Predictive Factors of Amputation in Infrainguinal Vascular Trauma: A Monocentric Experience.

BACKGROUND: Infrainguinal vascular injuries (IIVIs) are emergencies involving both functional and vital prognosis. The choice between saving the limb or doing a first-line amputation is difficult even for an experienced surgeon. The aims of this work are to analyze early outcomes in our center and to identify predictive factors for amputation. METHODS: Between 2010 and 2017, we reviewed retrospectively patients with IIVI. The main criteria for judgment were as follows: primary, secondary, and overall amputation. Two groups of potential risk factors of amputation were analyzed: Those related to the patient: age, shock, ISS score and those related to the lesion: mechanism, above or below the knee, bone lesions, venous lesions and skin decay. A univariate and multivariate analysis were performed to determine the risk factor(s) independently associated with the occurrence of amputation. RESULTS: Fifty-seven IIVIs were found in 54 patients. The mean ISS was 32,3 ± 21. A primary amputation was performed in 19%, and secondary in 14% of cases. Overall amputation rate was 35% (n = 19). Multivariate analysis reveals that the ISS is the only predictor of primary (P = 0.009; odds ratio (OR):1.07; confidence interval (CI):1.01-1.12) and global (P = 0.04; OR:1.07; IC:1.02-1.13) amputation. A threshold value of 41 was selected as a primary amputation risk factor with a negative predictive value of 97%. CONCLUSIONS: The ISS is a good predictor of the risk of amputation in IIVI. A threshold of 41 is an objective criterion helping to decide for a first-line amputation. Advanced age and hemodynamic instability should not be important in the decision tree.

Clampless 2 Device: Experimental Study of a Lateral Aorto-Prosthetic Anastomosic Device Without Clamping or Suturing.

BACKGROUND: To offer an alternative to conventional techniques of lateral prosthetic anastomosis on arteries which require a long training, and impose an extensive open surgery, we are proposing the clampless 2 device (C2D) implanted by a simple arterial puncture and allows a lateral implantation of a polytetrafluoroethylene (PTFE) vascular graft in an artery, without arterial clamping or suture. METHODS: C2D is a "T" shaped 25-mm long and 8-mm diameter Nitinol stent with a 6-mm PTFE graft prosthesis mounted laterally on the stent, and implanted in an artery, via a 21-French sheath, and a compliant balloon inflation. In vitro testing of the C2D was first performed on a bench including a segment of a 7-mm internal diameter pig abdominal aorta. A series of 5 consecutive C2D implantation was analyzed with evaluation of the implantation time and the fluid losses at a fluid pressure of 80 and 150 mm Hg. The C2D implantation was finally controlled by angioscopy. An aorto-iliac bypass was then secondly performed on 8 living sows, with a side-to-end C2D implantation in the infrarenal abdominal aorta, followed by a conventional end-to-end prosthetic left iliac trunk anastomosis. The C2D and distal conventional anastomotic times were evaluated, as well as the total operative time and blood loss. A postoperative angiogram was systematically performed. RESULTS: The C2D was successfully implanted in all 5 in vitro tests, with an average implantation time of 2'58 (range: 2'25-3'22). The mean value of fluid losses was 84 ml (range: 67-94 ml), with no fluid leakage occurring at 80- and 150-mm Hg pressure. All anastomoses were patent after macroscopic study by angioscopy with a perfect application of the stent in the aortic wall. In 8 living sows (mean weight: 42 kg, 37-50 kg), an aorto-left iliac bypass was successfully implanted in all cases, with a total mean procedure time of 101 min (range: 90-130 min), and an average fluid loss of 77 ml (range:20-120 ml). The mean implantation time was 4'39 (range 3'29-5'52) for C2D and 16 min (range 12-17 min) to perform the conventional distal prosthetic-iliac anastomosis. Systematic arteriographic and angioscopy control showed perfect patency of the C2D implantations. CONCLUSIONS: Preliminary in vitro and acute in vivo testing of C2D implantation show good early results, allowing further long-lasting pig experiments on the way to human homologation.

