Role of Anticoagulation in Nonagenarian Patients with Acute Limb Ischemia.

BACKGROUND: Preoperative anticoagulant therapy is known to have a positive impact on the prognosis of patients with acute limb ischemia (ALI). However, little is known about its efficacy in elderly patients. We aimed to investigate the potential effect of anticoagulation in nonagenarian patients managed for ALI. METHODS: Between January 2015 and December 2021, we identified all nonagenarian patients managed for ALI at a single center. Long-term anticoagulation and hemostasis parameters (prothrombin rate, activated partial thromboplastin time [APTT], platelet count) measured on admission were reviewed. The primary end point was mortality at 30-day mortality (D30) in patients with or without long-term anticoagulation therapy. We also studied the effect of these factors on the occurrence of revascularization failure in operated patients (initial failure, ischemic recurrence during hospitalization, necrosis requiring major amputation). RESULTS: A total of 68 nonagenarian patients were managed for ALI, with a mean age of 93.8 years (from 90-107 years), 76.5% of whom were women. Of these patients, 47 (69%) were managed surgically. Long-term anticoagulation therapy was associated with better survival at D30, both in nonoperated (P < 0.01) and operated (P < 0.05) patients. In operated patients, the absence of long-term anticoagulation therapy was associated with the occurrence of revascularization failure (P < 0.05). In operated patients, survival to D30 and successful revascularization were associated with a longer APTT (P < 0,05). We were able to observe the survival of 4 patients contraindicated for surgery and treated with a single medical therapy (intravenous unfractionated heparin). CONCLUSIONS: Anticoagulation appears to have an impact on the survival and postoperative prognosis of nonagenarian patients with ALI. In addition, curative anticoagulation therapy may be an alternative treatment when surgery is contraindicated in this frail population.

Automatic Measurement of Vascular Calcifications in Patients with Aorto-Iliac Occlusive Disease to Predict the Risk of Re-intervention After Endovascular Repair.

BACKGROUND: There is currently a lack of consensus and tools to easily measure vascular calcification using computed tomography angiography (CTA). The aim of this study was to develop a fully automatic software to measure calcifications and to evaluate the interest as predictive factor in patients with aorto-iliac occlusive disease. METHODS: This study retrospectively included 171 patients who had endovascular repair of an aorto-iliac occlusive lesion at the University Hospital of Nice between January 2011 and December 2019. Calcifications volumes were measured from CTA using an automatic method consisting in three sequential steps: image pre-processing, lumen segmentation using expert system, and deep learning algorithms and segmentation of calcifications. Calcification volumes were measured in the infrarenal abdominal aorta and the iliac arterial segments, corresponding to the common and the external iliac arteries. RESULTS: Among 171 patients included with a mean age of 65 years, the revascularization was performed on the native external and internal iliac arteries in, respectively: 83 patients (48.5%), 107 (62.3%), and 7 (4.1%). The mean volumes of calcifications were 2,759 mm3 in the infrarenal abdominal aorta, 1,821 mm3 and 1,795 mm3 in the right and left iliac arteries, respectively. For a mean follow-up of 39 months, target lesion re-intervention was performed in 55 patients (32.2%). These patients had higher volume of calcifications in the right and left iliac arteries, compared with patients who did not have a re-intervention (2,274 mm3 vs. 1,606 mm3, P = 0.0319 and 2,278 vs. 1,567 mm3, P = 0.0213). CONCLUSIONS: The development of a fully automatic software would be useful to facilitate the measurement of vascular calcifications and possibly better inform the prognosis of patients.

Mycotic aortic and left iliac ruptured aneurysm due to Escherichia Coli: a case report and literature overview.

Mycotic aneurysm is a life-threatening disease often caused by Salmonella, Staphylococci and Streptococci species. Interestingly, Escherichia Coli (E. Coli) is described as a rare causative agent. We report the case of a patient who developed a mycotic aortic and ruptured left iliac aneurysm due to E. Coli. The patient developed a secondary aortic graft infection due to a mesenteric ischemia with fecal peritonitis. A literature overview of the current knowledge on mycotic aortic aneurysms specifically due to E. Coli is discussed including the clinical characteristics of patients, the management of the disease and the post-operative outcomes.

