Thrombosis of Medium-Sized and Large Arteries During Covid-19 Infection: Results of the COVIVASC Study.

BACKGROUND: COVID-19 infection is associated not only with venous thromboses but also with arterial thromboses (COV-ATs) in relation with an endothelial dysfunction, a coagulopathy and rhythm disorders. The incidence, the topography, and the prognosis of COV-ATs remain poorly known. The objective of this study was to report the overall experience of the Greater Paris University Hospitals (Assistance Publique - Hopitaux de Paris, AP-HP) during the first pandemic wave of COVID-19 infection. METHODS: After approval by the ethics committee, a study using the AP-HP clinical data warehouse was carried out between March and May 2020. Overall, 124,609 patients had a polymerase chain reaction for COVID-19 in our hospitals, of which 25,345 were positive. From 20,710 exploitable stays, patients tested positive for COVID who presented an episode of acute COV-AT (except coronary and intracranial arteries) were selected on the basis of the French medical classification for clinical procedures codes. The data are presented as absolute values with percentages and/or means with standard deviation. RESULTS: Over the studied period, 60 patients (aged 71±14 years, 42 men) presented a COV-AT at the time of their hospitalization, an incidence of 0.2%. The arterial complication occurred 3±7 days after the COVID infection and was inaugural in 30% of the cases (n = 18). The sites of COV-AT were the lower extremities (n = 35%, 58%), the abdominal aorta (n = 10%, 17%), the thoracic aorta (n = 7%, 12%), the upper limbs (n = 7%, 12%), the cerebral arteries (n = 7%, 12%), the digestive arteries (n = 6%, 10%), the renal arteries (n = 2%, 3%), and the ophthalmic artery (n = 1%, 2%). Multiple COV-ATs were observed in 13 patients (22%). At the time of diagnosis, 20 (33%) patients were in intensive care, including six (10%) patients who were intubated. On computed tomography angiography, COVID lesions were classified as moderate and severe in 25 (42%) and 21 (35%) cases, respectively. Revascularization was attempted in 27 patients (45%), by open surgery in 16 cases, using endovascular techniques in 8 cases and with a hybrid approach in three cases. Six patients (22%) required reinterventions. The duration of hospitalization was 12±9 days. Early mortality (in-hospital or at 30 days) was 30% (n = 18). Nine (15%) patients presented severe nonlethal ischemic complications. CONCLUSIONS: Arterial involvement is rare during COVID-19 infection. The aorta and the arteries of the limbs are the privileged sites. The morbi-mortality of these patients is high. Future studies will have to determine if the systematization of anticoagulation therapy decreases the incidence and the severity of the condition.

A Simple Technique to Perform Endovascular Repair of Abdominal Aortic Aneurysms with a Very Low Dose of Iodine Contrast Media.

Iodinated contrast media (ICM) dose is a major factor for postoperative acute kidney injury (AKI) in patients with severe chronic kidney disease (glomerular function rate [GFR] <30 mL/min) during endovascular aortic repair (EVAR). Fusion imaging in hybrid rooms and carbon dioxide angiography represent alternatives but are limited by significant cost and availability. We here describe a simple technique allowing EVAR with a limited ICM dose (<5 mL). Using a standard C-arm, the lowest renal artery and the hypogastric arteries are blindly catheterized based on noncontrast pre-operative imaging (duplex-scan associated with noncontrast computed tomography scan and/or magnetic resonance angiography). An injection of diluted ICM (1 mL ICM + 4 mL saline) can be performed to confirm the correct catheterisation and angiography catheters are let in place as landmarks. Ten patients with GFRs between 17 and 29 ml/min were successfully treated using these tips (median ICM = 3 mL) without postoperative AKI and satisfactory mid-term results.

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Managing Peripheral Artery Disease in Diabetic Patients: A Questionnaire Survey from Vascular Centers of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS).

