia (n = 8, 16%). Thirty stenoses >70% (59%) and 21 thromboses (41%) were treated with 56 autoexpandable stents, with an average diameter of 6 mm (range, 5–8 mm) and an average length of 5 cm (range, 4–15 cm), including 39 lesions in P1 (above the patella), 8 in P2 (articular), and 4 in P3 (distal popliteal artery). The following factors were analyzed according to univariate and multivariate models: age, gender, Society for Vascular Surgery score, symptomatology, type and location of lesion, number of stents deployed, and dimension of stents. Results Technical success was of 98% (n = 50), including 1 insufficient result of the endovascular treatment. At 30 days, one patient treated for critical ischemia died (2%) and one residual popliteal stenosis was treated by bypass (2%). After a 27.6 ± 10.07 month follow-up, restenosis (>50%) was detected in 5 cases including 4 asymptomatic and a popliteal thrombosis occurred in 9 cases, including 3 asymptomatic cases. Eight secondary interventions were necessary, including 4 endovascular procedures, 3 bypasses, and only 1 major amputation (thigh). The primary and secondary patencies at 12 months and 24 months were 80% and 65%, and 90% and 74%, respectively. The multivariate analysis showed that the type of lesion (stenosis versus occlusion; odds ratio [OR], 5.1; 95% confidence interval [CI], 1.2–22.9, P = 0.032) and the number of stents implanted (1 vs. 2 stents; OR [95% CI], 12.7 [1.8–88.5]; P = 0.011) were independent predictive factors of secondary thrombosis. Conclusions The endovascular treatment of the atheromatous popliteal lesions appears to be a satisfactory alternative. The implantation of 1 stent in the popliteal artery is recommended in the event of popliteal occlusion, whereas for a stenosis, it must be reserved for patients with residual stenosis or in the event of complications of angioplasty, such as dissection or elastic recoil. Stent must be single, with deployment of a long stent in the event of long lesion.

BACKGROUND This study aimed to identify patient, pathology and procedure-related factors affecting perioperative and mid-term mortality of thoracic aorta emergencies. METHODS Between 2007 and 2014, patients treated emergently with thoracic stent-graft were retrospectively reviewed. Variables analyzed were: age, renal insufficiency, shock, cardiac arrest, transfer status, pathology, debranching procedures, operation duration, vascular access and European System for Cardiac Operative Risk Evaluation (EuroSCORE). Seventy-four patients (54.5±22 years) were treated for traumatic rupture (N.=31), aneurysm (TAA) (N.=16), acute aortic syndrome (N.=18), aorto-esophageal fistula (N.=2), floating thrombus (N.=7). Thirty-four patients (46%) were in shock, including 3 suffering preoperative cardiac arrest. Proximal landing zones were: zone 0 (N.=4), zone 1 (N.=4), zone 2 (N.=37), zone 3 (N.=21) and zone 4 (N.=8). Debranching procedures were performed in 16 cases (22%). RESULTS Perioperative all-cause- mortality was 18.9% (N.=14). Univariable analysis identified age, renal insufficiency, shock, transfer status, cardiac arrest, debranching procedures in zones 0 or 4 and EuroSCORE as predictors of death (P=0.002, P=0.001, P=0.002, P=0.05, P=0.006, P=0.028, P

Background Most of the experience on fenestrated endovascular aneurysm repair involves the custom-made Zenith® endograft (Cook). The fenestrated Anaconda® endograft (Vascutek) was introduced with the potential advantages of complete repositioning and lack of stent material on the main aortic body for more versatility. However, few data are available. Our objective was to assess its mid-term results in the treatment of complex aortic aneurysms. Methods Consecutive patients treated with the custom-made fenestrated Anaconda endograft in France and the Principality of Monaco, from December 2010 to October 2015, were included. Results Eighty-six patients were included over 16 centers (82 men, mean age 73.4 ± 8.1 years, 16 (18.6%) symptomatic aneurysms). The repositioning system was used in 68 cases (79.1%). Two hundred ninety-two visceral/renal vessels were targeted, with a mean number of 3.4 ± 0.6 target vessels/patient and a successful reconstruction in 99.3% of the cases (290/292 vessels). Perioperative technical success was achieved in 86.0% (74/86 patients). In-hospital and 30-day mortality rates were 3.5% (3 patients) and 7.0% (6 patients), respectively. At 12 and 24 months, estimated overall survival rate was 88.3% and 85.2%, target vessel's patency rate was 97.2% and 96.3%, and freedom from aneurysm-related reintervention rate was 96.3% and 88.0%, respectively. At 24 months, there were 7 type II endoleaks (12.7%) and a significant reduction in aneurysm maximum transverse diameter in 70.4%. Five limb occlusions occurred at 1-year and 1 at 2-year follow-up (7.0%). Conclusions The fenestrated Anaconda stent-graft system offers acceptable technical success rates, mid-term efficacy, and durability with respect to aneurysm sac regression, target vessel patency, overall mortality, and reintervention rates. Long-term results are still awaited, until then, the rate of graft limb occlusion is of concern and should be further investigated, especially in case of particularly complex aortic anatomies.

