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.

Conformability of GORE Excluder Iliac Branch Endoprosthesis and COOK Zenith Bifurcated Iliac Side Branched Iliac Stent Grafts.

BACKGROUND: Forty percent of the abdominal aortic aneurysms present an extension to the iliac axes. The access to a distal neck requiring an embolization of the internal iliac artery (IIA) may cause buttock claudication, colic ischemia, perineal necrosis, erectile dysfunction, and spinal cord ischemia. The aim of the branched iliac stent grafts is to preserve pelvic vascularization while adapting to the constraints of arterial tortuosity which generate type Ib endoleaks, plications, and limb thromboses. The objective was to analyze and compare the in vivo anatomical conformability of the Gore Excluder® Iliac Branch Endoprosthesis (IBE) and the Zenith Bifurcated Iliac Side® (ZBIS) Cook Iliac Endovascular Device branched stent grafts. METHODS: This was a monocentric retrospective therapeutic study including 13 IBE and 9 ZBIS stent grafts. Three indices of tortuosity were measured with EndoSize: common iliac artery, pelvic artery index (PAI), and the double iliac sign (DIS). The centerline lengths of the iliac axes and the iliac axis and the IIA were measured by 2 different operators as a blind fashion. RESULTS: The interoperator correlation of the measurements was r = 0.841 (P < 0.0001). Twenty-two patients had a high iliac tortuosity: PAI ≥ 1.14 (mean PAI 1.43 [1.16-2.09]). The IBE stent graft modified neither the ipsilateral length nor tortuosity of the common iliac axis or the PAI (P ≤ 0.17, P ≤ 0.16, and P ≤ 0.23, respectively). The ZBIS stent graft significantly modified (P ≤ 0.02) the length and the tortuosity measured by the PAI compared with the IBE group (P ≤ 0.02). The use of IBE or ZBIS did not modify the postoperative length of the IIA (P ≤ 0.34). Three patients of the IBE group presented one DIS. Postoperatively, they did not present any DIS without significant modification of the postoperative PAI (P ≤ 0.07). CONCLUSIONS: In patients with a severe iliac tortuosity, the IBE Gore branched iliac stent graft is more conformable than the ZBIS Cook. IBE, more conformable with the anatomy of the patient, could thus make it possible to decrease the incidence of distal endoleaks without increasing the risk of limb thrombosis related to the anatomical constraints.

Cryopreserved Arterial Allografts and ABO and Rhesus Compatibility.

BACKGROUND: Arterial cryopreserved allografts are conduit of choice for arterial bypass in case of infection. They are sometimes submitted to accelerated degeneration: stenosis, thrombosis, or aneurysmal evolution. We hypothesized that ABO group and Rhesus compatibility could play a role in arterial cryopreserved allograft complications. METHODS: Patients who benefit from allograft bypass from 2006 to 2011 were retrospectively compared, regarding ABO or rhesus compatibility and irregular agglutinins. RESULTS: Seventy-two patients were included. Regarding ABO mismatch, there was no difference in terms of death (51% vs. 43%, P = 0.820), thrombosis (25% vs. 32%, P = 0.78), rupture (9% vs. 0%, P = 0.247), stenosis (3% vs. 12%, P = 0.331), aneurysmal degeneration (16% vs. 12%, P = 1), and 5 years of secondary patency rate (34% vs. 39%, P = 0.141). There was also no difference regarding Rhesus mismatch. CONCLUSIONS: Allograft degeneration does not seem to be related to ABO mismatch. This degeneration could be related to another way of immunogenicity, particularly Human Leukocyte Antigen mismatch, and needs further exploration.

Acute Ischemia due to Superficial Femoral Artery Thrombosis: Results of In Situ Fibrinolysis.

BACKGROUND: The management of acute ischemia due to the thrombosis superficial femoral artery (SFA) stents is complex. In situ arterial fibrinolysis, still not evaluated in this indication, would allow, by lifting the ischemia and uncovering its cause, to avoid thrombectomy, endovascular recanalization, or arterial bypass. The purpose of the study was to evaluate the effectiveness, the complications, and the assisted secondary patency of in situ fibrinolysis for thrombosis of SFA stents. METHODS: We conducted a retrospective monocentric study with prospective collection of the data. Between October 2011 and December 2014, 86 in situ fibrinolysis procedures were carried out for acute lower limb ischemia. Twelve procedures were carried out for acute ischemia due to the thrombosis of SFA stents. Clinical success was defined by the lifting of acute ischemia. The causes of thromboses, the complications related to the fibrinolysis, and the secondary assisted patency were analyzed. RESULTS: The mean age of the patients was 66.3 (55-90) years. The average length of the stents was 119.3 (18-270) mm. In 10 patients, the thrombosis extended in the full length of the artery. The average time between the implantation of the stent and the initiation of the fibrinolysis was 180 (11-369) days. The average time between the beginning of the symptoms and fibrinolysis was 5 (0-12) days. The average duration of treatment was 46 (24-72) hr. Clinical success was obtained in all the patients. Diagnosed isolated or associated lesions were a progression of the atheromatous disease upstream or downstream of the stent in 6 cases, and an isolated intrastent restenosis in 3 cases. In 2 cases, no obvious cause was found. One or more additional endovascular procedures were carried out in 9 cases at the end of the fibrinolysis, and consisted of a transluminal intrastent angioplasty with an active balloon in 5 cases, an additional stenting in 3 cases, and the stenting of upstream or downstream arteries in 5 cases. Secondary assisted patency was 100% at 5 months. No major hemorrhagic complication was observed. Two false aneurysms at the site of femoral puncture were observed. CONCLUSION: Our results suggest that ischemia due to the thrombosis of SFA stents can be dealt with first intention in situ fibrinolysis which allows the endovascular treatment of the causal lesion, thus avoiding thrombectomy or bypass.

