Spontaneous and isolated dissection of the superior mesenteric artery: proposal of a management algorithm.

BACKGROUND: Spontaneous and isolated dissection of the superior mesenteric artery (SIDSMA) is a rare pathology, and the treatment of symptomatic forms is not consensual. The objective of this study was to analyze the management of a series of patients presenting a symptomatic SIDSMA within a structure taking care of intestinal vascular emergencies. METHODS: From January 2010 to January 2014, the patients presenting a symptomatic SIDSMA were included retrospectively. The clinical and radiologic data as well as the treatment and the follow-up were analyzed. RESULTS: Nine patients were included. Among them, 2 patients presenting with acute mesenteric ischemia were revascularized surgically in emergency, and 1 patient presenting a rupture of a superior mesenteric artery aneurysm had an arteriography followed by medical care. The 6 other patients received medical treatment. Among these, 2 patients developed mesenteric angina requiring surgical revascularization during the follow-up. CONCLUSIONS: The revascularization of spontaneous and isolated dissections of the superior mesenteric artery is indicated in the cases complicated with acute mesenteric ischemia, aneurysmal rupture, or in the event of appearance of mesenteric angina or aneurysmal evolution. It should also be discussed in the event of failure of the medical treatment.

Acute Lower Extremity Ischemia due to the Popliteal Pseudoaneurysm in a 16-year-old Boy with Multiple Exostoses.

Osteochondromas or exostoses are the most common benign bone tumors. This is a case of a 16-year-old boy with multiple osteochondromatosis which caused the popliteal pseudoaneurysm and a subsequent distal embolism. Vascular complications, especially acute limb ischemia, caused by osteochondromas are very rare. This abnormality should be searched for when dealing with young patients with acute limb ischemia.

Hemiaortic arch debranching using native supra-aortic vessels.

Endovascular treatment of aortic arch aneurysms with a proximal landing zone in zone I requires carotid-carotid bypass. We report two patients with aortic arch aneurysms in whom we used a new hybrid approach by transposing the left common carotid artery and left subclavian artery to the right common carotid artery. This innovative technique uses a native vessel instead of prosthetic material and a shunt to maintain cerebral perfusion, thereby avoiding bilateral carotid clamping.

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.

The identification and management of heparin-induced thrombocytopenia in the vascular patient.

Heparin-induced thrombocytopenia (HIT) is a serious, acquired, prothrombotic disorder caused by an antibody response to the heparin-platelet factor 4 complex, which can precipitate arterial as well as venous thromboembolic complications. HIT should be suspected in patients exposed to heparin who present with an unexplained thrombosis or a significant drop in platelet count, or both. Once HIT is suspected or identified, there are specific approaches to its diagnosis and management, with emphasis on removal of all heparin compounds and administration of alternative nonheparin anticoagulants. Generally, HIT is a self-limiting syndrome that resolves when the antibody titers disappear. Patients should be anticoagulated for up to 6 months, depending on the clinical scenario; however, the management of patients with remote or recent HIT requiring a vascular procedure requires special considerations.

A novel model of accelerated intimal hyperplasia in the pig iliac artery.

There is no good animal model of large artery injury-induced intimal hyperplasia (IH). Those available are reproducible, providing only a few layers of proliferating cells or have the disadvantage of the presence of a metallic stent that complicates histology evaluation. This study was designed to develop a new, simple model of accelerated IH based on balloon injury in conjunction with disruption of the Internal Elastic Lamina (IEL) in pig external iliac arteries. Iliac artery injury (n = 24) was performed in 12 Yorkshire pigs divided in two groups: Group I (n = 10), overdistention injury induced by an oversized non-compliant balloon; Group II (n = 14), arterial wall disruption by pulling back an isometric cutting balloon (CB) followed by stretching with a compliant Fogarty Balloon (FB). At two weeks, arteries were processed for morphometric analysis and immunohistochemistry (IHC) for smooth muscle cells (SMC) and proliferating cell nuclear antigen (PCNA). When comparing the two groups, at 2 weeks, arteries of group II had a higher incidence of IH (100%vs. 50%, P = 0.0059), increased intimal areas (2.54 ± 0.33 mm(2) vs. 0.93 ± 0.36 mm(2) , P = 0.004), increased intimal area/Media area ratios (0.95 ± 0.1 vs. 0.28 ± 0.05; P < 0.0001) and decreased lumen areas (6.24 ± 0.44 vs. 9.48 ± 1.56, P = 0.026). No thrombosis was noticed in Group II. Neointima was composed by proliferating SMC located with the highest concentration in the area of IEL disruption (IHC). Arterial injury by pulling back CB and FB induces significant IH in pig iliac arteries by two weeks without thrombosis. This model is superior to the classical overdistention non-compliant model and should be useful and cost-effective for preclinical testing of procedures designed to inhibit IH in large peripheral arteries.

A new therapeutic approach to congenital pelvic arteriovenous malformations.

BACKGROUND: Internal iliac arteriovenous malformations (AVM) are difficult to treat. Arterial embolization is chosen in most cases but the angio-architecture of these arteriovenous shunts can provide an explanation for the several reported failures. We report the long-term results of peroperative intravenous embolization. METHODS: Between the years 1980 and 2008, seven patients were treated for complex and symptomatic internal AVM. These patients underwent a surgery which involved massive embolization of the venous hypogastric compartment, followed by the ligation of the hypogastric vein at its origin. RESULTS: There were no deaths reported in this group. The mean follow-up was 7 years (range: 10 months-12 years), with no cases of recurrences found. Computed tomographic scans of controls with reconstruction did not show any residual arteriovenous shunts. CONCLUSION: Intravenous embolization of the internal iliac AVM is a therapeutic strategy which is well adapted to the special angio-architecture of the arteriovenous shunts. Clinical and anatomic results have confirmed the validity of this strategy.