Hypoxia and hypoxia-inducible factors promote the development of neointimal hyperplasia in arteriovenous fistula.

KEY POINTS: Patients with end-stage renal failure need arteriovenous fistulas (AVF) to undergo dialysis. However, AVFs present a high rate of failure as a result of excessive venous thickness. Excessive venous thickness may be a consequence of surgical dissection and change in oxygen concentration within the venous wall. We show that venous cells adapt their metabolism and growth depending on oxygen concentration, and drugs targeting the hypoxic response pathway modulate this response in vitro. We used the same drugs on a mouse model of AVF and show that direct or indirect inhibition of the hypoxia-inducible factors (HIFs) help decrease excessive venous thickness. Hypoxia and HIFs can be targets of therapeutic drugs to prevent excessive venous thickness in patients undergoing AVF surgical creation. ABSTRACT: Because the oxygen concentration changes in the venous wall, surrounding tissue and the blood during surgical creation of arteriovenous fistula (AVF), we hypothesized that hypoxia could contribute to AVF failure as a result of neointimal hyperplasia. We postulated that modulation of the hypoxia-inducible factors (HIF) with pharmacological compounds could promote AVF maturation. Fibroblasts [normal human fibroblasts (NHF)], smooth muscle cells [human umbilical vein smooth muscle cells (HUVSMC)] and endothelial cells [human umbilical vein endothelial cells (HUVEC)], representing the three layers of the venous wall, were tested in vitro for proliferation, cell death, metabolism, reactive oxygen species production and migration after silencing of HIF1/2-α or after treatment with deferioxamine (DFO), everolimus (Eve), metformin (Met), N-acetyl-l-cysteine (NAC) and topoisomerase I (TOPO), which modulate HIF-α stability or activity. Compounds that were considered to most probably modify intimal hyperplasia were applied locally to the vessels in a mouse model of aortocaval fistula. We showed, in vitro, that NHF and HUVSMC can adapt their metabolism and thus their growth depending on oxygen concentration, whereas HUVEC appears to be less flexible. siHIF1/2α, DFO, Eve, Met, NAC and TOPO can modulate metabolism and proliferation depending on the cell type and the oxygen concentration. In vivo, siHIF1/2α, Eve and TOPO decreased neointimal hyperplasia by 32%-50%, 7 days after treatment. Within the vascular wall, hypoxia and HIF-1/2 mediate early failure of AVF. Local delivery of drugs targeting HIF-1/2 could inhibit neointimal hyperplasia in a mouse model of AVF. Such compounds may be delivered during the surgical procedure for AVF creation to prevent early AVF failure.

Prevalence of Thoracic Aortic Aneurysms in Patients with Degenerative Abdominal Aortic Aneurysms: Results from the Prospective ACTA Study.

OBJECTIVE: There are no recommendations for screening for thoracic aortic aneurysms (TAAs), even in patients with infrarenal abdominal aortic aneurysms (AAAs). The aims of this study were to determine the prevalence of TAAs in patients with AAAs and to analyse the risk factors for this association. METHODS: This was a multicentre prospective study. The Aortic Concomitant Thoracic and Abdominal Aneurysm (ACTA) study included 331 patients with infrarenal AAAs > 40 mm between September 2012 and May 2016. These patients were prospectively enrolled in three French academic hospitals. RESULTS: Patients were classified as having a normal, aneurysmal, or ectatic (non-normal, non-aneurysmal) thoracic aorta according to their maximum aortic diameter indexed by sex, age, and body surface area. Thoracic aortic ectasia (TAE) was defined as above or equal to the 90th percentile of normal aortic diameters according to gender and body surface area. Descending TAA was defined as ≥ 150% of the mean normal value, and ascending TAA as > 47 mm in men and 42 mm in women; 7.6% (n = 25) had either an ascending (seven cases; 2.2%) or descending aortic TAA (18 cases; 5.4%), and 54.6% (n = 181) had a TAE. Among the 25 patients with TAAs, five required surgery; two patients had TAAs related to penetrating aortic ulcers < 60 mm in diameter, and three had a TAA > 60 mm. In the multinomial regression analysis, atrial fibrillation (AF) (odds ratio [OR] 11.36, 95% confidence interval [CI] 2.18 - 59.13; p = .004) and mild aortic valvulopathy (OR 2.89, 1.04-8.05; p = .042) were independent factors associated with TAAs. Age (OR 1.06, CI 1.02 - 1.09; p = .003) and AF (OR 4.36, 1.21 - 15.61; p = .024) were independently associated with ectasia. CONCLUSION: This study confirmed that TAAs coexisting with AAAs are not rare, and one fifth of these TAAs are treated surgically. Systematic screening by imaging the whole aorta in patients with AAAs is clinically relevant and should lead to an effective prevention policy.