Systematic review and meta-analysis of endovascular versus open repair for common femoral artery atherosclerosis treatment.

BACKGROUND: Encouraging recent reports on endovascular treatment of common femoral artery (CFA) atherosclerotic disease has rendered the question regarding the place of this technique evermore pertinent and legitimizes the performance of randomized trials. The present comprehensive review focused on the early and midterm outcomes to help assess the benefit/risk balance of endovascular vs open repair for CFA treatment. METHODS: Embase and Medline searches were conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) standards to identify studies from 2000 to 2018 reporting on endovascular repair (ER), open surgery (OS), and comparisons of both techniques for CFA atherosclerosis treatment. The outcomes measured were 30-day mortality, morbidity, reintervention rates, midterm patency, late reintervention, and restenosis rates. RESULTS: Twenty-eight studies were eligible: 14 OS (1920 patients), 12 ER (1900 patients), and 2 comparative randomized trials (197 patients). The meta-analysis of the comparative studies revealed no differences in 30-day mortality or reintervention rates but improved 30-day morbidity after ER. At 1 year, the primary patency rates did not differ between ER and OS, nor did the late reintervention rate. In the noncomparative studies, with a mean follow-up period of 23.8 months for ER and 66 months for OS, the restenosis rate was 14.4% and 4.7%, respectively. The reported stent fracture rate was 3.6%. In the ER cohort, the overall primary patency at 1, 2, and 3 years was 81.9%, 77.8%, and 75.1%, respectively. For the OS cohort, the overall primary patency rate at 1, 2, and 3 years was 93.4%, 91.4%, and 90.5%, respectively. CONCLUSIONS: Despite expectations, our analysis of the reported data suggests that the perioperative mortality is not in favor of ER; however, the perioperative morbidity showed an advantage for ER compared with OS. Also, although comparable in the first year, the long-term primary patency rate was much greater after OS. At present, the place of ER for CFA treatment still requires further definition. Additional clarification of the indications and more research are both required to determine the optimal endovascular technology and femoral bifurcation reconstruction with stenting.

Editor's Choice - A Cost Effectiveness Analysis of Outpatient versus Inpatient Hospitalisation for Lower Extremity Arterial Disease Endovascular Revascularisation in France: A Randomised Controlled Trial.

OBJECTIVE: The AMBUVASC trial evaluated the cost effectiveness of outpatient vs. inpatient hospitalisation for endovascular repair of lower extremity arterial disease (LEAD). METHODS: AMBUVASC was a national multicentre, prospective, randomised controlled trial conducted in nine public and two private French centres. The primary endpoint was the incremental cost effectiveness ratio (ICER), defined by cost per quality adjusted life year (QALY). Analysis was conducted from a societal perspective, excluding indirect costs, and considering a one month time horizon. RESULTS: From 16 February 2016 to 29 May 2017, 160 patients were randomised (80 per group). A modified intention to treat analysis was performed with 153 patients (outpatient hospitalisation: n = 76; inpatient hospitalisation: n = 77). The patients mainly presented intermittent claudication (outpatient arm: 97%; inpatient arm: 92%). Rates of peri-operative complications were 20% (15 events) and 18% (14 events) for the outpatient and inpatient arms respectively (p = .81). Overall costs (difference: €187.83; 95% confidence interval [CI] -275.68-651.34) and QALYs (difference: 0.00277; 95% CI -0.00237 - 0.00791) were higher for outpatients due to more re-admissions than the inpatient arm. The mean ICER was €67 741 per QALY gained for the base case analysis with missing data imputed using multiple imputation by predictive mean matching. The outpatient procedure was not cost effective for a willingness to pay of €50 000 per QALY and the probability of being cost effective was only 59% for a €100 000/QALY threshold. CONCLUSION: Outpatient hospitalisation is not cost effective compared with inpatient hospitalisation for endovascular repair of patients with claudication at a €50 000/QALY threshold.

French Guidelines for the Management of Ambulatory Endovascular Procedures for Lower Extremity Peripheral Artery Disease.

