18F-FDG PET/CT Detection of a Popliteal Mycotic Aneurysm Complicating Staphylococcus aureus Bacteremia.

ABSTRACT: A 75-year-old man presented with Staphylococcus aureus bacteremia, fever, and right posterior knee pain. Venous Doppler ultrasound of the lower extremity showed an isolated right calf muscle vein thrombosis, without any sign of deep vein thrombosis. 18F-FDG PET/CT revealed an intense focal uptake on the right popliteal artery, suggesting a mycotic aneurysm (MA). Lower limb CT angiography confirmed an MA of the right popliteal artery. The patient underwent surgical procedure with excision of the MA, whose cultures grew methicillin-sensitive S. aureus. Our case highlights the importance of including lower limbs in 18F-FDG PET/CT acquisition in case of suspicion of septic emboli.

Is it mandatory to carry out completion arteriography after carotid endarterectomy with patch angioplasty?

BACKGROUND: This study compares the neurologic evolution and number of restenoses between 2 groups of patients who underwent internal carotid endarterectomy with patch angioplasty (CEP): one group with systematic intraoperative completion arteriography (CA) and another group without. METHODS: This monocentric retrospective study was performed from January 2000 to December 2008 on 559 consecutive CEPs; 179 were controlled with CA and 380 were not. Surgery was chosen for patients with greater than 50% symptomatic or greater than 60% asymptomatic stenosis (North American Symptomatic Carotid Endarterectomy Trial criteria). Each patient's neurologic and ultrasound status was followed-up postoperatively, and at 3 months in the presence of neurologic symptoms, and at the end of the follow-up. Residual stenosis and restenosis were defined by a reduction in diameter of greater than 50% or a maximal systolic velocity greater than 150 cm/s. The surgical team included 4 vascular surgeons: 2 experienced surgeons who did not perform CA, 1 experienced surgeon monitoring surgical trainees, and 1 who had little experience performing CA. RESULTS: In both groups, the patients were comparable in terms of cardiovascular risks, except for age, gender, statin treatment, and neoplastic medical history. During the first 30 postoperative days, the mean rate of cerebrovascular accident (CVA) and death was 0.4%. In the CA group, 1 incidence (0.6%) of partial monocular blindness occurred, and in the no-CA group, 1 incidence (0.2%) of hemorrhagic CVA and 3 (0.5%) transient ischemic attacks (TIAs) occurred. One of these TIAs resulted from a residual stenosis. Mean follow-up was 41 months. During this time, 6 ipsilateral neurologic accidents occurred in the CA group (1 ischemic CVA, 3 TIAs, 1 partial monocular blindness, and 1 hemorrhagic CVA), whereas 10 occurred in the no CA group (1 ischemic CVA, 4 TIAs, 3 hemorrhagic CVAs, 1 partial monocular blindness, and 1 recurrence of vertebrobasilar insufficiency). The combined morbidity and mortality rates in the 2 groups were 3.3% and 2.8%, respectively (P > 0.05). Two residual stenoses (0.5%) and 6 significant restenoses (1.6%) were diagnosed in the no-CA group; 4 significant restenoses (2.2%) occurred in the CA group (P > 0.05). CONCLUSIONS: When performed by experienced surgeons, systematic intraoperative CA does not reduce the incidence of ipsilateral neurologic complications after CEP. Systematic intraoperative arteriography enables surgical trainees to obtain results as satisfactory as those of experienced surgeons.

Ambulatory percutaneous angioplasty in patients with claudication.

BACKGROUND: The aim of this study was to evaluate the feasibility of outpatient peripheral angioplasty in patients who were treated for lower limb claudication. METHODS: Between February 1 and December 31, 2007, a monocentric observational study was carried out on 98 consecutive patients who presented with claudication (mean age: 63 years [range: 31-90]; 81 men) and were treated by using a percutaneous femoral approach for either iliac (n = 62) or femoropopliteal lesions (n = 36). Exclusion criteria were requiring a renal angioplasty or an associated surgical procedure, having a creatinine clearance value of <30 mL/min/1.73 m(2), body mass index exceeding 35 kg/m(2), and critical ischemia or vascular surgery history at the site of femoral puncture. Treatment involved manual compression and/or use of a closure system, after which the patients were made to wear a compression bandage. After 4 hours, the patients were carefully examined for the presence of a local complication (puncture site), a general complication (thoracic pain), or a complication related to the surgical procedure (early thrombosis). When no complications were detected, the patients were allowed to get up and walk. At the sixth hour, the patients were again examined for the presence of the aforementioned complications. In the absence of any complications, the patients were deemed as "fit to be discharged" and were allowed to stroll about inside the hospital. The following day, a final evaluation was carried out just before their discharge. The risk factors and comorbidities were evaluated. RESULTS: At the sixth postoperative hour, 78 patients (80%) were deemed as "fit to be discharged." The remaining 20 (20%) were deemed as "unfit to be discharged" because of either a major hematoma (n = 3, including two redo surgeries and a blood transfusion) or a minor evolutive hematoma. All the complications (n = 17) occurred before the fourth postoperative hour. Bilateral femoral puncture was the only risk factor found to be associated with contraindication to being discharged in the evening (OR = 3.8, p = 0.02). CONCLUSION: Ambulatory treatment for patients with claudication treated with an endovascular approach was possible because complications that required overnight surveillance always occurred within the first 4 postoperative hours. Bilateral femoral puncture is a potential risk factor for failure of outpatient management.

