Influence of Home Location on Follow-Up Compliance after Endovascular Treatment for Abdominal Aortic Aneurysm.

BACKGROUND: The complications of EVAR require compliance to a close follow-up imaging. The purpose of this study was to determine whether home location predicted a poor compliance to imaging follow-up after EVAR. METHODS: We analyzed a cohort of patients treated by EVAR at the Besançon University Hospital between 2007 and 2017. Follow-up imaging followed the French High Health Authority recommendations. Noncompliance with follow-up compliance was defined as a first missed postoperative appointment or 2 consecutive missed appointments after the first control CT-scan, and 2 groups of patients were identified: compliant (group C) or noncompliant (group NC). Univariate and multivariate analyzes were used to investigate compliance risk factors. Collected complications included endoleaks, limb thrombosis, infections, and secondary ruptures. RESULTS: Two hundred and fifty-eight of the 359 patients treated during this period were enrolled, including 233 men (90.3%), with a mean age of 74.0 years (±9.0) and a mean follow-up of 5.0 years (±2.6). The compliance rate was 38.8% and the 1-year mortality rate was 12.0%. Using univariate and multivariate analysis, a place of residence greater located over 60 min away from the hospital had a poor effect on compliance (Odd ratio [OR] = 0.58; P = 0.047). Peripheral arterial occlusive disease (PAD) and an abdominal aortic aneurysm (AAA) diameter greater than 5.0 cm were protective factors (OR = 2.23; P = 0.006 and OR = 1.85, respectively; P = 0.002). Four-year all-cause mortality was 21.0% in group C and 17.0% in the NC group (P = 0.54). Complications were more significant in group C (59.0%) compared to group NC (39.0%) (P = 0.001). Two ruptures occurred in the NC group (1.3%), versus none in the C group (P = 0.25). CONCLUSIONS: In this study, a long distance from the home to the hospital was a detrimental factor for follow up compliance. However, a good compliance did not decrease the 4-year mortality rate. The high rate of noncompliance found should lead to a more personalized follow-up strategy taking into account the anatomical elements but also the comorbidities and some social aspects.

Obturator Bypass Remains a Useful Option.

BACKGROUND: The femoral tripod remains technically crucial in vascular surgery, as well for an elective revascularization as for an extensive approach to the arterial tree. The management of septic complications and healing disorders in this area is really challenging. Obturator bypass (OB) represents an alternative sometimes employed in this context, but few recent series were recently published. The objectives of this work were thus to evaluate the results of OB in terms of patency, morbi-mortality, healing evolution and absence of reinfection. METHODS: This was a monocentric retrospective study including all the patients treated by OB, whatever the cause, between January 2010 and December 2020. Primary outcomes were the primary and the secondary patencies. The secondary outcomes were the morbi-mortality, freedom from infection and healing. RESULTS: During this period, 23 OBs were carried out in 22 patients, with a majority of men (77%) whose median age was 70 years [34-87]. The indications were infection in 19 patients (86%), and iterative thrombosis in 3 patients (14%). The substitute was an arterial allograft in 82% of the cases, and the outflow was the deep femoral artery only in 14% of the cases. The median operative time was 224 min [111-391] and median blood losses were 900 mL [300-3,900]. We observed 7 systemic (32%), and 8 local complications (36%). Healing was obtained in 90% of the cases, and freedom from infection was obtained in 100% of the cases. The median duration of follow-up was 594 days [5-2,517]. One-year, 2-year and 3-year primary patency rates were 84%, 78%, and 63%, respectively. One-year, 2-year and 3-year secondary patencies were 94%, 94%, and 80%, respectively. One-month, 1-year, 2-year and 3-year survival rates were 86%, 73%, 67%, and 53%, respectively. CONCLUSIONS: Our study showed that the OB represents a relevant alternative in the event of complex lesions of the femoral tripod, with good patency and healing rates and good infection control. On the other hand, its consequences in terms of morbi-mortality confirm that OB is a major surgery that should be used when a traditional approach is not possible.