Significant sac retraction after endovascular aneurysm repair is a robust indicator of durable treatment success.

OBJECTIVES: The principal aim of this study was to demonstrate that significant sac retraction (SSR) was a predictive marker of durable success after endovascular aortic repair (EVAR). If verified, follow-up (FU) of patients with SSR may become unnecessary. In addition, the clinical features of the patients and aneurysms were analyzed to identify predictive factors of SSR. METHODS: A group of 371 patients treated by EVAR had a complete clinical exam, computed tomography (CT) scan, and duplex scan follow-up. Data were collected prospectively and analyzed retrospectively. We assessed the difference between the largest diameter of the aneurysm (D) and the diameter of the stent-graft body (D1) on each postoperative CT scan. SSR was defined as a minimum of 75% reduction of this difference between the first and any of the following CT scans. Treatment success was defined as survival free of aneurysm-related death, type I or III endoleak, aneurysm expansion exceeding 5 mm, rupture, surgical conversion, migration, and graft occlusion. To assess the predictive factors of SSR, we performed a multivariable analysis and a logistic regression of the most significant variables. RESULTS: SSR was observed in 24.8% (92/371) of the patients after an average of 26 ± 21 months of FU. The mean duration of FU in this group was 50 ± 26 months (vs 45 ± 25 months; P = NS). Survival was significantly longer in the SSR group (96 ± 3 months vs 93 ± 3 months; P < .05). No rupture, surgical, or endovascular conversion was reported in the SSR group. The frequency of type I (2.2% vs 15.4%; P < .001), type II (3.3% vs 29.4%; P < 10(-6)), and secondary interventions (3.3% vs 13.3%;P < .05) was lower in the SSR group. All type I and III endoleaks were diagnosed and treated before SSR detection. Since SSR was detected, treatment success remained until last follow-up in 98.9% (91 of 92) of the patients. The independent predictive factors of SSR were abdominal aortic aneurysm (AAA) diameter < 55 mm (odds ratio [OR] 3.91; 95% confidence interval [CI]: 2.16-7.11), infra renal aorta diameter < 23 mm (OR 2.96; 95% CI: 1.74-5.03), and a proximal neck length > 22 mm (OR 2.41; 95% CI: 1.42-4.10). CONCLUSION: In this series, SSR was accurately predictive of a durable success after EVAR. It occurred mostly in patients with a favorable anatomy. Less intensive follow-up work up seems to be safe in patients with SSR.

Clotting problems: diagnosis and management of underlying coagulopathies.

Vessel wall injury, stasis, and blood hypercoagulable state are major predisposing factors of thrombosis. Although, a procoagulable factor is found in half of patients with venous thromboembolism, relatively little is known about coagulopathies that predispose to arterial thromboembolism or unexplained arterial revascularization thrombosis. Those hypercoagulable states can be inherited or acquired and related to either an increase of a procoagulable factor or a decrease of an anticoagulation agent. However, most thrombotic episodes seem to occur with additive combination of acquired and inherited predisposing factors. Therefore, controversy exists as to which patients and family members to test for thrombophilia and which patients to treat with life-long anticoagulation. The aim of this review is to provide a practical overview with guidelines for detecting, and treatment of, the principal underlying coagulopathies that a vascular surgeon should be aware of in his/her practice and for the care of patients with vascular disease.

Impact of the introduction of endovascular aneurysm repair in high-risk patients on our practice of elective treatment of infrarenal abdominal aortic aneurysms.

The aim of this work was to evaluate, in terms of activity and immediate postoperative results, the modifications of our elective surgical treatment of infrarenal abdominal aortic aneurysms (AAAs) resulting from the use of stent grafts to treat AAAs, following the recommendations issued by the French Health Products Safety Agency (AFSSAPS) in December 2003. This monocentric and retrospective study used the clinical data of patients operated on for asymptomatic AAA between January 2001 and December 2006. Endovascular treatment of AAAs with aortic stent grafts was introduced in our current practice in January 2004, following the recommendations of the AFSSAPS (high-risk patients for open surgery presenting with an AAA > or =50 mm). Group I was composed of patients operated on between January 2001 and December 2003 according to the standard open technique. Group II was composed of patients operated on between January 2004 and December 2006 with either standard open surgery or endovascular surgery. The main criteria of evaluation were the number of operated patients, their American Society of Anesthesiology (ASA) score of surgical risk, and the intrahospital morbidity and mortality. The number of treated patients significantly increased between these two periods (group I n = 49, group II n = 88, with 38 endovascular treatments; p < 0.001), without any changes in average age (70 vs. 72 years), percentage of men (93.7% vs. 95.5%), and mean AAA size (57.8 vs. 56 mm) between the two groups. ASA scores were significantly higher in group II (ASA III and IV, group I = 20.4% vs. group II = 55.7%; p < 0.0001), whereas the intrahospital mortality rate (4.1% vs. 3.4%) and the rate of major postoperative complications (16.3% vs. 11%) have remained stable. In group II, the median duration of hospitalization was significantly reduced (12 vs. 9 days, p < 0.001). In conclusion, in our center, following the AFSSAPS recommendations, the introduction of endovascular treatment has enabled us to electively treat a greater number of AAA patients with higher surgical risk, without aggravating the immediate postoperative results.