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Conventional open surgery is still important beside endovascular surgery in the management of abdominal aortic aneurysms, with less reinterventions in the long-term follow-up. Incisional hernias are the major complication open surgery in the mid- and long term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The objectives of our retrospective and bicentric study were to characterize the long-term risk factors for incisional hernias after open surgery for abdominal aortic aneurysms, in particular by comparing the 2 types of laparotomy, and to determine the prevalence of the operated and not operated incisional hernias.Between January 2009 and December 2011, all the patients having elective open surgery for abdominal aortic aneurysm (AAA) by midline laparotomy at the University hospital of Besancon or by transversal laparotomy at the University Hospital of Strasbourg were included retrospectively. The demographic data, the time of diagnosis of the incisional hernia and the parietal reinterventions were collected during a 5-year postoperative follow-up. A univariate and multivariate Cox model was used for the statistical analysis to determine the long-term risk factors for the appearance of an incisional hernia.During the study period, 223 patients presenting with AAA were included, 112 of them were operated by a midline laparotomy and 111 by a transverse laparotomy. The mean age of the patients was 69 ± 8,4years and 208 (93.3%) were men. The 5-year prevalence of incisional hernias was 14.3% (32), and 20 of these hernias (9%) had to be operated. Eighteen hernias (16.1%) occurred after a midline laparotomy and 14 (12.6%) after a transverse incision (P = 0.30). In univariate analysis, obstructive chronic pulmonary disease was the only significant risk factor for incisional hernia (P = 0.01) and an age over 65 years appeared to protect against this risk (P = 0.049). These results were confirmed by multivariate analysis, which showed that obstructive chronic pulmonary disease was an independent risk factor for incisional hernia (HR = 2.35, 95% CI 1.16-4.75), and that an age over 65 years was a protective factor (HR = 0.49 95% IC 0.00-0.99).The type of laparotomy did not modify the rate of incisional hernias. We showed that only 9% of the patients had to be operated to treat an incisional hernia during the first 5 years after surgery for AAA in our bicentric study. Chronic obstructive pulmonary disease was the only independent risk factor for the occurrence of an incisional hernia.

Summary: Asymptomatic carotid stenosis (ACS) can cause cognitive dysfunction, related to cerebral hypoperfusion and microemboli. These mechanisms could be treated by carotid revascularization, but the impact of carotid angioplasty stenting (CAS) or carotid endarterectomy (CEA) on cognitive functions remains unclear. The aim of this systematic review was to realize a report on the actual state of results about asymptomatic carotid stenosis revascularization and cognitive function. We performed a systematic literature review to analyze all studies assessing the impact of asymptomatic carotid stenosis revascularizations on cognitive functions. We reviewed all publications published in Medline database and Cochrane between January 2010 and January 2020 including subjects with a cognitive evaluation and receiving carotid revascularization for asymptomatic stenosis. We identified 567 records for review, and finally we included in the systematic review 20 studies about ACS revascularization and cognitive functions. Only observational studies analyzed the impact of CEA and CAS on cognitive functions. Thus, too heterogeneous data associated to the lack of randomized controlled trials with an evaluation of optimal medical treatment did not enable to affirm the interest of the revascularization management of ACS in cognitive domain. There was a lack of standardization and finally studies were too heterogeneous to conclude on the impact of carotid revascularization on cognitive functions. There is an urgent need to harmonize research in this domain in order to prevent and treat cognitive dysfunction related to ACS, especially in our society with an aging population.

Objectives A biomechanical approach to the rupture risk of an abdominal aortic aneurysm (AAA) could be a solution to ensure a personalized estimate of this risk. It is still difficult to know in what conditions, the assumptions made by biomechanics, are valid. The objective of this work was to determine the individual biomechanical rupture threshold and to assess the correlation between their rupture sites and the locations of their maximum stress comparing two computed tomography scan (CT) before and at time of rupture. Materials and Methods We included 5 patients who had undergone two CT; one within the last 6 months period before rupture and a second CT scan just before the surgical procedure for the rupture. All DICOM data, both pre- and rupture, were processed following the same following steps: generation of a 3D geometry of the AAA, meshing and computational stress analysis using the finite element method. We used two different modelling scenarios to study the distribution of the stresses, a “wall” model without intraluminal thrombus (ILT) and a “thrombus” model with ILT. Results The average time between the pre-rupture and rupture CT scans was 44 days (22-97). The median of the maximum stresses applied to the wall between the pre-rupture and rupture states were 0.817 MPa (0.555-1.295) and 1.160 MPa (0.633-1.625) for the "wall" model; and 0.365 MPa (0.291-0.753) and 0.390 MPa (0.343-0.819) for the "thrombus" model. There was an agreement between the site of rupture and the location of maximum stress for only one patient, who was the only patient without ILT. Conclusion We observed a large variability of stress values at rupture sites between patients. The rupture threshold strongly varied between individuals depending on the intraluminal thrombus. The site of rupture did not correlate with the maximum stress except for one patient.

