[Carotid Stenting in France after the EVA 3S and SPACE publications]. / Stenting carotidien en France après les publications d'EVA 3S et de SPACE?

Angioplasty of stenoses of the carotid bifurcation is a revascularization procedure that is used successfully in many patients. With more than 10 years of experience now, the feasibility of carotid stenting has been demonstrated. Its distribution is highly variable depending on the country, with a mean penetration rate in Europe of 15% of the number of carotid revascularizations. However, the complication rate is highly variable from one series to another and depends on the type of patient treated and the operator's learning curve. The results of the first two randomized studies comparing endarterectomy and carotid stenting, EVA 3S in France and SPACE in Germany, have just been published. The conclusions of these studies only relate to symptomatic patients, who make up a small proportion of revascularized patients. At 30 days, the French study concluded that surgery was better, and the German study showed no advantage to stenting. The analysis of these results compared to other publications should make it possible to best define the current indications for carotid stenting.

Carotid angioplasty and stenting with and without cerebral protection: clinical alert from the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) trial.

BACKGROUND AND PURPOSE: Whether cerebral protection during carotid angioplasty and stenting (CAS) is associated with a lower risk of periprocedural stroke or death remains to be established. We report on 80 patients randomized in the CAS arm of the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis trial comparing CAS (with or without cerebral protection) with carotid surgery in patients with recently symptomatic, severe carotid stenosis. SUMMARY OF REPORT: The Safety Committee recommended stopping unprotected CAS, because the 30-day rate of stroke was 3.9 (0.9 to 16.7) times higher than that of CAS with cerebral protection (4/15 versus 5/58). CONCLUSIONS: Although this result was not based on a randomized comparison of unprotected versus protected CAS, it suggests that the use of cerebral protection devices during CAS reduces periprocedural strokes.

Angiographic and electron-beam computed tomography studies of retrograde cardioplegia via the coronary sinus.

Retroperfusion of the coronary sinus does not provide homogeneous distribution of cardioplegic solution. The goal of this study was to analyze the distribution of flow during retrograde cardioplegic infusion in cadaveric human hearts with two different techniques of coronary sinus cannulation: (1) internal occlusion of the coronary sinus by balloon inflation and (2) external occlusion by tightening the orifice of the coronary sinus around a simple catheter. To evaluate differences between the two techniques, angiographic and electron-beam computed tomographic studies were performed. Computed digital angiography was performed on 14 hearts. Angiographic patterns varied according to type of coronary sinus cannulation. With the balloon inflation technique, the marginal vein and the anterior descending vein were perfused first; the posterior descending vein was not perfused. This vein was opacified secondarily through a venovenous anastomosis located at the apex of the heart. Backward flow into the right atrium (steal phenomenon) was demonstrated. At completion of retroperfusion, the inferior part of the septum remained poorly opacified. Conversely, angiographic findings after external occlusion of the coronary sinus revealed simultaneous injection of all venous channels. The entire septum was well opacified at completion of retroperfusion. Electron-beam computed tomographic study was performed on eight hearts with the external occlusion technique and nine with the internal occlusion technique. The computed tomographic findings confirmed the results of digital angiography. The peak myocardial enhancement and the peak rising rate of myocardial enhancement within the interventricular septum were significantly more important (p < 0.0001) when the external coronary sinus occlusion mode was used than when the internal coronary sinus occlusion mode was used. In all hearts except one, the right ventricular wall was not opacified, regardless of the type of cannulation and the type of radiologic analysis. This study demonstrates the importance of coronary sinus cannulation technique in optimizing the protection of the interventricular septum with retrograde cardioplegic infusion.

Revival of the radial artery for coronary artery bypass grafting.