BACKGROUND: The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded on October 1, 2018, to enhance cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic arteriopathy has been selected as the very first topic to be investigated by the federation. METHODS: MeFAVS members were asked to reply to a questionnaire on the management of diabetic ischemic foot. Results were collected and analyzed statistically. The questionnaire consisted of 15 multiple choice answers regarding diabetic foot (DF) diagnosis and treatment. The questionnaire was submitted to 21 centers on April 20, 2019. RESULTS: Response rate was 62%. The survey revealed that vascular surgeons, diabetologists, and wound care nurses made-up the core of the diabetic teams present in 76.9%, 69.3%, and 92.3% of the centers, respectively. Diabetic teams were most often led by vascular surgeons (53.8%) and diabetologists (42.2%), but only in 7.9% of cases by nurses. Duplex ultrasonography and computed tomographic angiography were the most commonly available tools used to assess diabetic peripheral arterial disease (PAD). Surgical wound care was undertaken by vascular surgeons in the majority of cases, and only in 46.2% of the cases to orthopedic or plastic surgeons, while nonsurgical wound care was handled by specialized nurses (76.6%) and diabetologists (53.8%). First-line revascularization was preferred over conservative treatment (61.5% vs 53.8%) and endovascular strategy (45.3%) over open (33.7%) or hybrid (21.0%) surgery. Vascular surgeons and interventional radiologists were found to be the most common performers of endovascular revascularization (92.3% and 53.8%, respectively). Amputations had an overall rate of 16.6% (range 4-30%) and a mean reintervention rate of 22.5%, and were usually performed by vascular surgeons for both minor and major interventions (84.6%) followed by orthopedic surgeons (15.4% minor and 30.8% major). The availability of a DF clinic (84.6%) and endovascular (53.8%) and open surgery (46.2%) capabilities were considered fundamental to reduce amputation rates. CONCLUSIONS: Especially since the introduction and spreading of new endovascular techniques for the treatment of DF, it is a common consensus amongst vascular surgeons that a standardized approach to the discipline is necessary in order to improve outcomes such as amputation-free survival and mortality and it is with this perspective and purpose that transnational cooperation amongst vascular professionals and residents in training are aiming for greater proficiency in endovascular and open surgery.

Results of retrograde open mesenteric stenting for acute thrombotic mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) is an emergent event with a high mortality rate; survivors have high rates of intestinal failure. Restoration of blood flow using endovascular or surgical revascularization is associated with better outcome in terms of survival rate and intestinal resection. Retrograde open mesenteric stenting (ROMS), which is a hybrid technique, combines two benefits: prompt blood flow restoration with an endovascular approach and inspection and resection of the small bowel. The aim of the study was to assess the results of ROMS in thrombotic AMI in a retrospective multicenter study. METHODS: We retrospectively enrolled all consecutive patients who underwent ROMS revascularization for occlusive thrombotic AMI in three participating tertiary care centers between November 2012 and March 2017. RESULTS: Twenty-five patients (14 men and 11 women; mean age, 64.9 ± 11.6 years) were included. In two patients, ROMS was not possible because of failure of re-entry in the aortic lumen (technical success, 92%). One patient required revascularization of two visceral arteries and underwent an aortohepatic bypass. Five patients (20%) underwent endarterectomy and patch angioplasty of the superior mesenteric artery before retrograde stenting. Thirteen patients (52%) required bowel or colon resection (11 patients required both resections) during the initial procedure with a mean length of small bowel resection of 52 ± 87 cm. The 30-day operative mortality rate was 25%, and the overall 1-year survival rate was 65%. The 1-year primary patency rate was 92%. In one patient, postoperative imaging at 1 month showed stent migration in the aortic bifurcation. CONCLUSIONS: ROMS for thrombotic AMI has a high technical success rate and a high midterm primary patency rate. It could be an alternative procedure to retrograde superior mesenteric artery bypass for patients when percutaneous endovascular revascularization is not indicated or has failed.

Eligibility Rates for Ambulatory EVAR.

