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.

Editor's choice--hybrid treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms: a multicenter retrospective study.

OBJECTIVES: The aim of this study was to assess the results of hybrid techniques for the treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms based on multicenter results and the various series regarding hybrid procedures reported in the literature. METHODS: The results of 76 hybrid procedures performed in 19 French university hospital centers between November 2001 and October 2011 were collected. There were 50 men and 26 women, mean age 68.2 (35-86) years. All patients were considered at high risk (ASA≥3) for conventional surgery. Aneurysms involved the thoracic, abdominal, and thoracoabdominal aorta in five, 14, and 57 cases respectively. There were 11 emergent repairs. The revascularization of four visceral arteries was performed in 38 cases. Between one and three visceral arteries were revascularized in the other cases. Visceral artery debranching and stent graft deployment were performed in a one-stage procedure in 53 cases and in a two-stage procedure in 23 cases. RESULTS: There were 26 (34.2%) postoperative deaths. Nine of the survivors developed paraplegia, of which one resolved completely. Bowel ischemia occurred in 13 cases (17.1%), and one patient was treated by a superior mesenteric artery bypass. Four patients required long-term hemodialysis. Postoperative computed tomography scan showed a type II endoleak in two patients. CONCLUSIONS: Morbidity and mortality in this study were greater than previously reported. Candidates for hybrid aortic repair should be carefully selected.

Prognostic value of preoperative border-zone (watershed) infarcts on the early postoperative outcomes of carotid endarterectomy after acute ischemic stroke.

OBJECTIVES: To evaluate the prognostic value of cerebral border-zone infarctions (watershed infarctions) on the early postoperative outcomes of patients undergoing carotid endarterectomy (CEA) after acute ischemic stroke (AIS). METHODS: Sixty-six (66) patients with symptomatic carotid stenosis (SCS) that underwent ipsilateral CEA after AIS from January 2007 to March 2012 were included in this study. They were divided into two groups according to the topographic patterns of the stroke: group 1, Territorial Cerebral Ischemic Strokes (TCIS) caused by emboli of carotid origin; group 2, cerebral border-zone infarctions (CBZI) related to an SCS associated with hemodynamic impairment. All data was collected in a prospective database and analyzed. Outcome measures included postoperative neurological morbidity and 30-day mortality. RESULTS: Forty-three (43) patients (65.15%) experienced TCIS and were included in group 1, 23 patients (34.85%) had a CBZI and were included in group 2. There were no postoperative deaths. The postoperative neurologic morbidity rate was significantly higher in the CBZI group (22% vs. 2%, p = 0.02). Multivariate analysis demonstrates that CBZI was the only independent predictive factor of neurologic morbidity after CEA for AIS related to an SCS. Furthermore, the risk of postoperative neurologic morbidity remained significantly higher for patients with CBZI after adjustment for age, sex, initial NHISS scores, and associated contralateral carotid occlusion (HR: 0.059, 95% CI 0.004-0.85; p = 0.03). CONCLUSION: CBZIs, compared to TCIS, were associated with a higher neurological complication rate during the postoperative period after CEA for SCS in cases of AIS. Further studies are required to better define the timing and the best treatment modality for patients with CBZI related to an SCS in order to reduce associated procedural complications.

Arm composite autogenous vascular access using the great saphenous vein and the femoral vein: results from a single-centre study.

OBJECTIVES: The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery. DESIGN: Retrospective single-centre study. Prospectively collected clinical database. METHODS: Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates. RESULTS: The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access. CONCLUSION: With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

A systematic literature review of the efficacy and safety of the Prostar XL device for the closure of large femoral arterial access sites in patients undergoing percutaneous endovascular aortic procedures.