Snuff-Box Versus Wrist Radiocephalic Arteriovenous Fistulas for Hemodialysis: Maturation Tend and its Affecting Factors.

BACKGROUND: Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. METHODS: We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. RESULTS: From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. CONCLUSIONS: No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.

Stress Analysis in AAA does not Predict Rupture Location Correctly in Patients with Intraluminal Thrombus.

BACKGROUND: A biomechanical approach to the rupture risk of an abdominal aortic aneurysm could be a solution to ensure a personalized estimate of this risk. It is still difficult to know in what conditions, the assumptions made by biomechanics, are valid. The objective of this work was to determine the individual biomechanical rupture threshold and to assess the correlation between their rupture sites and the locations of their maximum stress comparing two computed tomography scan (CT) before and at time of rupture. METHODS: We included 5 patients who had undergone two CT; one within the last 6 months period before rupture and a second CT scan just before the surgical procedure for the rupture. All DICOM data, both pre- and rupture, were processed following the same following steps: generation of a 3D geometry of the abdominal aortic aneurysm, meshing and computational stress analysis using the finite element method. We used two different modelling scenarios to study the distribution of the stresses, a "wall" model without intraluminal thrombus (ILT) and a "thrombus" model with ILT. RESULTS: The average time between the pre-rupture and rupture CT scans was 44 days (22-97). The median of the maximum stresses applied to the wall between the pre-rupture and rupture states were 0.817 MPa (0.555-1.295) and 1.160 MPa (0.633-1.625) for the "wall" model; and 0.365 MPa (0.291-0.753) and 0.390 MPa (0.343-0.819) for the "thrombus" model. There was an agreement between the site of rupture and the location of maximum stress for only 1 patient, who was the only patient without ILT. CONCLUSIONS: We observed a large variability of stress values at rupture sites between patients. The rupture threshold strongly varied between individuals depending on the intraluminal thrombus. The site of rupture did not correlate with the maximum stress except for 1 patient.

Risk Factors of Long-Term Incisional Hernia after Open Surgery for Abdominal Aortic Aneurysm: A Bicentric Study.

BACKGROUND: Conventional open surgery is still important beside endovascular surgery in the management of abdominal aortic aneurysms, with less reinterventions in the long-term follow-up. Incisional hernias are the major complication open surgery in the mid- and long term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The objectives of our retrospective and bicentric study were to characterize the long-term risk factors for incisional hernias after open surgery for abdominal aortic aneurysms, in particular by comparing the 2 types of laparotomy, and to determine the prevalence of the operated and not operated incisional hernias. MATERIALS AND METHODS: Between January 2009 and December 2011, all the patients having elective open surgery for abdominal aortic aneurysm (AAA) by midline laparotomy at the University hospital of Besancon or by transversal laparotomy at the University Hospital of Strasbourg were included retrospectively. The demographic data, the time of diagnosis of the incisional hernia and the parietal reinterventions were collected during a 5-year postoperative follow-up. A univariate and multivariate Cox model was used for the statistical analysis to determine the long-term risk factors for the appearance of an incisional hernia. RESULTS: During the study period, 223 patients presenting with AAA were included, 112 of them were operated by a midline laparotomy and 111 by a transverse laparotomy. The mean age of the patients was 69 ± 8,4years and 208 (93.3%) were men. The 5-year prevalence of incisional hernias was 14.3% (32), and 20 of these hernias (9%) had to be operated. Eighteen hernias (16.1%) occurred after a midline laparotomy and 14 (12.6%) after a transverse incision (P = 0.30). In univariate analysis, obstructive chronic pulmonary disease was the only significant risk factor for incisional hernia (P = 0.01) and an age over 65 years appeared to protect against this risk (P = 0.049). These results were confirmed by multivariate analysis, which showed that obstructive chronic pulmonary disease was an independent risk factor for incisional hernia (HR = 2.35, 95% CI 1.16-4.75), and that an age over 65 years was a protective factor (HR = 0.49 95% IC 0.00-0.99). CONCLUSIONS: The type of laparotomy did not modify the rate of incisional hernias. We showed that only 9% of the patients had to be operated to treat an incisional hernia during the first 5 years after surgery for AAA in our bicentric study. Chronic obstructive pulmonary disease was the only independent risk factor for the occurrence of an incisional hernia.

