Prevalence and Causes of Normal Exercise Oximetry in the Calf in Patients with Peripheral Artery Disease and Limiting Calf Claudication.

OBJECTIVE: In patients with claudication, an ankle brachial index (ABI) under 0.90 is considered to be abnormal and a sufficient argument for the arterial origin of exercise induced pain. Exercise transcutaneous oxygen pressure (Ex-tcpO2) can provide evidence of exercise induced regional blood flow impairment (RBFI) and confirm the arterial origin of walking induced pain. The frequency with which calf Ex-tcpO2 remains apparently normal in patients with claudication and abnormal ABI is unknown. Causes of these discrepant results have yet to be analysed. METHODS: A retrospective analysis of 4575 Ex-tcpO2 tests performed on 3,281 patients was conducted. The focus was on patients with a history of calf claudication and ABI under 0.90. Duplicate or non-standard tests were excluded, as were patients with no pain or those able to walk more than 15 minutes (on a treadmill). Searches were conducted for possible explanations of normal calf Ex-tcpO2 in the selected patients. RESULTS: Cardiorespiratory limitation was identified in 50 patients and isolated non-calf ischemia in 36 of the 106 patients selected. There was no obvious explanation during Ex-tcpO2, but clinical improvement after non-vascular treatment or total absence of improvement after a technically successful revascularisation was noted in 12 patients. Four patients were lost on follow up. Four patients improved after revascularisation, which suggests that the Ex-tcpO2 result was false negative. CONCLUSIONS: Ex-tcpO2 is negative in more than 20% of tests performed in patients with an ABI under 0.90 and a history of calf claudication. In most cases, when excluding re-tests and non-limiting or non-calf claudication on the treadmill, non-calf ischemia or a non-vascular limitation occurring during the test were observed. This observation supports both the value of treadmill testing in patients with calf claudication assumed to be of arterial origin (ABI<0.90) and the use of Ex-tcpO2 to detect non-calf ischemia.

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study.

OBJECTIVE: During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. METHOD: From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75 ± 9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. RESULTS: The technical success rate was 97.6%. Failures were device migration (n = 1), navigation failure (n = 2), and release outside the target zone (n = 1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111 ± 51 mL and the radiation dose was 127,777 ± 89,528 mGy/cm(2). The total fluoroscopy time was 854 ± 538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n = 41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. CONCLUSION: This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

Hypogammaglobulinemia and risk of severe infection in kidney transplant recipients.

BACKGROUND: Recent data have outlined a link between hypogammaglobulinemia (HGG) and infection risk and suggested that HGG correction may decrease post-transplant infections. METHODS: We analyzed the risk factors of HGG and the relationship between HGG and the risk of severe infection in a cohort of 318 kidney transplant recipients (KTR) who were transplanted between 2003 and 2013. Immunoglobulin (Ig) concentration was measured prospectively at day 15 (D15), month 6 (M6), month 12 (M12), and month 24 (M24) post transplant. RESULTS: The prevalence of IgG HGG was 56% and 36.8% at D15 and M6, respectively. Age was the sole identified risk factors for D15 IgG HGG (odds ratio [OR] 1.02, P = 0.019). Risk factors for M6 IgG HGG were the presence of D15 IgG HGG (OR 6.41, P < 0.001) and treatment of acute rejection (OR 2.63, P = 0.014). Most infections occurred between D15 and M6 post transplant. Only age (hazard ratio 1.03, P < 0.001) was identified as a risk factor of infection between D15 and M6 post transplant. Survival free of infection (overall infections and bacterial or viral infections) did not differ significantly between patients with or without D15 IgG HGG. Only septicemia occurring between M6 and M12 post transplant was more frequently observed in patients with HGG. The low prevalence of severe HGG (<400 mg/dL) did not allow conclusions on the infectious risk associated with this patient subgroup. CONCLUSIONS: This study does not support the existence of a strong link between post-transplant HGG and the risk of severe infections in KTR. Correction of HGG to minimize the risk of severe infections in KTR is thus questionable and needs to be reevaluated in prospective studies.

Estimation of running capacity can likely be removed from questionnaires estimating walking impairment in patients with claudication.