BACKGROUND: Ambulatory hospitalization for endovascular repair of lower extremity peripheral arterial disease (PAD) could be a real opportunity to respond to the burden of PAD, to reduce costs, and to improve patients' empowerment. The French Society of Vascular and Endovascular Surgery (SCVE) established guidelines to facilitate the development of ambulatory hospitalization in France. METHODS: In 2017, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and MEDLINE database to conduct a systematic review of available literature. A total of 448 relevant articles were found. Twelve articles, all published after the year 2000, were included and reviewed by two independent investigators. The SCVE mandated a scientific committee to collectively establish these guidelines. RESULTS: Eligibility for ambulatory management shall be based on the assessment of the triad: (1) patient, (2) procedure, and (3) structure. Comprehensive information and a detailed procedural pathway should be provided for the patient. No age limit is recommended. American Society of Anesthesiologists I, II, and III stable patients are eligible for ambulatory intervention. Specific comorbidities such as severe obesity, sleep apnea, and/or chronic kidney failure should be assessed preoperatively. Critical limb ischemia and complex lesions have not been considered as exclusion criteria. Antiplatelet drug use (aspirin and/or clopidogrel) has not been considered as a contraindication. Femoral ultrasound-guided puncture is recommended. Manual compression or closure devices have been recommended for 7F sheath or less. A minimum of 4 hours of monitoring after percutaneous femoral access is required before discharge. CONCLUSIONS: The SCVE guidelines aim to frame the practice of ambulatory endovascular procedures for lower extremity peripheral artery disease and to give vascular interventionalists help in their routine practice.

Endovascular creation and validation of acute in vivo animal model for type A aortic dissection.

BACKGROUND: Animal modeling is a prerequisite for clinical transfer of new therapies. This study targets an acute in vivo animal model of type A dissection using endovascular approach with a view to test future stent grafts dedicated to this aortic segment. METHODS: Experiments were conducted on 13 swine. Two arterial accesses, femoral and percutaneous transapical, were required. Entry tear was created by endovascular instrumental means inserted through transapical access with either Outback catheter (group 1, n = 3) or EchoTip Endoscopic Ultrasound Needle (group 2, n = 10). Afterward, dissection extension was obtained in antegrade direction by looped guidewire technique, and, as often as possible, re-entry tear was created with either looped guidewire or Outback catheter. Finally, entry tear, dissected space, and re-entry tear when existing were dilated with 8-mm balloon. In our acute model, animals were euthanized at the end of the experiment day, and aortas were explanted for macroscopic and histologic examination. RESULTS: The model was successfully created in 10 out of 13 animals. In group 1, dissection was limited to arch with 23 mm average length and no possibility of achieving re-entry tear. One aortic perforation was observed. In group 2, dissection was extended up to descending thoracic or thoracoabdominal aorta, with 110 mm average length (range 40-165 mm), and re-entry tear was created in seven cases. Histologic examination confirmed the presence of intimo-medial flap. CONCLUSIONS: The present experiment validates a new type A dissection animal model, which morphologically reproduces human aortic dissection features. As such, it provides an advantageous basis for testing future stent grafts.

Aortic Anatomy and Complications of the Proximal Sealing Zone after Endovascular Treatment of the Thoracic Aorta.

