Percutaneous radial access for peripheral transluminal angioplasty.

OBJECTIVE: The radial approach is currently gaining popularity in the setting of coronary percutaneous transluminal angioplasty (PTA) because it decreases the incidence of vascular complications. This study reports our initial results with radial access for peripheral PTA. METHODS: Between November 2011 and January 2014, we performed peripheral PTA in 526 patients. PTA was performed through left radial access in 24 ambulatory patients (4.6%) presenting with TransAtlantic Inter-Society Consensus A or B lesions on preoperative computed tomography angiography. Materials included a 110-cm-long introducer, a 0.018-inch 400-cm-long wire, 150-cm-long angiography catheters, 180-cm-long shaft balloons and stents. Data were prospectively collected. RESULTS: There were 22 men (92%), median age was 65 years (range, 45-88 years), and 38 target lesions were treated. Indication for revascularization was disabling claudication in 22 patients (92%) and critical ischemia in two (8%). Indication for choosing the radial approach was bilateral hostile groins in 12 patients (50%), bilateral infrainguinal lesions in 4 (17%), need for a contralateral femoral approach in the setting of kissing iliac stents or bifurcated surgical aortic grafts in 3 (13%), and elective in 5 (21%). Radial puncture failed in one patient (4%), and PTA was performed through brachial access. Technical success was 91% (20 of 22 patients). Thirty-seven stents were implanted. Total procedure duration was 45 minutes (range, 30-120 minutes). Fluoroscopy time was 9 minutes (range, 5-35 minutes), and 40 mL (range, 20-90 mL) of contrast was necessary. Radial artery rupture secondary to spasm was noted at the end of the procedure in two patients (8%). All patients could ambulate 2 hours after the procedure. No patient died. Median follow-up was 8 months (range, 1-23 months). Three radial arteries (13%) were occluded at the last follow-up. At 6 months, freedom from target lesion revascularization and target vessel revascularization were 91% and 91%, respectively, for iliac lesions and 93% and 86%, respectively, for infrainguinal lesions. CONCLUSIONS: This study demonstrates the feasibility of radial access for peripheral PTA. Radial access could represent an alternative to brachial access for peripheral and visceral interventions. Although complication rates of the present series are concerning, larger studies are needed to determine the role of transradial PTA once the learning curve is overcome. A wider diffusion of the technique mandates (1) smaller-diameter sheaths, (2) longer shaft devices, and (3) the development of specifically designed rescue devices such as covered stents and thromboaspiration catheters.

Mini-invasive treatment of abdominal aortic aneurysms: current roles of endovascular, laparoscopic, and open techniques.

BACKGROUND: Endovascular aortic repair (EVAR), laparoscopic aortic surgery (LAS), and open surgery (OS) are three established treatment methods of abdominal aortic aneurysms (AAA). While these techniques are often percieved as competitive between them, they are complementary for the vascular surgeon, whose goal is to provide a treatment adapted to each case that is noninvasive and durable. The objective of this study was to report our results of AAA repair to better define the roles of the three techniques. METHODS: From January 2009 to December 2011, we operated on 235 patients for AAAs. Patients for whom the three technical methods were discussed preoperatively were selected. Cases where the three techniques were not discussed were excluded (ruptured AAA, technique not available). One hundred seventy-five (75%) patients were included. Four groups were established based on the surgical risk and the anatomic EVAR criteria of the French Health Authority (Haute Autorité de Santé [HAS]), including: (1) good risk and favorable anatomy (GR-FA); (2) good risk and unfavorable anatomy (GR-UA); (3) high-risk and favorable anatomy (HR-FA); and (4) high-risk and unfavorable anatomy (HR-UA). Data collection was prospective. The numerical data were expressed as median and range. RESULTS: There were 166 (95%) men, aged 74 years (range 38-97 years). AAA diameter was 51 mm (range 30-81 mm). Mini-invasive treatment (EVAR or LAS) was chosen in 156 (89%) cases. Mortality at 30 days was 3.4% (6 patients, 1 EVAR, 1 LAS, and 4 OS), including 3 patients presenting with a "shaggy aorta." There were 58, 19, 65, and 33 patients in groups GR-FA (33%), GR-UA (11%), HR-FA (37%), and HR-UA (19%), respectively. The distribution of the three techniques (EVAR, LAS, OS) according to the groups was as follows: GR-FA (9, 46, 3); GR-UA (0, 13, 6); HR-FA (50, 13, 2); and HR-UA (12, 13, 8), respectively. The results by subgroups are presented. CONCLUSIONS: Based on our results, we present a new algorithm for AAA treatment. Among GR-FA patients, EVAR and LAS should be discussed according to life expectancy and wish of the patient. In GR-UA patients, LAS and OS can be proposed. For HR-FA patients, EVAR remains the first choice, but LAS can be used in cases with good life expectancy. In the HR-UA patients, LAS is the best choice because of the late complications of EVAR, but a broader use of fenestrated stent grafts or the chimney technique may be beneficial. Last, the surgical threshold should be pushed back among AAA patients presenting with a shaggy aorta.

