Functional Results of Cervical Rib Resection for Thoracic Outlet Syndrome: Impact on Professional Activity.

BACKGROUND: The aim of this study is to report long-term functional results following cervical rib (CR) resection for thoracic outlet syndrome (TOS). METHODS: This monocentric study included all cases of resection of CR for TOS performed between January 2004 and December 2016. Data were retrospectively collected from the hospital electronic database including preoperative symptoms and the evaluation of occupational well-being, intraoperative data, and early clinical evaluation and occupational well-being during the postoperative period. Patients were categorized as neurogenic TOS (NTOS), arterial TOS (ATOS), arterial and neurogenic TOS (ANTOS), venous TOS (VTOS), or asymptomatic according to preoperative evaluation. We evaluated the improvement in work life between the preoperative and the postoperative period. Further assessment was a negative Roos or elevated arm stress test (EAST) during the postoperative period. RESULTS: Thirty-three patients with a median age of 38.5 years (30-46) were included. Thirty-six procedures were performed: 33% to treat ATOS (12/36), 39% for NTOS (14/36), 19% for ANTOS (7/36), 3% for VTOS (1/36), and 6% (2/36) for asymptomatic lesions. There were 9 cases of subclavian artery aneurysms leading to additional arterial repair. Due to distal embolization, a cervical sympathectomy was associated in 5 procedures. First rib resection was associated in 4 procedures (11%) and C7 transverse process resection was performed in 15 procedures (42%). The technical success rate was 100% and intraoperative complications were observed in 4 patients (11%) with favorable postoperative outcomes. During the early postoperative period, 3 Claude Bernard-Horner's syndrome and 1 asymptomatic subclavian dissection were detected. Late complications included 2 bypass thromboses (6%) at 6 weeks and 16 months. Postoperative EAST improved in 16 limbs (44%). Prior to the procedure, only 27% (9/33) patients had normal work lives. After the procedure, 64% (21/33) of patients were able to return to their normal work activity. CONCLUSIONS: CR resection for TOS seems to be a safe procedure leading to good short- and long-term clinical results with a favorable impact on recovering a normal work life in these young patients.

Femoral Bifurcation Endarterectomy with Transection-Eversion of the Superficial Femoral Artery: Technique and Results.

BACKGROUND: We evaluated the results of femoral bifurcation endarterectomy using the eversion technique with transection of the superficial femoral artery (femoral bifurcation endarterectomy with eversion [FBEE]). METHODS: We included all patients who underwent a femoral revascularization using the eversion technique, with or without antegrade or retrograde revascularization, from January 2006 to December 2015. Data were retrospectively collected. Primary and primary assisted patency (PAP) of the femoral bifurcation were analyzed. Secondary outcomes were 30-day postoperative complications. RESULTS: A total of 129 patients (143 limbs) underwent consecutive FBEE (86.8% men, with a mean age of 69.7 years). Patients presented with claudication (93, 65%) and critical ischemia (46, 32.2%). Primary patency was 96.3%, 94.6%, and 93% at 1, 2, and 5 years, respectively. PAP was 99% at 3 time points. Reintervention was necessary in 8 patients during follow-up. The 30-day mortality was 0.7% (1 patient), and the access complication rate was 18.8% (n = 27), of which only 2.8% (n = 4) were major complications. CONCLUSIONS: This retrospective study confirmed the efficiency and the reproducibility of this technique for the treatment of femoral bifurcation lesions. This technique allowed treating extensive atherosclerotic lesions of the deep femoral artery and may be associated with antegrade and retrograde revascularizations.

A Femoral Common Vein Aneurysm in a Patient with Neurofibromatosis Syndrome Type 1.

Neurofibromatosis type I (NFI), also called Von Recklinghausen disease, is an autosomal dominant disease secondary to a genetic mutation on the long arm of chromosome 17. This disorder affects neural crest cells. Cutaneous clinical forms are the most frequent with multiple benign skin neurofibromas, associated with café au lait skin spots and iris hamartomas. Vascular abnormalities in NF1 are rare but have also been well described. The most frequent abnormalities are characterized by arterial aneurysm degeneration, stenosis, and malformations. Venous locations are rare, but some cases of venous aneurysms were described with ruptures as complications. We present a rare case of thrombosed venous femoral aneurysm associated with a pulmonary embolism in a patient affected by NF1.

