Proximal radial artery ligation (PRAL) for reduction of flow in autogenous radial cephalic accesses for haemodialysis.

OBJECTIVE: Juxta-anastomosis proximal radial artery ligation (PRAL) is a new surgical technique for reduction of excessive blood flow of radial cephalic fistulas (RCFs). PATIENTS AND METHODS: This prospective study included 37 consecutive patients (eight children and 29 adults) who underwent PRAL of high-flow RCFs causing ischaemia (n = 2), aneurysmal degeneration of the vein (n = 14), and cardiac insufficiency (n = 7) or for prevention of cardiac overload (n = 14). Mean fistula age was 2.6 years for children and 7.4 years for adults. None had diabetes. Anatomical prerequisites (side-to-end anastomosis fistula and retrograde flow in the distal radial artery) were checked by ultrasound or angiography. Division and ligation of the juxta-anastomosis proximal radial artery were performed under regional anaesthesia. Patency following ligation was estimated according to the life table method. RESULTS: The success rate was 92% (34/37). The three failures included one excessive and two insufficient reductions of flow (<33%). Mean flow reduction rates were 50% in children and 53% in adults. Primary patency rates at 1 and 2 years were 88% +/- 6% and 74% +/- 9%, respectively. Secondary patency rates were 88% +/- 6% and 78% +/- 8%, respectively. CONCLUSION: PRAL is a simple, safe, and effective technique for reduction of flow in RCFs.

Local endovascular treatment of aortic aneurysms. From operating theater to lab bench.

Current treatment of aortic abdominal aneurysms by conventional surgery or endoprosthesis is flawed by high post-operative mortality and unpredictable durability of haemodynamic exclusion, respectively. We have developed endovascular approaches with cell and gene transfer, aimed at controlling further diameter expansion in an animal model of already-developed aneurysms in rats. Preliminary results suggest that both cell and gene endovascular therapy can be used to control expansion of aneurysms generated by inflammation and proteolytic destruction of the aortic wall.

Subintimal angioplasty: feasible and durable.

OBJECTIVE: To assess prospectively the feasibility and durability of subintimal angioplasty (SA) clinically and by duplex scans every 3 months. PATIENTS AND METHODS: Within a period of 54 months, we selected 96 patients with 100 occlusions (mean length: 11.5 cm) of femoro-popliteal or tibial arteries, for SA. RESULTS: The technical success rate was 88% and seven out of 12 failures were treated by conventional surgery. Five below-the-knee amputations were performed despite a patent recanalization. The following complications occurred: arterial perforation (6), arterial thrombosis (4), extensions beyond the planned re-entry site (5), and arterial dissection (2). Primary, assisted-primary and secondary patency rates were 61, 68 and 74%, respectively at 24 months. The 24 month-limb salvage and survival rates were 78 and 85%, respectively. Duplex imaging demonstrated 10 restenosis (five symptomatic >70%, five asymptomatic 30-70%), seven occlusions (five asymptomatic, two symptomatic treated by a bypass) and one asymptomatic dilatation. CONCLUSION: In a selected group of patients SA is feasible with a high initial technical success rate. SA is a good alternative in patients who are poor candidates for bypass surgery.

Robotically assisted aorto-femoral bypass grafting: lessons learned from our initial experience.

OBJECTIVE: The da Vinci trade mark Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) is a computer-enhanced telemanipulator that may help to overcome some limitations of traditional laparoscopic instruments. This prospective study was performed to assess the safety and feasibility of robotically assisted aorto-femoral bypass grafting (AF). METHODS: Five patients undergoing elective AF were enrolled in this study. In three patients, a laparotomy of 6 cm was first performed, the aorta being exposed using an Omnitract degrees retractor. In two patients, aortic dissection was performed with laparoscopy, with the patient in a modified right lateral decubitus position. In all patients, the proximal anastomosis was attempted with the da Vinci trade mark system by a remote surgeon. The role of the assistant at the patient's side was limited to exposure, haemostasis and maintaining traction on the running sutures performed by the robot. Six weeks after the operation, all patients underwent a duplex scan of the graft. RESULTS: Mean operative time was 188 min. Robotically assisted aortic anastomoses were successfully completed in four out of five patients. In these four patients, adequate blood flow was observed within the graft with no need for conversion for haemostasis. In the fifth patient, despite an adequate laparoscopic aortic dissection, the anastomosis was impossible to perform due to external conflicts between the robotic arms. A conversion using conventional suture was successfully performed. No robot-related complications were noted. Six weeks after the operation, the duplex scans demonstrated a graft patency of 100%. CONCLUSION: Robotically assisted anastomoses are possible by their unique ability to combine conventional laparoscopic surgery with stereoscopic 3D magnification and ultra-precise suturing techniques due to the flexibility of the robotic-wristed instruments using different motion scaling of surgeon hand movements. In addition, prior training in laparoscopic aortic surgery is not necessary for surgeons to obtain the level required for suturing. Further clinical trials are needed to explore the clinical potential and value of robotically assisted AF.

Vascular complications after surgical repair of aneurysms in Behçet's disease.

The poor prognosis of vasculo Behcet's disease is often due to postoperative vascular complications (false aneurysm and graft occlusion). We report a case of an abdominal aortic aneurysm associated with an aneurysm of the left common femoral artery in a 23-year-old Portuguese man. The primary treatment was surgical (aneurysmectomy and prosthetic revascularization). The early occlusion of the left femoral revascularized artery was treated surgically with a new bypass. The occlusion of the right limb of the aortoiliac graft was asymptomatic and was not treated. Two months after admission to our hospital, the stenosis of the infrarenal aorta successfully treated by angioplasty via the occluded right limb of the graft. The patient was followed up for 18 months. He could only walk a short distance and had rest pain in the left foot. Magnetic resonance angiography showed a false aneurysm of the infrarenal aorta, and an occlusion of the remaining left limb of the aortoiliac graft. The endovascular treatment performed does not avoid the need for surgical treatment, because occlusion and false aneurysm may occur after dilatation. The endovascular approach can also be used during a sudden inflammatory surge, and makes it possible to wait for a quiescent period when surgery can be performed.

[Abdominal aortic aneurysms and kidney transplantation]. / Anévrisme de l'aorte abdominale et transplantation rénale.

Protection of the kidney is fundamental during the treatment of abdominal aortic aneurysms (AAA). This applies particularly in patients with a renal transplant, the artery of which has been implanted on an iliac artery. Reviewing 27 AAA in patients with a renal transplant, the authors discuss the various techniques used. The authors disagree with renal function preservation methods. To maintain perfusion during clamping, different types of bypasses have been described: axillo-femoral, the Gott aortofemoral shunt or a partial extracorporeal perfusion (Campbell). With local or total hypothermia, the clamping time can be lengthened and this is used particularly when an end-to-end anastomosis into the internal iliac artery has been carried out. Since the Lacombe 1986 publication, no renal protection has been carried out for the sake of the technical needs of an operation. To reduce relative ischemia time, either the blood flow in the aortic bifurcation is maintained during the aortic clamping and the fashioning of the proximal anastomosis, or the distal anastomoses are fashioned first (Mathey), thus ensuring sufficient flow into the kidney through the collateral anastomoses between the iliacs, or by combining the 2 techniques (Mellière). The risk of infection in these immuno-depressed patients is discussed and it is concluded that the simultaneous repair of an AAA and the performance of a renal transplantation (Cerilli) is not recommended because of the risk of sepsis.