Surgical Treatment of Multiple Venous and Arterial Aneurysms Due to Arteriovenous Malformations of the Arm.

Introduction: Arteriovenous malformations (AVMs) are rare, especially in elderly patients. Occasionally, AVM can produce aneurysmal degenerations, which can lead to bleeding or rupture. The aim of this case report was to describe the surgical treatment of large arterial and venous aneurysms in the arm associated with an AVM. Report: An 83 year old woman of White ethnicity who was a non-smoker presented with a large pulsatile aneurysm at the left elbow with paresis of the first three fingers. The diagnosis was made by duplex ultrasonography (DUS), computed tomography angiography (CTA), and arteriography. Additional tests confirmed aneurysms of the brachial artery and the outflow veins, with the largest more than 7 cm in diameter. A very proximal brachial artery bifurcation and increased venous flow were noted. DUS confirmed the AVM by showing continuous flow in the axillary vein. The decision for surgical resection involved vascular surgeons, radiologists, angiologists, and anaesthetists. Treatment involved opening and excision of multiple venous aneurysms and AVMs. A short segment of the aneurysmal brachial artery was also resected and repaired with end to end anastomosis. The deep brachial artery which supplied AVMs and venous aneurysms was ligated and excision of these lesions was performed. At one year follow up, there were no complications and the revascularisation was patent. Discussion: Arterial and venous aneurysms occurring together with AVMs are rare and not well documented in the medical literature. In this case, surgical intervention, including resection with direct anastomosis of the arterial aneurysm coupled with excision of venous aneurysms and AVM, proved to be effective, as evidenced by stable post-operative outcomes after one year.

Oncovascular Surgery for Soft-Tissue Sarcomas of the Lower Limbs with Vascular Contact: Comparison of Arterial Reconstruction and Arterial Subadventitial Dissection.

BACKGROUND: Soft-tissue sarcomas represent approximately 1% of adult malignancies. When they involve the lower limbs (LLs) and come into contact with blood vessels, the therapeutic choice was historically a primary amputation. Today, radical surgical resection with wide margins of safety is the primary therapeutic option for multidisciplinary limb-salvage surgery. The aim was to compare the morbidity and mortality results of an oncologic resection of LL soft-tissue sarcomas with arterial replacement (AR) to that obtained with arterial subadventitial dissection (ASD). METHODS: All consecutive patients with arterial close contact soft-tissue sarcomas of LL were included. Two groups were formed: an AR group where AR was performed following surgical resection and an ASD group in which the artery in contact with the tumor was preserved by ASD. Fisher's exact test was used. RESULTS: Eighteen patients with a median age of 61.50 (interquartile range [IQR] 54.25-69.75) years underwent oncovascular surgery with orthopedic and vascular surgeons between August 2013 and May 2022. Sarcomas were all located in the thigh. Nine patients were enrolled in each of the 2 groups. The 6-month survival rate was 77.78% in the AR group and 100% in the ASD group (P = 0.4). In the AR group, 2 patients presented local recurrence, with a median recurrence-free time of 24.48 (IQR 14.08-34.87) months, and 2 patients presented distant metastases, with metastasis-free time of 13.45 (IQR 8.12-35.11) months. In the ASD group, no local recurrence was observed, and 2 patients presented metastases with a median metastasis-free time of 3.90 (IQR 3.18-4.61) months. Six patients in the AR group and 7 in the ASD group required surgical revision (P = 0.017). No major amputation was necessary. CONCLUSIONS: Oncovascular surgery for LL sarcomas with ASD is certainly more locally morbid perioperatively than that with AR but provides patients with better medium-term survival.

Calcium in the (Big) Pipes: Intra-TEVAR Calcifications!

