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ObjectivesTo analyse perioperative and midterm outcomes of carotid artery stenting (CAS) for symptomatic >50% and asymptomatic >70% restenosis after open carotid surgery (OCS).DesignA multicentric retrospective study.MethodsOutcome measures 30-day death, neurologic and anatomic (thrombosis, restenosis) events. Univariant and multivariant logistic regression analyses were performed to identify predictive factors for neurologic and anatomic events.ResultsA total of 249 patients with a mean age of 69 years (range, 45–88) were treated for asymptomatic (86%) or symptomatic (14%) restenosis. The 30-day combined operative mortality and stroke morbidity was 2.8% in asymptomatic patients and 2.9% in symptomatic patients. Events during follow-up (mean duration, 29 months) included stroke in four cases, TIA in two, stent thrombosis in four and restenosis in 21. Kaplan–Meier estimates of overall survival, neurologic-event-free survival, anatomic-event-free survival and reintervention-free survival were 95.4%, 94.7%, 96.7% and 99.5%, respectively, at 1 year and 80.3%, 93.8%, 85.1% and 96%, respectively, at 4 years. Multivariant analysis showed that statin use was correlated with a lower risk of anatomic events (odds ratio (OR) = 0.15 (95% confidence interval (CI) 0.03–0.68), p = 0.01) and that bypass was associated with a higher risk of anatomic events than endarterectomy (OR = 5.0 (95% CI 1.6–16.6), p = 0.009).ConclusionCAS is a feasible therapeutic alternative to OCS for carotid restenosis with acceptable risks in the perioperative period. Restenosis rate may be higher in patients treated after bypass.

Objectifs Nous avons evalue l’influence des systemes de fixation proximale de l’endoprothese sur la dilatation du collet proximal de l’anevrisme en inter et en sous-renal apres traitement endovasculaire d’un anevrisme de l’aorte abdominale (EVAR). Des facteurs predictifs cliniques et anatomiques de dilatation du collet et de migration proximale de l’endoprothese ont ete recherches. Materiel et methodes A partir d’un registre prospectif et monocentrique, 58 dossiers de malades avec un suivi complet minimum de 3 ans ont ete analyses apres traitement par endoprothese avec fixation supra-renale (FSR : 33 Talent) ou avec fixation infra-renale (FIR : 25 AneuRx). Les deux groupes etaient compares en terme de dilatation du collet inter-renal (D1 : diametre entre les deux arteres renales), sous-renal (D2 : diametre 7 mm sous l’artere renale la plus basse) et de complication specifique (migration proximale, endofuite). Le diametre mesure sur le dernier controle tomodensitometrique etait compare au diametre post- operatoire. La dilatation du collet etait definie par une augmentation du diametre superieure a 3 mm et la migration proximale par un deplacement caudal de l’endoprothese superieur ou egal a 10 mm. Des facteurs predictifs de migration proximale ou de dilatation du collet ont ete recherches (anatomie du collet, anatomie de l’anevrisme, pourcentage de surdimensionnement de l’endoprothese, facteurs demographiques). Resultats Les deux groupes etaient comparables en termes de caracteristiques demographiques et anatomiques de l’anevrisme en pre-operatoire. Le recul moyen etait superieur dans le groupe AneuRx® (62 ± 17 mois vs 53 ± 13 mois, p = 0,045) et le pourcentage de surdimensionnement de l’endoprothese etait superieur dans le groupe Talent® (18 ± 6% vs 13 ± 5%, p