Background In this study we analyzed embolization and stent-graft results. Methods Demographics, indications, procedures, and outcomes of patients treated with embolization or stent grafting for late postoperative bleeding after major abdominal surgery were retrospectively recorded. Outcomes were analyzed on an intention-to-treat basis. Results Between 2004 and 2008, 14 consecutive patients (11 men and 3 women, mean age 64 years) were treated for hemorrhage responsible for shock in 6 patients (43%), occurring after pancreaticoduodenectomy (n = 13) or subtotal gastrectomy (n = 1). Mean onset occurred at 23 days postoperatively (range 7–75 days). Bleeding site included: the stump of the gastroduodenal artery (n = 10), splenic artery (n = 2), common hepatic artery (n = 1), and right gastric artery (n = 1). Initial success was obtained in 13 patients (93%); the only failure of stent-graft deployment required re-laparotomy. Treatment included embolization in 8 patients and stent grafting in 5 patients. In the embolization group, 5 complications (62%) occurred: 4 rebleeding and 1 gastric perforation, compared with no early complications in the stent-graft group. One patient died in each group. The mean follow-up was 25 months (range 6–57 months). Conclusions Stent grafting seems to provide definitive hemostasis and fewer complications compared with embolization.

Objective To assess a practice of claudicant revascularization with either subintimal angioplasty (SIA) plus stenting or femoropopliteal bypass. Methods All claudicants related to femoropopliteal occlusions treated either with above-the-knee femoropopliteal (AKFP) bypass (group 1) or SIA and stent (group 2) between 2004 and 2011 were reviewed. The two groups were analyzed with regard to patency and freedom from re-intervention. Results One hundred and fifty limbs were consecutively treated with AKFP bypass (n = 82), SIA plus stenting (n = 58), or SIA (n = 10). Bypasses were performed with synthetic grafts in 49 limbs (59.7%). Covered stents were used in 34 limbs (63%) and self-expandable stents in the remainder. Mean follow-up was 26 and 36 months, respectively, in group 1 and 2. At 24 months, primary, primary-assisted, and secondary patency for bypass versus SIA + stent groups was, respectively, 66.6 versus 70.1%, 76.5 versus 90.1%, and 88.2 versus 90.1%. Freedom from re-intervention rates at 12 and 36 months were, respectively, 78.8 and 68.4% for group 2 and 86.4% and 65.2% for group 1. Conclusion SIA plus stenting is an effective and useful option for the management of claudicants with femoropopliteal occlusions, and can be considered as complementary to surgical bypass.

Background Technical and clinical success of thoracic aortic endovascular procedures relies mainly on the choice of the proximal sealing zone (PSZ). The latter can be affected by multiple complications, all of them having a potential gravity and a direct link with the quality of the PSZ. The objective of this study was to analyze the risk factors of PSZ complications occurrence. Methods Between 2007 and 2015, all the patients treated by a thoracic stent graft in zones 2, 3, or 4 were retrospectively reviewed, with analysis of the preoperative and postoperative angio-computed tomography. Proximal sealing zone complications are type Ia endoleaks, bird beak ≥20 mm, malposition ≥11 mm, migration ≥10 mm, and retrograde dissection. Three types of potential risk factors were analyzed: (1) related to the patients (age, gender, pathology, urgency, hybrid surgery); (2) related to the stent graft (bare or covered proximal stent, degree of oversizing, number of stents, generation); (3) related to the morphology (radius of curvature, diameter, degree of conicity, calcifications and thrombus of the neck, depth of the arch, angulation of the proximal sealing zone, and tortuosity index of the arch and the thoracic aorta. Results Seventy-six patients (mean age: 54 years, 17–93 years) were treated for traumatic aortic rupture (n = 27, 35.5%), aortic dissection (n = 26, 34%), aneurysm (n = 15, 20%), and other diseases (floating thrombus, aortoesophageal fistula) (n = 8, 10.5%). A hybrid surgery was carried out in 18 patients (24%). Primary technical success was 93.5% (n = 71). With a mean follow-up of 29 months, 30 PSZ complications were observed in 21 patients (28%): type Ia endoleaks (n = 3, 4%), bird beak (n = 7, 9%), malposition (n = 3, 4%), migration (n = 1, 1.5%), retrograde dissection (n = 1, 1.5%), or several complications (n = 6, 7.8%). Among the morphological factors, 2 parameters were significantly associated with the occurrence of complications: tortuosity index (group without PSZ complications 1.62 ± 0.2 vs. group with PSZ complications 1.72 ± 0.2, P = 0.042), and the diameter of the proximal neck (group without PSZ complications 25.7 ± 5 vs. group with PSZ complications 31 ± 6.0, P = 0.001). Neither the demographic factors nor those related to the stent graft presented a statistically significant relation with the occurrence of complications. Conclusions This work clearly highlights the relation between PSZ complications, independently of their type, and the local and global aortic morphology. A wide proximal neck, > 34 mm, and an important aortic tortuosity, > 1.8, are situations at risk.

