A renal angiomyolipoma with a challenging presentation: a case report.

INTRODUCTION: Renal angiomyolipoma is considered a benign mesenchymal tumor composed of fat, smooth muscle, and blood vessels. It represents 1-3% of solid renal tumors. Despite this tumor's benignity, it can be aggressive with a locoregional extension. CASE REPORT: A 41-year-old north African caucasian woman consulted with chief complaints of right lower back pain with no hematuria and no urinal sign. Thoracic-abdominopelvic contrast-enhanced computed tomography showed a right inferior polar heterogeneous renal mass complicated with venous thrombus ascending to the right atrium level. The patient underwent radical nephrectomy under extracorporeal circulation and direct supervision of the fatty thrombus at the right atrium level. The postoperative period was uneventful. The final histologic examination was concordant with renal angiomyolipoma. CONCLUSION: Renal angiomyolipoma is the most common benign kidney tumor. Despite its benignity, it can be associated with lethal complications such as hemorrhage, and it can also show signs of local extension mimicking malignant tumors. The cornerstone of the treatment remains surgery.

[Telemedicine and social Media in the management of ECMOs in the era of COVID-19: The Tunisian experience]. / La télémédecine et les réseaux sociaux dans la gestion des ECMO à l'ère de COVID-19 : l'expérience Tunisienne.

INTRODUCTION: In Tunisia, as elsewhere in the world, severe forms of acute respiratory distress syndrome (ARDS) related to SARS-Covid19 have been observed. When the usual means of resuscitation were no longer sufficient, the implementation of the Extracorporeal membrane oxygenation or ECMO was needed. AIM: The whole problem of the management of these patients in this pandemic period has been to manage the operation of the ECMO machine, usually reserved for expert and specialized centers in the field. METHODS: The cardio-vascular surgery department of La Rabta teaching hospital of Tunis has tried the experience of management of ECMO implanted in the different reanimations of Tunis, remotely, using telemedicine and social networks. Thus, a Facebook-Messenger discussion group was created and enabled the management of patients under ECMO via video conferencing in real time involving all stakeholders. RESULTS: A call was made whenever the physician needed it. The video provided an opportunity to discuss with surgeons and perfusionists in real time the complications or problems of these patients. Their clinical status was continuously shared on the focus group. Following the instructions of the expert surgeons and the exchanges made on the group, the reanimator could then intervene on this or that parameter. CONCLUSION: Social media have invaded everyone's daily lives and health professionals are not exception to this trend. The Covid-19 pandemic has only strengthened this digital alternative with the goal of efficiency and patient interest. While their use in a professional setting offers many advantages, it must nevertheless be done in compliance with the rules of ethics and bring real added value.

[Arterial trauma of the upper limbs: Particularities of the population in Tunisia and risk factors for amputation]. / Traumatismes artériels des membres supérieurs : particularités de la population en Tunisie et facteurs de risque d'amputation.

AIM OF THE STUDY: The purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss. METHODS: This was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate. RESULTS: The average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma. CONCLUSION: Prompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

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.

[Predictive factors of amputation after iliac angioplasty in patients with severe artery disease]. / Facteurs prédictifs d'amputation après angioplastie de l'artère iliaque chez les patients avec artériopathie sévère.

INTRODUCTION: Despite the success of angioplasty of the iliac artery, this technique remains associated with significant amputation rates. The purpose of this study was to identify predictive factors for lower limb amputation after iliac angioplasty in patients with critical ischemia. METHODS: We reported a retrospective study including patients who successfully underwent angioplasty of the iliac artery between 2014 and 2018. The primary endpoint was limb salvage at 1 month. The variables were studied in univariate and multivariate analysis. RESULTS: Our study included 86 patients. The median age was 57±10 and the sex ratio was 4.7. Cardiovascular risk factors were represented by smoking in 14 cases (16.3%), diabetes in 25 cases (29.1%), arterial hypertension in 2 cases (2.3%) and dyslipidemia in 2 cases (2.3%). Seventy patients (81.3%) were classified as stage 4 according to the Leriche and Fontaine classification and 16 patients (18.7%) were classified as stage 3. The lesions were stenosing in 48 cases (55.8%) and occlusive in 38 cases (44.2%). These lesions were classified according to the TASC classification "Trans-Atlantic-Society-Consensus" in TASC A-B in 61 cases (70.9%) and TASC C-D in 35 cases (29.1%). Distal arteritis was found in 8 cases (9.3%). Balloon angioplasty was performed in 36 cases (41.8%) and angioplasty stenting in 50 cases (58.2%). At 1 month, the amputation rate was 9.3%. Univariate analysis showed that diabetes and smoking were the most important factors associated with amputation (respectively P=0.007, OR=9.31, 95% CI=[1.73-50.07] and P=0.022; OR=6.8; 95% CI=[1.46 to 31.61]). Multivariate analysis showed that diabetes and distal arteritis were the predictive factors for amputation (respectively P=0.034, OR=21.06, 95% CI=[1.25 to 354.46] and P=0.008, OR=11,61, 95% CI=[1.88 to 71.69]). CONCLUSION: Diabetes and distal arteritis are the predictive factors for lower limb amputation after iliac angioplasty.