Association between carotid revascularization for asymptomatic stenosis and cognitive functions.

Asymptomatic carotid stenosis (ACS) can cause cognitive dysfunction, related to cerebral hypoperfusion and microemboli. These mechanisms could be treated by carotid revascularization, but the impact of carotid angioplasty stenting (CAS) or carotid endarterectomy (CEA) on cognitive functions remains unclear. The aim of this systematic review was to realize a report on the actual state of results about asymptomatic carotid stenosis revascularization and cognitive function. We performed a systematic literature review to analyze all studies assessing the impact of asymptomatic carotid stenosis revascularizations on cognitive functions. We reviewed all publications published in Medline database and Cochrane between January 2010 and January 2020 including subjects with a cognitive evaluation and receiving carotid revascularization for asymptomatic stenosis. We identified 567 records for review, and finally we included in the systematic review 20 studies about ACS revascularization and cognitive functions. Only observational studies analyzed the impact of CEA and CAS on cognitive functions. Thus, too heterogeneous data associated to the lack of randomized controlled trials with an evaluation of optimal medical treatment did not enable to affirm the interest of the revascularization management of ACS in cognitive domain. There was a lack of standardization and finally studies were too heterogeneous to conclude on the impact of carotid revascularization on cognitive functions. There is an urgent need to harmonize research in this domain in order to prevent and treat cognitive dysfunction related to ACS, especially in our society with an aging population.

Results of the Surgical Management of Acute Limb Ischemia in the Nonagenarians.

BACKGROUND: The aging of the population leads us to treat older patients, in particular presenting with acute limb ischemia (ALI). However, there has been little evaluation of this pathology in the nonagenarians. The objectives of this work are thus to evaluate the 1-month and 1-year mortality of the nonagenarians treated for ALI, which made possible to determine the 1-year survival and to highlight the factors influencing the mortality. METHODS: This is a monocentric retrospective study including all the patients aged 90 years old or more surgically treated for ALI between January 2012 and December 2016. In all the patients, we recorded the 1-month mortality and the 1-year survival and the demographic, clinical, and paraclinical data. RESULTS: We operated 83 nonagenarians, with a majority of women (59, 71.1%), using general anesthesia in 20 patients (16.6%), including 10 cases of upper limb acute ischemia (12.0%). The overall mortality rate at 1 month was 22.9%, and the 1-year survival rate was 43.4%. Major amputation rate was 9.6% at 1 year. The survival of the patients operated for upper or lower limb ischemia was similar (P = 0.82). Univariate analysis showed that the 1-year survival was lower in patients having a history of cerebrovascular problems (P = 0.0003), heart failure (P = 0.0027), dementia (P = 0.0452), or in patients that were institutionalized (P = 0.0125), invalid (P = 0.0001), or presented with a complete acute ischemia (P = 0.0002). In multivariate analysis, 3 risk factors remained statistically significant: a previous history of cerebrovascular accident (hazard ratio [HR] = 3.05 [1.54-6.02]; P = 0.0014), cardiac failure (HR = 2.21 [1.23-3.97]; P = 0.0083), and complete ALI (HR = 3.07 [1.64-5.75]; P = 0.0005). CONCLUSIONS: Our study showed that a history of cerebrovascular accident, cardiac failure, or complete ALI is a poor prognostic factor for the 1-year survival of nonagenarians dealt operated for ALI. These elements should be taken into account when deciding either to operate or not in this precise context.

Impact of Accessory Renal Artery Coverage on Renal Function during Endovascular Aortic Aneurysm Repair.