International audience; Objective: The present study aimed at quantifying mal-positioning during ă thoracic endovascular aortic repair and analysing the extent to which ă anatomical factors influence the exact stent graft positioning. ă Methods: A retrospective review was conducted of patients treated ă between 2007 and 2014 with a stent graft for whom proximal landing zones ă (LZ) could be precisely located by anatomical fixed landmarks, that is ă LZ 1, 2, or 3. The study included 66 patients (54 men; mean age 51 ă years, range 17-83 years) treated for traumatic aortic rupture (n = 27), ă type B aortic dissection (n = 21), thoracic aortic aneurysm (n = 8), ă penetrating aortic ulcer (n = 5), intramural hematoma (n = 1), and ă floating aortic thrombus (n = 4). Pharmacologic hemodynamic-control was ă systematically obtained during stent graft deployment. Pre- and ă post-operative computed tomographic angiography was reviewed to quantify ă the distance between planned and achieved LZ and to analyze different ă anatomical factors: iliac diameter, calcification degree, aortic ă angulation at the proximal deployment zone, and tortuosity index (TI). ă Results: Primary endoleak was noted in seven cases (10%): five type I ă (7%) and two type II (3%). Over a mean 35 month follow up (range 3-95 ă months), secondary endoleak was detected in two patients (3%), both ă type I, and stent graft migration was seen in three patients. ă Mal-positioning varied from 2 to 15 mm. A cutoff value of 11 mm was ă identified as an adverse event risk. Univariate analysis showed that TI ă and LZ were significantly associated with mal-positioning (p = .01, p = ă .04 respectively), and that aortic angulation tends to reach ă significance (p = .08). No influence of deployment mechanism (p = .50) ă or stent graft generation (p = .71) or access-related factors was ă observed. Multivariate analysis identified TI as the unique independent ă risk factor of mal-positioning (OR 241, 95% CI 1-6,149, p = .05). A TI ă >1.68 was optimal for inaccurate deployment prediction. ă Conclusion: TI calculation can be useful to anticipate difficulties ă during stent graft deployment and to reduce mal-positioning. (C) 2016 ă European Society for Vascular Surgery. Published by Elsevier Ltd. All ă rights reserved.

Rationnelle Chez les patients hemodynamiquement instables, la gestion du traumatisme vasculaire retroperitoneal est difficile et represente un defi. Les techniques endovasculaires sont devenues une alternative a la chirurgie dans de nombreux centre d'accueil des traumatises. Methodes Entre 2004 et 2006, 16 patients (neuf hommes, âge moyen: 46 ans, extremes: 19-79 ans) avec traumatisme vasculaire retroperitoneal et instabilite hemodynamique ont ete traites par voie endovasculaire. Les scores moyens de severite de lesions etaient de 30,7 ± 13,1. La tension arterielle systolique moyenne et l'index de choc moyen etaient respectivement de 74 mm Hg et de 1,9. Des drogues vasopressives ont ete necessaires dans 68,7% des cas (n = 11). Les lesions etaient attribuables a un accident de la voie publique (n = 15) et a une chute (n = 1). Les sites hemorragiques ont inclus l'artere iliaque interne ou ses branches (n = 12) avec des lesions bilaterales dans un cas, l'artere renale (n = 2), l'aorte abdominale (n = 1), et une artere lombaire (n = 1). Resultats Au total, 14 embolisations par coils et trois stent couverts ont ete implantees. Le taux de succes technique etait de 75%, car une embolisation iterative precoce a ete necessaire dans un cas et trois patients sont decedes en peri operatoire. Six patients sont decedes au cours de l'hospitalisation (37,5%). Aucune conversion chirurgicale ou complication majeure n'a ete rapportee. Conclusion Par rapport aux particules, l'embolisation par coils ± stent couvert peut donner une efficacite semblable en ce qui concerne la survie, et peut etre ainsi une solution valable quand l'embolisation par particules n'est pas disponible ou faisable.

BACKGROUND: Angiomyolipoma can worsen during pregnancy. Inferior vena cava thrombus of renal angiomyolipoma during pregnancy is rare, and threatens to cause massive emboli. We report a case of vena cava tumor thrombectomy during the second trimester of pregnancy with delayed renal tumorectomy. CASE: A 34-year-old woman with bilateral known angiomyolipomas presented asymptomatic at 30 weeks of gestation with an inferior vena cava thrombus at renal follow-up ultrasonography. Retro-hepatic thrombus had fatty signal on magnetic resonance imaging (MRI). The woman had renal vein and vena cava tumor initial thrombectomy, and had normal cesarean delivery at 39 weeks of gestation. The tumor was treated by postpartum right partial nephrectomy. CONCLUSION: Successful angiomyolipoma isolated thrombectomy during pregnancy with delayed partial nephrectomy is possible. Angiomyolipoma needs follow-up during pregnancy with repeated renal ultrasonography.

