Surgical anatomy of the right gastro-omental artery: a study on 100 cadaver dissections.

PURPOSE: The gastro-omental artery (GOA) with the greater omentum (GO) is known for its high quality as a vascular graft, its resistance to infections as an omental flap and for its multiple applications in surgery. A better knowledge of anatomical variations of GO and its vascularization can improve the application in surgery and decrease complications. The purpose of this study was to measure diameters and lengths of the right GOA (RGOA) and study the interindividual variability of these anatomical structures. METHODS: In 100 cadaveric dissections, we carried out dissection of the RGOA and of the GO. In 70 unfixed cadavers, the transillumination technique was used to identify all RGOA branches. In the remaining 30 cadavers, prepared with Winckler's solution, barium sulfate with colored latex was injected. Digital X-ray was used to measure RGOA lengths, internal diameters and the distribution of the omental branches. The gastro-omental vein was also dissected. RESULTS: The mean proximal and distal diameters of RGOA were 2.68 (± 0.39) mm and 0.94 (± 0.24) mm, respectively. The mean length was 244.3 (± 34.4) mm. The thickness of the omentum ranged from 5 to 15.5 mm. The arteria omentalis magna, defined in this study for the fist time as the longest and widest omental branch, was present in 73.3% cases. The trans-omental arch was present in 6% cases. CONCLUSIONS: This morphometric study allowed us to define the vascularization and the anatomical variations of RGOA and GO. This may lead to improvement of applications in surgery and decrease complications.

Epiploic bypass flap: a new method of limb salvage. Anatomic basis and clinical application.

BACKGROUND: The incidence of critical limb ischemia increases with the aging of the population. Two-thirds of patients with critical limb ischemia present with trophic disorders. Revascularization decreases the rate of amputation. Infected wounds with exposure of the tendons, bones, or points of articulation cannot heal in spite of bridging and local debridement. Surgery associated with a distal venous bypass or recanalization and a free flap makes it possible to cover major tissue loss and offers a hemodynamic advantage by increasing the flow of the bypass, thanks to the vascular bed added by the flap. It is a complex surgery because of the multiplicity of anastomoses on the same arterial axis, with a risk of thrombosis and complications related to the venous autograft. To mitigate these disadvantages, we propose a new surgical method based on the use of a single anatomic unit, the epiploic bypass flap (BF), based on the gastroepiploic artery (GEA) as the inflow for a bypass and a free flap. The objective of this work was to analyze the anatomic feasibility of an epiploic BF and to determine its limits. METHODS: One hundred anatomic preparations were conducted with a measure of the internal and external diameters and the lengths of GEA and its branches and a radiograph after injection of a radiopaque product. A first clinical application was carried out. RESULTS: According to the data, our study confirms the anatomic feasibility of a BF. The average available length of GEA is 245 mm (range: 210-280 mm). The average proximal diameter is 3 mm, and the distal diameter is 1.5 mm. The most distal epiploic branch that feeds the bypass is approximately 180 mm (range: 161-195 mm) of the origin of the GEA. The anatomic unit based on the GEA provides an arterial graft that is relatively long and a large flap that is both malleable and resistant to infection. CONCLUSIONS: Epiploic BF is a surgical technique that allows for distal revascularization and a simultaneous cover of the limb extremity. This technique can be useful in patients requiring a distal revascularization associated with a cutaneous cover.

Secondary procedures after infrarenal abdominal aortic aneurysms endovascular repair with second-generation endografts.

BACKGROUND: To study the incidence, the types, and the results of secondary procedures performed after endovascular treatment of infrarenal abdominal aortic aneurysm (AAA). To compare the population of patients who underwent secondary procedure (P2) with the population of those who did not require it. MATERIAL AND METHODS: Between 1998 and 2008, this study included all the patients electively treated for AAA with stentgrafts that were still available on the market on January 1, 2009. Data were prospectively collected and retrospectively analyzed. The postoperative follow-up included at least a systematic computed tomography scan at 6, 12, 18, and 24 months and then every year. P2 were defined as any additionnal procedures performed to treat aneurysm related complications after initial stentgraft implantation. RESULTS: We studied 162 patients with a mean 40 ± 31 months' follow-up. In 32 patients (19.7%), there were 46 P2, 3 of them were surgical conversion and 1 with endovascular conversion. Thirty-nine P2 were scheduled, and seven were performed in emergency. Nine patients underwent more than one P2. P2 was indicated for type II endoleak in 17 cases, 13 of them with a diameter increase; for type I endoleak in 10 cases; for AAA rupture in 3 cases; for occlusion or stentgraft stenosis in 13 cases; and for 1 type III endoleak, 1 endotension, and 1 femoro-femoral crossover bypass infection. Two ruptures occurred in patients who had undergone P2. The immediate technical success was 89.1%. At 30 days, morbidity was 10.9%, and there was no mortality. Survival rates at 3 and 5 years were respectively 85.2% and 71.9% in patients with secondary procedure and 70.6% and 47.5% in the others (p = 0.046). CONCLUSIONS: In patients treated for AAA with second generation stentgrafts, in the long term, secondary procedure rate was 19.7%. Survival rate for patients who underwent a secondary procedure was better, which was probably related to the fact that they were younger at the time of stentgraft implantation. Large AAA diameter was a secondary-procedure risk factor.

Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data.

BACKGROUND: Results from randomised controlled trials have shown a higher short-term risk of stroke associated with carotid stenting than with carotid endarterectomy for the treatment of symptomatic carotid stenosis. However, these trials were underpowered for investigation of whether carotid artery stenting might be a safe alternative to endarterectomy in specific patient subgroups. We therefore did a preplanned meta-analysis of individual patient data from three randomised controlled trials. METHODS: Data from all 3433 patients with symptomatic carotid stenosis who were randomly assigned and analysed in the Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial, and the International Carotid Stenting Study (ICSS) were pooled and analysed with fixed-effect binomial regression models adjusted for source trial. The primary outcome event was any stroke or death. The intention-to-treat (ITT) analysis included all patients and outcome events occurring between randomisation and 120 days thereafter. The per-protocol (PP) analysis was restricted to patients receiving the allocated treatment and events occurring within 30 days after treatment. FINDINGS: In the first 120 days after randomisation (ITT analysis), any stroke or death occurred significantly more often in the carotid stenting group (153 [8·9%] of 1725) than in the carotid endarterectomy group (99 [5·8%] of 1708, risk ratio [RR] 1·53, [95% CI 1·20-1·95], p=0·0006; absolute risk difference 3·2 [1·4-4·9]). Of all subgroup variables assessed, only age significantly modified the treatment effect: in patients younger than 70 years (median age), the estimated 120-day risk of stroke or death was 50 (5·8%) of 869 patients in the carotid stenting group and 48 (5·7%) of 843 in the carotid endarterectomy group (RR 1·00 [0·68-1·47]); in patients 70 years or older, the estimated risk with carotid stenting was twice that with carotid endarterectomy (103 [12·0%] of 856 vs 51 [5·9%] of 865, 2·04 [1·48-2·82], interaction p=0·0053, p=0·0014 for trend). In the PP analysis, risk estimates of stroke or death within 30 days of treatment among patients younger than 70 years were 43 (5·1%) of 851 patients in the stenting group and 37 (4·5%) of 821 in the endarterectomy group (1·11 [0·73-1·71]); in patients 70 years or older, the estimates were 87 (10·5%) of 828 patients and 36 (4·4%) of 824, respectively (2·41 [1·65-3·51]; categorical interaction p=0·0078, trend interaction p=0·0013]. INTERPRETATION: Stenting for symptomatic carotid stenosis should be avoided in older patients (age ≥70 years), but might be as safe as endarterectomy in younger patients. FUNDING: The Stroke Association.

Open surgical reconstruction of the internal carotid artery aneurysm at the base of the skull.

OBJECTIVES: Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report a standardized surgical technique of ICA reconstruction with long-term results. METHODS: Between 1988 and 2005, 13 patients (11 men; age 18 to 76 years, mean 42.6 years) underwent lateral skull base approach with cervical-to-petrous carotid artery bypass for repair of ICA aneurysms. Principal elements of the technique were: partial resection of the parotid gland without rerouting of the facial nerve; luxation of mandibula; drilling of the bone. RESULTS: The 13 patients had unilateral aneurysm of the ICA at the base of the skull. Four aneurysms were of atherosclerotic origin; six fibromuscular dysplasia; two post-traumatic; one cause was undetermined. The mean diameter of the aneurysms was 12 mm (range, 7-21 mm). Twelve patients were symptomatic: six presented neurological events (four strokes, two transient ischemic attack [TIA]); two retinal events; three compressive symptoms (two Horner's syndrome and one paralysis of the glossopharyngeal nerve); one patient presented a visible pulsatile mass in the neck. One patient was asymptomatic. There were no post-operative deaths, one TIA, 13 transient palsies of the lower facial nerve, and one transient palsy of accessory nerve. Palsy of cranial nerves was partial and disappeared within a mean of 5.6 months (range, 1-10 months). The postoperative angiogram showed patency in all but one case (one asymptomatic thrombosis). During follow-up (mean, 152 months), there was one unrelated death, one focal epileptic seizure, and one controlateral TIA. In November 2008, duplex showed patency of all 11 grafts (one death, one thrombosis). At 10 years, the survival, cumulative stroke-free survival, ipsilateral stroke-free, and patency rates was were 90.9%, 100%, 100%, and 92.3%. CONCLUSION: Venous graft bypass from the cervical-to-petrous ICA can be performed safely with such an approach and produces durable satisfactory results.

Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis.

BACKGROUND: Carotid stenting is less invasive than endarterectomy, but it is unclear whether it is as safe in patients with symptomatic carotid-artery stenosis. METHODS: We conducted a multicenter, randomized, noninferiority trial to compare stenting with endarterectomy in patients with a symptomatic carotid stenosis of at least 60%. The primary end point was the incidence of any stroke or death within 30 days after treatment. RESULTS: The trial was stopped prematurely after the inclusion of 527 patients for reasons of both safety and futility. The 30-day incidence of any stroke or death was 3.9% after endarterectomy (95% confidence interval [CI], 2.0 to 7.2) and 9.6% after stenting (95% CI, 6.4 to 14.0); the relative risk of any stroke or death after stenting as compared with endarterectomy was 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At 6 months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). There were more major local complications after stenting and more systemic complications (mainly pulmonary) after endarterectomy, but the differences were not significant. Cranial-nerve injury was more common after endarterectomy than after stenting. CONCLUSIONS: In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting. (ClinicalTrials.gov number, NCT00190398 [ClinicalTrials.gov].).

Extra-anatomical revascularization of the Adamkiewicz artery using the internal mammary artery: preliminary anatomical study.

Ischemic spinal cord injury remains a major complication of both open and endovascular repairs of extensive lesions of the thoracic or thoracoabdominal aorta. Patients undergoing endovascular treatment cannot benefit from direct revascularization of the Adamkiewicz artery (AA). Primary revascularization of the intercostal artery (ICA) giving rise to the AA using the internal mammary artery (IMA) could ensure uninterrupted flow in the AA even if the origin of the feeding ICA was obstructed. The purpose of this study was to assess the anatomical feasibility of revascularization of the ICA giving rise to the AA using the IMA. Twenty-four dissections were carried out on 12 cadavers (eight men, four women) with a mean age of 76 at the time of death. Preparation consisted of intra-arterial injection of polymethylsiloxane (Rhodorsil, Rhodia, France). For each IMA, the following parameters were determined: diameter in relation to the ICA in the paravertebral region before division, length, and level of the intercostal space in which direct anastomosis was possible. Dissection showed that the mean diameter at the end of the IMA was 1.8mm (range 1.2-2.4). The mean diameter of the ICA in the paravertebral region was compatible with that of the IMA, i.e., 1.6mm (range 0.9-2.5). The mean length of the IMA was 185 mm (range 165-230). The lowest intercostal space available in the paravertebral region for direct anastomosis between the IMA and ICA was the seventh space in one case, the eighth in 12, the ninth in eight, and the tenth in three. The findings of this preliminary study document the feasibility of using the IMA to revascularize the ICA in the paravertebral region. This technique could provide a means of preserving spinal cord vascularization during endovascular treatment of thoracic or thoracoabdominal aortic lesions.

Bypass flap reconstruction, a novel technique for distal revascularization: outcome of first 10 clinical cases.

