Algorithm of Femoropopliteal Endovascular Treatment.

Background and Objectives: Indications for the endovascular treatment of femoropopliteal lesions have steadily increased over the past decade. Accordingly, the number of devices has also increased, but the choice of the best endovascular treatment remains to be defined. Many devices are now available for physicians. However, in order to obtain a high success rate, it is necessary to respect an algorithm whose choice of device is only one step in the treatment. Materials and Methods: The first step is, therefore, to define the approach according to the lesion to be treated. Anterograde approaches (femoral, radial, or humeral) are distinguished from retrograde approaches depending on the patient's anatomy and surgical history. Secondarily, the lesion will be crossed intraluminally or subintimally using a catheter or an angioplasty balloon. The third step corresponds to the preparation of the artery, which is essential before the implantation of the device. It has a crucial role in reducing the rate of restenosis. Several tools are available and are chosen according to the lesion requiring treatment (stenosis, occlusion). Among them, we find the angioplasty balloon, the atherectomy probes, or intravascular lithotripsy. Finally, the last step corresponds to the choice of the device to be implanted. This is also based on the nature of the lesion, which is considered short, up to 15 cm and complex beyond that. The choice of device will be between bare stents, covered stents, drug-coated balloons, and drug-eluting stents. Currently, drug-eluting stents appear to be the treatment of choice for short lesions, and active devices seem to be the preferred treatment for more complex lesions, although there is a lack of data. Results: In case of failure to cross the lesion, the retrograde approach is a safe and effective alternative. Balloon angioplasty currently remains the reference method for the preparation of the artery, the aim of which is to ensure the intraoperative technical success of the treatment (residual stenosis < 30%), to limit the risk of dissection and, finally, to limit the occurrence of restenosis. Concerning the treatment, the drug-eluting devices seem to present the best results, whether for simple or complex lesions. Conclusions: Endovascular treatment for femoropopliteal lesions needs to be considered upstream of the intervention in order to anticipate the treatment and the choice of devices for each stage.

The Common Femoral Artery Is a Fixed Arterial Segment.

BACKGROUND: The risk of stent fracture caused by the movements of the hip joint is one of the limitations of the endovascular treatment of the common femoral artery (CFA). The aim of this study was to describe and analyze the deformations of the iliofemoral axis during flexion and extension of the hip, and to evaluate the impact of stents implanted in the CFA on the deformations observed. MATERIALS AND METHODS: This monocentric descriptive study was carried out on the pelvis obtained from three fresh cadavers (two men aged 72 and 71 years, respectively, and one 94-year-old woman). Arteriography was carried out to appreciate the deformations of the external iliac and common femoral arteries, and to analyze the femoral junctions. A first arteriography was carried out on native arteries, and a second one was carried out after the implantation of a stent in the CFA (Zilver PTX, Cook Medical, Bloomington, IN, USA). In all the cases, anterior and lateral images were obtained, with the hip maintained in extension (0°) or flexion (45°, 90°). RESULTS: In a neutral position (extension), four points of deformation of the iliofemoral axis were identified in the frontal (A, B, C, and D) and sagittal (A', B', C', D') planes. These points were the vertices of the angles formed by the arterial deformation in the frontal and sagittal planes. These four points of deformation observed in the two planes appeared overlapping (A/A', B/B', C/C', and D/D') and were located on the external iliac artery, the origin of the CFA, the femoral bifurcation and the superficial femoral artery, respectively. In the frontal plane, all the angles closed during flexion, and the closure of the angle increased with the degree of flexion. In the sagittal plane, we observed that the angles with the A', C', and D' vertices closed during the flexion of the hip, and that the angle with the B' vertex opened during flexion. The higher was the degree of flexion, the more the angles were accentuated. The implantation of one stent in the CFA modified neither the localization of the points of deformation nor the modifications of angles previously observed on the frontal and the sagittal sections. CONCLUSIONS: As seen from the front and side, the CFA is a fixed segment during the movements of extension and flexion of the hip. The implantation of a stent does not modify this observation.

Treatment of an Abdominal Aortic Aneurysm Infected by Coxiella Burnetii Using a Cryopreserved Allograft.