There is a growing need for dedicated endovascular devices to treat pathologies affecting the venous system. However, because of a lack of research into venous diseases and treatments, the optimal design, material, and mechanical properties of venous stents remain unknown. Development of the ideal venous stent should be based on a thorough understanding of the underlying venous pathology. There are multiple venous diseases that differ from each other depending on their location (iliocaval, superior vena cava), mechanism (thrombotic versus nonthrombotic lesions), and chronicity. Thus, it is likely that stent material, design, and features should differ according to each underlying disease. From a mechanical point of view, the success of a venous stent hinges on its ability to resist crushing (which requires high global and local radial rigidity) and to match with the compliant implant environment (which requires high flexibility). Device oversizing, textile coverage, and drug coating are additional features that should be considered in the context of venous diseases rather than directly translated from the arterial world. This review examines the unique forces affecting venous stents, the problems with using arterial devices to treat venous pathologies, preliminary results of a study comparing crush resistance of commercially available laser-cut stents with a novel braided stent design, and its applicability to venous interventions.

Background Ilio-caval stenting now represents the first line treatment for disabling obstructive ilio-caval lesions. Most patients are young women of child-bearing age. We herein report our experience of pregnancy in women who have a history of ilio-caval stenting. Materials and Methods From November 1995 to April 2008, 119 patients had ilio-caval stenting for obstructive venous disease in our department. Of these, 62 women were able to become pregnant. When pregnancy occurred, they received preventive treatment with low molecular weight heparin (LMWH) from the 3rd month of pregnancy to 1 month after delivery and had to wear elastic stockings. Patients also had to sleep on their right side if possible. They were followed during the pregnancy by duplex scanning at 3, 6, and 8 months, and then 1 month after delivery. Results Eight pregnancies occurred in 6 patients (mean age 26.5 years) who had a patent self-expanding stent (1 patient had 3 pregnancies). They had stenting for May-Thurner disease in 3 patients, for post-deep venous thrombosis (DVT) left common iliac vein occlusion in 1 patient, and during venous thrombectomy in 2 patients. All stents were self-expanding metallic stents located on the left common iliac vein. One patient had unrelated spontaneous abortion after 2 months of pregnancy. No DVT or symptomatic pulmonary embolism occurred during pregnancy, delivery, or during the postpartum period. Four patients needed cesarean delivery and none had hemorrhagic complications. None of the patients had adverse effects from the treatment. Duplex scan showed compression of the stent(s) at 8 months in 4 patients with inflow obstruction in 3 patients. Postpartum duplex-scan showed no remaining stenosis in all patients. No stents had structural damage. Conclusion Ilio-caval stent compression can occur during pregnancy but does not lead to structural damage to the self-expanding stents. Despite this, no cases of DVT occurred with preventive LMWH treatment.

Hemorrhage after pancreaticoduodenectomy is a life-threatening complication, which occurs in 4% to 16% of cases, even in experienced centers. Many diagnostic and therapeutic options exist but no one has yet established management guidelines. This study aimed to determine the role of conservative management in delayed hemorrhage.From January 2005 to August 2008, 87 patients underwent pancreaticoduodenectomy at our center. We reviewed, retrospectively, the medical charts of all patients who had experienced postoperative hemorrhage.Early hemorrhage occurred in one patient, who underwent successful reoperation. Nine patients presented with delayed hemorrhage (10.3%), including three with sentinel bleeding. Mean onset was 20 days post-surgery. We used the same initial management for each patient: all had an urgent contrast computed tomography scan. In every case, the bleeding site was arterial. Conservative treatment (embolization or covered stent) was successful in every case. We reoperated on two patients for gastrointestinal perforation, at 9 days and 2 months after embolization, respectively. We transferred seven patients to an intensive care unit, with an average stay of 8 days. Mean hospital stay was 43 days (33-60). All patients survived.Conservative management, combining endovascular procedures and aggressive resuscitation, is appropriate for most cases of delayed hemorrhage after pancreaticoduodenectomy.