Vascular Calcifications are Associated with Increased Mortality in Patients with Acute Mesenteric Ischemia.

BACKGROUND: Vascular calcifications have been identified as predictors of mortality in several cardiovascular diseases but have not been investigated in context of acute mesenteric ischemia. The aim of this study was to investigate the impact of vascular calcifications in patients with acute mesenteric ischemia. METHODS: Patients admitted for an acute mesenteric ischemia were retrospectively included. The presence of calcifications in the visceral aorta, the celiac trunk, the superior mesenteric artery, and the renal arteries was assessed on computed tomography scan images at the arterial phase. The calcification volumes were measured using the software Aquarius iNtuition Edition®. RESULTS: The all-cause mortality was 55 out of 86 patients (63.9%) for a median follow-up of 3.5 days (1-243). The survival rate of patients with calcification in the superior mesenteric artery was significantly lower than that of those without calcification (22% vs. 55.6%, P = 0.019). Patients who died had significantly a higher frequency of calcifications in the superior mesenteric artery, the visceral aorta, the celiac trunk, and the renal arteries. CONCLUSIONS: The presence of vascular calcifications in the superior mesenteric artery is associated with increased mortality in patients diagnosed with acute mesenteric ischemia. Further studies are required to identify the mechanisms underlying this association.

Co-culture of human fibroblasts, smooth muscle and endothelial cells promotes osteopontin induction in hypoxia.

Arteriovenous fistulas (AVFs) are the preferred vascular access for haemodialysis of patients suffering from end-stage renal disease, a worldwide public health problem. However, they are prone to a high rate of failure due to neointimal hyperplasia and stenosis. This study aimed to determine if osteopontin (OPN) was induced in hypoxia and if OPN could be responsible for driving AVF failure. Identification of new factors that participate in remodelling of AVFs is a challenge. Three cell lines representing the cells of the three layers of the walls of arteries and veins, fibroblasts, smooth muscle cells and endothelial cells, were tested in mono- and co-culture in vitro for OPN expression and secretion in normoxia compared to hypoxia after silencing the hypoxia-inducible factors (HIF-1α, HIF-2α and HIF-1/2α) with siRNA or after treatment with an inhibitor of NF-kB. None of the cells in mono-culture showed OPN induction in hypoxia, whereas cells in co-culture secreted OPN in hypoxia. The changes in oxygenation that occur during AVF maturation up-regulate secretion of OPN through cell-cell interactions between the different cell layers that form AVF, and in turn, these promote endothelial cell proliferation and could participate in neointimal hyperplasia.

Relationship between metformin and abdominal aortic aneurysm.

Abdominal aortic aneurysm (AAA) is a life-threatening disease and pharmacologic agents to treat the disease remain lacking for clinical practice. Epidemiologic studies have highlighted a negative association between the use of antidiabetic drugs, including metformin, and AAA. Metformin is well-known for its blood glucose-lowering effect, but its action on both metabolism and inflammatory response has led to propose it as a potential therapeutic target in several cardiovascular diseases. In this review, we summarize the current knowledge on the link between metformin and AAA. Based on the known effects of the drug on the aortic wall, translational applications and clinical trials investigating the interest of metformin in the management of patients with AAA are discussed.

Artificial intelligence in abdominal aortic aneurysm.