Objectifs La colite ischemique postoperatoire (CIPO) reste une complication frequente et gravissime de la chirurgie de l’aorte abdominale sous-renale. Cependant son diagnostic et sa prise en charge ne sont toujours pas consensuels du fait d’une faible incidence. L’objectif de cette etude retrospective etait d’identifier les facteurs pronostiques de colite severe consecutive a la chirurgie de l’aorte sous-renale. Materiel et methodes Nous avons analyse les donnees per-operatoires et perioperatoires des malades operes de l’aorte abdominale sous-renale entre 1998 et 2004 ayant presente une CIPO confirmee. Nous avons distingue deux groupes : le groupe de colites severes (CIPO operee, deces peri-operatoire ou evolution vers une stenose colique operee secondairement) et le groupe de colites moderees (guerison sans sequelles, sans avoir recours a la chirurgie). Le but principal etait d’individualiser des facteurs pronostiques de colite severe. Les potentiels facteurs pronostiques ont ete compares entre les deux groupes par le test t de Student ou le test exact de Fisher. Resultats Entre 1998 et 2004, 679 malades ont ete operes de l’aorte abdominale sous-renale. Parmi ces malades, 28 cas de CIPO ont ete confirmes. Vingt malades avaient une CIPO severe et 8 une CIPO moderee. Les donnees demographiques et peroperatoires etaient comparables pour les deux groupes. Parmi les 20 malades avec une CIPO severe, 17 ont ete operes avec un taux de mortalite postoperatoire de 58,8 %. Tous avaient au minimum une atteinte colique gauche. L’intervention de Hartmann realisee dans 59% des cas etait grevee d’un taux de mortalite de 50%. L’existence de symptomes digestifs precoces ( p = 0,05), l’utilisation de vasopresseurs ( p = 0,0377), un diagnostic en unite de soins intensifs ( p = 0,0095), un pH p = 0,0261) etaient associes de facon independante a la survenue de colite ischemique severe. Par ailleurs, nous avons pu observer le role important de l’endoscopie digestive basse a visee diagnostique et pronostique. Conclusion Cette etude a mis en evidence des facteurs pronostiques significatifs de colite severe. Ces facteurs pourraient aider a la decision operatoire des CIPO notamment pour diminuer l’incidence du syndrome de defaillance multi-viscerale (SDMV).

Purpose Evaluate the results of the two modalities used for the treatment of Secondary Aorto-Enteric Fistula (SAEF): In situ Reconstruction (ISR) and Extra-Anatomic Reconstruction (EAR). The primary endpoints of this study were early standard 30-day mortality and reinfection (RI). Secondary endpoints were perioperative morbidity, late mortality, primary graft patency, and major amputation rates. Material & method Diagnosis of SAEF was based on clinical examination and the results of pre-operative duplex or CT scans. Surgical management was performed according to local protocols at the participating institutions: – Elective surgery: ISR or staged EAR – Emergency surgery: aortic clamping followed by ISR or EAR – Selected high-risk patients: endovascular repair. Statistical analyses were performed using the actuarial method. Univariate analysis was used for analysis of categorical variables, and multivariate analysis was performed with a Cox proportional hazard regression. Results A total of 37 patients were included in this retrospective multicentre study. Mean follow-up was 41 months. The majority of the patients (20, 54%) presented acutely. EAR was performed in 9 patients (24%), ISR in 25 (68%), and 3 patients underwent endovascular repair. Bacteriological cultures were negative in 3 patients (9%). The most frequent organisms identified were Candida species and Escherichia coli . The 30-day mortality was 43% (16 patients). Patient age (>75 years) was the sole predictive factor associated with operative mortality ( p = 0.02); pre-operative shock was not statistically significant ( p = 0.08). There were 2 graft thromboses and 1 femoral amputation. Primary graft patency was respectively 89% at 1 year and 86% at 5 years; limb salvage rates were 100% at 1 and 5 years and 86% at 6 years, with no difference between ISR and EAR. RI occurred after 9.3 ± 13 months in 8 of 17 surviving patients and was fatal in all cases. For all surviving patients, the RI rate at 1 and 2 years was 24% and 41% respectively. There was no significant difference in the rate of RI after ISR or EAR. Conclusion EAR does not appear to be superior to ISR. The risk of RI increased with the length of follow-up, irrespective of the treatment modality. Life-long surveillance is mandatory. Our results with endovascular sealing of SAEF should be considered a bridge to open repair.

Objective To evaluate the causes and results of conversion to open repair after aortic aneurysm endovascular treatment (EVAR). Design Retrospective study of open conversion after EVAR was performed in eight French academic centres. Primary conversion (PC) within 30 days after EVAR and secondary conversions (SC) were analysed separately. Result Between 1997 and 2007, open conversions were performed in 34 patients (most often in high-risk patients): 14 PC and 20 SC. Two main causes of PC were unfavourable iliac artery anatomy and renal artery coverage. In hospital mortality was 21%. SC occurred at a median of 44 months after primary EVAR. Nine were urgent cases for rupture or infection and 11 elective for aneurysm growth, infection or thrombosis. Early mortality was similar after emergent or elective SC (25%). Conclusion Open conversion, and, in particular, PC and urgent SC, was associated with a poor outcome. According to the literature, mortality after elective SC is low but remains high in high-risk patients.

