Early Impact on Renal Parenchymal Vascularization of Chimney Grafts Versus Fenestrated Grafts.

OBJECTIVE: The primary objective of this retrospective study was to analyze the early impact of chimney (CG) versus fenestrated grafts (FG) on renal parenchymal vascularization and function. METHODS: All consecutive patients with juxta-renal abdominal aortic aneurysm (JR-AAA) treated by endovascular repair from December 2013 to July 2014 at the vascular unit, Pellegrin University Hospital, Bordeaux, France, were included. Serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) were reported at baseline and at J2 for acute kidney injury (AKI) incidence, and at J7 for AKI staging (KDIGO criteria); renal resistive indices (RRI) were reported for renal parenchymal repercussion at J-1, J0, and J1. RESULTS: Ten patients were included in the CG group and 25 in the FG group, with 13 and 50 renal target vessels, respectively. Successful target vessel revascularization was achieved in 92.3% and 100.0% of patients. The incidence of AKI (10% and 32%), baseline SCr, and eGFR did not differ significantly. SCr was more elevated in the FG group at J1 (p = .025), J2 (p = .051), and J7 (p = .052), and eGFR was significantly lower from baseline to J1 (p = .015) and J2 (p = .014). RRI did not differ significantly between both groups. RRI augmentation was only noted in the FG group from J-1 to J0 (p = .039) and J-1 to J1 (p = .059). Patients with a KDIGO score <2 versus ≥2 showed significantly different RRI at J0 (p = .038) and J1 (p = .007). ROC curve analysis showed that RRI measures could be a predictive factor for AKI at J0 (cutoff = 0.72, sensitivity [Se] = 50%, specificity [Sp] = 86%) and J1 (cutoff = 0.71, Se = 70%, Sp = 84%). CONCLUSIONS: This study showed no significant difference in terms of RRI, eGFR, and the incidence of AKI or CKD between CG and FG. However, post-operative SCr levels were higher with FG, which was corroborated by comparison between pre- and post-operative RRI. Results are limited by the small sample size, but early repeated measures of RRI could be helpful in alerting the clinician to post-operative renal degradation, allowing better-informed attempts to preserve renal function.

The "open" chimney graft technique for juxtarenal aortic aneurysms with discrepant renal arteries.

OBJECTIVES: A straightforward original Chimney Graft (CG) protocol has been developed at our institution in selected cases of juxtarenal aortic aneurysm (JRAA). The aim of this study was to present our clinical experience of consecutive series with use of uncovered self-expanding stent (SES) as "Open Chimney" (OCh) in the endovascular repair (EVAR) of JRAA. METHODS: A standard endograft with suprarenal fixation struts is delivered with its proximal covered edge just below the highest RA in JRAA presenting the ostium of the two renal arteries at a different aortic level and the distance between the highest renal artery and the beginning of the aneurysm (improved landing zone) ≥10 mm. The low-lying renal artery is maintained patent by the OCh graft (standard SES) delivered from left brachial access (6 Fr). All clinical, anatomical, and operative data were prospectively collected and retrieved for the study analysis. RESULTS: From July 2010 to November 2012, OCh EVAR was offered to 22 consecutive patients considered unfit for JRAA open repair. All procedures were technically successful with aneurysm exclusion and patent OCh graft. One small perioperative type Ia endoleak spontaneously disappeared at the 3-month CT control. One patient died because of acute decompensated heart failure. One patient presented a left hemispheric stroke. The median follow-up of 18 months (range 7-35) showed aneurysm exclusion in all patients without type I and III endoleaks, SES stenosis, and/or renal impairment. CONCLUSIONS: OCh-EVAR is a straightforward technique that can be employed in selected cases of JRAA, avoiding the more complex and expensive fenestrated EVAR.

In-situ revascularisation for secondary aorto-enteric fistulae: the success of silver-coated Dacron is closely linked to a suitable bowel repair.