The femoral tripod remains technically crucial in vascular surgery, as well for an elective revascularization as for an extensive approach to the arterial tree. The management of septic complications and healing disorders in this area is really challenging. Obturator bypass (OB) represents an alternative sometimes employed in this context, but few recent series were recently published. The objectives of this work were thus to evaluate the results of OB in terms of patency, morbi-mortality, healing evolution and absence of reinfection.This was a monocentric retrospective study including all the patients treated by OB, whatever the cause, between January 2010 and December 2020. Primary outcomes were the primary and the secondary patencies. The secondary outcomes were the morbi-mortality, freedom from infection and healing.During this period, 23 OBs were carried out in 22 patients, with a majority of men (77%) whose median age was 70 years [34-87]. The indications were infection in 19 patients (86%), and iterative thrombosis in 3 patients (14%). The substitute was an arterial allograft in 82% of the cases, and the outflow was the deep femoral artery only in 14% of the cases. The median operative time was 224 min [111-391] and median blood losses were 900 mL [300-3,900]. We observed 7 systemic (32%), and 8 local complications (36%). Healing was obtained in 90% of the cases, and freedom from infection was obtained in 100% of the cases. The median duration of follow-up was 594 days [5-2,517]. One-year, 2-year and 3-year primary patency rates were 84%, 78%, and 63%, respectively. One-year, 2-year and 3-year secondary patencies were 94%, 94%, and 80%, respectively. One-month, 1-year, 2-year and 3-year survival rates were 86%, 73%, 67%, and 53%, respectively.Our study showed that the OB represents a relevant alternative in the event of complex lesions of the femoral tripod, with good patency and healing rates and good infection control. On the other hand, its consequences in terms of morbi-mortality confirm that OB is a major surgery that should be used when a traditional approach is not possible.

Current decision about when to operate abdominal aortic aneurysms (AAAs) is based only on the maximum aneurysm diameter (MAD). However, small aneurysms still rupture and we can observe very large AAA without any symptom. A simple morphologic analysis could be a tool to assess the risk of rupture. The main objective of this study was to assess the relevance of ratios between MAD and healthy aorta on computed tomography (CT) as a risk factor of AAA rupture. The secondary objective was to evaluate CT signs as risk factors of AAA rupture.Retrospective observational bicentric study comparing CT scans of a ruptured AAA group and a control group treated electively was conducted. Appariement 1:1 based on MAD was applied. Ratios between healthy aorta diameters at several levels, celiac trunk (CTR), superior mesenteric artery (SMA), highest renal artery (RA), and the MAD were calculated. The presence of blebs, crescent signs, ruptures of calcifications of the aneurysm sack, and draped aorta were notified.From 2010 to 2016, 38 ruptured AAA and 38 controls were included. Ratios were superior in the rupture group, respectively: MAD/CTR [2.77 (±0.5) versus 2.58 (±0.4) P 0.095], MAD/SMA [2.92 (±0.7) versus 2.74 (±0.5) P 0.194], and MAD/RA [3.02 (±0.70) versus 2.76 (±0.5) P 0.054] but not significatively. Receiver operating characteristic curve analysis demonstrated optimal threshold to detect rupture at 2.8 for the ratio MAD/CTR (area under the curve (AUC) 0.593, sensitivity 47.4%, specificity 78.9%), at 3.3 for the ratio MAD/SMA (AUC 0.564, sensitivity 31.6%, specificity 92.1%), and at 3.3 for the ratio MAD/RA (AUC 0.591, sensitivity 31.6%, specificity 94.7%). Bivariate analysis for rupture risk factor showed significance for the three ratios (MAD/CTR 2.8 [OR = 11 (1.42; 85.20) P 0.0217], MAD/SMA 3.3 [OR = 10 (1.28; 78.12) P 0.0281], and MAD/RA3.3 [OR = 11.00 (1.42; 85.20) P 0.0217]). One scannographic sign was more present in the rupture group: crescent sign 36.8% versus 5.3%, P = 0.0007, as well in bivariate analysis [OR = 7 (1.59; 30.80) P 0.0326].In our experience, specific ratios when they exceed calculated threshold, seem to be more prone to rupture. We could consider that these measures, easy to apply in clinical practice, would be complementary keys for rupture risk individual assessment.

Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas.We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed.From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula.No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.

Background The main objective of this study was to identify the changes that have occurred in the treatment of abdominal aortic aneurysms (AAA) in France over a period of 10 years. Materials and methods Comprehensive data for AAA surgical activity from all French health establishments between 2006 and 2015 were collected from the records of the “Agence Technique de l'Information sur l'Hospitalisation.” Based on the common classification of medical procedures, our research was conducted on surgical procedures involving open and endovascular surgical treatment of AAA. A year-by-year descriptive analysis was completed for the number of procedures, the change in the type of surgery performed in each type of institution, and the mean duration of hospital stays. Results During the study period, the number of AAA treated increased overall by 28.2% (from 6,412 procedures in 2006 to 8,221 in 2015). The proportion of endovascular procedures increased in this period (from 27.0% in 2006 to 68.5% in 2015) like their number from 1,735 to 5,632. The number of fenestrated endovascular aneurysm repair (listed since 2013) increased from 251 to 373 in 3 years. Open repair decreased from 4,677 interventions in 2006 to 2,589 in 2015 with higher proportion of suprarenal clamping in open surgery (from 23% in 2006 to 40% in 2015). The number of ruptured AAA treated in open surgery remained stable over this period (473 in 2006 and 462 in 2015). Conclusions In France, the number of AAA operated between 2006 and 2015 increased by 28.2%. There was a significant increase in endovascular techniques, which became largely predominant in 2015. In open repair, the proportion of complex procedures increased in this period. However, this transformation, which is in line with current recommendations and major publications, needs to be reassessed in the long term.