[Conservative aneurysmorrhaphy for hemodialysis arteriovenous fistula]. / Anévrysmorraphie conservatrice des fistules artérioveineuses pour hémodialyse.

The aim of this study was to evaluate the results of conservative surgical treatment of the aneurysmal complications of arteriovenous hemodialysis fistulae and to determine the factors predictive of long- and mid-term patency of treated fistulae. The surgical treatment was mainly based on caliber reduction and reconstruction. METHODS: This was a descriptive retrospective study with a five-year duration, going from January 2013 to December 2018. This study included 40 patients presenting aneurysmal complications of their hemodialysis vascular access who were treated with aneurysmorrhaphy. RESULTS: The mean age of the aneurysmal-complicated hemodialysis vascular access was 42 months. The indications for treatment were puncture-related difficulties in 42.5% of cases, rapid increase of the aneurysmal diameter in 27.5%, skin thinning in 25% and aneurysmal rupture in 5%. The mean aneurysmal course was 6.6 months with an average diameter of 3.25cm at the moment of management. The initial technical success rate was 100%. Twenty patients had complications in the postoperative period. Patency rates at 3, 6, 12 and 24 months were 89.5%, 81.6%, 71% and 63.1%, respectively. Factors predictive of thrombosis were diabetes (P=0.001), peripheral arterial disease (P=0.003), number of punctures per week (P=0.003) and context of emergency presentation (P=0.001). CONCLUSION: Aneurysmorrhaphy seems to be the best conservative surgical treatment for aneurysmal complications of hemodialysis vascular access fistulae. This surgical approach allows us to conserve the native autologous vascular access and spare the patient's venous network.

[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.

Bilateral absence of the superior vena cava. Case report and literature review.

Bilateral absence of the superior vena cava (SVC) is an uncommon congenital vascular anomaly, mainly asymptomatic, usually undetected, and often associated with other cardiac anomalies. Though usually harmless and totally innocent, this vascular anomaly might complicate cardiovascular surgery, the insertion of a central venous catheter and the transvenous placement of a pacemaker. This SVC anomaly is still not well known, underdiagnosed and its incidence is much higher than described. A better understanding of this anomaly and its detection could play a key role in avoiding its potential complications. We are sharing a case of a female adult, with no medical history, who presented herself to the department of visceral surgery with a collateral venous circulation of the upper thorax, that was at first, mistaken for a portal hypertension syndrome, findings were pushed to finally conclude a bilateral absence of the SVC.

[Short- and long-term outcomes of surgical treatment of popliteal aneurysms]. / Traitement chirurgical des anévrismes poplités : résultats à court et à long termes.

INTRODUCTION: The popliteal artery aneurysm (PAA) is a rare vascular disease, but represents the most common site of peripheral aneurysms. We report in this paper our experience in the surgical management of PAA. OBJECTIVES: The aim of this work was to clarify the indications and the results of the surgical management of PAA. METHODS: It was a retrospective study, extended over a period of 12years, going from 2007 to 2018, covering 26 patients operated on surgically for popliteal aneurysm. RESULTS: We have operated 26 patients for PAA. All patients were male. The average age was 59years [39-80years]. The aneurysm was symptomatic in 22 cases and asymptomatic in 4 cases. The mean aneurysm diameter was 37mm [26-70mm]. Twenty-two patients have received a planned surgery and we did emergency surgery for 4 patients because of a limb ischemia complication. The surgical treatment consisted in a surgical bypass after the aneurysm removing. The restoration of blood continuity was achieved by a vein graft in 23 cases and prosthetic in 3 cases. Three patients needed major amputation within 30days (11.53%) and no mortality was observed during this period. Mean follow-up was 24months [12-96months]. Two-years mortality, complication rate and limb salvage was respectively 7.69%, 15.38% and 84.62%. CONCLUSION: The PAA represents a serious disease that can affect the vitality of the lower limb. Surgical treatment is currently the gold standard because of its good results.

[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.