OBJECTIVES: The purpose of this study was to assess short- and mid-term results of in-situ revascularisation (ISR) using silver-coated Dacron prostheses and bowel repair for management of secondary aorto-enteric fistulae (SAEF). DESIGN: Single-centre retrospective chart review. MATERIAL AND METHODS: This study includes all the patients treated by ISR using silver-coated Dacron for SAEF between 2006 and 2010. Primary end points were mortality and survival rates. Secondary end points were reinfection-free survival and secondary patency rates. RESULTS: Eighteen male patients with SAEF with a median age of 64 years were operated by ISR using silver-coated Dacron during the study period without operative death. The 30-day mortality was 22% and the in-hospital mortality rate was 39%. Indeed, during hospitalisation, a duodenal leak was observed in four patients including three who died. Four others patients died due to multi-system organ failure. Median follow-up was 16 months (range 1-66). The survival rate at 12 months was 55%. One duodenal leak was observed leading to death. The reinfection-free survival and the secondary patency rates at 12 months were 60% and 89%, respectively. CONCLUSION: In-situ revascularisation with silver-coated Dacron provides acceptable results in terms of mortality. This treatment may be useful for simple vascular reconstruction and allow greater attention to bowel repair that is a determinant in short- and mid-term survival.

Salvage treatment for venous aneurysm complicating vascular access arteriovenous fistula: use of an exoprosthesis to reinforce the vein after aneurysmorrhaphy.

OBJECTIVES: We report a new salvage technique for treating venous aneurysms (VAs) complicating vascular access arteriovenous fistula (AVF) using externally reinforced venous aneurysmorrhaphy. DESIGN: A retrospective study over a 20-month period from a single centre. PATIENTS: Patients presenting to the vascular surgery department, Bordeaux University Hospital for revision of a vascular access AVF were included. METHODS: Reinforced venous aneurysmorrhaphy consisted in removal of redundant vessel wall followed by reinforcement using an external prosthetic graft. Patency, diameter and flow were assessed by duplex ultrasound at 1, 6 and 12 months after salvage. RESULTS: Thirty-eight eligible patients were identified. Five were excluded because VA was associated with central vein stenosis; the remaining 33 underwent salvage. Indications were rapidly expanding or painful VA in seven cases; VA with frequent bleeding or damaged overlying skin in eight; VA in close relation to a stenosis in two; and VA associated with high-flow rate in 16. Cannulation was attempted after 30 days. Mean follow-up time was 12 S.D. 5 months (range: 4-22). Two repaired AVFs failed. Primary 1-year patency was 93%. No aneurysm or infection occurred. Reduction of high flow was successful in 12 of 16 patients. The remaining four required re-operation. CONCLUSIONS: Reinforced venous aneurysmorrhaphy is effective in controlling venous dilation and achieving patency. Reduction of high-flow rates was not always achieved. Further study is needed to evaluate long-term efficacy of this treatment.

Rio de La Plata study: a multicenter, cross-sectional study on cardiovascular risk factors and heart failure prevalence in peritoneal dialysis patients in Argentina and Uruguay.

A multicenter cross-sectional study was performed to evaluate the prevalence of heart failure (HF) and the associated cardiovascular (CV) risk factors in 298 peritoneal dialysis (PD) patients from Argentina and Uruguay, representing almost 30% of the total number of PD patients in the two countries. Bidimensional echocardiography, electrocardiography, and biochemical analysis were performed. Systolic HF was defined as an ejection fraction <50%. According to echocardiography, 84.6% showed left ventricular hypertrophy (LVH), 38.3% valvular heart disease, and 35.4% valvular calcification, whereas 20% showed intraventricular conduction disturbances on the electrocardiogram. The prevalence of CV risk factors was of 73% hypertension, 51% sedentarism, 18% diabetes, 16.8% obesity, 12% smokers, 42.3% phosphorus >5.5 mg per 100 ml, 42.3% parathyroid hormone>300 pg ml(-1), and 29.6% calcium phosphate product >55. The prevalence of systolic HF was 9.9%, being significantly associated with diabetes: odds ratio (OR)=4.11 (P<0.006) and hypoalbuminemia: OR=3.45 (P<0.011). Forty percent of patients with a diagnosis of left ventricular dysfunction at the time of the study were asymptomatic. Variables associated with LVH in the multivariate analysis were anemia (OR=4.06; P<0.001) and previous hemodialysis (OR=1.99; P<0.031). The identification of reversible risk factors associated to HF and the diagnosis of asymptomatic ventricular dysfunction in this PD population will lead our efforts to establish guidelines for prevention and early treatment of congestive HF in patients on PD.

Association of primary varicose veins with dysregulated vein wall apoptosis.

