Delayed severe median nerve palsy due to undiagnosed brachial pseudoaneurysm.

Post-catheterization pseudoaneurysms are a well-known complication of many endovascular procedures at the site of arterial puncture. However, long-term neurological complications due to undiagnosed compression are rare. A 60-year-old man presented to our unit for round, non-pulsatile, painless swelling in the inner side of his upper arm. Clinical examination showed finger paralysis, associated with amyotrophy of the forearm. Large brachial pseudoaneurysm with median nerve compression was diagnosed. The patient underwent autologous vein bypass, with poor 6-month neurological recovery. Early diagnosis of pseudoaneurysms is paramount because, when associated with nerve compression, the longer the diagnostic delay, the poorer the neurological prognosis.

Influence of micro- and macro-vascular disease and Tumor Necrosis Factor Receptor 1 on the level of lower-extremity amputation in patients with type 2 diabetes.

BACKGROUND: Patients with type 2 diabetes (T2D) face a high amputation rate. We investigated the relationship between the level of amputation and the presence of micro or macro-vascular disease and related circulating biomarkers, Tumor Necrosis Factor Receptor 1 (TNFR1) and Angiopoietin like-2 protein (ANGPTL2). METHODS: We have analyzed data from 1468 T2D participants in a single center prospective cohort (the SURDIAGENE cohort). Our outcome was the occurrence of lower limb amputation categorized in minor (below-ankle) or major (above ankle) amputation. Microvascular disease was defined as a history of albuminuria [microalbuminuria: uACR (urinary albumine-to-creatinine ratio) 30-299 mg/g or macroalbuminuria: uACR ≥ 300 mg/g] and/or severe diabetic retinopathy or macular edema. Macrovascular disease at baseline was divided into peripheral arterial disease (PAD): peripheral artery revascularization and/or major amputation and in non-peripheral macrovascular disease: coronary artery revascularization, myocardial infarction, carotid artery revascularization, stroke. We used a proportional hazard model considering survival without minor or major amputation. RESULTS: During a median follow-up period of 7 (0.5) years, 79 patients (5.5%) underwent amputation including 29 minor and 50 major amputations. History of PAD (HR 4.37 95% CI [2.11-9.07]; p < 0.001), severe diabetic retinopathy (2.69 [1.31-5.57]; p = 0.0073), male gender (10.12 [2.41-42.56]; p = 0.0016) and serum ANGPTL2 concentrations (1.25 [1.08-1.45]; p = 0.0025) were associated with minor amputation outcome. History of PAD (6.91 [3.75-12.72]; p < 0.0001), systolic blood pressure (1.02 [1.00-1.03]; p = 0.004), male gender (3.81 [1.67-8.71]; p = 0.002), and serum TNFR1 concentrations (HR 13.68 [5.57-33.59]; p < 0.0001) were associated with major amputation outcome. Urinary albumin excretion was not significantly associated with the risk of minor and major amputation. CONCLUSIONS: This study suggests that the risk factors associated with the minor vs. major amputation including biomarkers such as TNFR1 should be considered differently in patients with T2D.

Impact of angiosome- and nonangiosome-targeted peroneal bypass on limb salvage and healing in patients with chronic limb-threatening ischemia.

BACKGROUND: Direct (DIR) or indirect (IND) revascularization of pedal angiosomes in patients with chronic limb-threatening ischemia (CLTI) has an unclear impact on limb salvage and healing. The aim of this study was to evaluate the outcomes of DIR and IND revascularization in patients with a peroneal bypass and tissue loss. METHODS: We conducted a retrospective study of a prospectively maintained database in two European university centers from 2004 to 2015. We extracted from this database all patients with CLTI and tissue loss who had received a bypass to the peroneal artery. All patients underwent angiography before bypass. Revascularization was considered DIR if the wound was in a peroneal angiosome. Wounds, ischemia, and infection were categorized according to the Wound, Ischemia, and foot Infection (WIfI) classification. Limb salvage and amputation-free survival were calculated using the Kaplan-Meier method. Cox regression was used to compare the role of patient characteristics, including diabetes, peroneal runoff, pedal arch angiosome, WIfI grade, chronic kidney disease, and diabetes, in amputation-free-survival. RESULTS: From January 2004 through October 2015, there were 120 peroneal bypasses performed in 120 patients with CLTI and foot tissue loss. Only 55 wounds (46%) could be ascribed to a peroneal angiosome. At 3 years, amputation-free survival in patients with DIR revascularization was 54.9% ± 7.3% compared with 56.5% ± 6.3% in patients with IND revascularization (P = .44), with no significant difference in wound healing. Amputation-free survival at 3 years in patients with two patent peroneal branches was 74.8% ± 6.9% compared with 45.0% ± 6.0% in patients with one patent peroneal branch (P = .003). Amputation-free survival at 3 years in patients with a patent pedal arch (Rutherford 0-1) was 73.0% ± 7.0% vs 45.7% ± 6.0% in patients with incomplete pedal arch (Rutherford 2-3; P = .0002). Amputation-free survival at 3 years in patients with grade 1 or grade 2 WIfI was 87.4% ± 8.3% compared with 48.4% ± 5.3% in patients with grade 3 or grade 4 WIfI (P = .001). Amputation-free survival at 3 years in patients with diabetes was 43.7% ± 6.2% compared with 73.1% ± 6.7% in patients without diabetes (P = .002). Wound healing at 6 months was not significantly improved by its location within or outside a peroneal angiosome. Cox regression analysis demonstrated that diabetes, patency of both peroneal branches, patency of pedal arch, and WIfI stage but not DIR angiosome revascularization were significant predictors of amputation-free survival. CONCLUSIONS: Our results suggest that in patients with CLTI and tissue loss receiving a peroneal bypass, patency of both peroneal branches and pedal arch was associated with a better healing rate and a better amputation-free survival rate irrespective of wound angiosome location.