Introduction: Calcification of a vascular endograft and adjacent tissues (adventitia, media, and neointima) can result in graft failure. This report shows a rare case of intraluminal calcifications in the distal end of a thoracic endovascular aortic repair (TEVAR) endograft implanted 11 years previously for grade IV blunt traumatic aortic injury (BTAI) in a young patient. Report: A 24 year old man required TEVAR for a BTAI caused by a motorcycle accident. The procedure consisted of TEVAR and an emergency left carotid subclavian venous bypass. Eleven years after the procedure, he had severe hypertension. Intra-TEVAR calcifications appeared, gradually increasing on computed tomography angiography (CTA). Calcifications in the distal luminal end of the TEVAR were responsible for a 60% stenosis on CTA. An open approach was indicated after multidisciplinary discussion, based on the gradient value. The patient underwent explantation, with total replacement of the aortic arch and descending thoracic aorta with re-implantation of the supra-aortic vessels, under extracorporeal circulation. Macroscopic analysis showed no device degeneration but revealed a solid mass at the distal end of the TEVAR. Both microcomputed tomography and histopathology confirmed the calcific nature of the lesions. Conclusion: This case highlights a rare long term graft failure due to calcified neo-atherosclerosis in a TEVAR.

Editor's Choice - Infra-inguinal Endovascular Revascularisation and Bypass Surgery for Chronic Limb Threatening Ischaemia: a Retrospective European Multicentre Cohort Study with Propensity Score Matching.

OBJECTIVE: The aim of this study was to compare the long term efficacy of lower limb bypass with that of endovascular treatment (EVT) in patients with chronic limb threatening ischaemia (CLTI). METHODS: This retrospective, multicentre study evaluated the outcomes of patients with CLTI who underwent first time infra-inguinal bypass or EVT. The primary outcome was to compare amputation free survival (AFS) rates between the two propensity score matched groups. The secondary outcome was to compare wound healing within the first six months. Major adverse events were compared according to the type of revascularisation. RESULTS: Overall, 793 patients fulfilled the eligibility criteria, from whom 236 propensity score matched pairs were analysed. The mean follow up was 52 months. The 236 bypass procedures included 190 autogenous bypass grafts (80.5%), 151 (64.0%) of which were infrapopliteal. Among the 236 EVT procedures, the target lesion was the femoropopliteal segment in 81 patients (34.3%), the femoropopliteal and infrapopliteal segments in 101 patients (42.8%), and the infrapopliteal segment in 54 patients (22.9%). AFS was significantly better in the bypass group at five years (60.5 ± 3.6%) compared with the EVT group (35.3 ± 3.6%) (p < .001). Major amputation occurred in 61 patients (25.8%) in the bypass group and 85 patients (36.0%) in the EVT group (HR 0.66, 95% CI 0.47 - 0.92; p = .014). The probability of healing was significantly better in the bypass group at six months compared with the EVT group (p = .003). The median length of stay was shorter for the EVT group (4 days) than for the bypass group (8 days) (p = .001). Urgent re-intervention and re-admission rates were high and did not differ significantly between the groups. CONCLUSION: This study has shown that lower limb bypass surgery offered a significantly higher probability of AFS and wound healing compared with EVT in patients with CLTI.

Mortality and Delays of Management of Acute Mesenteric Ischemia: The Need of a Dedicated Program.