Background The main aim of this study was to compare the 5 years rates of secondary patency of above-knee femoropopliteal revascularizations with autologous veins or prosthetic grafts. The secondary objectives were to compare the rates of primary patency, limb salvage, morbidity, and mortality between the 2 groups. Methods This was a single-blind randomized study of noninferiority (ratio 1:1), carried out in 11 centers of vascular surgery with 2 parallel groups between July 2002 and November 2005. Follow-up finished in May 2011. The monitoring protocol included a clinical examination and an ultrasound control at 1 month, 3 and 6 months, then annually. Results One hundred patients were included and randomized in the study, 52 in the prosthetic group and 48 in the autologous vein group. Four patients randomized in the vein group received a prosthetic graft. No patient was excluded from the analysis. In the in intent-to-treat analysis, the 5 years secondary patency was 84.6% in the prosthetic group (IC 95%, 71.9–93.1) and 70.8% in the autologous vein group (IC 95%: 55.9–83.1), and the difference in secondary patency between the prosthetic and the autologous vein groups was 13.8% (IC 95%, −4.4 to 32.0). In the under treatment analysis, the 5 years secondary patency was 96.2% among patients receiving a prosthesis (IC 95%, 80.4–99.9) and 90.5% among patients receiving an autologous vein (IC 95%, 66.9–98.9), and the difference in the rate of patency between prostheses and veins was 5.7% (IC 95%, −13.2 to 24.6). Although there was no significant difference at 5 years, the death rate and the rate of amputation were higher in the prosthetic group. Conclusions Although it is impossible to conclude definitely to the noninferiority of prosthetic bypass compared with venous bypass because of the insufficient number of inclusions, this randomized study nevertheless showed at 5 years the satisfactory results obtained with prostheses compared with autologous vein for above-knee femoropopliteal bypasses.

Objective: Hyaluronan (HA) is an important constituent of the extracellular matrix and is known to regulate cellular events through binding to CD44 and the receptor for HA-mediated motility (RHAMM). Here we investigated the role of these receptors and the signaling pathways involved in HA-mediated effects in arterial smooth muscle cells (ASMC). Methods: Effects of high-molecular weight HA (1 to 5 mg/ml) were analyzed in cultured ASMC from rat aorta. Results: HA promoted actin stress fiber and lamellipodia formation and dose-dependently induced ASMC migration without effect on proliferation. Pull-down assay of Rho protein activity indicated that HA activated RhoA and Rac. HA-induced ASMC migration was not affected by the RhoA inhibitor Tat-C3 (10 μg/ml), the Rho kinase inhibitor Y-27632 (10 μM) and blocking anti-CD44 antibody, but was reduced by the non-selective Rho protein inhibitor simvastatin (10 μM), the Rac inhibitor LT-toxin (1 μg/ml), small interfering RNA (siRNA) targeting Rac and the phosphatidyl inositol 3-kinase (PI3K) inhibitor LY294002 (25 μM), which also blocked HA-induced Rac activation. CD44 knockdown by siRNA inhibited HA-mediated RhoA activation without effect on ASMC migration. In contrast, siRNA targeting RHAMM inhibited both HA-induced migration and Rac activation. Conclusions: High-molecular weight HA independently activates RhoA and Rac through CD44 and RHAMM, respectively. HA-induced migration depends exclusively on RHAMM-mediated PI3K-dependent Rac activation.

Objective Nasogastric tube (NGT) decompression after abdominal surgery is still largely used to prevent nausea and vomiting. However, indications are based more on practice than on studies. Moreover, prolonged NGT decompression can lead to complications. In this prospective and randomized study, we evaluated the effects of early withdrawal of NGTs in patients undergoing surgery of the infrarenal aorta. Methods Between October 2001 and May 2002, consecutive patients underwent scheduled infrarenal aortic operations. Patients were prospectively randomised into two groups: group 1, NGT maintenance until the passage of flatus; and group 2, NGT removal at the time of tracheal extubation. Preoperative and perioperative data were collected. The main end point was the occurrence of nausea and vomiting. Secondary end points were tolerance of NGT withdrawal and postoperative complications. Criteria were compared between groups by using Mann-Whitney or Fisher exact tests. Results Forty-six patients underwent aortic operations. Six patients were subsequently excluded from the study. Of the 40 randomized subjects, 20 patients were included in each group. Preoperative and intraoperative data were similar in both groups. There was no statistical difference between groups regarding nausea and vomiting. In group 1, the occurrence of respiratory complications was more frequent compared with group 2 (5 vs 0 complications; P = .023). There was no significant difference in intensive care unit stay, but the hospital stay was shorter in group 2 (mean, 9 ± 3 days vs 15 ± 9 days; P = .016). There were no differences in other adverse events. Conclusions This study does not support a significant effect of early removal of NGTs on nausea and vomiting in patients undergoing open repair of the infrarenal aorta. However, these findings suggest that NGT maintenance increases the risk of respiratory complications and the length of hospital stay.