Q fever is a worldwide zoonosis caused by an intracellular bacillus named Coxiella burnetii (CB) and is a rare cause of vascular infections. We report a case of abdominal aortic aneurysm infected by CB with bilateral paravertebral abscesses and contiguous spondylodiscitis treated by open repair using a cryopreserved allograft and long-term antibiotic therapy by oral doxycycline and oral hydroxychloroquine for a duration of 18 months. Twenty months after the operation, the patient had no infections signs and vascular complication.

Endovascular balloon occlusion is associated with reduced intraoperative mortality of unstable patients with ruptured abdominal aortic aneurysm but fails to improve other outcomes.

BACKGROUND: Proximal aortic control by endovascular balloon occlusion (EBO) is an alternative to conventional aortic cross-clamping (CAC) in hemodynamically unstable patients presenting with a ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to evaluate the potential clinical benefit of EBO over CAC. METHODS: Data from 72 patients with rAAA treated at our institution from 2001 to 2013 were retrospectively analyzed. All patients were hemodynamically unstable (mean arterial blood pressure at admission <65 mm Hg or associated unconsciousness, cardiac arrest, or emergency endotracheal intubation). Clinical end points of hemodynamic restoration, mortality rate, and major postoperative complications were assessed for CAC (group 1) and EBO (group 2). RESULTS: At admission, 72 patients were unstable. CAC was performed in 40 and EBO in 32. Intraoperative mortality was 43% in group 1 vs 19% in group 2 (P = .031). In group 1, the approach for CAC (thoracotomy [n = 23] vs laparotomy [n = 17]) did not influence intraoperative mortality (43% vs 41%). There was no significant difference in 30-day (75% vs 62%) and in-hospital (77% vs 69%) mortality rates between groups. After EBO, the treatment-open vs endovascular repair-did not influence the intraoperative mortality rate (31% vs 43%; P = .5). Eight surgical complications were secondary to CAC (1 vena cava injury, 3 left renal vein injuries, 1 left renal artery injury, 1 pancreaticoduodenal vein injury, and 2 splenectomies), but no EBO-related complication was noted (P = .04). Differences in colon ischemia (15% vs 28%) and renal failure (12% vs 9%) were not statistically significant. Abdominal compartment syndrome occurred in four patients in group 2 and in no patients in group 1. CONCLUSIONS: Compared with CAC, EBO is a feasible and valuable strategy and is associated with reduced intraoperative mortality of unstable rAAA patients, but not in-hospital mortality, in this retrospective study.

A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms.

OBJECTIVE: The benefit of fenestrated endovascular aortic aneurysm repair (FEVAR) compared with open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) is unknown. This study compares 30-day outcomes of these procedures from two high-volume centers where FEVAR was undertaken for high-risk patients. METHODS: Patients undergoing FEVAR with commercially available devices and OSR of CAAAs (total suprarenal/supravisceral clamp position) were propensity matched by demographic, clinical, and anatomic criteria to identify similar patient cohorts. Perioperative outcomes were evaluated using univariate and multivariate methods. RESULTS: From July 2001 to August 2012, 59 FEVAR and 324 OSR patients were identified. After 1:4 propensity matching for age, gender, hypertension, congestive heart failure, coronary disease, chronic obstructive pulmonary disease, stroke, diabetes, preoperative creatinine, and anticipated/actual aortic clamp site, the study cohort consisted of 42 FEVARs and 147 OSRs. The most frequent FEVAR construct was two renal fenestrations, with or without a single mesenteric scallop, in 50% of cases. An average of 2.9 vessels were treated per patient. Univariate analysis demonstrated FEVAR had higher rates of 30-day mortality (9.5% vs. 2%; P = .05), any complication (41% vs. 23%; P = .01), procedural complications (24% vs. 7%; P < .01), and graft complications (30% vs. 2%; P < .01). Multivariable analysis showed FEVAR was associated with an increased risk of 30-day mortality (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.1-24; P = .04), any complication (OR, 2.3; 95% CI, 1.1-4.9; P = .01), and graft complications (OR, 24; 95% CI, 4.8-66; P < .01). CONCLUSIONS: FEVAR, in this two-center study, was associated with a significantly higher risk of perioperative mortality and morbidity compared with OSR for management of CAAAs. These data suggest that extension of the paradigm shift comparing EVAR with OSR for routine AAAs to patients with CAAAs is not appropriate. Further study to establish proper patient selection for FEVAR instead of OSR is warranted before widespread use should be considered.