BACKGROUND: The current results of endovascular repair of abdominal aortic aneurysms (EVAR) and the wide use of percutaneous closure systems suggest that ambulatory treatment is feasible in selected patients. The objective of this study was to evaluate the rate of eligibility to ambulatory EVAR (EVAR-Ambu) and its potential medicoeconomic impact. METHODS: Between January 2014 and December 2016, 245 patients were operated of an abdominal aortic aneurysm (AAA) in our center. The 128 patients whose anatomy was unfavorable with EVAR, which were operated in urgency or who were classified as American society of anesthesiologists 4, were excluded from the study. The 117 remaining files were reexamined to evaluate the eligibility for EVAR-Ambu retrospectively. The patients were considered as eligible if they presented all the following criteria: (1) normal surgical risk, (2) logistic feasibility of an ambulatory procedure (home <1 hr away from the hospital, available relatives), and (3) anatomical criteria of percutaneous feasibility according to angio-computed tomography. The surgical risk was evaluated according to the French High Health Authority (HAS) and the Society for Vascular Surgery (SVS) score. The balance between costs and revenue was evaluated for each patient according to the length of stay. RESULTS: Among the 117 patients, 43 (37%) and 57 (49%) were eligible for EVAR-Ambu by percutaneous route according to whether the surgical risk was assessed according to the HAS or the SVS criteria. If a conventional surgical approach was considered as compatible with EVAR-Ambu, 12 (10%) and 13 (11%) additional patients were eligible according to whether the surgical risk was assessed according to the HAS or the SVS criteria, respectively. In terms of medicoeconomic evaluation, the cost of the initial intervention depended was mainly on the cost of the stent graft and the operating room services. The cost spent of 1 night conventional hospitalization (CH) after EVAR was 603€ per day versus 490€ in the Day Surgery Unit (DSU). In comparison, the revenue for the institution was identical for DSU and a 1-night CH. According to our estimates, the balance between revenue and expenditures amounted to +122€ per patient for EVAR-Ambu versus +10€ or +119€ per patient hospitalized 1 or 2 nights, respectively. CONCLUSIONS: EVAR-Ambu is possible in a substantial proportion of patients treated for infrarenal AAA. Its medicoeconomic interest is real for the health system although it appears low at the individual level. The safety of this approach in clinical practice must be confirmed by a prospective study in selected patients.

Laser Uses in Noncoronary Arterial Disease.

BACKGROUND: In the past decade, excimer laser angioplasty (ELA) has emerged in the field of peripheral artery disease (PAD). Laser indications now extend to off-label uses, such as in situ fenestration of aortic endograft. The aim of this study was to review the different therapeutics applications of lasers in arterial disease treatment. METHODS: We reviewed the English-language literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We selected 106 relevant papers. We excluded unrelated papers (n = 67), letters and commentaries (n = 6), and review articles (n = 7), leaving 26 articles to form the basis of this review. RESULTS: A total of 18 articles were included in the analysis of ELA applications in PAD. Nine articles were related to atherosclerotic plaques. With a mean follow-up of 15 ± 7 months, primary patency was 65% ± 20%. The mean distal embolism rate during the procedure was 5%. Eight more articles focused on in-stent restenosis. The mean technical success was 98%, and the rate of distal embolism during the procedure was 9%. With a mean follow-up of 10 ± 4 months, primary patency was 68% ± 18%. Eight articles described "off-label" excimer laser indications in endovascular therapy, including 5 papers regarding in situ fenestrations for complex aortic aneurysms. CONCLUSION: Laser atherectomy and laser-assisted techniques are an important part of a vascular surgeon and interventionalist's armamentarium.

Acute Kidney Injury after Open Repair of Intact Abdominal Aortic Aneurysms.

