Bypass grafting to the third segment of the vertebral artery for symptomatic extensive vertebrobasilar atherosclerotic disease.

Symptomatic vertebrobasilar atherosclerotic disease is rarely encountered but represents a high-risk factor for recurrent transient ischemic attack or stroke. Posterior strokes are usually associated with embolism or hemodynamic impairment. Extensive disease involving the V3 and V4 segments of the vertebral artery (VA) remains infrequent, and optimal management is limited owing to the infrequency of this disease. We illustrate the case of a 65-year-old man who presented with recurrent transient episodes of dizziness with acute onset of instability, nausea, and left visual blurring. Magnetic resonance imaging findings of the head were normal, and computed tomography angiography revealed severe atherosclerotic disease of both VAs, with proximal occlusion of the right VA and multiple tight stenoses of the left VA at the V1 and V4 segments. Duplex ultrasound found markedly reduced anterograde flow in the VAs and basilar arteries and nonsignificant stenosis of the internal carotid arteries. Optimal medical treatment led to a decrease of transient symptoms. However, the patient developed a cerebellar infarction in the left posteroinferior cerebellar artery territory with left VA V4 segment occlusion. Surgical revascularization of the right VA was decided by the multidisciplinary team. Through an anterolateral approach of the right VA V3 segment, revascularization was performed using a common carotid artery-to-right VA bypass using a reversed saphenous vein graft. The patient fully recovered and was free of symptoms during the next 14 months of follow-up. In the case of extensive VA occlusive disease, surgical reconstruction of the distal VA using a bypass from the common carotid artery represents an option to improve hemodynamics and/or eliminate an embolic source of posterior stroke on a case-by-case basis.

Single Primary Retrograde Access to Treat Femoro-Popliteal Occlusive Lesions.

INTRODUCTION: The retrograde puncture of a distal artery is considered a bailout procedure in case of anterograde approach failure for peripheral artery disease (PAD) treatment. A single primary retrograde access has been suggested as an efficient and safe option. As scant data are available, we present our results using this approach. MATERIAL AND METHODS: Between August 2019 and October 2022, we performed this technique in selected patients with femoro-popliteal PAD. Chronic total occlusions (CTOs) were selected on the basis of the CTOP classification. An ultrasound-guided retrograde puncture of a tibial artery at the ankle level was performed, followed by the preferential use of 4F materials. Hemostasis of the puncture site was obtained using manual compression. Postoperative duplex scan examination systematically included an evaluation of the punctured artery. Demographics, intraoperative, and follow-up data were collected retrospectively. The results are expressed as means with standard deviations and numbers with percentages when appropriate. RESULTS: In total, 55 procedures were performed in 46 patients (9 bilateral). Of these, 57% (N=26) were considered at risk for femoral puncture (obesity, history of groin surgery, challenging crossover approach) and 54% (N=25) presented with critical limb-threatening ischemia (CLTI). The TASC-II femoro-popliteal classification was generally B (60%) and also C (33%) or D (7%). Mean lesion length was 105.6±49.4 mm and 65% were CTOs. Most patients were operated in an outpatient setting (N=25; 54%) under potentialized local anesthesia (N=41, 89%). The punctured site was the posterior tibial artery in 73% (N=40). The procedure time was 65.1±25.7 minutes, and the fluoroscopy time was 10.7±8.5 minutes. The technical success rate was 100%. There were no intraoperative complications. All patients could walk the same day. One CLTI patient presented an erysipelas related to the puncture in postoperative period. At 30 days, the primary patency of the treated and the punctured arteries were 98% and 100%, respectively. CONCLUSION: A single primary retrograde access can be used safely to treat femoro-popliteal PAD. It represents a valuable alternative to the femoral puncture and allows fast ambulation. Prospective and long-term studies on larger populations are necessary to confirm our results. CLINICAL IMPACT: This study demonstrates that a single primary retrograde access can be used safely without damaging the punctured artery to treat femoro-popliteal lesions, especially in claudicant patients. Chronic total occlusions can be treated successfully using this technique. This approach represents a valuable alternative to the femoral puncture and allows fast ambulation without risk of major bleeding.

Surgical Treatment of Femoral Artery Bifurcation Without Material: Technique and Follow-Up.