Arterial involvement in Behçet's disease is rare, occurring in various locations with multiple clinical expressions. When Behçet's disease is associated with large arteries, lesions are usually in the form of aneurysms or occlusions. The simultaneous occurrence of these two lesions is even more unusual. We present a case of Behçet's disease in which arterial involvement included an iliac artery thrombosis and an asymptomatic aneurysm of the infrarenal abdominal aorta. Behçet's disease must be considered in the diagnosis of any unexplained inflammatory arteriopathy. Surgery is indicated for the majority of aneurysms and severe symptoms. The postoperative follow-up is based on noninvasive radiologic examinations.

Currently, endovascular treatment is indicated to treat femoropopliteal lesions ≤15 cm. However, the Achilles’ heel of femoropopliteal endovascular repair remains restenosis. Paclitaxel eluting stents have shown promising results to prevent restenosis in femoropopliteal lesions compared to percutaneous transluminal angioplasty. A recently released prospective registry using a newer generation of self-expandable nitinol stents (Misago®; Terumo Corp., Tokyo, Japan) supports primary bare metal stenting as a first-line treatment for femoropopliteal lesions. To date, no studies have been designed to compare bare metal stents to paclitaxel eluting stents for the treatment of femoropoliteal lesions. The BATTLE trial was designed to compare paclitaxel eluting stents (Zilver® PTX®) and a last generation bare self-expandable nitinol stents (Misago® RX, Terumo Corp., Tokyo, Japan) in the treatment of intermediate length femoropopliteal lesions (≤14 cm). A prospective, randomized (1:1), controlled, multicentric and international study has been designed. One hundred and eighty-six patients fulfilling the inclusion criteria will be randomized to one of the two assessments of endovascular repair to treat de novo femoropopliteal lesions ≤14 cm in symptomatic patients (Rutherford 2 to 5): bare stent group and paclitaxel eluting stent group. The primary endpoint is freedom from in-stent restenosis at 1 year defined by a peak systolic velocity index >2.4 (restenosis of >50%) at the target lesion and assessed by duplex scan. Our main objective is to demonstrate the clinical superiority of primary stenting using Zilver® PTX® stent system versus bare metal self-expandable stenting in the treatment of femoropopliteal lesions in patients with symptomatic peripheral arterial disease. This is the first randomized and controlled study to compare the efficacy of bare metal stents and paclitaxel eluting stents for the treatment of femoropopliteal lesions. It may clarify the indication of stent choice for femoropopliteal lesions of intermediate length. Clinicaltrials.gov identifier: NCT02004951 . 3 December 2013.

Infected aneurysms (IA) of neck and limb arteries are uncommon. This report describes the results of a retrospective study undertaken by the University Association for Surgical Research (AURC) to evaluate etiology, bacteriology, location, diagnostic features, and therapeutic methods associated with IA. A total of 58 IA in 52 patients were reviewed. The lesion was located in a lower extremity artery in 47 patients (81%), internal carotid artery in 7 (12%), and upper extremity artery in 4 (6%). Eleven patients had multilocular aneurysm (21%). Symptoms of local infection were observed in 43 patients (82.6%). Rupture or splitting was the presenting manifestation in 13 patients (25%). Primary IA following bacteremia or septicemia without endocarditis was the most common type of IA observed in 34 patients (65.3%). Twelve patients (23%) presented mycotic IA secondary to bacterial endocarditis. In the remaining six patients (11.5%), IA resulted from direct contamination or spreading from a contiguous infection site. Surgical treatment included ligation of the artery without reconstruction in 19 patients and exclusion bypass in 33 patients. The duration of antibiotic treatment ranged from 15 days to 3 months. No recurrence of aneurysm was observed but three patients developed bypass infection. Primary IA was associated with high mortality due to severe septicemia.