Preliminary Experience with the GORE(®) EXCLUDER(®) Iliac Branch Endoprosthesis for Common Iliac Aneurysm Endovascular Treatment.

BACKGROUND: The aim of this study is to assess the safety and the short-term results of endovascular treatment of common iliac artery (CIA) aneurysms using the new GORE EXCLUDER iliac branch endoprosthesis (IBE) device. METHODS: The study is a retrospective with prospective follow-up nonrandomized, single-arm evaluation. Patients with a CIA aneurysm (diameter >30 mm) extending to the iliac bifurcation underwent endovascular treatment with the Gore IBE. Anatomic and procedural data were collected. Computed tomography angiography (CTA) was performed within the 30 days after the procedure and every 6 month. Thirty-day and at least 6-months outcomes were investigated. RESULTS: From February 2014 to December 2014, 10 male patients with aneurysmal CIA (mean age 75 years old) underwent consecutive endovascular treatment with the Gore IBE. The CIA aneurysm (mean diameter 43.2 mm, range 32-49) treated with the Gore IBE was associated with an abdominal aortic aneurysm (AAA) in 5 patients. One patient had a previous AAA open repair. CIA aneurysm was bilateral in 5 patients. Preliminary procedure of internal iliac artery embolization was performed in 3 patients. Technical success rate of the Gore IBE implantation was 100% with a median fluoroscopy time of 35 min (range 12-64, ±16) and median contrast load of 150 mL (range 100-250, ±45). No perioperative complications were observed. Median length of stay was 4 days (range 3-7, ±2). One aortic type Ia endoleak was observed on the postoperative CT scan requiring an aortic extension at day 3. Branch patency was observed in all 10 patients at 1 month and 9 patients at 6 month. All CIA aneurysms were excluded without type Ib or type III endoleak. CONCLUSIONS: The technical success and short-term results demonstrate encouraging results and clinical benefits of the new GORE EXCLUDER IBE. A longer follow-up is needed to assess midterm and long-term results.

Treatment of sac expansion after endovascular aneurysm repair with obliterating endoaneurysmorrhaphy and stent graft preservation.

BACKGROUND: Persistent type II endoleaks (T2Ls) with sac enlargement after endovascular abdominal aortic aneurysm repair are still of concern in view of the potential for rupture. Current treatments (embolization and stent graft [SG] explantation) are associated with lack of efficacy or high perioperative morbidity and mortality. This study evaluated an alternative technique that combines sacotomy, ligation of patent back-bleeding vessels, and SG preservation for T2L or unspecified endoleak repair. METHODS: This multicenter study in France included 28 patients (27 men; median age, 78 years). Twenty-one patients (75%) had a bifurcated SG (including 3 fenestrated SGs) and seven (25%) had an aortouni-iliac SG (2 for ruptured aneurysm). Unsuccessful embolization had been performed in 10 patients (36%). Four patients (14%) presented sac enlargement with no endoleak visible on computed tomography. The origin of the endoleak remained unspecified in three patients 3 (11%). The median diameter of the aneurysmal sac was 78 mm (vs 55 mm at the time of endovascular abdominal aortic aneurysm repair) after a median follow-up of 24 months. RESULTS: A transperitoneal approach was used in 21 patients (75%) and a retroperitoneal approach was used in seven (25%). A guidewire was placed in the supraceliac aorta in 14 patients, and an occlusion balloon was temporarily inflated in six. Aortic cross-clamping was performed in five patients. T2Ls were identified in 26 patients, and associated with a distal type I endoleak in 1 patient, a type III endoleak in 3, and a type IV endoleak in 1. Two patients presented with endotension. All the endoleaks were treated successfully, with a mean operating time of 120 minutes and a mean blood loss of 450 mL. One SG was explanted 12 days after the procedure because of early infection. One patient died during SG explantation for an aortoduodenal fistula 26 months after the endoaneurysmorrhaphy. During a median follow-up of 24 months, the control computed tomography scan showed shrinkage of the aneurysmal sac with stable diameters in all patients. No missed T2Ls, no recurrence of T2L, and no SG migration or disjunction was observed. CONCLUSIONS: Obliterating endoaneurysmorrhaphy with SG preservation can be considered as an alternative to SG removal in cases of persistent T2L responsible for aneurysmal sac enlargement after embolization failure. By avoiding extensive dissection for surgical aortic cross-clamping, minimizing hemodynamic changes, and reducing blood loss and operating time, this procedure can be performed even in patients initially considered unfit for surgery.

