Systematic review of respiratory viral pathogens identified in adults with community-acquired pneumonia in Europe.

Community-acquired pneumonia (CAP) is an important respiratory disease and the fifth leading cause of mortality in Europe. The development of molecular diagnostic tests has highlighted the contributions of respiratory viruses to the aetiology of CAP, suggesting the incidence of viral pneumonia may have been previously underestimated. We performed a systematic review and meta-analysis to describe the overall identification of respiratory viruses in adult patients with CAP in Europe, following PRISMA guidelines (PROSPERO; CRD42016037233). We searched EMBASE, MEDLINE, CINAHL, WHOLIS, COCHRANE library and grey literature sources for relevant studies, and screened these against protocol eligibility criteria. Two researchers performed data extraction and risk of bias assessments, independently, using a piloted form. Results were synthesised narratively, and random effects meta-analyses performed to calculate pooled estimates of effect; heterogeneity was quantified using I2. Twenty-eight studies met inclusion criteria of which 21 were included in the primary meta-analysis. The pooled proportion of patients with identified respiratory viruses was 22.0% (95% CI: 18.0%-27.0%), rising to 29.0% (25.0%-34.0%) in studies where polymerase chain reaction (PCR) diagnostics were performed. Influenza virus was the most frequently detected virus in 9% (7%-12%) of adults with CAP. Respiratory viruses make a substantial contribution to the aetiology of CAP in adult patients in Europe; one or more respiratory viruses are detected in about one quarter of all cases.

Morphological Analysis of Healthy Aortic Arch.

OBJECTIVE/BACKGROUND: This study aimed to describe an arch morphology protocol in a healthy population, and to assess the impact of age and sex. METHODS: A retrospective morphology evaluation was conducted in a population with no personal history of thoracic aorta surgery or pathology, through computed tomography (CT) imaging analysis, using a standardised protocol. Based on centreline three dimensional coordinates, a single investigator calculated a series of parameters in the arch zones and in the total arch, using Matlab scripts. These were categorized as: (i) morphometric data: diameter, length and aortic angle of each zone, total arch angle, and length; (ii) geometric data: tortuosity index (TI), arch width, assimilated curvature radius (CRi), and attachment zone angles. Student or Mann-Whitney tests were used to compare parameter means. Their variability with age and sex was assessed through univariate and multivariate regression analysis. RESULTS: CT images from 123 subjects (mean ± SD age 53 ± 19 years) were reviewed. Significant correlation between age and morphology was found. The aorta expanded homogeneously and stretched heterogeneously with age because of posterior arch elongation. TI decrease, CRi, and attachment zone angle increase were also observed with aging. Age remained significantly associated with these morphological parameters, independently of body surface area and hypertension. Sex also affected morphology: longer total arch length and higher CRarch in men; lower zone 3 attachment angle in women CONCLUSION: Using mathematical algorithms, and with a view to improving endovascular arch treatment, this study provides a standardised arch morphology protocol and objectively identifies both age related evolution and sex related variation in the different zones.

Risk Factor Analysis for the Mal-Positioning of Thoracic Aortic Stent Grafts.

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

Risk Factor Analysis of Bird Beak Occurrence after Thoracic Endovascular Aortic Repair.

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

Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Elective stent-graft treatment for the management of thoracic aorta mural thrombus.