Background Ambulatory management of patients is an alternative to conventional hospitalization. In this study we evaluate the results of a prospective cohort study of patients receiving ambulatory endovascular treatment for peripheral arterial lesions. Methods From June 2008 to October 2010, ambulatory management was proposed for endovascular treatment of peripheral arterial lesions. An arterial closure device (Angio-Seal®; St. Jude Medical) was used. For ambulatory treatment, patients were prohibited from driving a vehicle at discharge, had to be accompanied the first night after the procedure, had to live

We report a case of acute compartment syndrome of the thigh secondary to common femoral vessel injury. The lesion was associated with common femoral artery dissection and common femoral vein rupture. Emergency surgical treatment consisted of resection-anastomosis of the arterial dissection, vein ligature, and fasciotomies. The patient is symptom-free after 15 months of follow-up. Isolated vascular injury is an unusual cause of acute compartment syndrome of the thigh. This case serves to increase awareness that isolated vascular injury, without femoral fracture or multiple injury, can result in thigh compartment syndrome. Early recognition and treatment of vascular involvement contributes to better functional outcome of this rare condition, but treatment modalities remain subject to discussion.

This report describes a case of ruptured internal iliac artery aneurysm into the bladder after repair of an infrarenal abdominal aortic aneurysm. Aortic repair consisted of resection of the aneurysm followed by prosthetic interposition to reestablish arterial continuity. During the postoperative period, the patient had ischemia of left colon, which was successfully treated by the Hartmann procedure. A right internal iliac artery aneurysm measuring 50 mm in diameter was demonstrated by an abdominal CT scan during the initial hospitalization but was considered stable, since ultrasonography showed no change in diameter at 3 months and 1 year. The patient was lost from follow-up until 3 years later when he was hospitalized after rupture of the right iliac artery aneurysm, then measuring 120 mm in diameter, into the bladder. Surgical repair was undertaken. The procedure involved aortobifemoral bypass with suture of the bladder defect and branches of the internal iliac artery by the endoaneurysmal route. Postoperative recovery was uneventful. Upon reexamination 1 month after discharge from the hospital, the patient was asymptomatic. This rare case confirms the gravity of internal iliac artery aneurysm and the importance of therapeutic management to prevent rupture.

We report the case of a 62-year-old man with Behçet's disease revealed by double aneurysmal involvement of the posterior tibial and popliteal arteries. The diagnosis was suggested because of repeated phlebitis, buccal aphthous ulcerations, and results of human leukocyte antigen gene typing. The different arguments leading to the diagnosis of Behçet's disease and appropriate treatment are presented.

Background We evaluated the influence of the proximal fixation systems of stentgrafts on proximal inter-renal or infrarenal aneurysm neck dilatation after endovascular repair of abdominal aortic aneurysms. Anatomic and clinical predictive factors of neck dilatation and stentgraft proximal migration were searched for. Material and Methods Taking account of a prospective and monocenter register, 58 patients’ files, with a complete minimum 3-year follow-up, were analyzed after treatment with stentgrafts with a suprarenal fixation (SRF: 33 Talent) or an infrarenal fixation (IRF: 25 AneuRx). Both groups were compared in terms of inter-renal neck dilatation (D1: diameter between the two renal arteries), infrarenal neck dilatation (D2: 7-mm diameter under the lowest renal artery), and specific complication (proximal migration, endoleak). The diameter measured on the last control computed tomography scan was compared with the postoperative diameter. Neck dilatation was defined by a diameter increase exceeding 3 mm and by the proximal migration due to a caudal displacement of the stentgraft ≥10 mm. Predictive factors of proximal migration or neck dilatation were searched for (anatomy of the neck, aneurysm anatomy, stent graft oversize percentage, demographic factors). Results Preoperatively, both groups were comparable in terms of anatomic and demographic characteristics of the aneurysm. Mean follow-up was longer in the AneuRx group (62 ± 17 months vs. 53 ± 13 months, p = 0.045) and the percentage of stent graft oversize was greater in the Talent group (18 ± 6% vs. 13 ± 5%, p −4 ). Freedom from a dilatation exceeding 3 mm in D1 and D2 did not bring any significant difference between the two groups. In each group, the remodeling of the aneurysmal sac (AneuRx median = −4 mm, Talent median = −5 mm, p > 0.05) was only moderately related to proximal neck remodeling. A small angulation of the neck and a smaller neck were the only predictive factors of neck dilatation found respectively in D1 ( p = 0.007) and in D2 ( p = 0.022). Stent graft proximal migration was more frequent in the AneuRx group ( p = 0.031) and was more frequent with large aneurysms ( p = 0.029). Conclusion In the long term, the absence of proximal stent graft fixation system on the dilatation of the aneurysm proximal neck enhances proximal migration. Conversely, the inter-renal or infrarenal proximal neck dilatation does not depend on the type of proximal fixation but on anatomic factors and on the natural evolution of the aneurysmal disease.

