Update About the Management of Low-Density Lipoprotein Cholesterol and Hypertriglyceridemia in Lower Extremity Peripheral Artery Disease Patients: Consensus of the French Society of Vascular Medicine and the French Society for Vascular and Endovascular Surgery.

BACKGROUND: A French intersociety consensus on behalf the Société Française de Médecine Vasculaire and the Société de Chirurgie Vasculaire et Endovasculaire was proposed in 2021 for the management of patients with lower extremity peripheral artery disease (LEAD). Recent studies have been published and an update of this consensus about the management of low-density lipoprotein cholesterol (LDLc) and hypertriglyceridemia was required. METHODS: A steering committee of 12 vascular physicians and surgeons defined questions of interest about LDLc and hypertriglyceridemia management. A French expert panel voted the proposals. Consensus was considered to have been achieved if more than 80% of the responses corresponded to either "Agreement" or "Disagreement". RESULTS: Among the 56 experts who were asked to participate, 46 (82%) accepted. After the first round of the Delphi procedure, the 4 proposals reached consensus. The following suggestions and recommendations were approved: 1. For LEAD patients treated by the highest tolerated statin dose ± ezetimibe and who have an LDLc ≥0.70 g/L, we recommend adding a proprotein convertase subtilisin/kexin type 9 inhibitor. 2. For LEAD patients treated by statin and who have elevated triglyceride level between ≥150 mg/dL and ≤500 mg/dL, we suggest adding Icosapent Ethyl. 3. Before adding Icosapent Ethyl in LEAD patients treated with statin, we suggest looking for symptoms that may suggest atrial fibrillation. 4. For LEAD patients treated by Icosapent Ethyl and who have symptoms that suggest atrial fibrillation, we recommend performing an electrocardiogram. CONCLUSIONS: This update will help clinicians to improve LEAD patient management.

Exercise transcutaneous oximetry in functional popliteal artery entrapment syndrome diagnosis.

INTRODUCTION: Functional popliteal artery entrapment syndrome is a subtype of popliteal artery entrapment syndrome (PAES) without vascular disease or musculotendinous anomaly behind the knee. Symptoms are induced by popliteal artery extrinsic compression, leading to calf pain during lower limbs exercise. Non-invasive tests are still required to improve the diagnostic management of functional PAES. Exercise transcutaneous oxygen pressure (Ex-tcpO2) is of interest to provide objective arguments for the presence of regional blood flow impairment. OBJECTIVES: The aim of the study was to analyze whether Ex-tcpO2 could serve as a non-invasive technique for detecting ischemia resulting from PAES. METHODS: Patients with suspected PAES were recruited between 2017 and 2020. The diagnosis was confirmed or rejected, according to the surgical decision based on our diagnosis management involving a multidisciplinary team. Each patient underwent Ex-tcpO2 with specific maneuvers. The decrease from rest of oxygen pressure (DROP) index served for the interpretation of exercise results. RESULTS: Sixty-five legs with suspected PAES were recruited. Diagnosis was confirmed in 34 (52.3%) and rejected in 32 (47.7%). The average DROP values found in confirmed and rejected group at left leg were - 21.6 ± 15.4 mmHg and - 10.9 ± 11.1 mmHg, respectively (p for Mann-Whitney 0.004), and - 15.8 ± 11 mmHg and - 11.1 ± 7.5 mmHg, respectively, at right leg (p = 0.088). Ex-tcpO2 sensitivity and specificity were 52.9% and 78.1%, respectively. CONCLUSION: Ex-tcpO2 is an original non-invasive investigation for patients with claudication of doubtful arterial origin. The sensitivity and specificity are 52.9% and 78.1% in functional PAES diagnosis using 15 mmHg as threshold to detect ischemia during tiptoeing elevations.

Popliteal Entrapment Syndrome: Diagnostic, Surgical Management, and Short-Term Results of a Ten-Year Experience.