Eighteen years after its first introduction for coronary artery revascularization, the radial artery (RA) was reinvestigated because of unexpected good long-term results in the early series. Since July 1989, 104 patients underwent myocardial revascularization using 122 RA grafts (18 patients received two grafts). The left internal mammary artery (IMA) was concomitantly used as a pedicled graft in 100 cases and the right IMA in 19 cases; a free IMA graft was used in 29 cases and a saphenous vein graft in 24 cases. A mean of 2.8 grafts per patient were performed. Nine patients underwent associated procedures: carotid endarterectomy (3), aortic valve replacement (3), Bigelow procedure (1), and mitral valve repair (2). The target artery receiving the RA was the circumflex (n = 59), diagonal (n = 29), right coronary (n = 27), and left anterior descending (n = 7). One patient died (0.96%) and 2 had perioperative myocardial infarct. Sternal wound infection was noted in 3 cases of double IMA implantation. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition aspirin (100 mg/day) was given at discharge. Early angiographic controls (less than 2 weeks) were obtained in the first 50 consecutive patients and revealed 56 of 56 patent RA grafts, 48 of 48 patent left IMA grafts, 11 of 11 patent right IMA grafts, 14 of 18 patent free IMA grafts, and 8 of 9 patent vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of cardiac tumor by percutaneous thromboaspiration. A case report]. / Diagnostic d'une tumeur cardiaque par thromboaspiration percutanée. A propos d'un cas.

Percutaneous endovascular thromboaspiration is a valuable tool as illustrated by the case of a patient suffering from a large intracardiac tumour. Histological and immuno-histochemical analysis of the tumour fragments provided the diagnosis of a cardiac angiosarcoma. The patient was a 44 year old man admitted for a large sero-sanguinous pericardial effusion which recurred after drainage. The case was complicated by a haemorrhagic cerebrovascular accident unrelated to a secondary deposit. Initially suspected after transthoracic echocardiography, the diagnosis of a tumour invading the right atrium was confirmed by transoesophageal echocardiography and cardiac CT scan. Surgery was declined and as the diagnosis of lymphoma could not be excluded, the patient underwent biopsy by an original method of percutaneous thromboaspiration. This minimally invasive, low cost technique would appear to be a valuable alternative to other endovascular biopsy techniques (saber, biotome) and to surgical biopsy, and could be proposed as the technique of first intent in an a priori non-operable intra-cardiac tumour or when lymphoma is suspected.

[Critical limb ischaemia: endovascular treatment in diabetic patients?]. / Approche interventionnelle des artériopathies périphériques. Existe-t'il des spécificités chez le diabétique?

Endovascular treatment has an increasing role in the treatment of patients with critical limb ischemia, particularly in diabetic patients with a majority of infrapopliteal lesions. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses and short occlusions that impair distal vascularization. Stents are indicated when there is a suboptimal results following balloon angioplasty (recoil or dissection). Restenosis rate after primary stenting for long lesion is high. Angioplasty is a safe and effective procedure, allowing limb salvage rate in a majority of the cases with a low mortality and morbidity rate.

[Early angiographic evaluation of coronary bypass using arterial grafts]. / Evaluation angiographique précoce des pontages coronaires par greffons artériels.

The aim of this study was to evaluate the early postoperative angiographic features of arterial coronary bypass grafts in 83 asymptomatic patients referred consecutively from the surgical unit. The patients aged 33 to 78 years (average 62 years) were operated between August 1989 and March 1992 and received only arterial coronary bypass grafts: 209 arteries bypassed (121 internal mammary including 10 sequential grafts, 46 radial, 36 epigastric including 4 sequential grafts and 6 gastroepiploic arterial grafts), an average of 2.4 bypass grafts per patient. Selective angiography of the arterial grafts was performed systematically between the 7th and 15th postoperative days in patients with uncomplicated recoveries. The native coronary arterial network was opacified only when a graft was "non-functional": haemodynamic (> 70%) stenosis or occlusion. 3.8% of pediculated mammary grafts were occluded. On the other hand, 16.6% of free internal mammary grafts were occluded. None of the radial artery grafts were occluded, but 8% were stenotic. Finally, 30% of epigastric and 50% of the gastroepiploic grafts were occluded. These results confirm the good function of in situ mammary artery grafts by suggest that systematic multiple arterial grafts should be used with caution. Radial artery grafts give very encouraging results which require long-term evaluation. Early postoperative evaluation of coronary arterial grafts provides important information and should be considered a routine procedure.

[Use of the radial artery for coronary artery bypass. A new experience after 20 years]. / Utilisation de l'artère radiale pour les pontages coronaires. Nouvelle expérience 20 ans après.