BACKGROUND: To study the mortality and delays of management of patients with acute mesenteric ischemia (AMI) admitted to the emergency department of a tertiary hospital and identify risk factors for 1-month mortality. METHODS: A single-center and retrospective study including all consecutive patients treated for AMI from January 2008 to December 2018 was conducted. Short- and medium-term survival was studied with a Kaplan-Meier analysis. Delays before diagnosis and surgical intervention were collected. To determine factors associated with mortality at 1 month postoperatively, univariate and multivariate analyzes were performed. RESULTS: The survival rate of the 67 included patients was 55.22% at 1 month and 37.31% at 1 year. In-hospital mortality was 50.74%. The average delay between admission and diagnosis was 4.83 ± 5.03 hr (95% confidence interval [CI], 3.60-6.05), and the delay between admission and surgical treatment was 10.64 ± 8.80 hr (95% CI, 8.49-12.79). The independent variables associated with an increased mortality at 1 month postoperatively in the univariate analysis were age >65 years old (odds ratio [OR] = 3.52; P = 0.046), lactate >3.31 mmol/l at admission (H0) (OR = 7.38; P < 0.001), lactate >3.32 mmol/l on day 1 (H24) (OR = 5.60; P = 0.002), creatinine >95.9 µmol/l at H0 (OR = 4.66; P = 0.004), aspartate aminotransferase (AST) >59 U/l at H0 (OR = 3.55; P = 0.017), and having hypertension as comorbidity (OR = 9.32; P = 0.040). Early curative anticoagulation (z = -2.4; P = 0.016) was an independent protective factor for mortality, and lactate >3.31 mmol/l at H0 (z = 2.62; P = 0.009) was an independent predictor factor of mortality at 1 month postoperatively in the multivariate analysis. CONCLUSION: AMI remains a serious and lethal condition with delays of surgical management remaining too long due to a lack of a dedicated therapeutic protocol allowing an early diagnosis.

Robot Assisted Laparoscopy for Median Arcuate Ligament Syndrome Relief.

Objective: To evaluate the outcomes of robot assisted laparoscopic surgery for median arcuate ligament syndrome (MALS) relief. Methods: This was a single centre and retrospective study, including all consecutive patients with symptomatic MALS treated with robot assisted laparoscopic surgery. Symptom relief and quality of life (QoL) were evaluated post-operatively. A comparison between the peak systolic velocity (PSV) of the coeliac artery (CA) measured pre-operatively and post-operatively was carried out. Results: Nine interventions were performed. No conversion to laparotomy was required. There was post-operative abdominal pain relief in eight patients and QoL was improved in seven patients. Post-operatively, the CA PSV decreased (175 (IQR 160 - 195) cm/s vs. 365 (IQR 350 - 419) cm/s; p < .001). Conclusion: MALS relief with robot assisted laparoscopy is safe and provides satisfactory outcomes in terms of symptom relief and CA compression release.

Vascular grafts collagen coating resorption and healing process in humans.

Background: The objective of the present study was to evaluate the bioresorption rate of collagen coating (CC) sealed on textile vascular grafts (VGs) and their healing in humans using histologic analysis of explanted VGs. Methods: A total of 27 polyester textile VGs had been removed during surgery from 2012 to 2020. The segments underwent histologic assessment. The CC bioresorption rate was assessed using morphometric analysis to determine the internal and external capsule thickness, inflammatory reaction degree, presence of neovessels, and endothelial cell layer. Results: A total of 27 VGs were explanted from 25 patients because of infection (n = 5; 18.5%), thrombosis (n = 7; 25.9%), stenosis (n = 2; 7.4%), rupture (n = 4; 14.8%), aneurysmal degeneration (n = 3; 11.1%), revascularization (n = 4; 14.8%), or another cause (n = 2; 7.4%), with a median implantation duration of 291 days (interquartile range [IQR], 48-911 days). VGs with remaining CC (n = 7; 26%) had been explanted earlier than had those without (n = 20; 74%; 1 day [IQR, 1-45 days] vs 516 days [IQR, 79-2018 days]; P = .001). After 1 year, no remaining CC was detected on the analyzed VG sections. VGs implanted for <90 days had had a greater CC maximal thickness (63.90 µm [IQR, 0-83.25 µm] vs 0 µm [IQR, 0-0 µm]; P = .006) and a greater CC surface coverage (180° [IQR, 0°-360°] vs 0° [IQR, 0°-0°]; P = .002) than those implanted for >90 days. VGs implanted for >90 days had a greater external capsule thickness (889.2 µm [IQR, 39.6-1317 µm] vs 0 µm [IQR, 0-0 µm]; P = .002), a higher number of inflammatory mononuclear cells and giant cells (168 cells [IQR, 110-310 cells] vs 0 cells [IQR, 0-94 cells]; P < .0001) and a higher number of neovessels (4 [IQR, 0-5] vs 0 [IQR, 0-0]; P = .001) than those implanted for <90 days. Conclusions: CC had a slow bioresorption rate in humans. Complete healing was never achieved, with no endothelial coverage observed. This finding implies that CC might not help graft healing.

