Prognostic significance of reverse dipping status on lower limb event in type 2 diabetic patients without peripheral arterial disease.

AIMS: We assessed reverse dipping influence on the risk of lower limb events in type 2 diabetic patients without peripheral arterial disease. METHODS: Patients with type 2 diabetes addressed for cardiovascular risk stratification in our university hospital from 2008 to 2012 underwent 24 h blood pressure monitoring. Patients with a prior history of limb revascularization or with a stenosis > 50% of the legs were excluded. Reverse dipping was defined as a greater night-versus day-time systolic blood pressure. The endpoint was the first occurrence of lower limb revascularization or limb amputation. Hazard ratios (HRs) and 95% confidence intervals were calculated using the Cox model. RESULTS: Two hundred and eighty-one patients were included. During a median follow-up of 9.4 [7.7-10.6] years, 20 lower limb events and 45 all-cause deaths were observed. Thirty-five patients were reverse dippers. The reverse dipping status was associated with lower limb events when considering all-cause death as a competitive risk, (HR 3.61 [1.16-11.2], P = 0.026). Reverse dipping, HbA1C and proteinuria were independently associated with lower limb outcome in a multivariable analysis (respectively HR 4.09 [1.29-12.9], P = 0.017, HR 1.30 [1.04-1.63], P = 0.022 and HR 1.06 [1.02-1.11], P = 0.001). CONCLUSIONS: Reverse dipping status is independently associated with worse limb outcome in type 2 diabetic patients.

Hybrid Room: Does it Offer Better Accuracy in the Proximal Deployment of Infrarenal Aortic Endograft?

BACKGROUND: This work aims to evaluate the impact of hybrid rooms and their advanced tools on the accuracy of proximal deployment of infrarenal bifurcated endograft (EVAR). METHODS: A retrospective single center analysis was conducted between January 2015 and March 2019 including consecutive patients that underwent EVAR. Groups were defined whether the procedure was performed in a hybrid operating room (HOR group) or using a mobile 2D fluoroscopic imaging system (non-HOR group). The accuracy of the proximal deployment was estimated by the distance (mm) between the bottom of the lowest renal artery (LwRA) origin and the endograft radiopaque markers parallax (LwRA/EDG distance) after curvilinear reconstruction. The impact of HOR on the LwRA/EDG distance was investigated using a multiple linear regression model. A composite "proximal neck"-related complications event was studied (Cox models). RESULTS: Overall, 93 patients (87 %male, median age 73 years) were included with 49 in the HOR group and 44 in the non-HOR group. Preoperative CTA analysis of the proximal neck exhibited similar median length, but different median aortic diameter (P = 0.012) and median beta angulation (P = 0.027) between groups. The median LwRA/EDG distance was shorter in the HOR group (multivariate model, P = 0.022). No difference in "proximal neck"-related complications was evidenced between the HOR and non-HOR groups (univariate analysis, P = 0.620). Median follow-up time was respectively 25 [14-28] and 36 months [23-44] in the HOR group and in the non-HOR group (P < 0.001). CONCLUSION: HOR offer more accurate proximal deployment of infrarenal endografts, with however no difference in "proximal neck"-related complications between groups.

Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair.

OBJECTIVE: Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR). METHODS: A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan-Meier were determined for each group and compared. RESULTS: Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n = 26) or F-EVAR (n = 33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34-85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86 mm (65-100) and 70 mm (60-80), respectively (p = .008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p = .016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%). CONCLUSION: Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.

Protocol Adaptation of Optical Coherence Tomography in Lower Limb Arteries Revascularization.

In lower limb arteries, assessment of stent apposition and/or the single opening of the diseased artery remains poor since this relies on 2-dimensional angiogram. Extrapolating experience gained with coronary arteries, optical coherence tomography (OCT) could provide 3-dimensional reconstructions of the arterial wall and the stent implanted. A modified protocol of OCT acquisition, which usually includes large amount of iodine contrast flush, is presented here in 3 patients with long and complex occlusion of the superficial femoral artery. Its potential benefits and wider application to improve patient outcomes are discussed.