BACKGROUND: Complete eversion of the femoral tripod is interesting to reduce clinical consequences of wound infection, in particular for patients at a high risk (e.g., obese, diabetics, cancer). Experience and follow-up of this technique are scarce. The different technical possibilities and results are reported here. METHODS: A single-center prospective study including patients operated on for femoral occlusive lesions using eversion of the common femoral artery and its bifurcation. Clinical and imaging preoperative data, surgical technique, and follow-up are detailed. RESULTS: Thirty five patients (37 limbs) have been included between June 2014 and April 2016. The mean Rutherford index was 3.6 and 65% of the patients were claudicants. Lesions were limited to the common femoral artery in 14 (38%) of the cases and spread to the superficial femoral artery in 2 (7%) and to the 3 branches in 21 (57%) of the cases, respectively. Postoperatively, one death, one major amputation, and 3 reinterventions were noted, resulting in an 8% rate of major complications. The mean follow-up was 37 months. At this time, 11 major adverse cardiovascular events, 9 deaths, and no additional major amputation were noted. The mean Rutherford index was 1.7 (P < 0.001) and 3 reinterventions were necessary (one for septic occlusion at 3 months and 2 for restenosis at 12 and 42 months), translating into primary and secondary patency rates of 93.3% and 96.1%, respectively. CONCLUSIONS: This work further confirms that eversion of the femoral tripod is safe and effective. This experience adds to the existing body of the literature and describes alternative techniques of eversion. The technique should be considered when treating patients at a high risk of postoperative infection.

A hybrid clampless technique for aortic anastomoses.

BACKGROUND AND PURPOSE: In various circumstances of aortic repairs (heavy circumferential calcifications or shaggy aorta with extensive thrombus), open and endovascular techniques are at high risk. In addition to a likelihood of emboli, aortic clamping can be complicated by rupture and endovascular techniques may not be successful. We here describe a simple and reproducible hybrid technique that allows performing an aortic anastomosis without clamping in these situations. METHODS: After a limited exposure of the anterior aortic wall in a healthy segment, a prosthetic graft is sutured without any arteriotomy or clamping (adventitial suture), mimicking the final aspect of an end-to-side anastomosis. The graft and the anastomosis site are punctured using a long needle, allowing a guidewire to be positioned in the aorta under fluoroscopic guidance. Protected covered stenting of the anastomosis site opens the anastomosis without aortic clamping. After tunneling the graft to the target artery, the distal anastomosis is performed in a usual fashion. RESULTS: This technique was successfully used in 10 challenging consecutive cases with a sustained patency. CONCLUSIONS: This hybrid clampless technique for aortic anastomosis represents a useful alternative for challenging lesions unsuitable for a simple open or endovascular treatment.

Revascularization Outcomes in Patients With Acute Limb Ischemia and Active Neoplastic Disease.

PURPOSE: To report the outcomes of surgical (ST), endovascular (ET), and hybrid (HT) treatment in cancer patients with acute limb ischemia (ALI). MATERIALS AND METHODS: A multicenter retrospective registry collected 139 patients (mean age 72.3±12.4 years; 73 men) with ALI and active malignancy treated by ET (41, 29%), ST (70, 51%), or HT (28, 20%) in 7 European centers between July 2007 and February 2019. In 22 cases (16%) ALI was the first manifestation of the malignancy. Lung cancer was the most common diagnosis (38, 27%). The primary composite outcome was amputation-free survival (AFS). Overall survival, amputation-free time (AFT), and reintervention-free time (RFT) were also assessed. Cox regression analysis was applied to identify independent risk factors for the primary and secondary outcomes. Results are presented as the hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS: ET was associated with improved 12-month AFS compared with both ST (HR 2.27, 95% CI 1.20 to 4.28, p=0.002) and HT (HR 2.14, 95% CI 1.09 to 4.18, p=0.008). ST (HR 2.50, 95% CI 1.19 to 5.53, p=0.003) and HT (HR 3.10, 95% CI 1.45 to 6.65, p<0.001) were related to an increased risk for mortality compared with ET. At 12 months, the AFT was similar between the 3 groups (ET vs ST: HR 1.52, 95% CI 0.51 to 4.53, p=0.45 and ET vs HT: HR 1.21, 95% CI 0.36 to 4.11, p=0.73). The 12-month RFT also did not differ significantly between the 3 treatment options (ET vs ST: HR 1.10, 95% CI 0.49 to 2.46, p=0.79 and ET vs HT: HR 0.51, 95% CI 0.22 to 1.17, p=0.19). ST and/or HT increased the risk for the major amputation and/or death (HR 1.76, 95% CI 1.05 to 2.05, p=0.03), while Rutherford class I ischemia (HR 0.12, 95% CI 0.02 to 0.90, p=0.04) and previous vascular interventions on the index limb (HR 0.55, 95% CI 0.32 to 0.97, p=0.04) showed a protective effect. CONCLUSION: In patients with ALI and active malignant disease, ET was associated with increased AFS and overall survival compared with both ST and HT, while the limb salvage and reintervention rates were comparable among the 3 groups.

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.

Outcome of Lung Transplantation Using Grafts From Donors Over 65 Years of Age.