Endovascular treatment of aortic and primitive iliac artery aneurysms associated with Behçet disease.

Behçet disease is a systemic vasculitis that can cause vascular complications. We describe a 42-year-old woman with an aortic aneurysm and common right iliac aneurysm, both saccular and complicating Behçet disease. The patient was successfully treated by an endovascular method, which currently seems to be the best therapeutic choice given the frequent anastomotic complications of conventional surgical treatment.

Unusual foreign body in urinary bladder due to vascular surgery intervention.

Iatrogenic bladder injury in vascular surgery is very rare. We report a case of bladder injury by penetration secondary to the tunneling of a vascular graft through the space of Retzius. The diagnosis of an intravesical graft was made by computed tomography 1 week later. The patient underwent open bladder surgery associated with complete graft resection without immediate vascular reconstruction.

[Consequences of critical appraisal of medical literature on 2009 National Ranking in France]. / Influence de la lecture critique d'articles sur les classements des étudiants aux épreuves classantes nationales 2009.

AIM: To assess the impact of the introduction of the critical appraisal of medical literature (LCA) on the rating ranks of students and faculties of medicine in the National Ranking (NR). A secondary objective was the evaluation of each test of the NR on the rating ranks of students and faculties of medicine. METHODS: From the official results of the NR in 2009, the academic ranks of students were recalculated after eliminating the note in each file. Medical schools were ranked on the basis of mean scores for students from these schools in each file. RESULTS: The notes of 6258 students tested in 40 faculties of medicine and the military health department were selected. The Spearman rank correlation for LCA notes and clinical records was Rho=0.44 (p<0.001). The test of LCA aims to award 561 places to a student and lose up to another 595. The rate ranking rank of a faculty of medicine has been modified by 5 places with the LCA. CONCLUSION: The LCA test in 2009 had a significant effect on the rate ranking of students, whereas the LCA accounted for only 5 % of the total score. The LCA test effect on the ranking of faculties of medicine was more modest. The influence of the LCA may be more pronounced in 2010 because it will count for 10 % of the notes. The rate ranks were heterogeneous within each medical faculty, which should raise questions about the teaching of some medical specialities in each faculty.

Tracheoinnominate artery fistula: combined endovascular and surgical management by emergency stent-graft placement followed by cryopreserved arterial allograft repair.

Tracheoinnominate artery fistula is an uncommon but life-threatening complication usually requiring emergency ligation of the artery. The recent introduction of stent-grafts offers a new therapeutic option for emergency management of hemorrhage. Stent-grafts can be used for definitive treatment or as a bridge to surgery. The purpose of this report is to describe a case of hemoptysis due to a tracheoinnominate artery fistula that occurred after a single orotracheal intubation for general anesthesia and was treated by placement of a covered stent followed 12 hours later by surgical revascularization of the innominate artery using a cryopreserved arterial allograft.

Abdominal aortic aneurysm and Coxiella burnetii infection: report of three cases and review of the literature.

