Tuberculosis lymphadenopathy: A rare etiology of the superior vena cava syndrome.

Superior vena cava syndrome is the clinical expression of the obstruction of the superior vena cava reducing the blood flow. Malignant etiologies are the most common. Its management is multidisciplinary and despite the progress of endovascular procedures, conventional surgery retains its place in certain indications. Mediastinal fibrosis secondary to tuberculosis lymphadenopathy may be associated with superior vena cava syndrome. In the presence of symptomatic SVCS associated with extensive mediastinal fibrosis compressing the superior vena cava with sub occlusive thrombosis, conventional surgery remains a treatment option, with cavo-venous derivation by prosthetic bypass.

Endovascular repair of traumatic aortic isthmic rupture: Early and mid-term results.

INTRODUCTION: Conventional open repair of a traumatic aortic isthmic rupture is associated with a significantly high mortality and morbidity rates. Thoracic endovascular aortic repair (TEVAR) is currently often performed because it is a less invasive treatment than surgery. The aim of this study was to evaluate short and mid-term results of TEVAR in traumatic aortic isthmic rupture. METHODS: This is a retrospective study conducted between 2010 and 2018 including patients who underwent TEVAR for traumatic aortic isthmic rupture. RESULTS: Thirty-six consecutive patients were included. All patients had sustained a violent blunt chest trauma after a sudden deceleration with associated injuries. The injury severity score (ISS) was 40 (14-66). All patients were hemodynamically stable at admission. We deployed thoracic aorta stent grafts with a mean diameter of 26mm (18-36). The procedural success rate was 100%. We reported one intra-operative complication which was a distal migration of the graft, managed by an implantation of an aortic extension graft. On the first postoperative day, one patient presented an acute lower limb ischemia, probably due to the surgical femoral access, treated with an embolectomy with a Fogarty catheter with satisfactory results. The mean follow-up was 40.41 months (6.5-96). The mortality and paraplegia rates were 0% at one month and during the follow-up period. We reported a case of kinking of the graft that occurred at 6 months. No cases of endoleak neither re-intervention were reported. CONCLUSION: TEVAR is a safe and a reliable method for the treatment of sub-acute traumatic thoracic aortic injuries.

[Endovascular treatment of chronic mesenteric ischemia]. / Traitement endovasculaire des angors mésentériques.

INTRODUCTION: Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries. METHODS: We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018. RESULTS: Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day. CONCLUSION: Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

[Revascularization delay and complications in acute upper limb ischemia]. / Délai de revascularisation et complications dans l'ischémie aiguë du membre supérieur.

INTRODUCTION: Acute upper limb ischemia is a medical and surgical emergency. Studies that have reported revascularization results in acute upper limb ischemia are rare. For this reason, the revascularization delay has remained poorly defined. The purpose of this study was to evaluate surgery results of acute upper limb ischemia related to revascularization delay. METHODS: We report a retrospective study of patients operated for acute upper limb ischemia between 2008 and 2016. Patients with thrombotic, traumatic or iatrogenic ischemia were excluded from this study. Patients were divided into two groups (those operated before 12hours and those operated after 12hours). A statistical analysis was performed to compare surgery results between the two groups in terms of limb salvage rate and neurological sequelae rate. RESULTS: Our population consisted of 138 patients. The average age was 69 [31,92]. There were 90 women and 48 men. The mean revascularization delay was 20hours [2,240]. Seventy-six patients were operated on before 12hours and 62 patients after 12hours. At one month, the mortality was 1.4% and the morbidity was 5.7%. The overall limb salvage rate was 86.9% and the overall neurologic sequelae rate was 31.8%. Statistical analysis showed that there was no significant difference between patients operated before or after 12hours in terms of limb salvage (86.8% versus 87%, P=0.258). However, there was a statistically significant difference in terms of neurological sequelae in favor of patients operated after 12hours (15.7% versus 51.6%, P=0.012). CONCLUSION: Revascularization of acute embolic upper limb ischemia is often associated with good results even if performed late. Beyond 12hours of ischemia, amputation rate is not significantly higher, however, the rate of neurological sequelae can be high.