Resume Buts de l’etude Faut-il disposer d’une circulation extracorporelle (CEC) pour traiter en urgence des lesions de l’aorte thoracique descendante ? Materiels et methodes Entre janvier 2004 et mai 2006, parmi 16 patients, 13 (81 %) ont ete traites en urgence (neuf hommes ; âge moyen : 75,4 ans, de 30 a 94 ans), pour rupture traumatique de l’aorte ( n = 3 ; 23 %), dissection aortique aigue type B ( n = 4 ; 31 %), anevrisme thoracique douloureux ou rompu ( n = 4 ; 31 %), fistule aorto-œsophagienne ( n = 1 ; 7,5 %) et hematome intramural ( n = 1; 7,5 %). L’angioscanner systematique a montre dans cinq cas (38 %) un hemomediastin et/ou hemothorax ; l’echocardiographie transœsophagienne (ETO) et l’arteriographie ont ete realisees respectivement chez deux (15 %) et un patients. Chez deux patients (15 %), un drainage du LCR a ete mis en place. Resultats Le taux de succes technique etait de 92,3 %. Un deces (7,5 %) est survenu a j8 et une paraplegie differee (7,5 %). Durant un suivi moyen de 10,2 mois (deux a 24 mois), aucune rupture et deux (15 %) endofuites type I ont ete traitees. Deux deces sont survenus a distance sans rapport direct avec la pathologie aortique thoracique. Chez aucun patient, une CEC n’a ete necessaire. Conclusion La non-disponibilite de la CEC ne semble pas compromettre la prise en charge de ce type de pathologie mais une maitrise des techniques endovasculaires est indispensable.

PurposeIliac vein occlusive disease leads to 73% of rethrombosis that occurs after venous thrombectomy when left untreated. The goal of this study is to present our long-term results of stenting of iliocaval occlusive lesions persisting after surgical venous thrombectomy.MethodsFrom November 1995 to April 2007, 29 patients (19 women), with a median age of 38 years, had surgical venous thrombectomy with creation of an arteriovenous fistula and angioplasty and stenting. All were admitted for acute (

We report a case of ruptured abdominal aortic aneurysm emergently treated by endovascular aneurysm repair (EVAR) that developed a primary type II endoleak leading to persistent blood loss and retroperitoneal hematoma increase. Coil embolization resolved this. Although to our knowledge there are no recommendations regarding this, our report suggests that early type II endoleaks occurring after emergency EVAR for ruptured AAA should be treated when it is associated with blood extravasation outside the aneurysm sac.

Objective Review of a 10 year-experience, to evaluate the efficacy of pre-operative investigations in the detection of external iliac artery (EIA) endofibrosis in top endurance athletes. Design Retrospective study. Materials From September 1995 to March 2004, 13 highly-trained athletes (all men, mean age 32.3 years) underwent surgery for disease involving 14 lower limbs (11 left, one right, one bilateral). Methods We compared ultrasound scan (US) and digital subtraction angiography (DSA) data, at rest and at hip flexion with intra-operative findings for all 14 lower limbs. We analyzed the presence of stenosis in the external and common iliac arteries, the presence of psoas muscle arteries and the presence of excessive EIA length. Results In the affected limbs, before treatment, the mean ankle brachial index (ABI) at rest was 0.98 compared with 0.56 after exercise, p=0.0001. The sensitivities of the US vs DSA examination in the detection of external and common iliac artery stenosis were, respectively, 84.6 and 53.8% vs 53.8 and 12.5%. The muscle psoas artery was detected by DSA with a sensitivity of 57.1 and 100% specificity. For the detection of excessive EIA length, the sensitivity of US was 85.7% with 57.1% specificity. Conclusions A fall of ABI after exercise proves the presence of a significant stenosis in symptomatic athletes. Color coded duplex ultrasonography is recommended for non-invasive imaging of suspected endofibrotic stenosis in young athletes, since it detects reliably both stenosis and elongation of iliacal arteries.

Long-standing arteriovenous fistula (AVF) can lead after closure to late arterial aneurysm formation. We report the case of an extensive iliofemoral aneurysm extending from the aorta to a left venous above-knee to below-knee popliteal bypass occurring 14 years after closure of a post-traumatic popliteal AVF. While the arterial axis, which was not dilated at closure, became aneurysmal, it is remarkable that the vein bypass performed at the same time was not altered. The pathophysiologic mechanism of such a complication could be morphologic modification of the arterial wall while the AVF is open and hemodynamic change after its closure.

Objectives: This study was undertaken to evaluate the consequences on patient selection and on early and mid-term results during the learning curve of a surgical team performing laparoscopy-assisted surgery to treat abdominal aortic aneurysm (AAA). Patients and Methods: Between December 1998 and January 2002, 24 patients (22 men, 2 women; mean age, 68.2 years [range, 57-82 years]) were included in a prospective study and underwent laparoscopic transperitoneal AAA dissection followed by graft implantation through a 6 to 9 cm minilaparotomy. Perioperative data for the first 10 patients, obtained during the first 25 months of the study (group 1), were compared with data for the last 14 patients, obtained during the last 13 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomographic scanning before discharge and yearly thereafter. Results: One patient (4.3%) died in the immediate postoperative period. In this patient and two others (12.5%), the minilaparotomy was extended intraoperatively, from 12 cm to 16 cm. With experience, initial contraindications such as obesity and short proximal or calcified aortic neck were eliminated, enabling increase in rate of patients included, from 27.7% during the first 25 first months to 56% during the last 13 months (P =.063). Mean duration of operative clamping decreased from 275 minutes in group 1 to 195 minutes in group 2 (P

We report two cases of iliocaval occlusion caused by retroperitoneal fibrosis; one presented acute symptoms and one chronic. Both were treated by use of transluminal angioplasty and stenting with excellent clinical, hemodynamic, and imaging results at 36 and 51 months. These cases confirm the benefit of endovascular techniques in the treatment of nonmalignant obstructive disease of large veins, and specifically in the case of retroperitoneal fibrosis. (J Vasc Surg 2002;36:849-52.)