Background Postoperative ischemic colitis (POIC) remains a frequent and extremely severe complication of infrarenal abdominal aorta surgery. However, its diagnosis and treatment are not always consensual because the incidence is very small. The aim of this retrospective study was to evaluate the prognostic factors of severe colitis after infrarenal aorta surgery. Materials and Methods We analyzed peroperative and perioperative data of the patients who, between 1998 and 2004, underwent infrarenal abdominal aorta surgery and were presented with confirmed POIC. We set two distinct groups: acute colitis group (operated POIC, perioperative deaths, or evolution toward a colic stenosis secondarily operated on) and a moderate colitis group (recovery without aftereffects and no surgery). The main goal was to individualize the prognostic factors of acute colitis. Using the Student's t -test or the Fisher's exact test, the potential prognostic factors were compared between these two groups. Results Between 1998 and 2004, 679 patients underwent infrarenal abdominal aorta surgery. Among these patients, 28 POIC cases were confirmed: 20 patients had acute POIC and eight had moderate POIC. Demographic and peroperative data were similar in the two groups. Among the 20 patients with acute POIC, 17 were operated on with a postoperative mortality rate of 58.8%. All the patients had at least a left colitis. In 59% of the cases, Hartmann's procedure was performed with a mortality rate of 50%. Early digestive symptoms ( p = 0.05), use of vasopressors ( p = 0.0377), diagnosis in intensive care unit ( p = 0.0095), and a pH p = 0.0261) were independently associated with acute ischemic colitis. Moreover, we could observe the important role of endoscopy aiming at making diagnosis and prognosis. Conclusion This study highlighted significant prognosis factors of severe colitis. These factors could help take the decision to operate POIC, especially to lower the effect of multiple organ failure syndrome (MOFS).

Purpose: Atherosclerotic lesions of the aortic arch are potential sources of arterial embolism. Here we investigate whether surgery, with the necessary circulatory supports, can be proposed as a good option for treatment of this problem. Study of these lesions on a national scale in France has made possible the assessment for future indications of techniques and results of the surgical management of aortic arch lesions, which retrospectively proved to be embolic. Methods: Thirty-eight patients, (19 men and 19 women) underwent surgery between 1976 and 1996 in 17 French cardiovascular surgical centers. The average age at the time of surgery was 49 ± 12 years (range, 31 to 82 years). Atherosclerotic lesions were detected with transesophagial echocardiography (n = 19), angiography of the aortic arch (n = 16), computed tomography (n = 9), and magnetic resonance imaging (n = 10). Surgery consisted of thrombectomy and endarterectomy (n = 22), aortic resection and graft replacement (n = 10), and patch aortoplasty (n = 5; one thrombus disappeared spontaneously before surgery was performed). Results: The average postoperative period was 30 months (range, 3 to 82 months). Contact was lost with four patients after a follow-up period of 12 months. On pathologic specimens obtained at surgery, an atherosclerotic plaque was found in 73% of the cases (n = 28). In 15% of the cases, the aorta appeared normal (n = 6) and four other types of lesion were identified: angiosarcoma (n = 1), ectasia at the insertion of the remains of the ductus arteriosus (n = 1), rupture of tunica intima (n = 1), and a fibroblastic plaque (n = 1). A thrombus was identified in 26 cases, attached to the arterial wall in 18 cases. When transesophagial echocardiographic results showed mobile lesions (n = 22), histopathologic examination of specimens allowed the detection of a thrombus in 18 cases and an atherosclerotic plaque with a mobile projection in four cases. The postoperative mortality rate was 2.6%. The morbidity rate (28.9%; n = 11) was related to neurologic complications (n = 6), vascular complications (n = 4), and infection (n = 1). Four cases (12%) were reoperated. Conclusion: Nonaneurysmal aortic arch lesions are a frequent and still underestimated source of stroke and peripheral embolization. Surgery with circulatory support can be recommended in good operative candidates with recurrent critical events despite medical management and with high embolic potential (young patients with no calcified plaques). (J Vasc Surg 2002;36:1186-93.)

