Editor's Choice - Ex vivo Renal Artery Repair with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Long-term Results of Sixty-seven Procedures.

OBJECTIVE/BACKGROUND: To evaluate the long-term outcome of renal revascularization by ex vivo renal artery reconstruction and autotransplantation for renal artery branch aneurysms (RABAs). METHODS: Between 1991 and 2015, 67 ex vivo renal artery reconstructions with kidney autotransplantation were performed in 55 adults (mean age 47 years) and 10 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia in 34 patients. Other etiologies were systemic congenital disease in eight patients, spontaneous dissecting aneurysms in five, iatrogenic aneurysms in three, atheromatous aneurysms in two and unknown etiology in 13. Median RABA diameter was 20.5 mm. Fifty-three patients (82%) were hypertensive, 60 had normal renal function and no patient was on hemodialysis. Seven patients (11%) were operated on after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 14 patients (22%). The hypogastric artery was used in 41 patients, the saphenous vein in 18, the superficial femoral artery in five and a combination of different materials in three. RESULTS: No deaths occurred during the first 30 days. Primary patency at 30 days was 90.8% following to six early thromboses. Three patients (5%) were lost to follow up. No other thrombosis occurred. At 8 years, the primary and primary-assisted patency were 88% and 91%, respectively. Survival was 95% at 9 years. Among the 53 hypertensive patients, two were lost to follow up. At 9 years, 22 (43%) were cured and nine (18%) were improved with a significant reduction of antihypertensive medication (p < .05). The pre-operative modification of the diet in renal disease (MDRD) clearance was 93 ± 29 mL/minute, the immediate post-operative MDRD was 94 ± 33 mL/minute, and at the end of follow up it was 86 ± 26 mL/minute (p > .05). CONCLUSION: Ex vivo renal artery reconstruction for complex RABAs eliminates the risk of rupture, confers a benefit to hypertension, and preserves renal function with a satisfactory long-term patency.

Common hepatic artery as inflow in kidney transplantation.

Kidney transplantation originating from the hepatic artery has not previously been reported. Herein, we report a third kidney transplantation with the common hepatic artery as inflow. A 62-year-old male with chronic renal failure due to polycystic kidney disease was proposed to a third kidney transplantation. CT-scan showed diffuse calcification of the aorto-iliac axis and the splenic artery. The common hepatic artery was the only artery suitable for anastomosis and as such was chosen as the inflow for retransplantation. The operation was performed through a right subcostal laparotomy. A saphenous bypass was interposed between the common hepatic artery and the graft, then the renal vein was anastomosed to the suprarenal inferior vena cava. Duration of warm ischemia was 27 min. Postoperative course was complicated with delayed graft function of 17 days and pulmonary infection. Patient was discharged at day 30. With a follow-up of 40 months, serum creatinine level and eGFR are, respectively, 191 µmol/L and 32 mL/min. Hepato-renal bypass technique can be used in kidney retransplantation when patient anatomy is not compatible with other classical options.

Early and late results of ex vivo repair and autotransplantation in solitary kidneys.

INTRODUCTION: Autotransplantation of a solitary kidney provides an excellent opportunity to study the immediate and long-term consequences of intra-operative renal ischaemia. The purpose of this report is to describe a series of nine patients who underwent ex vivo repair and autotransplantation on solitary kidneys. PATIENTS AND METHODS: The series included six females and three males with a mean age of 36 years. Seven of the nine patients were hypertensive (mean number of anti-hypertensive agents: 3). Two patients had chronic renal failure (serum creatinine levels: 192 and 205 µmol l(-1)). All arteries except one with Takayasu disease were affected by dysplastic aneurysm or fibrodysplasia lesion. There was no atherosclerotic lesion. The mean number of renal artery branches repaired was 3.1 per patient. Mean duration of ischaemia was 161 min. RESULTS: Creatinaemia increased in all patients following the procedure. Creatinaemia and clearance returned to preoperative values between the 3rd and 10th postoperative days. One kidney was lost due to renal vein thrombosis. Late findings indicated that renal function was stable and there was no deterioration in the function of the autotransplanted kidneys after a follow-up period of 89 months. Preoperative versus postoperative creatinaemia and clearance levels were respectively 111 vs. 105 µmol l(-1) and 66.9 vs. 62.0 ml min(-1) (ns). During the same time, the mean number of anti-hypertensive agents decreased slightly from 3 to 2.5. CONCLUSION: In this small series of patients who underwent ex vivo repair and autotransplantation on solitary kidneys, intra-operative renal ischaemia had no detrimental effect on renal function.