Risk Factors of Long-Term Incisional Hernia after Open Surgery for Abdominal Aortic Aneurysm: A Bicentric Study.

BACKGROUND: Conventional open surgery is still important beside endovascular surgery in the management of abdominal aortic aneurysms, with less reinterventions in the long-term follow-up. Incisional hernias are the major complication open surgery in the mid- and long term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The objectives of our retrospective and bicentric study were to characterize the long-term risk factors for incisional hernias after open surgery for abdominal aortic aneurysms, in particular by comparing the 2 types of laparotomy, and to determine the prevalence of the operated and not operated incisional hernias. MATERIALS AND METHODS: Between January 2009 and December 2011, all the patients having elective open surgery for abdominal aortic aneurysm (AAA) by midline laparotomy at the University hospital of Besancon or by transversal laparotomy at the University Hospital of Strasbourg were included retrospectively. The demographic data, the time of diagnosis of the incisional hernia and the parietal reinterventions were collected during a 5-year postoperative follow-up. A univariate and multivariate Cox model was used for the statistical analysis to determine the long-term risk factors for the appearance of an incisional hernia. RESULTS: During the study period, 223 patients presenting with AAA were included, 112 of them were operated by a midline laparotomy and 111 by a transverse laparotomy. The mean age of the patients was 69 ± 8,4years and 208 (93.3%) were men. The 5-year prevalence of incisional hernias was 14.3% (32), and 20 of these hernias (9%) had to be operated. Eighteen hernias (16.1%) occurred after a midline laparotomy and 14 (12.6%) after a transverse incision (P = 0.30). In univariate analysis, obstructive chronic pulmonary disease was the only significant risk factor for incisional hernia (P = 0.01) and an age over 65 years appeared to protect against this risk (P = 0.049). These results were confirmed by multivariate analysis, which showed that obstructive chronic pulmonary disease was an independent risk factor for incisional hernia (HR = 2.35, 95% CI 1.16-4.75), and that an age over 65 years was a protective factor (HR = 0.49 95% IC 0.00-0.99). CONCLUSIONS: The type of laparotomy did not modify the rate of incisional hernias. We showed that only 9% of the patients had to be operated to treat an incisional hernia during the first 5 years after surgery for AAA in our bicentric study. Chronic obstructive pulmonary disease was the only independent risk factor for the occurrence of an incisional hernia.

Arterial Embolization of Polycystic Kidneys for Heterotopic Transplantation.

INTRODUCTION: The purpose of this study was to evaluate the efficacy of polycystic kidney embolization, performed to reduce kidney volume before heterotopic kidney transplantation, as this technique could be an alternative to pretransplant nephrectomy. MATERIALS AND METHODS: All patients who underwent pretransplant embolization of polycystic kidneys were included in a prospective register from June 2014 to February 2020. All patients underwent computed tomography (CT) scan with volumetric reconstruction (OsiriX, Bernex, Switzerland) before embolization and were then followed up at 3 and 6 months after embolization. Primary outcome was percentage of kidney volume reduction. Secondary outcomes were 30 day mortality and morbidity. RESULTS: Thirty-one embolizations performed on 29 patients (medium age = 55.6; 62.1% male) were included between June 2014 and February 2020. All patients were under dialysis before embolization (9 peritoneal dialysis and 20 hemodialysis). Technical success was observed in 96.8% of cases. Mean procedural time was 65 minutes (range = 35-106 minutes) and mean length of in-hospital stay was 3.8 days (range = 3-6 days). A volume reduction allowing a kidney transplant was obtained for 28 patients (96.5%). The mean volume reduction was 39.9% (range = 6.01-68.2). The main observed complication was postembolization pain in 10 cases (32.2%). One patient needed complementary nephrectomy due to insufficient volume reduction. Twenty-three patients (79.3%) received renal transplant during follow-up with a mean delay of 19.5 month (range = 4-54). CONCLUSION: Polycystic kidney embolization is an effective and safe minimally invasive technique. It can be proposed as the first-choice technique for kidney transplant recipients as an alternative to pretransplantation nephrectomy.