BACKGROUND: Optimal management of aorta mural thrombus (AMT) continues to be controversial. The aim of this study was to describe the management of AMT in the thoracic aorta with either conservative or stent-graft treatment and to analyze the role of morphological characteristics of thrombus in the selection of suitable candidates for intervention. METHODS: A retrospective review was conducted of all patients admitted for thoracic AMT. Clinical data, treatment used, and outcomes were recorded. Patients were divided in two groups according to the treatment used: either conservative or stent-graft. Morphological features of thrombus, including size, sessile or pedunculated aspect and mobility, were compared between the two groups. RESULTS: From January 2006 to March 2013, 13 consecutive patients (nine male, mean age 53, range 37-76) were admitted for symptomatic (n = 8) or asymptomatic AMT (n = 5). All patients received unfractionated heparin. Management of primary aortic thrombus required stent-graft in seven patients, aortic thrombectomy in one, and anticoagulation therapy alone in five. Indications for intervention were recurrent embolism (n = 4), occurrence of embolism under heparin (n = 1), or persistent thrombus (n = 2). Endovascular exclusion of AMT was successful in all cases, with no complications or deaths at 30 days and no recurrence at midterm. Analysis of the morphological features of the thrombus identified solely the high degree mobility as associated with adverse outcome (p = .048). CONCLUSION: In our experience, stent-graft exclusion of AMT is an effective approach. Systematic evaluation of thrombus mobility by a real-time imaging study can be helpful to better define the indications for radical treatment of the aortic lesion.

Subintimal recanalization plus stenting or bypass for management of claudicants with femoro-popliteal occlusions.

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

A clampless and sutureless aorto-prosthetic end-to-side anastomotic device: an experimental study.

OBJECTIVES: A feasibility study. METHODS: Eight pigs (all females; mean weight: 29 kg) underwent a conventional transperitoneal aortic approach with implantation of an aorto-prosthetic end-to-side anastomosis using a Clampless device and deployment of a 5-mm polytetrafluoroethylene (PTFE) graft. After proximal ligature, a conventional end-to-end anastomosis was then performed between the graft and the left iliac artery. RESULTS: The first pig died during the procedure due to graft misplacement. The seven other procedures were successful with a mean operative and anastomosis time of 101 min (range: 81-115 min) and 3.35 min (range: 2.25-4.25 min), respectively; mean blood loss was 152 ml (range: 30-235 ml). Another pig with a patent graft died at day 4 as a result of a severe unrelated pneumonopathy. The angiogram performed during the procedure and before sacrifice, at 2 (n=2), 4 (n=2) and 6 weeks (n=2), showed no graft stenosis or thrombosis. Microscopic examination revealed a tissue covering the intraluminal stent, which evolved over time, with no visible endothelial proliferation or inflammation. CONCLUSION: An aorto-prosthetic anastomosis can be performed safely and efficiently with our new clampless and sutureless device. The next step will be a laparoscopic Clampless implantation.

[The role of laparoscopic surgery in the treatment of occlusive and abdominal aortic aneurys. Review of the literature]. / Il ruolo della chirurgia laparoscopica nella patologia aneurismatica e occlusiva dell'aorta addominale. Revisione della letteratura.

UNLABELLED: The objective of this systematic review of the literature is to evaluate whether a laparoscopic operation can be performed on patients with occlusive or abdominal aortic aneurysm as a minimally invasive and durable alternative. For this purpose, the literature was reviewed and laparoscopic surgery results were compared with those of conventional and endovascular surgery. All series were included, even when containing also one case. Operative and clamping times, mortality and morbidity and hospital stay were evaluated. Thirty-five studies were identified about conventional (4), minilaparotomy (4), endovascular (4), total (12) and video-assisted (11) laparoscopic surgery. Operative and clamping times were shorter for video-assisted procedures than total-laparoscopic procedures. The mortality rate ranged from 3% to 4.5% for conventional surgery, from 0% to 3% for endovascular surgery, from 0% to 6% for total-laparoscopic surgery and from 0% to 4.2% for video-assisted laparoscopic surgery. A variable morbidity was described for all techniques, with a higher incidence in total-laparoscopic surgery. Mean hospital stay was similar for laparoscopic surgery procedures. The learning curve of a surgical team performing laparoscopic surgery improves the RESULTS: Laparoscopic abdominal aortic surgery is feasible and may offer good postoperative recovery with excellent mid-term patency. Shorter hospital stay and simple mid-term follow-up allow more comfort for the patient and probably monetary savings for the community. A steep learning curve is needed. For these reasons laparoscopic video-assisted technique can be considered a third means of treating severe occlusive and aortic aneurysm, but only new instruments for performing aortoprosthetic anastomoses can diffuse the total laparoscopic technique as a routine approach.