BACKGROUND: Technical and clinical success of thoracic aortic endovascular procedures relies mainly on the choice of the proximal sealing zone (PSZ). The latter can be affected by multiple complications, all of them having a potential gravity and a direct link with the quality of the PSZ. The objective of this study was to analyze the risk factors of PSZ complications occurrence. METHODS: Between 2007 and 2015, all the patients treated by a thoracic stent graft in zones 2, 3, or 4 were retrospectively reviewed, with analysis of the preoperative and postoperative angio-computed tomography. Proximal sealing zone complications are type Ia endoleaks, bird beak ≥20 mm, malposition ≥11 mm, migration ≥10 mm, and retrograde dissection. Three types of potential risk factors were analyzed: (1) related to the patients (age, gender, pathology, urgency, hybrid surgery); (2) related to the stent graft (bare or covered proximal stent, degree of oversizing, number of stents, generation); (3) related to the morphology (radius of curvature, diameter, degree of conicity, calcifications and thrombus of the neck, depth of the arch, angulation of the proximal sealing zone, and tortuosity index of the arch and the thoracic aorta. RESULTS: Seventy-six patients (mean age: 54 years, 17-93 years) were treated for traumatic aortic rupture (n = 27, 35.5%), aortic dissection (n = 26, 34%), aneurysm (n = 15, 20%), and other diseases (floating thrombus, aortoesophageal fistula) (n = 8, 10.5%). A hybrid surgery was carried out in 18 patients (24%). Primary technical success was 93.5% (n = 71). With a mean follow-up of 29 months, 30 PSZ complications were observed in 21 patients (28%): type Ia endoleaks (n = 3, 4%), bird beak (n = 7, 9%), malposition (n = 3, 4%), migration (n = 1, 1.5%), retrograde dissection (n = 1, 1.5%), or several complications (n = 6, 7.8%). Among the morphological factors, 2 parameters were significantly associated with the occurrence of complications: tortuosity index (group without PSZ complications 1.62 ± 0.2 vs. group with PSZ complications 1.72 ± 0.2, P = 0.042), and the diameter of the proximal neck (group without PSZ complications 25.7 ± 5 vs. group with PSZ complications 31 ± 6.0, P = 0.001). Neither the demographic factors nor those related to the stent graft presented a statistically significant relation with the occurrence of complications. CONCLUSIONS: This work clearly highlights the relation between PSZ complications, independently of their type, and the local and global aortic morphology. A wide proximal neck, > 34 mm, and an important aortic tortuosity, > 1.8, are situations at risk.

Examination of factors in type I endoleak development after thoracic endovascular repair.

OBJECTIVE: The objective of this study was to assess the effects of operative indication, anatomy, and stent graft on type I endoleak occurrence after thoracic endovascular aortic repair. METHODS: A retrospective review was conducted of patients admitted for thoracic endovascular aortic repair between 2007 and 2013. All computed tomography angiography imaging was analyzed for the presence of endoleak and measurement of diameters and lengths. Variables studied included underlying disease, emergency, achieved aortic neck length, difference between proximal and distal neck diameters, landing zone 2, and stent graft characteristics (diameter, number, type of device, oversizing degree, and covered aorta length). RESULTS: The study population involved 84 patients (mean age, 56 years; range, 17-94 years) who were treated for thoracic aortic aneurysm (TAA) (n = 29; 34.5%), traumatic aortic rupture (n = 27; 32%), type B aortic dissection (n = 19; 22.5%), intramural hematoma (n = 2; 2%), penetrating aortic ulcer (n = 5; 6%), and aortoesophageal fistula (n = 2; 2%). Of these, 60 patients (71.5%) were treated emergently and 24 (28.5%) electively. Primary type I endoleak was noted in eight patients (9.5%), of which two resolved spontaneously. After a mean follow-up of 32 months (range, 3-76 months), secondary type I endoleak was detected in four patients (4.5%). All of them occurred after emergent TAA treatment. Comparison between emergent and elective groups revealed no significant differences in neck length (19.5 mm vs 26.5 mm; P = .197), oversizing degree (11.1% vs 10.9%; P = .811), or endoleak rates (13.3% vs 8.3%; P = .518). Hemorrhagic shock was not predictive of endoleak (P = .483). Cox regression analysis of the different anatomic and stent graft-related factors revealed short proximal landing zone as the unique independent predictor of type I endoleak (hazard ratio, 0.89; 95% confidence interval, 0.81-0.99; P = .032). CONCLUSIONS: Endoleak risk seems not to be increased by an emergency setting. However, the relatively high rate of late endoleak observed after emergent TAA repair advocates for close follow-up, contrary to traumatic aortic rupture. Furthermore, regardless of the pathologic process, a longer proximal landing zone is likely to guarantee early and late success.

