Treatment of TASC C and D Femoropoliteal Lesions with Paclitaxel eluting Stents: 12 month Results of the STELLA-PTX Registry.

OBJECTIVE: The aim was to evaluate the safety and the efficacy of primary stenting with paclitaxel eluting stents for TASC C and D femoropopliteal lesions. METHODS: Patients with TASC C/D de novo femoropopliteal lesions were treated by implanting paclitaxel eluting stents. Patients were included in a single center registry and prospectively followed by clinical and ultrasound evaluation. X-ray of the stented zone was systematically performed 12 months after implantation. The primary endpoint was primary sustained clinical improvement after 12 months. RESULTS: A total of 45 patients (48 limbs) suffering from claudication (25 limbs) or CLI (23 limbs) were enrolled. Lesions were either TASC C (28 limbs) or TASC D (20 limbs). The mean length of the treated segment was 252 ± 90 mm. The mean number of stents was 2.9 ± 1 (2-5). Mean follow up was 12.7 months. No patient was lost to follow up. At 1 year post procedure, primary and secondary sustained clinical improvements were 56.3 ± 7.4% and 80.1 ± 5.9% respectively. Freedom from target lesion and target extremity revascularization were 63.6% and 90.1%, respectively. Primary and secondary patency rates were 52.5% and 79.6%. One year primary sustained clinical improvement rates for TASC C/D were 63.3 ± 9.2% and 45.6 ± 11.7%, respectively (p = .34). One year primary sustained clinical improvement rates for claudication/CLI patients were 68 ± 9.3% and 41.6 ± 11.1%, respectively (p = .13). The incidence of in stent re-stenosis and in stent thrombosis were 25% and 14%, respectively. The incidence of stent fracture was 12.5% on a limb basis and 9% on a per stent basis. CONCLUSIONS: The paclitaxel eluting stent did not achieve its goal in terms of prevention of in stent re-stenosis for TASC C/D femoropopliteal lesions. It requires frequent re-interventions during the first year to maintain satisfactory clinical results.

State-of-the-art treatment of common femoral artery disease.

Atherosclerotic common femoral artery (CFA) disease is a well-known and frequent cause of symptomatic peripheral artery disease (PAD). Not so long ago, surgical treatment was considered the gold standard and the main treatment option. Therapeutic advances have, however, provided a wide and suitable armamentarium. These advances concern medical treatment and the direct treatment of lesions by open surgery or endovascular treatment. The aim of this manuscript was to summarize therapeutic updates and to describe the current endovascular and open surgical procedures used to treat common femoral artery disease.

Incidence and the clinical impact of stent fractures after primary stenting for TASC C and D femoropopliteal lesions at 1 year.

BACKGROUND: The clinical impact of stent fractures is still controversial. This study analyzed the incidence and the clinical impact of stent fractures after stenting of long femoropopliteal lesions. METHODS: From November 2008 to October 2009, 58 patients (62 limbs) were treated in a single center with a primary nitinol self-expanding stent for Trans-Atlantic Inter-Consensus (TASC) C and D de novo femoropopliteal lesions. Patients were prospectively followed by medical and duplex scan examinations. Stent fractures were assessed by biplane X-rays at 12 months. Logistic regression analysis was performed. RESULTS: At 1 year a complete follow-up was obtained in 42 limbs/90 stents. The median length of the stented segment was 240 ± 180 cm with a mean of 2.1 (1-4) stents per patient. Sixteen stents (17.8%) were fractured: one type I (asymptomatic); seven type II (2 restenosis); five type III (asymptomatic), and three type IV stent fractures (1 restenosis). Stent diameter (p = .04) and stent implantation in the distal part of the superficial femoral artery (p = .05) were positively associated with stent fractures. Stent fracture had no influence on restenosis. CONCLUSION: This study suggests that the high stent fracture rate associated with endovascular treatment of long femoropopliteal lesions should be balanced with its low clinical impact.

One-year clinical outcome after primary stenting for Trans-Atlantic Inter-Society Consensus (TASC) C and D femoropopliteal lesions (the STELLA "STEnting Long de L'Artère fémorale superficielle" cohort).