OBJECTIVES: To identify and analyse existing evidence from published studies evaluating the efficacy and safety of a percutaneous vessel closure device for the closure of large arterial femoral arterial access sites (≥ 10 French). DESIGN: This study was a systematic literature review and meta-analysis. MATERIALS AND METHODS: Electronic databases were searched for studies published on the evaluation of the Prostar XL vessel closure device. There was no restriction by study design or patient population. Appraisal of studies for inclusion and data extraction were performed independently by two reviewers. Meta-analysis was performed where feasible. RESULTS: Twenty-one studies were included, which reported data specifically for closure of large (≥ 10 Fr) femoral arterial access sites using the Prostar XL device. The Prostar XL device, used for closure of these large femoral artery access sites, had a high rate of procedural success equal to that reported for closure by femoral artery surgical cut-down. There was evidence for reduced procedural time, time to discharge and time to ambulation. Complication rates were lower, but not significantly so, with Prostar XL vs. surgical cut-down. CONCLUSIONS: The Prostar XL is an effective and safe device for use in percutaneous closure of large (≥ 10 Fr) femoral artery access sites, comparable to open surgical femoral artery cut-down. Furthermore, it may reduce procedure times and hospitalisations, thereby leading to potential cost savings.

A comparison of the mid-term results following the use of bifurcated and aorto-uni-iliac devices in the treatment of abdominal aortic aneurysms.

PURPOSE: To compare the mid-term results following the use of bifurcated (ABIS) and aorto-uniiliac (AUIS) endovascular devices in the treatment of abdominal aortic aneurysms (AAA) in a population of patients deemed to be at high risk for open surgery. MATERIAL AND METHODS: Over a 4 year period (January 2003 to December 2007), 447 underwent elective endovascular aneurysm repair (EVAR) using ZENITH) stent-grafts. Group I comprised patients treated using the AUIS (n=124), and group II those receiving ABIS (n=323). Outcome measures included the assisted technical success rate, perioperative mortality, major complications, freedom from reintervention, and primary and secondary patencies. Factors associated with mid-term clinical failures were determined using univariate and multivariate analyses. RESULTS: The assisted primary technical success rate was 94% and 99% in groups I and II respectively (p=.002). Major perioperative complications occurred in 13 group I patients (10%) vs. 12 group II patients (4%) (p=.005). The 30-day mortality rate was 3.2% vs.1.5% (p=0.2). TASC C and D iliac lesions significantly increased the risk of major perioperative complications (35% vs. 3%; OR=14.94; 95% CI: 5.75 to 38.78; p<.0001). During the follow-up period (median 24 months), secondary procedures were required in 11% and 5% of group I and group II patients respectively (p=.01). Freedom from reintervention at 12, 24 and 36 months was 98%, 90%, and 85% in group I vs. 96%, 92%, and 92% in group II (P<0.005). The primary and secondary patency rates at 3 years were 92% vs. 98% (p=.003) and 97% vs. 99% (p=.04) for groups I and II respectively. In group I, the Crossover Femoro-Femoral Bypass (CFFB) was responsible for 3 major complications (2.4%) which occurred at 7, 12 and 57 months of follow-up. However, the use of AUIS with CFFB did not independently increase the risk of major complications during follow-up (HR=0.108; 95% CI: 0.007 to 1.637; p=.11, Cox proportion model). In both univariate and multivariate analysis, concomitant iliac arterial occlusive disease (IAOD) was the only significant predictor of clinical failure in study population as a whole (OR=3.996; 95% CI: 1.996 to 7.921; p<.0001). CONCLUSION: This study demonstrates that ABIS is associated with better results than AUIS in the management of patients with AAA. Iliac artery occlusive disease was more frequently diagnosed in the AUIS group and this was significantly associated with a higher risk of complications, while the crossover graft itself was not. Nevertheless, the outcomes for both groups are encouraging in this high risk population.

In-situ revascularisation for patients with aortic graft infection: a single centre experience with silver coated polyester grafts.

OBJECTIVE: The aim of this study was to evaluate the early and mid term outcome of patients with aortic graft infection who underwent in-situ revascularisation with a silver coated prosthesis. MATERIAL: From January 2000 to December 2006, 24 consecutive patients (22 male, 2 female) with mean age 67 years were prospectively entered in this study of aortic graft infection at our single centre. Infection was managed with either total (n=19) or partial (n=5) excision of the infected graft and in- situ reconstruction with a silver coated prosthesis, Inter Gard Silver (IGSG). METHODS: The primary endpoint was recurrence of infection. Secondary endpoints were early and late mortality, peri-operative morbidity, primary graft patency, major amputation rates and patient survival. RESULTS: Fourteen patients had a primary graft infection, however 10 of 24 patients had graft infection secondary to aorto digestive (n=9) or aorto urinary (n=1) tract fistulas. Bacteriological cultures were negative in 8 (33%) patients. Most organisms cultivated where virulent and the majority of graft infections were polymicrobial (71%). Silver grafts were placed emergently in 6 (25%) patients. Mean follow up 32.5+/-31.0 months (range 2-78 months). Peri-operative morbidity and mortality were 46% and 21% respectively. Early interventions occurred in 6 (25%) patients and late secondary intervention were required in 3 (15.7%), caused by silver graft reinfection. The late mortality was 26%. CONCLUSION: In-situ reconstruction with the silver graft confirms similarity with other modalities. The greatest advantage for the silver graft is its ease of use but the risk of reinfection remains significant.