BACKGROUND: These last years, considerable attention has been given to renal issues following endovascular aortic repair but acute kidney injury (AKI) also remains one of the most frequent complications following open repair (OR). Since AKI definition has evolved, our aim was to review the etiology, incidence, classifications, and consequences of AKI after OR for intact abdominal aortic aneurysm (AAA). METHODS: A review of the English language literature published between 2004 and 2016 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Studies regarding ruptured AAA, combination of emergency and elective repairs without results stratification, and thoracoabdominal aneurysms were excluded, as well as studies not using recent consensual AKI classifications. RESULTS: In total, 6 studies including 658 patients (394 from prospective studies and 264 from retrospective studies) used recent consensual classifications (risk injury failure loss end-stage renal disease [RIFLE], Acute Kidney Injury Network classification [AKIN], kidney disease-improving global outcomes [KDIGO], and Aneurysm Renal Injury Score [ARISe]) and were considered for analysis. After infrarenal clamping, AKI rates were quite similar between studies, observed in 24% cases when using the RIFLE classification, 20% cases with the AKIN criteria, and 26.3% cases when using the ARISe classification. Pooled rates of renal replacement therapy (RRT) and 30-day mortality were 0.3% and 1.4%, respectively. In the long term, no patient mandated chronic RRT. After suprarenal clamping, 2 retrospective studies used the RIFLE criteria to define the incidence of AKI, and the pooled AKI rate was 36.8%. The AKI rate was 26.5% in smaller retrospective study using the KDIGO criteria. Rates of RRT and 30-day mortality were 3.8% and 2.9%, respectively. In the long term, 1.2-3% of patients mandated chronic RRT. CONCLUSIONS: AKI is a common but generally transient complication after OR for AAA. Its incidence depends on definitions used, and few studies were found to use recent consensual AKI criteria. In the future, large prospective studies using consensual AKI definitions will facilitate comparison between repair strategies.

Physician-Modified C3 Excluder Endograft as the Preferred Solution to Treat a Juxtarenal Para-Anastomotic Aneurysm.

Feasibility and early satisfactory results of physician-modified endografts have been reported. Most reports described the use of Cook Dacron aortic endografts (Cook Medical, Inc., Bloomington, IN). However, in some specific anatomic features (short aortic length, narrow aorta), the use of this device may not be appropriate.We here report a case of juxtarenal aortic aneurysm proximal to a former aortobifemoral graft in a high surgical risk patient. Due to a narrow proximal neck and a short aortic length, a physician-modified Gore C3 Excluder device (W. L. Gore & Associates, Inc., Flagstaff, AR) incorporating a fenestration for a large accessory renal artery was implanted. At 6-month follow-up, the aneurysm remains excluded and computed tomography scan demonstrates patent renal vessels.Surgeon-modified Gore C3 Excluder device implantation is feasible. Because of specific device characteristics (short main body, repositioning ability), it represents a valuable alternative in high-risk patients with juxtarenal aneurysms not amenable to other techniques.

Management of Vascular Trauma during the Paris Terrorist Attack of November 13, 2015.

BACKGROUND: On November 13, 2015, Paris and Saint-Denis were the targets of terrorist attacks. The Public Hospitals of Paris Organization and the Percy Armed Forces Instruction Hospitals were mobilized to face the mass casualty situation. The objective of this study is to analyze the management of the victims presenting with a nonthoracic vascular trauma (NTVT). METHODS: All the data relating to the victims of NTVT who required a specific vascular open or endovascular treatment were analyzed retrospectively. A 6-month follow-up was obtained for all the patients. RESULTS: Among the 351 wounded, 20 (5.7%) patients had an NTVT and were dispatched in 8 hospitals (11 men of average age 32). NTVTs were gunshots in 17 cases (85%) or due to a handmade bomb in 3 cases (15%). Twelve patients (60%) received cardiopulmonary resuscitation during prehospital care. NTVT affected the limbs (14 cases, 70%) and the abdomen or the small pelvis (6 cases, 30%). All the patients were operated in emergency. Arterial lesions were treated with greater saphenous vein bypasses, by ligation, and/or embolization. Eleven venous lesions were treated by direct repair or ligation. Associated lesions requiring a specific treatment were present in 19 patients (95%) and were primarily osseous, nervous, and abdomino-pelvic. Severe postoperative complications were observed in 9 patients (45%). Fourteen patients (70%) required blood transfusion (6.4 U of packed red blood cells on average, range 0-48). There were no deaths or amputation and all vascular reconstructions were patent at 6 months. CONCLUSIONS: The effectiveness of the prehospital emergency services and a multisite and multidisciplinary management made it possible to obtain satisfactory results for NTVT casualties. All the departments of vascular surgery must be prepared to receive many wounded victims in the event of terrorist attacks.

