Outcomes of Cold Stored Saphenous Vein Allografts for Haemodialysis Vascular Access.

OBJECTIVE: The aim of this study was to evaluate the outcomes of cold stored saphenous vein allografts (CSVAs) for haemodialysis vascular access. METHODS: A retrospective, two centre study was conducted between January 2016 and December 2020 of all patients who had CSVA placement for haemodialysis vascular access. Primary, primary assisted, and secondary patency were analysed, as well as procedural complications and re-interventions. RESULTS: One hundred and nine patients (n = 55 women) with a mean age of 67.2 ± 13.6 years, with no options for creating an autogenous arteriovenous fistula, were included in the study. At one year, primary, primary assisted, and secondary patency were 37.6%, 59.0%, and 73.3%, respectively; and at two years 19.9%, 42.5%, and 54.9%, respectively. During a mean follow up period of 26 ± 18 months, five patients (4.6%) had an access infection, with no related death. During the follow up period, 32 patients (29.4%) died and 13 patients (11.9%) underwent a kidney transplant. None of these patients showed immunoconversion before transplantation. The cumulative incidence of adverse events by the Fine-Gray method was calculated. Considering competing risks (death and renal transplantation), 9.2% of patients lost their vascular access at one year and 18% at two years. Moreover, 57.8% patients had stenosis, mainly on the outflow (45.9%), and 49.5% had thrombosis. CONCLUSION: With a comparable patency rate associated with a low infection rate, CSVA offers a potential alternative to expanded polytetrafluoroethylene grafts. This creates haemodialysis vascular access when the venous capital is exhausted in patients with reported risk factors for vascular access infection, i.e., insertion in the thigh, advanced age, diabetes mellitus, immunocompromised state, obesity, or revision of an infected prosthetic graft.

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms.

OBJECTIVE: Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS: This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS: Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS: Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

Outcomes of cold-stored venous allograft for below-knee bypasses in patients with critical limb ischemia.

OBJECTIVE: Critical limb ischemia (CLI), the most advanced form of peripheral arterial disease, is associated with strikingly high morbidity and mortality rates. Autogenous single-segment great saphenous vein (GSV) remains the optimal conduit for infrainguinal revascularization. Unfortunately, GSV is unavailable in up to 20% of patients. There is no consensus about the alternative graft that should be used for infragenicular bypass grafting when the GSV is unavailable. Currently, there are no outcome data for cold-stored venous allograft use in regard to recent safety and efficacy objective performance goals described by the Society for Vascular Surgery. METHODS: This is a retrospective analysis of 118 infragenicular revascularizations performed for CLI with cold-stored venous allografts obtained from varicose vein stripping surgery in a single institution from November 2002 to August 2013. RESULTS: Mean age (± standard deviation) was 75 ± 12 years (male, 76%; diabetes, 73%; dialysis, 16%), and 38% (n = 45) had a history of failed ipsilateral revascularization. None had suitable autogenous conduit for even composite vein bypass. The distal anastomosis was performed to an infrapopliteal artery in 85 cases (72%). At 30 days, perioperative death rate was 6.8%, major adverse cardiovascular event rate was 7.6%, and major adverse limb event rate was 11.9%. Mean follow-up was 34 ± 29 months (range, 1-113 months). At 1 year, freedom from major adverse limb event or perioperative death, limb salvage, survival, amputation-free survival, and secondary patency rates were, respectively, 64.9%, 82.5%, 85.4%, 73.3%, and 58.3%. Ejection fraction <45% and dialysis were the most significant factors predicting failure of revascularization. CONCLUSIONS: Cold-stored venous allografts may be used for performing infragenicular revascularization for CLI with acceptable safety and efficacy results despite poor long-term patency. Their level of performance remains inferior to autologous vein sources but seems comparable to alternative allografts or prosthetic conduit. Their availability is a major advantage compared with other biologic alternative sources.

Characterization of resident B cells of vascular walls in human atherosclerotic patients.

Animal models of atherosclerosis suggest that B cells have contradictory protective or proatherogenic effects that are also subset and context dependent. To further understand the pathophysiology of human atheroma, we characterized local Ig production and functional properties of resident B cells in human arterial lesions. Ig repertoires were analyzed by RT-PCR in carotid endarterectomy samples. Cytokine, differentiation marker and transcription factor mRNA expression was studied on arterial wall lymphocytes isolated by laser capture microdissection. Ig sequence analysis revealed that individual samples each contained a limited number of B cell clones. Functional α and γ mRNAs made up the majority of H chain mRNAs in the adventitia. Clonal evolution of Ig V regions, expression of activation-induced cytidine deaminase, clonal H chain switch, and an inverted λ/κ ratio of Ig L chain usage indicated that a local differentiation process was taking place in arterial walls. Clonotypic markers revealed different plaque and adventitia Ig repertoires and a B cell recirculation between adventitia and draining lymph nodes. Microdissected mononuclear cells had an activated phenotype expressing IL-6, GM-CSF, and TNF-α, whereas IL-2, IL-4, IL-10, M-CSF, and IFN-γ were not detected. Adventitial oligoclonal resident B cells of atherosclerotic patients are mainly mature B2 (conventional) CD20⁻ plasmablasts lacking markers of terminal differentiation to plasma cell (CD138 and Blimp-1). They present hallmarks of Ag-driven maturation and could act on inflammation and disease progression directly or by promoting polarization of other immune cells.

[Acute and chronic pathologies of the thoracic aorta: From diagnosis to treatment]. / Pathologie aortique thoracique aiguë et chronique : du diagnostic au traitement.