This report describes an exceptional case of popliteal artery thrombosis secondary to exostosis of the superior extremity of the superior tibia in a young adult. Correct diagnosis was made during re-operation for recurrent thrombosis. Surgical treatment consisted of resection of the bony tumor and venous bypass to reestablish arterial continuity. Femoropopliteal vascular complications of exostosis are rare, with most cases involving arterial aneurysms or false aneurysms. Differential diagnosis in our young patient took into account the other causes of popliteal thrombosis: entrapped popliteal artery, adventitious cyst, fibrodysplasia, and juvenile arteriopathy. In patients with major functional disability, operative treatment is recommended to remove the bony abnormality and repair the arterial lesion.

We retrospectively reviewed perioperative cardiac complications in a series of 214 patients who underwent surgical treatment for infrarenal aortic aneurysm between 1992 and 1996. There were 192 men and 22 women, with a mean age of 68.3 years. Cardiac risk factors included angina in 28% of patients and previous myocardial infarction in 25%. Resting electrocardiography was normal in 80 patients (37.5%). Depending on clinical findings, thallium-201 scintigraphy was undertaken in 76 patients (35.5%) and led to elective coronary arteriography in 22 patients (10%). Results of coronary arteriography revealed lesions in 14 patients. Aortic reconstruction was performed by the transperitoneal route in all patients. Procedures consisted of aortoaortic bypass (63%), aortobiiliac bypass (27.5%), or aortobifemoral bypass (9.5%). Nine patients (4.2%) died within the first 30 postoperative days. The cause of death was myocardial infarction (MI) in two patients (1%), colonic necrosis in two (1%), acute pancreatitis in one (0.5%), acute renal insufficiency in three (1.4%), and multiple organ failure in one patient (0.5%). Nonfatal cardiac complications were observed in 15 patients (7%). Statistical analysis of risk factors revealed two predictors of perioperative cardiac complications, i.e., history of chronic bronchitis and reoperation. On review of the literature, we cannot propose a routine preoperative work-up. Prospective multicentric studies are needed to determine the predictive value of current preoperative screening methods.

We describe a case of intestinal angina caused by spontaneous dissection of the celiac artery and thrombosis of the superior mesenteric artery. Spontaneous dissection of a visceral artery is an uncommon occurrence that is usually diagnosed after fatal hemorrhage or ischemia. The underlying mechanism is unclear but the frequent association with multiple arterial lesions suggests general arterial disease. In symptomatic forms, surgical reconstruction is mandatory, to treat the lesion and allow definitive histological diagnosis.

In 163 carotid reconstructions under peridural anesthesia performed from 1988 to 1991, we routinely measured residual systemic and carotid artery pressure during clamping. Seventy-nine patients (48.5%) were asymptomatic and 84 (51.5%) had a history of neurologic manifestations in the form of transient ischemic attacks (28%) or stroke (13.5%). None of the patients died perioperatively. Eight patients (4.9%) had strokes, with complete recovery in five. A shunt was placed in 22 patients (13.5%) because of neurologic evidence that carotid clamping was poorly tolerated. This study showed a distinct association between residual pressure in the internal carotid artery and systemic arterial pressure and intraoperative neurologic morbidity. Using a cutoff value of 35 mm Hg for residual pressure, the sensitivity was 77% and specificity 81%. Using a cutoff of 80 mm Hg, the sensitivity was 60% and specificity 86%. There was no correlation between mean systemic arterial pressure and residual carotid artery pressure. The use of a shunt was the only factor with predictive value for postoperative neurologic complications. These findings suggest that measurement of systemic arterial pressure and residual carotid artery pressure is useful during carotid surgery, but further study is needed before this information can be extrapolated to carotid surgery under general anesthesia.

Objective The common femoral artery (CFA) is an unusual location for endovascular repair (ER). We report the early results after ER of the CFA in a single centre. Design This is a cohort study. Materials/Methods From 2006 to 2008, ER of the CFA was proposed to 36 patients (mean age 67.9, range 51–92). CFA lesions were classified into four types: in type I, lesions were located at the iliac external artery and were extended to the CFA; in type II, lesions were limited to the CFA; in type III, lesions were located at the CFA and its bifurcation; type IV represents restenosis bypass anastomosis. All patients were treated by stenting. Results Indications for ER of the CFA included 25 patients (70%) for claudication and 11 patients (30%) for critical limb ischaemia. Forty-three stents were implanted. The mean follow-up was 22 months (range, 12–42). At 1 year, primary and secondary sustained clinical improvements were 80% and 90%; target lesion revascularisation and target extremity revascularisation free cumulative survival were 85% and 80%, respectively, and in-stent restenosis rate was 20%. One stent fracture was noted. Conclusions ER of CFA and concomitant arterial lesions seems to be a safe technique with acceptable clinical outcome at 1 year.