Computed-tomography-based predictive scores of surgical complications to help decision-making in enrolling obese patients in kidney transplantation list.

This study aimed at developing scores predicting surgical complications in obese transplant recipients, based on preoperative computed tomography (CT) parameters. All consecutive patients with a body mass index (BMI) ≥ 30 kg/m2 who underwent kidney transplantation between 2012 and 2019 were included. The preoperative CT parameters were assessed: total fatty surface (TFS), subcutaneous fatty surface (SFS), iliac vessel to skin distance (VSD), and abdominal perimeter (AP). Per- and postoperative complications (vascular, urinary, parietal, and digestive complications) within 30 days were listed. Predictive models of surgical complications were generated based on the results of the logistic regression. Among the 163 patients included, 53 (32.5%) experienced surgical complications. The AP was a risk factor for complications in multivariate analysis (OR: 1.050; 95% CI: 1.016-1.087; p = 0.03). Two predictive models of complications were created based on the statistical analysis: a one-variable model based on AP (sensitivity 86.8%, specificity 41.8%, area under the curve (AUC) 65.3, with a cutoff value of 107 cm) and a five-variable model based on BMI, TFS, SFS, VSD, and AP (sensitivity 73.6%, specificity 57.3%, AUC 66.2). These models, based on patient morphometric measurements, could allow predicting the occurrence of surgical complications in obese candidates for kidney transplantation.

Robotic Surgery For in situ Renal Artery Aneurysm Repair: Technical Note and Literature Review About a Mini- Invasive Alternative.

CASE REPORT: Classical surgical options for renal artery aneurysm (RAA) are usually restricted to endovascular surgery or open repair, either using an in-situ or ex-situ approach. A 45-year-old woman presenting with a 20-mm complex RAA with hilum location, not suitable for endovascular repair renal was treated with a mini-invasive robotic approach. This approach allowed an in-situ reconstruction in a complete mini-invasive manner with the Da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA). The robotic system was used for both surgical exposure and aneurysmectomy with patch closure. Clamping time was 38 minutes (warm ischemia), total operative time was 210 minutes. LIITERATURE REVIEW: A comprehensive literature review was performed concerning the studies reporting a robotic approach for RAA. Main outcomes of interest were surgical technique, total operative time, clamping time, blood loss and postoperative renal function. Seven studies were identified, reporting a total of 20 RAAs. Most of the RAA were treated by aneurysmoraphy (n=9). Median total operative time varied between 228 and 300 min (range: 155 - 360 minutes), median clamping time varied between 26 and 44 minutes (range: 10 - 82 minutes). Median blood loss was comprised between100 and 150 mL (range: 25 - 650 mL). No alteration of renal function in the early post-operative period was reported. CONCLUSION: RAA in-situ repair with a robotic approach is feasible and safe and should be considered as an alternative to open surgical repair when endovascular technique cannot be an option.

Radiation-induced lower-limb arteriopathy: report of 4 cases and systematic literature review.

