Targeted Radiation Exposure Induces Accelerated Aortic Valve Remodeling in ApoE-/- Mice.

Thoracic radiation therapy may result in accelerated atherosclerosis and in late aortic valve stenosis (AS). In this study, we assessed the feasibility of inducing radiation-induced AS using a targeted aortic valve irradiation (10 or 20 Grays) in two groups of C57Bl6/J (WT) and ApoE-/- mice compared to a control (no irradiation). Peak aortic jet velocity was evaluated by echocardiography to characterize AS. T2*-weighted magnetic resonance imaging after injection of MPIO-αVCAM-1 was used to examine aortic inflammation resulting from irradiation. A T2* signal void on valve leaflets and aortic sinus was considered positive. Valve remodeling and mineralization were assessed using von Kossa staining. Finally, the impact of radiation on cell viability and cycle from aortic human valvular interstitial cells (hVICs) was also assessed. The targeted aortic valve irradiation in ApoE-/- mice resulted in an AS characterized by an increase in peak aortic jet velocity associated with valve leaflet and aortic sinus remodeling, including mineralization process, at the 3-month follow-up. There was a linear correlation between histological findings and peak aortic jet velocity (r = 0.57, p < 0.01). In addition, irradiation was associated with aortic root inflammation, evidenced by molecular MR imaging (p < 0.01). No significant effect of radiation exposure was detected on WT animals. Radiation exposure did not affect hVICs viability and cell cycle. We conclude that targeted radiation exposure of the aortic valve in mice results in ApoE-/-, but not in WT, mice in an aortic valve remodeling mimicking the human lesions. This preclinical model could be a useful tool for future assessment of therapeutic interventions.

Overcoming Resistance to Anti-Nectin-4 Antibody-Drug Conjugate.

Antibody-drug conjugates (ADC) represent a fast-growing drug class in oncology. However, ADCs are associated with resistance, and therapies able to overcome it are of utmost importance. Recently, enfortumab vedotin-ejfv (EV) was approved in nectin-4+ metastatic urothelial cancer. We previously described PVRL4/nectin-4 as a new therapeutic target in breast cancer and produced an efficient EV-like ADC comprising a human anti-nectin-4 mAb conjugated to monomethyl auristatin-E (MMAE) named N41mab-vcMMAE. To study the consequence of the long-term treatment with this ADC, we developed a preclinical breast cancer model in mice, and report a mechanism of resistance to N41mab-vcMMAE after 9-month treatment and a way to reverse it. RNA-sequencing pointed to an upregulation in resistant tumors of ABCB1 expression, encoding the multidrug resistance protein MDR-1/P-glycoprotein (P-gp), associated with focal gene amplification and high protein expression. Sensitivity to N41mab-vcMMAE of the resistant model was restored in vitro by P-gp pharmacologic inhibitors, like tariquidar. P-gp is expressed in a variety of normal tissues. By delivering the drug to the tumor more specifically than classical chemotherapy, we hypothesized that the combined use of ADC with P-gp inhibitors might reverse resistance in vivo without toxicity. Indeed, we showed that the tariquidar/N41mab-vcMMAE combination was well tolerated and induced a rapid regression of ADC-resistant tumors in mice. In contrast, the tariquidar/docetaxel combination was toxic and poorly efficient. These results show that ABC transporter inhibitors can be safely used with ADC to reverse ADC-induced resistance and open new opportunities in the fight against multidrug resistance.

Clinical Outcomes of Ambulatory Endovascular Treatment Using 4-French and 6-French Femoral Access Strategies: The Bio4amb Multicentre Trial.