OBJECTIVE: The Estimating Ambulation Capacity by History-Questionnaire (EACH-Q) and the Walking Impairment Questionnaire (WIQ) are used to estimate maximal walking distance (MWD). The EACH-Q and WIQ included 4 and 14 items respectively, among which one item dealing with running capacity. We hypothesised that this item was of little interest in patients with claudication. DESIGN: The WIQ and EACH-Q were self-completed and corrected before a constant load (3.2 km h(-1); 10% slope) treadmill tests, maximised to 15 min. PATIENTS: 371 patients (298 males/73 females, 62.9 ± 11.2 years). METHODS: The number of errors (duplicate, absent or paradoxical answers to one item) and correlation of questionnaire scores with MWD on treadmill were calculated, before and after skipping the answer to the running item. RESULTS: The proportion of questionnaires with errors was 27% with the EACH-Q and 48% with the WIQ. Two-hundred and twenty-one (59.6%) and 245 (66%) out of 371 patients reported to be unable to run, for the EACH-Q and WIQ, respectively. The rate of errors was reduced by 15% for the EACH-Q (p < 0.05) when skipping the running item for scoring. The correlation coefficients between the MWD and the questionnaire scores were 0.449 and 0.485 for the EACH-Q and were 0.571 and 0.572 for the WIQ, before and after skipping the running item, respectively. CONCLUSION: Most of our patients reported to be unable to run and skipping the running item reduce the rate of errors in self-completing the questionnaires without impairing the correlation of questionnaire scores with treadmill results. It is likely that the running item could be removed from the WIQ and EACH-Q questionnaires.

Exercise treadmill testing in patients with claudication, with and without diabetes.

AIM: To compare symptoms and walking capacities of patients with and without diabetes reporting vascular-type claudication. METHODS: We recorded self-reported maximal walking distance, maximal walking distance on treadmill test (3.2 km h(-1) , 10% slope), exercise transcutaneous oxygen pressure DROP index [limb transcutaneous oxygen pressure (TcpO2) changes from rest minus chest TcpO2 changes from rest] and symptoms on treadmill in 230 patients with diabetes and 982 patients without diabetes. Exercise-induced proximal and distal symptoms were analysed in the perspective of underlying proximal and distal ischaemia (DROP value < negative 15 mmHg). RESULTS: Self-reported maximal walking distance did not differ between groups, whereas maximal walking distance on treadmill test was lower in patients with diabetes vs. patients without diabetes (261 ± 257 and 339 ± 326 m, respectively; P < 0.05 when adjusted for potential confounders). In patients with ischaemia, the number of ischaemic areas (proximal and/or distal on right and/or left) was comparable between the two groups. Patients with diabetes had more distal ischaemia than patients without diabetes (38 vs. 29%, respectively; P < 0.01), whereas proximal ischaemia was similar between groups. The prevalence of lower-limb exercise-related symptoms without ischaemia was comparable between groups. There were more symptoms other than lower-limb pain in patients with diabetes than patients without diabetes (29.6 vs. 18.3%, respectively; P < 0.01). CONCLUSIONS: Patients with diabetes show more severe limitation on the treadmill and more non-limb symptoms than patients without diabetes, although self-reported walking capacity is comparable between the two groups. Using TcpO2, we confirm that patients with diabetes reporting claudication show more distal ischaemia than patients without diabetes, with no difference at the buttock level. Treadmill testing is of interest in patients with peripheral artery disease and diabetes.

Patency of direct revascularisation of the hypogastric arteries in patients with aortoiliac occlusive disease.

