Ten-year Experience of Surgical Management of Paget-Schroetter Syndrome.

BACKGROUND: Paget-Schroetter syndrome (PSS) or effort-induced thrombosis is an acute (<14 days) venous thrombosis of the axillosubclavian vein. Early catheter-directed thrombolysis (CDT) is required to improve patency rate and avoid postthrombotic syndrome. This study aimed to report the management of PSS in our center across 10 years and compare it to the established guidelines. METHODS: Some of the selected patients were treated with CDT if the diagnosis of acute vein thrombosis was established 6 weeks after the appearance of the first symptoms and if a vascular surgeon was involved in the care and management of the patient. Patients underwent first rib removal 6 weeks after the CDT. Some patients with primary upper limb venous thrombosis were not immediately referred to a vascular surgeon after the initial diagnosis. They were instead discharged home with the prescription of oral anticoagulation therapy (OAT) alone for at least 3 months. RESULTS: Between 2010 and 2020, 426 first rib removal procedures were performed for 338 patients with thoracic outlet syndrome (TOS) at our center. Among them, 18 (4.2%) patients with PSS were identified. 5 (27.8%) patients underwent CDT. The median duration between first symptoms and thrombolysis was 10 days (range, 1-32). Thirteen (72.2%) patients were discharged home with OAT alone and referred to a vascular surgeon with a median time of 365 days (range, 8-6,422) for TOS diagnosis. Postthrombotic syndrome was noticed in 5 (38%) patients in the OAT group and 1 (20%) patient in the CDT group. CONCLUSIONS: Despite the guidelines being in favor of early CDT in PSS, most patients are discharged home with OAT alone. The study findings demonstrate that better information about this specific complication must be provided to the concerned practitioners who are likely to encounter such patients.

Evaluation of Quality of Life after Surgical Treatment of Thoracic Outlet Syndrome.

BACKGROUND: To evaluate the quality of life of surgically treated patients for TOS. METHODS: A prospective observational study, including patients treated surgically for TOS in 2018. Two standardized questionnaires: Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Short-Form 12 (SF-12) were used. The SF-12 consists of a physical and mental component (PCS-SF-12 and MCS-SF-12). The questionnaires were completed during the preoperative and postoperative consultations and at 3, 6, and 12 months. RESULTS: We performed 53 interventions. The population was mostly female (n = 35, 66.0%) of 40.1 ± 10.0 years. The preoperative DASH score was 46.3 ± 19.7. It was 40.9 ± 21.7 at 6 weeks, 33.5 ± 22.7 at 3 months, 28.9 ± 22.6 at 6 months, and 21.1 ± 20 at 9 to 12 months. The improvement of DASH becomes statistically significant at 3 months (P = 0.036), 6 months (P = 0.002), and 12 months (P = 0.001). The preoperative MCS-SF-12 was 36.6 ± 9.4. It was 41.6 ± 10.9 at 6 weeks, 43.8 ± 11.1 at 3 months, 46.2 ± 11.8 at 6 months, and 51.4 ± 8 at 8 to 12 months. The improvement of MCS-SF-12 became significant at 3 months (P = 0.009), 6 months (P = 0.001), and 12 months (P = 0.001). The preoperative PCS-SF-12 was 35.5 ± 6.4. It was 37.1 ± 8.7 at 6 weeks, 39.9 ± 8.7 at 3 months, 41.6 ± 8.4 at 6 months, and 46.1 ± 8.1 to 12 months. The improvement of PCS-SF-12 became significant at 6 months (P = 0.005) and 12 months (P = 0.001). CONCLUSIONS: The surgical management of TOS allows for an improvement in quality of life in the short and medium terms.

Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome.