[Femoropopliteal angioplasty: Short- and mid-term results]. / Angioplastie de l'axe fémoro-poplité : résultats à court et à moyen terme.

BACKGROUND: Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease. METHODS: Femoropopliteal percutaneous transluminal angioplasty was performed on 162 consecutive limbs (160 patients) from January 2006 to January 2016. RESULTS: In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included angioplasty only in 70 cases (43.2%), and the remaining 92 (56.8%) received at least one stent. Technical success was achieved in 98.7% of patients, with three deaths and a major morbidity rate of 15%. The actuarial primary patency at 12 and 36 month was 65.4% and 40.2%, respectively, 33 peripheral reinterventions were performed after femoropopliteal axis occlusion, resulting in an actuarial primary limb preservation rate of 94.4 at 12 months. Comparison between angioplasty only and the use of stent show no difference in primary patency (P=0.832) and limb salvage (P=0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P<0.001) and TASC D (P<0.001). However, diabetes mellitus (P=0.001) and poor run off (P<0.001) were the principal predictive factors of limb loss. CONCLUSION: Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization.

Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture.

Most popliteal arteriovenous fistula and pseudoaneurysm formation are related to trauma. Few cases have previously been reported after acupuncture therapy. Such events are typically observed when the procedure is performed by non-medical acupuncturist. They may present with acute ischemia, recent claudication, distal emboli, or less commonly rupture. Duplex ultrasound should be considered as the 1st method of investigation. Computed tomography scanning is particularly accurate in making the diagnosis. Treatment strategies consist of surgery or endovascular management. The most commonly performed surgical technique for popliteal pseudoaneurysm repair is resection with bypass grafting, whereas popliteal arteriovenous fistula are usually treated surgically with ligation and primary repair. Endovascular procedure using a stent-graft is thought to be a reasonable option for treating popliteal false aneurysm or even arteriovenous fistula. We will describe two cases of an arteriovenous fistula and pseudoaneurysm of the popliteal artery that developed after acupuncture needling in the region of the popliteal artery.

[Middle aortic coarctation: a rare vascular disorder]. / La coarctation de l'aorte thoracique descendante: mid-aortic syndrome. À propos de trois cas.

OBJECTIVE: Coarctation of the descending thoracic aorta is uncommon, with controversial etiology. Usually, severe hypertension is the main symptom; lower extremity claudication is less often found. Surgical management remains the standard for long coarctation and provides good results. METHODS: We report three cases of coarctation of the descending aorta operated at our department of cardiovascular surgery of Hospital La Rabta between January 2012 and December 2013. RESULTS: The median age was 19 years and the median follow-up was 16 months. Hypertension was the most common clinical manifestation. The diagnosis was made by computed tomography angiography. Two cases were treated by an aorto-aortic bypass and one by subclavian-descending aorta bypass. Recovery was excellent, with a decrease in antihypertensive medications (four to two) and restoration of all distal pulses. CONCLUSIONS: Middle aortic coarctation is a rare entity. Etiologies include congenital, acquired, inflammatory and infectious causes. The condition is considered a life-threatening emergency as a result of the complications associated with severe hypertension. Depending on technical considerations, open surgical bypass remains the standard repair for mid-aortic syndrome.

[Aortic stent migration: a rare complication after endovascular repair]. / Migration d'endoprothèse aortique : une complication rare après traitement endovasculaire.

