True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis: Five Cases and Literature Review.

BACKGROUND: The donor artery after a long-standing arteriovenous fistula (AVF) for hemodialysis usually evolves exceptionally toward a true aneurysmal degeneration (AD). The purpose of this article was to describe true brachial artery AD in end-stage renal disease patients after AVF creation, as well as its influencing factors and treatment strategies. METHODS: We present a retrospective, observational, single-center study realized in Caen University Hospital's Vascular Surgery Department from May 1996 to November 2015. The inclusion criteria were true AD of the brachial artery after a vascular access for hemodialysis. A literature research, using the same criteria, was performed on the articles published between 1994 and 2015. The used databases included MEDLINE (via PubMed), EMBASE via OVID, Cochrane Library Database, and ResearchGate. RESULTS: Our series includes 5 patients. Twenty-one articles were found in the literature: 17 case reports, 3 series, and 1 review. The same triggering factors for AD (high flow and immunosuppressive treatment) were found. The mean age at the time of AVF creation, first renal transplantation, and AD's diagnosis were respectively 26 (range 15-49), 29.2, and 48.6 years (range 37-76) in our series versus 34 (range 27-39), 40.4 (range 28-55), and 55.5 years (range 35-75) in cases found in the literature. The time spread after AVF creation and aneurysmal diagnosis was about 20.6 years (range 18-25) in our study versus 20.5 years (range 9-29) in the case reports. Our surgical attitude corresponds principally to that described in the literature. Nevertheless, we describe for the first time one case of arterial transposition to exclude the brachial aneurysm using superficial femoral artery. CONCLUSIONS: Arterial aneurysm is a rare, but significant complication after a long-term creation of hemodialysis access. High flow and immunosuppression may accelerate this process. Young age of the patients may act as a benefic factor and delay the AD. Arterial transposition could be an option in the absence of any venous conduit, if anatomy does not permit the use of prosthetic grafts.

Technique and results of femoral bifurcation endarterectomy by eversion.

OBJECTIVE: This study evaluated, in a contemporary prospective series, the safety and efficacy of femoral endarterectomy using the eversion technique and compared our results with results obtained in the literature for the standard endarterectomy with patch closure. METHODS: Between 2010 and 2012, 121 patients (76% male; mean age, 68.7 years; diabetes, 28%; renal insufficiency, 20%) underwent 147 consecutive femoral bifurcation endarterectomies using the eversion technique, associating or not inflow or outflow concomitant revascularization. The indications were claudication in 89 procedures (60%) and critical limb ischemia in 58 (40%). Primary, primary assisted, and secondary patency of the femoral bifurcation, clinical improvement, limb salvage, and survival were assessed using Kaplan-Meier life-table analysis. Factors associated with those primary end-points were evaluated with univariate analysis. RESULTS: The technical success of eversion was of 93.2%. The 30-day mortality was 0%, and the complication rate was 8.2%; of which, half were local and benign. Median follow-up was 16 months (range, 1.6-31.2 months). Primary, primary assisted, and secondary patencies were, respectively, 93.2%, 97.2%, and 98.6% at 2 years. Primary, primary assisted, and secondary maintenance of clinical improvement were, respectively, 79.9%, 94.6%, and 98.6% at 2 years. The predictive factors for clinical degradation were clinical stage (Rutherford category 5 or 6, P = .024), platelet aggregation inhibitor treatment other than clopidogrel (P = .005), malnutrition (P = .025), and bad tibial runoff (P = .0016). A reintervention was necessary in 18.3% of limbs at 2 years: 2% involving femoral bifurcation, 6.1% inflow improvement, and 9.5% outflow improvement. The risk factors of reintervention were platelet aggregation inhibitor (other than clopidogrel, P = .049) and cancer (P = .011). Limb preservation at 2 years was 100% in the claudicant population. Limb salvage was 88.6% in the critical limb ischemia population, with a statistically higher rate for patients with malnutrition (P = .029), preoperative platelet count >450 ×10(9)/L (P = .0071), platelet aggregation inhibitor treatment other than clopidogrel (P = .022), preoperative deep femoral artery occlusion or stenosis >75% (P = .0064), and poor tibial runoff (P = .00042). CONCLUSIONS: Eversion femoral bifurcation endarterectomy is a safe, efficient, and reproducible technique for the treatment of atherosclerotic femoral lesions. Advantages are notable, especially the lack of need for prosthetic angioplasty, eliminating the risk of patch infection or pseudoaneurysms and permitting direct puncture if endovascular procedures are needed for assisted patency.