Percutaneous closure devices for endovascular repair of infrarenal abdominal aortic aneurysms: a prospective, non-randomized comparative study.

PURPOSE: This study was designed to describe and evaluate our preliminary results with a percutaneous arterial closure device as compared to those obtained with conventional femoral surgical cut down during endovascular repair of abdominal aortic aneurysms (AAA). MATERIAL AND METHODS: Between January 2004 and December 2006, 40 of 86 AAA patients selected for endovascular repair met the criteria for inclusion in this study. Nineteen of these patients (Group A) received a bifurcated endograft placed by direct puncture of the femoral arteries (38 femoral triangles) with closure by a Prostar((R)) percutaneous arterial closure device (Abbott). The other 21 patients (control group B) were managed with a bifurcated endograft placed by conventional open surgery (42 femoral triangles). Data concerning all 40 patients were collected prospectively and analyzed. RESULTS: The technical success rate was 92% (group A) vs 90% (group B), P=0.79. The incidence of perioperative complications was 16% (3/19) in group A and 14% (3/21) in group B (P=0.89). The mean hospital stay was 5.8 days in group A and 7.8 days in group B (P=0.05). The difference in the length of hospitalisation was associated with reduced cost for the percutaneous group (5579.60 euros vs. 7503.60 euros; P=0.04), that counterbalanced the cost induced by the Prostar XL((R)) suture mediated device. Mean follow-up in both groups was 12 months. The overall incidence of locoregional complications after one year of follow-up was 11% (2/19) in group A and 19% (4/21) in group B (P=0.45). CONCLUSION: This study confirms the feasibility and safety of total percutaneous endovascular AAA repair. Our preliminary results suggest that the costs paid by healthcare providers for endovascular AAA repair might not be increased with the selective use of percutaneous closure devices.

Endovascular repair of ruptured aneurysms of the infrarenal abdominal aorta: feasibility and results.

AIM: Endovascular repair may represent an interesting alternative to open surgery for ruptured abdominal aortic aneurysms (AAA). This study evaluated the feasibility and short-term results of endovascular repair of ruptured AAA at our center. METHODS: Between April 2004 and December 2005, all patients admitted to our center for a ruptured AAA were considered for endovascular repair. Patients whose hemodynamic status was too unstable to permit a preoperative CT scan and patients with an unfavorable anatomy for endovascular repair underwent open surgery. Endovascular repair consisted in emergency placement of an aorto-uni-iliac endograft associated with a crossover femoro-femoral bypass and deployment of an occluder in the contralateral common iliac artery. Follow-up postoperative CT scans were obtained 1, 6, 12 and 18 months after intervention and then annually. Data concerning diagnosis, the operative risk, treatment, and follow-up were collated prospectively in a registry and were analyzed on an intention-to-treat basis. RESULTS: Between April 2004 and December 2005, 17 patients were admitted to our Department for a ruptured AAA. Ten patients (59 %) underwent emergency endovascular repair and were included in this study (8 men and 2 women, mean age 81 years, range 51-97). The mean duration of the operation was 167 +/- 37 min. The mean blood transfusion volume was 3 700 +/- 1 400 mL. The mean duration of hospitalization was 19 days (range: 9-60). Mortality at day 30 was 20% (2 patients): one death occurred on day 2 due to multi-organ failure in an 80-year-old patient and another death occurred on day 2 owing to myocardial infarction in an 87-year-old patient. Mean follow-up was 6 months. Late mortality occurred in 2 cases. No endoleaks were observed during follow-up. CONCLUSION: Our initial results using endografts for the repair of ruptured AAA were satisfactory, with a feasibility of 59% and an operative mortality of 20%. Randomized studies are necessary to determine the true value of endovascular repair of ruptured AAA compared to conventional open repair.