OBJECTIVE: The study aims to evaluate the safety and the efficacy of primary stenting for Trans-Atlantic Inter-Society Consensus Document II on Management of Peripheral Arterial Disease (TASC) C and D femoropopliteal lesions. DESIGN: Prospective cohort study. METHODS: Patients with TASC C and D de novo femoropopliteal lesions were treated with the same endovascular technique by implanting a primary nitinol self-expanding stent (LifeStent(®), Bard Peripheral Vascular, Tempe, AZ, USA). Patients were included in a single-centre registry and prospectively followed up. The primary end point was primary sustained clinical improvement after 12 months. Secondary end points were secondary sustained clinical improvement, primary and secondary patency rates, freedom from target lesion revascularisation (TLR), freedom from target extremity revascularisation (TER) and stent fracture rate. RESULTS: We enrolled 58 patients (62 limbs) suffering from either claudication (40.3%) or critical limb ischaemia (59.7%). Lesions were either TASC C (62.9%) or TASC D (37.1%). Median length of the treated segment was 220 ± 160 mm. The mean number of stents was 2.2. Mean follow-up was 17 months, with one patient lost to follow-up. At 1 year, the primary end point was 68.6% while secondary sustained clinical improvement was 82.6%. Freedom from TLR and TER rates were 81.1% and 96.3%. Primary and secondary patencies were 66% and 80.9%. One-year primary and secondary sustained clinical improvement rates were 76.7% ± 7.2 for TASC C and 46.3% ± 11.1 for TASC D (p = 0.03) and 87.6% ± 5.9 for TASC C and 67.3% ± 11.3 for TASC D (p = 0.09), respectively. The ankle-brachial pressure index increased from 0.58 to 0.94 (p = 0.001) at 1 year and the incidence of in-stent restenosis (ISR) was 19.3%. Stent fracture and disconnection rate was 17.7%. CONCLUSIONS: Primary stenting of TASC C and D lesions appears to be safe and efficient given the high-sustained clinical improvement and the low rate of ISR observed in our study. Endovascular treatment of such long and severe lesions exposes to high rate of stent fractures, which should not be a concern given their low clinical impact.

Endovascular repair of common femoral artery and concomitant arterial lesions.

OBJECTIVE: The common femoral artery (CFA) is an unusual location for endovascular repair (ER). We report the early results after ER of the CFA in a single centre. DESIGN: This is a cohort study. MATERIALS/METHODS: From 2006 to 2008, ER of the CFA was proposed to 36 patients (mean age 67.9, range 51-92). CFA lesions were classified into four types: in type I, lesions were located at the iliac external artery and were extended to the CFA; in type II, lesions were limited to the CFA; in type III, lesions were located at the CFA and its bifurcation; type IV represents restenosis bypass anastomosis. All patients were treated by stenting. RESULTS: Indications for ER of the CFA included 25 patients (70%) for claudication and 11 patients (30%) for critical limb ischaemia. Forty-three stents were implanted. The mean follow-up was 22 months (range, 12-42). At 1 year, primary and secondary sustained clinical improvements were 80% and 90%; target lesion revascularisation and target extremity revascularisation free cumulative survival were 85% and 80%, respectively, and in-stent restenosis rate was 20%. One stent fracture was noted. CONCLUSIONS: ER of CFA and concomitant arterial lesions seems to be a safe technique with acceptable clinical outcome at 1 year.

[Thrombophlebitis of the right ovarian vein with thrombosis of the inferior vena cava]. / Thrombose de la veine cave inférieure par thrombophlébite de la veine ovarienne droite.

A 39-years-old woman was admitted with pelvic pain and fever occurring one month after a caesarean. An echography-doppler and an abdominal tomodensitometry were performed. Thrombophlebitis of the right ovarian vein was diagnosed with extension of a floating thrombus into the inferior vena cava. We decided to perform a surgical thrombectomy due to a pulmonary embolism which occurred while the patient was under heparin and antibiotic treatment. A temporary percutaneous caval filter was successfully used in the peri-operative period, preventing a second embolism. This observation focuses on a rare pathology occurring in young women and emphasises the safe use and removal of a temporary percutaneous caval filter in the peri-operative period.

Transesophageal echocardiography diagnosis of tricuspid obstruction by a vena cava tumour.

PURPOSE: To present the anesthetic management for excision of a primary tumour of the inferior vena cava. CLINICAL FEATURES: Resection of a primary tumour of the inferior vena cava without extension to the right atrium was scheduled without extra-corporeal circulation (ECC). The operation consisted of tumour excision with transtumoral clamping. During the immediate postoperative period, tricuspid obstruction was suspected when a "cannon a wave" was recorded from the right atrial pressure curve. Transesophageal echocardiography confirmed the diagnosis of tumour obstruction of the tricuspid valve. CONCLUSION: Tricuspid obstruction due to postoperative mobilization of a primary tumour of the inferior vena cava was diagnosed by transesophageal echocardiography. Perioperative management particularities of the primary tumour of the vena cava are discussed.

Infected aneurysms of neck and limb arteries: a retrospective multicenter study.