Delirium in elderly vascular surgery patients.

The elderly represent a large percentage of patients seen in departments of vascular surgery. Delirium is a frequent perioperative complication in this population and contributes to increased morbidity and mortality. Prevention of problems associated with mental confusion rests in identifying comorbidities, their severity, and the risk factors associated with delirium syndrome. The aging of our population implies management of increasing numbers of older patients who often have concomitant pathologies and, consequently, polypharmacy. Optimization of their management rests on collaboration between surgeons, anesthetists, and geriatrists.

Bitubular graft as an adjunct for laparoscopic hybrid repair of an abdominal aortic aneurysm.

Laparoscopic repair (LR) of abdominal aortic aneurysms (AAAs) has been developed as a less invasive alternative to open repair. LR in the setting of diseased (ectatic, aneurysmal, calcified) aortic bifurcation or common iliac arteries (CIAs) is more challenging than LR of AAAs limited to the infrarenal aorta. In such cases, a bifurcated graft is necessary with an increased procedural time, more blood loss, and challenging distal anastomoses. We here present a new surgical technique using a custom-made bitubular graft (BTG), which allows LR of AAAs with diseased aortic bifurcation or CIAs while performing an aorto-aortic LR. During the same or a later intervention, covered stent grafts can be distally mated with the BTG using percutaneous femoral accesses to treat an extension of the disease to the aortic bifurcation and/or the CIAs. The BTG represents an interesting option for patients subjected to LR and presenting with an AAA associated with ectatic/aneurysmal proximal CIAs or heavily calcified aortic bifurcation.

Hybrid repair of type II dissecting thoracoabdominal aneurysm using Amplatzer vascular plugs for entry tear closure.

Endovascular repair of chronic aortic dissections (CAD) intend to promote false lumen thrombosis (FLT). This article describes a technique using Amplatzer vascular plugs (AVPs) for entry tear closure of CAD. A 70-year-old man presented with a type II dissecting thoracoabdominal aneurysm. Computed tomography scan showed a very tight true lumen, partial FLT, and 2 entry tears at the level of the left subclavian artery and the visceral aorta, respectively. During a first procedure, aortic debranching was performed using the ascending aorta as bypass inflow. In a second intervention entry tears were closed using AVPs protected by short stent grafts. Technical success was achieved. No paraplegia occurred. Eighteen months later, FLT was complete and aortic diameter decreased. Entry tear closure using AVPs is feasible and allows FLT. Further reports are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify technical aspects of the procedure.

Results of laparoscopic surgery for abdominal aortic aneurysms in patients with standard surgical risk and anatomic criteria compatible with EVAR.

