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.

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.

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.

99Tcm-labelled anti-fibrin Fab' fragment for evaluating the course of venous thrombosis in the rabbit.

Immunoscintigraphy was performed using the Fab' fragment of 99Tcm-labelled T2G1s anti-fibrin monoclonal antibody in a rabbit experimental model of venous thrombosis of known and increasing age (1, 3 and 7 days). Scans were positive in 3/7 cases for 1-day thrombosis (fibrin-poor network) and in 7/7 cases for 3-day thrombosis (fibrin-rich network). In rabbits with 7-day thrombosis, the scan was positive (2/4 cases) only when connective tissue was not present in the clot. Scintigraphic results were concordant with those of biodistribution studies showing the mean percentage of injected dose per gram 99Tcm-T2G1s present in the thrombosed vein wall (0.043, 0.082 and 0.07 for thrombi at 1, 3 and 7 days, respectively). Mean thrombosed vein wall-to-blood ratios were 1.027, 2.291 and 1.301, respectively. Immunoscintigraphy with T2G1s anti-fibrin monoclonal antibody thus enabled hematological status to be evaluated.

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.

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.

[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.

[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.

[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.

[Ehlers-Danlos syndrome type IV, revealed by a primary dissecting aneurysm of the left subclavian artery]. / Syndrome d'Ehlers-Danlos de type IV, révélé par un anévrysme disséquant primitif de l'artère sous-clavière gauche.

The authors report an unusual dissecting aneurysm of the left subclavian artery occurring in a patient suffering from the Ehlers-Danlos syndrome. Clinical history and skin biopsy permitted this diagnosis. Surgical treatment associated resection of the aneurysm, ligation of the proximal part of the subclavian artery and a prosthetic bypass between carotid and subclavian artery. Spontaneous dissecting aneurysm is a rare disease and one must think before surgery to arterial dysplasia. Technical features of the surgical treatment are discussed.

[Fibromuscular dysplasia of the arteries of the leg. Apropos of 1 case]. / Dysplasie fibro-musculaire des artères de jambe. A propos d'un cas.

A 40 year old man presented fibromuscular hyperplasia of posterior tibial artery media, a rare lesion, and only exceptionally reported in the calves since a total of 3 cases were found in the literature.

[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.

[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.

[Chronic rupture of an aneurysm of the abdominal aorta]. / Rupture chronique d'un anévrysme de l'aorte abdominale.

The chronic rupture of an aneurysm in the abdominal aorta produces an atypical clinical picture. Computed tomography is the method of choice for diagnosis. This is a therapeutic emergency because of the risks involved by evolution.

[Infected arterial aneurysms. Anatomo-clinical and surgical aspects apropos of 12 cases]. / Anévrysmes infectieux artériels. Aspects anatomocliniques et chirurgicaux à propos de 12 observations.

Twelve cases of mycotic aneurysm are reported. These rare lesions (2 to 3% of all aneurysms) may affect all arteries. Primary aneurysm is currently the most frequent type observed in France, with onset being related to a bacteremia or septicemia with development on an atheromatous lesion (8 of the 12 cases in this series). Manifestations are often misleading or diagnosis delayed in relation to the infectious process, apart from in rupture, which is the commonest cause of detection of aneurysm (half of the present series). Ideal surgical treatment is exclusion with extra-anatomic revascularization: but revascularization in situ has been reported by many authors (6 of the 12 cases in this series). Localization of aneurysm determines surgical procedure and also very variable mortality rate: 4 of the 12 patients in this series.

[Mechanical obstruction of the duodenum after surgery of the abdominal aorta]. / Occlusions mécaniques du duodénum après chirurgie de l'aorte abdominale.

The authors report two cases of duodenal obstruction occurring after insertion of an aorto-iliac prosthesis. This form of mechanical obstruction is much rare than the other forms of post-operative mechanical intestinal obstruction. While the need for surgery is often evident, precise diagnosis before the procedure is seldom obtained. CT scan appears to be the investigation of choice. This complication could be prevented by an epiploplasty covering the graft implant region.

[Gritti's amputation in vascular surgery]. / L'amputation de Gritti en chirurgie vasculaire.

Gritti's amputation was performed in 35 patients, mean age 71 years, with vascular disease of leg. There was no immediate postoperative mortality. Of twenty patients fitted with an appliance using a specific technique, only one had a poor functional result. The results obtained in this preliminary series were compared with those after amputations and knee disarticulations. They showed that Gritti's amputation should be considered for patients with arteritis when a functional knee is impossible to conserve.

[Results of surgery in 144 cases for aneurysms of the infra-renal abdominal aorta in patients over 75 years of age]. / Résultats de 114 interventions pour des anévrysmes de l'aorte abdominale sous-rénale chez des patients âgés de 75 ans et plus.

114 patients aged over 75 underwent surgery for aneurysm of the infra-renal abdominal aorta in the University Teaching Hospitals in Nantes and Angers between 1979 and 1988. A retrospective study of these patients was performed to evaluate the immediate and long-term results. The mean age of the patients was 79 (+/- 4) years, the oldest being 94. 70% were men. Half of the patients underwent emergency or semi-emergency surgery (52 cases). Cardiovascular factors (in particular coronary insufficiency in 17% of cases) were the most common risk factors. In all cases grafting after laying open the aneurysm was performed, with an aorto-aortic graft in 32% of patients, an aorto-iliac graft in 37% or an aorto-bifemoral graft in 27% of patients. Combined intestinal revascularisation was performed in 10% of case either involving the inferior mesenteric artery or at least one internal iliac artery; renal revascularisation was performed in 3.5% of cases. 75% of patients underwent simple grafting. The mean duration of hospitalisation was 14 days (+/- 6), including a mean period of 7 days in ICU. 36 patients (31%) died in the first post-operative month. The mortality rate in patients who underwent emergency surgery for a complication of the aneurysm (essentially rupture) was 61% versus 6' for elective surgery. 96% of the patients who survived the first post-operative month were independent at the end of the study or at the time of their death.(ABSTRACT TRUNCATED AT 250 WORDS)