BACKGROUND: Popliteal artery entrapment syndrome (PAES) is a rare cause of lower limb claudication in young sportsperson without cardiovascular risk factor. We reported our diagnostic approach, surgical management, and short-term outcomes of this syndrome, over a 10-year period. METHODS: Sportsperson with intermittent claudication systematically received color duplex ultrasonography with dynamic maneuvers in the sport medicine department. In case of PAES suspicion, diagnosis was confirmed by dynamic computed tomography or dynamic magnetic resonance angiography. Each patient was then evaluated by a vascular surgeon and surgery was performed. We retrospectively screened patients who underwent PAES surgery between 2010 and 2020 in the Department of Surgery in Angers University Hospital. RESULTS: Between January 2010 and December 2020, 38 patients with 67 symptomatic legs underwent surgery for PAES. Twenty three (60.5%) were men. The mean age at the time of surgery was 24.7 +/- 9 years. Clinical presentation was bilateral in 30 patients (81.1%). Duplex ultrasound demonstrated severe stenosis or occlusion in 45 legs (77%). When performed, CT-scan demonstrated popliteal artery compression in all cases (100%). As per Whelan and Rich classification, 36 patients (94.7%) had type 6 PAES. There was no mortality or severe complication after surgery. Morbidity included 4 postoperative hematoma (6%) and 8 prolonged healing (13%). The mean time of follow-up was 2.3 months +/- 1.2 months. After surgery, D-scan showed no signs of remaining popliteal artery compression in 92.5% of the case. Twelve patients (33.3%) were able to resume sport, 18 (50%) partially, and 6 (16.6%) did not resume sport yet. CONCLUSIONS: We report a cohort of 38 patients who underwent surgery for PAES. Among them, 36 (94.7%) were functional PAES. Morbidity included 13% of prolonged healing. Two months follow-up demonstrated good results at dynamic D-scan without signs of remaining popliteal artery compression in 92.5% of the cases. These short-term results showed that one-third of patients were able to resume sport activity at an initial level.

Long-Term Functional Outcomes After Surgery of Functional Popliteal Artery Entrapment Syndrome.

BACKGROUND: Functional popliteal artery entrapment syndrome (fPAES) is a subtype of PAES without anatomic abnormalities entrapment of the popliteal artery. One of the management of symptomatic fPAES is surgical exploration of the popliteal region with popliteal artery release with lysis of fibrous bands. There is a lack of data regarding the long-term functional results of this surgery, most of the studies focusing on vascular patency in anatomical PAES. The aim of this study was to assess the efficacy of surgery in functional PAES, focusing on long-term physical activity return after surgery with the Tegner activity scale. METHODS: All patients who underwent surgery for fPAES from January 1, 2010, to December 31, 2020, were searched. After ethical approval, all patients were called to evaluate physical activity since surgery. The Tegner activity scale is a numerical scale with each value (0 to 10) representing specific activity. The aim was to evaluate everyday activity limitations and participation restriction after surgery. The results for each patient were recorded: "before symptoms," "before surgery," and "after surgery." RESULTS: Over the study period, 33 patients were included with 61 symptomatic legs. The mean time between surgery and phone call was 38.6 ± 21.9 months. The median score of the Tegner activity scale "before symptoms" was 7 (4-7), the median score "before surgery" was 3 (2-3), and the median score at the time of the phone call "after surgery" was 5 (3-7). P value was <0.0001 by comparing results "before surgery" and "after surgery." CONCLUSIONS: Results demonstrated that the sport activity and intensity level is significantly higher after surgery even if patients did not reach their initial sport activity level.

Ten-year Experience of Surgical Management of Paget-Schroetter Syndrome.

BACKGROUND: Paget-Schroetter syndrome (PSS) or effort-induced thrombosis is an acute (<14 days) venous thrombosis of the axillosubclavian vein. Early catheter-directed thrombolysis (CDT) is required to improve patency rate and avoid postthrombotic syndrome. This study aimed to report the management of PSS in our center across 10 years and compare it to the established guidelines. METHODS: Some of the selected patients were treated with CDT if the diagnosis of acute vein thrombosis was established 6 weeks after the appearance of the first symptoms and if a vascular surgeon was involved in the care and management of the patient. Patients underwent first rib removal 6 weeks after the CDT. Some patients with primary upper limb venous thrombosis were not immediately referred to a vascular surgeon after the initial diagnosis. They were instead discharged home with the prescription of oral anticoagulation therapy (OAT) alone for at least 3 months. RESULTS: Between 2010 and 2020, 426 first rib removal procedures were performed for 338 patients with thoracic outlet syndrome (TOS) at our center. Among them, 18 (4.2%) patients with PSS were identified. 5 (27.8%) patients underwent CDT. The median duration between first symptoms and thrombolysis was 10 days (range, 1-32). Thirteen (72.2%) patients were discharged home with OAT alone and referred to a vascular surgeon with a median time of 365 days (range, 8-6,422) for TOS diagnosis. Postthrombotic syndrome was noticed in 5 (38%) patients in the OAT group and 1 (20%) patient in the CDT group. CONCLUSIONS: Despite the guidelines being in favor of early CDT in PSS, most patients are discharged home with OAT alone. The study findings demonstrate that better information about this specific complication must be provided to the concerned practitioners who are likely to encounter such patients.