OBJECTIVE: Thoracic outlet syndrome (TOS) should be considered of arterial origin only if patients have clinical symptoms that are the result of documented symptomatic ischemia. Simultaneous recording of inflow impairment and forearm ischemia in patients with suspected TOS has never been reported to date. We hypothesized that ischemia would occur in cases of severely impaired inflow, resulting in a non-linear relationship between changes in pulse amplitude (PA) and the estimation of ischemia during provocative attitudinal upper limb positioning. DESIGN: Prospective single center interventional study. MATERIAL: Fifty-five patients with suspected thoracic outlet syndrome. METHODS: We measured the minimal decrease from rest of transcutaneous oximetry pressure (DROPm) as an estimation of oxygen deficit and arterial pulse photo-plethysmography to measure pulse amplitude changes from rest (PA-change) on both arms during the candlestick phase of a "Ca + Pra" maneuver. "Ca + Pra" is a modified Roos test allowing the estimation of maximal PA-change during the "Pra" phase. We compared the DROPm values between deciles of PA-changes with ANOVA. We then analyzed the relationship between mean PA-change and mean DROPm of each decile with linear and second-degree polynomial (non-linear) models. Results are reported as median [25/75 centiles]. Statistical significance was p < 0.05. RESULTS: DROPm values ranged -11.5 [-22.9/-7.2] and - 12.3 [-23.3/-7.4] mmHg and PA-change ranged 36.4 [4.6/63.8]% and 38.4 [-2.0/62.1]% in the right and left forearms, respectively. The coefficient of determination between median DROPm and median PA-change was r 2 = 0.922 with a second-degree polynomial fitting, but only r 2 = 0.847 with a linear approach. CONCLUSION: Oxygen availability was decreased in cases of severe but not moderate attitudinal inflow impairments. Undertaking simultaneous A-PPG and forearm oximetry during the "Ca + Pra" maneuver is an interesting approach for providing objective proof of ischemia in patients with symptoms of TOS suspected of arterial origin.

Surgery of Renal Artery Aneurysms: A Monocentric Retrospective Study.

BACKGROUND: The aim of the study was to report the results of conventional surgery for renal artery aneurysms (RAAs) in our center. MATERIAL AND METHODS: We retrospectively reviewed the files of all the patients operated for RAAs between 2009 and 2018 in our center. We collected demographic, biological (renal function), morphological (computed tomography [CT] scan), and functional (ultrasound examination and resistance index) preoperative and postoperative data. Clinical and paraclinical operative data were examined. Results were expressed as average ± standard deviation or median and extremes. RESULTS: A total of 26 aneurysms were operated in 20 kidneys (10 right kidneys) among 19 patients, including 13 (68%) women with an average age of 55 (±12) years. Three (16%) patients presented an aneurysm in a single kidney. The discovery of the aneurysm was fortuitous in 14 (74%) patients. One patient with Marfan syndrome was operated after a postpartum rupture. The median diameter of the operated aneurysms was 22 mm (7-48), and 23 (90%) were hilar aneurysms. Arterial repair was carried out in situ in 16 (80%) kidneys. The surgery consisted of a direct arterial repair in 21 cases (81%), including 4 resections and anastomoses, 12 aneurysmorrhaphies, and 5 complex reconstructions. Four arterial replacements were carried out (one prosthetic graft, 2 femoral grafts, and one internal iliac graft). The average duration of renal clamping was 30.5 (±17.3) min. Postoperative renal function was unchanged in all the patients except for one (5.2%) who required 2 days of postoperative dialysis. The resistance index of all the operated kidneys was normal (0.66 ± 0.08) at discharge. Sixteen (70%) of the 23 aneurysms were examined, and anatomopathology concluded them to be of dysplastic origin. At 3 months, a systematic CT scan objectified the patency of 95% of the arterial reconstructions, with 3 stenoses >50%. One stenosis >80% was treated at 7 months by balloon angioplasty. Only one operated kidney presented a loss of viability of its upper pole. The mean duration of follow-up was 54 ± 35 months. By the end of the follow-up, primary and secondary patency rates evaluated by Doppler ultrasound were 90% and 95%, respectively. CONCLUSIONS: Conventional surgery generally performed in situ remains a sure and effective treatment for RAAs. This challenging surgery for a rare disease should be performed in experimented centers.

Treatment of Carotid Restenoses after Endarterectomy: A Retrospective Monocentric Study.