PURPOSE: Ambulatory peripheral vascular interventions have been steadily increasing. In ambulatory procedures, 4F devices might be particularly useful having the potential to reduce access-site complications; however, further evidence on their safety and efficacy is needed. MATERIALS AND METHODS: BIO4AMB is a prospective, non-randomized mulitcentre, non-inferiority trial conducted in 35 centres in Europe and Australia comparing the use of 4F- and 6F-compatible devices. The main exclusion criteria included an American Society of Anaesthesiologists class ≥ 4, coagulation disorders, or social isolation. The primary endpoint was access-site complications within 30 days. RESULTS: The 4F group enrolled 390 patients and the 6F group 404 patients. Baseline characteristics were similar between the groups. Vascular closure devices were used in 7.7% (4F group) and 87.6% (6F group) of patients. Patients with vascular closure device use in the 4F group were subsequently excluded from the primary analysis, resulting in 361 patients in the 4F group. Time to haemostasis was longer for the 4F group, but the total procedure time was shorter (13.2 ± 18.8 vs. 6.4 ± 8.9 min, p < 0.0001, and 39.1 ± 25.2 vs. 46.4 ± 27.6 min, p < 0.0001). Discharge on the day of the procedure was possible in 95.0% (4F group) and 94.6% (6F group) of patients. Access-site complications were similar between the groups (2.8% and 3.2%) and included predominantly groin haematomas and pseudoaneurysms. Major adverse events through 30 days occurred in 1.7% and 2.0%, respectively. CONCLUSIONS: Ambulatory peripheral vascular interventions are feasible and safe. The use of 4F devices resulted in similar outcomes compared to that of 6F devices.

Molecular imaging of endothelial activation and mineralization in a mouse model of accelerated atherosclerosis.

PURPOSE: Preclinical imaging of endothelial activation and mineralization using both positron emission tomography (PET) and magnetic resonance (MR) remains scarce. PROCEDURES: A group of uremic ApoE-/- (Ur), non-uremic ApoE-/- (NUr), and control C57Bl/6 J mice (Ctl) were investigated. Mineralization process was assessed using sodium fluoride ([18F]NaF) PET, and MR imaging combined with intravenous injection of MPIO-αVCAM-1 was used to evaluate endothelial activation. Micro- and macrocalcifications were evaluated by flame atomic absorption spectroscopy and von Kossa staining, respectively. RESULTS: Ur mice showed an active and sustained mineralization process compared to Ctl mice (p = 0.002) using [18F]NaF PET imaging. Calcium plasma level was increased in Ur (2.54 ± 0.09 mM, n = 17) compared to NUr and Ctl mice (2.24 ± 0.01, n = 22, and 2.14 ± 0.02, n = 27, respectively; p < 0.0001). Likewise, vascular calcium content was increased in Ur (0.51 ± 0.06 µg Ca2+ per milligram of dry weight aorta, n = 11) compared to NUr (0.27 ± 0.05, n = 9, p = 0.013) and Ctl (0.28 ± 0.05, n = 11, p = 0.014). Ur mice also had a higher inflammatory state using MPIO-αVCAM-1 MR (p global = 0.01, post hoc analysis Ur vs. Ctl p = 0.003) associated with increased VCAM-1 expression (p global = 0.02). Aortic remodeling at the level of the brachiocephalic trunk, brachiocephalic trunk itself, and aortic arch in Ur mice was also demonstrated using MR. CONCLUSIONS: Preclinical molecular imaging allowed in vivo characterization of the early phase of atherosclerosis. [18F]NaF PET showed early and sustained vascular mineralization in uremic ApoE-/- mice. MPIO-αVCAM-1 MR imaging demonstrated aortic endothelial activation, predominantly in segments with vascular remodeling.

Endovascular Treatment of Aortic Arch Vessel Stent Migration: Three Case Reports.

Percutaneous angioplasty and stenting is nowadays the treatment of choice for atherosclerotic stenotic lesions of the supraaortic trunks. Stent migration is a seldom published complication that can alter the short-term results of these procedures. Herein, we report three cases, from three different institutions, of secondary autoexpandable stent migration, after endovascular treatment of major arch vessel stenosis, and their subsequent endovascular management using three different retrieval techniques. Technical success was achieved in all cases. There were no immediate complications related to the retrieval of the migrated stents. A late complication of iliac thrombosis required complementary surgical intervention. Percutaneous retrieval of migrated self-expanding stents is feasible and can be effectively performed with few complications as a first-line option.