Endovascular management of chronic disabling ilio-caval obstructive lesions: long-term results.

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

[Is endovascular treatment of acute thoracic aortic disease possible in centers where extracorporal circulation is not available?]. / Le traitement endovasculaire des lésions urgentes de l'aorte thoracique descendante est-il possible dans un centre ne disposant pas de circulation extracorporelle?

OBJECTIVE: To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease. METHOD: From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%). RESULTS: Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC. CONCLUSION: The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.

Evaluation of a new vascular suture system for aortic laparoscopic surgery: an experimental study on pigs and cadavers.

OBJECTIVES: The aim of this study was to assess the feasibility and efficacy of a new laparoscopic vascular suturing device. METHODS: Animal study: six pigs underwent surgery using a retroperitoneal laparoscopic approach. Aorto-prosthetic side-to-end and end-to-end anastomoses were performed laparoscopically on each pig using SuDyn. Clamping and anastomosis times, as well as the properties of the anastomoses, were recorded. Study on cadavers: four aorto-prosthetic end-to-end anastomoses were performed using the direct transperitoneal laparoscopic approach to assess the feasibility of the SuDyn device on atherosclerotic aortas. RESULTS: Animal study: No pigs died and 12 patent and impermeable anastomoses were obtained. Mean anastomosis time was 38(+/-8)min for end-to-side anastomoses and 37(+/-5)min for end-to-end anastomoses. Study on cadavers: Totally laparoscopic anastomoses were performed in 4 human cadavers with a mean anastomosis time of 37(+/-3)min. CONCLUSIONS: SuDyn makes laparoscopic aorto-prosthetic anastomoses easier to perform, produces good results and does not require a learning curve.

Efficacy of Viabahn in the treatment of severe superficial femoral artery lesions: which factors influence long-term patency?

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

Efficacy of Hemobahn in the treatment of superficial femoral artery lesions in patients with acute or critical ischemia: a comparative study with claudicants.

PURPOSE: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease. METHOD: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001). RESULTS: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II. CONCLUSION: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.

Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.

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

Are laparoscopic staplers effective for ligation of large intraabdominal arteries?

OBJECTIVES: To evaluate ligation of aortoiliac arteries with laparoscopic staplers in order to develop specifically designed staplers. METHODS: Cadaveric study. Seven human cadaver aortas were stapled using EndoGIA60 staplers. Efficiency was evaluated macroscopically and on a hydrodynamic bench. Clinical study. Twelve patients had ligation of 14 large abdominal arteries (aorta: nine, iliac artery: four, hepatic artery: one) using a laparoscopic stapler. Stapling efficiency was judged on peroperative clinical and postoperative CT scan criteria. RESULTS: Cadaveric study. Stapling was performed perfectly on four moderately calcified aortas, without leakage with a pulsatile pressure of >250 mmHg. For three aortas with severe calcification, stapling was not efficient and major leakage occurred. Clinical study. Stapling appeared clinically efficient on all arteries but one aorta: this severely calcified aorta was ligated conventionally. The staplers are not easy to use due to their shape and their lack of articulation. After a mean follow-up of 31.3 months, all the other stapled arteries were effectively ligated. CONCLUSION: The commercially available staplers can be used securely on moderately calcified arteries but stapling of severely calcified arteries should be avoided. These devices should be redesigned to facilitate their use in vascular surgery.

[Prostheto-prosthetic and aorto-prosthetic anastomosis using stents, threads, clips and staples. In vitro comparative study]. / Anastomoses prothéto-prothétiques et aorto-prothétiques par stents, fils de suture, clips et agrafes. Etude comparative sur banc d'essai.