Risk Factors for Incomplete Aortic Remodeling With Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair for Complicated Aortic Dissection: Results of a Multicenter Study.

PURPOSE: The STABILISE technique has extended the treatment of aortic dissection to the thoracoabdominal aorta to achieve complete aortic remodeling. The aim of this multicenter study was to analyze the short- and midterm anatomical results of the STABILISE technique. MATERIALS AND METHODS: We retrospectively analyzed patients treated with the STABILISE technique for complicated aortic dissection at 3 French academic centers. The aortic diameter at different levels was measured preoperatively, postoperatively, and at 1 year. RESULTS: Between 2018 and 2020, 58 patients, including 47 men (average patient age: 60±11 years), were treated for type B aortic dissection in 34 cases and residual aortic dissection after type A repair in 24 cases. Three (5.2%) patients died postoperatively. Complete aortic remodeling (false lumen thrombosis and complete reapposition of the intimal flap) was achieved in 45/55 patients (81.8%), and false lumen thrombosis in the thoracic aorta was achieved in 52/55 patients (94.5%). At 1 year, with a computed tomographic (CT) scan available for 98.2% (54/55) of patients, we observed a significant decrease in the maximal thoracic aortic diameter and a significant increase in the aortic diameter at the bare-stent level compared with the preoperative CT scan. Severe aortic angulation (p=0.024) was a risk factor for incomplete aortic remodeling and significantly increased the aortic diameter (p=0.032). Chronic aortic dissection was associated with an increased risk of incomplete aortic remodeling (p=0.002). CONCLUSIONS: STABILISE for complicated aortic dissection results in false lumen thrombosis, complete reapposition of the intimal flap, and a decrease in the maximum aortic diameter in most cases. Incomplete reapposition of the intimal flap, which is more frequent in cases of chronic aortic dissection and severe aortic angulation, is a risk factor for a significant increase in the aortic diameter at the bare-stent level, and this risk justifies close follow-up and better patient selection. CLINICAL IMPACT: STABILISE technique for complicated aortic dissection results in false lumen thrombosis, complete aortic remodeling and a decrease in the maximum aortic diameter in most cases. At the bare-stent level, incomplete reapposition of the intimal flap, more frequent in chronic aortic dissection and severe aortic angulation, is a risk factor for an increased aortic diameter. This finding justifies close follow-up and better patient selection; thus, the STABILISE technique should be used with care in chronic aortic dissection and severe aortic angulation.

Relationship Between the Severity of Exercise Induced Ischaemia and the Prevalence of Exercise Induced Calf Symptoms During Treadmill Testing With Transcutaneous Oximetry.

OBJECTIVE: It was hypothesised that there is a linear relationship between the severity of exercise induced calf ischaemia and the prevalence of calf claudication on a treadmill until a plateau is reached. It was expected that no pain would be present in the absence of ischaemia and all severely ischaemic calves would be symptomatic. METHODS: This was a retrospective analysis of a cross sectional acquired database recording. Transcutaneous oxygen pressure (TcPO2) on the chest and on each calf was used to evaluate calf ischaemia during treadmill tests with simultaneous recording of calf pain in 7 884 subjects (15 768 calves). The minimum value of calf changes from rest minus chest changes from rest (DROPm) was calculated. Regression analyses were used to determine the correlation between the proportion of exercise induced symptoms present in the calves and each unit of DROPm values. Analysis was repeated after objective determination of the cutoff point between the linear increase and the plateau. RESULTS: A linear relationship was found between the degree of ischaemia and the proportion of symptomatic calves for DROPm values ranging from 0 mmHg to -28 mmHg (proportion = -0.014 × DROPm + 0.32, r = 0.961, p <.001). For DROPm values lower than -28 mmHg (severe ischaemia), on average one of three limbs remained asymptomatic. The biphasic relationship between DROPm and prevalence of symptoms persists after exclusion of patients with diabetes mellitus, exercise induced hypoxaemia, and no evidence of lower extremity arterial disease (LEAD). CONCLUSION: The relationship between exercise induced pain and ischaemia is biphasic with a linear increase in the proportion of symptomatic limbs with ischaemia severity, until a plateau is reached for the more severely ischaemic limbs. The presence of exercise related calf symptoms should not automatically be reported as indicating the presence of LEAD; and the absence of exercise induced symptoms is not proof that ischaemia does not occur during exercise.