BACKGROUND: Disordered programmed cell death may play a role in the development of superficial venous incompetence. We have determined the number of cells in apoptosis, and the mediators regulating the intrinsic and extrinsic pathways in specimens of varicose vein. METHODS: Venous segments were obtained from 46 patients undergoing surgical treatment for primary varicose veins. Controls samples were obtained from 20 patients undergoing distal arterial bypass grafting surgery. Segments of the distal and proximal saphenous trunk as well as tributaries were studied. Cell apoptoses and mediators of the mitochondrial and trans membrane pathway were evaluated with peroxidase in situ apoptosis detection, Bax and Fas detection, caspase-9 and 8 detection in the medial layer. RESULTS: Disorganised histological architecture was observed in varicose veins. Primary varicose veins also contained fewer peroxidase in situ-positive cells than control veins (2.6% S.D. 0.2% versus 12% S.D. 0.93%, P=.0001, Mann-Whitney u test), fewer Bax positive cells (2.1.% S.D. 0.3% versus 13% S.D. 0.9%, P=.0001) and fewer Caspase 9 positive cells (3.2% S.D. 1% versus 12% S.D. 1.3%, P=.0001). Similar findings were observed in saphenous trunk, main tributaries and accessory veins. In patients with recurrent varicose veins in whom the saphenous trunk had been preserved showed similar findings to primary varicose veins. Residual varicose veins contained fewer peroxidase in situ-positive cells than healthy veins (3.2% S.D. 0.6% versus 11% S.D. 2%, P=.0001), fewer Bax positive cells (2.2% S.D. 0.3% versus 12% S.D. 0.7%, P=.0001) and fewer Caspase 9 positive cells (2.6% S.D. 0.6% versus 12% S.D. 1%, P=.0001). Immunohistochemical detection for Fas and caspase 8 remained equal was the same in the varicose vein and control groups. CONCLUSION: Apoptosis is down regulated in the medial layer of varicose veins. This dysregulation is attributable to a disorder of the intrinsic pathway and involves the great saphenous vein trunk, major tributaries and accessory veins. This process may be among the causes of primary varicose veins.

[Laparoscopic management of median arcuate ligament syndrome]. / Traitement du syndrome du ligament arqué médian par voie coelioscopique.

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac trunk. The classic management of median arcuate ligament syndrome involves the surgical division of the median arcuate ligament fibers in order to decompress the celiac trunk. This has traditionally required an upper midline incision. A few authors have described a successful laparoscopic release of celiac artery compression syndrome. Laparoscopy provides a less invasive, but equally effective method for decompressing the celiac trunk.

Embolization for persistent type IA endoleaks after chimney endovascular aneurysm repair with Onyx®.

PURPOSE: The purpose of this study was to determine retrospectively the safety and technical success rate of embolization using ethylene vinyl alcohol copolymer (Onyx®) for persistent type 1A endoleaks after chimney endovascular aneurysm repair (EVAR) for complex aortic aneurysms. MATERIAL AND METHODS: Nine consecutive patients (6 men, 3 women) with a mean age of 78.6 years (range: 62-87 years) presenting with persistent type IA endoleaks after chimney EVAR and an increase of aneurysm size were treated using transarterial embolization with Onyx®. RESULTS: Technical success was obtained in all patients (100%) and no complications were observed. Mean follow-up was 16 months (range: 3-35 months). Primary clinical efficacy was obtained for 8/9 patients (89%) and primary technical efficacy for 6/9 patients (67%). Secondary clinical efficacy was 100%, and secondary technical efficacy was 78%. CONCLUSION: Our results suggest that arterial embolization using Onyx® appears as a feasible and safe endovascular procedure of type IA endoleaks after chimney EVAR, although further validation is now required.

Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair.