OBJECTIVES: Various indications for internal iliac artery (IIA) revascularisation have been reported. Revascularisations for gluteal ischaemia and buttock claudication remain controversial and uncommon. The objective of the study was to assess the patency of direct conventional revascularisations (CRs) of the IIA in patients with aortoiliac occlusive disease because few studies have focussed on this specific topic. MATERIALS AND METHODS: The charts of all patients who underwent CR of the IIA, between August 2000 and January 2009, were retrospectively reviewed. We recorded for each patient preoperative vascular work-up. All patients were tested for patency on January 2009. A computed tomography (CT) scan was requested if the duplex scan casts any doubt with regard to patency. If non-patent, the last date for confirmed patency was kept for the analysis. Functional outcomes at the proximal level were also collected. RESULTS: We studied 40 patients with occlusive disease. Buttock claudication was observed in 27 patients (66%), including eight (20%) in whom these symptoms were isolated. The 13 other patients had distal claudication or rest pain and documented proximal ischaemia, justifying the IIA revascularisations. We performed 44 conventional direct revascularisations of the IIA concomitant to aorto- or iliofemoral bypasses in these patients. The overall postoperative patency rate was 89%. Five early occlusions of the IIA remained asymptomatic. The median duration of follow-up was 39 months (3-86 months). The survival rate was 95% at 1 year and 86% at 5 years. The primary patency rate of the IIA was 89% at 1 year and 72.5% at 5 years. Buttock claudication disappeared in 23 of the 27 patients (85%), who were symptomatic at the proximal level prior to surgery. CONCLUSION: Direct IIA concomitant revascularisation has an acceptable patency rate in patients undergoing aorto- or iliofemoral bypasses for occlusive disease. When feasible, this technique appears to be safe for the treatment and prevention of buttock claudication.

[Surgical-site infections following varicose vein surgery according to a continuous series of 408 interventions in a teaching hospital]. / Infections du site opératoire sur ablation de varices d'après une série continue de 408 interventions réalisées dans un centre hospitalier universitaire.

OBJECTIVE: To determine the incidence of surgical-site infections (SSI) following varicose vein surgery in the vascular surgery ward of a French teaching hospital. PATIENTS AND METHODS: A prospective surveillance of SSI was conducted during one year, with a 30-day postoperative follow-up. SSI cases were identified by using the definitions of the Centers for Disease Control (CDC, USA). Data acquisition and analysis were performed with the Epi-Info 6.04 software (CDC). RESULTS: Three quarters of the 408 included interventions were characterized by a NNIS score equal to 0. All patients underwent a hair removing practice before intervention. Hair removing methods were very heterogeneous and often not in accordance with national recommendations (e.g. mechanic shaving for 44.6% of patients). The incidence of SSI was 1.2% (95% confidence interval=[0.2-2.2]). All infections were identified after hospital discharge. Four infected patients out of five presented obesity or excess weight, and two patients had diabetes mellitus. The mean age of infected patients was significantly higher than non-infected ones (70.4 years versus 52.0; p<0.01). All SSI had consequences like rehospitalization, reintervention, or antimicrobial therapy. CONCLUSION: According to our results, SSI following varicose vein surgery are scarce and mainly concerned high-risk patients. However, in an aim of prevention, it seems necessary to homogenize hair removing methods in this ward.

Functional outcome of hypogastric revascularisation for prevention of buttock claudication in patients with peripheral artery occlusive disease.

We have defined proximal lower limb ischaemia as a decrease in Exercise-transcutaneous oxygen pressure (TcPO(2)) lower than minus 15mmHg at the buttock level in patients with peripheral artery occlusive disease. The purpose of this study was to objectively evaluate the benefits of direct versus indirect revascularisation of internal iliac arteries (IIAs) for prevention of buttock claudication in this population. We retrospectively reviewed the charts of proximal ischaemia patients who underwent revascularisation and both preoperative and postoperative stress TcPO(2) testing. Revascularisation procedures were classified as either direct revascularisation, including percutaneous transluminal angioplasty and internal iliac artery bypass, resulting in a direct inflow in a patent IIA (group 1) or indirect revascularisation, including aortobifemoral bypass and recanalisation of the femoral junction on the ischaemic side, resulting in indirect inflow from collateral arteries in the hypogastric territory (group 2). Patency was checked 3 months after revascularisation in all cases. Treadmill exercise stress tests were performed before and after revascularisation using the same protocol designed to assess pain, determine maximum walking distance (MWD) and measure TcPO(2) during exercise. In addition, ankle-brachial indices (ABIs) were calculated. Between May 2001 and March 2008, a total of 93 patients with objectively documented proximal ischaemia underwent 145 proximal revascularisation procedures using conventional open techniques in 109 cases and endovascular techniques in 36. Direct revascularisation was performed on 50 limbs (35%) (group 1) and indirect revascularisation on 95 limbs (65%) (group 2). The mean interval between revascularisation and stress testing was 60+/-74 days preoperatively and 149+/-142 days postoperatively. No postoperative thrombosis was observed. Buttock claudication following revascularisation was more common in group 2 (p<0.001). No difference was observed between the two groups with regard to improvement in MWD (365 / 294 m) and ABI (0.20/0.22). Disappearance of proximal ischaemia was more common after direct revascularisation (p<0.01). The extent of lesions graded according to the TASC II classification appeared not to be predictive of improvement in assessment criteria following revascularisation. Conversely, patency of the superficial femoral artery was correlated with improvement (p<0.01). This study indicates that direct revascularisation, if feasible, provides the best functional outcome for prevention of buttock claudication.