Atheromatous occlusive lesions of the popliteal artery treated with stent grafts: predictive factors of midterm patency.

BACKGROUND: Because of its location, the popliteal artery is exposed to important biomechanical constraints, inducing a specific risk of thrombosis of stents, little studied in the literature. The objective of this monocentric retrospective study was to evaluate the patency of stents implanted in the popliteal artery to treat atheromatous lesions and the risk factors predisposing to thrombosis. METHODS: Between January 2009 and July 2013, all the patients receiving stents for a residual stenosis or a complication of angioplasty in the popliteal artery or the distal anastomosis of a femoropopliteal bypass were included retrospectively and in an intention to treat. Forty-six patients (17 women), with a 71.5 years median age (range, 45-90 years), including 17 diabetic patients (37%) and 7 hemodialysis patients (15%), were operated in 51 limbs for claudication (n = 25, 49%), critical ischemia (n = 18, 35%), or acute ischemia (n = 8, 16%). Thirty stenoses >70% (59%) and 21 thromboses (41%) were treated with 56 autoexpandable stents, with an average diameter of 6 mm (range, 5-8 mm) and an average length of 5 cm (range, 4-15 cm), including 39 lesions in P1 (above the patella), 8 in P2 (articular), and 4 in P3 (distal popliteal artery). The following factors were analyzed according to univariate and multivariate models: age, gender, Society for Vascular Surgery score, symptomatology, type and location of lesion, number of stents deployed, and dimension of stents. RESULTS: Technical success was of 98% (n = 50), including 1 insufficient result of the endovascular treatment. At 30 days, one patient treated for critical ischemia died (2%) and one residual popliteal stenosis was treated by bypass (2%). After a 27.6 ± 10.07 month follow-up, restenosis (>50%) was detected in 5 cases including 4 asymptomatic and a popliteal thrombosis occurred in 9 cases, including 3 asymptomatic cases. Eight secondary interventions were necessary, including 4 endovascular procedures, 3 bypasses, and only 1 major amputation (thigh). The primary and secondary patencies at 12 months and 24 months were 80% and 65%, and 90% and 74%, respectively. The multivariate analysis showed that the type of lesion (stenosis versus occlusion; odds ratio [OR], 5.1; 95% confidence interval [CI], 1.2-22.9, P = 0.032) and the number of stents implanted (1 vs. 2 stents; OR [95% CI], 12.7 [1.8-88.5]; P = 0.011) were independent predictive factors of secondary thrombosis. CONCLUSIONS: The endovascular treatment of the atheromatous popliteal lesions appears to be a satisfactory alternative. The implantation of 1 stent in the popliteal artery is recommended in the event of popliteal occlusion, whereas for a stenosis, it must be reserved for patients with residual stenosis or in the event of complications of angioplasty, such as dissection or elastic recoil. Stent must be single, with deployment of a long stent in the event of long lesion.

Endovascular management of severe bleeding after major abdominal surgery.

BACKGROUND: In this study we analyzed embolization and stent-graft results. METHODS: Demographics, indications, procedures, and outcomes of patients treated with embolization or stent grafting for late postoperative bleeding after major abdominal surgery were retrospectively recorded. Outcomes were analyzed on an intention-to-treat basis. RESULTS: Between 2004 and 2008, 14 consecutive patients (11 men and 3 women, mean age 64 years) were treated for hemorrhage responsible for shock in 6 patients (43%), occurring after pancreaticoduodenectomy (n=13) or subtotal gastrectomy (n=1). Mean onset occurred at 23 days postoperatively (range 7-75 days). Bleeding site included: the stump of the gastroduodenal artery (n=10), splenic artery (n=2), common hepatic artery (n=1), and right gastric artery (n=1). Initial success was obtained in 13 patients (93%); the only failure of stent-graft deployment required re-laparotomy. Treatment included embolization in 8 patients and stent grafting in 5 patients. In the embolization group, 5 complications (62%) occurred: 4 rebleeding and 1 gastric perforation, compared with no early complications in the stent-graft group. One patient died in each group. The mean follow-up was 25 months (range 6-57 months). CONCLUSIONS: Stent grafting seems to provide definitive hemostasis and fewer complications compared with embolization.

