Aortic stent-grafts: Endoleak surveillance.

Endoleaks have been referred to as the "Achilles heel" of endovascular aortic aneurysm repair (EVAR) and are the most common complication of this procedure. An endoleak can maintain a high systemic blood pressure within the aneurysm sac, potentially leading to rupture. Follow-up is therefore mandatory to detect and classify possible endoleaks. Computed tomography (CT) remains the gold standard for follow-up, but provides no hemodynamic information on endoleaks and has the disadvantages of exposing patients to iodine contrast and X-ray radiation. Exposure to radiation could be reduced in various ways, by simplifying the triphasic protocol using dual-energy CT imaging, limiting the amount of radiation per slice using iterative reconstruction, and reducing the follow-up schedule that could be altered to include non-ionizing radiation imaging techniques. Contrast-enhanced ultrasound (CEUS) is an interesting alternative to CT, as is magnetic resonance (MR) imaging that can be used as an alternative or for complementary imaging. Long-term follow-up schedules are currently based on repeated CT. However, more recently alternative follow-up protocols have been proposed for patients with no endoleaks nor increase in aneurysmal sac size. These new protocols consist of CT imaging at 1month and 1year after treatment, subsequently followed by CEUS. Nevertheless, the mechanical structure of the stent-graft must still be verified by CT. The use of patient-specific risk-adjusted follow-up protocols, based on preoperative imaging and the first postoperative results, is gradually becoming more and more widespread.

Traumatic injuries of the thoracic aorta: The role of imaging in diagnosis and treatment.

Traumatic injury of the thoracic aorta remains the leading cause of death in multiple trauma patients and it requires urgent management. Computed tomography has a key diagnostic role and allows the clinician to choose an appropriate treatment strategy. The development of new classifications, based on a better understanding of the mechanisms of these injuries, has clarified the indications for treatment. Advances in techniques, especially in endovascular management, have contributed to improving prognosis for patients. Interventional radiology, which usually consists of endovascular placement of a covered stent, now constitutes the gold standard treatment in these injuries. Due to the potentially grave prognosis of these patients, it is crucial to know how to detect these injuries and to describe the imaging signs of serious damage.

A hospital discharge risk score for 1-year all-cause mortality or non-fatal cardiovascular events in patients with lower-extremity peripheral artery disease, with and without revascularisation.

OBJECTIVES: This study aims to determine a hospital discharge prognostic risk score for patients with lower-extremity peripheral artery disease (PAD) with and without revascularisation. DESIGN, MATERIALS AND METHODS: A prognostic score on mortality or non-fatal cardiovascular events was determined using the database of a multicentre prospective study enrolling consecutive patients hospitalised for PAD (COhorte de Patients ARTeriopathes, COPART). RESULTS: We analysed the data of 640 patients in the derivation cohort and 517 in the validation cohort. The risk score (and corresponding points) included the following factors: age 75-84 years (+2), ≥ 85 years (+3); previous myocardial infarction (+1); creatinine clearance: ≤ 30 ml min(-1) 1.73 m⁻² (+1.5), 0.30-0.59 (+1), ankle-brachial index: <0.3 (+2), 0.3-0.49 (+1.5) and >1.3 (+2); C-reactive protein (CRP) ≥ 70 mg l⁻¹ (+2); and association of statins, anti-platelet agents and renin-angiotensin system inhibitors (-1.5). The frequency of the composite outcome increased significantly with the predicted risk: low risk (≤ 0 point), 2%; medium (0.5-2 points), 12.8%; high (2.5-4 points), 23%; very high (≥ 4.5 points): 42.2%. The model had a good performance in terms of discrimination (C-statistic 0.74 and 0.76) and calibration (Hosmer-Lemeshow 0.65). CONCLUSIONS: We propose the validated COPART risk score for hospitalised severe PAD. This prognostic risk score is based on six variables easily identifiable in clinical practice. Our study highlights the favourable prognostic impact of the prescription at discharge of combined drug therapies.

Laparoscopic surgery for coeliac artery compression syndrome: current management and technical aspects.

OBJECTIVES: The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS). DESIGN: Retrospective chart review involving four European vascular surgery departments and two surgical teams. MATERIALS AND METHODS: charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed. RESULTS: Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 ± 23 months (range: 12-78 months). CONCLUSION: Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique.

Early and late results of contemporary management of 37 secondary aortoenteric fistulae.

PURPOSE: Evaluate the results of the two modalities used for the treatment of Secondary Aorto-Enteric Fistula (SAEF): In situ Reconstruction (ISR) and Extra-Anatomic Reconstruction (EAR). The primary endpoints of this study were early standard 30-day mortality and reinfection (RI). Secondary endpoints were perioperative morbidity, late mortality, primary graft patency, and major amputation rates. MATERIAL & METHOD: Diagnosis of SAEF was based on clinical examination and the results of pre-operative duplex or CT scans. Surgical management was performed according to local protocols at the participating institutions: - Elective surgery: ISR or staged EAR. - Emergency surgery: aortic clamping followed by ISR or EAR. - Selected high-risk patients: endovascular repair. Statistical analyses were performed using the actuarial method. Univariate analysis was used for analysis of categorical variables, and multivariate analysis was performed with a Cox proportional hazard regression. RESULTS: A total of 37 patients were included in this retrospective multicentre study. Mean follow-up was 41 months. The majority of the patients (20, 54%) presented acutely. EAR was performed in 9 patients (24%), ISR in 25 (68%), and 3 patients underwent endovascular repair. Bacteriological cultures were negative in 3 patients (9%). The most frequent organisms identified were Candida species and Escherichia coli. The 30-day mortality was 43% (16 patients). Patient age (>75 years) was the sole predictive factor associated with operative mortality (p = 0.02); pre-operative shock was not statistically significant (p = 0.08). There were 2 graft thromboses and 1 femoral amputation. Primary graft patency was respectively 89% at 1 year and 86% at 5 years; limb salvage rates were 100% at 1 and 5 years and 86% at 6 years, with no difference between ISR and EAR. RI occurred after 9.3 ± 13 months in 8 of 17 surviving patients and was fatal in all cases. For all surviving patients, the RI rate at 1 and 2 years was 24% and 41% respectively. There was no significant difference in the rate of RI after ISR or EAR. CONCLUSION: EAR does not appear to be superior to ISR. The risk of RI increased with the length of follow-up, irrespective of the treatment modality. Life-long surveillance is mandatory. Our results with endovascular sealing of SAEF should be considered a bridge to open repair.

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.