Preoperative Evaluation of the Renal Function before the Treatment of Abdominal Aortic Aneurysms.

BACKGROUND: Chronic impaired renal function constitutes a major risk factor of morbi-mortality during the treatment of an abdominal aortic aneurism (AAA). The inflammatory state due to the AAA could result in a reduction in the muscular mass and an overestimation of the glomerular filtration rate (GFR) with the usual formulas. The objective of this study was to determine if the formulas used to evaluate the estimated GFR were adapted in patients with AAA. MATERIALS AND METHODS: Between August 2013 and November 2014, we conducted an exploratory study to evaluate the renal function before surgery for AAA in 28 patients. The renal function was evaluated by (1) the dosage of plasmatic creatinine, (2) the GFR estimated with the Cockroft-Gault, Modification of Diet in Renal Disease (MDRD), and chronic kidney disease epidemiology collaboration (CKD-EPI) formulas, (3) the creatinine clearance (CC), and (4) the direct measurement of the GFR with a reference method (iohexol clearance). Statistical analysis was carried out to compare and correlate the GFR estimated by the various formulas with the GFR measured by the reference technique. RESULTS: The study included 21 men (75%) and 7 women (25%), with a median age of 76 years (58-89). The measured GFR was correlated with the GFR estimated from the CKD-EPI (rho = 0.78, P < 0.0001), the MDRD (rho = 0.78, P < 0.0001), the Cockroft-Gault (rho = 0.65, P = 0.0002), and CC (rho = 0.86, P < 0.0001). However, there were important individual variations between estimated and measured GFR. As regards the detection of the patients presenting a GFR <60 mL/min/1.73 m2, the sensitivities of the CKD-EPI, MDRD, Cockroft-Gault formulas and CC were 64%, 64%, 71%, and 70%, respectively. Specificities were 71%, 79%, 57%, and 100%, respectively. The estimation of the GFR by the CKD-EPI formula had the lowest bias (-3.0). Bland-Altman plots indicated that the estimation of the GFR by the CKD-EPI formula had the best performance in comparison with the other methods. CONCLUSIONS: This study found a statistical correlation between the measurement of the GFR and the various formulas available to estimation the GFR among AAA patients. The CKD-EPI formula is most appropriate. However, there were important individual variations between the measurement and the estimations of the GFR. A larger scale study is necessary to determine the profile of the patients with a risk of error in the estimation of the GFR. The French recommendations on the evaluation of the renal function before AAA treatment remain based on serum creatinine and should be revalued.

Primary Open Stenting to Simplify Distal Anastomosis on Heavily Calcified Artery: The POSE Technique.

Despite improvements in surgical techniques, performing distal anastomosis on a heavily calcified artery (HCA) remains technically challenging. Clamping lesions and arterial wall trauma while suturing can lead to immediate or delayed arterial dissection and thrombosis. These issues are generally overcome by performing an extensive search for supple arterial zones, using sutureless techniques with covered stent-grafts and/or stenting the anastomosis under fluoroscopic guidance after unclamping. We describe a technique intended to simplify open surgical procedures on HCA. It consists of primary open stenting followed by localized endarterectomy (namely, the primary open stenting followed by localized endarterectomy [POSE] technique) to secure a distal anastomosis on an HCA. So far, we have successfully used the POSE technique in 24 patients but the durability of the technique remains to be determined.

