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

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

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

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

Endovascular repair of aortic allograft aneurysmal degeneration: a case report.

Aortoenteric graft fistula remains a dreadful complication of aortic surgery. Good results have been reported using in situ graft replacement with arterial allografts. Late aneurysmal degeneration of the graft itself may necessitate further repair. We report the case of such an aneurysmal degeneration 7 years after implantation of the allograft. Endovascular repair was performed with a Vanguard device; complete exclusion was obtained immediately. At 6-month follow-up, the patient was alive and well. Duplex and computed tomography scans showed an excluded aneurysm with a slight reduction in size. Endovascular stent grafting may be a therapeutic option for treating patients with late allograft degeneration.

[Use of radiotherapy in cardiovascular disease. Radiophysical basis, current results, indications and perspectives]. / La curiethérapie en pathologie cardiovasculaire. Bases radiophysiques, résultats actuels, indications et perspectives.

Restenosis is the main limitation of percutaneous angioplasty, especially in vessels of small diameters such as the coronary arteries, the femoro-popliteal and tibial-peroneal arteries and the arterio-venous dialysis grafts. The extensive use of tents has not entirely prevented its occurrence, whereas treating in-stent restenosis gives even more uncertain results. Endovascular radiotherapy has emerged over the past few years as a promising approach to both prevent and cure it. The analogy between the tumour-like cellular proliferations observed in post-angioplasty restenosis and tumour processes prompted pioneering works to study the effect of ionizing radiations in animal models of arterial restenosis. The demonstrated feasibility, tolerance and efficacy of this approach lead to test this strategy in humans. The results of 3 recently presented randomized double-blind trials in the treatment of coronary in-stent restenosis have been so promising that endovascular brachytherapy might now be considered the treatment of choice in this indication. Other randomized trials are currently carried out to test whether endovascular brachytherapy may prevent restenosis in coronary and femoro-popliteal arteries as well as in hemodialysis shunts. In the present review, we describe the basics of the biological effects of ionizing radiations, the technical modalities to deliver endovascular radiations, our current knowledge about their effects on the vascular wall and the restenosis mechanisms, and the results of the first clinical studies. Finally, we address the remaining problems in the use of endovascular curietherapy and question the promises and challenges of its clinical application.

Infectious pseudoaneurysms suspected at echocardiography: electron-beam CT findings.

PURPOSE: To review the electron-beam computed tomographic (CT) findings in patients with clinical endocarditis and suspected of having perivalvular pseudoaneurysms at echocardiography and to compare these findings with echocardiographic data. MATERIALS AND METHODS: Data on 17 patients who underwent electron-beam CT for suspicion of perivalvular infectious pseudoaneurysm at echocardiography were retrospectively reviewed. Thirteen patients had a history of valvular surgery. Electron-beam CT findings-lesion size, number, extent, and relationships with surrounding structures, and associated lesions-were compared with echocardiographic and surgical and/or autopsy data. RESULTS: In all patients, electron-beam CT depicted one or more abnormal cavities that filled with contrast material after bolus injection. The mean size (3.5 cm) and number (n = 21) of pseudoaneurysms recorded with electron-beam CT were greater than those recorded with echocardiography (2.9 cm and n = 13, respectively). Associated electron-beam CT findings included valvular vegetations in three patients; mediastinitis in two; and coronary arterial involvement in six. In eight (47%) patients, electron-beam CT depicted a pseudoaneurysm or an additional pseudoaneurysm that was only suspected-not depicted-at echocardiography. Transthoracic and transesophageal echocardiography resulted in underestimation of lesion number, size, and extent and associated lesions, particularly in patients with valvular prostheses or voluminous lesions. CONCLUSION: Thoracic infectious pseudoaneurysms are well depicted with electron-beam CT, which may be a useful addition to echocardiography for detection of this disease and thus help in preoperative planning.

Preoperative assessment of the efficacy of distal radial artery ligation in treatment of steal syndrome complicating access for hemodialysis.

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. We report here a case in which we applied a new diagnostic method to assess the efficacy of distal radial ligation to treat this syndrome. A favorable comparison of distal radial artery pressure measurements before and after temporary occlusion of the artery with a balloon catheter indicated that perfusion of the hand would be dramatically improved after surgical artery ligation.

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

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

[Spontaneous regression of a false aneurysm of the ascending aorta following surgery for dissection]. / Régression spontanée d'un faux anévrisme de l'aorte ascendante consécutif à une chirurgie pour dissection.