OBJECTIVE: Abdominal aortic aneurysm (AAA) is a life-threatening disease, and the only curative treatment relies on open or endovascular repair. The decision to treat relies on the evaluation of the risk of AAA growth and rupture, which can be difficult to assess in practice. Artificial intelligence (AI) has revealed new insights into the management of cardiovascular diseases, but its application in AAA has so far been poorly described. The aim of this review was to summarize the current knowledge on the potential applications of AI in patients with AAA. METHODS: A comprehensive literature review was performed. The MEDLINE database was searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search strategy used a combination of keywords and included studies using AI in patients with AAA published between May 2019 and January 2000. Two authors independently screened titles and abstracts and performed data extraction. The search of published literature identified 34 studies with distinct methodologies, aims, and study designs. RESULTS: AI was used in patients with AAA to improve image segmentation and for quantitative analysis and characterization of AAA morphology, geometry, and fluid dynamics. AI allowed computation of large data sets to identify patterns that may be predictive of AAA growth and rupture. Several predictive and prognostic programs were also developed to assess patients' postoperative outcomes, including mortality and complications after endovascular aneurysm repair. CONCLUSIONS: AI represents a useful tool in the interpretation and analysis of AAA imaging by enabling automatic quantitative measurements and morphologic characterization. It could be used to help surgeons in preoperative planning. AI-driven data management may lead to the development of computational programs for the prediction of AAA evolution and risk of rupture as well as postoperative outcomes. AI could also be used to better evaluate the indications and types of surgical treatment and to plan the postoperative follow-up. AI represents an attractive tool for decision-making and may facilitate development of personalized therapeutic approaches for patients with AAA.

Evaluation of the Impact of Sarcopenia in Patients with Acute Mesenteric Ischemia.

BACKGROUND: Sarcopenia has been identified as a prognostic factor in several diseases. The aim of this study was to investigate the impact of sarcopenia in patients with acute mesenteric ischemia. METHODS: Consecutive patients admitted for acute mesenteric ischemia were retrospectively included at the University Hospital of Nice. Sarcopenia was assessed by the measurement of total psoas area normalized for height (TPA/H) on CT-scan and was defined as a TPA/H inferior to the lowest sex-specific quartile. The management of the patients and the 30-day outcomes were compared between sarcopenic and nonsarcopenic patients. Correlations between the TPA/H and biological characteristics were investigated. RESULTS: Among the 80 patients included, the lowest quartile of TPA/H that defined sarcopenia was 406.1 mm2/m2 for men and 307 mm2/m2 for women. The rate of revascularization or the need of intestinal resection did not significantly differ between sarcopenic and nonsarcopenic patients (10.5% vs. 26.2%, P = 0.214 and 26.3% vs. 47.5%, P = 0.118 respectively). The 30-day mortality did not significantly differ between the two groups (63.2% vs. 47.5%, P = 0.297). The TPA/H was significantly negatively correlated with the neutrophil, thrombocyte, and monocyte counts (r = -0.283; -0.288, -0.225, P < 0.05) and positively correlated with the hemoglobin concentration and the glomerular filtration rate (r = 0.368; 0.261, P < 0.05). CONCLUSIONS: Further studies on longer follow-up period would be of interest to fully understand the prognostic value of sarcopenia in patients with acute mesenteric ischemia.

Comparison of Cryopreserved Arterial Allografts Versus Heparin-bonded Vascular Grafts in Infragenicular Bypass for Chronic Limb Threatening Ischemia.

BACKGROUND: The purpose of this study was to compare cryopreserved arterial allograft (CAA) to heparin-bonded prosthesis (HBP) in infragenicular bypasses for patients with chronic limb-threatening ischemia (CLTI). METHODS: This retrospective study took place in 2 university hospitals and included 41 consecutive patients treated for CLTI. In the absence of a suitable saphenous vein, an infragenicular bypass was performed using either CAA (24 cases) or HBP (17 cases). Kaplan-Meyer analysis compared primary and secondary patency and amputation-free survival rates. Binomial logistic regression analyzed risk factors for major amputation and thrombosis. RESULTS: The mean followup was 18.5 months (±14.3) in the CAA group, 17.6 (±6.1) in the HBP group. In the CAA group, primary and secondary patency rates at 12 months were 52% (±10.6) and 61% (±10.3), compared to 88% (±7.8) and 94% (±5.7) in the HBP group, respectively. The difference in patency rates was not statistically different (P = 0.27 and P = 0.28, respectively). The statistically significant factors of graft thrombosis were, a stage 4 from the WIfI classification (Wound Ischemia foot Infection) with a 6 times higher risk (P = 0.04), and a distal anastomosis on a leg artery with a 9 times higher risk of thrombosis (P = 0.03). Amputation-free survival rates at 18 months were similar between the groups (CCA: 75% (±9) versus HBP: 94% (±6), P = 0.11). Patients classified as WIfI stage 4 had 13 times higher odds to undergo major amputation than patients with WIfI stage 2 or 3 (95% CI, 1.16-160.93; P = 0.04). The intervention was longer in the CCA group of 74 min (278 min ± 86) compared to the HBP group (203 min ± 69). This difference was statistically significant (95% CI, 17.86-132.98), t(35) = 2.671, P = 0.01. CONCLUSIONS: CCA is not superior to HBP in infragenicular bypasses for CLTI, and may not be worth the extra cost and the longer operative duration.