Migration of an aortic stent is one of the most serious complications that can occur during follow-up after endovascular repair of an abdominal aortic aneurysm. We report the case of a 75-year-old man who underwent endovascular treatment for an infra-renal aortic aneurysm using an aorto-mono-iliac stent associated to a femoro-femoral bypass. The angiography performed at the end of procedure showed complete exclusion of the aneurysm. The postoperative course was uneventful. CT scans at 1, 6 and 12 months were normal. The CT scan at the 18th month showed a proximal migration of the stent, which was complicated by a type 1 endoleak and a stent disjunction with a type 3 endoleak. Revision surgery was indicated but the patient died from aneurismal rupture pending treatment. The migration of an aortic stent is a rare but serious complication of endovascular aneurysmal repair. Prevention requires a precise anatomical selection and adequate deployment of the stent graft.

[Acute rupture of an abdominal aortic aneurysm revealing Takayasu arteritis]. / Anévrysme de l'aorte abdominale sous-rénale rompu inaugural d'une maladie de Takayasu chez un homme de 39ans.

Arterial aneurysms are most commonly (60% of cases) located in the infrarenal abdominal aorta. An inflammatory mechanism is involved in only 10% of cases. Infrarenal abdominal aortic aneurysms revealing Takayasu's disease is unusual. Takayasu's disease is a rare vasculitis affecting large arteries in young people. It is 10 times more common in women. We report the case of an acute rupture of an abdominal aortic aneurysm revealing Takayasu arteritis in a 39-year-old man with an uneventful medical history.

[Management of traumatic aortic rupture. About 37 cases]. / Prise en charge des ruptures de l'isthme aortique post-traumatiques. À propos de 37 cas.

OBJECTIVES: The aim of this study was to review our experience in the management of traumatic rupture of the aortic isthmus, to evaluate the results of surgery and endovascular exclusion and to develop an adequate therapeutic strategy based on the existence and severity of associated injuries. MATERIAL: A series of 37 patients presenting posttraumatic aortic rupture associated with other severe lesions was collected from 2000 to 2012. There were 33 males and four females, mean age 38 years. In this series, 25 patients underwent surgical treatment and 12 endovascular exclusion. RESULTS: Six patients died during or after surgery. Overall mortality was 16% (24% in the surgery group). The postoperative period was uneventful in all patients treated with the endovascular procedure. Postoperative computed tomography controls at one week, 1 month and 12 months showed good positioning of the stent without endoleakage. CONCLUSION: Traumatic aortic rupture is often the result of a severe high-energy chest trauma. Other serious injuries are often associated. Results of immediate surgical repair are associated with high morbidity and mortality. The advent of endovascular treatment has revolutionized the treatment of traumatic aortic rupture, especially in patients with a high surgical risk.

[Surgical management of extracranial carotid artery aneurysm]. / Traitement chirurgical des anévrismes carotidiens extracrâniens : à propos de dix cas.

OBJECTIVE: Aneurysm of the extracranial carotid artery is rare. The embolic risk mandates prompt intervention once diagnosed. The aim of this study was to determine therapeutic techniques, their indications and outcomes. PATIENTS AND METHODS: We report a series of ten patients who underwent surgery for extracranial carotid artery aneurysm in the cardiovascular surgery department of La Rabta hospital. RESULTS: There were six men and four women, mean age 43 years. All patients were symptomatic (swelling and pulsatile cervical mass). Two patients had dysphonia and one patient underwent an emergency procedure because of aneurismal rupture. Aneurismal excision was performed in most patients. The arterial reconstruction was performed by end-to-end anastomosis in four cases, interposition of an autologous venous graft in four, interposition of a prosthetic graft in one and suture of a small rent in the artery in one. There was no postoperative mortality. Early postoperative morbidity included one recurrent laryngeal nerve injury, one hypoglossal nerve injury, one stroke and one infection with thrombosis of a prosthetic graft. The follow-up was uneventful. CONCLUSION: Surgical treatment of extracranial carotid aneurysms is required, in most cases with good results. Endovascular treatment may be an effective therapy in selected cases.

[False aneurysm of left ventricle after nonpenetrating chest trauma (about one case)]. / Faux anévrisme du ventricule gauche après un traumatisme fermé du thorax (à propos d'un cas).