Evaluation of Quality of Life after Surgical Treatment of Thoracic Outlet Syndrome.

BACKGROUND: To evaluate the quality of life of surgically treated patients for TOS. METHODS: A prospective observational study, including patients treated surgically for TOS in 2018. Two standardized questionnaires: Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Short-Form 12 (SF-12) were used. The SF-12 consists of a physical and mental component (PCS-SF-12 and MCS-SF-12). The questionnaires were completed during the preoperative and postoperative consultations and at 3, 6, and 12 months. RESULTS: We performed 53 interventions. The population was mostly female (n = 35, 66.0%) of 40.1 ± 10.0 years. The preoperative DASH score was 46.3 ± 19.7. It was 40.9 ± 21.7 at 6 weeks, 33.5 ± 22.7 at 3 months, 28.9 ± 22.6 at 6 months, and 21.1 ± 20 at 9 to 12 months. The improvement of DASH becomes statistically significant at 3 months (P = 0.036), 6 months (P = 0.002), and 12 months (P = 0.001). The preoperative MCS-SF-12 was 36.6 ± 9.4. It was 41.6 ± 10.9 at 6 weeks, 43.8 ± 11.1 at 3 months, 46.2 ± 11.8 at 6 months, and 51.4 ± 8 at 8 to 12 months. The improvement of MCS-SF-12 became significant at 3 months (P = 0.009), 6 months (P = 0.001), and 12 months (P = 0.001). The preoperative PCS-SF-12 was 35.5 ± 6.4. It was 37.1 ± 8.7 at 6 weeks, 39.9 ± 8.7 at 3 months, 41.6 ± 8.4 at 6 months, and 46.1 ± 8.1 to 12 months. The improvement of PCS-SF-12 became significant at 6 months (P = 0.005) and 12 months (P = 0.001). CONCLUSIONS: The surgical management of TOS allows for an improvement in quality of life in the short and medium terms.

Calf and non-calf hemodynamic recovery in patients with arterial claudication: Implication for exercise training.

BACKGROUND: Previous studies in patients with arterial claudication have focused on calf hemodynamic recovery. We hypothesized that the duration of hemodynamic recovery with TcpO2 at calf and non-calf levels would be shorter than 10 min. We analyzed the factors that influence the recovery time. METHODS: We monitored limb changes minus chest changes from rest (DROP) of transcutaneous oximetry on buttocks, thighs and calves, during and following a treadmill test (3.2 km/h; 10% grade). We calculated the time required to reach 50% (50%RT) and 10% (90%RT) of minimal DROP value (DROPm) from walking cessation. Regression analyses were used to determine the factors associated to 50%RT and 90%RT. RESULTS: Of the 132 patients studied, 18.2% reported isolated non-calf pain by history. Of the 792 recovery time values, only 3 (0.4%) and 23 (2.9%) were in excess of 10 min for 50%RT and for 90%RT, respectively. A weak correlation was found between each of the 792 DROPm and 50%RT (r = -0.270, p < 0.001) as well as for 90%RT (r = -0.311 p < 0.001). Lowest DROPm and BMI (but not age, sex, the use of beta-blockers, the duration of the walking period) were associated to both 50%RT and 90%RT. CONCLUSION: Although recovery duration correlates significantly with the severity of ischemia of the same location, a wide discrepancy exists and the longest recovery time does not always correlate to the localization of the most severe ischemia. Non-calf ischemia should be measured when one aims at objectifying the biological effects of exercise or the effects of treatments on recovery from exercise.

Disparities Between International Guidelines (AHA/ESC/ESVS/ESVM/SVS) Concerning Lower Extremity Arterial Disease: Consensus of the French Society of Vascular Medicine (SFMV) and the French Society for Vascular and Endovascular Surgery (SCVE).

Several international guidelines concerning lower extremity arterial disease (LEAD) have been published recently, in particular, by the American Heart Association the European Society of Cardiology/European Society for Vascular Surgery, the European Society for Vascular Medicine and the Society for Vascular Surgery. These guidelines differ in some respects and certain issues are not addressed. The objective of this consensus driven by the French Societies of vascular Medicine and surgery was to analyze the disparities between the different guidelines, as well as certain issues not covered, and develop proposals with regard to these points. The following fields of LEAD have been explored: 1) classifications, 2) clinical evaluation, 3) diagnostic criteria, 4) quantification of arterial stenosis using duplex ultrasound, 5) detection of asymptomatic multisite lesions, 6) screening for LEAD in the context of cardiac disease, 7) medical treatment, 8) supervised exercise therapy, 9) revascularization and revascularization of the internal artery stenosis, 10) management of chronic limb ischemia, 11) longitudinal follow-up, and 12) diet.