The Common Femoral Artery Bifurcation Lesions: Clinical Outcome of Simple Versus Complex Stenting Techniques - An Analysis Based on the TECCO Trial.

BACKGROUND: Common femoral artery (CFA) stenting appears as a promising alternative treatment to the open surgery for de novo CFA stenosis. The stenting of lesions just located at the CFA is simple, whereas stenting of CFA bifurcation lesions is more complex, and outcomes are still matter of debate. The aim of this study was to describe and to compare clinical outcomes of techniques used to treat simple over complex lesions for the stenting of CFA lesions. MATERIALS/METHODS: From the French randomized controlled trial, TECCO, a total of 54 patients underwent stenting intervention and were enrolled in this study. Patients were excluded if they had CFA thrombosis, restenosis, and nonatheromatous lesions. Patients were classified by simple and complex lesions based on the type of lesion. The primary end point was the primary sustained clinical improvement. RESULTS: Eighteen patients were included in the simple lesion group, and 36 patients, in the complex lesion group. Baseline characteristics of patients were comparable between the 2 groups. The technical success was 100% in the simple lesion group and 91.7% in the complex lesion group. There was no significant difference between the 2 groups, regarding the primary sustained clinical improvement. The primary patency rates at 24 months for simple and complex lesion groups were 86.3% and 79%, respectively (P = 0.66). Freedom from target lesion revascularization was of 93.3% and 82% in the simple and complex lesion group, respectively (P = 0.34). CONCLUSIONS: The stenting technique for CFA bifurcation lesions is a safe and effective technique. More trials with a large number of patients are needed to define the optimal stenting technique.

Translational applications of glucose metabolism in abdominal aortic aneurysm.

Even though diabetes mellitus is a major risk for cardiovascular events and atherosclerosis-related diseases, it is negatively associated with abdominal aortic aneurysm. The understanding of the mechanisms underlying this negative association could bring new insights to identify prognostic and therapeutic targets. Here we summarize current knowledge of the relationship between glycemic parameters and clinical outcomes of patients with abdominal aortic aneurysm. Translational applications of glucose-targeted approaches as well as their potential interest for clinical practice are discussed in this context.

Transforming growth factor ß neutralization finely tunes macrophage phenotype in elastase-induced abdominal aortic aneurysm and is associated with an increase of arginase 1 expression in the aorta.