Deep hypothermia and low flow for surgery for abdominal or extraperitoneal tumors with cavoatrial extension.

BACKGROUND: Surgical treatment of retroperitoneal tumors with cavoatrial involvement can be challenging. Completeness of resection of the cava tumor extension is crucial for the patient's survival. We report a monocentric experience with the use of cardiopulmonary bypass and deep hypothermic low flow for the surgical resection of caval and atrial involvement of retroperitoneal tumors. METHODS: Between 2006 and 2011, 9 patients were admitted in our cardiovascular surgery department for retroperitoneal tumors with cavoatrial extension. Every case was performed with cardiopulmonary bypass under deep hypothermia (18°C) with a continuous low-flow perfusion (1 to 1.5 L/min). Cardiopulmonary bypass output was tuned to obtain a nearly bloodless field. Reconstruction of the atriohepatic confluent was carried out with a pericardium patch without inferior vena cava reconstruction. RESULTS: There was no perioperative death. Mean duration of deep hypothermic low flow was 52.2 ± 18.2 minutes. The lowest mean esophageal temperature obtained during procedure was 18.2° ± 1.4°C. No neurologic event was noted postoperatively. Three patients had early complications: one reintervention for bleeding, one reintervention for mediastinitis, and one transient moderate renal failure. After a year, all patients were alive with patent atriohepatic reconstruction. CONCLUSIONS: Cardiopulmonary bypass with deep hypothermic low flow facilitates tumor resection and reconstruction of the atriohepatic confluent. It provides satisfactory postoperative results. It should be considered as an option in the management of these retroperitoneal tumors with cavoatrial involvement.

Lower extremity bypass vs endovascular therapy for young patients with symptomatic peripheral arterial disease.

The uncertainty continues over the best approach to patients with symptomatic peripheral arterial disease. Medical therapy and risk factor modification is part of any treatment regimen; with this there is little disagreement. However, with the introduction of lesser invasive percutaneous technologies, the discussion regarding surgical and endovascular therapies has become more and more complicated. Unfortunately, there is a relative shortage of robust outcomes data to support many of our specific treatment recommendations. Younger patients are an especially troublesome patient cohort. They have consistently shown poorer outcomes after any intervention compared with older patients and may represent a subset of more aggressive atherosclerotic disease. Our debaters will discuss their preferred approaches to these difficult patients in the context of the currently available supporting literature.

Statin therapy is associated with aneurysm sac regression after endovascular aortic repair.

BACKGROUND: Several anatomic factors have been identified as predictive of sac behavior after endovascular aneurysm repair (EVAR). The effects of statin therapy on aneurysm sac size reduction remain controversial. This study tested the hypothesis that statin therapy enhances aneurysmal sac regression after EVAR. METHODS: This monocentric retrospective study included patients with abdominal aortic aneurysms treated by EVAR using the Zenith (Cook, Bloomington, Ind) graft device. We excluded patients presenting with perioperative sac enlargement factors such as endoleaks, endotension, infectious, inflammatory, ruptured, or anastomotic aneurysms. We prospectively assessed standard clinical and anatomic data, as well as statin use, at the time of EVAR and during follow-up. The primary end point was the decrease in the largest transverse aortic diameter at 24 months compared with the preoperative diameter. RESULTS: Among 166 patients treated by a Zenith device and meeting the inclusion criteria, 120 were identified as statin users and 46 as nonstatin users, with comparable characteristics. At 24 months of follow-up, statin group patients had a greater aneurysm sac reduction (25% vs 14%; P < .0001). At a threshold of 5 mm in diameter regression, statin use was a positive factor of retraction (odds ratio, 7.93; 95% confidence interval, 3.22-15.52; P < .0001). Multivariate analysis revealed statin use was an independent predictive factor of sac regression (adjusted odds ratio, 9.39; 95% confidence interval, 3.45-25.56). CONCLUSIONS: This study showed that statin use was predictive of sac regression after EVAR with the Zenith graft device. This effect needs to be confirmed by larger randomized trials or by large population evaluation.