Endovascular treatment of external iliac artery stenoses for claudication with systematic stenting.

The results of the endovascular treatment of external iliac artery lesions in patients with claudication are not well known. In the literature, very often, the studied populations are not homogenous (people with claudication and with acute ischemia) and the external iliac artery is not differentiated from the primary iliac artery. Moreover, systematic stenting is still debated. Our goal was to study the results of systematic stenting for atheromatous lesions of the external iliac artery in a consecutive and homogenous population of patients with claudication. From June 2000 to December 2006, 90 external iliac arteries were treated with systematic stenting for atheromatous lesions in 81 consecutive patients with claudication (74 men and 7 women, aged 62+/-12 years). Lesions were classified according to the Trans-Atlantic Intersociety Consensus (TASC). Endovascular treatment was systematically chosen for TASC A (n=40) and B (n=30) patients and patients at high surgical risk for TASC C (n=18) and D (n=2). One hundred and seven stents were placed; they were 37+/-21 mm long with a 7+/-0.6mm diameter. Clinical examination and duplex follow-up were carried out at a minimum of 3 months and at the end of the follow-up. There was a 2.2% complication rate, without any deaths (retroperitoneal hematoma). Mean follow-up was 23 months (with a 13-month median). Primary patency rate was 97% (standard error [SE] 2%) at 1 year, 90% (SE 4.6%) at 2 years, and 84% (SE 6.6%) at 3 years. Secondary patency rate was 98% (SE 1.5%) at 1 year, 93% (SE 3.9%) at 2 years, and 93% (SE 4.5%) at 3 years. Ten restenoses were detected and treated by endovascular techniques (n=6), bypass (n=2), or medication (n=2). At the end of the follow-up, the patients were asymptomatic (n=62) or presented with a moderate (n=17) or severe (n=8) claudication. A patient with hemodialysis was amputated at the metatarsal level. No significant predictive restenosis factor was discovered. However, the C or D TASC classification seemed to favor an earlier restenosis (p=0.06). In conclusion, our study demonstrates that, in a larger population than in the literature, systematic stenting on the external iliac artery gives satisfying results in patients with claudication.

Simultaneous ipsilateral infrainguinal angioplasty and bypass procedures.

We studied the efficacy of surgeon-performed combined ipsilateral endovascular and open arterial concomitant reconstruction at the infrainguinal level. It was a retrospective analytic study. The study included 15 patients (9 men, 6 women) who underwent 15 combined procedures between January 2000 and January 2004. They were divided into two groups. The first group consisted of nine patients with an inflow angioplasty. The second group included six patients with an outflow angioplasty. Indications for arterial reconstruction were claudication (one patient), ischemic rest pain (three patients), and gangrene (eleven patients). Immediate technical success of the combined procedures was 100%. In the first group, one patient died owing to a myocardial infarction, ischemic lesions healed in eight patients, one patient required revision of the graft and three reconstructions occluded, with one amputation of the affected limb. In the second group, one patient died owing to stoke, one patient needed a graft revision and one underwent a limb amputation. The cumulative limb salvage at 42 months was 85%. Our results suggest that simultaneous ipsilateral infrainguinal angioplasty and bypass procedures could be performed with good results. Inflow and outflow angioplasty allow using a shorter single graft segment. Outflow angioplasty ameliorates the bypass flow and accelerates the healing of ischemic lesions. The restenosis rate of the inflow angioplasty at the femoral level remains low.

Distal bypass for limb salvage: should the contralateral great saphenous vein be harvested?

The great saphenous vein (GSV) is unusable in 20% of cases. The best alternative in these cases is the GSV of the contralateral lower limb (CLL). However, many surgeons are reluctant to harvest the contralateral GSV for fear that it might be needed for future treatment of critical ischemia in the CLL. The purpose of this retrospective study was to observe the long-term behavior of the CLL and to identify prognostic factors for the development of critical ischemia as a basis for contraindicating harvest of the contralateral GSV. The study was conducted in patients who underwent distal bypass for trophic manifestations between January 1995 and December 1997. Patients who had a history of contralateral bypass using the GSV or major amputation were not included. Eighty-one of the 86 patient records could be analyzed with a minimum follow-up of 5 years. Survival was 59% and 40% at 2 and 5 years, respectively. Statistical analysis focused on age, risk factors, trophic manifestations on the CLL, ankle-brachial index, and arteriographic findings. After 5 years of follow-up, seven of the 81 patients (8.6%) required contralateral long bypass. Presence of contralateral trophic manifestations at the time of initial bypass was the only statistically significant prognostic factor for requirement of contralateral long bypass (p < 0.01). These findings support harvesting of the contralateral GSV for lower limb salvage. The risk that long contralateral bypass will be required is low except in patients with contralateral trophic manifestations.