Infected aneurysms (IA) of neck and limb arteries are uncommon. This report describes the results of a retrospective study undertaken by the University Association for Surgical Research (AURC) to evaluate etiology, bacteriology, location, diagnostic features, and therapeutic methods associated with IA. A total of 58 IA in 52 patients were reviewed. The lesion was located in a lower extremity artery in 47 patients (81%), internal carotid artery in 7 (12%), and upper extremity artery in 4 (6%). Eleven patients had multilocular aneurysm (21%). Symptoms of local infection were observed in 43 patients (82.6%). Rupture or splitting was the presenting manifestation in 13 patients (25%). Primary IA following bacteremia or septicemia without endocarditis was the most common type of IA observed in 34 patients (65.3%). Twelve patients (23%) presented mycotic IA secondary to bacterial endocarditis. In the remaining six patients (11.5%), IA resulted from direct contamination or spreading from a contiguous infection site. Surgical treatment included ligation of the artery without reconstruction in 19 patients and exclusion bypass in 33 patients. The duration of antibiotic treatment ranged from 15 days to 3 months. No recurrence of aneurysm was observed but three patients developed bypass infection. Primary IA was associated with high mortality due to severe septicemia.

Rupture of internal iliac artery aneurysm into the bladder following aortic aneurysm repair.

This report describes a case of ruptured internal iliac artery aneurysm into the bladder after repair of an infrarenal abdominal aortic aneurysm. Aortic repair consisted of resection of the aneurysm followed by prosthetic interposition to reestablish arterial continuity. During the postoperative period, the patient had ischemia of left colon, which was successfully treated by the Hartmann procedure. A right internal iliac artery aneurysm measuring 50 mm in diameter was demonstrated by an abdominal CT scan during the initial hospitalization but was considered stable, since ultrasonography showed no change in diameter at 3 months and 1 year. The patient was lost from follow-up until 3 years later when he was hospitalized after rupture of the right iliac artery aneurysm, then measuring 120 mm in diameter, into the bladder. Surgical repair was undertaken. The procedure involved aortobifemoral bypass with suture of the bladder defect and branches of the internal iliac artery by the endoaneurysmal route. Postoperative recovery was uneventful. Upon reexamination 1 month after discharge from the hospital, the patient was asymptomatic. This rare case confirms the gravity of internal iliac artery aneurysm and the importance of therapeutic management to prevent rupture.

Popliteal artery thrombosis secondary to exostosis of the tibia.

This report describes an exceptional case of popliteal artery thrombosis secondary to exostosis of the superior extremity of the superior tibia in a young adult. Correct diagnosis was made during re-operation for recurrent thrombosis. Surgical treatment consisted of resection of the bony tumor and venous bypass to reestablish arterial continuity. Femoropopliteal vascular complications of exostosis are rare, with most cases involving arterial aneurysms or false aneurysms. Differential diagnosis in our young patient took into account the other causes of popliteal thrombosis: entrapped popliteal artery, adventitious cyst, fibrodysplasia, and juvenile arteriopathy. In patients with major functional disability, operative treatment is recommended to remove the bony abnormality and repair the arterial lesion.

Influence of respiratory disease on perioperative cardiac risk in patients undergoing elective surgery for abdominal aortic aneurysm.

We retrospectively reviewed perioperative cardiac complications in a series of 214 patients who underwent surgical treatment for infrarenal aortic aneurysm between 1992 and 1996. There were 192 men and 22 women, with a mean age of 68.3 years. Cardiac risk factors included angina in 28% of patients and previous myocardial infarction in 25%. Resting electrocardiography was normal in 80 patients (37.5%). Depending on clinical findings, thallium-201 scintigraphy was undertaken in 76 patients (35.5%) and led to elective coronary arteriography in 22 patients (10%). Results of coronary arteriography revealed lesions in 14 patients. Aortic reconstruction was performed by the transperitoneal route in all patients. Procedures consisted of aortoaortic bypass (63%), aortobiiliac bypass (27.5%), or aortobifemoral bypass (9.5%). Nine patients (4.2%) died within the first 30 postoperative days. The cause of death was myocardial infarction (MI) in two patients (1%), colonic necrosis in two (1%), acute pancreatitis in one (0.5%), acute renal insufficiency in three (1.4%), and multiple organ failure in one patient (0.5%). Nonfatal cardiac complications were observed in 15 patients (7%). Statistical analysis of risk factors revealed two predictors of perioperative cardiac complications, i.e., history of chronic bronchitis and reoperation. On review of the literature, we cannot propose a routine preoperative work-up. Prospective multicentric studies are needed to determine the predictive value of current preoperative screening methods.