BACKGROUND: To compare the different techniques for the treatment of carotid restenosis after carotid artery endarterectomy (CAE). METHODS: Among 1,218 carotid surgeries carried out in our center between January 2010 and November 2017, 45 procedures were performed for carotid restenosis after CAE, including 11 by iterative conventional surgery and 34 with endovascular techniques (7 transluminal angioplasties alone [TLA], 9 carotid artery stenting [CAS], and 18 angioplasties with active balloons [drug-coated balloon {DCB}]). Perioperative data (cumulated rate of morbimortality [CRMM], duration of hospitalization) and postoperative results (survival, symptomatic restenoses > 50% or asymptomatic stenoses > 70% on ultrasound, reinterventions) were collected retrospectively and analyzed with Fisher's exact test. The long-term results were estimated according to the Kaplan-Meier estimator and were compared with the log rank test (P < 0.05 was regarded as significant). RESULTS: There was one secondary death due to a massive postoperative stroke in the endovascular (ENDO) group. No significant difference regarding CRMM (2.9%, P = 0.756) between the iterative conventional surgery (open surgery; OS) and the ENDO groups of was observed. Three hematomas were found in the OS group versus one in the ENDO group (P = 0.04). The length of hospital stay was shorter in the ENDO group (P < 0.001). No difference was found between the ENDO group and the OS group regarding the two-year survival or the survival without recurrent restenosis (86 vs. 100%, log rank = 0.804, and log rank = 0.114). There were 5 restenoses >70% and two reinterventions in the ENDO group (P > 0.05). The comparison of the different endovascular techniques did not show significant differences regarding the CRMM, the one-year overall survival, the survival without recurrent restenosis, or the survival without reintervention (89% in the DCB and CAS groups vs. 100% in the percutaneous transluminal angioplasty [PTA] group, log rank = 0.286; 87% in the DCB group vs. 100% in the PTA and CAS groups, log rank = 0.137; and 94% in the DCB group vs. 100% in the PTA and CAS groups, log rank = 0.585, respectively). CONCLUSIONS: In our experience, endovascular procedures are equivalent to iterative conventional surgery for the treatment of carotid restenoses in terms of major complications, news restenoses, or survival with less hematoma and a shorter duration of hospitalization. We however could not identify the best endovascular strategy in this indication, and a controlled study comparing the various endovascular strategies is proposed.

High prevalence of exercise-induced ischemia in the asymptomatic limb of patients with apparently strictly unilateral symptoms and unilateral peripheral artery disease.

BACKGROUND:: The prevalence of exercise-induced ischemia in the asymptomatic limb of patients with unilateral claudication based on history and treadmill evaluation, and with unilateral ipsilateral peripheral artery disease (i.e ankle-to-brachial systolic pressure index <0.90) is unknown. METHODS:: We detected exercise-induced ischemia in the asymptomatic limb of patients with apparently unilateral claudication. Among 6059 exercise-oximetry tests performed in 3407 nondiabetic and 961 diabetic patients. We estimated the intensity of ischemia in the both limb (buttocks and calves) using the lowest minimum value of the decrease from rest of oxygen pressure (DROP; limb changes minus chest changes from rest), with significant ischemia defined as DROP lower than -15 mmHg. RESULTS:: We found 152 tests performed in 142 nondiabetic patients and 40 tests performed in 38 diabetic patients. The asymptomatic limb showed significant ischemia in 46.7% and 37.5% of the tests. Strictly unilateral exercise-induced claudication with apparently unilateral peripheral artery disease was rare (<4% of all tests). However, among these highly selected tests, significant ischemia was found in the asymptomatic limb in more than one-third of cases. CONCLUSION:: The asymptomatic limb of patients with peripheral artery disease should not be considered a normal limb.

Frequency of the Pectoralis Minor Compression Syndrome in Patients Treated for Thoracic Outlet Syndrome.