Twenty years after its first introduction by A. Carpentier, the use of the radial artery (RA) for coronary bypass was reinvestigated because of unexpected good long term results in some patients. Since July 1989, 158 patients (pts) underwent myocardial revascularization using 189 RA grafts (31 pts received 2 grafts). The left internal mammary artery (LIMA) was concomitantly used as a pedicled graft in 151 cases and the right internal mammary artery (RIMA) in 31 cases, a free IMA graft was used in 29 cases and a saphenous vein graft in 40 cases. A mean of 2.8 graft/pt was performed. The target artery receiving the RA was: circumflex (n = 93), diagonal (n = 39), right coronary (n = 47) and LAD (n = 10). Two patients died (1.3%) and three presented a perioperative myocardial infarct (2.5%). Sternal wound infection was noted in three cases of double IMA implant. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition, aspirin (100 mg/day) was given at discharge. Early angiographic controls (< 3 weeks) were obtained in the first 60 consecutive patients and revealed: 73/73 patent RA grafts, 58/58 patent LIMA grafts, 16/16 patent RIMA grafts, 15/19 patent free IMA grafts and 10/11 patent vein grafts. Six patients presented a localized narrowing of the RA conduit unrelated to the anastomotic lines (spasm). Late angiographic control (6 to 24 months) was obtained after a mean follow-up of 11 months in 37 patients: 42/46 RA grafts were patent (91.3%) and free of spasm and 4 were occluded.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ostial stenosis of the renal arteries: treatment by angioplasty]. / Sténoses ostiales des artéres rénales: traitement par angioplastie.

In a series of 50 patients (22 females, 28 males); 52 ostial renal artery stenoses were treated by transluminal balloon angioplasty. The mean age of patients was 66 years (range 36-81); mean arterial pressures were 181 mmHg for the systolic pressure and 87 mmHg for the diastolic pressure. The mean level of serum creatinine was 179 mumol/l +/- 128. An immediate success was obtained in 86.5% (residual stenosis of 26%). There were 7.6% of immediate failures and 13.5% of residual stenosis above 50%. Mortality within 1 month was observed in 2 patients. Morbidity included one aortic dissection and 5 cholesterol embolisms. After a mean follow-up of 10 months, 78% of the series were controlled: 66.6% exhibited a residual stenosis below 50%, 25.9% had restenosis and 7.4% had an occlusion of the renal artery. Since patients with ostial renal artery stenosis constitute a high surgical risk group, transluminal balloon angioplasty might be considered as an acceptable and safe alternative treatment.

[Immediate results and 2-year follow-up of percutaneous transluminal angioplasty in intermittent claudication in patients over 70 years of age]. / Résultats immédiats et à 2 ans de l'angioplastie transluminale percutanée dans la claudication intermittente du sujet âgé de plus de 70 ans.

PURPOSE: This retrospective study was aimed at assessing immediate and mid-term results of percutaneous transluminal angioplasty for intermittent claudication in patients over 70 years of age, and the overall morbidity and mortality during follow-up. METHODS: Fifty-one percutaneous transluminal angioplasties were performed between 1993 and 1997 in 30 men and eight women (mean age: 78 +/- 5.2; range 71-91) for intermittent claudication (walking distance < 250 m). RESULTS: Angioplasties were supra-inguinal in 24 cases (47%) and infra-inguinal in 27 cases (53%). Clinical success (walking distance > 500 m) was obtained in 92% of the patients. Significant complications (5.9%) were inguinal hematoma requiring subsequent surgery in one patient and common femoral false aneurysms in two patients. Mean duration of hospitalization was 3 days and a half. After a mean follow-up of 25 months (range: 4-51 months), improvement in the walking distance was still present in 31 patients (82%). The condition of seven (18%) patients did not improve. No patient presented with critical ischemia. As well, no patient underwent surgical revascularization or amputation. However, the condition of eight (21%) patients required subsequent percutaneous transluminal angioplasty. Four (10.5%) patients died. Following percutaneous transluminal angioplasty, six (18%) patients presented with a major non-fatal clinical event. All the patients lived at home. CONCLUSION: Percutaneous transluminal angioplasty has little immediate risk when lesions are accessible and leads to positive mid-term clinical results in the treatment of intermittent claudication in patients over 70 years of age.