Ischemic heart disease is the most common etiology of aneurysms of the left ventricle. The latter can also result from trauma. We report a case of a patient operated for false aneurysm of the left ventricle revealed by dyspnea and occurring six years after a nonpenetrating chest trauma. Follow-up after surgery was good with no complication occurring. In conclusion, this lesion must be considered in case of chest trauma and can be easily detected by echocardiography or CT scan.

[Anastomotic false aneurysms after under-diaphragmatic bypasses: about 25 cases]. / Les faux anévrismes anastomotiques sur pontages sous-diaphragmatiques: a propos de 25 cas.

The purpose of our study is to determine the causes and the management of anastomotic aneurysms. We report the cases of 25 patients with a mean age of 64 years at the time of initial surgical revascularisation. The mean interval between the first operation and the occurrence of anastomotic aneurysm is 5 years (range 2 months-11 years). The treatment consists on the interposition of a graft in 8 patients, anastomotic angioplasty in 9 patients and the reconstruction of the anastomosis in 8 patients. Hospital mortality was 20%. Late death occurs 3 patients and the long-term morbidity was evaluated at 22%. A recurrence of anastomotic false aneurysm occurred in 4 patients (16%) (Range 7 months-1 year). In conclusion anastomotic false aneurysm is one of the major complications of vascular reconstruction; careful follow-up can detect the rare instances of anastomotic aneurysm and reoperation can be accomplished with a low-rate of adverse outcome.

[Cross over bypasses ilio-femoral and femoro-femoral. Indications and results about 60 cases]. / Les pontages croisés fémoro-fémoraux et ilio-fémoraux. Indications et résultats. A propos de 60 cas.

UNLABELLED: The goal of this retrospective study is to review indications and results of cross over bypasses. METHODS AND MATERIAL: between January 1990 and December 2000, 60 patients (all males with mean age = 60 years) underwent cross over bypass for unilateral iliac occlusive disease: femoro-femoral in 48%, ilio-femoral in 44% and ilio-popliteal in 8%. RESULTS: mortality was 5% while complications occurred in 13.3%. Early limb salvage rate was 92%. During follow-up (mean: 32 months) we noticed 13 late thrombosis. The actuarial patency rate being at 83.5%, 74% and 67% at 1 year, 3 years and 5 years respectively. CONCLUSION: cross over bypasses are technically simple with low morbidity and acceptable results. In addition to widely accepted indications (general or local unfavourable conditions to approach abdominal aorta), cross over bypasses may be considered as satisfactory challenge even in young patients with how operative risk.

[Mycotic aneurysm of the subrenal abdominal aorta: extra anatomical reconstruction in five patients]. / Les anévrismes mycotiques de l'aorte abdominale sous-rénale. Reconstruction extra-anatomique: à propos de 5 cas.

Between 1988 and 2001, five patients with mycotic aneurysm of the abdominal aorta underwent surgery. Extra-anatomical reconstruction with axillo-bifemoral bypass grafting was performed in all patients. The hospital mortality rate was 20%. During the follow-up period two patients presented thrombosis of the axillo-bifemoral bypass, descending aorto-bifemoral bypass was performed in one. Extra-anatomic revascularization is a satisfactory procedure in the treatment of mycotic abdominal aortic aneurysm. The results are acceptable and the prognosis is mainly related to the underlying pathology and the severity of the infection.

[Revascularization of the lower limbs with extra-anatomic shunts. Report of 80 cases]. / Revascularisation des membres inférieurs par pontages extra-anatomiques. A propos de 80 cas.