Performance Evaluation of a Dedicated Preclinical PET/CT System for the Assessment of Mineralization Process in a Mouse Model of Atherosclerosis.

PURPOSE: The purpose of this study was to assess the impact of positron emission tomography/X-ray computed tomography (PET/CT) acquisition and reconstruction parameters on the assessment of mineralization process in a mouse model of atherosclerosis. PROCEDURES: All experiments were performed on a dedicated preclinical PET/CT system. CT was evaluated using five acquisition configurations using both a tungsten wire phantom for in-plane resolution assessment and a bar pattern phantom for cross-plane resolution. Furthermore, the radiation dose of these acquisition configurations was calculated. The PET system was assessed using longitudinal line sources to determine the optimal reconstruction parameters by measuring central resolution and its coefficient of variation. An in vivo PET study was performed using uremic ApoE-/-, non-uremic ApoE-/-, and control mice to evaluate optimal PET reconstruction parameters for the detection of sodium [18F]fluoride (Na[18F]F) aortic uptake and for quantitative measurement of Na[18F]F bone influx (Ki) with a Patlak analysis. RESULTS: For CT, the use of 1 × 1 and 2 × 2 binning detector mode increased both in-plane and cross-plane resolution. However, resolution improvement (163 to 62 µm for in-plane resolution) was associated with an important radiation dose increase (1.67 to 32.78 Gy). With PET, 3D-ordered subset expectation maximization (3D-OSEM) algorithm increased the central resolution compared to filtered back projection (1.42 ± 0.35 mm vs. 1.91 ± 0.08, p < 0.001). The use of 3D-OSEM with eight iterations and a zoom factor 2 yielded optimal PET resolution for preclinical study (FWHM = 0.98 mm). These PET reconstruction parameters allowed the detection of Na[18F]F aortic uptake in 3/14 ApoE-/- mice and demonstrated a decreased Ki in uremic ApoE-/- compared to non-uremic ApoE-/- and control mice (p < 0.006). CONCLUSIONS: Optimizing reconstruction parameters significantly impacted on the assessment of mineralization process in a preclinical model of accelerated atherosclerosis using Na[18F]F PET. In addition, improving the CT resolution was associated with a dramatic radiation dose increase.

A targeted remifentanil administration protocol based on the analgesia nociception index during vascular surgery.

BACKGROUND: The intraoperative modulation of opioids continues to be based on clinical signs. This may result in adverse events such as sympathetic reactivity or opioid-induced hyperalgesia. Recently, the Analgesia/Nociception Index (ANI), a non-invasive 0-100 index derived from heart rate variability analysis, has been proposed for nociception assessment. However, the ability of the ANI to adequately guide intraoperative opioid administration has never been demonstrated. We designed a prospective study to evaluate the ability of the ANI to guide remifentanil administration in vascular surgery. METHODS: One hundred and eighty adults presenting for elective surgery were included. All received total intravenous anaesthesia with propofol adjusted to entropy and remifentanil adjusted to the ANI. The primary endpoint was the number of patients without any episode of reactivity defined as a 20% increase in heart rate or arterial pressure or the occurrence of movement. Secondary endpoints included opioid use and maximal pain rate in the first postoperative day. RESULTS: Anaesthesia was achieved without any episode of reactivity in 160 (89%) patients. Twenty-five episodes of reactivity occurred in 20 (11%) patients. The median remifentanil dose was 0.042 [0.040-0.044]µg.kg-1.min-1. At 24hours, the maximal NRS pain score was 2 [2,3]. One hundred and fifty-five patients (86%) did not receive any postoperative opioids, whereas 25 (14%) received a median dose of 5[5-10] mg of oxycodone. CONCLUSION: This prospective study demonstrated that the ANI can be used to adequately guide intraoperative remifentanil administration during vascular surgery. Such guidance resulted in low remifentanil consumption, low postoperative pain rates and low opioid rescue analgesia.

True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis: Five Cases and Literature Review.