[Lower limb arterial disease: Doppler sonography follow-up after revascularization]. / Artériopathie des membres inférieurs: suivi par échographie-Doppler après revascularisation.

Follow-up color duplex sonography after arterial surgery or angioplasty for lower limb arterial disease evaluates the outcome of the procedure and searches for lesions compromising patency. The various types of lesions are described. After surgical bypass, lesions include stenosis, anastomotic abnormality (enlargement, false-aneurysm), arterio-venous fistula, intrinsic bypass abnormalities, and collections. After endoluminal treatment, the main lesions include residual stenosis, restenosis, and in-stent hyperplasia. Local complications related to arterial puncture are described. The frequency and the type of lesions encountered depend on the interval between the date of the revascularization and the follow-up examination.

[Drug thrombolysis and mechanical recanalization in recent femoro-popliteal arterial occlusions]. / Thrombolyses médicamenteuses et recanalisations mécaniques dans les occlusions artérielles récentes fémoro-poplitées.

Acute femoro-popliteal occlusions (native arteries or bypass grafts) were treated by medical and surgical treatment. Despite improvement in surgical technique, patient mortality was high and limb loss remained frequent. Percutaneous endoluminal treatment of such lesions is feasible using in situ fibrinolysis and/or thromboaspiration singly or in association with balloon angioplasty. Those techniques are effective and are currently the first intention treatment of many of those acute femoro-popliteal occlusion. The advantages and disadvantages of those techniques are discussed, as well as their respective indications, and particularly their place compared to surgical techniques. New devices such as mechanical thrombectomy may increase effectivity and indications of endovascular treatment however such devices need to be better evaluated.

[Isolated stenosing calcified lesions of the aorta]. / Les bourgeons calcifiés sténosants isolés de l'aorte.

Two cases of isolated calcified lesions of the aorta are reported. The first observation is that of a 25 years old man suffering from mild intermittent claudication predominant in the left leg. Radiological examination showed a calcified isolated lesion of the infra renal abdominal aorta. The patient underwent surgical treatment (thromboendarteriectomy) and was asymptomatic after 6 months. The second observation concerns a 30 years old man treated for benign thrombocytemia in whom a severe arterial hypertension associated with a thoracic bruit was discovered incidentally. Radiological workup demonstrated a solitary calcified lesion of the descending thoracic aorta. Endarteriectomy was performed and the patient was still asymtomatic at 12 months. A review of the literature as well as physiopathological hypothesis and diagnostic and therapeutic management of these uncommon lesions is proposed.

[Imaging of the extracranial carotid arteries: when, how and why?]. / Quand, comment et pourquoi réaliser une imagerie des carotides extracrâniennes?

The indications for treating carotid artery stenosis are related to the symptomatic nature of the lesion and the degree of stenosis. Duplex sonography is adequate for screening. While some groups believe that Duplex US alone or in combination with transcranial Doppler imaging may be sufficient for presurgical evaluation, it often is recommended to complete the evaluation with either MRA or CTA. Both techniques are advantageous since they allow evaluation of the cervical and intracranial arteries as well as cerebral parenchyma hence providing valuable information prior to definitive management. Catheter angiography remains indicated in patients with multi-vessel disease and ischemic cardiomyopathy, when results at non-invasive evaluation are discordant or in an emergency setting. Duplex US is used for routine follow-up of non-surgical lesions and after endarterectomy. Transcranial Doppler as well as advances in MRA and CTA techniques will be reviewed. Even though the treatment of atherosclerotic carotid artery stenoses remains primarily surgical, specific considerations related to angioplasty will be reviewed. Finally, diseases of the intracranial carotid artery and non-atherosclerotic diseases (dissection...) will also be discussed.

[Percutaneous endoluminal angioplasty of the transplanted kidney. Long-term follow-up]. / Angioplastie endoluminale percutanée des reins transplantés. Suivi à long terme.