BACKGROUND: Pectoralis minor compression syndrome (PMCS) is a compression of the neurovascular structures in the subpectoral tunnel and remains underestimated in the management of patients with thoracic outlet syndrome (TOS). Its underdiagnosis may be responsible for incomplete or failed treatment. The aim of the study was to evaluate the frequency of PMCS in our experience. METHODS: We retrospectively reviewed all patients treated for TOS in our department. We selected those in whom PMCS was diagnosed with a systematic dynamic arteriography. Surgery was performed using the Roos axillary approach when a first rib resection was associated or an elective approach when a first rib resection was not associated. RESULTS: From January 2004 to December 2014, 374 surgeries for TOS were performed in 279 patients, which included 90 men (sex ratio = 0.48) with a mean age of 40.1 ± 10 years old. Among these patients, 63 (22.5%) underwent 82 interventions (21.9%) for PMCS, including 26 men (sex ratio = 0.70, P < 0.05) with a mean age of 37.9 ± 9.4 years old. Tenotomy of the pectoralis minor muscle was performed using axillary approach if it was associated with a first rib resection in 74 cases (90.2%) or through an elective approach in 8 cases (9.8%) if it was isolated. Four (4.9%) postoperative complications were found (1 hematoma [1.2%], 1 hemothorax [1.2%], 1 scapula alata [1.2%], and 1 subclavian vein thrombosis [1.2%]), all after an axillary approach. In 63 cases (79.7%), preoperative symptoms were resolved. In 14 cases (17.7%), symptom resolution was incomplete, and 2 patients (2.6%) had recurrent symptoms. CONCLUSIONS: Evaluation of PMCS in TOS is justified by its frequency and the simplicity and low morbidity of the surgical procedure.

Evaluation of the Vascular Surgical Complications of Renal Transplantation.

BACKGROUND: Renal transplantation is the treatment of choice of end-stage renal failure. However, vascular surgical complications can compromise the functional prognosis of the transplant or even be life threatening in the short term. Since few data are available in the literature, the objective of this study was to evaluate the vascular surgical complications of renal transplantation. METHODS: In a retrospective and monocentric study, the records of all the patients receiving a kidney transplant between January 2008 and December 2014 were reviewed. The demographic data and the follow-up of the patients who presented a vascular surgical complication in relation to their transplant were collected. Minor, intermediate, or major vascular complications were defined according to the need for monitoring, reoperation, or the risk of transplant loss or a life-threatening situation. Predictive factors of vascular complications were also looked for. RESULTS: Mean age was 50.9 ± 15.0 years, and 312 kidney transplants were carried out (205 men). Fifty vascular surgical complications (16.0%) were found. Among them, 23 vascular complications (7.4%) were major, including 6 (1.9%) which required transplantectomy, after 4 arterial thromboses (1.3%), 1 early venous thrombosis (0.3%), and 1 injury of the inferior vena cava (0.3%). Twelve complications (3.8%) were minor. Surgical revision was necessary in 76% of the vascular complications (n = 38). The average follow-up of the transplanted population was 37.4 ± 24.0 month, 268 kidney transplants (85.8%) were functional and 21 patients (6.7%) returned to dialysis. Surgical complications were more frequent when the recipient had hypertension (P = 0.02, OR = 2.5; 95% CI [1.1-6.1]), in case of right kidney transplant (P = 0.0004, OR = 3.1; 95% CI [1.6-5.8]) and when the kidney hilum consisted of at least arteries (P = 0.02, OR = 10.0; 95% CI [1.3-34]). Male gender (P = 0.03, OR = 0.5; 95% CI [0.3-0.9]) as well as the choice of the common iliac arterial (P = 0.001, OR = 0.4; 95% IC [0.2-0.7]) and venous (P = 0.002, OR = 0.3; 95% IC [0.2-0.8]) axes to carry out the vascular anastomoses appeared as protective factors. CONCLUSIONS: The vascular surgical complications of kidney transplantation, especially thromboses, can be serious and lead to transplant loss. The expertise of vascular surgeons finds its place here and makes it possible to maintain low rates of vascular complications and loss of transplants.