First report of an ilio-popliteal bypass through the greater sciatic foramen. Case report.

A 47 year-old man, who had a history of pelvic radiotherapy for the treatment of testicular tumour 30 years ago, was referred with minor tissue loss of the right lower extremity, grade III, category 5 of the Rutherford classification. His groin region presented with severe radiation damage. Arteriography demonstrated the occlusion of external iliac and femoral arteries. Revascula-risation was performed in the lateral decubitus position, with a ringed polytetrafluoroethylene (PTFE) graft bypass between normal common iliac and popliteal arteries through the greater sciatic foramen. Quick healing was observed. Patient is well 6 months postoperatively. Immediate and 6 month postoperative imaging demonstrated the good patency of the graft. A duplex ultrasound performed 6 month postoperatively showed no significant compression while the patient was in the sitting position.

Mitochondrial complex I defect resulting from exercise-induced lower limb ischemia in patients with peripheral arterial disease.

This study aims to compare the structural and mitochondrial alterations between muscle segments affected by exercise-induced ischemia and segments of the same muscle without ischemia, in the same subject. In a prospective analysis, 34 patients presenting either peripheral arterial disease or chronic coronary syndrome without any evidence of peripheral arterial disease were eligible for inclusion based on findings indicating a need for either a femoro-popliteal bypass or a saphenous harvesting for coronary bypass. Before surgery, we assessed the level of exercise-induced ischemia in proximal and distal sections of the thigh by the measurement of transcutaneous oxygen pressure during an exercise treadmill test. Distal and proximal biopsies of the sartorius muscle were procured during vascular surgical procedures to assess mitochondrial function and morphometric parameters of the sartorius myofibers. Comparisons were made between the distal and proximal biopsies, with respect to these parameters. Thirteen of the study patients that initially presented with peripheral arterial disease had evidence of an isolated distal thigh exercise-induced ischemia, associated with a 35% decrease in the mitochondrial complex I enzymatic activity in the distal muscle biopsy. This defect was also associated with a decreased expression of the manganese superoxide dismutase enzyme and with alterations of the shapes of the myofibers. No functional or structural alterations were observed in the patients with coronary syndrome. We validated a specific model ischemia in peripheral arterial disease characterized by muscular alterations. This "Distal-Proximal-Sartorius Model" would be promising to explore the physiopathological consequences specific to chronic ischemia. NEW & NOTEWORTHY We compared proximal versus distal biopsies of the sartorius muscle in patients with superficial femoral artery stenosis or occlusion and proof of, distal only, regional blood flow impairment with exercise oximetry. We identified a decrease in the mitochondrial complex I enzymatic activity and antioxidant system impairment at the distal level only. We validate a model to explore the physiopathological consequences of chronic muscle ischemia.

Surgery of the pretransversal vertebral artery: indications and results.

AIM: The aim of this study was to evaluate our results with elective vertebral arteries surgery, to emphasize the indications of such revascularization and to compare it with previous larger studies. METHODS: The medical records of all patients who underwent a pretransversal vertebral artery (VA) revascularization between 1990 and 2004 at our University Hospital were retrospectively reviewed. RESULTS: Forty patients, with a mean age of 60.5 years, met the criteria for VA surgery and accounted for 4.2% of the vascular surgeries involving the brain. Seventeen (42.5%) patients presented with vertebrobasilar insufficiency of hemodynamic origin, 16 (40%) with embolism, and 7 (17.5%) had no neurological symptoms. Direct vertebrocarotid reimplantation was the main procedure performed. No death or stroke occurred preoperatively or during the perioperative period. Mean follow-up was 31 months. Overall survival was 86.9% at 3 years and the primary patency rate was 97.5% at 3 years. CONCLUSION: Our study confirms the good results achieved by the pretransversal conventional VA surgery. This surgery remains few in number despite the fact that about 25% of ischemic strokes occur in the vertebrobasilar region. Vertebrobasilar signs should be better recognized to avoid performing this type of procedure merely based on imaging criteria.