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.

Background The aging of the population leads us to treat older patients, in particular presenting with acute limb ischemia (ALI). However there has been little evaluation of this pathology in the nonagenarians. The objectives of this work were thus to evaluate the one-month and one-year mortality of the nonagenarians treated for ALI, which made possible to determine the one-year survival and to highlight the factors influencing the mortality. Methods This was a monocentric retrospective study including all the patients aged 90 years old or more surgically treated for ALI between January, 2012 and December, 2016. In all the patients, we recorded the one-month mortality and the one-year survival and the demographic, the clinical and the paraclinical data. Results We operated 83 nonagenarians, with a majority of women (59, 71.1%), using general anesthesia in 20 patients (16.6%), including 10 cases of upper limb acute ischemia (12.0%). The overall mortality rate at one month was 22.9%, and the one-year survival rate was 43.4%. Major amputation rate was 9.6% at one year. The survival of the patients operated for upper or lower limb ischemia was similar (p=0.82). Univariate analysis showed that the one-year survival was lower in patients having a history of cerebrovascular problems (p=0.0003), heart failure (p=0.0027), dementia (p=0.0452), or in patients that were institutionalized (p=0.0125), invalid (p=0.0001), or presented with a complete acute ischemia (p=0.0002). In multivariate analysis, three risk factors remained statistically significant: a previous history of cerebrovascular accident (HR= 3.05 [1.54-6.02]; p=0.0014), cardiac failure (HR= 2.21 [1.23-3.97]; p=0.0083) and complete AI (HR= 3.07 [1.64-5.75]; p=0.0005). Conclusion Our study showed that a history of cerebrovascular accident, cardiac failure or a complete AI are poor prognostic factors for the one-year survival of nonagenarians dealt operated for ALI. These elements should be taken into account when deciding either to operate or not in this precise context.

Background Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients. Methods Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI. Results This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9–20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29–48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90–95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90–95) and 39% (95% CI, 27–50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9–9.6). DUS sensitivity reached 73% (95% CI, 51–96) in patients requiring an effective reintervention. Conclusions DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01230203.

Background Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. Hypothesis The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. Material and methods A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. Results The study included 36 patients with a mean age of 40.6 ± 22.1 years. The main sources of injury were traffic accidents (n = 19, 52.8%), crush injury (n = 8, 22.2%), and falls (n = 5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0–74.8] months. Discussion Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. Level of evidence IV, retrospective observational study.

Despite current progress, the prognosis of critical limb ischemia (CLI) remains poor. The ageing of the population, the increasing prevalence of diabetes mellitus, and the stability of tobacco use will increase the prevalence of CLI. CLI patients have risk factors for malnutrition, and the impact of malnutrition on morbidity and mortality has been demonstrated in the general population. However, we have little information on the consequences of undernutrition in the CLI population. The aim of this study is to assess the impact of malnutrition on the early outcomes in CLI patients.This is a double-center prospective study that included all consecutive hospitalized patients with CLI. All patients were screened for malnutrition and divided into 2 groups: severe malnourished patients (group A) and moderate malnourished and well-nourished (group B). This distribution was based on age-indexed clinical and biological data and the patient's general condition: the Nutritional Risk Index for patients younger than 75 years, the Mini Nutritional Assessment, or the Geriatric Nutritional Risk Index for those older than 75 years. The primary end point was defined as the rate of 30-day death. Outcomes were compared in a univariate analysis. Stepwise logistic regression was used for the multivariate analysis. Variables with a P value0.2 in the univariate analysis were introduced in the multivariate model.We included 106 patients. The prevalence of malnutrition was 75.5%, divided into moderate malnutrition (51.9%) and severe malnutrition (23.6%). Six patients (24%) died in group A compared with 8 in group B (4.9%) (P = 0.01). By univariate analysis, severe malnutrition was the only factor associated with death at 30 days. By stepwise logistic regression, severe malnutrition (odds ratio 6.1, 95% confidence interval 1.6-23.7, P = 0.006) was found to be the significant risk factors for death at 30 days.This study is the first to demonstrate prospectively the major importance of malnutrition in the early prognosis of CLI patients.

Background The aim of this study is to evaluate radiation exposure, endovascular theatre equipment, and practices in France during iliac angioplasty. Methods A prospective observational study was performed among vascular surgeons who attended a half day of radiation safety training in 2012 and 2015 and had to collect data on 3 patients undergoing iliac procedure. In 2012, 330 surgeons performed 899 procedures, compared with 114 surgeons and 338 procedures in 2015. Due to exclusions, 653 and 306 procedures were analyzed in 2012 and 2015, respectively. Endovascular environment, practices, anatomical characteristics, and radiation parameters were collected, analyzed, and compared generally and between the 2 groups. Results Endovascular theatre equipment significantly improved over the 3 years: mobile flat-panel detector (1.1% vs. 5.9%), hybrid rooms (1.5% vs. 14.7%), and dedicated radiology tables (37.2% vs. 51.2%). Lesion’s classification (Trans-Atlantic Society Consensus) was similar between groups but procedure complexity increased overtime: more than one stent implanted (32.3% vs. 41%, P