Chirurgie aortique totalement laparoscopique ou par laparotomie: comparaison des résultats après appariement par un score de propension.

STUDY OBJECTIVE: To compare the postoperative and medium-term outcomes of laparoscopic aortic surgery with those of conventional aortic surgery performed by a surgical team trained in laparoscopic aortic surgery. METHODS: A prospective study was conducted between January 2006 and December 2011 with 228 consecutive patients having undergone aortic bypass surgery for either an abdominal aortic aneurysm (n = 139) or an occlusive aortoiliac disease (n = 89). Conventional open aortic surgery was carried out in 145 patients, and total laparoscopic repair in 83 patients. The composite primary endpoint measure grouped together the following adverse events (AE): (1) any details < 30 days or later deaths related to the operation, (2) postoperative hemorrhage necessitating reoperation, (3) myocardial infarction I 30 days. (4) stroke I 30 days, (5) postoperative respiratory failure necessitating reintubation or assisted ventilation J 4 days, (6) aortic prosthesis infection, (7) aortic prosthesis occlusion, (8) any reoperation related to aortic surgery. In order to diminish biases attributable to the absence of randomization, the two surgical groups were matched by a propensity score enabling analysis of 50 pairs of patients having presented with identical preoperative characteristics. Univariate analysis of the AE occurring during the first 30 postoperative days was followed by multivariate analysis through logistic regression. The incidence rate of AE during follow-up was calculated using the Kaplan-Meier method and the roles of the different covariables were analyzed using the Cox model. RESULTS: Univariate analysis of the groups adjusted for propensity score showed that laparoscopic repair was associated with significantly higher risk of AE over the first 30 postoperative days (p = 0.03). Logistic regression analysis showed that laparoscopic aortic technique (Odds Ratio (OR) ; 4.50) and coronary artery disease (OR ; 4.67) were independently related to occurrence of an AE during the postoperative period. Occurrence of AE during follow-up was analyzed using the Cox model. Only two variables, laparoscopic aortic surgery [Hazard Ratio (HR) ; 4,40 ; CI 95 % 1.70-11.38 ; p. = 0.002] and coronary artery occurrence of an AE during follow-up. The small number of patients prevented a separate analysis with regard to aneurysmal and occlusive aortic disease. CONCLUSIONS: This study suggests that even with a well-trained surgical team, the laparoscopic approach increases risk for AE observed in the course of aortic surgery. ClinicalTrials. gov Identifier: NCT02325700.

Femur Lengthening in a Patient with a Pseudoaneurysm of the Superficial Femoral Artery Treated with Covered Stent.

This case report presents a 29-year-old male patient who presented an articular distal femoral fracture sustained in a road traffic accident in Benin. After the different surgical procedures, the patient presents a knee stiffness and a shortening of the left leg of 7 cm. An ablation of osteosynthesis material and a Judet procedure was done. After this surgical intervention, the patient developed pain, pulsatile swelling of the left knee. A false aneurysm of the superficial femoral artery was evidenced, and a percutaneous endovascular procedure was performed. As a result of the important leg-length discrepancy, a femoral lengthening of 6 cm was performed using intramedullary skeletal kinetic distractor nail. We show that a 6 cm femur lengthening in a patient with a femur stent is possible using intramedullary nails provided that orthopedic and vascular surgeons monitor the patient in strict clinical and paraclinical followup conditions.