Intraoperative autotransfusion for repair of unruptured aneurysms of the infrarenal abdominal aorta. A multicenter study of 203 patients. Association Universitaire de Recherche en Chirurgie (AURC).

BACKGROUND: The goals of this study were to evaluate the costs and savings of intra- and postoperative blood transfusions as well as the potential biological modifications associated with the use of intraoperative blood salvage. METHODS: Intraoperative autotransfusion (IOAT) with wash-out was prospectively studied during the repair of unruptured aneurysms of infrarenal abdominal aorta in 203 patients operated on in 13 institutions. RESULTS: The mean quantity of blood retrieved was 688+/-468 mL The mean quantity of blood derivatives and intraoperative solutes used for repletion was 4,261 ml, ranging from 1,723 ml between days 0 to D2 to 562 ml from D3 to D8. Ninety-eight patients did not receive any blood derivatives at all. Thirty-five patients received plasma to correct coagulation factors. The quantity of autotransfused globular concentrate was less than 500 ml in 89 patients. CONCLUSIONS: IOAT precluded the need for transfusion of homologous globular concentrates, particularly in those patients who had bled most. On average, more than two globular concentrates were recuperated. Use of IOAT led to financial savings. Perioperative bleeding is not the only factor that intervenes in the decision to transfuse globular concentrates. Postoperative dilution is the most important factor as attested by the amount of protides and the hematocrit. Coagulation factors are modified but remain compatible with normal hematosis in 83% of patients undergoing operation.

Spontaneous dissection of the celiac artery.

We describe a case of intestinal angina caused by spontaneous dissection of the celiac artery and thrombosis of the superior mesenteric artery. Spontaneous dissection of a visceral artery is an uncommon occurrence that is usually diagnosed after fatal hemorrhage or ischemia. The underlying mechanism is unclear but the frequent association with multiple arterial lesions suggests general arterial disease. In symptomatic forms, surgical reconstruction is mandatory, to treat the lesion and allow definitive histological diagnosis.

Bilateral extracranial aneurysms of the internal carotid artery. A case report.

The authors report a case study of bilateral extracranial atherosclerotic aneurysms of the internal carotid artery, discovered simultaneously in a 58 year-old man. The patient had previously undergone polyarterial surgery for a subrenal abdominal aortic aneurysm 11 years earlier. The operation was performed in two stages with a few days interval, with an identical procedure on each side: under general anesthesia, resectioning of the aneurysm, restauration of the arterial flow by an internal saphenous venous graft between the internal and common carotids, and repositioning the external carotid. The surgical follow-up was uneventful. Extracranial aneurysms of the internal carotid artery are rare, although well-documented. To be found bilaterally, as in our case, is exceptionally unusual. The seriousness and the frequency of complications from internal carotid artery aneurysms indicate that surgical treatment is warranted.

Arterial pressure and neurologic morbidity during carotid surgery under peridural anesthesia.

In 163 carotid reconstructions under peridural anesthesia performed from 1988 to 1991, we routinely measured residual systemic and carotid artery pressure during clamping. Seventy-nine patients (48.5%) were asymptomatic and 84 (51.5%) had a history of neurologic manifestations in the form of transient ischemic attacks (28%) or stroke (13.5%). None of the patients died perioperatvely. Eight patients (4.9%) had strokes, with complete recovery in five. A shunt was placed in 22 patients (13.5%) because of neurologic evidence that carotid clamping was poorly tolerated. This study showed a distinct association between residual pressure in the internal carotid artery and systemic arterial pressure and intraoperative neurologic morbidity. Using a cutoff value of 35 mm Hg for residual pressure, the sensitivity was 77% and specificity 81%. Using a cutoff of 80 mm Hg, the sensitivity was 60% and specificity 86%. There was no correlation between mean systemic arterial pressure and residual carotid artery pressure. The use of a shunt was the only factor with predictive value for postoperative neurologic complications. These findings suggest that measurement of systemic arterial pressure and residual carotid artery pressure is useful during carotid surgery, but further study is needed before this information can be extrapolated to carotid surgery under general anesthesia.

[Evaluation of a computer graphic representation of echo-Doppler (Echotrace) in the assessment of atherosclerosis of the legs]. / Evaluation d'une représentation graphique de l'écho-Doppler (Echotrace) dans le bilan de l'athérosclérose des membres inférieurs.