Combined distal venous bypass grafting and free flap transfer can achieve successful treatment of soft tissue defects due to advanced leg ischemia. However, this combined approach is a complex technique involving multiple anastomoses on the same arterial axis with an increased risk of thrombosis. To reduce this risk, we have proposed a new bypass-flap (BF) reconstruction technique using an arterial graft and a free flap supplied by a collateral branch of the graft. The purpose of this report is to document the outcome in the first 10 patients treated using the BF reconstruction technique. From 2002 to 2004, a total of 10 patients with a mean age of 67 years (range 55-78) were treated using a BF. All patients presented critical ischemia with soft tissue defects resulting in exposure of tendons and muscles on the foot or ankle. Distal anastomosis was made between the distal branch of the BF and the pedal artery in five cases, the posterior tibial artery or plantar artery in four cases, and the peroneal artery in one case. In six cases proximal anastomosis was performed between the leg artery and arterial autograft. In the remaining four cases proximal anastomosis required extension of the bypass using a venous graft. The mean duration of hospitalization was 25 days. During the postoperative period, one patient died due to stercoral peritonitis and one patient required major amputation due to unrelenting sepsis. Bypass occlusion was not observed. Mean follow-up was 24 months (range 14-36). No patient was lost to follow-up and no patient died after the first 30 postoperative days. Follow-up examinations including clinical assessment and Doppler ultrasound imaging were performed at 3 months and every 6 months thereafter. Findings demonstrated bypass patency and healing of the covered defect in all cases. Outcome in this initial series demonstrates the clinical feasibility of the new BF reconstruction technique, which allows revascularization and coverage of tissue defects using a one-piece anatomic unit.

False aneurysm at the origin of the anterior tibial artery after opening wedge osteotomy.

We report the case of a false aneurysm at the origin of the anterior tibial artery complicating upper tibial osteotomy. The proximally located lesion compressed the posterior tibial nerve, and despite successful decompression, the patient suffers from probably irreversible neurologic after-effects. Even though it is rare, this complication must be considered when faced with leg pain consecutive to upper tibial osteotomy without deep venous thrombosis.

Brown-Sequard-type myelopathy due to cervical disc herniation associated with severe carotid stenosis prompting rapid combined corpectomy and carotid endarterectomy under deep anticoagulant therapy.

BACKGROUND CONTEXT: The risk of stroke because of carotid retraction during an anterior cervical spine surgery as well as the risk of bleeding complications after an anterior cervical corpectomy under deep anticoagulation and antiplatelet therapy is a surgical issue poorly addressed in the literature. PURPOSE: To describe the feasibility and safety of a simultaneous carotid endarterectomy and anterior corpectomy and fusion under deep anticoagulation in a patient with a cervical spinal cord compression and a severe carotid artery stenosis. STUDY DESIGN: Case report. METHODS: The authors describe the case of a 79-year-old man who had a 1-month history of progressive pain in the neck and left arm, associated with progressive weakness in the left arm and leg. He also presented a history of coronaropathy and bilateral severe carotid stenosis for which he was receiving a regimen of antiplatelet therapy. RESULTS: The cervical magnetic resonance imaging demonstrated a C4-C5 disc herniation migrating down to C5. His condition worsened rapidly during hospitalization prompting a rapid decompression. Given the necessity of a C5 corpectomy and the risk of stroke during anterior cervical spine surgery, it was therefore decided to undertake the surgical procedure under efficient anticoagulant and antiplatelet therapy. A combined endarterectomy and spinal decompression and fusion were then performed. The postoperative course was uneventful, and the patient recovered neurologically. CONCLUSIONS: This case suggests that such a combined carotid endarterectomy and cervical corpectomy with fusion under anticoagulant and antiplatelet therapy is feasible. However, even if the unique clinical presentation of our patient led us to undertake such a surgical strategy, therapeutic decision in patients presenting with both severe carotid stenosis and cervical spinal cord compression should rely on a case-by-case analysis.

Endovascular management of a significantly kinked aortomonoiliac stent graft.

We report our endovascular management of a highly kinked aortomonoiliac stent graft. This complication is unusual because kinks generally occur in bifurcated stent grafts and they are managed with extra-anatomic bypass. We will then expose the possible reasons for such complication. With long term follow-up severe kink might be reported more often.

Subscapular artery Y-shaped flow-through muscle flap: a novel one-stage limb salvage procedure.

OBJECTIVES: Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage. METHODS: Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally. RESULTS: One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg. CONCLUSION: We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.

Endovascular repair of abdominal aortic aneurysms with a unibody stent-graft: 3-year results of the French Powerlink Multicenter Trial.