INTRODUCTION: Radiation-induced arteriopathy (RIA) is a rare complication but may become more common due to the increased use of radiotherapy and the prolonged survival of patients. There is still a lack of evidence concerning treatment options. The aim of this study is to review reported cases of lower-limb RIA in order to provide guidelines for management. EVIDENCE ACQUISITION: We reported 4 cases treated for lower limb RIA and performed a systematic literature review without time limitation in the Medline database using the MeSh tems "iliac artery/radiation effects" OR "femoral artery/radiation effects." Main outcomes of interest were radiation dose, time before symptoms, symptoms, involved vessels, treatment and outcome. EVIDENCE SYNTHESIS: Twenty-five studies were included, reporting a total of 43 patients. Median time between irradiation and symptoms was 12 years (range: 9 days-49 years), with a median irradiation dose of 40Gy. Clinical presentation was claudication in 18 patients (52%), critical limb threatening ischemia (CLTI) in 4 patients (11%), acute limb ischemia (ALI) in 3 patients (9%) and hemorrhage in 6 patients (17%), the remaining 4 patients were asymptomatic (11%). Vessels involved were iliac arteries in 65% of the cases, femoropopliteal arteries in 28% of cases and concomitant supra and infrainguinal vessels in 7% of the cases. Claudication was mostly treated by open surgery (62%). Treatment of CLTI included primary amputation (50%), open surgery (25%) or endovascular surgery (25%). ALI was treated medically (33%), by open surgery (33%) or in situ thrombolysis (33%). Hemorrhagic cases or pulsatile masses were mostly treated by open surgery (66%). Follow-up was reported in 26 patients (67%), with mean follow-up of 12 months (range: 2 weeks - 5 years). During follow-up, 16% of these patients presented a recurrence of symptoms, and 8% required a reintervention. CONCLUSIONS: There seems to be no evidence for open versus endovascular treatment, but close and long-term follow-up is needed in these patients due to the possible late presentation and recurrence of symptoms after treatment.

Clinical trial outcomes and thoracic aortic morphometry after one year with the Valiant Navion stent graft system.

AUTHORS' NOTE: On February 17, 2021, Medtronic Incorporated issued a global voluntary recall of the Valiant Navion Thoracic Stent Graft System (the device under study in the Valiant Evo Global Clinical Program that is the subject of this publication), and instructed physicians to immediately cease use of the Valiant Navion system and return any unused product. Medtronic initiated the recall in response to three clinical trial subjects recently observed with stent fractures, two of whom have confirmed type IIIb endoleaks. The data collection, analysis, and manuscript submission occurred before the notice of this recall, and, specifically, the 100 procedures reviewed for this series were free of events at 1 year related to the reason for this device recall. The authors of this article and the manufacturer were unaware of the recently detected adverse events at the time of the preparation of the manuscript, and the 1-year trial results, and imaging-based analyses described are unchanged. Management of thoracic aortic aneurysms continues to be a challenging problem and outcomes are dependent on patient anatomy. The present publication focuses on the importance of achieving proximal and distal seals and the consideration of the temporal changes of the aortic morphology as a part of the TEVAR planning process. The authors believe there is still scientific merit in disclosing this information, despite the current nonavailability of the Valiant Navion system. OBJECTIVE: The Valiant Navion stent graft system (Medtronic Inc, Santa Rosa, Calif) is a third-generation device with improved conformability. We have reported the 1-year clinical trial outcomes, with a focus on an imaging-based analysis of the aortic morphology. We assessed the effects of graft implantation on the native anatomy and the effects of the 1-year changes in thoracic aorta morphology on the original seal zones of the stent graft. METHODS: A total of 100 subjects were enrolled in a prospective single-arm clinical trial investigating the Valiant Navion stent graft system. An independent core laboratory (Syntactx, New York, NY) assessed the anatomic characteristics and performance outcomes. RESULTS: Through 1 year of follow-up, the freedom from all-cause mortality, aneurysm-related mortality, and secondary procedures was 89.8%, 97.0%, and 94.8% respectively. Of the 100 patients, 5 had undergone a total of six secondary procedures, and 9 patients had developed an endoleak (type Ia and Ib in 1, type Ia in 1, type Ib in 3, and type II in 4 patients) within the first year. After 1 year, 2 of 76 patients (2.6%) had had an increase in their maximum aneurysm diameter of ≥5 mm, 62 (81.6%) had had stable sacs, and 12 (15.8%) had experienced sac shrinkage. Although no deployment failures had occurred, 36 of the 100 proximal (36%) and 31 of the 100 distal (31%) attachment zones were considered short according to our definitions. The stent graft had conformed to the native anatomy at implantation, because the preprocedural thoracic aorta tortuosity (1.45 ± 0.02) had not significantly changed at 1 month after implantation (1.46 ± 0.02). Despite a natural increase in thoracic tortuosity after 1 year (1.49 ± 0.02), wall apposition had been maintained over time, as evidenced by the low endoleak rates. Aortic elongation and dilation had occurred at the proximal end of the graft by an average of 1.2 mm and 1.6 mm, respectively. Aortic remodeling was more pronounced at the distal end, with an average increase of 4.2 mm in length and 2.8 mm in diameter. CONCLUSIONS: The included patients had had positive 1-year outcomes with high freedom from mortality, endoleak development, and secondary procedures. Aortic elongation and dilation were more prevalent at the distal end, emphasizing the importance of distal attachment zone consideration as part of preoperative planning. Because aortic remodeling can be expected to continue over time, additional follow-up and imaging analysis in the trial will be necessary to assess the aortic morphology and its effects on stent graft performance.