BACKGROUND: The outcome of lung transplantation (LT) is correlated with donor selection. A donor age of 65 years is classically considered a contraindication to lung procurement, and the results of LT from elderly donors remain to be established. METHODS: This was a retrospective study of a prospectively maintained database including all LTs performed in a single institution (Bichat Hospital, University of Paris, Paris, France) from January 2014 to March 2019. Donors65 years of age or older were included in the elderly group, whereas donors younger than 65 years of age were included in the control group. RESULTS: The study group included 241 LTs, including 44 (18%) in the elderly group and 197 (82%) in the control group. As compared with the control group, the elderly group was characterized by the following: donors of shorter stature (166 cm vs 172 cm; P = .04) and with less smoking history (14% vs 40%; P = .001), less bronchoscopic abnormality (20% vs 36%; P = .042), and less chest opacity (16% vs 30%; P = .048); and recipients of shorter stature (166 cm vs 170 cm; P = .04) but with similar diagnoses and gravity. There was no significant difference between the groups in any of the outcomes studied, including primary graft dysfunction, 30-day mortality, 1-year survival, chronic lung allograft dysfunction-free survival, and overall survival. In univariate analysis, the Oto lung donor score was the only factor associated with 1-year survival (score of 6 in alive patients vs score of 7 in dead patients; P = .04); donor age 65 years old or older was not. CONCLUSIONS: Carefully selected lung grafts from donors 65 years of age or older are associated with outcomes similar to those reported with grafts from younger donors Grafts from older donors thus provide an interesting option to expand the donor pool during a shortage.

Surgical repair of radiation-induced carotid stenosis.

OBJECTIVE: Carotid endarterectomy and carotid artery stenting are both valid therapeutic options for the treatment of radiation-induced carotid stenosis (RICS). The second has the advantage of being less invasive, although it seems to result in more restenosis than the first. Meanwhile, progress in radiation therapy and head and neck surgery has significantly increased the survival of these patients. As a result, treatment of RICS should be considered from a long-term perspective. This works presents perioperative and follow-up outcomes of surgical treatment of RICS. METHODS: This single-center retrospective study included all patients who underwent carotid endarterectomy for RICS from January 1998 to June 2017. Clinical and duplex ultrasound examination-based follow-up was performed postoperatively, at 1 month, 6 months, 12 months, and yearly thereafter. Kaplan-Meier curves were used for survival plots based on a log-rank test. Any abnormal finding led to angio-computed tomography scan and specialized neurovascular examination. RESULTS: Between 1998 and 2017, 128 patients (162 lesions) were treated. The median interval between radiation therapy and surgery was 16 years. Forty-five patients (35%) were symptomatic. The eversion technique was performed in 79 cases (49%), and the patch was favored in 24 cases (15%), prosthetic bypass graft in 51 cases (31%), and a venous bypass graft in 8 cases (5%). Two postoperative deaths (1.5%) (one secondary to massive stroke) were noted. The primary end point of early postoperative cerebrovascular event was 2.5%. Two cervical hematomas (1.2%) required surgical revision and seven cases of permanent cranial nerve injury were recorded. The median follow-up was 29 months (range, 2-199 months). There were no additional strokes. The 3-year primary patency rate was 96% and the 3-year freedom from neurologic event was 98%. CONCLUSIONS: Open surgical treatment of RICS lesions is a safe and durable option. Our results suggest that the outcomes of such treatment are good and in particular that rates of cerebrovascular event and restenosis are low and that cranial nerve injury should not be a concern. As a result, we consider that open surgery for RICS lesions should be offered as a first-line treatment. However, comparative data are mandated to address this issue.

Comparative Study of Antibiotic Elution Profiles From Alternative Formulations of Polymethylmethacrylate Bone Cement.

BACKGROUND: Polymethylmethacrylate (PMMA) bone cement is commonly used in orthopedic surgery for implant fixation and local antibiotic delivery following surgical debridement. The incidence of nephrotoxicity necessitates the balance of antiinfective properties with the potential for toxicity. Thus, understanding antibiotic elution characteristics of different PMMA formulations is essential. We sought to address this by assessing elution of vancomycin, daptomycin, and tobramycin from Palacos LV (Palacos), Stryker Surgical Simplex P (Simplex), BIOMET Cobalt HV (Cobalt), and Zimmer Biomet Bone Cement R (Zimmer) radiopaque bone cements. METHODS: Antibiotics were mixed with each cement formulation, and molds were used to produce beads of cement. Beads were incubated in phosphate-buffered saline at 37°C, and antibiotic elution was measured daily for 10 days with vancomycin and 5 days with daptomycin and tobramycin. Active antibiotic was quantified by serial dilution and comparison to the minimum inhibitory concentration. RESULTS: The elution profiles of Simplex were significantly lower than all other cements with all antibiotics (P < .00093). Palacos exhibited a significantly higher vancomycin elution profile than all other cements (P < .00001). The difference in daptomycin elution profiles for Cobalt and Palacos was not significant (P > .43), but both were significantly higher than Zimmer (P < .0006). CONCLUSION: Overall, Stryker Surgical Simplex P exhibits a significantly lower elution profile than all other cements tested. In general, Palacos LV exhibits an increased elution profile compared with other cements. This elution information may assist the surgeon in choosing different cement formulations for the local delivery of antibiotics.

External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures.

INTRODUCTION: On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)<15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution. PATIENTS AND METHODS: Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables. RESULTS: In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative. CONCLUSION: With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS<15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.