This report describes mid-term results of endovascular treatment of obstructive iliocaval lesions. Between November 1995 and December 1999, a total of 15 patients were treated by angioplasty and stent placement in the iliac vein. These patients were divided into two groups. Group I consisted of six patients with acute iliofemoral thrombosis of less than 10 days duration, with associated caval involvement in three cases. Angioplasty was performed after surgical thrombectomy, and creation of an arteriovenous fistula as a one-stage procedure in four cases and as a two-stage procedure in two cases. The underlying chronic lesion was stenosis of the left iliocaval junction (Cockett syndrome) in five cases and retroperitoneal fibrosis in one. Group II comprised nine patients with chronic symptomatic stenosis or occlusion. The etiology was Cockett syndrome in seven cases, post-thrombotic syndrome in three cases, including two associated with Cockett syndrome, and retroperitoneal fibrosis in one case. The mean number of stents per patient was 1.5. The mean duration of follow-up was 23.5 months. Evaluation of clinical outcome according to CEAP criteria for chronic syndromes showed significant improvement. Given good mid-term findings, venous angioplasty with stent placement appears to be a safe and effective technique for treatment of acute or chronic obstructive iliocaval lesions.

The purpose of this study was to develop a sealing technique for polyester prosthetic grafts able to promote healing and reduce intimal hyperplasia. The porcine experimental model was aortoiliac bypass with a 6-mm diameter knitted polyester prosthetic graft implanted for 14 and 90 days. Animals were divided into three groups according to sealing technique as follows: pre-clotting with blood (group I, n = 12), sealing with autologous fibrin glue (group II, n = 14), and sealing with autologous fibrin glue and bone marrow cells (group III, n = 16). Feasibility and quality of sealing were evaluated by scanning electron microscopy prior to implantation and by assessment of blood loss. After removal, prostheses were cut into three segments comprising the proximal anastomosis, midsection, and distal anastomosis. Pieces were fixed, embedded in paraffin, and serially sectioned for histologic study. Histological study focused on the degree of stenosis and hyperplasia of the neointima of each prosthesis. The results of this short-term study indicate that sealing of polyester vascular prosthetic grafts with autologous fibrin glue and bone marrow cells is effective in reducing intimal hyperplasia. However further study will be needed to assess long-term healing.

Objective to define the respective advantages and pitfalls of the trans- or retroperitoneal approaches in laparoscopic abdominal aortic reconstruction (LAOR). Design prospective study. Material ten patients (8 males; average age 58) underwent an aortouni- ( n =2) or bifemoral bypass ( n =8) to treat aortoiliac occlusive disease ( n =8) or an aortic aneurysm ( n =2). Methods a retroperitoneal approach (the “apron” technique) was used in the first 5 cases (Group I) and a transperitoneal approach in the last 5 cases (Group II). Results no early or late death occurred, and all bypasses remain patent after a mean follow-up of 5.7 months. Mean surgical and clamping times are similar in both groups (370 and 126 min in Group I; 324 and 137 min in Group II). One intraoperative conversion to open surgery and two postoperative surgical complications occurred in Group I. Four minilaparotomies of 8–10 cm were necessary in Group II. Two patients were discharged on postoperative day 6 in Group I and five in Group II. Conclusion this preliminary study shows the feasibility of LAOR through both approaches. In Group II, a better exposure of the right aortic wall and of the right iliac axis was noted and division of the inferior mesenteric artery was not always necessary.