The renal safety of suprarenal (SR) fixation stent grafts has not been demonstrated yet. The principal objective of this study was to analyze the effect of the type of fixation of stent grafts on the renal function at 1 year, by calculating the estimated glomerular filtration rate (eGFR). The secondary objective was the evaluation of the morphological repercussion of the implants at the renal level by computed tomography.This is a monocentric retrospective study, including all the patients treated electively between 2008 and 2014 with a bifurcated aortic stent graft. We compared the characteristics of the SR and infrarenal (IR) populations and the evolution of the preoperative and 1-year postoperative renal function. Renal function was evaluated by eGFR, according to the Chronic Kidney Disease Epidemiology Collaboration formula, and expressed as mL/min/1.73 mDuring the study period, 102 patients were treated: 42 IR and 60 SR. The populations were comparable in terms of operative risk factors and impaired renal function. Preoperative eGFR was similar (SR 71.7 ± 17.8 vs. IR 70.3 ± 17.5, P = 0.7). There was no variation in eGFR at 1 year in the IR group (-0.9; P = 0.4), whereas a significant decrease was observed in the SR group (-5.6, P 0.0001), a difference which proved to be significant in the intergroup comparison (P = 0.0065). This difference persisted after the exclusion of the patients in which at least one polar renal artery had been covered (P = 0.019). The proportion of patients with a degradation ≥20% of the eGFR was significantly higher in the SR group (SR 13.3%, n = 8 vs. IR 2.4%, n = 1; P = 0.046). We observed significantly more new or progressing RAS in the SR group (SR 21.67%, n = 13 vs. IR 2.38%, n = 1; P = 0.0035). Overall, 15 infarctions were detected but 9 were due to the cover of a polar artery including 8 in the SR group SR, which were thus excluded (SR 6.7%, n = 4 vs. IR 4.8%, n = 2; P = 0.52). No renal artery thrombosis was diagnosed.The report of a significant difference in the evolution of the renal function and the progression of renal stenoses makes us wonder about the real harmlessness of SR fixation stent grafts. If further reflection is necessary, their systematic use should be called into question, in particular in the presence of an anatomy authorizing the use of IR fixation stent grafts.

Background Patients suffering from chronic mesenteric ischemia are at risk of malnutrition due to the fear of food and weight loss. However, the impact of malnutrition on the morbidity and mortality at the time of surgery is not studied extensively, just as its prevalence. The main objective of this study was to evaluate the influence of malnutrition on the survival of the patients operated for chronic mesenteric ischemia. The secondary objectives were to evaluate the prevalence of malnutrition in this population and to evaluate the early complications after surgery according to the nutritional condition of the patients. Methods We conducted a monocentric retrospective observational study including consecutively all the patients operated for chronic mesenteric ischemia between 2005 and 2016. The nutritional status was determined a posteriori according to the criteria of the French High Health Authority using body mass index, the percentage of weight loss, and albumin. We thus divided the patients into 2 groups, “malnourished” and “non-malnourished.” We compared the survival of the patients of the 2 groups with a log-rank test. Results We enrolled 54 patients including 35 men (65%), with a mean age of 68.1 years (±12.3). The prevalence of malnutrition was 70% (38 patients), including 9 severely malnourished patients (23.6%). Twenty-nine patients (53.7%) were treated by endovascular technique, and twenty-five had conventional surgery (46.3%). The type of management was not different between the 2 groups: 20 patients of the malnourished group (52.6%) and 9 patients of the non-malnourished group (56.3%) were treated by endovascular technique (P = 0.8). The 30-day mortality was null in the non-malnourished group, whereas ten patients (26.3%) died in the malnourished group (P = 0.02). The short-term complications were not significantly different between the malnourished and the non-malnourished groups (37% vs. 19%, P = 0.32). The mean duration of follow-up was 639 days (±660). The 3-year survival was not different between the endovascular group and the open surgery group (43% vs. 52%, P = 0.7). The 3-year survival was statistically higher in the non-malnourished group (87%) than in the malnourished group (49.6%) (P = 0.01). Conclusions In our experience, preoperative malnutrition is a factor significantly decreasing the survival of the patients treated with open surgery or with endovascular technique for chronic mesenteric ischemia. A more optimal preoperative management of this malnutrition could improve the results of these procedures.

Pancreaticoduodenal artery aneurysms (PDAAs) are rare, but rupture can occur at any time regardless of the size. We describe here the case of 53-year-old woman who presented with a ruptured PDAA associated with compression of the celiac trunk by the median arcuate ligament. We first performed revascularization of the celiac trunk without intervening on the PDAA because of surgically hostile conditions. We observed complete regression of the PDAA, probably due to the dramatic decrease in inflow to the PDAA, thanks to the revascularization procedure. This prompted us to cancel the secondary endovascular embolization. The patient remained asymptomatic at 3 months.