Randomized Study of Noninferiority Comparing Prosthetic and Autologous Vein Above-Knee Femoropopliteal Bypasses.

BACKGROUND: The main aim of this study was to compare the 5 years rates of secondary patency of above-knee femoropopliteal revascularizations with autologous veins or prosthetic grafts. The secondary objectives were to compare the rates of primary patency, limb salvage, morbidity, and mortality between the 2 groups. METHODS: This was a single-blind randomized study of noninferiority (ratio 1:1), carried out in 11 centers of vascular surgery with 2 parallel groups between July 2002 and November 2005. Follow-up finished in May 2011. The monitoring protocol included a clinical examination and an ultrasound control at 1 month, 3 and 6 months, then annually. RESULTS: One hundred patients were included and randomized in the study, 52 in the prosthetic group and 48 in the autologous vein group. Four patients randomized in the vein group received a prosthetic graft. No patient was excluded from the analysis. In the in intent-to-treat analysis, the 5 years secondary patency was 84.6% in the prosthetic group (IC 95%, 71.9-93.1) and 70.8% in the autologous vein group (IC 95%: 55.9-83.1), and the difference in secondary patency between the prosthetic and the autologous vein groups was 13.8% (IC 95%, -4.4 to 32.0). In the under treatment analysis, the 5 years secondary patency was 96.2% among patients receiving a prosthesis (IC 95%, 80.4-99.9) and 90.5% among patients receiving an autologous vein (IC 95%, 66.9-98.9), and the difference in the rate of patency between prostheses and veins was 5.7% (IC 95%, -13.2 to 24.6). Although there was no significant difference at 5 years, the death rate and the rate of amputation were higher in the prosthetic group. CONCLUSIONS: Although it is impossible to conclude definitely to the noninferiority of prosthetic bypass compared with venous bypass because of the insufficient number of inclusions, this randomized study nevertheless showed at 5 years the satisfactory results obtained with prostheses compared with autologous vein for above-knee femoropopliteal bypasses.

The role of the deep femoral artery in the treatment of thigh claudication in case of hypogastric occlusion.

BACKGROUND: This study evaluated the clinical and functional efficiency of deep femoral artery (DFA) revascularization in treating thigh claudication associated with ipsilateral internal iliac artery (IIA) occlusion. PATIENTS AND METHODS: The files of patients presenting with proximal claudication, ipsilateral IIA occlusion, and conventional surgical revascularization of DFA were retrospectively reviewed. Each patient benefited from preoperative and postoperative measurement of dynamic transcutaneous pressure of oxygen (TcPO2) and presented with preoperative proximal stress-related ischemia and with the clinical symptoms of buttock, thigh, or groin pain. RESULTS: Between May 2001 and December 2009, 23 DFA revascularizations were performed on 19 patients. Proximal stress-related pain disappeared in 17 lower limbs (74%). No postoperative thromboses were noted. Mean maximum walking distance (MWD) significantly improved (149±113 vs. 414±257 m; P<0.025), as did the ankle to arm systolic pressure index (0.71±0.17 vs. 0.90±0.19; P<0.005). Disappearance of proximal stress ischemia, revealed through postoperative dynamic TcPO2, measurement, occurred in 6 lower limbs (26%). Patency of ipsilateral superficial femoral artery, ipsilateral to the symptoms, seemed to be a predictive factor of MWD improvement (P<0.05). CONCLUSIONS: DFA revascularization is an efficient treatment for thigh claudication in case of IIA occlusion, even if the results are less satisfactory than those obtained through direct revascularizations of this artery.

Surgical reconstruction of the superior vena cava system: indications and results.