Incidental visceral and renal artery stenosis in patients undergoing coronary angiography.

PURPOSE: The study aimed to examine the association between incidentally discovered mesenteric artery stenosis, renal artery stenosis (RAS) and coronary artery disease in patients undergoing coronary angiography. MATERIALS AND METHODS: We performed a prospective analysis of consecutive patients undergoing routine cardiac catheterisation. Abdominal aortograms in lateral and antero-posterior view were obtained to assess arterial stenosis of the coeliac axis, superior mesenteric artery and renal arteries. Significant arterial stenosis was defined as a narrowing of at least 50% compared with the normal artery. Demographic data and cardiovascular risk factors were analysed. RESULTS: The prevalence of visceral artery stenosis (VAS) was 63/450 (14%) including 48/450 (10.6%) cases of coeliac axis stenosis and 15/450 (3.3%) cases of superior mesenteric artery stenosis. Female sex (p = 0.01), older age (p = 0.03) and the presence of coronary artery disease (p = 0.05) were significant predictors for the presence of VAS in univariate analysis. The determinants for VAS in multivariate analysis were female sex and three-vessel coronary artery disease, while two- and three-vessel coronary artery disease was significant for RAS. CONCLUSION: Screening for VAS and RAS in female patients older than 60 years with more than two diseased coronary segments could have a high diagnostic value.

Bypass to the perigeniculate collateral arteries: mid-term results.

PURPOSE: The purpose of this report is to present mid-term results of infrainguinal revascularizations using either the highest genicular artery or medial sural artery as the distal anastomosis site. MATERIAL AND METHODS: Between 1996 and 2005, a total of 59 bypass procedures to perigeniculate collateral arteries were performed in 57 patients (14 women, 43 men) with a mean age of 74. Fifty five patients presented with critical ischemia (tissue loss in 28 and rest pain in 27). Four patients presented with intermittent claudication. Mean ankle brachial index was 0.48. The distal anastomosis site was the highest genicular artery in 18 patients, medial sural artery in 37 cases, highest genicular and/or medial sural artery and/or tibial artery in sequential fashion in four cases. The proximal anastomosis was to the common femoral artery in 26 cases and superficial femoral artery in 33. RESULTS: There were two deaths during the immediate postoperative period. Mean follow-up duration was 35 months (range 1-108 months). One patient was lost to follow-up. Six patients required major amputation. At 3 years, primary patency was 65+/-7%, secondary patency was 70+/-7%, limb salvage and survival rate were 90+/-4% and 64+/-7% respectively. CONCLUSION: Bypass to perigeniculate collateral arteries provides acceptable patency and limb salvage rates.

Risk factors for systemic emboli in infective endocarditis.

A retrospective study was undertaken to analyse the risk factors for systemic emboli in infective endocarditis. Patients (n = 80; 70% males; mean age 65 years; range 20-91 years) with infective endocarditis, as defined by the Duke criteria and diagnosed using transoesophageal echocardiography during the period January 1995 to March 2001, were included. The average time between the start of the illness and the beginning of antibiotic treatment was 55 days (range 0-405 days). The pathogens identified were streptococci (n = 47), staphylococci (n = 11), enterococci (n = 9), and others (n = 4). In nine cases, blood cultures were sterile. Thirty patients with at least one embolic episode were compared with 50 control patients. According to univariate analysis, the main risk factor for systemic emboli was the size of the vegetation (12.4 mm vs. 7.8 mm; p = 0.0005). The risk of emboli was 57% when the vegetation measured > 10 mm and only 22% when it was < 10 mm (p = 0.003). The mobility of the vegetation was also a risk factor: 48% if the vegetation was mobile; and 9% if fixed (p = 0.003). Sex, age, pathogen, antibiotic treatment, type of valve and the number and position of the vegetations were not found to be risk factors. With multivariate analysis, only mobility was identified as a risk factor. Overall, mobile vegetations > 10 mm in size were associated with an increased risk of embolic episodes in infective endocarditis.

Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms.

The objective of this report was to analyze the current surgical results of operative treatment in patients suffering ruptured AAA (abdominal aortic aneurysms) and to define those independent predictive factors for mortality. During a period of 2 years, from January 1996 to December 1997, 144 patients operated on for ruptured AAA in 10 hospitals were included in a multicenter retrospective study. Among the collected variables concerning each patient, those with potential relation to surgical mortality were studied: gender, age, diabetes, hypertension, cardiopathy, pulmonary obstructive disease, preoperative renal dysfunction, symptomatic cerebrovascular disease, peripheral vascular disease, hematocrit on admission, preoperative hypotension < 80 mmHg, loss of consciousness, cardiac arrest, aortic aneurysm location (infrarenal versus non-infrarenal), iliac involvement, aneurysm size, type of rupture, left renal vein ligature, ligature of a patent inferior mesenteric artery, place of aortic cross-clamping, type of grafting, exclusion of both hypogastric arteries, venous technical complications, associated surgery, use of cell saver, intraoperative blood loss, and postoperative complications (renal failure, sepsis, coagulopathy, cardiac complications, pulmonary complications, colon ischemia, prosthetic graft complications, and need for reoperation). Those variables with statistical significance in the univariate analysis were introduced into a multivariate logistic regression model to determine the independent predictors of death. From our results we concluded that surgery for ruptured abdominal aortic aneurysms continues to have an excessively high mortality rate. Even though some preoperative variables could be identified as predictors of mortality, an absolute mortality risk has not yet been determined and the decision to negate surgery should be individualized rather than taken on that basis only. Early diagnosis and treatment of symptomatic aneurysms would improve mortality figures and selective screening should be contemplated.

[Two new cases of cardiac papillary fibroelastoma with ischemic stroke]. / Deux nouveaux cas de fibroélastome papillaire cardiaque responsable d'accident vasculaire ischémique.

A 22 and 25 year-old man were admitted to our emergency care unit for a stroke of the left superficial middle cerebral artery territory and vertebrobasilar infarction. Complete assessment of ischemic attack retained, in both cases, the presence of a valvular cardiac tumor. After heparin treatment, surgery confirmed the data provided by echocardiography. Histology confirmed the diagnosis of a papillary fibroelastoma. The diagnosis of cardiac tumors is based on transthoracic echocardiography and transesophageal echocardiography (TEE). High definition TEE allows localizing the tumor and determining its relationship with the contiguous anatomical structures. TEE is also a better guide for surgical procedure. Echocardiography is essential in the management of cerebral ischemic attacks in young patients.

Long-term results of arterial allograft below-knee bypass grafts for limb salvage: a retrospective multicenter study.