Comparison of exercise oximetry and ankle pressure measurements for patients with intermittent claudication: an observational study of 433 patients.

To study the concordance of exercise-oximetry and of ankle-brachial pressure index (ABI) and ankle pressure (AP) at rest, and after exercise, in patients complaining of vascular-type claudication to diagnose lower extremity artery disease (LEAD). Treadmill test in 433 patients with exercise-oximetry included constant load (3.2 km/h, 10% slope) phase for up to 15 min followed by an increment phase, if necessary. The presence (TcpO2e+) or absence (TcpO2e-) of ischemia was a decrease of limb minus chest oxygen pressure change greater than or less than - 15 mmHg. The post-exercise ABI and AP were measured after another test of a maximum of 5 min except if resting-ABI < 0.90. LEAD was diagnosed (+) based on resting-ABI < 0.90, post-exercise ABI < 0.8∙resting-ABI, or a difference of 30 mmHg between post-exercise and resting AP, or diagnosis was considered negative for all other cases (-). The discrepancies between the exercise-oximetry and pressure results were analyzed. We found 351 patients with resting-ABI+, of whom 52 were classified as TcpO2e-. Of the 82 patients with resting-ABI-, 25 had post-exercise ABI+ or AP+, of whom, 10 had TcpO2e-, while 57 had post-exercise ABI- and AP-, of whom, 28 had TcpO2e+. Discrepancies arose mainly from nonvascular limitations, isolated proximal ischemia, and detection of LEAD in the incremental phase of the exercise-oximetry. Post-exercise pressure measurements were easy and useful, but exercise-oximetry provided additional information for both resting-ABI- and resting-ABI+ patients and can help to prove the vascular origin of walking limitation of LEAD patients.

A pilot study of forearm microvascular impairment and pain while using a telephone.

OBJECTIVE: To determine if using a telephone can induce forearm pain and ischemia. DESIGN: Prospective case-control trial. SETTING: Vascular laboratory in the university hospital in Angers between September 2018 and March 2019. PARTICIPANTS: Fifteen apparently healthy subjects (controls) and 32 patients with suspected thoracic outlet syndrome (TOS) of vascular or non-vascular origin. INTERVENTION: Hand-holding a cellular phone to answer a call from investigators. MAIN OUTCOME MEASURES: Presence of forearm fatigue or pain (primary outcome), ability to hold the phone with each hand for 1 min (secondary outcome 1) and decrease in forearm transcutaneous oxygen pressure DROP index indicating forearm ischemia (secondary outcome 2). A DROP < -15 mm Hg defined ischemia. RESULTS: Answering a phone call resulted in 25(78%) patients with forearm fatigue or pain and in 18 (56%) cases in the inability to hold the phone for 1 min, on one or both arms in patients with suspected TOS, but never occurred in healthy volunteers (p < .05 and p < .001). The presence of ischemia was observed in one or both arms in 10 (31%) patients with proved TOS and was always associated to phone-induced pain. Three (20%) of the controls had phone-induced ischemia. All had asymptomatic TOS and remained asymptomatic during the phone test (p = .42 from suspected-TOS patients). CONCLUSION: The phone conversation resulted in pain in many patients with suspected TOS. Transcutaneous oximetry can document the underlying ischemia. Forearm phone-call-induced pain may be indicative of TOS provided that no earplug or headset is used. Trial registrationClinicalTrials.govNCT03355274.

Surgery of Renal Artery Aneurysms: A Monocentric Retrospective Study.