BACKGROUND: The recent Anévrisme de l'aorte abdominale: Chirurgie versus Endoprothèse (ACE) study showed that open surgery of infrarenal abdominal aortic aneurysms (AAAs) provided very good results in patients with standard surgical risk, with good anatomic results for endovascular aneurysm repair (EVAR). The goal of the current study was to show that aortic laparoscopy is a minimally invasive alternative to open surgery while avoiding the complications associated with laparotomy. METHODS: From February 2002 to August 2010, the authors performed 239 laparoscopic AAA repairs. A subgroup of 99 patients with standard surgical risk presented with AAAs compatible with EVAR. The evaluation criteria of surgical risk and anatomic criteria compatible with EVAR corresponded to those edicted by the Agence Française de Sécurité Sanitaire des Produits de Santé and the Haute Autorité de Santé. The patients' database was prospective and the file analysis was retrospective. Digital data were given in median and extremes. RESULTS: The patient age was 68 years (range, 53-79 years). The aneurysmal diameter was 51 mm (range, 45-69 mm). Surgery and clamping times were 210 min (range, 180-520 min) and 81 min (range, 35-140 min), respectively. There were 60 aortic tubes and 39 bifurcated prostheses. Five patients (5%) required conversion. No hospital mortality occurred. Three patients presented with severe systemic complications (3%): 1 perioperative cardiac arrest on atrioventricular block grade 3, 1 case of febrile hypoxic atelectasis, and 1 colonic ischemia with transient renal failure with transient dialysis. Ten patients had a moderate systemic complication (10%): 7 transitory elevations of creatinemia, 1 pneumonia, 1 prostatitis, 1 sigmoiditis, and 1 cardiac arrhythmia/atrial fibrillation (CA/AF). Intensive care stay and hospitalization durations were 24 hours (range, 12-768 hours) and 6 days (range, 4-39 days), respectively. Four local complications occurred: 1 limb thrombosis, 1 compartment syndrome, 1 spleen rupture, and 1 parietal hematoma. On multivariate analysis, the overall procedure time was a predictive factor of severe systemic complications (P=0.02). Follow-up was 42 months (range, 1-97 months). Two patients required late surgery (2%): 1 for limb thrombosis after neuroendovascular procedure and 1 for iliac thrombosis. Morphologic tests did not show any defects at the aortic prosthesis level. The only abdominal complication was a rupture at the level of a laparotomy conversion. The 6 late deaths (6%) were not related to the AAA. CONCLUSIONS: This study shows that AAA laparoscopic surgery is a safe, long-lasting, minimally invasive technique in patients with standard surgical risk when EVAR can be considered.

Anatomic feasibility of endovascular treatment of abdominal aortic aneurysms in emergency in the era of the chimney technique: impact on an emergency endovascular kit.

BACKGROUND: Despite promising results, endovascular aortic repair (EVAR) of ruptured/painful abdominal aortic aneurysms (RPAAA) continues to have limited use due to anatomic constraints linked to RPAAA morphology. Currently, EVAR for RPAAA is reserved for patients presenting with a long infrarenal aortic neck, because commercially available fenestrated stent grafts are not available in an emergency setting. Recently, the chimney technique (ChT) has been utilized to treat infrarenal abdominal aortic aneurysms (AAA) with short necks, but this technique requires specific materials. The aim of this study was to determine the rate of RPAAA eligible for EVAR since the advent of the ChT and to ascertain the standard materials needed in this context. METHODS: We carried out a retrospective study of patients operated on for RPAAA (<24 hours after admission) at our center between 2006 and 2011. Patients' computed tomography (CT) scans were analyzed by two independent operators using 3-dimensional reconstruction software with a centerline of flow. To perform standard EVAR, the anatomic criteria used were those provided by the manufacturer (proximal neck diameter 18-32 mm with length >15 mm, angulation <60°, iliac diameter >7 mm). ChT anatomic feasibility criteria were: (1) a healthy aortic area >15 mm between the renal arteries and celiac trunk; (2) caudal orientation of renal arteries; and (3) a healthy descending thoracic aorta. Patients were classified according to the feasibility or nonfeasibility of standard EVAR and ChT. RESULTS: In total, over the period of study, 55 patients were operated on for RPAAA. In 5 patients (9%), CT scan quality was unsatisfactory and thus 50 patients (mean age 76 years, 75% men) were analyzed. Among them, 35 (70%) had a ruptured aneurysm and 17 (34%) were unstable. Anatomically, 22 (44%) patients were eligible for standard EVAR. Taking the ChT into consideration, an additional 11 (22%) patients were eligible for EVAR. Among these EVAR-eligible patients, mean proximal neck diameter was 23 ± 3 mm and stent grafts with 24-, 28-, and 32-mm diameters could fit in 33% (11 of 33), 51% (17 of 33), and 12% (4 of 33) of the cases, respectively. These results enabled us to determine the material that should be made available in the emergency setting in centers treating RPAAA. Among the 17 patients who were not eligible for EVAR, an iliac pathology (calcifications, stenosis) and a very hostile proximal neck (angulation, thrombus), respectively, were involved in 88% (15 of 17) and 12% (2 of 17) of the cases. CONCLUSIONS: The ChT increases EVAR feasibility by 50% in RPAAA. Taking into consideration our results, we recommend continued availability of emergency kits, including suitable aortouni-iliac stent grafts and basic material for performing ChT to allow surgeons to provide EVAR to the greatest number of RPAAA cases.