PURPOSE: To report the results of a prospective multicenter study on endovascular repair of abdominal aortic aneurysms (AAA) using the bifurcated Powerlink stent-graft. METHODS: Between June 2000 and July 2001, endovascular AAA repair using the bifurcated Powerlink stent-graft was performed at 14 centers on 64 patients (61 men; mean age 70 years, range 56-90) fit for open repair. All procedures were attended by a proctor. Data were collected prospectively, and surveillance computed tomograms were reviewed by an independent center. RESULTS: Technical success was achieved in all cases. There was no postoperative death. During a minimum 3-year follow-up (mean 40.6 months, range 1-51), there were 3 (4.7%) stent-graft migrations associated with type I endoleaks. Two (3.1%) of these patients were converted to open repair, and 1 had a proximal extension implanted. No aneurysm rupture occurred, and no stent-graft degradation was observed. Six (9.4%) patients had secondary endoleak (3 type I and 3 type II). The limb occlusion rate was 3.1%. Six (9.4%) patients had secondary procedures. At 3 years, 58 (91.0%) patients were available for follow-up (4 deaths, the 2 conversions). There was a significant decrease between preoperative and 3-year mean AAA diameter (54.6+/-7 versus 47.6+/-10 mm, respectively; p<0.001). Aneurysm sac shrinkage was observed in 32 (55.2%) patients. Twenty-five (43.1%) patients had a stable aneurysm sac diameter. CONCLUSIONS: Endovascular repair using the bifurcated Powerlink stent-graft is safe and effective. Unibody design seems to confer advantages in terms of durability. These results need to be confirmed by longer follow-up and larger series.

Anatomical bases of the bypass-flap: study of the thoracodorsal axis.

Cutaneous tissue loss in patients with lesions on the arterial axes remains difficult to treat. Currently, combined surgery associating distal bypass and free flap seems to be the technique that yields the best results. The hemodynamic advantages of this technique, recently demonstrated, are the distal resistance and the increase in bypass flow. Nevertheless, it is complex and its indications limited. Two major drawbacks can be noted: The increasing risk of thrombosis due to the multiplication of anastomoses on the same arterial axis and the deterioration in venous autograft. To overcome these inconveniences we propose a new technique that we call bypass-flap (BF): the graft of an anatomical entity comprised of one artery and one flap. This graft secures the cover of tissue loss and the revascularization of the limb. Apart from its combined nature this technique presents three major advantages. The arterial autograft is superior to the venous graft, the gradually decreasing diameter of the artery secures the congruence of the anastaomoses, and the arterial flow of the graft is higher than a simple bypass due to the joint vascularization of the flap. The arterial graft includes the subscapular and the thoracodorsal arteries. The free flap is composed of serratus anterior muscle supplied by branches of the graft. This investigation studied the feasibility of the bypass flap and determined the length and diameter of the arterial graft and its muscular branch. Forty anatomical preparations were performed on 20 cadavers. The dissections were performed after injection of Rhodorsil. The anatomical feasibility of the bypass flap was confirmed in 37 cases. The total length of the arterial graft that preserved an external diameter above 2 mm was measured at 13 cm (8.5-15.5). This includes the subscapular artery and the thoracodorsal artery with its intramuscular part (if external diameter of that part always above 2 mm). The length of the pedicle of the serratus anterior flap was measured at 7.5 cm (3.0-12.5 cm).

Aorfix stent graft for abdominal aortic aneurysms reduces the risk of proximal type 1 endoleak in angulated necks: bench-test study.

Neck angulation (NA) is an important risk factor for type 1 proximal endoleaks following stenting of abdominal aortic aneurysms. The Aorfix (Lombard Medical, Oxon, UK) is a new flexible stent graft designed to overcome this issue. The aim of this study was to compare the endoleak flow rate (EFR) in relation to NA between the Aorfix and other manufactured stent grafts. A flow model with silicone proximal and distal necks was used. EFRs corresponding to 10 neck angles between 0 and 70 degrees were measured. Eight stent grafts were tested: Aorfix, Ancure (Guidant, Indianapolis, IN), Powerlink (Endologix, Irvine, CA), AneuRx (Medtronic, Sunnyvale, CA), Excluder (W.L. Gore & Associates, Flagstaff, AZ), Zenith and Zenith-Flex (Cook Inc., Bloomington, IN), and Lifepath (Edwards Lifesciences, Irvine, CA). For all stent grafts except the Aorfix, the EFR was greater than at baseline for NA >or= 30 degrees (p < .01). The EFR at NA >or= 30 degrees was lower with the Aorfix compared with the other stent grafts (p < .01). NA had no influence on the EFR with the Aorfix. The Aorfix may decrease the incidence of proximal type 1 endoleak in patients with a severely angulated aortic neck.

The bypass flap: an innovative technique of distal revascularization--anatomical study and clinical application.