[Infrarenal aortic pseudo-aneurism due to Coxiella burnetii]. / Pseudo-anévrisme aortique sous-rénal à Coxiella burnetii.

Peripheral vascular expressions of Coxiella burnetti Q fever are not well known. Endocarditis with negative blood culture is the most frequent clinical presentation of chronic Q fever. To date, very few cases of aneurisms or vascular grafts infections have been described. We report the case of a 54-year-old man who presented an infrarenal abdominal aorta infection, leading to a giant pseudo aneurismal formation. Blood serology and polymerase chain reaction amplification identified C. burnetti from the aortic thrombus after pseudo aneurism surgery. The treatment associated infrarenal abdominal aorta repair using a cryopreserved aorta allograft, and long-term antibiotic therapy.

Validation of a new device for transcutaneous oxygen pressure recordings in real and simulated exercise tests.

AIM: Measurement of transcutaneous oxygen pressure (tcpO2) is of interest in critical limb ischemia at rest and also during exercise in patients suffering proximal claudication or claudication of questionable origin. The recent commercialization of the computerized multiprobe-TCM400 device (Radiometer, Copenhagen, DK) appears attractive for exercise tests but comparison with the previous devices has not been reported. Indeed, the final endpoint for the physician is to be sure that a new apparatus will not interfere with the results observed in patients. METHODS: Using a 5 probe-TCM400 and 5 single probe-TCM3s, simultaneous recordings of tcpO2 were performed: 1) in vitro during 25 simulated exercises and 2) in vivo during exercise treadmill tests in 27 vascular patients. We analyzed resting (REST), minimal absolute (MIN) and DROP (limb-changes minus chest-changes) values. TcpO2 absolute and DROP profiles were analyzed through cross-correlation to detect response delays between the devices. RESULTS: In simulated tests, the Pearson coefficient of correlation between TCM400 and TCM3 was r=0.99 for REST, MIN and minimal DROP. In treadmill tests, the Pearson coefficient of correlation between TCM400 and TCM3 was significantly higher with minimal DROP (r=0.88) than with REST (r=0.63) or MIN (r=0.7). A 15 s delay was observed with TCM3 as compared to TCM400 responses for both tcpO2 and DROP profiles. The rmax(2) of the cross-correlation was 0.74 and 0.67 for tcpO2 and DROP, respectively. CONCLUSIONS: Our observations underline the limits of the clinical in vivo comparison of 2 transcutaneous devices. Despite the differences observed in absolute values during in vivo tests with simultaneous recordings (assumed to rely on physiological and not technical problems), we suggest that TCM400 is valid for exercise tests with the advantage of improved user interface, automatic memorization and integrated multiple probes of this newly commercially available apparatus.

[Spinal destruction caused by chronic contained rupture of an infra-renal abdominal aortic aneurysm]. / Erosion vertébrale par rupture chronique d'un anévrysme de l'aorte abdominale sous-rénale.

The erosion of the lumbar vertebral bodies by a chronic contained rupture of an infra-renal abdominal aortic aneurysm is a rare event. Chronic contained rupture can cause diagnostic difficulties as there are many clinical presentations, such as: back pain, sciatic pain or an expansive abdominal mass. The diagnosis is sometimes made following an incidental finding on radiological examination. Currently a CT scan is the gold standard diagnostic tool. The outcome following urgent surgical or endovascular repair is equivalent to that of an elective aneurysm repair. We report a case of a 59 year old man admitted for septic rupture of a cutaneous fistula resulting from a false aneurysm in the left groin. Pre-operative CT scan revealed a 6 cm abdominal aortic aneurysm, with chronic contained rupture. This had caused bone erosion of the vertebral body of the third lumbar vertebrae.