The significance of endoleaks in thoracic endovascular aneurysm repair.

BACKGROUND: Endoleak is one of the rare complications that occur after thoracic endovascular aneurysm repair (TEVAR). The aim of this study was to assess the incidence of endoleaks and the predictive factors for their occurrence, as well as their effect on secondary interventions after TEVAR. METHODS: Medical and radiological data of all TEVAR procedures performed between 2004 and 2008 were entered prospectively into our database and reviewed retrospectively. Primary endpoints included were the incidence and the type of endoleak, aneurysmal sac expansion, and secondary interventions. RESULTS: In all, 67 patients (18 women and 49 men; mean age, 67 ± 14 years) were treated consecutively for descending thoracic aortic aneurysms (mean diameter: 69 ± 18 mm) by TEVAR during the observed period, using 83 stent-grafts (11 Cook TX2, 31 Gore TAG, and 41 Medtronic Valiant), with a median follow-up of 27 months (range: 2-64). In 13 of 67 patients, 14 (19.4%) endoleaks were diagnosed, of which 71% (10 of 14) were type I, 29% (4 of 14) were type II, and none were type III. Ten endoleaks (71%) were diagnosed on the first postoperative computed tomographic angiography at 1 month, and the other four (29%) developed later on. Predictive factors for endoleaks on univariate analysis included age (p = 0.04), length of the proximal neck immediately after the left subclavian artery (p = 0.04), the fusiform morphology of the descending thoracic aortic aneurysms (p = 0.04), and the type of stent-graft used (p = 0.02). Eight of the 10 type I endoleaks (80%) were successfully treated by endovascular means, using proximal cuffs (n = 5) or distal extensions (n = 3). None of type II endoleaks were treated by secondary intervention. The six endoleaks treated conservatively were all associated with a significant mean increase of their aneurysmal sac (+3.2 ± 2.6 mm) during follow-up. No secondary conversion to open surgery was performed to treat an endoleak. CONCLUSIONS: On the basis of the study, it seems as if endoleaks are detected in one of the five patients treated with TEVAR during follow-up period, particularly if they are old with a proximal and fusiform aneurysm. Short- and mid-term follow-up suggest that most type I endoleaks can successfully be treated by endovascular techniques and that type II endoleaks treated conservatively require a close radiological monitoring.

[Digital arterial embolization from a previously thrombosed arteriovenous access: a rare and misdiagnosed complication]. / Ischémie digitale par embolie à partir d'un abord d'hémodialyse thrombosé: une complication rare à ne pas méconnaître.

Surgical removal of a hemodialysis access after thrombosis is generally not performed as it remains clinically well tolerated. However, it may be the source of distal embolization. We report the case of a 43-year-old patient, kidney recipient, who presented with digital ischemia of the right hand. He had a forearm arteriovenous fistula at the right wrist which thrombosed 5 years ago. Digital ischemia was due to thrombus formation at the anastomotic site and migration into the downstream arterial bed. Heparine was initiated together with antiplatelet treatment. The ischemia resolved after a few days, no recidive was observed. Surgical ligation of the arteriovenous fistula was rapidly performed and antiplatelet treatment was maintained after surgery. After a follow-up of 6 months, the patient remained asymptomatic without new embolization. This observation underlines the necessity of clinical monitoring after access thrombosis and preventive surgical ligation might be discussed when the risk of distal embolization is high.