Objectives Abdominal compartment syndrome (ACS) is poorly identified in surgery for ruptured abdominal aortic aneurysm and an early management is crucial. The aim of this study was to validate how many risk factors were needed to predict ACS. Secondary objectives were to assess its prevalence and the 30-day mortality. Methods All patients operated for ruptured abdominal aortic aneurysm during 5 years were included. An independent committee performed a retrospective diagnosis of ACS. Eight criteria were selected from the literature, and corresponded to pre- and intraoperative period: anemia (hemoglobin lower than 10 g/dL), prolonged shock (systolic blood pressure 30), massive fluid resuscitation (≥3500 mL per hour for at least 1 h) and transfusions (>10 units packed blood red cell since the beginning of the treatment), severe hypothermia (≤33℃), acidosis (pH Results Eight patients were ACS+ and 28 ACS-, with three criteria for ACS+ and 1.5 for ACS- ( p = 0.002). Three criteria among the eight selected criteria have the best cutoff for sensitivity and specificity (75% and 82%) with a positive predictive value of 54% and a negative predictive value of 92%. The prevalence of ACS was 17%. The 30-day mortality in ACS+ tended to be higher than in ACS- ( p = 0.108). Conclusion The present results suggest that patients with an ACS seemed to have higher mortality and the threshold of three factors among eight specific factors is enough to predict this.

Introduction: Anterior shoulder dislocation can be associated with vascular and neurological complications. However, axillary artery injury associated with shoulder dislocation is rare and extremely rare without bone fracture. An early diagnosis of these complications allows predicting long-term functional outcomes. Methods: This article reports the case of a 66-year-old patient who presented an anterior shoulder dislocation after a ski fall without any neurological dysfunction or pulse deficit. Results: The first reduction attempts were unsuccessful and during the new attempt, we observed a hematoma. A CT scan showed a disruption of the axillary artery and a bilateral pulmonary embolism. Conclusion: Neurovascular injury must be systematically sought before and after reduction, and a multidisciplinary approach is always necessary.

Background Randomized controlled trials that have established recommendations for carotid surgery have excluded patients >79 years of age, and in our day to day practice, patients in this age group are becoming more common. We sought to analyze the outcomes of carotid endarterectomy (CEA) in octogenarians, determine the risk factors of morbidity and mortality, and evaluate the midterm survey of these patients. Methods Age was the only selection criteria for inclusion in this study. We compared symptomatic and asymptomatic populations and retrospectively analyzed the CEA results performed in patients ≥80 years of age in each group. We calculated the combined ipsilateral stroke/death for each group. Results In the 6-year study period (2002–2007), 132 CEAs were performed in 118 octogenarians. The mean age was 83.2 years (range: 80–93), and there were 70 men (59.3%) and 48 women (40.6%). In this study group, 37.9% of patients were symptomatic and 62.1% were asymptomatic; the rate of internal carotid stenosis was 81.6% (standard deviation: ±8.5%). The combined ipsilateral stroke/death rate was 3.79% (4 deaths and 1 stroke): 2% in the symptomatic patients and 4.88% in the asymptomatic patients. No differences were found between the groups' combined ipsilateral stroke/death rate ( P > 0.05), but there were significant more patients with coronary artery disease and peripheral artery disease in the asymptomatic patients. A contralateral significant internal carotid stenosis was a risk factor of combined ipsilateral stroke and death ( P = 0.024). The mean duration of follow-up was 3.8 ± 2.0 years, and 73% ± 5% of the patients were alive at 3 years. Conclusion The good immediate results and good probability of survival at 3 years after surgery conveys a real benefit of this surgery in this age group, but patients should be selected on a case by case basis. In our experience, the presence of bilateral lesions should be a significant influence criterion in the preoperative risk assessment. Other evaluation criteria, such as cardiac status, are needed to optimize the selection of asymptomatic patients in particular.

Background To assess our current practice concerning the indications and the immediate and midterm results of femorofemoral bypass. Methods We retrospectively included all patients, from 1997 to 2008, operated on for aortoiliac occlusive disease using an extra-anatomical bypass from a donor iliac artery or a femoral artery to the contralateral femoral artery (common or profunda artery). Demographic data, initial clinical status, characteristics of the interventions, and short- and midterm results were collected. Elective surgery was distinguished from urgent surgery (critical limb ischemia, acute ischemia, vascular infection). Results One hundred twenty-four femorofemoral bypasses were performed (103 male), mean age 68 (±12) years. Indications were critical limb ischemia (47.1%), intermittent claudication (38.8%), acute ischemia (12.1%), and vascular infections (1.7%). Perioperative outcomes were 5.6% mortality (elective surgery 0.0%, urgent surgery 9.7%, P = 0.02) and 27.4% morbidity without any secondary graft infections (elective surgery 22.5%, urgent surgery 31.9%, P = 0.17). Mean follow-up period was 3 years, and overall survival was 69.4% (elective surgery 88.7%, urgent surgery 56.7%, P = 0.08). At 3 years, primary patency was 81.8% and secondary patency was 89.3% (elective surgery 96.4%, urgent surgery 84.2%, P = 0.68). No significant risk factors for immediate and secondary thromboses were found. Conclusion In our current practice, femorofemoral bypasses are applied mainly for urgent procedures when avoiding a direct aortic approach is mandatory, with good midterm results. Although indications are limited for good-fit patients, femorofemoral bypass has confirmed safety (no perioperative deaths, no infections) and high durability (good secondary patency).