Combined surgery for placement of a distal venous bypass and a free flap enables successful treatment of tissue loss caused by ischemia. This complex surgery has limited indications. The multiple anastomoses on the same arterial axis increase the risk of thrombosis and a certain number of venous grafts are likely to undergo mid-term deterioration. Because of these difficulties, we propose a new concept: the bypass flap (BF), which is based on the harvesting of an arterial axis to provide an arterial graft and a free flap supplied by a collateral branch of the graft. The aim of the anatomic part of this study was to evaluate the length and diameter of the arterial graft and its tissue branch and to study the feasibility of the BF. Thirty-two anatomic preparations were made by intraarterial injection of Rhodosil in 16 cadavers. The arterial graft included the subscapular artery and the thoracodorsal artery. The flap consisted of the anterior serrate muscle supplied by the branch of that graft. The distribution, length, and diameter of the arteries were examined. The mean length of the arterial graft line maintaining diameter above 2 mm was 12.5 cm (8.5-15.5). Three clinical applications of the BF based on the thoracodorsal artery axis were performed on three patients with tissue loss caused by severe ischemia of the lower limb. No occlusion of the BF occurred and healing of the tissue loss was achieved after 4, 7, and 10 months, respectively. This technique has the advantage of decreasing vascular distal resistance, which may contribute to improvement of vessel reconstruction patency. It is simpler because the anastomoses are fewer and it presents the advantage of requiring only autologous arterial material of an appropriate diameter.

Modalities of preoperative imaging of the internal carotid artery used in France.

A survey of the 382 members of the Société de Chirurgie Vasculaire de Langue Française was conducted to determine preferred imaging techniques for preoperative assessment of the proximal internal carotid artery. A total of 180 questionnaires were returned concerning 9390 carotid stenoses treated in the year 2000. Doppler ultrasound (DUS), angiography, magnetic resonance angiography (MRA), and computed tomography angiography (CTA) were routinely used in 99%, 51.5%, 4%, and 3% of cases. Usual work-up methods involved DUS and angiography in 64% of cases, DUS and MRA in 7%, and DUS and CTA in 4% of cases. Indications for endarterectomy were based on DUS and angiography findings in 69% of cases, on DUS and MRA findings in 14%, on DUS and CTA findings in 9%, and on DUS findings alone in 8%. In-house access to CTA or MRA was more frequent at state-run institutions (p = 0.00001). Indication of endarterectomy based on DUS and MRA was more common at institutions equipped with technical facilities for MRA (21% vs. 8%; p = 0.001). An inverse correlation was observed between the number of carotid artery procedures performed and use of DUS and angiography work-up. The number of carotid endarterectomies without angiography is increasing in France. Preoperative DUS is still routinely used. Combined DUS and MRA is the preferred work-up for endarterectomy without angiography. Lack of access to MRA is still a limiting factor. Further study will be needed to evaluate the benefits and risks of endarterectomy without angiography.

Extraanatomical revascularization of the artery of Adamkiewicz: anatomical study.

Spinal cord ischemia is a major cause of complications after operative and endovascular treatment of descending thoracic or thoracoabdominal aortic aneurysms. Prior revascularization of the intercostal artery (IA) giving rise to the artery of Adamkiewicz (AA) using an artery of the thoracic wall would preserve circulation in the AA and allow obstruction of the IA at its origin. The purpose of this study was to determine the feasibility of revascularization of the IA giving rise to the AA using three thoracic wall arteries, i.e., lateral thoracic artery, thoracodorsal artery, and descending scapular artery. A total of 16 specimens from 8 cadavers (6 men and 2 women) were prepared. The length and diameter of the thoracic wall arteries were measured to ascertain the feasibility of revascularization of the IA giving rise to the AA. In addition, 12 preoperative spinal cord arteriograms were studied. We found that revascularization of the IA giving rise to the AA using thoracic wall arteries is feasible. This technique could be used to prevent spinal cord complications after treatment of descending thoracic or thoracoabdominal aortic aneurysms.

Periaortitis heralding Wegener's granulomatosis.

We describe a 47-year-old man who successively presented atheromatous coronary artery disease, cholesterol embolism after angioplasty, periaortitis with presence of c-ANCA, and finally typical pulmonary lesions caused by Wegener's granulomatosis. This case illustrates the link between atheromatous and inflammatory process and emphasizes that periaortitis may be a feature of Wegener's granulomatosis.