Fibromuscular dysplasia of the popliteal artery is rare. We report a case in a 20-year-old man complicated by aneurysm revealed by recurrent synovial effusion of the right knee. Diagnosis was based on pathology reports which showed severe destruction in the media. Two other cases with histopathological documentation were found in the literature.

We report three cases of fatal retrograde dissection of the aortic arch after exclusion-bypass with metal clamps according to Carpentier's thromboexclusion method. All three patients were male, aged 59, 66, and 73 years. Initial operative indications were chronic dissections in two cases and atheromatous aneurysm of the descending thoracic aorta in the other. Two of these patients were operated on in an emergency setting for a ruptured aneurysm. In all three cases, an extraanatomic bypass between the ascending aorta and abdominal aorta was performed as the first step: The proximal clamp was then placed distal to the origin of the left subclavian artery. Death occurred two hours, 12 hours, and eight days after operation, respectively. Autopsy revealed retrograde dissection initiating in the aortic arch and reaching the aortic ring as the cause of death. Pathological examination of aortic specimens confirmed that the dissections began just proximal to the site of clamping. To explain this complication, two etiologic factors, occurring either alone or together, have been postulated: postoperative hypertension and trauma to the aortic wall from the clamp.

Background The clinical impact of stent fractures is still controversial. This study analyzed the incidence and the clinical impact of stent fractures after stenting of long femoropopliteal lesions. Methods From November 2008 to October 2009, 58 patients (62 limbs) were treated in a single center with a primary nitinol self-expanding stent for Trans-Atlantic Inter-Consensus (TASC) C and D de novo femoropopliteal lesions. Patients were prospectively followed by medical and duplex scan examinations. Stent fractures were assessed by biplane X-rays at 12 months. Logistic regression analysis was performed. Results At 1 year a complete follow-up was obtained in 42 limbs/90 stents. The median length of the stented segment was 240 ± 180 cm with a mean of 2.1 (1–4) stents per patient. Sixteen stents (17.8%) were fractured: one type I (asymptomatic); seven type II (2 restenosis); five type III (asymptomatic), and three type IV stent fractures (1 restenosis). Stent diameter ( p = .04) and stent implantation in the distal part of the superficial femoral artery ( p = .05) were positively associated with stent fractures. Stent fracture had no influence on restenosis. Conclusion This study suggests that the high stent fracture rate associated with endovascular treatment of long femoropopliteal lesions should be balanced with its low clinical impact.

Tuberculous aneurysm of the descending thoracic aorta is a rare entity. To our knowledge the present case is the sixth on record to have been successfully treated surgically. These aneurysms present the usual difficulties of surgical therapy of the thoracic aorta: spinal cord and renal circulatory protection and the choice between distant or in situ revascularization. This case is of particular interest for its evolution and its treatment: resection of the aneurysm without shunting and insertion of a graft in situ covered by a flap of omentum. (J VASC SURG 1987;6:408-11.)

Spontaneous dissections of the superior mesenteric artery are exceptional events because only 26 reports have been published. We present a new case, revealed with an acute abdominal syndrome. Computed tomographic angiography and arteriography allowed a rapid diagnosis and urgent surgical intervention. Progress in imagery makes diagnosis and follow-up examination easier. Surgery is indicated for acute symptomatic forms with suspicion of mesenteric ischemia. In the other cases, a simple follow-up examination may be appropriate. (J Vasc Surg 2002;35:1003-5.)

Twenty-two cases of vascular graft failures (thrombosis, pseudoaneurysm, dilation, infection) were investigated by means of physicochemical, histological, and ultrastructural studies. A general decrease of mechanical resistance to stress of the prostheses was observed. Its magnitude ranged from 2 to 75% of the values of identical virgin prostheses and there was no relation with the duration of implantation. In addition to the breakage of yarn filaments (SEM), migration of fiber debris (histology) was observed in 7 cases. The structure of the polyester molecule had evolved after implantation. A decrease of crystallinity (x-ray diffraction and differential scanning calorimetry) was noted. These observations raise the question of the established stability of vascular prostheses and emphasize the need for further investigations in human graft retrieval programs.