PURPOSE: To retrospectively evaluate the safety and efficacy of embolization of persistent type II endoleaks occurring after abdominal endovascular aneurysm repair (EVAR) using ethylene vinyl alcohol copolymer (Onyx®). MATERIAL AND METHODS: Between 2008 and 2016, 28 consecutives patients (25 men, 3 women) with a mean age of 75.3years±9 (SD) (range: 59-90years) were treated for 29 persistent type II endoleaks with increasing aneurysm size>5mm occurring after EVAR. A total of 35 embolization procedures were performed using Onyx®, via a transarterial route (n=25) or direct puncture (n=10), with or without additional metallic coils. The endpoints were to evaluate the clinical efficacy, corresponding to the stabilization or decrease of aneurism size, and the technical efficacy, corresponding to the ability to complete the embolization. RESULTS: No severe complications were observed during and after embolization. The primary and secondary clinical efficacies were 75% (21/28) and 96.4% (27/28), respectively. Overall primary technical efficacy rate was 58.6% (17/29), greater for transarterial technique (72.8%) than for direct puncture (14.3%) (P=0.01). Secondary technical efficacy was 72.4% (21/29), with no differences between transarterial (81.8%) and direct puncture (42.8%) (P=0.06). CONCLUSION: Embolization with Onyx® of type II endoleaks after EVAR appears a safe and effective procedure.

[Treatment of below the knee lesions: Broadening the limits of vascular surgery]. / Traitement de l'artérite jambière : les frontières de la chirurgie vasculaire sont repoussées.

One third of patients with critical limb ischemia (CLI) has below the knee lesions and requires a restoration of direct blood flow into the foot. However, many of these patients are ineligible for open surgery. The primary goals thus become pain relief and limb salvage over patency. The angiosome concept helps determine the target artery to treat in priority. The endovascular approach has decreased morbidity and mortality rates compared to distal bypass surgery; while subintimal retrograde, trans-collateral and loop techniques push the limits of open surgery by reopening the plantar arch, thereby improving run-off. Early restenosis phenomena after angioplasty have been improved by the use of - limus drug eluting balloons and balloon expandable stents in case of flow limiting dissection or recoil with increased limb salvage rates. Moreover, drug-eluting stents have been proposed, and allow a reduction in reintervention and in-stent restenosis rates in short lesions; however, results on amputation rates or survival are limited. Vessel preparation is a key to overcoming some current limitations, including atherectomy, which increases technical success rates and reduces restenosis rates, especially in calcified lesions, chronic total occlusions and restenosis. These advanced techniques in distal endovascular revascularization have revolutionized limb salvage and support the interest of an endovascular first approach in CLI treatment.

What is the best management for abdominal aortic aneurysm in patients at high surgical risk? A single-center review.

AIM: To determine the best treatment for high-risk patients with abdominal aortic aneurysms (AAA). METHODS: We reviewed a prospective database of all patients who underwent conventional (OPEN) or endovascular aneurysm repair (EVAR) between January 1998 and December 2002. Patients were preoperatively classified according to the American Society of Anesthesiology (ASA). Comorbidities and medical risk factors were categorized according to the Ad Hoc Committee on Reporting Standards. Perioperative mortality and morbidity rates were analyzed according to the type of surgical procedure (OPEN vs EVAR) and ASA class. Patients in ASA classes I and II were excluded. Continuous data were expressed as mean +/- standard deviation. All data were calculated using the cumulated actuarial method of event outcome probability. Kaplan-Meier curves were constructed and the log-rank statistic and chi squared test were used for comparative data. P values less than 0.05 were considered to indicate statistical significance. RESULTS: Of the total 375 patients who underwent AAA repair, 168 (45%) belonged in ASA classes III and IV (85 submitted OPEN and 83 EVAR to repair). Among general risk factors only coronary artery disease differed significantly between the 4 groups (P = 0.04). The Bonferroni correction identified a statistically significant difference between ASA classes III and IV for the OPEN technique and for EVAR (P = 0.007 and P = 0.012). Neither 30-day morbidity or mortality differed significantly according to ASA class and surgical technique. The median follow-up was 19 months (range 5-60 months). The overall survival was 78% at 60 months. Survival rates during follow-up differed significantly in the 2 risk classes (ASA III 5/123, 4% vs ASA IV 9/38, 24%), (P = 0.0001). The deaths in the ASA class 4 patients (12/14; 86%) were caused by preexisting medical comorbidities (in 9 patients cardiovascular, in 1 cancer and in 2 cirrhosis). CONCLUSIONS: Except patients with small aneurysms (< 6 cm), in whom the risk of death at 1-year due to comorbidities exceeds the risk of a ruptured aneurysm, all patients at high surgical risk (ASA class IV) benefit from AAA repair. Patients with small aneurysms must undergo strict surveillance to assess growth and aneurysmal wall changes to prevent unexpected rupture.

Evidence for the use of drug eluting stents in below-the-knee lesions.