Accurate identification of arterial injury in the emergency setting constitutes one of the essential prognostic factors in patients presenting with acute popliteal arterial injury (APAI). The modalities of angioscopy performed intraoperatively by the vascular surgeon, including the details of how angioscopy can contribute to therapeutic decisions in this setting, are presented. Between June 1987 and August 1993, 26 patients presenting with 27 APAIs (one patient had a bilateral APAI) were treated at our institution. Eighteen (67%) lesions were due to closed trauma, three (11%) to shotgun pellets, three (11%) to knife wounds, two (7%) to iatrogenic wounds, and one (4%) to a bullet wound. Between June 1987 and January 1992 (group I, n = 20), treatment consisted of 15 (75%) saphenous vein bypasses and five (25%) local repairs. Pre- or intraoperative arteriograms were obtained in 14 (70%) cases. Three (15%) major amputations were required after popliteal reconstruction. Between February 1992 and August 1993 (group II, n = 7), two (29%) saphenous vein grafts and five (71%) local repairs were performed after routine intraoperative angioscopy. Arteriograms were obtained in six (86%) instances. No amputations were necessary in this group. As a complement to arteriography, intraoperative angioscopy can determine the extent and number of injuries, provides direct visualization of the intima of the entire femoropopliteal artery, even when the latter is obscured by thrombus, and ensures a final control of popliteal artery repair at completion. After angioscopy, local repair was possible more often (71% vs. 25%, p = 0.03) and treatment was associated with a better functional result (0% vs. 15% amputation rate, p = 0.04) in group II.

Unite de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, Faculte de Medecine, Universite de la Mediterranee, Marseille, France (M Million MD, Elisabeth Botelho-Nevers MD, Prof P Brouqui MD, Prof D Raoult MD); Service de Chirurgie Vasculaire, (O Hartung MD, M Claudel MD), Service d’Imagerie Medicale, (F Craighero MD), and Service des Maladies Infectieuses et Tropicales, Hopital Nord, Marseille, France (C Melenotte MD, M Million MD, Elisabeth Botelho-Nevers MD, Prof P Brouqui MD)

Venous obstructive lesions represent a therapeutic challenge. Postthrombotic lesions are the most complex and very prone to rethrombosis. Technical success can be achieved in more than 85% of the cases (100% when recanalization with thrombolysis is not needed) with a low rate of periprocedural complications and no mortality. The overall rate of thrombotic events after stenting is around 5%. Patency rates depend on multiple criteria, including the need for thrombolysis and the involvement of the common femoral vein and of the inferior vena cava. Primary, assisted-primary, and secondary patency rates were 67%, 89%, and 93%, respectively, at 6 years in the study by Neglen and 66%, 70%, and 77%, respectively, in the intention-to-treat European multicentric study, at 5 and 10 years. Stenting is a minimally invasive and safe technique with good long-term clinical results and patency rates. It represents the method of choice for the treatment of postthrombotic iliofemoral venous obstructions.

Objective To report the long-term results of stenting for chronic ilio-caval obstructive lesions. Material and methods From January 1996 to January 2008, 89 patients (72 women, 17 men; median age 43 years) were admitted for endovascular treatment of chronic disabling non-malignant obstructive ilio-caval lesions. Patients were classified as C2 in 15 cases, C3 in 59, C4 in seven, C5 in two and C6 in six. Median preoperative venous disability score (VDS) and venous clinical severity score (VCSS) were 2 and 9, respectively. Aetiology was primary in 52 patients, secondary in 35 and congenital in two. Lesions were bilateral in seven cases, eight patients had inferior vena cava (IVC) involvement and 18 had common femoral vein (CFV) obstructive lesions. Complete occlusion was found in 30 cases. Results Technical success was achieved in 98%. The median hospital stay was 2 days. During a median follow-up of 38 months (range: 1–144 months), one patient died and five cases of thromboses occurred. Iterative stenting was performed for restenosis in six cases. Primary, assisted-primary and secondary patency rates, in terms of intention to treat, were 83%, 89% and 93%, respectively, at 3 and 10 years, with a median VDS of 1. Univariate analysis found that significant factors affecting patency were CFV involvement for primary patency and history of deep venous thrombosis (DVT) and CFV involvement for secondary patency. The last 46 patients had statistically more severe lesions than the first 43 (higher VDS, more secondary lesions, more occlusions, more stented segments, higher length of stented vein), and in spite of which patency rates are not different. Conclusion Endovenous angioplasty, combined with stenting, is a sure, safe, effective and very minimally invasive technique which provides good long-term patency rates. Currently, it is recognised as the technique of choice for the treatment of ilio-caval obstructive lesions. Surgery should be proposed only in case of failure.

Purpose To evaluate superficial femoral artery (SFA) occlusive disease treatment by means of covered stents. Study design retrospective. Method From 2000 to 2005, a Hemobahn/Viabahn ® endoprosthesis was implanted in 102 limbs (95 patients; mean age: 72.1 years, 52–94) for intermittent claudication (group I, n =50 limbs), critical (group II, n =32) or acute ischemia (group III, n =20). Lesions treated were Trans-Atlantic Inter-Society Consensus (TASC) A ( n =9) B ( n =42), C ( n =28) or D ( n =23), associated with a good (2 or 3 leg arteries, n =60) or a poor (1 or 0 artery, n =42) runoff. Results The endograft was placed successfully in all cases, but 3 early deaths (3.2%) (1 in group II and 2 in group III), and 4 acute thromboses (4%) occurred. Primary and secondary actuarial patency rates were 97±1.7%, and 99±1% at 1 month, 74±4.8% & 84±4.1% at 1 year,and 71±9.5% & 79±8.5% at 3 years, after a mean follow-up of 30.2 months (1–60). Long-term primary and secondary patencies were significantly different between TASC Cand TASC D lesions (P .004 & .001) . Conclusion Severity of lesions, rather than preoperative symptoms or runoff, is mainly to be considered before using Hemobahn/Viabahn ® endoprosthesis in severe SFA occlusive lesions.