Coxiella burnetii, the etiologic agent of Q fever, is mainly responsible for endocarditis with negative blood culture results, but only a few cases of C. burnetii infections of aortic aneurysms have been published. We report three cases of abdominal aortic aneurysms treated in patients with Q fever infection with simultaneous endocarditis (n = 1) and previous history of cardiac valve replacement for endocarditis (n = 1). A coeliac aortic aneurysm was diagnosed in one patient treated for acute Q fever with persistent serologic results showing chronic infection despite adequate antibiotic therapy and without endocarditis. Resection of the aneurysm cured the chronic infection, and C. burnetii was identified by culture of the aneurysmal wall. In the two other cases, chronic infection of C. burnetii was diagnosed by serologic examination after surgery for an abdominal aortic aneurysm. One patient with negative blood culture results had amaurosis fugax due to endocarditis and required aortic valve replacement; recurrent fever without evidence of valve dysfunction or infection developed in one patient who had had prosthetic cardiac valve replacement 6 months earlier for endocarditis. Aortic aneurysms were treated with in situ prosthetic grafts and long-term antibiotic therapy. At a mean follow-up of 12 years, no septic aortic complications occurred, and serologic test results have remained negative. The presence of an aortic aneurysm and cardiac valve disease seems to be a predisposing factor for chronic C. burnetii infection. Diagnosis particularly relies on the physician's awareness of this condition and is confirmed by serologic examination. Aortic aneurysm resection is mandatory to cure the chronic infection and must be associated with long-term antibiotic therapy.

Treatment of hand ischemia following angioaccess surgery using the distal revascularization interval-ligation technique with preservation of vascular access: description of an 18-case series.

Hand ischemia is a rare complication of angioaccess surgery for hemodialysis. Management usually requires ligation of the arteriovenous fistula (AVF). The purpose of this report is to describe our experience with the use of the distal revascularization interval-ligation (DRIL) technique for treatment of ischemia without ligation of the AVF. From January 1999 to September 2002, the DRIL technique was used to treat 18 patients (10 men, 8 women, 10 diabetic patients) with severe paresthesia of the hand (n = 9) and finger necrosis (n = 10). The AVF was located at the elbow in 16 patients and at the wrist in 2 patients. Mean flow distal to the AVF was less than 10 mL in 5 patients, less than 5 mL in 10, and unmeasurable in 3. The conduit used for all DRIL arterial bypasses, including 15 brachiobrachial bypasses, 1 axillobrachial bypass, 1 brachioradial bypass, and 1 radioradial bypass, was the great saphenous vein graft. Trophic manifestations required finger amputation in five patients, pulpar necrosis resection in four, and transmetacarpal amputation of the index finger in one patient. Symptoms disappeared in 13 patients (73%) and improved in 5 (27%). The time required for healing of finger amputations and trophic manifestations ranged from 15 days to 2 months. Mean arterial flow through the DRIL bypass was 50 mL/min (range, 20-90 mL/min). With a mean follow-up interval of 16 months (range, 5-48 months), primary patency of the DRIL artery bypass and AVF was 94% and the limb salvage rate was 100%. The DRIL technique is the most effective procedure for treatment of angioaccess-induced hand ischemia. This technique can be used to achieve persistent relief of symptoms with continued access patency. The DRIL artery bypass improves vacularization of the hand, and ligature of the artery stops the vascular steal without affecting hemodialysis access. The DRIL technique should be proposed as first-line treatment for hand ischemia due to AVF for hemodialysis.

Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients.