Peripheral arterial disease has become more and more present in daily practice, mostly due to the increase of cardiovascular risk factors, especially in below the knee (BTK) area in diabetic patients. Critical limb ischemia (CLI) is the most usual clinical presentation with a major amputation rate of 30%, mortality rate of 25%, and chronic pain of 20% at one year. Nowadays, endovascular treatment is usually the first choice, given the high comorbidity of those patients. Angioplasty and stenting in BTK lesions have already proven their efficacy in CLI treatment. However, BTK revascularization remains highly controversial in the treatment of intermittent claudication in TASC 2 recommendations. Restenosis being the major pitfall in BTK procedures, the use of drug-coated devices is one of the actual answers. We performed an extensive review of the literature over the last 15 years on the use of drug-eluting stents (DES) in BTK revascularization. DES has been compared to balloon angioplasty, in the ACHILLES trial, bare metal stents (BMS), in the DESTINY and YUKON trials, drug eluting balloons, in a trial guided by Siablis, and paclitaxel has even been compared to sirolimus in the PARADISE trial. In conclusion, DES is one of the solutions to the increase of BTK arteriopathy in CLI patients. Angiographic results are better, compared to BMS, in terms of primary patency, restenosis and TLR rates. However clinical results are missing. Treated lesions in the literature are short lesions. And DES is a metal balloon expandable stent with greater risks of compressions and stent fractures than nitinol self expandable stents, and such complications are known to increase post operative restenosis rates. Further reports are still needed on this matter.

Emergency and early carotid endarterectomy in patients with acute ischemic stroke selected with a predefined protocol. A prospective pilot study.

AIM: The appropriateness of early carotid endarterectomy (CEA) in patients with acute ischemic stroke is still unsettled. The aim of this study was to verify the safety and feasibility of early CEA in a consecutive series of patients with acute ischemic stroke observed in an emergency Department Stroke Unit. METHODS: During a 24-month study, out of 756 patients with acute ischemic stroke 33 (4.4%) were scheduled for early CEA. Endarterectomy procedures were distinguished according to the time between the onset of stroke and operation as emergency (within 8 hours), early CEA (1-18 days). Patients with impaired consciousness or an infarct larger than 2.5 cm on computed tomographic (CT) or magnetic resonance (MR) scans or both were excluded from surgery. All patients underwent spiral CT, echo-color-Doppler (ECD) sonography, transcranial Doppler (TCD) sonography and, when necessary, MR angiography within 6 hours of admission. No patient underwent conventional angiography. Most patients were operated on under cervical block (CB) anesthesia; general anesthesia (GA) was used only for those with an unstable neurological deficit. Selective shunting was used on the basis of intra-operative transcranial Doppler in patients under GA and the onset or worsening of neurological deficit under CB anesthesia. RESULTS: Of the 6 patients operated on within a median 6 hours after the onset of stroke, 1 (16.5%) had a fatal hemorrhagic transformation of the infarct, while the remaining 5 (83.5%) stopped fluctuating or progressing and had a favourable neurological outcome. Of the 16 patients operated on within a median 36 hours and of the 11 patients operated on within 7 days, none deteriorated after operation. CONCLUSION: Emergency CEA is feasible for acute ischaemic stroke provided that strict selection criteria are applied and the door-to-surgery interval is kept short (within 8 hours). Early CEA for secondary prevention is feasible and safe, confirming that a delayed operation is in most cases unwarranted. Large randomized trials are warranted before implementing emergent and early CEA in routine clinical practice.

[Can minimal arterial aggressions using non-penetrating mechanical clip suture prevent myo-intimal hyperplasia? Preliminary results]. / L'agression artérielle minimale lors de suture par clips mécaniques non pénétrants prévient-elle l'hyperplasie myo-intimale? Résultats préliminaires.