Endovascular stent-graft placement in the descending aorta through an ascending aorto-bifemoral bypass.

PURPOSE: To report a combined conventional and endovascular strategy to treat a descending aorta anastomotic aneurysm. CASE REPORT: A 60-year-old man with previous obliteration of the infra renal aorta suffered from bilateral lower limb acute ischemia. Lower limb vascularization was provided by a previous thoraco-bifemoral bypass. Computed tomography and angiography revealed an aortic anastomotic false aneurysm and an embolic aspect of the first centimeters of the graft. Treatment combined revascularisation of the lower limbs by an ascending aorta bifemoral bypass through a median sternotomy and endovascular coverage of the false aneurysm by stent-graft placement in the descending aorta. Stent-grafts were introduced through a graft's limb and across the anastomosis in the ascending aorta. Imaging at 3 months revealed no endoleak and perfect patency of the bypass. CONCLUSION: This case illustrates how combined endovascular and conventional procedures can minimize surgical risks in complex cases.

Transcutaneous oxygen pressure measurements (tcpO2) at ankle during exercise in arterial claudication.

AIM: Although a time consuming technique, tcpO2 provides complementary information as compared to other tests. Simultaneous recording of systemic and peripheral oxygen pressure changes with exercise could be interesting to confirm that local hypoxemia is of arterial origin, but accuracy versus gold standard arteriography and objectively determined cut-off points to be used in arterial claudication at the ankle are not reported. EXPERIMENTAL DESIGN: retrospective plus prospective study. SETTING: institutional practice, ambulatory care. PATIENTS: 100 patients suffering stage 2 claudication (group A) were retrospectively studied to objectively define cut-off points derived from tcpO2 recordings to be used in exercise testing. Then, applicability and reproducibility of these cut-off points were analysed prospectively in another 50 patients (group B). INTERVENTION: tcpO2 was measured on both calves and with a chest reference electrode. Arteriography on each side was quoted positive for a diameter stenosis superior to 75% or occlusion on the aorto-popliteal axis or of all-3-calf arteries. RESULTS: The best performance was obtained with tcpO2 changes from rest at the calf normalised to eventual chest changes (DROP) during or following the treadmill test. Optimal cut-off point determined through ROC curve analysis for DROP was -15 mmHg in group A. Applying this cut-off point in group B provided a 86/84% sensitivity/specificity and showed excellent reproducibility. CONCLUSIONS: TcpO2 measurement on the calf during exercise could be useful in a selected population of patients with claudication of questionable vascular origin and/or when other non-invasive investigations cannot be performed.

Systematic diagnostic approach to proximal-without-distal claudication in a vascular population.

BACKGROUND: Very few observations of proximal-without-distal claudication have been reported in the literature. This is likely due to the use of questionnaires limiting vascular claudication to the calves and to the problems encountered in attributing unexplained "buttock" claudication to a vascular origin. METHODS: During a 2 1/2-year period, we searched for proximal-without-distal exercise-related pain with the San Diego claudication questionnaire among some 2000 patients referred for lower limb arterial investigations. Of these patients, 97 presented no contraindication to treadmill testing and were investigated with exercise transcutaneous oxygen pressure (tcpO2). We used buttock tcpO2 (DROP index<-15 mm hg) to argue for the presence of ischemia on the corresponding side. RESULTS: Ischemia consistent with symptoms was found in 61 patients, whereas pain on one or both sides without underlying ischemia was found in 36 patients, suggesting a non-arterial origin of the symptoms. More than half of the patients with proximal-without-distal claudication and underlying exercise-related ischemia had been suffering for more than 2 years before they were referred to the laboratory. Eleven of the patients were treated. The treatment was successful in all but one of them. CONCLUSIONS: An important delay before diagnosis is frequently observed in proximal-without-distal claudication. TcpO2 is useful in attributing proximal exercise-related pain to a vascular origin. Given the number of detected and successfully treated patients in this small monocentric study, it is surprising that so few observations have been published to date, suggesting that proximal-without-distal arterial claudication is most likely an underestimated diagnosis.