Emergency stent graft implantation for ruptured visceral artery pseudoaneurysm.

BACKGROUND: Literature series that include visceral artery pseudoaneurysms rarely separate them from true aneurysms, although they address different issues. Guidelines for optimal management of these lesions are lacking. We report our experience of stent graft treatment of these lesions with midterm results. METHODS: We retrospectively reviewed all patients with a visceral pseudoaneurysm who were treated with a stent graft in our institution. Patient history, clinical characteristics, procedure details, and outcome were recorded and analyzed. RESULTS: From March 2004 to June 2009, 10 consecutive patients (9 men), who were a mean age of 59 years, were treated for symptomatic visceral artery pseudoaneurysm, with hemorrhagic shock in 8 patients (80%), after pancreaticoduodenectomy in 8, gastrectomy in 1, and abdominal trauma in 1. A mean of 24 days (range, 7-60 days) passed between the initial surgery or trauma and pseudoaneurysm diagnosis. Septic complications were associated in six patients (60%). The pseudoaneurysm was in the hepatic artery in 8 patients, the splenic artery in 1, and the superior mesenteric artery in 1. Technical and clinical success was achieved in 80% of patients. Two failures of catheterization were followed by redo surgery and death (20%). No patients died postoperatively, and no complications among the patients who were treated successfully. Mean follow-up was 37 months (range, 10-63 months). All stent grafts were patent, with no signs of infection. Two patients died secondary to neoplasm. No rebleeding or recurrent aneurysms were noted. CONCLUSION: Stent graft exclusion of visceral artery pseudoaneurysm seems to be a valid therapeutic approach regardless of the patient's septic or hemodynamic status.

Unstable patients with retroperitoneal vascular trauma: an endovascular approach.

BACKGROUND: In hemodynamically unstable patients, the management of retroperitoneal vascular trauma is both difficult and challenging. Endovascular techniques have become an alternative to surgery in several trauma centers. METHODS: Between 2004 and 2006, 16 patients (nine men, mean age: 46 years, range: 19-79 years) with retroperitoneal vascular trauma and hemodynamic instability were treated using an endovascular approach. The mean injury severity score was 30.7 ± 13.1. Mean systolic blood pressure and the shock index were 74 mm Hg and 1.9, respectively. Vasopressor drugs were required in 68.7% of cases (n = 11). Injuries were attributable to road traffic accidents (n = 15) and falls (n = 1). The hemorrhage sites included the internal iliac artery or its branches (n = 12) with bilateral injury in one case, renal artery (n = 2), abdominal aorta (n = 1), and lumbar artery (n = 1). RESULTS: In all, 14 coil embolizations and three stent-grafts were implanted. The technical success rate was 75%, as early re-embolization was necessary in one case and three patients died during the perioperative period. Six patients died during the period of hospitalization (37.5%). No surgical conversion or major morbidity was reported. CONCLUSION: In comparison with particulates, coil ± stent-graft may provide similar efficacy with regard to survival, and thus may be a valuable solution when particulate embolization is not available or feasible.

Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome.

Reimplantation of the left renal vein into the infrarenal inferior vena cava is the standard surgical procedure for nutcracker syndrome. A 40-year-old woman with a solitary left kidney suffered from left lumbar pain and hematuria. Imaging techniques found a large kidney with nutcracker syndrome. A totally laparoscopic transposition of the left renal vein was performed. Twelve months later, the patient is improved and has no more hematuria. Duplex scan showed no residual stenosis. Laparoscopic transposition of the left renal vein into the inferior vena cava is feasible with short length of stay and good short-term result.

A comparison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions.