Endovascular repair of infrarenal abdominal aortic aneurysms in high-risk-surgical patients.

PURPOSE: Following the publication of a prospective randomized trial (EVAR2) that questioned the benefit of endovascular repair of abdominal aortic aneurysms (AAA) for high-surgical-risk patients, we evaluated our own initial and long-term results with endovascular AAA repair for this patient population. MATERIAL AND METHODS: Between January 2000 and December 2005, 115 patients with an AAA managed by an aortic endograft were entered in a registry. Data concerning diagnosis, operative risk, treatment, and follow-up were analyzed on an intention-to-treat basis for all patients considered to be poor candidates for surgery. Patients with a ruptured AAA and those who were good surgical candidates were excluded from analysis. The main goal was evaluation of the operative mortality and the long-term survival of these patients. Secondary goals were determination of the frequency of secondary operations, the outcome of the aneurysm sac, and primary and secondary patency rates after aortic endograft placement. RESULTS: A total of 92 high-surgical-risk patients treated by an endograft were entered in this study. Sixty-seven patients (73%) were classed ASA III and 18 (20%) were ASA IV (20%). Mean aneurysm diameter was 58 mm+/-9 mm. The technical success rate was 99%. Operative mortality was 4.3% (4 cases). Four patients required re-intervention during the mean follow-up of 18 months. The survival rate at 3 yr was 85%. One type I endoleak (1%) and 9 type II endoleaks (9.7%) occurred during the follow-up period. Primary and secondary patency rates at 3 yr were respectively 96% and 100%. CONCLUSION: Our initial and long-term results with endograft repair of AAA in high-surgical-risk patients were satisfactory. These results appear to justify endovascular repair for this patient population.

Penetrating atherosclerotic ulcers of the infrarenal aorta: life-threatening lesions.

OBJECTIVES: To analyze the incidence, clinical features, natural history, and treatment of penetrating atherosclerotic ulcers (PAU) of the abdominal aorta. MATERIAL AND METHODS: From January 2000 to June 2003, an abdominal PAU was diagnosed at our institution in eight patients (seven men, one woman; mean age 70 year). These eight cases were analyzed together with 38 additional cases found in a review of the literature (total 46 cases). RESULTS: Occurring at an incidence of approximately 1%, abdominal PAU are less common than thoracic PAU. Seventy percent of cases are symptomatic: pain 52.5% (n =21), acute lower limb ischemia due to distal embolism 12.5% (n =5), shock 5% (n =2). Diagnosis is usually made by CT (66%) (n =26) that demonstrates a PAU in 35% (n =16) of cases, a subadventitial pseudoaneurysm in 28% (n =13), and rupture in 37% (n =17). An intramural hematoma (IMH) is observed in 9% (n =4) of cases. There were no cases of aortic dissection in this series. Calcifications of the abdominal aorta were frequent (56%) (n =26); while intra-aortic mural thrombus was found in 24% of cases (n =11), and 46% of patients (n =21) had an associated aneurysm. Twelve patients were treated medically while 34 underwent surgery (one postoperative death). CONCLUSION: Review of the literature and this series suggests that PAU of the abdominal aorta is a life-threatening lesion, the main risk being rupture. Surgical management is recommended owing to its low morbidity and mortality.

[Laparoscopic aortoiliac surgery for occlusive disease and or aneurysms]. / Chirurgie laparoscopique aorto-iliaque pour lésions occlusives ou anévrismales.

The techniques of video-assisted surgery have been recently applied to aortoiliac surgery. The choices between first the retroperitoneal approach or the transperitoneal approach and the place of video-assisted surgery in relation to totally laparoscopic surgery are at the centre of debates. The aim of this clarification is to relate the evolution of laparoscopic aortoiliac surgery for occlusive disease and aneurysms through a review of the literature on this subject.

Value of stent placement during percutaneous transluminal angioplasty of the iliac arteries.