Visceral artery aneurysms (VAA) can be treated by revascularization, ligation, or, most often, endovascular techniques depending on clinical presentation, hemodynamic status, and location. From 1975 to 2002 a total of 42 VAA in 34 patients were treated. The lesion involved the splenic artery (SA; 19), pancreaticoduodenal artery (PDA; 6), celiac trunk (CT; 5), superior mesenteric artery (SNA; 4), common hepatic artery (CHA; 3), gastroduodenal artery (GDA; 2), left hepatic artery (LHA; 1), a branch of the inferior mesenteric artery (BIMA; 1), and a branch of the SMA (BSMA; 1). Twenty-seven VAA in 21 patients (64%) were uncomplicated (group I) and 15 VAA in 13 patients (36%) had ruptured (group II) (PDA; 6; CT, 3; SA, 1; CHA, 1; LHA, 1; BSMA, 1; BIMA, 1). In group I VAA were treated by embolization (n = 11), splenectomy (n = 6), bypass (n = 7), ligation (n = 2), and aneurysmorraphy (n = 1). No deaths were observed. The morbidity rate associated with surgical treatment was 12% including hepatic bypass thrombosis without ischemic complications in two cases. The morbidity rate associated with endovascular treatment was 18% including cholecystitis in one case and bile duct stenosis in one case. The VAA recanalization rate following embolization was 9%. In group II, 12 VAA (80%) were treated by ligation in association with splenectomy in two cases and left hepatectomy in one case. Only one bypass procedure was performed and embolization was used to treat two VAA (1 SMA and 1 PDA). The mortality rate was 20% (3/15). The morbidity rate associated with surgical treatment was 46% (6/13) including bile duct stenosis in one case, ischemic cholecystitis in one case, duodenal fistula in one case, pancreatic fistula in one case, bile tract fistula in one case, and colonic ischemia in one case. No patient died after endovascular treatment and the morbidity rate was 50% (1/2) with duodenal stenosis occurring in one case. In sum, VAA can rupture. Emergency cases can be treated by ligation in most cases or by embolization if the hemodynamic status of the patient allows. Regardless of treatment technique, the morbidity and mortality rate remains high after rupture, especially in cases involving PDA. Embolization can be proposed as a first-line treatment for most VAA. Because of the risk of rupture, endovascular or open repair is warranted for VAA and has a favorable prognosis.

A virtual reality based navigation system for endovascular surgery.

Endovascular surgery provides a minimally invasive solution for the treatment of aortic aneurysms. Fluoroscopic guidance involves X-rays exposure and loss of space information. We have developed a navigation system allowing real-time visualisation of the endovascular tools in a 3D model of the vessels without any radiation exposure. A modified endoprosthesis is equipped with a magnetic sensor tracked by the Aurora magnetic localizer. The registration step uses 2.5D ultrasonography to replace pre-operative CT data in the Operating Room referential. The Virtual Reality based navigation system shows the location of the endoprosthesis inside a 3D CT model of the aorta. Endovascular procedure benefits from a reduced radiation exposure.

In situ revascularization with silver-coated polyester grafts to treat aortic infection: early and midterm results.

PURPOSE: In this prospective study we analyzed the immediate and midterm outcome in patients with abdominal aorta infection (mycotic aneurysm, prosthetic graft infection) managed by excision of the aneurysm or the infected vascular prosthesis and in situ replacement with a silver-coated polyester prosthesis. METHODS: From January 2000 to December 2001, 27 consecutive patients (25 men, 2 women; mean age, 69 years) with an abdominal aortic infection were entered in the study at seven participating centers. Infection was managed with either total (n = 18) or partial (n = 6) excision of the infected aorta and in situ reconstruction with an InterGard Silver (IGS) collagen and silver acetate-coated polyester graft. Assessment of outcome was based on survival, limb salvage, persistent or recurrent infection, and prosthetic graft patency. RESULTS: Twenty-four patients had prosthetic graft infections, graft-duodenal fistula in 12 and graft-colonic fistula in 1; and the remaining 3 patients had primary aortic infections. Most organisms cultured were of low virulence. The IGS prosthesis was placed emergently in 11 patients (41%). Mean follow-up was 16.5 months (range, 3-30 months). Perioperative mortality was 15%; all four patients who died had a prosthetic graft infection. Actuarial survival at 24 months was 85%. No major amputations were noted in this series. Recurrent infection developed in only one patient (3.7%). Postoperative antibiotic therapy did not exceed 3 months, except in one patient. No incidence of prosthetic graft thrombosis was noted during follow-up. CONCLUSION: Preliminary results in this small series demonstrate favorable outcome with IGS grafts used to treat infection in abdominal aortic grafts and aneurysms caused by organisms with low virulence. Larger series and longer follow-up will be required to compare the role of IGS grafts with other treatment options in infected fields.