[Results of surgical treatment for renal artery dysplasia]. / Résultats de la prise en charge chirurgicale des dysplasies des artères rénales.

PURPOSES: To retrospectively assess functional results of surgical treatment for renal artery dysplasia. PATIENTS AND METHOD: From January 1992 to December 2001, 11 symptomatic patients including 9 women (mean age 47 years, range 23-67), underwent surgery for renal artery dysplasia. Three patients presented with normalized hypertension, three others presented with isolated systolic hypertension, and the five remaining presented with grade II or III hypertension. Angiograms showed evidence of dysplasia of 16 renal arteries. Six arteries showed stenosis (37.5%), four aneurysms (25%), four both (25%), and two arteries showed wall irregularities (12.5%). Endovascular revascularizations were performed in five patients (45%) during the treatment of six renal arteries (37.5%). All endovascular procedures were angioplasties without any stent placement. Six patients (55%) underwent conventional procedures (in situ or ex-situ surgery) for the treatment of seven renal arteries (44%). RESULTS: In the short term, the treatment had a significant decrease on the systolic arterial pressure (p=0.019) and in the number of drugs used (p=0.009), but was not significant in the diastolic arterial pressure (p=0.084). The benefits persisted after two years of follow-up (PAS, p=0.023, PAD, p=0.047, drugs p=0.03). Benefits persisted in all of the six patients who had had hypertension for less than five years. There was 60% functional failure in the treatment of the five patients with a more than five years history of hypertension. CONCLUSION: This study confirms the short and long term's beneficial results of the surgical treatment of symptomatic renal artery dysplasia. Rapid care of those patients should optimize the functional results.

[Endovascular treatment for obstructive disease of the aortoiliac bifurcation by the kissing stent technique]. / Traitement endovasculaire par "kissing stent" des lésions oblitérantes du carrefour aorto-iliaque.

PURPOSE: To evaluate short and medium-term results of endovascular repair of the aortoiliac bifurcation for occlusive disease by the kissing stent technique. METHOD: Twenty patients were included in this retrospective study between May 1999 and November 2002 (13 men, mean age 58 years, range 42-86). Fifteen were treated for bilateral common iliac artery stenosis (75%), four for unilateral common iliac artery occlusion with or without controlateral stenosis (20%), and one for bilateral common iliac artery occlusion (5%). Each patient had a clinical examination and dupplex-scan prior to discharge, at three months, twelve months then yearly. RESULTS: All procedures were successful. Forty balloon expandable stents were deployed in the kissing position (mean length and diameter, 45 mm and 9 mm). Nine other stents were also deployed either in the abdominal aorta (one patient) either in the lower portion of the common iliac artery. Intra-operative complications were represented by one hematoma of the groin region treated surgically, one emboli of the femoral bifurcation treated by Forgarty balloon embolectomy, three dissections of the common iliac arteries treated by stenting, and one internal iliac artery occlusion not treated. Mean follow-up was 21 months (range 3-36). Three significant restenoses (>50%) were diagnosed during this period and one patient had an additional transluminal procedure. No intra-stent occlusion was found. Primary and secondary cumulative patencies at 12 and 36 months were respectively 94.7%, 84,4% and 100%, 89%. CONCLUSION: We confirm the feasibility, and the reliability of endovascular aorto-iliac kissing stent reconstruction in occlusive disease for selected patients.

Imaging of thoracic aortic injury.

Isthmic aortic rupture or disruption should be systematically sought when there is high kinetic energy trauma to the thorax. This condition is extremely serious and life threatening. It needs to be diagnosed rapidly but diagnostic pitfalls must be avoided. CT angiography is the standard examination. The main CT signs of rupture or disruption of the thoracic aorta are periaortic hematoma, intimal flap, pseudo-aneurysm and contrast agent extravasation. There are three types of lesion: intimal, subadventitial or pseudo-aneurysmal, and complete rupture with lesion of the three tunicae, and it is important to grade them for better therapeutic management. The main diagnostic pitfalls of the CT scan are the presence of a ductus diverticulum and post-isthmic fusiform dilatation. Associated lesions must not be overlooked. The most common are ruptures of the aortic root and the thoracic aorta in the diaphragmatic hiatus.