We report the case of a 50-year-old man admitted to hospital for a type A aortic dissection. After conventional surgical repair, he was asymptomatic and underwent computed tomography imaging at 15 days, 3 and 6 months. The first CT scan showed a small perigraft circulating false aneurysm which totally disappeared on the last exam. This case emphasizes the potential role of CT scan in the follow-up of patient after aortic surgery and the likely favorable outcome of some false aneurysm.

Cardiac metastatic melanoma investigated by magnetic resonance imaging.

There is a high rate of cardiac involvement in malignant melanoma (MM), but such cardiac metastases are usually diagnosed late. This report describes four cases with different clinical presentations of MM cardiac involvement that were investigated by magnetic resonance imaging (MRI). The MM cardiac involvement was asymptomatic in one case, detected because of a superior vena cava syndrome in a second, and because a tamponade in the remaining two cases. MRI permitted the diagnosis of cardiac metastases of MM, which was not made by echocardiography in one case. By precisely detecting the extent of the tumors, MRI was a great help in management, especially when an isolated cardiac metastasis was suitable for surgical ablation (two cases). Because both clinical signs and transthoracic echocardiogram are not very sensitive for diagnosing MM myocardial involvement, MRI can help provide such a diagnosis and ensure better treatment-monitored decisions.

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

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

Evaluation by electron beam computed tomography of intracardiac masses suspected by transoesophageal echocardiography.

OBJECTIVES: To assess the suitability of electron beam computed tomography (EBT) in evaluating and subsequently managing cardiac masses suspected as a result of examination by transthoracic and transoesophageal cross sectional echocardiography. DESIGN AND PATIENTS: In 76 consecutive patients with suspected cardiac masses, the impact of the EBT examination was analysed by reviewing whether EBT examination altered management by confirming or excluding a mass, whether EBT imaging substantially contributed to decision-making, and lastly whether EBT influenced the decision to operate on the patient. RESULTS: EBT modified the diagnosis or confirmed results which had been questionable with cross sectional echocardiography in 53 cases (70%): these cases included those with anatomical features such as dense calcifications or fatty structures (n = 20), lipomatous lesions (n = 5), equivocal thrombi (n = 5), pericardial masses (n = 5), or hydatid cysts (n = 2). EBT gave information over and above cross sectional echocardiography in all patients with malignant tumours (n = 16) by providing a better delineation of the relation between intracavity masses and normal structures, including the mural site of tumour attachment and tumour extension to the great vessels and the adjacent extracardiac mediastinal structures. EBT provided no additional information over cross sectional echocardiography in the remaining patients (n = 23), particularly in those with myxomas (n = 11) or small valvar lesions (n = 6). EBT only confirmed that the lesion was well demarcated, limited in extent, or not associated with a mass. CONCLUSIONS: EBT has considerable potential for clinical management and surgical planning and may help clinicians to decide against surgery, particularly in patients with unresectable tumours.

Percutaneous treatment of acute iliac artery injury after intraaortic balloon counterpulsation.

We report on a novel approach to correcting iliac artery occlusions caused by aortic counterpulsation. Two patients who had leg ischemia after retrieval of an intraaortic balloon pump underwent angiograms that showed occlusion of the right external iliac artery because of dissection (one case) or thrombosis (one case). Percutaneous self-expandable stents were implanted in the occluded vessels, and they fully restored normal iliac patency with no complications and satisfactory midterm follow-up results. We conclude that iliac artery occlusion induced by aortic counterpulsation can be safely treated by implanting self-expandable stents in cases of acute iatrogenic dissection.

Self-expandable stents for the treatment of iliac artery obstructive lesions: long-term success and prognostic factors.

OBJECTIVE: The purpose of our study was to report long-term (more than 2 years of follow-up) angiographic patency after self-expandable stent implantation in the iliac artery and to identify patient- or procedure-related prognostic factors of angiographic patency. SUBJECTS AND METHODS: Ninety-five consecutive patients (101 arteries) underwent Wallstent implantation to treat claudication (n=95 limbs), rest pain (n=2), and nonhealing ulcer (n=3). Another patient was asymptomatic but was treated for acute occlusion of the iliac artery after coronary angioplasty. After implantation of self-expandable stents, we followed up by examining clinical and angiographic records at 6 months, 1 year, and annually thereafter. The Kaplan-Meier survival curve was used to determine primary and secondary patency rates. Primary patency was that achieved after the initial procedure only. Secondary patency was defined as that achieved after one or more successful additional percutaneous procedures within the stent or beyond the stent. Multivariate analysis using the Cox proportional hazard model was performed to identify predictive factors of angiographic failure, defined as restenosis of 50% or greater or occlusion. RESULTS: Four-year patency rates of 61% (primary) and 86% (secondary) were found (mean follow-up, 29 months). The following five factors were associated with long-term angiographic failure: occlusion of the superficial femoral artery (relative hazard = 5.21), absence of hypertension (relative hazard = 4.85), a stent diameter of less than 8 mm (relative hazard = 4.45), two or more stents implanted (relative hazard = 3.56), and current tobacco consumption (relative hazard = 2.46). CONCLUSION: Improved patency rates may be obtained by selecting patients for Wallstent implantation in the iliac artery based on five factors shown to be prognostically important.