A hundred and ninety five percutaneous transluminal angioplasty (PTA) of a renal transplant artery were attempted before january 1st, 1990 in 151 patients. Analysis of the series was essentially based on follow-up after PTA. PTA was initially successful in 85% of the patients. Restenoses occurred in 30% of the patient. They were usually amenable to repeat PTA. Restenosis rate after repeat PTA was of 26%. The five year secondary patency rate of the renal artery was over 85%. After a successful PTA, the blood pressure, the number of antihypertensive drug per patient and serum creatinine returned to a level close to their basal value within few days and remained stable long. After an immediate failure of PTA, secondary patency rate of the renal transplant artery was over 80% at one year. Blood pressure returned to a level close to its basal value. But, that improvement was slower (1 to 6 months) and antihypertensive drug regimen and serum creatinine remained stable. We conclude that PTA is an effective treatment at long term of hypertension and of decline in renal function due to stenoses of renal transplant arteries. However PTA carried some risks and should be attempted only stenoses of renal transplants arteries cause, severe hypertension resisting to medical therapy or decline in renal function.

[Current role of angioplasty in lower limb arteriopathy obliterans]. / Aspect actuel de l'angioplastie dans l'artériopathie oblitérante des membres inférieurs.

For intermittent claudication caused by aorto iliac artery occlusive disease, percutaneous transluminal angioplasty is a safe and successful treatment. The introduction of vascular stents has been helpful in case of insufficient luminal gain (recoil or local dissection) or complications (extensive dissection). The results of angioplasty of femoropopliteal lesions must be compared with those obtained with medical or surgical treatment. In case of significant stenosis or short occlusions, conventional angioplasty alone is employed most of the time. Interventional radiology has an increasing role in the treatment of patients with critical ischemia. The majority of the culprit lesions are infra-inguinal. The goal of endovascular treatment is limb salvage (obtained in more than 80%) of the cases, not long-term patency. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses/short occlusions.

Fuzzy classification of renal artery lesions from angiograms in the context of angioplasty.

This paper describes a system that automatically classifies renal artery lesions from arteriograms in the context of Percutaneous Transluminal Renal Angioplasty (PTRA). PTRA outcomes have been categorized into type A (success) or type B (failure) according to morphological features. The morphological features are naturally represented by fuzzy sets. The classification process is based on a fuzzy pattern matching procedure between fuzzy prototypes of lesions in the classes A and B and fuzzy quantified assessments of lesions in angiograms. The system provides a meaningful membership degree to the class rather than an abrupt yes or no answer. The system is expected to be a good framework to study the technical results of PTRA according to the anatomy of the lesion.

[Endovascular treatment of sclerotic arteriopathies of the lower limbs]. / Traitement endovasculaire des artériopathies scléreuses des membres inférieurs.

Percutaneous transluminal angioplasty is performed to treat arterial stenoses or occlusions. Currently, balloon angioplasty is still considered as the gold standard even if new interventional devices and techniques have been proposed to improve immediate and long-term results: stents, intraarterial thrombolysis, percutaneous aspiration embolectomy, atherectomy, laser and ultrasound angioplasty. Evaluations of these methods in the treatment of peripheral arterial diseases are ongoing. An interventional procedure is indicated only after a thorough analysis of the medical and anatomo-angiographic data. A stenosis or a short occlusion of the iliac or the femoro-popliteal arteries are typical indications for percutaneous angioplasty in case of claudication; more complex lesions become gradually accessible to percutaneous methods in patients with chronic critical and even acute arterial ischaemia of the lower limbs. During the follow-up, the development of a restenosis is detected by careful clinical examination and ultrasound duplex scanning.

Uretero-iliac fistula: modern treatment via the endovascular route.

We report three cases of ureteral-iliac fistula (UIF) in patients referred for treatment of macroscopic haematuria. Though it is a classic aetiology of haematuria, it is often difficult to diagnose and the treatment is not yet standardized. A diagnostic evaluation in combination with multidisciplinary approach improves the prognosis of the patients. Curative treatment via the endovascular route is effective and safe, and has a rapidly favourable course in all of our patients. The use of covered stents combined with the Amplatzer™ vascular plug makes the procedure easy and safe.

Radiocephalic fistula complicated by distal ischemia: treatment by ulnar artery dilatation.

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. However, its frequency is increasing with the rise in numbers of elderly and diabetic patients. This complication, which is more common for proximal than for distal accesses, can be very severe and may cause loss of hand function, damage to fingers, and even amputation of fingers or the hand. Its treatment is difficult and often leads to access loss. We report here a case of severe hand ischemia related to a radiocephalic fistula successfully treated by ulnar artery dilatation.