BACKGROUND: Long-term outcomes of accessory renal artery (ARA) coverage after endovascular aneurysm repair (EVAR) are unknown. We analyzed the impact of ARA coverage on renal function long-term. METHODS: This retrospective, monocentric study included patients treated by EVAR between 2008 and 2016. Patients with at least one ARA covered with EVAR (ARA group) were compared with patients with no covered ARA (control group). Renal function was determined by estimating the glomerular filtration rate (eGFR) and graded according to chronic kidney disease (CKD) classification stages. RESULTS: A total of 184 patients were included (ARA group, n = 25; control group, n = 159). Renal risk factors were similar in the 2 groups. Mean (±standard deviation) duration of follow-up was 41.6 ± 25.8 months. Preoperative eGFR (mL/min/1.73 m2) was 68.9 ± 17.8 in the ARA group and 72.5 ± 17.4 in the control group (P = 0.33), with a similar decline in the 2 groups during follow-up (-6.52 ± 11.6 ARA group vs. -6.43 ± 13.8 control group; P = 0.97). At the end of the study, 8 ARA patients and 56 controls had deteriorated by one CKD stage (32% vs. 35.2%, respectively; P = 0.75). Rate of renal infarction was significantly higher in the ARA group (96% vs. 1.9%; P < 0.0001). In multivariate analysis, suprarenal fixation was identified as a risk factor for a decline in renal function (odds ratio = 2.01 [95% confidence interval: 1.05-3.84]; P = 0.04). CONCLUSIONS: ARA coverage after EVAR does not appear to affect renal function long-term. Suprarenal fixation led to a greater decline in renal function.

Scannographic Study of Risk Factors of Abdominal Aortic Aneurysm Rupture.

BACKGROUND: Current decision about when to operate abdominal aortic aneurysms (AAAs) is based only on the maximum aneurysm diameter (MAD). However, small aneurysms still rupture and we can observe very large AAA without any symptom. A simple morphologic analysis could be a tool to assess the risk of rupture. The main objective of this study was to assess the relevance of ratios between MAD and healthy aorta on computed tomography (CT) as a risk factor of AAA rupture. The secondary objective was to evaluate CT signs as risk factors of AAA rupture. METHODS: Retrospective observational bicentric study comparing CT scans of a ruptured AAA group and a control group treated electively was conducted. Appariement 1:1 based on MAD was applied. Ratios between healthy aorta diameters at several levels, celiac trunk (CTR), superior mesenteric artery (SMA), highest renal artery (RA), and the MAD were calculated. The presence of blebs, crescent signs, ruptures of calcifications of the aneurysm sack, and draped aorta were notified. RESULTS: From 2010 to 2016, 38 ruptured AAA and 38 controls were included. Ratios were superior in the rupture group, respectively: MAD/CTR [2.77 (±0.5) versus 2.58 (±0.4) P < 0.095], MAD/SMA [2.92 (±0.7) versus 2.74 (±0.5) P < 0.194], and MAD/RA [3.02 (±0.70) versus 2.76 (±0.5) P < 0.054] but not significatively. Receiver operating characteristic curve analysis demonstrated optimal threshold to detect rupture at 2.8 for the ratio MAD/CTR (area under the curve (AUC) 0.593, sensitivity 47.4%, specificity 78.9%), at 3.3 for the ratio MAD/SMA (AUC 0.564, sensitivity 31.6%, specificity 92.1%), and at 3.3 for the ratio MAD/RA (AUC 0.591, sensitivity 31.6%, specificity 94.7%). Bivariate analysis for rupture risk factor showed significance for the three ratios (MAD/CTR > 2.8 [OR = 11 (1.42; 85.20) P < 0.0217], MAD/SMA > 3.3 [OR = 10 (1.28; 78.12) P < 0.0281], and MAD/RA >3.3 [OR = 11.00 (1.42; 85.20) P < 0.0217]). One scannographic sign was more present in the rupture group: crescent sign 36.8% versus 5.3%, P = 0.0007, as well in bivariate analysis [OR = 7 (1.59; 30.80) P < 0.0326]. CONCLUSIONS: In our experience, specific ratios when they exceed calculated threshold, seem to be more prone to rupture. We could consider that these measures, easy to apply in clinical practice, would be complementary keys for rupture risk individual assessment.

Prevalence and Impact of Malnutrition in Patients Surgically Treated for Chronic Mesenteric Ischemia.