BACKGROUND: Obstruction of the superior vena cava (SVC) secondary to malignant or benign diseases is rarely treated by surgical reconstruction. The purpose of this retrospective study is to report our experience and compare our results with previous data in the literature. METHODS: From 1993 to 2006, 24 patients underwent operative reconstruction of the SVC. Mean patient age was 58 years. The underlying disease was primary bronchopulmonary malignant neoplasm in 50%, mediastinal malignant neoplasm in 21%, and symptomatic benign disease in 29%. Forty-six percent of patients presented clinical signs of superior vena cava compression (SVCC). Our indications were based on two criterions: clinical symptoms of superior vena caval compression or histological examination of the superior vena caval lesion that indicates potential for complete surgical excision. RESULTS: Median duration of postoperative intensive care was two days. Mortality at 30 days was 12% for malignant diseases. All patients presenting clinical signs of SVCC improved. Mean follow-up was 28 months (range, 1-129). No thrombosis was observed during follow-up. Overall survival was 53% at 1 year and 35% at 5 years. For patients with malignant bronchopulmonary disease, survival was 50% at 1 year and 25% at 5 years. Mortality was 0% for patients with benign disease. CONCLUSION: Review of the literature indicates that replacement of the SVC is an uncommon procedure. Our experience suggests that the need for SVC reconstruction should not, however, be considered as a contraindication for resection of a bronchopulmonary or mediastinal neoplasm in an otherwise potentially curable patient, provided it can be achieved in a single block with clear margins. Replacement of the SVC can also be performed with low mortality and morbidity for effective treatment of SVCC secondary to benign disease that fails to respond to medical therapy.

Contribution of magnetic resonance cholangiography to the anatomic study of bile ducts.

BACKGROUND/AIMS: Until recently, in-depth anatomic study of the biliopancreatic ducts was only possible with injection-corrosion techniques or peroperative radiology. These were tedious and tributary of the quality of anatomic specimens. Since 1990, a new minimally invasive technique has been available: nuclear magnetic resonance cholangiography (NMRCP). The aim of the study was to evaluate the feasibility and the results of NMRCP applied to the study of the biliopancreatic tract. METHODOLOGY: NMRCP was performed in 50 healthy volunteers and results were interpreted by two readers in consensus. RESULTS: NMRCP showed the common bile, left hepatic and paramedian ducts in 100% of cases. The right hepatic duct was seen in 78% of cases. The lateral duct was seen in 98% of cases. Segmental ducts were found in 68 to 78% of cases for segments II, III, VI, VII and VIII. Only 18% of ducts for segment I were found. The gallbladder was seen in only 72% of cases. The cystic duct was clearly seen in 64% of cases. The hepato-pancreatic duct was seen in 82% of cases. In 70% of cases, distribution of the hepatic ducts was modal. The remaining 30% displayed variations. CONCLUSIONS: The anatomic and radiological results reported in our study of 50 cases demonstrate the excellent feasibility and reliability of magnetic resonance cholangiography applied to the anatomic study of the bile ducts. We suggest that a wide scale multicenter study in living healthy individuals may be worth considering.

Ruptured aneurysm on a double origin of the posterior inferior cerebellar artery: a pathological entity in an anatomical variation. Report of two cases and review of the literature.

The posterior inferior cerebellar artery (PICA) is known to be very variable, and some of its anatomical variations can explain ischemic complications that occur during endovascular treatment of aneurysms. The authors report two cases of anatomical variation of the PICA that they have called its double origin, one of which gave rise to an aneurysm. The first patient was a 36-year-old man who presented with a subarachnoid hemorrhage related to the rupture of a PICA aneurysm. The aneurysm was treated by the endovascular route. Selective and superselective studies showed that the PICA origin was low on the fourth segment of the vertebral artery (VA). The aneurysm was located on an anastomosis between the PICA and a small upper arterial branch originating from the VA. Embolization was performed through the small branch with no problem, but a lateral medullary infarct followed, probably due to occlusion of the perforating vessels. The same anatomical variation was incidentally discovered in the second patient. To the authors' knowledge, neither this anatomical variation of the PICA nor the aneurysm's topography have been previously described angiographically. This highlights the role of angiography in pretreatment evaluation of aneurysms especially when perforating vessels or small accessory branches that are poorly visualized on angiographic studies are concerned, as in the territory of the PICA. Anatomy is sometimes unpredictable, and the surgeon must be very careful when confronted with these variations because they are potentially dangerous for endovascular treatment.