OBJECTIVE: Macrophages play a critical role in the initiation and progression of abdominal aortic aneurysm (AAA) and are classically distinguished into M1 "proinflammatory" and M2 "anti-inflammatory" macrophages. Topical application of elastase associated with transforming growth factor ß (TGF-ß) systemic neutralization reproduces the main pathologic features of human AAA, offering a new model to investigate their role. The aim of this study was to investigate whether macrophages contribute to the expression of canonical M1/M2 markers in the aorta in the AAA model induced by elastase and systemic blockade of TGF-ß and whether blocking of TGF-ß activity affects macrophage phenotype and the expression of the M2 marker arginase 1 (ARG1). METHODS: C57Bl/6J male mice (6-8 weeks old) were randomly assigned to three experimental groups: mice that had local application of heat-inactivated elastase or elastase and mice that had elastase application and received injection of anti-TGF-ß (elastase + anti-TGF-ß group). Monocyte-macrophage depletion was achieved in the elastase + anti-TGF-ß group using liposome clodronate. Macrophage phenotype was characterized by quantitative polymerase chain reaction, flow cytometry, and immunohistochemistry. Human infrarenal AAA tissues (n = 10) were obtained to analyze ARG1 expression. RESULTS: Analysis of gene expression in the infrarenal aortic wall revealed that after 14 days, no significant difference for the expression of CCL2, NOS2, and Ym1/2 was observed in the elastase group compared with the elastase + anti-TGF-ß group, whereas the expression of ARG1, interleukin (IL) 1ß, and IL-6 was significantly increased. Macrophage depletion in the elastase + anti-TGF-ß group led to a significant decrease of IL-1ß, IL-6, ARG1, and Ym1/2 gene expression. Immunofluorescent staining confirmed that TGF-ß neutralization significantly enhanced ARG1 protein expression in the aneurysmal tissue. Flow cytometry analysis revealed an increase of macrophages expressing ARG1 in the aorta of mice treated with elastase + anti-TGF-ß compared with the elastase group, and their proportion increased with aneurysmal dilation. In humans, ARG1 protein expression was increased in aneurysmal tissues compared with controls, and positive cells were mainly found in the adventitia. CONCLUSIONS: TGF-ß neutralization finely tunes macrophage phenotype in elastase-induced AAA and leads to an increase in ARG1 gene and protein expression in the aortic wall. Even if further studies are required to elucidate its role in AAA development, ARG1 could represent a new prognostic or therapeutic target in aneurysmal disease.

Impact of Polar Renal Artery Coverage after Fenestrated Endovascular Aortic Repair for Juxtarenal and Type IV Thoracoabdominal Aortic Aneurysms.

BACKGROUND: Fenestrated endovascular aortic repair (FEVAR) of complex aneurysm can require the coverage of polar renal artery. The aim of this study was to investigate the impact of the procedure on postoperative outcomes in patients with juxtarenal or thoracoabdominal aortic aneurysms. METHODS: Patients who had FEVAR for juxtarenal or type IV thoracoabdominal aortic aneurysm were retrospectively included between January 2010 and October 2017. The estimated glomerular filtration rate (eGFR) was recorded before and at 1 day, 7 days after surgery, and at the last follow-up. The occurrence of renal infarct was analyzed on the injected computed tomography scan images. RESULTS: Forty-three patients deemed at high-risk for open repair underwent FEVAR; 10 patients (23.3%) had polar renal artery coverage and were compared to patients without polar renal artery. The eGFR did not differ between the groups at 1 day and 7 days after FEVAR (69 vs 61.6 mL/mn/1.73 m2, P = 0.8708 and 68.4 mL/mn/1.73 m2 vs 68, P = 0.9440, respectively). For a median follow-up of 233 days, the eGFR at the latest follow-up was 38 mL/mn/1.73 m2 (21.8-56.3) in patients who had polar renal artery covered and 57 mL/mn/1.73 m2 (46.5-76) in patients without polar renal artery (P = 0.0748). Patients who had polar renal artery had a higher rate of postoperative kidney renal infarct (60% vs 21.2%, P = 0.0441). The proportion of vascular complications did not differ (30% vs 30.3%, P = 0.9999). No endoleak related to polar renal artery coverage was observed. The 30-day postoperative mortality was 4.7%. CONCLUSIONS: Polar renal artery coverage during FEVAR is not associated with critical renal and vascular short-term outcomes but could impact long-term renal function.

High Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio are Associated with Symptomatic Internal Carotid Artery Stenosis.