BACKGROUND: The aim of the study was to report the results of conventional surgery for renal artery aneurysms (RAAs) in our center. MATERIAL AND METHODS: We retrospectively reviewed the files of all the patients operated for RAAs between 2009 and 2018 in our center. We collected demographic, biological (renal function), morphological (computed tomography [CT] scan), and functional (ultrasound examination and resistance index) preoperative and postoperative data. Clinical and paraclinical operative data were examined. Results were expressed as average ± standard deviation or median and extremes. RESULTS: A total of 26 aneurysms were operated in 20 kidneys (10 right kidneys) among 19 patients, including 13 (68%) women with an average age of 55 (±12) years. Three (16%) patients presented an aneurysm in a single kidney. The discovery of the aneurysm was fortuitous in 14 (74%) patients. One patient with Marfan syndrome was operated after a postpartum rupture. The median diameter of the operated aneurysms was 22 mm (7-48), and 23 (90%) were hilar aneurysms. Arterial repair was carried out in situ in 16 (80%) kidneys. The surgery consisted of a direct arterial repair in 21 cases (81%), including 4 resections and anastomoses, 12 aneurysmorrhaphies, and 5 complex reconstructions. Four arterial replacements were carried out (one prosthetic graft, 2 femoral grafts, and one internal iliac graft). The average duration of renal clamping was 30.5 (±17.3) min. Postoperative renal function was unchanged in all the patients except for one (5.2%) who required 2 days of postoperative dialysis. The resistance index of all the operated kidneys was normal (0.66 ± 0.08) at discharge. Sixteen (70%) of the 23 aneurysms were examined, and anatomopathology concluded them to be of dysplastic origin. At 3 months, a systematic CT scan objectified the patency of 95% of the arterial reconstructions, with 3 stenoses >50%. One stenosis >80% was treated at 7 months by balloon angioplasty. Only one operated kidney presented a loss of viability of its upper pole. The mean duration of follow-up was 54 ± 35 months. By the end of the follow-up, primary and secondary patency rates evaluated by Doppler ultrasound were 90% and 95%, respectively. CONCLUSIONS: Conventional surgery generally performed in situ remains a sure and effective treatment for RAAs. This challenging surgery for a rare disease should be performed in experimented centers.

Treatment of Carotid Restenoses after Endarterectomy: A Retrospective Monocentric Study.

BACKGROUND: To compare the different techniques for the treatment of carotid restenosis after carotid artery endarterectomy (CAE). METHODS: Among 1,218 carotid surgeries carried out in our center between January 2010 and November 2017, 45 procedures were performed for carotid restenosis after CAE, including 11 by iterative conventional surgery and 34 with endovascular techniques (7 transluminal angioplasties alone [TLA], 9 carotid artery stenting [CAS], and 18 angioplasties with active balloons [drug-coated balloon {DCB}]). Perioperative data (cumulated rate of morbimortality [CRMM], duration of hospitalization) and postoperative results (survival, symptomatic restenoses > 50% or asymptomatic stenoses > 70% on ultrasound, reinterventions) were collected retrospectively and analyzed with Fisher's exact test. The long-term results were estimated according to the Kaplan-Meier estimator and were compared with the log rank test (P < 0.05 was regarded as significant). RESULTS: There was one secondary death due to a massive postoperative stroke in the endovascular (ENDO) group. No significant difference regarding CRMM (2.9%, P = 0.756) between the iterative conventional surgery (open surgery; OS) and the ENDO groups of was observed. Three hematomas were found in the OS group versus one in the ENDO group (P = 0.04). The length of hospital stay was shorter in the ENDO group (P < 0.001). No difference was found between the ENDO group and the OS group regarding the two-year survival or the survival without recurrent restenosis (86 vs. 100%, log rank = 0.804, and log rank = 0.114). There were 5 restenoses >70% and two reinterventions in the ENDO group (P > 0.05). The comparison of the different endovascular techniques did not show significant differences regarding the CRMM, the one-year overall survival, the survival without recurrent restenosis, or the survival without reintervention (89% in the DCB and CAS groups vs. 100% in the percutaneous transluminal angioplasty [PTA] group, log rank = 0.286; 87% in the DCB group vs. 100% in the PTA and CAS groups, log rank = 0.137; and 94% in the DCB group vs. 100% in the PTA and CAS groups, log rank = 0.585, respectively). CONCLUSIONS: In our experience, endovascular procedures are equivalent to iterative conventional surgery for the treatment of carotid restenoses in terms of major complications, news restenoses, or survival with less hematoma and a shorter duration of hospitalization. We however could not identify the best endovascular strategy in this indication, and a controlled study comparing the various endovascular strategies is proposed.

Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting.

PURPOSE: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. MATERIALS AND METHODS: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. RESULTS: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2-month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. CONCLUSION: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents.

Treadmill Measured vs. Questionnaire Estimated Changes in Walking Ability in Patients With Peripheral Artery Disease.