The problems generally encountered in interpreting written reports of echo-Doppler examinations led us to develop a graphic software system to visualize the vascular network: Echotrace. The objective of the present work was to evaluate the reliability of Echotrace in patients with atherosclerosis of the lower limbs using arteriography as the standard for assessing sonographic findings. This prospective study was conducted in 29 consecutive patients. Nineteen strategic sites of the arterial network were investigated with duplex-scan and arteriography: lesions scores were attributed for each examination and data for a given site were compared. On the 551 sites compared, we found 26 disagreements including 23 concerning lesion quantification and 3 on localizations. There were also 21 minor disagreements with a single variation in the pathology score. The statistical comparisons could not be made on these scores so the results were compared with the arteriography data on the basis of therapeutic decision taking into account all the arterial lesions and the patient's general status. We observed a perfect agreement between the two imaging techniques in 12 patients, one disagreement which would not change the treatment in 15 patients and, in 2 patients, a disagreement which would modify treatment. This study demonstrated that graphic visualization of arterial lesions with Echotrace is a reliable, easy-to-interpret method.

[Blood salvage: decisive progress in vascular surgery]. / Récupérateurs de sang: un progrès décisif en chirurgie vasculaire.

There are two different methods of autotransfusion during an operation; one without blood washing and the other with wash red cells obtained after the filtering and concentration of the recovered blood. The first method has the advantage of being simple and cheap while recovering 1500-2000 ml of blood. Nevertheless it is insufficient in the case of an important or rapid bleeding. The weight of haemoglobin in the recovered blood is relatively low and the hemolysis is without clinical consequences. The rate of the coagulation factors is reduced. The autotransfusion with wash red cells requires a more important investment at the beginning. But the washing process eliminates the cell micro-aggregates and nearly all of the substances in the recovered blood. Therefore concentrated units of red cells may be obtained with hematocrits between 45 and 65%. Autotransfusion with washing offers a greater security when the bleeding is important or violent. The autotransfusion is useful for a bleeding between 1 and 3 litres. The average volume recovered corresponds to 2.5 pockets of blood extract, thus covering the costs for the kits. If the bleeding exceeds 1.5 times the blood volume, blood extract and plasma will be required in addition. The risk of homologue blood transfusion can only increase the development of autotransfusion techniques and particularly the recovery of blood during the operation process.

[Diagnosis of venous thrombosis. Evaluation of immunoscintigraphy with 99M technetium labelled antifibrin]. / Diagnostic des thromboses veineuses. Evaluation de l'immunoscintigraphie antifibrine marquée au technétium 99m.

OBJECTIVES: We evaluated the interpretation, reliability and usefulness of 99m technetium labelled antifibrin immunoscintigraphy for the diagnosis of deep vein thrombosis in the lower limbs. METHODS: The diagnostic value of 99m technetium labelled antifibrin immunoscintigraphy was assessed in 44 patients with suspected venous thrombosis. The reference examination was bilateral ascending phlebography; 40 patients had doppler ultrasonography of the veins; 0.5 mg of antibody labelled by 17.5 mCi on average of 99m technetium were injected intravenously, and serial scintigraphic images were collected 1 min, 90 min and 18 hours after injection. RESULTS: The best results were obtained by comparison between the 90 min and the immediate post-injection images, with 86 percent sensitivity, 73 percent specificity and 81 percent accuracy. Heparin therapy and past history of phlebitis had no influence on the results. The doppler ultrasonography/immunoscintigraphy combination had a 100 percent specificity. 99m Technetium labelled antifibrin immunoscintigraphy had about the same diagnostic value as 111 indium labelled antifibrin immunoscintigraphy. CONCLUSION: The introduction of 99m technetium as isotopic marker will make immunoscintigraphy easier and available in numerous nuclear medicine centres. Antifibrin immunoscintigraphy can be an additional diagnostic tool for the difficult diagnosis of deep vein thrombosis.

[Coarctation of the subrenal abdominal aorta revealed by aortic thrombosis]. / Thrombose de l'aorte révélatrice d'une coarctation de l'aorte abdominale sous-rénale.

The authors report the case of a 44 year-old female patient with no particular history who presented with a suddenly occurring severe ischemia of the lower limbs during exercise which revealed a total thrombosis of the subrenal abdominal aorta. Angiography confirmed the diagnosis and demonstrated a partial compensation of the lesion by an important collateral network developed from the parietal and mesenteric arteries. Ultrasonography and computerized tomography showed an extensive coarctation of the abdominal aorta. The main visceral (particularly renal) arterial branches were not involved. The pathologic subrenal aortic segment was surgically resected, and a prosthetic aortobifemoral bypass provided. The further course was marked by several occlusions of the low anastomoses by fibrous hyperplasia. Coarctation of the abdominal aorta is briefly reviewed. This disorder is infrequent, and its infrarenal form can be compatible with a normal life. It can be revealed late, particularly when a thrombotic complication occurs.