BACKGROUND: The donor artery after a long-standing arteriovenous fistula (AVF) for hemodialysis usually evolves exceptionally toward a true aneurysmal degeneration (AD). The purpose of this article was to describe true brachial artery AD in end-stage renal disease patients after AVF creation, as well as its influencing factors and treatment strategies. METHODS: We present a retrospective, observational, single-center study realized in Caen University Hospital's Vascular Surgery Department from May 1996 to November 2015. The inclusion criteria were true AD of the brachial artery after a vascular access for hemodialysis. A literature research, using the same criteria, was performed on the articles published between 1994 and 2015. The used databases included MEDLINE (via PubMed), EMBASE via OVID, Cochrane Library Database, and ResearchGate. RESULTS: Our series includes 5 patients. Twenty-one articles were found in the literature: 17 case reports, 3 series, and 1 review. The same triggering factors for AD (high flow and immunosuppressive treatment) were found. The mean age at the time of AVF creation, first renal transplantation, and AD's diagnosis were respectively 26 (range 15-49), 29.2, and 48.6 years (range 37-76) in our series versus 34 (range 27-39), 40.4 (range 28-55), and 55.5 years (range 35-75) in cases found in the literature. The time spread after AVF creation and aneurysmal diagnosis was about 20.6 years (range 18-25) in our study versus 20.5 years (range 9-29) in the case reports. Our surgical attitude corresponds principally to that described in the literature. Nevertheless, we describe for the first time one case of arterial transposition to exclude the brachial aneurysm using superficial femoral artery. CONCLUSIONS: Arterial aneurysm is a rare, but significant complication after a long-term creation of hemodialysis access. High flow and immunosuppression may accelerate this process. Young age of the patients may act as a benefic factor and delay the AD. Arterial transposition could be an option in the absence of any venous conduit, if anatomy does not permit the use of prosthetic grafts.

Below-The-Knee Angioplasty for Critical Limb Ischemia: Results of a Series of 157 Procedures and Impact of the Angiosome Concept.

BACKGROUND: To evaluate the long-term clinical results of below-the-knee percutaneous transluminal angioplasty (BTK-PTA) with or without stenting, in patients with critical limb ischemia (CLI), and to determine factors affecting clinical results including the role of the angiosome concept. METHODS: All patients undergoing primary BTK-PTA from January 2007 to December 2011 were included. Primary patency, assisted patency, limb salvage, survival, and wound healing were assessed using the Kaplan-Meier method. Predictors of patency, limb salvage, survival, and wound healing, including the role of the angiosome theory, were determined using multivariate models. RESULTS: A total of 157 procedures were performed in 139 patients with CLI (Rutherford IV 10.8%; Rutherford V-VI 89.2%). Mean age was 74.2 years and 68.3% were men; 60% had diabetes and 31% renal insufficiency. PTA was confined to the infrapopliteal segment alone in 53.5% of cases. Technical success was 87.9%. Stents were placed in 42.6% of cases. The mean follow-up was 14.7 months (range, 1-67 months). Four-year primary and secondary patency were 51% and 61%, respectively. Limb salvage at 4 years was 68.8%. Complete wound healing was 52% at 4 years. Positive predictors of survival were the absence of renal insufficiency (P < 0.0001) and technical success (P = 0.029). Target vessel occlusion of >50% was a negative predictor of limb salvage (P = 0.0072). Positive predictors of wound healing were technical success (P = 0.0067), the absence of renal insufficiency (P < 0.0001) and continuity between a leg artery and a foot artery (P = 0.02). CONCLUSIONS: BTK-PTA can be performed with favorable long-term results in patients with limited longevity. Secondary interventions may be necessary to maintain target vessel patency. In our experience, the angiosome concept had no impact on clinical success.

Volume analysis of true and false lumens in acute complicated type B aortic dissections after thoracic endovascular aortic repair with stent grafts alone or with a composite device design.