A new technique for intra-abdominal arteries revascularization via extra-anatomic bypass from the brachiocephalic artery with a videoscopic retrosternal tunnel.

Extra-anatomic revascularizations of intra-abdominal or lower limbs arteries, or both, are indicated (1) when the aorta is unsuitable for anatomic bypasses, (2) in patients unfit for aortic surgery, (3) for graft infections, and (4) for visceral debranching during hybrid treatment of a thoracoabdominal aneurysm. We describe a new extra-anatomic bypass from the brachiocephalic artery with video-guided retrosternal tunneling. We discuss the advantages and drawbacks of this technique.

A technical tip for total laparoscopic type II endoleak repair.

Laparoscopy is a minimally invasive alternative for type II endoleak repair after endovascular aneurysm repair. However, control of lumbar and median sacral arteries is considered technically difficult due to the dense inflammatory tissue surrounding the aorta. We describe a technical tip that avoids close dissection of the aneurysm sac. After the transperitoneal approaches we commonly use during laparoscopic aortic surgery, the aneurysm is drawn rightward to access the plane of the anterior longitudinal ligament. This technique allows a direct exposure of the lumbar and median sacral arteries, which are all methodically dissected and ligated along the anterior wall of the spine without close dissection of the aneurysm sac. In our experience, this technical tip was always feasible and simplified laparoscopic type II endoleak repair.

Percutaneous radial access for peripheral transluminal angioplasty.

OBJECTIVE: The radial approach is currently gaining popularity in the setting of coronary percutaneous transluminal angioplasty (PTA) because it decreases the incidence of vascular complications. This study reports our initial results with radial access for peripheral PTA. METHODS: Between November 2011 and January 2014, we performed peripheral PTA in 526 patients. PTA was performed through left radial access in 24 ambulatory patients (4.6%) presenting with TransAtlantic Inter-Society Consensus A or B lesions on preoperative computed tomography angiography. Materials included a 110-cm-long introducer, a 0.018-inch 400-cm-long wire, 150-cm-long angiography catheters, 180-cm-long shaft balloons and stents. Data were prospectively collected. RESULTS: There were 22 men (92%), median age was 65 years (range, 45-88 years), and 38 target lesions were treated. Indication for revascularization was disabling claudication in 22 patients (92%) and critical ischemia in two (8%). Indication for choosing the radial approach was bilateral hostile groins in 12 patients (50%), bilateral infrainguinal lesions in 4 (17%), need for a contralateral femoral approach in the setting of kissing iliac stents or bifurcated surgical aortic grafts in 3 (13%), and elective in 5 (21%). Radial puncture failed in one patient (4%), and PTA was performed through brachial access. Technical success was 91% (20 of 22 patients). Thirty-seven stents were implanted. Total procedure duration was 45 minutes (range, 30-120 minutes). Fluoroscopy time was 9 minutes (range, 5-35 minutes), and 40 mL (range, 20-90 mL) of contrast was necessary. Radial artery rupture secondary to spasm was noted at the end of the procedure in two patients (8%). All patients could ambulate 2 hours after the procedure. No patient died. Median follow-up was 8 months (range, 1-23 months). Three radial arteries (13%) were occluded at the last follow-up. At 6 months, freedom from target lesion revascularization and target vessel revascularization were 91% and 91%, respectively, for iliac lesions and 93% and 86%, respectively, for infrainguinal lesions. CONCLUSIONS: This study demonstrates the feasibility of radial access for peripheral PTA. Radial access could represent an alternative to brachial access for peripheral and visceral interventions. Although complication rates of the present series are concerning, larger studies are needed to determine the role of transradial PTA once the learning curve is overcome. A wider diffusion of the technique mandates (1) smaller-diameter sheaths, (2) longer shaft devices, and (3) the development of specifically designed rescue devices such as covered stents and thromboaspiration catheters.

In Situ Fenestration Through the Contralateral Iliac Artery to Convert an Aortouni-iliac Into a Bifurcated Endograft.