INTRODUCTION: The neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) have been identified as predictive factors in several cardiovascular diseases but their significance in patients with internal carotid artery (ICA) stenosis is still poorly known. The aim of this study was to determine the clinical significance of the preoperative NLR and PLR in patients with ICA stenosis undergoing carotid endarterectomy. MATERIAL AND METHODS: Consecutive patients who underwent carotid endarterectomy for ICA stenosis were retrospectively included (n = 270). The population was divided into 2 series of 4 groups based on the quartile values of the preoperative NLR and PLR: group Ia (NLR < 1.5), IIa (1.50 < NLR < 2.07), IIIa (2.07 < NLR < 2.95), IVa (NLR>2.95), and group Ib (PLR < 86.6), IIb (86.6 < PLR < 111.7), IIIb (111.7 < PLR < 148.3), IVb (PLR > 148.3). Clinical characteristics and 30-day postoperative outcomes were compared among the groups. RESULTS: One death (.4%) was reported during the 30-day postoperative period and the overall stroke and death rate was 1.5%. The proportion of patients with symptomatic ICA stenosis were significantly higher in group IVa compared to groups Ia, IIa, IIIa (64.2% vs 33.8%, 44.8% and 45.6%, respectively, P = .005), and higher in group IVb compared to groups Ib, IIb, IIIb (59.7% vs 47.1%, 35.8%, 45.6%, P = .051). No significant difference on 30-day postoperative all-cause complications was observed among the groups. CONCLUSIONS: A high preoperative NLR and PLR is significantly associated with symptomatic ICA stenosis. Further studies are required to determine their interest as predictors of postoperative outcomes in patients undergoing carotid endarterectomy.

Sexual Dysfunction After Abdominal Aortic Aneurysm Surgical Repair: Current Knowledge and Future Directions.

BACKGROUND: Abdominal aortic aneurysm (AAA) represents a major health concern and the curative treatment relies on surgical approaches including open and endovascular aortic repair (EVAR). While epidemiological studies have addressed the major outcomes including mortality and life threatening complications, the impact of surgical intervention on sexual function has been less well described. The aim of this review was to summarise current knowledge on the occurrence of sexual dysfunction in the context of AAA surgical repair and to explore whether surgical techniques could have differential impact. METHODS: The MEDLINE database was searched in May 2017 and all studies related to sexual dysfunction assessment following AAA surgical repair were included. Given the heterogeneity of the definitions of sexual dysfunction and its assessment, a comprehensive literature review was performed rather than a meta-analysis. RESULTS: The published literature search identified 29 studies including prospective, retrospective, and single centre and multicentre trials. The post-operative erectile dysfunction prevalence varied from 7.4% to 79% following open repair and from 4.7% to 82% following EVAR. The incidence of de novo erectile dysfunction was estimated, respectively, at 20%, 26.6%, and 83% after open repair and at 11% and 14.3% after EVAR. Erectile dysfunction rates varied from 5.3% to 8.2% in patients who had EVAR with unilateral hypogastric artery exclusion and from 5.1% to 46.6% in patients who had bilateral hypogastric artery exclusion. The rates of retrograde ejaculation after surgery varied from 3.3% to 9% after open repair and from 6% to 6.6% after laparoscopic repair. CONCLUSION: Clinical studies demonstrated heterogeneous results, which could be attributed mainly to methodology including study design and criteria used to evaluate sexual dysfunction. Given the potential consequences of sexual dysfunction on quality of life, this review highlights the real need to inform patients and to better assess this potential side effect to improve its management in patients undergoing AAA surgical repair.

Cerebral Infarct Topography and Early Outcome after Surgery for Symptomatic Carotid Stenosis: A Multicentre Study.

INTRODUCTION: Although carotid stenosis can cause both territorial and border-zone (BZ) cerebral infarcts (CI), the influence of CI topography on postoperative complications after surgery remains unclear. We compared early outcomes after endarterectomy on the basis of CI location: territorial (T group) or BZ group. MATERIAL AND METHODS: During the period between 2009 and 2013, ischaemic stroke patients who had undergone surgery for symptomatic carotid stenosis were identified from prospective databases from 3 French centres. The outcome was the identification of a combined stroke/death rate 30 days after endarterectomy. RESULTS: Two hundred and eighty-nine patients were included, 216 (74.7%) in the T group and 73 (25.3%) in the BZ group. The mean degree of stenosis was comparable in the 2 groups (78 ± 12% in the T group vs. 80 ± 12% in the BZ group, p = 0.105), with, however, more sub-occlusions (stenosis >90%) in the BZ group (38.4 vs. 23.1%, p = 0.012). The mean time between the time CI developed and the time surgery was performed was 19.6 ± 24.8 days, with a majority of patients being operated upon within 2 weeks following the formation of CI (66.7% in the T group vs. 60.3% in the BZ group, p = 0.322). The combined endpoint was significantly more frequent in the BZ group (9.6 vs. 1.9%, p = 0.003), with 4 ischaemic strokes and 3 deaths. In multivariate analysis, BZ CI was an independent predictor of postoperative stroke or death at 30 days (HR 4.91-95% CI [1.3-18.9], p = 0.020). CONCLUSION: BZ infarcts carry a greater risk of postoperative complications after carotid surgery, thus suggesting that topography of the CI should be considered in the decision-making process regarding surgery.