OBJECTIVE: This study compared the 12-month evolution of the aortic volume in patients who underwent thoracic endovascular aortic repair (TEVAR) with stent grafts alone or a composite device (Zenith TX2 stent graft and Zenith Dissection stent; Cook Medical, Bloomington, Ind) for acute (≤2 weeks from onset) complicated type B aortic dissection. METHODS: This was a retrospective analysis comparing prospectively collected data from 45 patients who underwent standard TEVAR repair at three European institutions (TEVAR group) and 39 patients in the Study of Thoracic Aortic type B Dissection using Endoluminal Repair (STABLE I) study who received a composite device (STABLE group). The analysis included consecutive patients treated for acute, complicated type B dissection and with available baseline and 12-month computed tomography imaging. Volume analysis was performed by using a semiautomated centerline algorithm. RESULTS: Baseline demographics, medical history, extent of dissection, and clinical indications were largely similar between the two groups. There was no difference in the length of aorta covered by stent grafts (167 ± 47 mm in STABLE and 184 ± 49 mm in TEVAR; P = .11). The STABLE group had an initial larger false lumen volume in the thoracic (203 ± 72 cm(3) vs 162 ± 74 cm(3); P = .01) and abdominal aorta (63 ± 29 cm(3) vs 36 ± 27 cm(3); P < .001). In the thoracic aorta, each group exhibited a significant increase in true lumen volume and a significant decrease in false lumen volume through 12 months. The total aortic volume increased significantly in the STABLE group (P < .001) but not in the TEVAR group. In the abdominal aorta, only the STABLE group exhibited a significant increase in the true lumen volume (P < .001) and a significant decrease in the false lumen volume (P = .004) postoperatively. At 12 months, the true lumen continued to increase significantly in the STABLE group (P = .03). However, no statistically significant difference was detected when the two groups were compared for the overall changes in the true lumen and false lumen volumes from preprocedure to 12 months, and both groups exhibited a statistically significant increase in total abdominal aortic volume at 12 months. There was no statistical difference between the two groups in the proportions of patients who experienced >10% changes in the thoracic or abdominal total lumen volume after TEVAR. Patients in the two groups (all survived 12 months) had similar clinical outcomes, including rupture, conversion, and reinterventions. CONCLUSIONS: According to this volume analysis, thoracic endografting for acute complicated type B dissections promotes significant thoracic aortic remodeling. The use of bare-metal dissection stents leads to significant true lumen expansion and false lumen regression in the early follow-up and to subsequent continued true lumen expansion in the abdominal aorta; however, a definitive benefit in aortic remodeling over TEVAR alone was not demonstrated at 1 year.

Influence of Obesity on Access-Related Complications During Anterior Lumbar Spine Interbody Fusion.

OBJECTIVE: The anterior lumbar spine approach has gained in popularity in recent years, but the associated access-related complications for obese patients have not been clearly established. This study aimed to analyze the relationship between obesity or overweight and the safety of the anterior lumbar spine approach. METHODS: Eighty-four consecutive patients admitted for lumbar spine surgery by anterior approach between 2011 and 2014 were included. The surgical approach consisted of left lateral minilaparotomy and retroperitoneal dissection. The patients were categorized into 3 different groups according to their body mass index (BMI). The studied outcomes measures included medical history, BMI, the number of fused levels, surgery duration, blood loss, vascular injury, day of discharge, surgical revision, and wound infection. RESULTS: No significant difference was found across the BMI groups with regard to vascular or infectious complications. The duration of surgery was significantly higher in the obese group. CONCLUSIONS: Because BMI does not seem to increase the overall risk of complications, the anterior lumbar spine approach should be considered in obese or overweight patients, as in nonoverweight patients.

Transradial versus transfemoral approach for percutaneous coronary intervention in cardiogenic shock: A radial-first centre experience and meta-analysis of published studies.