Cragg covered stents in hemodialysis access: initial and midterm results.

PURPOSE: To report midterm follow-up after implantation of covered stents for hemodialysis access. PATIENTS AND METHODS: Over a 2-year period, a Cragg Endopro stent was placed in 14 patients (mean age, 66.6 years +/- 15) to treat angioplasty-induced ruptures (n = 3), pseudoaneurysm (n = 1), postangioplasty residual stenosis (n = 2), and early restenosis (n = 8, four of them in a Wallstent). RESULTS: Initial placement was successful in all cases. A clinical inflammatory reaction was observed in all three cases of placement in the forearm. When the covered stent was placed in a stenotic vessel, restenosis always occurred within 6 months. Primary and secondary patencies were 28.5% +/- 13.9 and 67.8% +/- 14.5, respectively, at 6 months. Covered stents were of undoubtable benefit in one case of rupture after Wallstent failure and in one case of restenosis in a Wallstent. CONCLUSION: Covered Cragg stents are effective in controlling angioplasty- induced rupture and sometimes for maintaining patency after restenosis in a Wallstent. They do not prevent restenosis and are responsible for an inflammatory reaction of unknown origin and long-term effect.

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

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

[MRI in cardiology: clinical applications and perspectives]. / IRM en cardiologie: applications cliniques et perspectives.

MRI is an effective tool in the evaluation of cardiovascular diseases. With continued improvements in MR angiography, velocity mapping, myocardial tagging, imaging speed and display, it is anticipated that MRI will play an ever-increasing role in the morphological evaluation of many cardiovascular anomalies. The need for quantification in cardiology has led to the development of a variety of techniques to assess cardiac size and function. In attempting to answer these clinical questions, MRI provides major advantages several: extraordinary flexibility, powerful contrast mechanisms, sensitivity to flow and motion, and freedom from ionizing radiation, contrast agent and acoustic windows. Because of accurate initial results in quantifying cardiac chamber size, global and segmental function, it is likely that MRI methods will play an increasing role in the evaluation of cardiac structure and function. Recently, MRI has emerged as an important tool in the evaluation of great vessel disease, particularly in the evaluation of both congenital and acquired abnormalities of the aorta. Early evidence suggests that magnetic resonance may help in distinguishing constrictive pericarditis from restrictive cardiomyopathy (e.g., amyloid heart disease). Cardiac-MRI lends itself to assessment of intracardiac masses. Spin-echo imaging alone is often sufficient for diagnosis. Cine-MRI has important additive value, however, when a mass lesion shows dynamic motion, or when abnormal flow patterns in conjunction with a mass lesion require evaluation.

[Dynamic cardiovascular studies with electron beam computed tomography]. / Etudes dynamiques cardiovasculaires par la tomodensitométrie par faisceau d'électrons.

Electron Beam CT (EBCT) is still emerging as a new functional imaging procedure in providing high morphological studies and dynamic quantitative functional data. Morphological EBCT studies have previously proven their usefulness in pathologic conditions of the thoracic aorta, in congenital diseases, in cardiac masses or tumors... Functional studies achieved using cine mode and/or flow mode are used to assess both mobility and perfusion of structures. Such dynamic analysis have confirmed that their applications will have a major impact on the knowledge of cardiac physiology, the understanding of cardiovascular diseases, if not in daily patient care. For instance, in studies on ventricular function, among the imaging modalities in current use, EBCT is probably most accurate for the evaluation of systolic regional or global function. EBCT is a cross-sectional imaging methods which overcome an important limitation shared by most other imaging modalities, namely the superimposition of overlapping cardiac and thoracic structures. Since in the method high spatial, contrast, and temporal resolution tomography displays the myocardial wall itself, an accurate delineating of endocardial and epicardial contours in contiguous levels can be obtained. Further developments in computer-automated analysis from dynamic EBCT studies have to be carried out to gain clinical acceptance and to facilitate the routine.