OBJECTIVE: Determining the maximum walking time (MWT) using the treadmill test is the gold standard method for evaluating walking capacity and treatment effect in patients with peripheral arterial disease (PAD). However, self reported functional disability is important when assessing quality of life. Changes in the Walking Estimated Limitation Calculated by History (WELCH) questionnaire scores were compared with the MWT. METHODS: A cross sectional study was performed in patients with intermittent claudication. The treadmill test (3.2 km/h; 10% gradient) and WELCH questionnaire were administered to all patients for objective evaluation of walking capacity. Given the log normal distribution of these parameters in patients with PAD, a log transformation was applied to the WELCH score (LnW) and maximum walking time (LnT). The responsiveness of the WELCH score was determined using mean changes and correlation coefficients of LnW and LnT changes. The effect of time on the "estimated minus real" (E - R) changes (LnW - change minus LnT - change) was assessed after categorisation of patients into various test-retest intervals. Patients who underwent lower limb revascularisation between the two tests and those who underwent medical treatment only were analysed. RESULTS: Correlation coefficients between LnW and LnT for tests 1 and 2 were r = 0.514 and r = 0.503, respectively (p < .001, for both). Correlation for LnW change vs. LnT change was 0.384 (p < .001). E - R was positive only early after surgery. E - R was negative for all test-retest intervals >1 year in revascularised and non-revascularised patients. CONCLUSION: Changes in WELCH scores correlated with changes observed on the treadmill in patients with intermittent claudication. For long test-retest intervals, WELCH changes tended to overestimate the worsening of walking impairment as compared with the measured difference observed in both revascularised and non-revascularised patients. A shortlived "honeymoon" (overestimation of the benefit for the shortest test-retest interval) was observed only in revascularised patients.

What Is the Secondary Patency of Thrombosed Bypasses of the Lower Limbs Cleared by Fibrinolysis In Situ?

BACKGROUND: In case of acute thrombosis, lower limb bypasses can, in certain cases, be cleared by local intra-arterial fibrinolysis (LIF). The aim of this study is to evaluate the secondary patency of thrombosed bypasses after fibrinolysis. METHODS: This retrospective study includes all patients hospitalized for thrombosed bypasses of the lower limbs that were treated with in situ fibrinolysis using urokinase, between 2004 and 2013, in 2 French university hospital centers. Fibrinolysis was indicated in case of recent thrombosis (<3 weeks) provoking acute limb ischemia without sensory-motor deficit and in the absence of general contraindications. The secondary patency of the grafts was defined as the time after fibrinolysis without a new thrombotic event. RESULTS: There were 207 patients, hospitalized for recent thrombosis of 244 bypasses. The LIF was efficient in 74% of the cases (n = 180). Secondary patency of these bypasses was 54.2% and 32.4% overall, 68.3% and 50.3% for the suprainguinal bypasses, and 48.3% and 21.5% for the infrainguinal bypasses at 1 and 5 years, respectively. There is a significant difference (P = 0.002) regarding the permeability of the suprainguinal and infrainguinal bypasses. The survival rate was 75% (±6.4%) at 5 years and the limb salvage rate was 89% (±3.3%), 78.2% (±5.1%), and 75% (±5.8%) at 1, 3, and 5 years, respectively. The only independent factor influencing the secondary patency of infrainguinal bypasses that was significant in a multivariate analysis was the infragenicular localization of the distal anastomosis (P = 0.023). CONCLUSIONS: LIF is an effective approach that often allows the identification of the underlying cause, permitting elective adjunctive treatment of the underlying cause. Although LIF is at least as effective as its therapeutic alternatives described in the literature, the secondary patency of the bypasses remains modest and encourages close monitoring, particularly in patients with an infragenicular bypass.

Transcutaneous Exercise Oximetry for Patients With Claudication　- A Retrospective Review of Approximately 5,000 Consecutive Tests Over 15 Years.

BACKGROUND: Exercise transcutaneous oximetry (Ex-tcPO2) is used to argue for the vascular origin of lower limb pain, especially at the proximal level, where the diagnosis of peripheral artery disease can be difficult. This study analyzed the principal indications, mean results, and limitations of Ex-tcPO2, as well as the relationship between the annual number of Ex-tcPO2 tests and internal iliac artery (IIA) revascularizations.Methods and Results:Data from our first 15 years' experience (3,631 patients, 5,080 tests) with Ex-tcPO2 were analyzed retrospectively using the minimal value of the decrease from rest of oxygen pressure (DROPmin). We had 99.7% of expected DROPminresults. The proportion of tests showing isolated proximal unilateral or bilateral ischemia ranged from ~5% to ~20%. A gradual increase with time was observed in both the annual number of Ex-tcPO2 tests (from 0 to ~500 per year) and the annual number of IIA revascularizations performed (from 0 up to 18 per year). At least 85% of patients (77/91) showed function improvement after IIA revascularization. CONCLUSIONS: Ex-tcPO2 (using DROPmin) provides an objective argument for exercise-induced ischemia, bilaterally at the distal and/or proximal level. Using Ex-tcPO2 has improved our diagnostic performance and markedly changed our therapeutic decisions, specifically for proximal claudication. The increased number of Ex-tcPO2 tests is associated with an increased number of IIA revascularizations, although a causal relationship was not proven.