BACKGROUND: The transradial approach for percutaneous coronary intervention (PCI) is associated with a better outcome in myocardial infarction (MI), but patients with cardiogenic shock (CS) were excluded from most trials. AIMS: To compare outcomes of PCI for MI-related CS via the transradial versus transfemoral approach. METHODS: A prospective cohort of 101 consecutive patients admitted for PCI for MI-related CS were treated via the transradial (n=74) or transfemoral (n=27) approach. Cox proportional hazards models adjusted for prespecified variables and a propensity score for approach were used to compare mortality, death/MI/stroke and bleeding between the two groups. A complementary meta-analysis of six studies was also performed. RESULTS: Patients in the transradial group were younger (P=0.039), more often male (P=0.002) and had lower GRACE and CRUSADE scores (P=0.003 and 0.001, respectively) and rates of cardiac arrest before PCI (P=0.009) and mechanical ventilation (P=0.006). Rates of PCI success were similar. At a mean follow-up of 756 days, death occurred in 40 (54.1%) patients in the transradial group versus 22 (81.5%) in the transfemoral group (adjusted hazard ratio [HR]: 0.49, 95% confidence interval [CI] 0.28-0.84; P=0.012). The transradial approach was associated with reduced rates of death/MI/stroke (adjusted HR: 0.53, 95%CI: 0.31-0.91; P=0.02) and major bleeding (adjusted HR: 0.34, 95%CI: 0.13-0.87; P=0.02). The meta-analysis confirmed the benefit of transradial access in terms of mortality (relative risk [RR]: 0.63, 95%CI: 0.58-0.68) and major bleeding (RR: 0.43, 95%CI: 0.32-0.59). CONCLUSION: The transradial approach in the setting of PCI for ischaemic CS is associated with a dramatic reduction in mortality, ischaemic and bleeding events, and should be preferred to the transfemoral approach in radial expert centres.

Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting: Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Carotid angioplasty and stenting (CAS) is associated with higher risk of periprocedural stroke and death when compared with carotid endarterectomy (CEA). By contrast, the risk of myocardial infarction (MI) was higher after CEA than after CAS in randomized trials. However, numbers were small, and risk factors are unknown. METHODS: We performed a systematic review and a meta-analysis of studies published from January 1980 to June 2014 and collected unpublished data. We extracted data on 9 predefined risk factors (age, contralateral carotid occlusion, coronary artery disease, diabetes mellitus, sex, hypertension, peripheral artery disease, type stenosis, and clinical presentation). We selected studies with data available on MI in at least 1 subgroup, calculated absolute and relative risks, and identified differential effects on risks of MI. RESULTS: The 30-day absolute risk of MI was 0.87% (95% confidence interval, 0.69-1.07) after CEA and 0.70% (95% confidence interval, 0.54-0.88) after CAS (Pint=0.38). After CAS, patients with symptomatic stenosis and restenosis were at higher risk of MI, whereas men were at lower risk. After CEA, age, history of coronary artery disease, peripheral artery disease, and restenosis increased the risk of MI. Only the effect of sex differed between CAS and CEA with men being at lower risk of MI than women after CAS, whereas there was no difference between after CEA (Pint=0.01). CONCLUSIONS: The risk of MI after CEA and CAS did not significantly differ. Risk factors for MI are overall similar in both techniques except that men are at lower risk of MI after CAS but not after CEA.

Midterm results of type B intramural hematoma endovascular treatment.

BACKGROUND: Recently, intramural hematoma (IMH) has been characterized as a rare variant of aortic dissection, falling within the acute aortic syndromes (AAS). Although aortic endovascular treatment seems to provide good results, no consensus has been established regarding the optimal management of IMH affecting the descending thoracic aorta (IMH B). The aim of this study was to assess long-term clinical and morphological results of IMH B treated with a stent graft. METHODS: Between 2002 and 2013, 15 of the 423 (3.5%) consecutive patients with AAS were found to have IMH B. During follow-up, complications related to IMH B were observed in 10 patients, including 5 during the acute period (<14 days). Surgical indications were ulcerations, refractory pain, aneurysm evolution, aortic rupture, and pleural effusion. An endovascular approach was taken for all forms with suitable anatomy. RESULTS: Technical success rate was 100%, with complete exclusion of lesions of the descending thoracic aorta in all cases treated with a stent graft. No neurological complications or deaths occurred within the first 30 postoperative days, nor at the end of the mean follow-up of 46 months (1-137 months). After the aortic stent graft, partial or complete regression of the hematoma was observed in all cases. CONCLUSIONS: IMH B is most often a progressive disease requiring long-term monitoring. In case of complications, stent-graft treatment of the descending thoracic aorta can be performed successfully in most cases. This procedure appears to be a safe technique that provides very good long-term results, with favorable remodeling of the aorta.