BACKGROUND: Patients suffering from chronic mesenteric ischemia are at risk of malnutrition due to the fear of food and weight loss. However, the impact of malnutrition on the morbidity and mortality at the time of surgery is not studied extensively, just as its prevalence. The main objective of this study was to evaluate the influence of malnutrition on the survival of the patients operated for chronic mesenteric ischemia. The secondary objectives were to evaluate the prevalence of malnutrition in this population and to evaluate the early complications after surgery according to the nutritional condition of the patients. METHODS: We conducted a monocentric retrospective observational study including consecutively all the patients operated for chronic mesenteric ischemia between 2005 and 2016. The nutritional status was determined a posteriori according to the criteria of the French High Health Authority using body mass index, the percentage of weight loss, and albumin. We thus divided the patients into 2 groups, "malnourished" and "non-malnourished." We compared the survival of the patients of the 2 groups with a log-rank test. RESULTS: We enrolled 54 patients including 35 men (65%), with a mean age of 68.1 years (±12.3). The prevalence of malnutrition was 70% (38 patients), including 9 severely malnourished patients (23.6%). Twenty-nine patients (53.7%) were treated by endovascular technique, and twenty-five had conventional surgery (46.3%). The type of management was not different between the 2 groups: 20 patients of the malnourished group (52.6%) and 9 patients of the non-malnourished group (56.3%) were treated by endovascular technique (P = 0.8). The 30-day mortality was null in the non-malnourished group, whereas ten patients (26.3%) died in the malnourished group (P = 0.02). The short-term complications were not significantly different between the malnourished and the non-malnourished groups (37% vs. 19%, P = 0.32). The mean duration of follow-up was 639 days (±660). The 3-year survival was not different between the endovascular group and the open surgery group (43% vs. 52%, P = 0.7). The 3-year survival was statistically higher in the non-malnourished group (87%) than in the malnourished group (49.6%) (P = 0.01). CONCLUSIONS: In our experience, preoperative malnutrition is a factor significantly decreasing the survival of the patients treated with open surgery or with endovascular technique for chronic mesenteric ischemia. A more optimal preoperative management of this malnutrition could improve the results of these procedures.

Evolution of Practices in Treatment of Abdominal Aortic Aneurysm in France between 2006 and 2015.

BACKGROUND: The main objective of this study was to identify the changes that have occurred in the treatment of abdominal aortic aneurysms (AAA) in France over a period of 10 years. MATERIALS AND METHODS: Comprehensive data for AAA surgical activity from all French health establishments between 2006 and 2015 were collected from the records of the "Agence Technique de l'Information sur l'Hospitalisation." Based on the common classification of medical procedures, our research was conducted on surgical procedures involving open and endovascular surgical treatment of AAA. A year-by-year descriptive analysis was completed for the number of procedures, the change in the type of surgery performed in each type of institution, and the mean duration of hospital stays. RESULTS: During the study period, the number of AAA treated increased overall by 28.2% (from 6,412 procedures in 2006 to 8,221 in 2015). The proportion of endovascular procedures increased in this period (from 27.0% in 2006 to 68.5% in 2015) like their number from 1,735 to 5,632. The number of fenestrated endovascular aneurysm repair (listed since 2013) increased from 251 to 373 in 3 years. Open repair decreased from 4,677 interventions in 2006 to 2,589 in 2015 with higher proportion of suprarenal clamping in open surgery (from 23% in 2006 to 40% in 2015). The number of ruptured AAA treated in open surgery remained stable over this period (473 in 2006 and 462 in 2015). CONCLUSIONS: In France, the number of AAA operated between 2006 and 2015 increased by 28.2%. There was a significant increase in endovascular techniques, which became largely predominant in 2015. In open repair, the proportion of complex procedures increased in this period. However, this transformation, which is in line with current recommendations and major publications, needs to be reassessed in the long term.

A Multicenter Survey of Endovascular Theatre Equipment and Radiation Exposure in France during Iliac Procedures.