Usefulness of Platelet-to-Lymphocyte Ratio as a Marker of Sarcopenia for Critical Limb Threatening Ischemia.

BACKGROUND: Sarcopenia is a factor of poor prognosis for patients with critical limb threatening ischemia (CLTI), but its diagnosis requires imaging measurements and is time consuming. We investigated whether preoperative platelet-to-lymphocyte ratio (PLR) could be an easy and rapid marker of sarcopenia. METHODS: Patients treated for CLTI between January 2019 and July 2019 were included in this single-center retrospective study. Sarcopenia was defined by a psoas muscle index (PMI) <5.5 cm2/m2 in men, and <4.0 cm2/m2 in women. PLR was calculated for all patients based on their systematic preoperative blood analysis. The diagnostic power of PLR was analyzed through a receiver operating characteristic (ROC) curve. Early outcomes of sarcopenic patients in terms of 30-day mortality and 30-day morbidity were retrieved. RESULTS: Sixty-four patients were included in the study: 48 nonsarcopenic patients (mean PMI 7.34 cm2/m2; interquartile range [IQR] 6.58-8.01) and 16 sarcopenic patients (mean PMI 4.30 cm2/m2; IQR 3.45-5.17). No difference was found between both groups regarding patient demographics, clinical characteristics, cardiovascular risk factors, comorbidities, or revascularization modalities. PLR was significantly higher in the sarcopenic group (mean 332.1; IQR 158.2-320.7) compared with the nonsarcopenic group (mean 204.6; IQR 133.8-265.6) (P = 0.02). A PLR value ≥292.5 was shown to be a diagnostic marker for sarcopenia based on the ROC curve (sensitivity 31.3%, specificity 91.7%). Thirty-day mortality was 12.5% in the sarcopenic group and 2.1% in the nonsarcopenic group (P = 0.15); 30-day morbidity was 56.3% in the sarcopenic group and 10.4% in the nonsarcopenic group (P < 0.001). CONCLUSIONS: PLR might help identifying a subgroup of CTLI patients associated with poor prognosis but does not seem appropriate to be used as a marker of sarcopenia given its low sensitivity.

Current status on vascular substitutes.

In the last decades, the main evolution in the field of vascular surgery was correlated to the development and introduction of vascular substitutes. Currently, two types of synthetic vascular substitutes have been widely adopted: polyethylene terephthalate and expanded polytetrafluoroethylene. Ideally, they should demonstrate a behavior as close as possible as that of human arteries in terms of mechanical and biological properties. However, no vascular substitute has been found to compare with the patency rates of gold-standard autologous conduits, and major drawbacks of current vascular substitutes remain both thrombogenicity and infectability.

Compliance of Textile Vascular Prostheses Is a Fleeting Reality.