Midterm results of type B intramural hematoma endovascular treatment.

BACKGROUND: Recently, intramural hematoma (IMH) has been characterized as a rare variant of aortic dissection, falling within the acute aortic syndromes (AAS). Although aortic endovascular treatment seems to provide good results, no consensus has been established regarding the optimal management of IMH affecting the descending thoracic aorta (IMH B). The aim of this study was to assess long-term clinical and morphological results of IMH B treated with a stent graft. METHODS: Between 2002 and 2013, 15 of the 423 (3.5%) consecutive patients with AAS were found to have IMH B. During follow-up, complications related to IMH B were observed in 10 patients, including 5 during the acute period (<14 days). Surgical indications were ulcerations, refractory pain, aneurysm evolution, aortic rupture, and pleural effusion. An endovascular approach was taken for all forms with suitable anatomy. RESULTS: Technical success rate was 100%, with complete exclusion of lesions of the descending thoracic aorta in all cases treated with a stent graft. No neurological complications or deaths occurred within the first 30 postoperative days, nor at the end of the mean follow-up of 46 months (1-137 months). After the aortic stent graft, partial or complete regression of the hematoma was observed in all cases. CONCLUSIONS: IMH B is most often a progressive disease requiring long-term monitoring. In case of complications, stent-graft treatment of the descending thoracic aorta can be performed successfully in most cases. This procedure appears to be a safe technique that provides very good long-term results, with favorable remodeling of the aorta.

Feasibility of ambulatory percutaneous femoral access without the use of arterial closure systems.

BACKGROUND: To evaluate the feasibility of early ambulation in patients treated for peripheral occlusive lesions by femoral percutaneous access, without the use of closure systems and the application to ambulatory practice. METHODS: This single-center observational exploratory study was undertaken among 99 consecutive patients between August 1-December 31, 2011 (mean age: 72 years; 72 men) who were treated by percutaneous femoral route for peripheral arterial lesions. All the patients had a manual compression then pressure bandage. A clinical evaluation was carried out after 4 hours, seeking a local or a general complication and checking the procedure. Rising and walking in the unit of hospitalization were authorized in the absence of complication as of 4 hours postoperatively. All patients remained in hospital for at least 1 night, with a clinical revaluation before discharge. All patients were contacted by telephone at postoperative day 7 in order to verify the absence of local complications. All the individual factors and those related to the procedure were analyzed. RESULTS: With criteria of complications related to the gesture, 72 patients (72.7%) were considered ready to be discharged as of postoperative hour 4. Among the 27 patients who were not able to leave, 7 presented with an early local complication without reoperation, and 20 could not walk because of a necrotic lesion (n = 8), their advanced age (n = 4), morbid obesity (n = 2), or a choice of the surgeon in charge (n = 6). Twenty-five patients could, however, stroll after 12 hours. The mean duration of hospitalization was 1.3 days (range: 0-10 days). Two patients required distal amputation during the same hospitalization, and 1 underwent a femoropopliteal bypass after failure of a femoropopliteal recanalization. With univariate analysis, the treatment by anticoagulants and the duration of the hospitalization were the only factors significantly related to the impossibility of early ambulation. The occurrence of complications was linked with the experience of the surgeon, the age of the patient, and the female sex. Three patients, including 2 regarded as ready to walk by postoperative hour 4, were rehospitalized after 1 week for reoperation because of 1 major hematoma and 2 femoral false aneurysms. CONCLUSION: Percutaneous endovascular surgery by the femoral route without using an arterial closure system is feasible in an ambulatory practice in nearly 75% of cases. Particular monitoring must be done in the oldest patients, women, and those treated with anticoagulants.

Delayed axillary artery pseudoaneurysm as an isolated consequence to anterior dislocation of the shoulder.

Injury to the axillary artery after anterior shoulder dislocation is a very rare occurrence; although infrequently seen as an iatrogenic complication, very few cases have been reported. We describe a case of delayed axillary artery pseudoaneurysm, presenting as single complication after anterior shoulder dislocation reduction, which was successfully managed by surgical intervention-resection-anastomosis. Although uncommon, pseudoaneurysms should not be forgotten after trivial trauma. The early diagnosis of upper-limb pseudoaneurysms should prevent the risk of vascular and neurological compromises with potential serious long-term sequelae.