BACKGROUND: The aim of this study is to evaluate radiation exposure, endovascular theatre equipment, and practices in France during iliac angioplasty. METHODS: A prospective observational study was performed among vascular surgeons who attended a half day of radiation safety training in 2012 and 2015 and had to collect data on 3 patients undergoing iliac procedure. In 2012, 330 surgeons performed 899 procedures, compared with 114 surgeons and 338 procedures in 2015. Due to exclusions, 653 and 306 procedures were analyzed in 2012 and 2015, respectively. Endovascular environment, practices, anatomical characteristics, and radiation parameters were collected, analyzed, and compared generally and between the 2 groups. RESULTS: Endovascular theatre equipment significantly improved over the 3 years: mobile flat-panel detector (1.1% vs. 5.9%), hybrid rooms (1.5% vs. 14.7%), and dedicated radiology tables (37.2% vs. 51.2%). Lesion's classification (Trans-Atlantic Society Consensus) was similar between groups but procedure complexity increased overtime: more than one stent implanted (32.3% vs. 41%, P < 0.01), cross over (11.5% vs. 16%, P < 0.05), and kissing procedures (19.3% vs. 24.2%, P = 0.05). The mean dose area product (DAP) was 14.2 ± 18.9 Gy cm2 in 2012 and 21.5 ± 37.6 Gy cm2 in 2015 (P < 0.01), and the mean fluoroscopy time was 4.8 ± 5.5 min and 5.2 ± 5.9 min, respectively (nonsignificant). Overall, hybrid rooms, body mass index over 25 kg/m2, more than one stent implanted, and crossover technique were associated with a significantly higher DAP. CONCLUSIONS: Over 3 years, a large population of vascular surgeons improved radiation safety knowledge, operative environment, and technical complexity. However, these changes have led to an increased DAP in 2015, which underline the outmost importance of low dose settings and application of ALARA (as low as reasonably achievable) principles in every day practice.

Ruptured Pancreaticoduodenal Artery Aneurysm due to a Median Arcuate Ligament Treated Solely by Revascularization of the Celiac Trunk.

Pancreaticoduodenal artery aneurysms (PDAAs) are rare, but rupture can occur at any time regardless of the size. We describe here the case of 53-year-old woman who presented with a ruptured PDAA associated with compression of the celiac trunk by the median arcuate ligament. We first performed revascularization of the celiac trunk without intervening on the PDAA because of surgically hostile conditions. We observed complete regression of the PDAA, probably due to the dramatic decrease in inflow to the PDAA, thanks to the revascularization procedure. This prompted us to cancel the secondary endovascular embolization. The patient remained asymptomatic at 3 months.

Is Suprarenal Fixation of Aortic Stent Grafts Really without Consequence on the Renal Function?

BACKGROUND: The renal safety of suprarenal (SR) fixation stent grafts has not been demonstrated yet. The principal objective of this study was to analyze the effect of the type of fixation of stent grafts on the renal function at 1 year, by calculating the estimated glomerular filtration rate (eGFR). The secondary objective was the evaluation of the morphological repercussion of the implants at the renal level by computed tomography. METHODS: This is a monocentric retrospective study, including all the patients treated electively between 2008 and 2014 with a bifurcated aortic stent graft. We compared the characteristics of the SR and infrarenal (IR) populations and the evolution of the preoperative and 1-year postoperative renal function. Renal function was evaluated by eGFR, according to the Chronic Kidney Disease Epidemiology Collaboration formula, and expressed as mL/min/1.73 m2. Regarding morphological evolution, we sought renal infarctions and thromboses or stenoses of the renal arteries (RAS). RESULTS: During the study period, 102 patients were treated: 42 IR and 60 SR. The populations were comparable in terms of operative risk factors and impaired renal function. Preoperative eGFR was similar (SR 71.7 ± 17.8 vs. IR 70.3 ± 17.5, P = 0.7). There was no variation in eGFR at 1 year in the IR group (-0.9; P = 0.4), whereas a significant decrease was observed in the SR group (-5.6, P < 0.0001), a difference which proved to be significant in the intergroup comparison (P = 0.0065). This difference persisted after the exclusion of the patients in which at least one polar renal artery had been covered (P = 0.019). The proportion of patients with a degradation ≥20% of the eGFR was significantly higher in the SR group (SR 13.3%, n = 8 vs. IR 2.4%, n = 1; P = 0.046). We observed significantly more new or progressing RAS in the SR group (SR 21.67%, n = 13 vs. IR 2.38%, n = 1; P = 0.0035). Overall, 15 infarctions were detected but 9 were due to the cover of a polar artery including 8 in the SR group SR, which were thus excluded (SR 6.7%, n = 4 vs. IR 4.8%, n = 2; P = 0.52). No renal artery thrombosis was diagnosed. CONCLUSIONS: The report of a significant difference in the evolution of the renal function and the progression of renal stenoses makes us wonder about the real harmlessness of SR fixation stent grafts. If further reflection is necessary, their systematic use should be called into question, in particular in the presence of an anatomy authorizing the use of IR fixation stent grafts.