OBJECTIVE: Compliance is considered to be a major property influencing the long term performances of synthetic vascular substitutes that could play a role in anastomotic false aneurysm and intimal hyperplasia stenosis onset. Over the last decades, manufacturers have tried to develop substitutes that mechanically mimic arterial properties and avoid a compliance mismatch at the anastomoses in particular. However, data are missing about how initial compliance properties could change with time. The goal of this study was to evaluate how the compliance of vascular grafts evolves under cyclic loading conditions in vitro. METHODS: The compliance of three different models of commercially available textile polyethylene terephthalate (PET) grafts was evaluated. Tests were performed with and without their original coating. Compliance was assessed with a specific device dedicated to measure the deformations undergone by a graft under cyclic pressure loading conditions, using image analysis software. In each experiment, image analysis was performed under 60 and 140 mmHg pressure loading conditions at loading start (H0) and after three, six, and 24 h (H3, H6, H24) loading time. Average radial, longitudinal, and volumetric compliance was calculated from the obtained images. RESULTS: Twenty-four samples were tested. Results demonstrate that all values decreased significantly within only a few hours. On average, the loss of compliance after 3 h of cyclic loading ranged on average from 35% for longitudinal compliance to 39% for radial compliance and 37% (p < .050) for volume compliance. After 24 h, the loss of radial, longitudinal and volume compliance was respectively 63 ± 3%, 60.5 ± 2% and 61 ± 7%. CONCLUSION: In this in vitro model, PET graft compliance has already decreased significantly within 3 h. The rapid loss of compliance identified in this experimental study helps explain the mismatch mentioned in clinical observations.

Computed Tomography-Aortography Versus Color-Duplex Ultrasound for Surveillance of Endovascular Abdominal Aortic Aneurysm Repair: A Prospective Multicenter Diagnostic-Accuracy Study (the ESSEA Trial).

Background Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients. Methods Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI. Results This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9-20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29-48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90-95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90-95) and 39% (95% CI, 27-50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9-9.6). DUS sensitivity reached 73% (95% CI, 51-96) in patients requiring an effective reintervention. Conclusions DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01230203.

Management of upper extremity aneurysms: a systematic review.

INTRODUCTION: The aim of this paper is to provide recommendations for diagnosis and management of arterial or venous aneurysms of the upper extremity. EVIDENCE ACQUISITION: A systematic review of the Medline and Cockrane databases was performed from 1988 to 2019 by a combined strategy of MeSh terms. EVIDENCE SYNTHESIS: One-hundred-forty-four publications were identified: 111 addressing arterial aneurysms and 33 addressing venous aneurysms. A total of 162 cases of arterial aneurysms, mostly brachial aneurysms (34.0% of cases) and 40 cases of venous aneurysms, mostly located in the forearm (60.0% of cases) were reported. For both types of aneurysms, most common presentation was the perception of a mass (56.3% for arterial one and 87.5% for venous one), but thromboembolic complication (46.7%), paresthesia (16.5%) or rupture (6.4%) could be observed in the setting of arterial aneurysms, while arm swelling (27.5%), neurological symptoms (12.5%), pulmonary embolism (10.0%) or rupture (2.5%) could occur in the setting of venous aneurysms. DUS was performed as first imaging modality for both settings, followed but CTA and MRA, especially in arterial aneurysms, to evaluate distal emboli and surrounding vasculature. Surgical treatment was mostly based on excision of the aneurysms with revascularization for arterial aneurysms (77.2%) and resection without reconstruction for the venous one (85.0%). Complications occurred in 10.5% of the cases of arterial aneurysms, none occurred after venous aneurysm resection. CONCLUSIONS: Prompt diagnosis and appropriate preoperative imaging are mandatory in order to offer the best treatment modality. Open resection with revascularization seems to be the treatment of choice for arterial aneurysms, although endovascular procedures became more popular. Venous aneurysms require excision without revascularization.

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.