The Antegrade Approach Using Transbrachial Access Improves Technical Success Rate of Endovascular Recanalization of TASC C-D Aortoiliac Occlusion in Case of Failed Femoral Access.

BACKGROUND: Technical success rates of endovascular recanalizations for Trans-Atlantic Inter-Society Consensus (TASC) C-D chronic occlusions are highly variable and depend on the characteristics and sites of the lesions as well as on the operator experience. We hypothesized that an antegrade approach via transbrachial access could improve the technical success rate of endovascular treatment of TASC C-D occlusions in case of failed femoral access. METHODS: From January 2010 to December 2012, all patients with symptomatic chronic TASC C-D aortoiliac occlusion were treated with an endovascular-first approach. Recanalization was first attempted using a femoral access. In case of failure, an antegrade approach using a transbrachial access was performed. Patient characteristics, anatomic details, procedural data, and immediate outcomes were prospectively recorded. RESULTS: During the study period, 73 patients (99 arteries) were included. Twenty-seven (37%) patients had TASC C occlusions including 11 bilateral common iliac artery occlusions and 16 external iliac artery (EIA) occlusions involving the common femoral or the internal iliac arteries. Forty-six (63%) patients had TASC D occlusions including 10 aortoiliac occlusions, 31 unilateral occlusions of both common and EIAs, and 5 bilateral EIA occlusions. Technical success with femoral access has been obtained in 53 arteries. An antegrade approach via transbrachial access allowed technical success in the other arteries, except in 7 arteries. Overall technical success rate was 93%, and 2 complications were related to the brachial accesses including 1 thrombosis and 1 pseudoaneurysm both requiring a reintervention. CONCLUSIONS: Brachial access for TASC C-D aortoiliac chronic occlusion improves the technical success rate without the need for reentry devices.

Angioplasty of the common femoral artery and its bifurcation.

BACKGROUND: To evaluate the efficacy of percutaneous transluminal angioplasty (PTA) of atherosclerotic lesions of the common femoral artery (CFA) and its bifurcation. METHODS: From 2009 to 2013, 53 patients (43 men, average age, 68 years) were included in a single-center, nonrandomized, prospective study. Indication was disabling intermittent claudication (n = 36) or chronic critical limb ischemia (n = 17). Thirty-four procedures (64%) were isolated CFA PTA, whereas 7 of 53 (13%) involved inflow (including 4 iliac occlusions) and 12 of 53 (23%) involved outflow vessels. Primary stenting was performed in 50 cases (95%). CFA occlusions were recanalized in 4 of 53. Lesions involved the bifurcation in 22 cases (40%). Follow-up consisted of clinical examination and duplex scanning with ankle-brachial index measurement at 1, 6, and 12 months. A biplane X-ray was performed at 1 year. The primary end point was the absence of binary restenosis (>50% reobstruction of the CFA). Secondary end points were freedom from target lesion revascularization (TLR) and stent fracture rate. RESULTS: Procedural success was achieved in 96% of cases. At a mean follow-up of 24 months (with 1 patient lost of follow-up), the absence of binary restenosis was 92.5%. At the end of follow-up, 82% of patients continued to show clinical improvement. Freedom from TLR was 97%. Stent fracture rate at 1 year was 9%. CONCLUSIONS: PTA of the CFA and its bifurcation is a reliable technique with good midterm functional results. These results justify performing a randomized study comparing surgery and endovascular treatment.

Intra-arterial thrombolysis in acute popliteal artery occlusion is a safe and effective technique reducing the rate of open surgery.

BACKGROUND: Acute popliteal artery occlusion is a frequent clinical entity with a risk of major amputation. Several attitudes are possible and treatment is not standardized. The purpose of this study is to demonstrate safety and effectiveness of intra-arterial thrombolysis in acute popliteal artery occlusion. METHODS: This is a retrospective analysis of a prospective database of patients treated by intra-arterial thrombolysis for acute lower-limb ischemia due to popliteal artery occlusion between 2001 and 2014.The primary endpoint was technical and clinical success. Etiologies and etiologic treatment, amputation-free survival, in-hospital mortality and bleeding complications rates were secondary endpoints. RESULTS: Seventy-one patients, with a mean 6-day-old ischemic time before thrombolysis, were analyzed. Technical and clinical success was 90% and 87% respectively. Etiology was embolic in 33 patients (cardiac N.=14, aortic=6, unknown=13) and thrombotic in 38 (atheromatous N.=19, entrapment N.= 4, popliteal aneurysm N.=11, Buerger N.=2, thrombophilia N.=1, hyperhomocysteinemia N.=1). Survival and amputation-free survival at 30 days were 97% and 94% respectively. There were no major bleeding complications. CONCLUSIONS: Intra-arterial thrombolysis of acute popliteal artery occlusion is an effective technique which reduces the rate of open surgery. The risk of bleeding complications is very low.