[Aortic prosthesis infection treated by using cryogenically conserved allograft]. / Utilisation d'une allogreffe artérielle cryopréservée dans le cadre d'une infection de prothèse aorto-bifémorale.

Infections of aortic prosthesis are quite unusual. When occurring, they represent a real challenge for both medical and surgical care, and their morbidity and mortality rates are high. Initially, these infections can be treated with antibiotics, but, in case of failure, the infected prosthesis must be removed and a new aorto-iliac system has to be reconstructed surgically. We report, the case of a woman affected by infection of an aortic prosthesis and whose problem has been solved by means of a new aorto-iliac graft by using cryogenically conserved allograft. Epidemiology, potential complications and treatment will be discussed.

Les infections de prothèses aortiques sont rares. Lorsqu'elles surviennent, leur prise en charge est un défi médico-chirurgical associé à un taux de morbi-mortalité élevé. Le traitement repose en première intention sur une antibiothérapie systémique ; le choix de l'antibiotique est empirique dans un premier temps et ciblé par la suite, après identification du germe responsable par des prélèvements bactériologiques. En cas d'échec, l'exérèse de la prothèse infectée et son remplacement par une greffe biologique (veines saphènes ou fémoro-poplitées, allogreffe artérielle) pouvant résister à l'infection est le traitement idéal. En ce qui concerne le choix du greffon, la littérature scientifique ne permet pas de départager l'allogreffe artérielle de l'allo- ou autogreffe veineuse dans l'évolution à long terme. Nous rapportons le cas d'une femme ayant présenté une infection de prothèse aortique, et qui a bénéficié d'une allogreffe aorto-bifémorale cryopréservée. L'épidémiologie, les complications potentielles et la prise en charge thérapeutique sont discutées.

Endovascular Aneurysm Repair (EVAR) : A Ten-Year Retrospective Study in a Low-Volume Center.

BACKGROUND: We evaluated clinical outcomes of EVAR procedures at a low-volume center in Belgium. We also analyzed the time before endoleak appeared. METHODS: We reviewed 77 EVAR procedures performed over 10 years in a low-volume center. Patients were reviewed at intervals of 1, 3, 6, 12, 24 and 36 months. RESULTS: The deployment of the endograft was successful for 76 of the 77 patients (98.7%). Perioperative mortality was 1.3%. Cardiac infarctus was reported in 5.19% of patients, 1.3% suffered hematoma, 1.3% renal insufficiency, 7.8%-respiratory diseases, and 2.6% strokes. The mortality rate during the first postoperative year was 9% and none of these deaths were AAA related. One endograft thrombosis was reported (1.3%) and there were no cases of endograft migration. Type 1 endoleak occurred in 3.9% of patients, and Type 2 in 22.1%. No other type of endoleak was reported. The mean period before endoleak diagnosis was 9.8 months. Two patients needed to be re-operated for a Type 1 endoleak. CONCLUSION: Performing EVAR procedures in a low-volume center did not increase morbidity and mortality risks. This is probably because the primary factor is the volume of procedures carried out by the surgeon, rather than the institution. EVAR follow-up is needed to diagnose endoleak, which can appear several months after.

Hepatic artery aneurysm. Case report.

Hepatic artery aneurysms represent about 20% of all visceral aneurysms and 0.01-0.2% of all arterial aneurysms. The authors report on a good risk patient with small infra-renal aortic aneurysm (AAA) and a large hepatic artery aneurysm. An excision and vein grafting of the hepatic artery aneurysm has been performed. The authors made a survey of recent literature concerning hepatic artery aneurysms.

Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections.

OBJECTIVES: To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP). METHODS: Amongst 102 thoracic aortic aneurysms and dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent, Excluder and Zenith endografts in 12, seven and six cases, respectively. RESULTS: Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15+/-5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen. CONCLUSIONS: Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.

Calf pain and cystic adventitial disease of the popliteal artery.

In a 61 year-old women, suffering a left calf pain for more 18 months, a diagnosis of cystic adventitial disease of the popliteal artery was confirmed by scanner. At the operation, we found an intramural cyst of the popliteal artery. A total resection of the cyst and of the artery (resection and end to end anastomosis) was performed. Adventitial cystic disease represents 0, 1% of the vascular diseases). The popliteal artery seems to be the most frequent site.

Endovascular treatment of thoracic aortic aneurysms.

UNLABELLED: Descending thoracic aortic aneurysms (TAA) and chronic dissections have high morbidity and mortality rates. For 10 years, the evolution of both imaging techniques and aortic stent-graft design has brought a new therapeutic hope for patients at high risk for surgery presenting non-ruptured or emergency cases of TAA. Our goal is to describe the endovascular technique, review its state of the art and compare its mid-term results to those of conventional surgery. We also describe surgical ways to manage complex TAA, involving the aortic arch and/or the celiac aorta, as therapeutic solutions for high risk patients for surgery with unfitted anatomy for endovascular repair. After a review of the literature dealing with the natural history, the etiology, and the surgical treatment, we describe the endovascular devices, the conventional stent-grafting technique and we detail the adjunctive procedures we used to manage complex cases. We then retrospectively report our personal 38-patient experience from October 1999 to February 2003. Thirty-three patients presented with TAA and the average age was 70 years old (35-88), while the male/female ratio was 5.3. All of them were at high risk for surgery, of which 27% required adjunctive procedures to achieve proximal and/or distal neck management. The in-hospital death rate was 9%. We reported no case of paraplegia and only 1 patient with post-operative regressive stroke (3%). All the aneurysmal sacs were successfully excluded without early endoleak. During follow-up period (mean: 2 years; 1-40 months), we observed a late death rate of 10%. All aneurysmal sac remained excluded by the endografts and no stent-graft migration was observed. No late endoleak appeared during the follow-up course, but 1 patient presented a proximal aortic enlargement, which required total transposition of the supra-aortic vessels and stent-graft extension. The endovascular repair of TAA and chronic dissections proved to be feasible and offers hopeful mid-term RESULTS: With a very low morbidity-mortality rate, compared to surgery, the endovascular technique may represent an unquestionable therapeutic options, especially for patients at high risk for surgery. However, long-term results are needed to point out the durability of descending thoracic aortic stent-grafting. Neck management must be encouraged in order to avoid type 1 endoleaks in cases with short landing zones.

The suturing concept for laparoscopic mesh fixation in ventral and incisional hernias: preliminary results.

Having found existing techniques for treatment of incisional hernias unsatisfactory, we developed a new laparoscopic approach with a Parietex Composite mesh. This study shows the preliminary results in order to analyze the validity of the concept on efficacy and safety. Three trocars are needed for this procedure. Non-reabsorbable sutures are mandatory for closure of large defects to avoid having to ultimately extrude the mesh. Ten to 12 cardinal stitches are applied on the polyester side of the mesh. The mesh is anchored to the anterior abdominal wall by transabdominal non-reabsorbable sutures without the use of staples or tacks. One hundred twenty patients with ventral and incisional hernias were included in this study. Early and late complications are reported, showing lower rates of morbidity and no mortality. This technique is satisfactory on the technical front, and the results are as good, or better, than in other trials.