PURPOSE: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centers where AAs were used for infrainguinal reconstruction in limb-threatening ischemia. METHODS: Between 1991 and 1997, 165 AA bypass procedures were performed in 148 patients (male, 90) with a mean age of 70 years (range, 20-93 years). Indications for operation were rest pain in 54 cases and tissue loss in 111 cases. Mean resting ankle pressure was 53 mm Hg in 96 patients who did not have diabetes and mean transcutaneous pressure of oxygen was 10 mm Hg in 52 patients who did have diabetes. In 123 cases (75%), there was at least one previous revascularization on the same limb. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 cases, and to a pedal artery in 17 cases. RESULTS: At 30 days, the mortality rate was 3.4%; the primary patency rate was 83.3%; the secondary patency rate was 90%; and the limb salvage rate was 98%. During follow-up (mean, 31 months), 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16 cases, graft degradation in 10 cases (four dilations, three stenoses, two ruptures, and one dissection), miscellaneous in eight cases, and not known in 16 cases. Primary patency rates at 1, 3, and 5 years were, respectively, 48.7% +/- 4%, 34.9% +/- 6%, and 16.1% +/- 7%. Secondary patency rates at 1, 3, and 5 years were, respectively, 59. 8% +/- 4%, 42.1% +/- 5%, and 25.9% +/- 8%. Limb salvage rates at 1, 3, and 5 years were, respectively, 83.8% +/- 3%, 76.4% +/- 5%, and 74.2 % +/- 8%. CONCLUSION: AA leads to an acceptable limb salvage rate but poor patency rates. A randomized trial that will compare AAs and polytetrafluoroethylene should be undertaken.

Vascular surgical society of great britain and ireland: mid-term results of arterial allograft below-knee bypasses for limb salvage

BACKGROUND: Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischaemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centres where AAs were used for infrainguinal reconstruction in critical limb ischaemia. METHODS: Between 1991 and 1997, 165 AA bypasses were performed in 148 patients (90 men) with a mean age of 70 (range 20-93) years. Indications for operation were rest pain in 54 patients and tissue loss in 111. Mean resting ankle pressure was 53 mmHg in 96 non-diabetic patients and mean transcutaneous partial pressure of oxygen was 10 mmHg in 52 diabetic patients. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 and to a pedal artery in 17. RESULTS: At 30 days, the mortality rate was 3 per cent, primary patency 83 per cent, secondary patency 90 per cent and limb salvage rate 98 per cent. During follow-up (mean 31 months) 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16, graft degradation in ten (four dilatations, three stenoses, two ruptures and one dissection), other causes in eight and not known in 16. Primary and secondary patency rates at 3 years were 35(s.e. 9) per cent and 42(s. e. 10) per cent. The limb salvage rate at 3 years was 76(s.e. 8) per cent. CONCLUSION: AAs lead to a good foot salvage rate but poor patency rates. The results are similar to those obtained with polytetrafluoroethylene grafts.

Bypass to the perigeniculate collateral vessels. A useful technique for limb salvage: preliminary report on 22 patients.

PURPOSE: We describe our initial experience with the use of perigeniculate vessels as outflow tracts in infrainguinal revascularizations for critical limb ischemia. METHODS: Twenty-two such reconstructions were carried out in 20 patients over a 2-year period. Indications for surgery consisted of tissue loss in 9 patients and rest pain in the other 13 patients. Inflow was obtained from the femoral vessels. A variety of graft materials were used, including saphenous vein (16 patients), polytetrafluoroethylene (2 patients), composite (1 patient), and arterial homografts (3 patients). The perigeniculate vessels used were the medial sural artery to the gastrocnemius (arteria suralis) in 16 patients and the highest genicular artery (arteria genu suprema) in the other 6 patients. These vessels were approached via a medial above-the-knee popliteal-type exposure. RESULTS: There were three postoperative deaths. Mean follow-up for the other 17 patients averaged 12 months (range, 3 to 37 months). Three grafts failed (thrombosis) during follow-up, leading to two above-the-knee amputations. One graft stenosis was treated with percutaneous angioplasty. The average postoperative increase in the ankle-brachial index was 0.20. CONCLUSION: These early results appear promising with a 1-year primary patency rate of 77%, assisted primary patency rate of 85%, and a limb-salvage rate of 90% according to the Kaplan-Meier life-table method. This technique is particularly useful when adequate length saphenous vein is not available, no other outflow vessels are available, or other outflow vessels are very calcified and not safely clamped. The continued study of the long-term effectiveness is warranted.

Residual inflammatory process after aortoiliac reconstructive surgery.