PURPOSE: To present a technique of in situ fenestration that allows conversion of an aortouni-iliac endograft into a bifurcated endograft, thereby avoiding crossover femorofemoral bypass and its complications. TECHNIQUE: Following conventional deployment of an aortouni-iliac endograft, in situ fenestration through the contralateral common iliac artery is performed with a transjugular intrahepatic access set. The fabric hole is enlarged using a cutting balloon and a high-pressure noncompliant balloon. Kissing iliac-covered stents are then positioned at the level of the bifurcation to convert the aortouni-iliac endograft into a bifurcated repair. To date, this technique has been successfully used in 4 patients with satisfactory short-term results. CONCLUSION: This technique represents another application of endograft in situ fenestration. This strategy provides a bifurcated repair in cases where bifurcated stent-grafts are usually precluded, such as a narrow distal aorta, ruptured abdominal aortic aneurysm, or combined aortoiliac occlusive disease.

Mini-invasive treatment of abdominal aortic aneurysms: current roles of endovascular, laparoscopic, and open techniques.

BACKGROUND: Endovascular aortic repair (EVAR), laparoscopic aortic surgery (LAS), and open surgery (OS) are three established treatment methods of abdominal aortic aneurysms (AAA). While these techniques are often percieved as competitive between them, they are complementary for the vascular surgeon, whose goal is to provide a treatment adapted to each case that is noninvasive and durable. The objective of this study was to report our results of AAA repair to better define the roles of the three techniques. METHODS: From January 2009 to December 2011, we operated on 235 patients for AAAs. Patients for whom the three technical methods were discussed preoperatively were selected. Cases where the three techniques were not discussed were excluded (ruptured AAA, technique not available). One hundred seventy-five (75%) patients were included. Four groups were established based on the surgical risk and the anatomic EVAR criteria of the French Health Authority (Haute Autorité de Santé [HAS]), including: (1) good risk and favorable anatomy (GR-FA); (2) good risk and unfavorable anatomy (GR-UA); (3) high-risk and favorable anatomy (HR-FA); and (4) high-risk and unfavorable anatomy (HR-UA). Data collection was prospective. The numerical data were expressed as median and range. RESULTS: There were 166 (95%) men, aged 74 years (range 38-97 years). AAA diameter was 51 mm (range 30-81 mm). Mini-invasive treatment (EVAR or LAS) was chosen in 156 (89%) cases. Mortality at 30 days was 3.4% (6 patients, 1 EVAR, 1 LAS, and 4 OS), including 3 patients presenting with a "shaggy aorta." There were 58, 19, 65, and 33 patients in groups GR-FA (33%), GR-UA (11%), HR-FA (37%), and HR-UA (19%), respectively. The distribution of the three techniques (EVAR, LAS, OS) according to the groups was as follows: GR-FA (9, 46, 3); GR-UA (0, 13, 6); HR-FA (50, 13, 2); and HR-UA (12, 13, 8), respectively. The results by subgroups are presented. CONCLUSIONS: Based on our results, we present a new algorithm for AAA treatment. Among GR-FA patients, EVAR and LAS should be discussed according to life expectancy and wish of the patient. In GR-UA patients, LAS and OS can be proposed. For HR-FA patients, EVAR remains the first choice, but LAS can be used in cases with good life expectancy. In the HR-UA patients, LAS is the best choice because of the late complications of EVAR, but a broader use of fenestrated stent grafts or the chimney technique may be beneficial. Last, the surgical threshold should be pushed back among AAA patients presenting with a shaggy aorta.

Delirium in elderly vascular surgery patients.

The elderly represent a large percentage of patients seen in departments of vascular surgery. Delirium is a frequent perioperative complication in this population and contributes to increased morbidity and mortality. Prevention of problems associated with mental confusion rests in identifying comorbidities, their severity, and the risk factors associated with delirium syndrome. The aging of our population implies management of increasing numbers of older patients who often have concomitant pathologies and, consequently, polypharmacy. Optimization of their management rests on collaboration between surgeons, anesthetists, and geriatrists.