Background The abdominal compartment syndrome (ACS) has been clearly identified as being one of the main causes of mortality after ruptured abdominal aortic aneurysm (rAAA). The ACS is defined as a sustained intra-abdominal pressure > 20 mm Hg associated with a new organ dysfunction or failure. A pilot study was conducted and found that the threshold of 3 among 8 selected criteria, we would predict an ACS occurrence with a 54% positive predictive value and a 92% negative predictive value. But a multicentric prospective study was clearly needed to confirm these results. The outcome of this new study is to assess the qualities of a predictive test on occurrence of the ACS after rAAA surgery. Methods This is a 30 months prospective cohort study conducted in 12 centers and 165 patients will be included. All patients with a rAAA will be consecutively included, whatever the surgical treatment. At the end of surgery, all patients have an abdominal closure and a monitoring of intrabladder pressure will be established every 3 to 4 hours. Decompressive laparotomy will be indicated when ACS occurs. Follow-up period is 1 month. Eight pre- and per-operative criteria will be studied: anemia, hypotension, cardiac arrest, obesity, massive fluid resuscitation, transfusion, hypothermia, and acidosis. Discussion In the literature, there is no recommendation about prophylactic decompression, but early decompressive laparotomy appears to improve survival. This study should make it possible to establish a predictive test, detect the ACS early, and consider a prophylactic decompression in the operating room. Trial registration ClinicalTrials.gov, NCT02859662, Registered on 4 August 2016.

The aim of this study was to evaluate the quality of the current treatment of patients presenting with ruptured abdominal aortic aneurysms (RAAAs), from the first symptoms to the operating room with an analysis of preoperative mortality risk factors.For 3 years, in four vascular surgery departments, we have collected all the consecutive cases of patients operated on for RAAA. We analyzed the initial clinical situation, the means of transportation, the time elapsed before treatment, and the mortality rate at 3 days. Sixty-six RAAAs were operated on. Mean patient age was 76 years (range, 52-93 years).The initial symptoms were a precisely located pain either abdominal (45.3%), lumbar (17.2%), or both (14.1%) or feeling faint (10.9%). In 22.7% of the cases, an initial hemodynamic instability was observed. In 46.8% of the cases, patients first went to a peripheral hospital before being admitted into a referral centre. In 84.5% of the cases, medical mean of transportation was used. The mean distance covered was 59.8 kilometers (range,5 km to 213 km). The initial diagnosis was accurate in 67.3% of the cases. The mean intrahospital waiting period between the arrival at a reference center and the admission into an operating room was 127 minutes. Global mortality rate was 44.2%. The main preoperative mortality factor to be noticed was the initial hemodynamic instability (p=0.0031). Among stable patients, only two of them (5.4%) worsened during the preoperative treatment.In our study, hemodynamic instability corresponds to the main prognosis factor of mortality. In most cases, the initial stability persisted and allowed additional evaluation. However, the intrahospital waiting periods appeared to be too long. To be optimal, the adequate treatment should be specifically designed as soon as a diagnosis has been established.

Rationnelle L’objectif de ce travail etait d’evaluer la qualite de la prise en charge actuelle des patients presentant un anevrysme de l’aorte abdominale sous renale rompu (AAAR), depuis les premiers symptomes jusqu’au bloc operatoire, avec une analyse des facteurs de risque de mortalite preoperatoires. Methodes Nous avons collige tous les cas consecutifs de patients operes pour AAAR dans 4 services de Chirurgie Vasculaire pendant trois ans. Nous avons analyse la situation clinique initiale, les conditions de transport, les delais de prise en charge, et la mortalite a 30 jours. Soixante six AAAR ont ete operes. L’âge moyen etait de 76 ans (extremes 52-93). Resultats Les signes initiaux etaient une douleur localisee abdominale (45,3%), lombaire (17,2%), les deux associees (14,1%), ou un malaise (10,9%). Il existait une instabilite hemodynamique initiale dans 22,7% des cas. Dans 46,8% des cas le patient a d’abord transite par un centre hospitalier peripherique avant d’arriver au centre de reference. Le transport etait medicalise dans 84,5% des cas, la distance moyenne parcourue etait de 59,8 kilometres (extremes p = 0,0031). Parmi les patients initialement stables, deux seulement (5,4%) se sont degrades pendant la prise en charge prehospitaliere. Conclusion Dans notre experience, l’instabilite hemodynamique correspond au principal facteur pronostique de mortalite. Dans la majorite des cas, la stabilite initiale persiste et autorise un bilan complementaire eventuel. Les delais intrahospitaliers mis en evidence restent toutefois trop longs. Une prise en charge optimale necessiterait un parcours de soins specifique des le diagnostic suspecte.

Objective The aim of this study was to evaluate the patency of human umbilical arteries treated with polyelectrolyte multilayers (PEMs) after rabbit implantation. Background The development of small-caliber vascular substitutes with high patency after implantation remains a real challenge for vascular tissue engineering. Methods Cryopreserved human umbilical arteries were enzymatically de-endothelialized and the luminal surfaces were coated with poly(styrene sulfonate)/poly(allylamine hydrochloride) (PSS/PAH) multilayers. The PEM-untreated arteries and PEM-treated rabbit carotids were used as graft control. The native rabbit carotids were bypassed by grafts. Results The Doppler ultrasound evaluation, performed in vivo, showed that all PEM-treated grafts remained patent during the full experimental period, whereas after only 1 week, no blood circulation was detected in untreated arteries. Scanning electron microscopy and histological graft examination showed pervasive thrombus formation on the luminal surface of untreated arteries after 1 week and clean luminal surface for treated arteries for at least up to 12 weeks. The arterial wall cells were identified through alpha-smooth muscle actin αυδ platelet endothelial cell adhesion molecule-1 expression. The smooth muscle cells positive to alpha-smooth muscle actin were identified in adventitia and media and the endothelial cells positive to platelet endothelial cell adhesion molecule in intima. Von Kossa reaction didn't reveal any calcium salt deposits on the wall arteries, suggesting a good wall remodelling with no sign of graft rejection. Conclusions The in vivo evaluation of human umbilical arteries treated with PSS/PAH multilayers demonstrated a high graft patency after 3 months of implantation. Such modified arteries could constitute a useful option for small vascular replacement.