SUBJECT: Vascular anastomosis is still associated with a significant rate of early (stenosis, thrombosis) and delayed (intimal hyperplasia) complications. Even though suture closure remains the most widespread standard procedure, many mechanical systems have been developed mostly using non penetrating clips, aiming to make the suture easier, to reduce the operating time and to reduce the scarring process of the arterial wall. We investigated the usefulness of non penetrating titanium Vascular Closure Staple (VCS) developed for peripheral blood vessels anastomosis, in a study on 20 rabbits with the small VCS system. MATERIAL AND METHODS: On 20 rabbits, 9 of the aortic sutures were done with VCS clips and 11 were done by standard closure. RESULTS: We found a significant improvement in the operating time of the closure (9 +/- 2 minutes versus 14 +/- 4 minutes), early and delayed (10 weeks) patency and the respect of the aorta diameter (0.248 +/- 0.01 centimetres versus 0.246 +/- 0.039 centimetres) and loss of surface (40.3 +/- 5.59% versus 45.6 +/- 6.34%). The main improvement is the reduced intimal hyperplasia (0.128 +/- 0.05 millimetres versus 0.198 +/- 0.032 millimetres. P=0.012). CONCLUSION: Arterial closure can be performed more rapidly with VCS clips than with suture closure, and with a marked reduced reaction of intimal hyperplasia. With those elements it is necessary to continue the experimental studies and to evaluate the VCS sutures at mean and long term.

[Evaluation of the venous network before arterial revascularization surgery]. / Evaluation du capital veineux avant chirurgie de revascularisation artérielle.

Correct evaluation of the venous network before arterial revascularization is required to avoid unsuccessful explorations, underestimation of calibre because of spastic reactions to dissection and use of defective veins with unrecognized parietal or intraluminal lesions. The homolateral internal saphenous vein cannot be used in 10 to 30% of cases. Success of venous bypass is 30 to 40% greater than with prosthetic implants. Other veins can be used including the contralateral internal saphenous vein, external saphenous veins and veins from the upper limbs. Clinical evaluation is insufficient. Phlebography provides good results but is an aggressive exploration with certain limitations compared with duplex Doppler. Its potential complications are also absent with ultrasound exploration. Duplex Doppler is thus the first-line choice. Close coordination between the angiologist and the surgeon is essential to compare the exact measurements obtained preoperatively and the surgical findings, particularly concerning the venous calibre. Correction coefficients may then be established.

[Superficial femoral artery autotransplantation for popliteal artery damage: a good solution?]. / L'autotransplantation de l'artère fémorale superficielle dans les lésions artérielles poplitées. Une bonne alternative?

We chose not to use a vein to bypass a popliteal artery lesion in four preferring to perform an autotransplantation of a proximal segment of the homolateral superficial femoral artery. The proximal arterial segment translated downstream being replaced by a synthetic graft. This approach was used to treat a popliteal aneurysm in two patients and cystic adventitiel disease in two others. The great saphenous was unfit for bypass in two patients. One patient died with a patent transplant nine Months after surgery due to an unrelated urological problem. The other three patients were alive and symptom free, at least forty-two Months after surgery. All three had a patent transplant despite obstruction of the proximal synthetic bypass in one patient. Provided that the outcome in a larger number of cases confirms these favourable results, we think that this technique offers an attractive alternative to venous bypass, at least whenever a venous graft cannot be used.

[Ionizing radiation and hyperplasia of the intimal matrix: current data and perspectives]. / Radiations ionisantes et maîtrise de l'hyperplasie intimale.

Vascular reconstruction (bypasses or endoluminal procedures) is still associated with a significant rate of restenosis. For restenosis, smooth muscular cells are the principal actor by their property to migrate, proliferate and secrete extra-cellular substance after their change of phenotype. A variety of pharmacological and mechanical strategies have been directed with limited success. Using ionizing radiation have been recently developed, aiming to reduce the cell proliferation and consecutive restenosis following vessel injury (anastomoses or angioplasty). We reviewed the use of radiations on animals, cellular action and recent clinical trials. Recent clinical trials confirm an effective action of using radiations for restenosis prevention. We reviewed methods of delivering radiations also drawback and consequences using these hopefully methods.

[Non-penetrating vascular staples prevent myo-intimal hyperplasia and maintain arterial vasomotor reaction]. / Les clips de suture vasculaire non pénétrants limitent l'hyperplasie myo-intimale et maintiennent les réactions artérielles.