Laparoscopy versus EVAR for the treatment of abdominal aortic aneurysms in the octogenarian.

BACKGROUND: Octogenarians are considered at high surgical risk for the treatment of abdominal aortic aneurysms (AAA). The laparoscopic aortic surgery (LAS) and the endovascular treatment (EVAR) are 2 minimum invasive techniques whose objective is to limit the operative traumatism. The objective of this study was to compare our results with short- and medium-term results with these 2 techniques in the octogenarians. METHODS: Between January 2002 and December 2012, the data of 674 operated consecutive AAA (315 LAS, 172 EVAR, and 187 open surgeries) were collected prospectively. Eighty-seven patients aged ≥80 years presenting a favorable anatomy were treated by LAS or EVAR. Twenty-five patients aged ≥85 years with a favorable anatomy were excluded because we generally did not propose LAS to them. Statistical analysis compared the demographic data and the results of the 2 groups. The principal criterion of judgment (PCJ) was the combined rate of mortality and severe systemic complications (MSSC) at 30 days. An uni/multivariate model was used to determine the factors associated with the occurrence of the PCJ. The data were expressed as means and standard deviations. A P value ≤0.05 was considered significant. RESULTS: Sixty-two patients (90% men, age 81.8 ± 1.4 years) were included. There were 31 EVAR and 31 LAS. The 2 groups were comparable concerning the demographic data, the comorbidities, and the aneurysmal anatomies. There was a nonsignificant tendency to higher rates of mortality (9.7 vs. 3.2%, P = 0.3) and MSSC at 30 days (16.1 vs. 3.2%, P = 0.09) in the LAS group. During the operation, LAS was associated with a longer operative time (289 ± 85 vs. 152 ± 57 min, P < 0.0001), more blood losses (1,073 ± 763 vs. 148 ± 194 mL, P < 0.0001), and more transfusions (2.0 ± 3.0 vs. 0.9 ± 1.1 units, P = 0.048). In the postoperative period, the patients operated by LAS had longer reanimation and hospitalization stays (12.9 ± 13.1 vs. 7.0 ± 2.5 days, P = 0.02; and 3.3 ± 4.4 vs. 0.6 ± 0.7 days, P = 0.002; respectively). However, in multivariate analysis, an operative duration >300 min was the only variable associated with the PCJ (P = 0.05). With a follow-up of 9.0 ± 10.7 month, there were 2 reinterventions in the EVAR group, whereas with a follow-up of 38.0 ± 23.9 month, no reintervention was observed in the LAS group. CONCLUSIONS: In the short run, EVAR significantly reduces the operative traumatism in comparison with LAS in the octogenarian presenting an AAA with a favorable anatomy. However, the choice of the technique is not independently predictive of MSSC at 30 days. When a durable repair is desirable, LAS remains a possible option in the octogenarian with a good general condition presenting a favorable aneurysmal anatomy.

Bitubular graft as an adjunct for laparoscopic hybrid repair of an abdominal aortic aneurysm.

Laparoscopic repair (LR) of abdominal aortic aneurysms (AAAs) has been developed as a less invasive alternative to open repair. LR in the setting of diseased (ectatic, aneurysmal, calcified) aortic bifurcation or common iliac arteries (CIAs) is more challenging than LR of AAAs limited to the infrarenal aorta. In such cases, a bifurcated graft is necessary with an increased procedural time, more blood loss, and challenging distal anastomoses. We here present a new surgical technique using a custom-made bitubular graft (BTG), which allows LR of AAAs with diseased aortic bifurcation or CIAs while performing an aorto-aortic LR. During the same or a later intervention, covered stent grafts can be distally mated with the BTG using percutaneous femoral accesses to treat an extension of the disease to the aortic bifurcation and/or the CIAs. The BTG represents an interesting option for patients subjected to LR and presenting with an AAA associated with ectatic/aneurysmal proximal CIAs or heavily calcified aortic bifurcation.