BACKGROUND: The aim of the present study was to investigate the inflammatory reaction and its evolution in patients who underwent a prosthetic vascular procedure. Moreover the participation of this chronic process, during the follow-up, as a promoting or a consequence of vascular injury must be discussed. METHODS: Thirty-four patients were enrolled in the study. All patients had an aortic disease and underwent a prosthetic vascular procedure. Preoperative exclusion criteria were an emergency situation, diabetes, infection, chronic inflammatory disease, cancer and hemopathy. Postoperative exclusion criteria were the same together with abdominal complications and additional surgery during the follow-up. The inflammatory process was investigated with the measurement of blood acute phase proteins, haptoglobin, alpha1-glycoprotein acid, C-reactive protein and interleukin-6, before, immediately after surgery and several months after surgery. RESULTS: An increase in acute phase proteins was not observed to the same extent for all the studied patients. Before the surgical procedure, chronic inflammatory process was revealed by an increase in haptoglobin (52.9 p 100) and alpha1 glycoprotein acid (52.9 p 100) whereas increase in C-reactive protein (26.4 p 100) and interleukin-6 (92 p 100) are related to an acute process. Later after surgery, the chronic inflammatory process remained but differed from the observed process before surgery only by haptoglobin (61.7 p 100) and interleukin-6 (47 p 100). CONCLUSIONS: The presented results, observed during the follow-up of vascular surgery focused on persistent inflammatory process and the surgical procedure did not modify the time course of this process. The evolutionary disease could be considered as chronic and independent of the local effect.

[An unusual cause of aorto-bronchial fistula: tuberculosis aortitis]. / Une cause rare de fistule aorto-bronchique: l'aortite tuberculeuse.

The aortic rupture in the pulmonary parenchyma or the bronchi rarely results in an haemoptysis. It means in most of the cases the rupture of an aortica aneurysm. We relate the observation of a aorto-bronchial fistula from a tuberculosa origin in an old woman case. Although the tuberculosa aortitis is becoming very exceptional, it still remains the cause of aorta rupture, with the formation of a false aneurysm which is rapidly fatal and so, it is important to search for it before any capricious haemoptysis.

Mechanical characteristics of fresh and frozen human descending thoracic aorta.

In this study, mechanical characteristics of descending thoracic aorta were evaluated after preservation at +4 degrees C in EuroCollins solution or after programmed cryopreservation with 15% dimethylsulfoxide and compared to control segments. Arterial allografts were procured from multiple organ harvesting over a period of 2 years. All the segments were allowed to incubate in EuroCollins enriched antibiotics solution for 18 to 24 hr after harvest and were then tested as a control group or preserved at +4 degrees C in EuroCollins solution for 4, 7, 21, and 31 days or cryopreserved for 2 or 4 months. Each aorta was cut into parallel blades either in the radial or in the circumferential direction and mounted over a traction-compression apparatus for mechanical testing. Stress-strain characteristics indicated that no discernible differences were found between cryopreserved aorta and the control group. For those preserved at +4 degrees C a greater high strain modulus was noted for graft preserved for 21 and 31 days; however, this difference was not statistically significant. The authors concluded that cryopreservation did not alter the mechanical characteristics of arterial allografts procured from multiple organ harvesting.

Results of transluminal angioplasty of infra-popliteal arteries.

Transluminal angioplasty is rarely used to treat arterial diseases at leg level. During the last 5 years we have performed 25 distal artery angioplasties in 24 patients. Average age was 70 years, half of them were diabetics. Twenty patients had critical ischemia and 4 asymptomatic patients had critical stenosis distal to a previous patent infra-genicular bypass. Arteriography showed a single leg artery stenosis in 23 cases and a two distal artery stenosis in one case. No material other than guide wire was used to pass through the stenosis. All the dilation was performed in the operating room. Immediate results were good in 20 patients (21 stenosis). Four early failures occurred: one technical, one for progressive limb gangrene with secondary amputation, one postoperative thrombosis and one residual stenosis over 50%. Six patients had recurrent stenosis at mean 9 months. Five of them were treated with a new balloon angioplasty and the last with femoro-distal bypass. The 2 years cumulative primary and secondary patency rates were respectively 46 and 64%. With only guide wire and balloon catheters it is possible to treat distal artery lesions with rather good results.