Increased Oxidative Stress and Hypoxia Inducible Factor-1 Expression during Arteriovenous Fistula Maturation.

BACKGROUND: The poor clinical results that are frequently reported for arteriovenous fistulae (AVF) for hemodialysis are typically due to failure of AVF maturation. We hypothesized that early AVF maturation is associated with generation of reactive oxygen species and activation of the hypoxia-inducible factor-1 (HIF-1) pathway, potentially promoting neointimal hyperplasia. We tested this hypothesis using a previously reported mouse AVF model that recapitulates human AVF maturation. METHODS: Aortocaval fistulae were created in C57Bl/6 mice and compared with sham-operated mice. AVFs or inferior vena cavas were analyzed using a microarray, Amplex Red for extracellular H2O2, quantitative polymerase chain reaction, immunohistochemistry, and immunoblotting for HIF-1α and immunofluorescence for NOX-2, nitrotyrosine, heme oxygenase-1 (HO-1), and vascular endothelial growth factor (VEGF)-A. RESULTS: Oxidative stress was higher in AVF than that in control veins, with more H2O2 (P = 0.007) and enhanced nitrotyrosine immunostaining (P = 0.005). Immunohistochemistry and immunoblot showed increased HIF-1α immunoreactivity in the AVF endothelium; HIF-1 targets NOX-2, HO-1 and VEGF-A were overexpressed in the AVF (P < 0.01). AVF expressed increased numbers of HIF-1α (P < 0.0001) and HO-1 (P < 0.0001) messenger RNA transcripts. CONCLUSIONS: Oxidative stress increases in mouse AVF during early maturation, with increased expression of HIF-1α and its target genes NOX-2, HO-1, and VEGF-A. These results suggest that clinical strategies to improve AVF maturation could target the HIF-1 pathway.

Radial artery deviation and reimplantation inhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalic fistulas for hemodialysis.

OBJECTIVE: Although the end cephalic vein-to-side radial artery arteriovenous fistula is the "gold standard" procedure for primary hemodialysis access, it is associated with high rates of primary failure because of the development of neointimal hyperplasia and juxta-anastomotic stenosis. We report initial results of a new approach to perform radial-cephalic fistulas, radial artery deviation and reimplantation (RADAR), designed to avoid juxta-anastomotic stenosis. METHODS: RADAR patients' data were prospectively maintained and retrospectively reviewed and compared with a historical control group of traditional radial-cephalic fistulas created in the same center. Duplex ultrasound was used to monitor maturation (flow ≥500 mL/min and venous diameter ≥5 mm) and to diagnose juxta-anastomotic stenosis. Study end points were rates of maturation, juxta-anastomotic stenosis, reintervention, and primary and secondary patency. RESULTS: There were 53 RADAR fistulas performed (follow-up, 10.5 ± 2.6 months) and compared with 73 control fistulas (follow-up, 12.0 ± 6.6 months). RADAR fistulas had increased rates of maturation compared with control fistulas (75% vs 45% at 6 weeks, P = .001; 92% vs 71% at 3 months, P = .003) and decreased incidence of juxta-anastomotic venous stenoses (2% vs 41%; P = .001). At 6 months, RADAR fistulas had increased primary patency (93% vs 53%; P < .0001) and secondary patency (100% vs 89%; P = .0003) and decreased incidence of reinterventions (10% vs 74%; P = .001) compared with control fistulas. No RADAR fistulas caused ischemic symptoms. CONCLUSIONS: The RADAR technique is associated with less juxta-anastomotic stenosis, increased maturation and patency, and fewer secondary interventions. These improved outcomes suggest that RADAR may be the preferred surgical technique to perform radial-cephalic arteriovenous fistula.