Impact of Nutritional State on Critical Limb Ischemia Early Outcomes (DENUCRITICC Study).

BACKGROUND: Despite current progress, the prognosis of critical limb ischemia (CLI) remains poor. The ageing of the population, the increasing prevalence of diabetes mellitus, and the stability of tobacco use will increase the prevalence of CLI. CLI patients have risk factors for malnutrition, and the impact of malnutrition on morbidity and mortality has been demonstrated in the general population. However, we have little information on the consequences of undernutrition in the CLI population. The aim of this study is to assess the impact of malnutrition on the early outcomes in CLI patients. METHODS: This is a double-center prospective study that included all consecutive hospitalized patients with CLI. All patients were screened for malnutrition and divided into 2 groups: severe malnourished patients (group A) and moderate malnourished and well-nourished (group B). This distribution was based on age-indexed clinical and biological data and the patient's general condition: the Nutritional Risk Index for patients younger than 75 years, the Mini Nutritional Assessment, or the Geriatric Nutritional Risk Index for those older than 75 years. The primary end point was defined as the rate of 30-day death. Outcomes were compared in a univariate analysis. Stepwise logistic regression was used for the multivariate analysis. Variables with a P value <0.2 in the univariate analysis were introduced in the multivariate model. RESULTS: We included 106 patients. The prevalence of malnutrition was 75.5%, divided into moderate malnutrition (51.9%) and severe malnutrition (23.6%). Six patients (24%) died in group A compared with 8 in group B (4.9%) (P = 0.01). By univariate analysis, severe malnutrition was the only factor associated with death at 30 days. By stepwise logistic regression, severe malnutrition (odds ratio 6.1, 95% confidence interval 1.6-23.7, P = 0.006) was found to be the significant risk factors for death at 30 days. CONCLUSIONS: This study is the first to demonstrate prospectively the major importance of malnutrition in the early prognosis of CLI patients.

How to identify patients at risk of abdominal compartment syndrome after surgical repair of ruptured abdominal aortic aneurysms in the operating room: A pilot study.

Objectives Abdominal compartment syndrome (ACS) is poorly identified in surgery for ruptured abdominal aortic aneurysm and an early management is crucial. The aim of this study was to validate how many risk factors were needed to predict ACS. Secondary objectives were to assess its prevalence and the 30-day mortality. Methods All patients operated for ruptured abdominal aortic aneurysm during 5 years were included. An independent committee performed a retrospective diagnosis of ACS. Eight criteria were selected from the literature, and corresponded to pre- and intraoperative period: anemia (hemoglobin lower than 10 g/dL), prolonged shock (systolic blood pressure <90 mmHg more than 18 min), preoperative cardiac arrest, obesity (body mass index > 30), massive fluid resuscitation (≥3500 mL per hour for at least 1 h) and transfusions (>10 units packed blood red cell since the beginning of the treatment), severe hypothermia (≤33℃), acidosis (pH < 7.2). Sensitivity and specificity were assessed for each number of criteria. Results Eight patients were ACS+ and 28 ACS-, with three criteria for ACS+ and 1.5 for ACS- ( p = 0.002). Three criteria among the eight selected criteria have the best cutoff for sensitivity and specificity (75% and 82%) with a positive predictive value of 54% and a negative predictive value of 92%. The prevalence of ACS was 17%. The 30-day mortality in ACS+ tended to be higher than in ACS- ( p = 0.108). Conclusion The present results suggest that patients with an ACS seemed to have higher mortality and the threshold of three factors among eight specific factors is enough to predict this.