UNLABELLED: The extra anatomical bypasses are those which do not follow the usual arterial pathway. The aim of this study is to define the indication of extra anatomical bypasses and to compare them with other revascularisation procedures. In this paper we report a retrospective study carried between January 1988 and December 1999 involving 80 patients (78 men and 2 women) who underwent extra anatomical bypasses for revascularisation of their lower limbs (83 bypasses). The mean age of the patients was 62 years. The indication for revascularisation was chronic arteritis of the lower limbs in 72 patients (90%), infected aneurysms in 6 cases (7.5%) and acute aortic dissection in 2 cases (2.5%). We performed an axillo-unifemoral bypass in 23 cases, an axillo-bifemoral in 17, a crossover ilio-femoral or femoro-femoral bypass in 41 cases, and 2 transobturator ilio popliteal bypass right and left in 1 case. Hospital mortality rate was 10%. Hospital morbidity was about 65%. Limb salvage was 78%. Sixty patients were regularly followed during a mean follow-up of 31 months. Late mortality was 10%. In the end of our study global limb salvage rate was 74%. IN CONCLUSION: extra-anatomical revascularization allows acceptable limb salvage rate along with lower operative risk even in poor state patients.

[Determining factors in mitral valve reconstructive surgery. Report of 150 cases]. / Les facteurs determinants dans la chirurgie reconstructrice de la valve mitrale. A propos de 150 cas.

150 patients had mitral valve repair for mitral valve incompetence. There were 57 males and 93 females with a mean age of 22 years. 60% of the patients were in Class II NYHA and 40% in Class III and IV. Type I was present in 18 patients, type II in 98 and type III in 34 cases. Mitral repair included correction of valve prolapse, valvular enlargement with pericardial patch and annuloplasty with semi-rigid ring in 128 cases and PTFE patch along the posterior leaflet in 12 cases. The perioperative mortality rate was 2.6%. All patients had early post-operative echocardiography. According to this, mitral regurgitation was absent or tiny in 135 patients, grade II in 10 cases and grade III in 2 cases. It was moderate or important in twelve patients. In the late post-operative period. All the others patients were reoperated upon for mitral dysfunction in a mean time of 37 months. The reason for reoperation was in the majority of the cases the recurrence of mitral regurgitation related to increase of valvular and sub valvular disease. The late mortality rate is 7%. Out of 126 reviewed survivors on the long run, 71 patients are asymptomatic in class I, 53 patients in class II and 2 patients in class III NYHA. The estimated mitral regurgitation by echography in those patients is absent or trivial in 96 cases. grade II in 29 cases and grade III in one case. Mitral valvuloplasty is the preferred procedure in mitral insufficiency surgical management. It is associated to a low early mortality and morbidity rate. Despite the need for reoperation in about 10% of the cases in the long follow-up, mitral repair offers a good quality of life without anticoagulant treatment.

[Peripheral infected aneurysm: report of 15 cases]. / Les anevrismes infectieux peripheriques: a propos de 15 cas.

In this retrospective study we report 15 cases of peripheral infected aneurysms. The sex ratio was 13/2 and the mean age was 23 years. Patients presented with infection syndrome in 9 cases, vascular mass in 11 cases and limb ischemia in 2 instances. Arterial lesion was documented and confirmed by echography, tomodensitometry and angiography. The infection was recognised by different criteria the main one being micro-organism isolation. In 10 cases aneurysm was secondary to bacterial endocarditis, in 4 it was primary and in one case it was related to arterial catheter procedure. Treatment is based on antibiotics and surgical management by removing of infected aneurysm and arterial restoration whenever possible. Arterial flowerest re-establishment was done in 10 patients among whom 6 by anatomic procedures 4 by extra-anatomic ones. Hospital mortality rate was 13% (2/15), all deaths occurred after cardiac surgery for endocarditis. Two patients were readmitted for adjacent spine infection, one month and one and a half respectively after surgery. One young patient required late surgery (aorto-bifémoral bypass) 24 months after initial treatment and one patient died by intra-duodenal rupture of recurrent false aneurysm. Analysis of our results and literature review allow discussion of clinical, physiopathological and specially therapeutic aspects of infected aneurysm.