Technique and results of femoral bifurcation endarterectomy by eversion.

OBJECTIVE: This study evaluated, in a contemporary prospective series, the safety and efficacy of femoral endarterectomy using the eversion technique and compared our results with results obtained in the literature for the standard endarterectomy with patch closure. METHODS: Between 2010 and 2012, 121 patients (76% male; mean age, 68.7 years; diabetes, 28%; renal insufficiency, 20%) underwent 147 consecutive femoral bifurcation endarterectomies using the eversion technique, associating or not inflow or outflow concomitant revascularization. The indications were claudication in 89 procedures (60%) and critical limb ischemia in 58 (40%). Primary, primary assisted, and secondary patency of the femoral bifurcation, clinical improvement, limb salvage, and survival were assessed using Kaplan-Meier life-table analysis. Factors associated with those primary end-points were evaluated with univariate analysis. RESULTS: The technical success of eversion was of 93.2%. The 30-day mortality was 0%, and the complication rate was 8.2%; of which, half were local and benign. Median follow-up was 16 months (range, 1.6-31.2 months). Primary, primary assisted, and secondary patencies were, respectively, 93.2%, 97.2%, and 98.6% at 2 years. Primary, primary assisted, and secondary maintenance of clinical improvement were, respectively, 79.9%, 94.6%, and 98.6% at 2 years. The predictive factors for clinical degradation were clinical stage (Rutherford category 5 or 6, P = .024), platelet aggregation inhibitor treatment other than clopidogrel (P = .005), malnutrition (P = .025), and bad tibial runoff (P = .0016). A reintervention was necessary in 18.3% of limbs at 2 years: 2% involving femoral bifurcation, 6.1% inflow improvement, and 9.5% outflow improvement. The risk factors of reintervention were platelet aggregation inhibitor (other than clopidogrel, P = .049) and cancer (P = .011). Limb preservation at 2 years was 100% in the claudicant population. Limb salvage was 88.6% in the critical limb ischemia population, with a statistically higher rate for patients with malnutrition (P = .029), preoperative platelet count >450 ×10(9)/L (P = .0071), platelet aggregation inhibitor treatment other than clopidogrel (P = .022), preoperative deep femoral artery occlusion or stenosis >75% (P = .0064), and poor tibial runoff (P = .00042). CONCLUSIONS: Eversion femoral bifurcation endarterectomy is a safe, efficient, and reproducible technique for the treatment of atherosclerotic femoral lesions. Advantages are notable, especially the lack of need for prosthetic angioplasty, eliminating the risk of patch infection or pseudoaneurysms and permitting direct puncture if endovascular procedures are needed for assisted patency.

Intimal angiosarcoma from the common femoral vein in a 27-year-old patient.

Intimal sarcoma is a rare and aggressive vascular pathology. The literature describes about 140 cases. Because of late diagnosis, the median survival time is only a few months. Presentations vary from the localization. The most common symptoms are intravascular obstruction or embolization. Diagnosis is difficult and vascular surgeons do not know the treatment very well. We present the first case of intimal angiosarcoma of the common femoral vein presenting with a deep venous thrombosis and discuss diagnosis and therapeutic approach.

Solitary kidney with renal artery aneurysm repaired by ex vivo reconstruction.

A 22-year-old pregnant female with pyelonephritis was found to have a 26-mm left renal artery aneurysm with unknown right kidney agenesis diagnosed by magnetic resonance imaging. Computed tomographic angiography with 3-dimensional reconstructions confirmed a saccular aneurysm localized at the bifurcation of the left posterior segmental artery. The patient ultimately underwent successful ex vivo left renal artery aneurysm repair with autotransplantation. Pathologic evaluation of the resected aneurysm confirmed the diagnosis of fibromuscular dysplasia. Fibromuscular dysplasia is the most common cause of renal artery stenosis and renovascular hypertension and can, in rare cases, be associated with the development of renal artery aneurysms.