OBJECTIVES: Vascular anastomosis is still associated with a significant rate of early or delayed complications, particularly restenosis. We have previously demonstrated that non-penetrating clips can help prevent intimal hyperplasia. The aim of this study was to evaluate how well the use of mechanical clips prevents intimal hyperplasia while maintaining arterial vasomotor function. MATERIAL AND METHODS: An aortic suture was performed in 38 rabbits. A standard closure was used for 15 sutures and a small vascular closure staple (VCS) for 23. Morphological analysis was performed with standard staining, histomorphometry and immunochemical staining for smooth muscle and endothelial cells. Vasomotor response was assessed using IntraVacularUltraSound with baseline luminal area and luminal area after injection of acetylcholine and nitroglycerin. Vasomotor response was assessed before suture and before removing the aorta. RESULTS: There was a significant improvement in operating time for closure with vascular staples (8 +/- 2 minutes versus 13 +/- 3 minutes) without thrombosis. We noted reduced intimal hyperplasia with staple closure (0.156 +/- 0.052 versus 0.087 +/- 0.042 mm, p<0.01). There was no difference for the medial thickness and the intima/media ratio was significantly different. The luminal area after suture was significantly better after vascular staple closure (16.78 +/- 0.639 mm(2) versus 17.24 +/- 0.492 mm(2), p=0.016). Vascular response to acteylcholine and nitroglycerin was equivalent for the two groups. CONCLUSION: Vascular closure staples are efficient for arterial closure. These non-penetrating systems prevent intimal hyperplasia and maintain physiological arterial vasomotor response.

[Homolateral transposition of the internal jugular vein for axillo-subclavian venous thrombosis (of effort)]. / Transposition veine jugulaire interne homolatérale pour thrombose veineuse axillo-sous-clavière (d'effort).

UNLABELLED: Indications for treating subclavian vein obstruction are still being developed, especially for endovascular procedures with or without first rib resection. This article explores our experience with chronic and acute subclavian vein thrombosis persisting after medical treatment. In our department of vascular surgery, we have observed 2 cases of subclavian vein obstruction in 2 patients with Paget-Schroetler syndrome who developed major pain and edema in the dominant upper limb. Initially, we managed these patients medically with thrombolysis and anticoagulation. Then, as the significant symptoms persisted and venous thrombolysis developed, we decided on surgical treatment. Because of hypertrophic venous impairment, we used an aggressive procedure with venous bypass using jugular vein transposition and temporary arteriovenous fistula. We observed significant symptom relief and also perfect permeability of the venous bypass at 30 months. CONCLUSION: On the basis of our anecdotal experience and reports by other groups, aggressive treatment with decompression (first rib resection and scalenectomy) and jugular vein transposition could be recommended for persistent subclavian vein thrombosis. Because of the presence of a thoraco-brachial outlet syndrome the endovascular procedures should be completed by first rib resection.

[High-dose external ionizing radiation prevents intimal hyperplasia and limits secretion of growth factors PDGFbb, bFGF, and TGFb1. Experiments and results]. / Les radiations ionisantes externes à doses élevées limitent l'hyperplasie intimale et diminuent la sécrétion des facteurs de croissance PDGF-bb, bFGF et TGFb1. Expérimentation et résultats.

PURPOSE: To evaluate the ionizing radiation for intimal hyperplasia prevention and to assess the production of growth factors. METHODS: An oversized injury using an embolectomy catheter was performed on a rabbit distal aorta (N=23), associated (test group; N=12) or not (control group; N=11) with a post-operative external radiation (25 Gy). At t=45 days, histological studies and morphometric studies were performed on the aorta. Smooth muscular cells and endothelial cells were stained using immuno-histologic revelation. Immuno-histological analysis was performed on arteries for growth factors PDGFbb, bFGF and TGFb1. RESULTS: Twenty-one animals survived the procedure, 11 were in the test group and 10 in the control group. Intimal thickness and ratio intima/media were significantly lower after radiation (respectively p=0.008, p=0.008). There was no difference for the medial thickness (p=0.155). Immuno-histochemical positive staining for PDGF and TGFb1 was lower after radiation (respectively 18.44 +/- 2.963% versus 47.64 +/- 6.86%, p<0.001 and 10.11 +/- 3.18% versus 29.45 +/- 4.156%, p<0.001). There was no difference for the expression of bFGF growth factor. After radiation, the media was found to be reduced and replaced by interstitial fibrosis. CONCLUSION: After external radiation the thickness parameter of the intima and the ratio intima/media decreased significantly in comparison with the control group. PDGF and TGFb1 were also less expressed in the artery irradiated. Fibrosis recasting needs to be confirmed by further investigation.