OBJECTIVE: --To evaluate mechanical strength of new potential systems of vascular prostheses anastomosis versus usual suture (4.0 yarn), --To advance objective quantified data in order to establish the specifications of a new quick and reliable mechanical anastomosis device for laparoscopic surgery. MATERIAL AND METHODS: Two experimental studies were conducted in order to quantify the mechanical resistance of anastomoses between two Dacron vascular prostheses and anastomoses between one Dacron vascular prosthesis and one cadaver abdominal aorta segment. Existing materials, which have generally used for other types of surgery, were applied for these studies (clips, staples, stents). These systems of anastomosis were compared to usual suture, used as reference. RESULTS: The mechanical strength of an anastomosis between two Dacron vascular prostheses performed with staples or the same number of stitches is of equivalent magnitude. Anastomoses made with clips or stent are ten to fifteen times weaker than those made with stitches. We did not succeed in performing an anastomosis with staples on cadaver aorta segments because aorta segments tear when staples are applied. In the experiments with a hand-sewn graft, the aorta always tor before the suture, without breakage of the suture. CONCLUSION: From these in vitro trials, we can advance that a continuous suture is probably far too resistant in relation to the aorta own resistance. As we do not know accurately the physiologic strength applied to a vascular prosthesis in vivo, one acceptance criterion from a safety point of view for a new anastomosis system must be that its strength will be equal to the well-proven continuous suture (greater than 150 N) or to the aorta breaking point (between 100 and 160 N). From that point of view, anastomoses performed with clips or a stent are not convenient, unless special clips or stents can be developed for this application. The mechanical strength is of staples sufficient but their design has to be adapted to this particular type of anastomosis.

[Thoracoscopic bypass from the descending thoracic aorta to the femoral artery. Experimental study and clinical application]. / Pontage thoracoscopique entre l'aorte thoracique descendante et l'artère fémorale. Etude expérimentale et application clinique.

OBJECTIVE: Descending thoracic aorta to femoral artery bypass (DTAFB) has demonstrated usefulness in the treatment of aorto-iliac occlusive disease but related morbidity and mortality are not negligible. We wanted to determine the feasibility of thoracoscopic DTAFB and to report our clinical experience. MATERIAL AND METHODS: An experimental study was performed on 8 pigs in helicoidal position under general anesthesia with right selective ventilation ). Three trocars were inserted and the descending aorta was dissected ). After tunnelisation of a 6 mm graft, a lateral aortic anastomosis was thoracoscopically performed ) then femoral anastomoses were made. At the end of the procedure, an angiogram and then an autopsy were performed ). Subsequently, three patients were operated, two for thrombosis of a previous aortobifémoral bypass and one for infrarenal aortic hypoplasia. Dissection and graft tunnelisation were performed thoracoscopically ). Then, the aortic anastomosis ) was constructed through a left lateral minithoracotomy (10 cm). RESULTS: One pig died during surgery of acute lung oedema due to the difficulties of selective ventilation. Excluding this case, the average times of surgery and of dissection were respectively 246 (205-325) and 68 minutes (50-90). The average aortic clamping and anastomosing times were 135 (105-220) and 120 minutes (80-210) ). Three aortic tears were noted; one was repaired. Angiogram was normal 5 times; one pig had a minor stenosis and a leak, and another one had a leak. All the anastomoses were patent without stenosis at autopsy; no organ lesion was found. In humans, the procedure was performed with simple postoperative course in 2 patients and a conversion (20 cm long thoracotomy) was necessary for the third due to poorly supported selective ventilation. CONCLUSION: Totally thoracoscopic DTAFB can be performed in pigs. In clinical practice, we recommend the use of a mini thoracotomy. This way, the aortic anastomosis can be performed with aortic clamping time under 30 minutes, reducing the risk of spinal cord ischemia. These results allow to propose mini invasive thoracoscopically assisted DTAFB for the patients for whom laparoscopic access of the abdominal aorta appears to be difficult (calcified aorta, hostile belly.).