Angioplasty of distal venous bypasses: is it worth the cost?

Saphenous vein is the best graft for long term patency infragenicular bypass. During follow-up, stenoses can appear on the graft. Is angioplasty a good solution for the treatment of these lesions? During the follow-up of 612 saphenous bypass with below-knee distal anastomosis, 90 stenoses (over 70%) were discovered. Among them 36 were treated with transluminal angioplasty (34 bypasses). Stenoses were detected at a mean follow-up of 7 months after bypass realization. They were located 17 times on the graft itself and 19 times near the anastomoses and they were never longer than 5 cm. Percutaneous approach was preferred for 11 cases and surgical for the others. Immediate success was obtained in 33 cases (91%). Among the 3 failed cases 2 needed a new bypass. Mean follow-up was 33 months after the initial bypass and 24 months after angioplasty. Graft patency was ensured by a single angioplasty in 18 cases. Assisted primary patency, cumulative patency, limb salvage rate were respectively 65%, 91%, 100% at one year and 53%, 72%, 96% at 2 years. Transluminal angioplasty can be advised for the treatment of short stenosis of infrainguinal vein graft: this technique has a weak risk, little surgical aggressiveness, short hospitalisation. Results are acceptable and not very different with the location of the stenosis.

[Pros and cons of use of collagenated arterial prostheses]. / Pour ou contre l'utilisation des prothèses artérielles collagénées.

Use of bovine collagen for collagen arterial grafts raises the problem of possible contamination with the agents causing subacute spongiform encephalopathy. The safety of these products is the confirmed by the manufacturers and the risk of contamination is practically zero. A prospective non-randomized study conducted from January 1991 to December 1992 compared non-impregnated arterial stents with collagen arterial stents. Among the parameters studied, only the amount of blood transfused was significantly different. Collagen arterial grafts generated less blood loss.

[Medical treatment of arm embolisms]. / Traitement médical des embolies du membre supérieur.

Emboli in the upper limb occur much less often than in other territories. They usually cause subacute ischaemia due to the importance of the arterial anastomotic network. Medical treatment is thus often sufficient. An analysis of the data in the literature show that medical treatment can give results comparable to surgery. Medical management should only be proposed as a complementary treatment when acute sensitivomotor acute ischaemia threatens the upper limb since priority must be placed on immediate restoration of the arterial flow.

Do collagen-impregnated knitted Dacron grafts reduce the need for transfusion in infrarenal aortic reconstruction?

The purpose of this study was to evaluate the benefits of collagen-impregnated Dacron grafts in patients undergoing infrarenal aortic reconstruction. We therefore prospectively compared two consecutive series of patients undergoing infrarenal aortic reconstruction with Dacron grafts between January 1991 and December 1992. The first group (group A) included 83 high-density knitted prosthetic grafts (Dialine I), whereas the second included 82 grafts of the same type but impregnated with collagen (Dialine II). The two groups were comparable with regard to age, sex, and operative risk factors. They were also comparable in terms of the proportion of patients with occlusive disease or aneurysms, that is, there were 39 and 36 patients with occlusive disease and 44 and 46 patients with aneurysms in groups A and B, respectively. The type of bypass was similar in both groups with 17 and 19 tubular grafts and 66 and 63 bifurcated grafts being inserted in groups A and B, respectively. Thirteen parameters were studied and compared within each group including (1) number of infected grafts, (2) number of postoperative occlusions, (3) maximum postoperative temperature, (4) number of positive postoperative blood cultures, (5) number of postoperative deaths, (6) intraoperative and (7) postoperative quantities of blood transfused, (8) difference between pre- and postoperative hemoglobin concentrations, (9) difference between pre- and postoperative fibrinogen levels, (10) difference between pre- and postoperative platelet counts, (11) duration of aortic clamping, (12) date of return of intestinal function, and (13) mean duration of pre- and postoperative hospital stays.(ABSTRACT TRUNCATED AT 250 WORDS)