Background Compression of the left renal vein between the aorta and the superior mesenteric artery is a rare but possibly underestimated condition. Surgical correction (42 cases reported in the literature) can be performed by means of a variety of different techniques. Although endovascular stenting is well accepted for iliocaval occlusive disease, it has been poorly evaluated in this indication. We describe five patients who were treated for nutcracker syndrome by using stenting and analyze the nine cases previously reported. Methods From November 2002 to September 2004, five women (mean age, 34.7 years) were admitted for endovascular treatment of a nutcracker syndrome. They all had incapacitating pelvic congestion syndrome, including two with a history of left ovarian vein embolization; moreover, two had left lumbar pain, and three had hematuria. The mean preoperative venous disability score was 2.4. The patients underwent a gynecologic examination and laparoscopy to eliminate other causes of pelvic pain. The laparoscopy revealed large pelvic varicose veins and no signs of endometriosis. Duplex scan, computed tomographic scan, and iliocavography revealed left renal vein compression, with proximal distention and collateral pathways, with dilatation and permanent reflux in the left ovarian vein in the three patients who had not had prior embolization. The mean renocaval pullback gradient was 4.3 mm Hg. A percutaneous endovascular procedure, during in which a self-expanding metallic stent was implanted, was performed under general anaesthesia. Results Technical success was achieved in all cases. One case of stent migration occurred: the stent was pulled down in the inferior vena cava, with uneventful follow-up (mean, 14.3 months). One month later, patients were all improved and stents were patent at the duplex scan examination, without restenosis. The mean venous disability score was 1. No further left ovarian vein reflux was evident at duplex scan in patients who did not have prior embolization. Pelvic pain recurred in one patient who had initially improved, and endometriosis was diagnosed 15 months after the procedure. Two other patients, who received 40-mm-long stents, had a secondary recurrence of the symptoms caused by stent dislodgement. The two other patients were asymptomatic. Conclusions This study shows that stenting is feasible, but some guidelines should be followed, mainly the use of long stents protruding into the inferior vena cava. Stenting can eliminate the symptoms of the condition, and the technique is only very slightly invasive. Further experience and follow-up are needed before accepting such a procedure for treatment of the nutcracker syndrome.

ObjectivesThe purpose of this study was to evaluate the consequences on patient selection and on early and midterm results of the learning curve of a surgical team performing laparoscopy-assisted surgery in the treatment of severe aortoiliac occlusive disease (AIOD).Patients and methodBetween January 1998 and June 2003, 58 patients (53 men, 5 women; mean age, 59.5 years [range, 37-76 years]) were included in a prospective study and underwent a laparoscopy-assisted aortofemoral reconstruction with graft implantation through a 5-cm to 8-cm minilaparotomy. Fifty-one patients (88%) had claudication (category 2 or 3, Rutherford classification), and seven patients (12%) had tissue loss; at presentation they had TransAtlantic Inter-Society Consensus C (n = 24, 41.4 %) or D (n = 32, 55.2%) iliac lesions, and the last 2 patients (3.4%) had severe aortic lesions. Perioperative data for the first 29 patients, obtained during the first 34 months of the study (group 1), were compared with data for the last 29 patients, obtained during the last 32 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomography before discharge and then every 2 years.ResultsOne intraoperative surgical conversion (1.7%) was necessary, and two other patients (3.4%) died in the immediate postoperative period. With experience, initial contraindications such as obesity or suprarenal artery aortic clamping were eliminated, making it possible to increase the percentage of patients included, from 53.7% during the first 34 months to 90.6% during the last 32 months (P = .003). The mean duration of the operative procedure decreased from 285 minutes in group 1 to 192 minutes in group 2 (P < .001), and the mean duration of aortic clamping decreased from 76.4 minutes in group 1 to 31.8 minutes in group 2 (P < .001). The number of early repeat interventions was reduced from three (10.3%) in group 1 to 2 (6.9%) in group 2 (P = NS), and the clinical recovery period decreased from 7 days to 4.5 days (P = .05). During a mean follow-up of 26.7 months (range, 1-66 months) there were 5 repeat surgeries (9%) to treat late graft occlusion, establishing midterm primary and secondary patency rates of 89.3% and 91%, respectively. No aortic false aneurysms were detected, and no major amputations were performed.ConclusionThese preliminary results assess the feasability and the safety of this minimally invasive video-assisted technique. A short period of postoperative recovery and good midterm patency rate are the two main benefits of this new surgical option.