OBJECTIVE: To assess the potential benefit of the addition of a covered stent to a subintimal recanalized artery in patients with femoro-popliteal occlusions. METHODS: From September 2003 to October 2005, we retrospectively analyzed all patients admitted for severe claudication or critical limb ischemia related to long femoro-popliteal occlusions and treated with subintimal recanalization. Patients were divided into two groups depending on whether they received a stent or not. All patients in the group treated with stent received a stent graft, and the entire length of the recanalized artery was covered in each case. Demographic data, indications, procedure, and outcomes were examined using survival analysis statistical techniques. RESULTS: Fifty-three patients (54 limbs) were treated consecutively for severe claudication (n=19) or critical limb ischemia (n=34). Thirty-four (64%) had a stent placed, while 19 (35.8%) did not. The mean length of the lesions treated was 20.11 cm (range, 5-35 cm). Statistically, there was no significant difference in lesion length, Rutherford stage of peripheral-artery disease, Transatlantic Inter-Society Consensus classification, and distal run-off between the two groups. The technical success rate was 94.5%, and two out of the three failures were treated with surgical bypass in one case and major amputation in the other. The third patient received only medical treatment. Combined procedures were required in the treatment of 68.2% of limbs in the no-stent group and 55.8% in the stent group. Mean follow up was 16.9 months (range, 1-35 months). At 1 year, primary, primary-assisted, and secondary patency for the stent vs no-stent groups was, respectively, 61.8% vs 78.9% (P=.49), 70.6% vs 78.9% (P=.78), and 88.2% vs 78.9% (P=.22). The 1-year limb salvage rate for the stent vs no-stent group was 94.1% vs 100% (P=.7). CONCLUSION: Combining subintimal angioplasty with a stent graft in femoro-popliteal lesions does not improve patency. The limb salvage rate remains high after addition of a stent graft. Rigorous monitoring is recommended to diagnose and treat restenosis early in order to improve patency.

Renal artery thrombosis caused by stent fracture: the risk of undiagnosed renal artery entrapment.

We report a case of renal artery thrombosis resulting from a stent fracture in a patient with a solitary functional kidney. It was successfully revascularized by surgical repair despite renal ischemia lasting more than 48 hours. This article illustrates the danger of generalizing endovascular stenting in renal artery disease regardless of the etiology. Renal artery entrapment must be kept in mind as a possible cause of renal artery stenosis. Treatment of compressive pathologies with stenting can lead to stent failure. Surgery remains the best approach for the treatment of this type of lesion.

The persistent sciatic artery: Report of ten cases.

OBJECTIVE: The persistent sciatic artery (PSA) is a rare congenital anomaly with a high rate of aneurysm formation, occlusion and stenosis. It may lead to severe complications including thrombosis, distal embolisation, or aneurysm rupture. We reported herein our experience in the management of PSA and its complications, and discuss the therapeutic options. METHODS: Eight patients with 10 PSA were managed in our institutions between 1985 and 2017. An analysis was done for the clinical data, surgical technique, and results. RESULTS: The series included six women and two men. The median age of the patients was 66,5 years (37-80 years). Physical examination found a pulsatile gluteal mass in five patients, sciatic neuropathy in two cases. Four patients had an acute ischemia of the lower limb. Cowie's sign was described in only two patients (diminished or absent femoral pulse but presence of popliteal pulse). Digital subtraction angiography was performed in all patients, and was completed with a computed tomography angiography (CTA) with a diagnosis of PSA, associated with a symptomatic aneurysmal lesion in seven cases and with an occlusion in one case. The treatment was surgical in all cases: bipolar exclusion of the aneurysm and bypass between the iliac artery and the PSA distal to the aneurysm was performed in four cases, only proximal and distal ligation was done in 2 other cases. A Chopart amputation was necessary in 2 cases. CONCLUSION: We consider that the treatment of PSA is usually surgical in symptomatic cases. Surgical techniques depend on symptoms and classification describing anatomy of the PSA. However, future studies should compare the open versus the endovascular approach to optimize patient selection criteria and identify the most safe and effective strategy. In an asymptomatic patient, PSA does not require any intervention; continued follow-up is required because of the high incidence of aneurysmal formation and the risk of thromboembolic events.

