Compressive pancreaticoduodenal artery aneurysm associated with celiac artery stenosis.

Peripancreatic artery aneurysms are a rare condition, representing <2% of all splanchnic artery aneurysms, and have been significantly related to celiac axis stenosis. While they are most often asymptomatic, those aneurysms have a strong tendency to rupture (52% rupture rate at the initial presentation) and, in this case, the outcome is often dramatic. Given that reports of this disease are rare, appropriate guidelines are difficult to formulate and different treatment strategies have been proposed. Endovascular management seems to be efficient in the large majority of most recent reports, but open surgery still remains necessary for complex cases, especially when associated with celiac axis stenosis. We report a new occurrence of a symptomatic compressive aneurysm related to common bile duct compression that we treated using a hybrid procedure.

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.

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.