Obesity is Not an Independent Factor for Adverse Outcome after Abdominal Aortic Aneurysm Repair.

BACKGROUND: The prevalence of obesity is increasing, and its impact on the outcome of open and endovascular abdominal aortic aneurysm (AAA) repair remains unclear, particularly in the European population. We herein assessed the impact of obesity on the postoperative course for both techniques. METHODS: From a database that consecutively collects all patients undergoing AAA repair; we selected all patients undergoing elective surgery for open or endovascular AAA repair, between January 2003 and December 2011. We considered obese patients (body mass index >30 kg/m(2)), overweight (25.1-30 kg/m(2)), and normal-weight patients (18.7-25 kg/m(2)), and compared mortality and/or severe complications at 30 days between obese and nonobese patients (overweight and normal weight) separately for each type of surgery by logistic regression analysis. We analyzed wound complications in the 2 groups. RESULTS: We included 748 patients, 174 obese, and 574 nonobese patients. Obese patients were younger (P < 0.001) and were less likely to have renal failure (P < 0.001) in both techniques. Obese patients in the open repair (OR) group showed a trend toward lower mortality and/or complication rates than in nonobese patients (4.8% vs. 7.5%, P = 0.34). In contrast, in the endovascular aortic aneurysm repair (EVAR) group, obese patients showed a trend toward higher mortality and/or complication rates than nonobese patients (7.1% vs. 3.2%, P = 0.17). In multivariate analysis, obesity was not an independent predictor of outcomes in OR (P = 0.18) or in EVAR (P = 0.20). Wound complications were not higher in obese patients in OR and in EVAR. CONCLUSIONS: Obesity should not be considered an independent risk factor of death and severe complications at 30 days in either open or endovascular AAA repair. Therefore, obesity should not systematically lead to the decision to use EVAR.

Carotid endarterectomy in octogenarian: short- and midterm results.

BACKGROUND: Randomized controlled trials that have established recommendations for carotid surgery have excluded patients >79 years of age, and in our day to day practice, patients in this age group are becoming more common. We sought to analyze the outcomes of carotid endarterectomy (CEA) in octogenarians, determine the risk factors of morbidity and mortality, and evaluate the midterm survey of these patients. METHODS: Age was the only selection criteria for inclusion in this study. We compared symptomatic and asymptomatic populations and retrospectively analyzed the CEA results performed in patients ≥80 years of age in each group. We calculated the combined ipsilateral stroke/death for each group. RESULTS: In the 6-year study period (2002-2007), 132 CEAs were performed in 118 octogenarians. The mean age was 83.2 years (range: 80-93), and there were 70 men (59.3%) and 48 women (40.6%). In this study group, 37.9% of patients were symptomatic and 62.1% were asymptomatic; the rate of internal carotid stenosis was 81.6% (standard deviation: ±8.5%). The combined ipsilateral stroke/death rate was 3.79% (4 deaths and 1 stroke): 2% in the symptomatic patients and 4.88% in the asymptomatic patients. No differences were found between the groups' combined ipsilateral stroke/death rate (P > 0.05), but there were significant more patients with coronary artery disease and peripheral artery disease in the asymptomatic patients. A contralateral significant internal carotid stenosis was a risk factor of combined ipsilateral stroke and death (P = 0.024). The mean duration of follow-up was 3.8 ± 2.0 years, and 73% ± 5% of the patients were alive at 3 years. CONCLUSION: The good immediate results and good probability of survival at 3 years after surgery conveys a real benefit of this surgery in this age group, but patients should be selected on a case by case basis. In our experience, the presence of bilateral lesions should be a significant influence criterion in the preoperative risk assessment. Other evaluation criteria, such as cardiac status, are needed to optimize the selection of asymptomatic patients in particular.