Management of pregnancy in women with previous left ilio-caval stenting.

BACKGROUND: Ilio-caval stenting now represents the first line treatment for disabling obstructive ilio-caval lesions. Most patients are young women of child-bearing age. We herein report our experience of pregnancy in women who have a history of ilio-caval stenting. MATERIALS AND METHODS: From November 1995 to April 2008, 119 patients had ilio-caval stenting for obstructive venous disease in our department. Of these, 62 women were able to become pregnant. When pregnancy occurred, they received preventive treatment with low molecular weight heparin (LMWH) from the 3rd month of pregnancy to 1 month after delivery and had to wear elastic stockings. Patients also had to sleep on their right side if possible. They were followed during the pregnancy by duplex scanning at 3, 6, and 8 months, and then 1 month after delivery. RESULTS: Eight pregnancies occurred in 6 patients (mean age 26.5 years) who had a patent self-expanding stent (1 patient had 3 pregnancies). They had stenting for May-Thurner disease in 3 patients, for post-deep venous thrombosis (DVT) left common iliac vein occlusion in 1 patient, and during venous thrombectomy in 2 patients. All stents were self-expanding metallic stents located on the left common iliac vein. One patient had unrelated spontaneous abortion after 2 months of pregnancy. No DVT or symptomatic pulmonary embolism occurred during pregnancy, delivery, or during the postpartum period. Four patients needed cesarean delivery and none had hemorrhagic complications. None of the patients had adverse effects from the treatment. Duplex scan showed compression of the stent(s) at 8 months in 4 patients with inflow obstruction in 3 patients. Postpartum duplex-scan showed no remaining stenosis in all patients. No stents had structural damage. CONCLUSION: Ilio-caval stent compression can occur during pregnancy but does not lead to structural damage to the self-expanding stents. Despite this, no cases of DVT occurred with preventive LMWH treatment.

Laparoscopy-assisted left ovarian vein transposition to treat one case of posterior nutcracker syndrome.

We report one case of posterior nutcracker syndrome treated by left ovarian vein (LOV) transposition. A 36-year-old woman was suffering from nutcracker syndrome associated with pelvic congestion syndrome. Color duplex scan, computed tomographic scan, and angiography demonstrated a stenosis of a retroaortic left renal vein with proximal dilatation and incompetence of the LOV. The renocaval pullback gradient was 10 mm Hg. The LOV was harvested laparoscopically and transposed into the inferior vena cava. Completion angiography showed a patent reconstruction with no significant gradient. At day 4, an asymptomatic thrombosis was treated by thromboaspiration. Forty months later, the patient remained asymptomatic with a patent transposition. Posterior nutcracker syndrome is a rare condition. When associated with pelvic congestion syndrome due to LOV reflux, it can be treated by LOV transposition.

Mechanical characterisation of human ascending aorta dissection.

Mechanical characteristics of both the healthy ascending aorta and acute type A aortic dissection were investigated using in vitro biaxial tensile tests, in vivo measurements via transoesophageal echocardiography and histological characterisations. This combination of analysis at tissular, structural and microstructural levels highlighted the following: (i) a linear mechanical response for the dissected intimomedial flap and, conversely, nonlinear behaviour for both healthy and dissected ascending aorta; all showed anisotropy; (ii) a stiffer mechanical response in the longitudinal than in the circumferential direction for the healthy ascending aorta, consistent with the histological quantification of collagen and elastin fibre density; (iii) a link between dissection and ascending aorta stiffening, as revealed by biaxial tensile tests. This result was corroborated by in vivo measurements with stiffness index, ß, and Peterson modulus, Ep, higher for patients with dissection than for control patients. It was consistent with histological analysis on dissected samples showing elastin fibre dislocations, reduced elastin density and increased collagen density. To our knowledge, this is the first study to report biaxial tensile tests on the dissected intimomedial flap and in vivo stiffness measurements of acute type A dissection in humans.