The purpose of this report is to propose an in vitro approach to predicting the long-term dilative behavior of knitted polyester prosthetic grafts. Various techniques were applied to five warp knitted fabric prosthetic grafts in order to determine the following fabric properties: knitted fabric structure, textile structure, number and respective linear density of threads and strands, and length of yarn in each stitch. Following these investigations, the prosthetic grafts underwent testing to determine specific strength at break, breaking extension, and stress-strain curve. On two prosthetic grafts, image analysis was performed during circumferential tensile strength testing in order to monitor changes in structural features as a function of stress. Changes in the distance between two wales and two courses of stitches and stitch surface were measured. In addition to surface deformation, thickness was measured, using an induction sensor. Study of fabric structure showed many differences between the five models made by different manufacturers. Knit fabric structure was Indeforma in three cases and half-tricot in two. Strand number and size varied greatly from one model to another. Pattern also varied from one model to another, with knit stitch density varying from 1 to 3. Specific strength at break testing showed great differences in the mechanical properties of the grafts. These differences were especially obvious in the first part of the rheograms, which reflects the ability of the graft to comply in response to low-strength forces, i.e., much lower than those necessary to cause rupture. Image analysis of stitch behavior under stress further confirmed differences in graft behavior depending on the fabric structure adopted by the manufacturers. The in vitro approach proposed in this study to analyze the fabric characteristics of knitted prosthetic grafts effectively revealed differences in construction and behavior. These differences could account for differences in the dilative behavior of grafts in vivo.

El objetivo de este estudio consistio en analizar un modelo in vitro para predecir el comportamiento de dilatacion a largo plazo de los implantes protesicos de poliester tejido. Se aplicaron varias tecnicas a 5 implantes protesicos textiles para determinar las siguientes propiedades del tejido: estructura del entramado, diseno textil, numero y densidad lineal respectiva de los hilos y las hebras, y longitud del estambre en cada punto. Tras estas investigaciones, los implantes protesicos fueron sometidos a diferentes pruebas para determinar la fuerza especifica de rotura, la extension de la rotura, y la curva tension-deformacion. En dos protesis se realizaron analisis de imagen durante la prueba de fuerza de tension circunferencial para monitorizar los cambios en las caracteristicas estructurales en funcion del estres. Se determinaron los cambios en la distancia entre dos pilares y dos hileras de puntos y la superficie de los puntos. Ademas de la deformacion de la superficie, se determino el grosor mediante un sensor de induccion. El estudio de la estructura del tejido mostro diversas diferencias entre los 5 modelos realizados por distintos fabricantes. La estructura del entramado fue indemallable en 3 casos y punto simple en 2. El numero y tamano de las hebras vario ampliamente de un modelo a otro. El patron tambien vario entre modelos, con una densidad de puntos que oscilo entre 1 y 3. La fuerza especifica en la prueba de rotura mostro grandes diferencias en las propiedades mecanicas de los implantes. Estas diferencias fueron especialmente obvias en la primera parte del reograma, que refleja el comportamiento del injerto en respuesta a fuerzas de baja intensidad, es decir, mucho menores que las necesarias para provocar su rotura. El analisis de la imagen del comportamiento de los puntos en condiciones de estres confirmo aun mas las diferencias de respuesta dependiendo del diseno textil adoptado por los fabricantes. El modelo in vitro propuesto en este estudio para analizar las caracteristicas de los implantes protesicos tejidos revelo efectivamente diferencias en el comportamiento en funcion del diseno. Estas diferencias podrian justificar las diferencias en la tendencia a la dilatacion de los implantes in vivo.