BACKGROUND: To determine the benefits of stents during percutaneous transluminal angioplasty (PTA) of the iliac arteries. Retrospective analysis of our 10-year surgical experience with iliac PTA from 1988-1997 permitted comparison of results during two consecutive periods: an initial period (1988-1992), during which stents were never used, followed by a second period (1992-1997), when stenting was performed on indication. METHODS: From January 1988 to October 1997, 287 iliac PTA procedures (158 common iliac arteries, 129 external iliac arteries) were performed on 250 patients. Thirty-seven patients had two iliac lesions that were treated simultaneously. Indications for PTA included stenosis (270 cases) and chronic occlusion (17 cases). Thirty-one patients (12.4%) underwent infra-inguinal bypass in addition to PTA owing to the existence of arterial lesions at two levels. Two consecutive patient groups were defined: Group I consisted of 75 patients who underwent 86 iliac PTA procedures between January 1988 and May 1992 without stent placement; Group II consisted of 175 patients who underwent 201 iliac PTA procedures between June 1992 and October 1997, when selective stenting was performed. A total of 55 stents (35 in the common iliac artery, 20 in the external iliac artery) were placed in Group II during PTA due to unsatisfactory immediate results (dissection, residual stenosis) or occlusion. RESULTS: There was no 30-day mortality. There were 15 immediate failures of PTA: 8 in Group I (10.7%) and 7 in Group II (4%). The cumulative initial success rate was 94%. Follow-up ranged from 3 months to 102 months (mean 37 months). The cumulative primary patency rate at 4 years was 62% (58% in Group I, 64% in Group II). The cumulative secondary patency rate at 4 years (including patients who subsequently underwent repeat angioplasty procedures) was 72% (68% in Group I, 74% in Group II). CONCLUSIONS: Stents were an effective means for treatment of initial failures of PTA in patients with iliac artery occlusive disease. However, there were no significant differences in the long term results between PTA alone and PTA with selective stent placement.

Impact of aortic diameter on the outcome of surgical treatment of abdominal aortic aneurysm.

Several recent articles have discussed ultrasonographic surveillance of small abdominal aortic aneurysms (AAA). The purpose of this study was to evaluate the impact of lesion size on immediate morbidity and mortality after surgical treatment of AAA. More specifically we investigated whether the mortality rate was lower after treatment of AAA measuring

Renal artery revascularization in combination with infrarenal aortic reconstruction.

Associated stenosis of one or both renal arteries is not uncommon in patients with infrarenal aortic disease (aneurysm or occlusive disease) requiring surgical repair. The purpose of this retrospective study was to analyze the short- and long-term outcome of concomitant renal artery and aortic reconstruction. The present series includes 39 consecutive concomitant procedures. Simultaneous aortic and renal artery reconstruction was performed in a total of 39 (7.2%) of the 540 patients who underwent elective infrarenal abdominal aortic repair between 1987 and 1996. There were 33 men and 6 women with a mean age of 66.7 years. Twenty-eight patients presented hypertension and 7 presented renal insufficiency associated with hypertension. In all cases, the indication for operative treatment was aortic disease, i.e., aortic aneurysm in 20 cases and occlusive aortoiliac disease in 19 cases. A total of 51 renal artery revascularization procedures were performed, including bypass in 40 cases, transposition in 7, and endarterectomy in 4. Combined aortic and renal artery reconstruction gives good short- and long-term results comparable to those of isolated aortic surgery. On the basis of these findings, we think that concomitant repair is the strategy of choice for patients presenting renal artery stenosis associated with infrarenal aortic disease requiring surgical therapy.

Surgical management of atherosclerotic carotid artery stenosis after cervical radiation therapy.

Carotid surgery following external cervical irradiation has not been a treatment of choice. The purpose of this retrospective study was to describe the immediate and long-term outcome in a series of 17 consecutive patients who underwent operative treatment for carotid artery stenosis after radiation therapy. From 1989 to 1997, surgical treatment of carotid artery disease was carried out in a total of 723 patients. Seventeen of these patients, 14 men and 3 women, had undergone previous external cervical irradiation; their mean age was 61.7 years. The indication for radiation therapy was ear-nose-throat cancer in 14 patients and lymphoma in 3 patients. In 10 patients, irradiation was associated with cervical surgery. The mean delay between radiation therapy and carotid artery repair was 10 years. All 17 patients were considered to be in remission at the time of carotid repair. The indication for carotid surgery was asymptomatic stenosis in 6 cases (33%) and symptomatic stenosis in 12 (67%). The procedure consisted of endarterectomy in 12 cases (67%) and venous bypass in 6 (33%). The outcome for these patients was favorable, indicating that carotid artery repair following cervical radiation therapy is safe. Results are comparable to those of procedures performed in patients with no history of cervical irradiation.