[A rare localization of angio-Behçet revealed by a false aneurism of a gluteal artery treated surgically]. / Une localisation rare de l'angio-Behçet révélée par un faux anévrisme d'une artère glutéale traité chirurgicalement.

Behçet's disease is a rare chronic systemic inflammatory disease. It is more common in Turkey, North Africa and Japan. The incidence of vascular involvement (angio-Behçet) is 7 to 38%. The gluteal localization of angio-Behçet is rarely reported and could be revealed late. Aside from aneurysmal rupture, nerve compression with pain and lower limb impotence could be the main clinical signs. Because of the deep location of the lesion, management of this disease can be difficult. The classic surgical treatment remains the gold-standard especially in case of extreme urgency, non-feasibility of endovascular treatment and especially in case of associated nerve compression. We report the case of a 45-year-old man with a history of pulmonary angio-Behcet, who underwent emergency surgery for a huge false aneurism of a collateral of the hypogastric artery treated via a double anterior and posterior approach with good outcome.

[Staff knowledge of radiation protection in endovascular surgery]. / Connaissances du personnel de chirurgie endovasculaire en radioprotection.

INTRODUCTION: Image intensification exposes the endovascular surgery staff to ionizing radiation. The aim of this study was to determine awareness of ionizing radiation risks among personnel working in the endovascular surgery environment and the availability of radiation protection clothes and to propose appropriate corrective measures. METHODS: This descriptive study was performed in the endovascular operating theatre equipped with a mobile image intensifier unit in La Rabta vascular department in September 2017. We visited the endovascular theatre to identify the availability of radiation protection clothes. We used a questionnaire to identify personnel knowledge about ionizing radiation. We established a global score of knowledge to classify our population. RESULTS: We identified 85 professionals exposed to ionizing radiation. Sixty-four of them (75%) responded to our questionnaire; 65% were male; median age was 34 years (range: 25-61). Endovascular theatre personnel were surgeons (35%), nurses (34%), qualified technicians (18%) and other department employees (13%). The mean global score of knowledge was 8.15/20 (2-18). This score increased significantly with grade and seniority (Kruskal-Wallis test). CONCLUSION: In the present study, the results indicate insufficiency knowledge about radiation exposure among the endovascular staff and in radioprotection tools availability. In order to minimize all unnecessary radiation, attempts should be made to increase vascular theatre staff knowledge about radiation protection. Safety culture is a referral method to reduce radiation exposure as low as possible.

[Femoral pseudoaneurysms in drug addicts: About 4 cases]. / Faux anévrisme de l'artère fémorale chez le toxicomane: à propos de 4 cas.

PURPOSE: To describe the therapeutic management of false aneurysms of the femoral artery in drug addicts. PATIENTS AND METHODS: We report the cases of four drug addicts with pseudoaneurysms of the femoral artery. RESULTS: All patients were male with a mean age of 36 years. Emergency surgical treatment involved removal of the pseudoaneurysm followed by a venous graft (n=3) or patch (n=1). The post-operative period was uneventful for three patients. One patient required early revision with a second venous bypass after bleeding from the first then later a second revision for resection of infected tissue and sartorius muscle plasty to cover the groin area. Late outcome was favorable for all patients after an average 12-month follow-up. CONCLUSION: No consensus has been reached concerning the appropriate treatment for false aneurysms of the femoral artery in drug addicts. Analyses of larger series with longer follow-ups are needed to elucidate the best emergency surgical methods capable of reducing the risk of rupture.

[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.

[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.

[Malignant recurrence of "mature" sacrococcygeal teratoma. A clinicopathological study of 4 cases]. / Récidive maligne du tératome sacrococcygien "différencié". Etude anatomoclinique de 4 cas.

Sacrococcygeal teratomas (SCT) are uncommon neonatal tumours which are usually benign. Our interest was aroused by encountering patients with reportedly benign SCT which later, after surgery, recurred as malignant tumours. We conducted a retrospective study of 17 patients treated for benign SCT during a period of 9 years. Of these patients, 4 developed malignant recurrence (3 females and 1 male) with a mean age of 19 months. The average time to recurrence was 17 months. Recurrence presented as a gluteal mass in one case, urinary and digestive compression signs in another case and as elevated alpha-fetoprotein levels in the two remaining cases. Histologically, one of the original tumors included tiny immature foci but none contained a malignant component after reading slides. Recurrences were as endodermal sinus tumour in all cases. After surgery and adjuvant chemotherapy, only one child died from complications related to chemotherapy. The other three were alive and well at mean follow-up of 5 years. These results emphasise the need for close clinical and biological follow-up for at least 2 years in all patients who had undergone excision of a neonatal SCT.