Frequency of the Pectoralis Minor Compression Syndrome in Patients Treated for Thoracic Outlet Syndrome.

BACKGROUND: Pectoralis minor compression syndrome (PMCS) is a compression of the neurovascular structures in the subpectoral tunnel and remains underestimated in the management of patients with thoracic outlet syndrome (TOS). Its underdiagnosis may be responsible for incomplete or failed treatment. The aim of the study was to evaluate the frequency of PMCS in our experience. METHODS: We retrospectively reviewed all patients treated for TOS in our department. We selected those in whom PMCS was diagnosed with a systematic dynamic arteriography. Surgery was performed using the Roos axillary approach when a first rib resection was associated or an elective approach when a first rib resection was not associated. RESULTS: From January 2004 to December 2014, 374 surgeries for TOS were performed in 279 patients, which included 90 men (sex ratio = 0.48) with a mean age of 40.1 ± 10 years old. Among these patients, 63 (22.5%) underwent 82 interventions (21.9%) for PMCS, including 26 men (sex ratio = 0.70, P < 0.05) with a mean age of 37.9 ± 9.4 years old. Tenotomy of the pectoralis minor muscle was performed using axillary approach if it was associated with a first rib resection in 74 cases (90.2%) or through an elective approach in 8 cases (9.8%) if it was isolated. Four (4.9%) postoperative complications were found (1 hematoma [1.2%], 1 hemothorax [1.2%], 1 scapula alata [1.2%], and 1 subclavian vein thrombosis [1.2%]), all after an axillary approach. In 63 cases (79.7%), preoperative symptoms were resolved. In 14 cases (17.7%), symptom resolution was incomplete, and 2 patients (2.6%) had recurrent symptoms. CONCLUSIONS: Evaluation of PMCS in TOS is justified by its frequency and the simplicity and low morbidity of the surgical procedure.

Evaluation of the Vascular Surgical Complications of Renal Transplantation.

BACKGROUND: Renal transplantation is the treatment of choice of end-stage renal failure. However, vascular surgical complications can compromise the functional prognosis of the transplant or even be life threatening in the short term. Since few data are available in the literature, the objective of this study was to evaluate the vascular surgical complications of renal transplantation. METHODS: In a retrospective and monocentric study, the records of all the patients receiving a kidney transplant between January 2008 and December 2014 were reviewed. The demographic data and the follow-up of the patients who presented a vascular surgical complication in relation to their transplant were collected. Minor, intermediate, or major vascular complications were defined according to the need for monitoring, reoperation, or the risk of transplant loss or a life-threatening situation. Predictive factors of vascular complications were also looked for. RESULTS: Mean age was 50.9 ± 15.0 years, and 312 kidney transplants were carried out (205 men). Fifty vascular surgical complications (16.0%) were found. Among them, 23 vascular complications (7.4%) were major, including 6 (1.9%) which required transplantectomy, after 4 arterial thromboses (1.3%), 1 early venous thrombosis (0.3%), and 1 injury of the inferior vena cava (0.3%). Twelve complications (3.8%) were minor. Surgical revision was necessary in 76% of the vascular complications (n = 38). The average follow-up of the transplanted population was 37.4 ± 24.0 month, 268 kidney transplants (85.8%) were functional and 21 patients (6.7%) returned to dialysis. Surgical complications were more frequent when the recipient had hypertension (P = 0.02, OR = 2.5; 95% CI [1.1-6.1]), in case of right kidney transplant (P = 0.0004, OR = 3.1; 95% CI [1.6-5.8]) and when the kidney hilum consisted of at least arteries (P = 0.02, OR = 10.0; 95% CI [1.3-34]). Male gender (P = 0.03, OR = 0.5; 95% CI [0.3-0.9]) as well as the choice of the common iliac arterial (P = 0.001, OR = 0.4; 95% IC [0.2-0.7]) and venous (P = 0.002, OR = 0.3; 95% IC [0.2-0.8]) axes to carry out the vascular anastomoses appeared as protective factors. CONCLUSIONS: The vascular surgical complications of kidney transplantation, especially thromboses, can be serious and lead to transplant loss. The expertise of vascular surgeons finds its place here and makes it possible to maintain low rates of vascular complications and loss of transplants.