Late survival after abdominal aortic aneurysm repair.

OBJECTIVES: This study was undertaken to determine the late survival of patients operated successfully for abdominal aortic aneurysm (AAA) repair, to compare survival data with that of the age- and sex-matched general population, to identify the causes of late death, and to determine the factors influencing late survival. MATERIALS AND METHODS: A total of 187 consecutive patients underwent elective surgical AAA repair between January 1987 and December 1991. There were 11 postoperative deaths (early mortality rate 5.9%). The remaining 176 patients formed the basis of this cohort-based retrospective study. Six patients (3.4%) were lost to follow-up. Mean follow-up was 71 months. RESULTS: A total of 70 patients (39.8%) died during the study period. Coronary artery disease (CAD) and cancer were the two main causes. The survival rate at five years (71.6%) was lower than that of the sex- and age-matched general population (90.6%). Neither arterial hypertension nor CAD had any influence on late survival. In contrast, age and chronic renal failure were predictive variables of late survival. CONCLUSIONS: The life expectancy of patients who undergo successful AAA repair is not as good as that of the age- and sex-matched general population. Late survival depends on the patients' age at the time of surgery and the existence of preoperative chronic renal failure.

Anatomic bases for compression of the superior gluteal artery at the level of the gluteal canal.

Based on dissections, angiograms, frozen sections, anatomopathologic examination, and CT reconstructions, this anatomic study demonstrates the potential causes of compression of the superior gluteal artery (SGA) at the level of the gluteal canal. Findings suggest the existence of an osseofibromuscular trap responsible for stenosis of the SGA.

Aortoiliac reconstruction and kidney transplantation: a multicenter study.

The occurrence of aortoiliac lesions with renal transplantation is an increasingly common combination that causes problems regarding operative strategy and indications for aortoiliac reconstruction and renal transplantation. To gain greater insight into these problems we undertook a retrospective multicenter study based on data from 24 kidney transplantation centers in France. A total of 83 patients who underwent both aortoiliac reconstruction and kidney transplantation were enrolled. Patients were divided into two groups according to the order in which the two procedures were performed. Group I included 36 patients in whom aortoiliac reconstruction was performed before kidney transplantation-either during the same procedure (6 patients) or as separate procedures (30 patients). Group II included 47 patients in whom aortoiliac reconstruction was performed after kidney transplantation. The mean age was 49.9 years. There were 43 abdominal aortic aneurysms (51.8%), 36 occlusive aortoiliac lesions (43.4%), and 4 aortoiliac dissections (4.8%). Prosthetic bypass grafting was performed in 72 cases (86.8%), transluminal angioplasty in 6 cases (7.2%), endarterectomy in 3 cases (3.6%), and arterial autograft bypass in 1 case. Renal transplant protection was used during aortoiliac clamping in only 3 patients in group II (7.3%). One month after the second procedure (i.e., kidney transplantation in group I and aortoiliac reconstruction in group II), creatinemia was <200 micromol/L in 27 patients (87.1%) in group I and in 37 patients (88.1%) in group II. The graft survival rate was 86.1% in group I and 89.3% in group II. The overall postoperative morbidity rate was 36.1% (13 cases) in group I and 36.1% (17 cases) in group II. One year after the second procedure creatinemia was <200 micromol/L in 29 patients (93.5%) in group I and 36 patients (93%) in group II. The graft survival rate was 86.1% in group I and 85.1% in group II. The outcome of kidney transplantation is comparable regardless of whether the procedure is performed alone or in association with aortoiliac reconstruction. This finding indicates that kidney transplantation should be performed in patients presenting indications for prior aortoiliac reconstruction. The outcome of aortoiliac reconstruction without graft protection in kidney transplant patients is comparable to the outcome of conventional aortoiliac reconstruction in patients with native kidneys.