Le but du travail etait de proposer un protocole d'analyse in vitro du comportement en dilatation des protheses en polyester tricotees afin de pouvoir essayer de predire la survenue de dilatation tardive. Nous avons etudie 5 modeles de protheses vasculaires tricot chaine par les investigations textiles suivante : analyse du liage, de la contexture, due nombre de fils et de filaments ainsi que leurs titres respectifs, mesure de la longueur de fil absorbee par maille. Les protheses ont ete ensuite soumises au test de resistance a la traction circonferentielle en consignant la force a la rupture, l'allongement a la rupture, et la courbe contrainte-deformation. Deux protheses ont ete etudiees par analyse d'image lors de la mise en contrainte afin de suivre les parametres de la structure en fonction de la traction. Nous avons mesure l'evolution de la distance entre 2 colonnes de mailles, de la distance entre 2 rangees de mailles, et la surface des mailles. La mesure de la deformation surfacique a ete completee par la mesure de l'epaisseur par un capteur inductif. L'analyse textile que les fabricants ont proposes des constructions textiles differentes. Il s'agissait de liages Indeforma pour 3 protheses et de liages demi-simples pour les deux autres. Ces structures faisaient appel a des fils comportant des filaments en nombre et titre tres differents d'un modele a l'autre. Ces protheses presentaient egalement des contextures variables d'un modele a l'autre puisque la densite de mailles dans le tricot pouvait varier du simple au triple. Le test de resistance a la traction circonferentielle a montre que ces prothese presentaient des comportement mecaniques tres differents, surtout lorsque l'on etudiait la partie initiale des rheogrammes, cette partie traduisant la faculte de la prothese a se deformer sous l'action de contraintes reduites, tres inferieures a celles generant la rupture. L'analyse d'image des mailles lors de la mise en contrainte a egalement permis de montrer des differences de comportement en fonction du type de structure textile retenue par les fabricants. Le protocole de caracterisation des protheses textiles tricotees que nous avons propose nous a permis de montrer les differences de construction et de comportement entre les modeles pouvant expliquer les differences de comportement en termes de dilatation observes in vivo.

Layer-by-layer (LBL) polyelectrolyte films offer extensive potentials to enhance surface properties of vascular biomaterials. From the time of implantation, PET prostheses are continuously subjected to multiple mechanical stresses such as important distorsions and blood pressure. In this study, three LBL films, namely (1) poly(sodium 4-styrenesulfonate)/poly(allylamine hydrochloride), (2) poly(L-lysine)/hyaluronan, and (3) poly(L-lysine)/poly(L-glutamic acid) were built on to isolated PET filaments, thread, and vascular prostheses. The three LBL films uniformly covered the surface of the PET samples with rough, totally smooth, and "wrinkled" appearances respectively for (PAH/PSS)(24), (PLL/HA)(24), and (PLL/PGA)(24) systems. We then assessed the behavior of these LBL films, in an aqueous environment [by environmental scanning electronic microscopy (ESEM)], when subjected to unidirectional longitudinal stretches. We found that stretching induces ruptures in the multilayer films on isolated filaments for longitudinal stretches of 14% for (PSS/PAH)(24), 13% for (PLL/PGA)(24), and 30% for (PLL/HA)(24) films. On threads, the rupture limit is enhanced to be respectively 26, 20, and 28%. Most interestingly, we found that on vascular prosthesis no rupture is visible in any of the three multilayers types, even for elongations of 200% (200% undergone by the PET prostheses is representative of those encountered during graft deployment) which by far exceeds elongations observed under physiological conditions (10-20%, blood pressure). In term of mechanical behaviors, these preliminary data constitute a first step toward the possible use of LBL film to coat and functionalize vascular prosthesis.

The prevalence of obesity is increasing, and its impact on the outcome of open and endovascular abdominal aortic aneurysm (AAA) repair remains unclear, particularly in the European population. We herein assessed the impact of obesity on the postoperative course for both techniques.From a database that consecutively collects all patients undergoing AAA repair; we selected all patients undergoing elective surgery for open or endovascular AAA repair, between January 2003 and December 2011. We considered obese patients (body mass index30 kg/m(2)), overweight (25.1-30 kg/m(2)), and normal-weight patients (18.7-25 kg/m(2)), and compared mortality and/or severe complications at 30 days between obese and nonobese patients (overweight and normal weight) separately for each type of surgery by logistic regression analysis. We analyzed wound complications in the 2 groups.We included 748 patients, 174 obese, and 574 nonobese patients. Obese patients were younger (P 0.001) and were less likely to have renal failure (P 0.001) in both techniques. Obese patients in the open repair (OR) group showed a trend toward lower mortality and/or complication rates than in nonobese patients (4.8% vs. 7.5%, P = 0.34). In contrast, in the endovascular aortic aneurysm repair (EVAR) group, obese patients showed a trend toward higher mortality and/or complication rates than nonobese patients (7.1% vs. 3.2%, P = 0.17). In multivariate analysis, obesity was not an independent predictor of outcomes in OR (P = 0.18) or in EVAR (P = 0.20). Wound complications were not higher in obese patients in OR and in EVAR.Obesity should not be considered an independent risk factor of death and severe complications at 30 days in either open or endovascular AAA repair. Therefore, obesity should not systematically lead to the decision to use EVAR.

The outcome of conventional elective open repair for infrarenal abdominal aortic aneurysm (AAA) has improved mainly as a result of screening to detect coronary artery disease, the main risk factor for morbidity and mortality. Our group's policy is to perform routine coronary angiography in patients scheduled to undergo elective AAA repair. The purpose of this study was to evaluate morbidity and mortality in our department using this work-up strategy. From January 1990 to December 2000 we performed elective open repair on 632 patients, including 580 men (92%) and 52 women (8%). Preoperative coronary angiography performed in 607 cases (96%) revealed significant coronary disease in 53% of patients and led to the decision to propose prior myocardial revascularization in 12.5% of cases. Mortality and morbidity in the first 30 days after AAA repair were 1.4% and 15%, respectively. Analysis with the Cox model showed that the only risk factor for mortality was chronic renal insufficiency. Our data support routine use of coronary angiography prior to AAA repair. Screening and, if necessary, treatment of coronary artery disease that is commonly associated with AAA enhances the outcome of open AAA repair.