Aortic pathologies benefit from imaging innovation and interventional radiology developments in order to improve patient management. At the early phase, vital risk should be considered. Whole body CT scan evaluate the complete aorta and its branches to assess the pathology and to choose the best approach between surgery or interventional radiology (fenestration, stentgraft, peripheral stenting). Algorithms, based on the understanding of the complications mechanisms and evolutive risk, modified the management specifically for aortic dissection. At chronic phase, GPs and angiologists should follow their patients in order to detect aortic complications and to treat cardiovascular risk factors. MRA is well indicated if possible.

Is First Rib Fracture a Culprit or a Sign of Injury Severity? It Is Both.

OBJECTIVES: First rib fractures (first RFX) have been correlated with increased morbidity and mortality. Whether this is due to the fracture of the rib itself or due to an increased number of associated injuries remains debatable. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: One thousand eighty-nine patients with rib fractures divided into 3 groups: group A (n = 44) with isolated first RFX, group B (n = 116) with first RFX combined with other rib fractures, and group C (n = 929) with rib fractures without first RFX. INTERVENTION: None. OUTCOME MEASUREMENTS: Age, sex, Injury Severity Score, mortality, number of ribs fractured (RFX), incidences of flail chest, multiple coinjuries, hospital and intensive care unit lengths of stay, and duration of mechanical ventilation. RESULTS: Group A, when compared with group B, had significantly lower Injury Severity Score, RFX, rates of flail chest, pulmonary coinjuries, and shorter hospital length of stay and intensive care unit length of stay. Group A compared with group C had significantly lower age, RFX, rates of flail chest, and hemopneumothorax. In group B, all outcome measurements were significantly higher than those in group C. Incidence of subclavian artery, brachial plexus, and first thoracic vertebra injuries was significantly higher in group A. Frequency of traumatic brain and orthopaedic coinjuries was comparable in both groups with first RFX. CONCLUSIONS: Isolated first RFX alone are associated with higher incidence of injuries to subclavian structures and the first thoracic vertebrae. When they are combined with fractures of other ribs, the overall severity of trauma expands significantly. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Tunnelled internal jugular vein catheters with taurolidine lock: an acceptable challenge to arterio-venous fistula in 70 years old haemodialyzed patients: a prospective pilot study]. / Les cathéters jugulaires internes tunnellisés avec verrou antiseptique par taurolidine : une alternative acceptable aux fistules artérioveineuses chez les hémodialysés de plus de 70ans : résultats d'une étude pilote prospective.

Arteriovenous fistula (AVF) is still in 2010 the gold standard of vascular(2) access in haemodialysis (HD) patients. Nevertheless it may be difficult to obtain and/or to use AVF in elderly. With this prospective randomised pilot study, we compare two strategies of vascular access in 70 years old or more new HD patients. AVF were compared to tunnelled jugular vein catheters (TIJC) with taurolidine as bacterial lock solution. Results were as follow: [table: see text] The responses with the visual analogic scale of comfort was 8/10 for TIJC and 5/10 with AVF * P<0.05. In five TIJC patients, heparin was added with success to taurolidine because of partial clotting of catheters. Albuminemia was significantly lower in AVF failure patients compared to AVF success patients (24.8g/L vs 31.1g/L). This pilot study allows to conclude that TIJC is an acceptable challenge to AVF in haemodialysed patients of 70 years or more in a two years long use.

Acute carotid artery thrombosis: description of 12 surgically treated cases.

The morbidity and mortality of stroke secondary to acute internal carotid artery thrombosis range from 40 to 69% and from 15 to 55%, respectively, after purely medical treatment. This report describes a series of 12 patients who underwent urgent surgical treatment for primary acute carotid artery thrombosis between January 1999 and December 2002. Upon admission, all patients had severe neurologic deficits contralateral to carotid artery thrombosis. One patient experienced ongoing changes in the level of consciousness. The interval between the onset of symptoms and admission was less than 6 hr in all cases. Initial work-up in all patients included a brain computed tomographic scan with contrast injection and carotid duplex scan. The operative procedure consisted of carotid thomboemdarterectomy after shunt placement with prosthetic patch closure. Intraoperative angiography was performed in all cases. Following treatment, we observed deterioration of neurologic status leading to death in one case; improvement with partial regression of initial neurologic deficit in two cases, including one patient who died from causes unrelated to carotid artery disease; and full neurologic recovery in nine cases. The delay to revascularization was longer than 6 hr in both patients who died. These data support surgical intervention for carotid artery thrombosis in selected patients without major disturbances of consciousness or hemorrhagic infarction, provided that the delay to revascularization is less than 6 hr.

Dissection of the abdominal aorta in blunt trauma: Endovascular or conventional surgical management?

BACKGROUND: Dissection of the abdominal aorta caused by blunt trauma is a rare injury, often complicated by thrombosis within the true and false lumens and sometimes aortic rupture. The mortality rate with conservative medical management is approximately 75%, whereas it ranges from 18% to 37% with surgical treatment. METHODS: At our institution, 7 of the 87 patients admitted because of blunt aortic trauma, between January 1995 and January 2002, had abdominal aortic dissection. RESULTS: Four patients were treated using endovascular techniques by percutaneous stent placement. The indications for endovascular management were lower limb ischemia in one case and extension of the dissection in two; one patient was asymptomatic. Aortic dissection was complicated by ischemic paraplegia in two patients, and both were treated by conventional operative repair. One patient was managed medically because of a minimal intimal disruption. No deaths were related to the aortic dissection or its treatment. Angiographic and computed tomographic (CT) studies showed thrombosis of the false lumen and complete obliteration of the dissection in the endovascular group. The neurologic condition of the two paraplegic patients either cleared completely or partially improved. CONCLUSION: In the absence of ischemic paraplegia or other injuries that require emergency surgery, endovascular treatment is a safe and efficient method for treating traumatic infrarenal aortic dissection.