Impact of conventional and biological disease-modifying anti-rheumatic drugs on arterial lesions in Takayasu arteritis.

BACKGROUND: The definition of Takayasu arteritis (TAK) remission and disease activity is still unclear. Vascular imaging is an essential tool for following-up patients. Herein, we aimed to compare the evolution of vascular lesions (ie vessel wall thickening and stenosis) under conventional disease-modifying anti-rheumatic drugs (cDMARDs) relatively to biological DMARDs (bDMARDs) in TAK patients followed with the same CT angiography modalities. METHOD: We compared 75 lines of therapy in TAK patients who received cDMARDs (n = 40 lines) and bDMARDs (n = 35 lines) using CT angiography. We established 1-3 main target vessels with vessel wall thickening and/or stenosis. Every targeted vessel had its thickness and its lumen diameter measured at the initiation of immunosuppressive treatment and at 12 months. RESULTS: We observed an overall reduction of arterial wall thickness in 73% of cases and 31% had >25% of wall thickness relative decrease. Using a linear mixed effects model, first line immunosuppressive therapy (p= 0.012) and bDMARDs relatively to cDMARDs (p= 0.026) were independently associated with vessel wall thickness reduction in TAK. Thirty-eight percent of the stenotic vessels had a > 25% relative increase in lumen diameter under immunosuppressive therapy. The relative increase >25% in lumen diameter was noted in 56% vs 17% with bDMARDs compared with cDMARDs. CONCLUSION: Immunosuppressive treatments can reduce arterial wall thickness and widen lumen diameter in TAK. bDMARDs seems to be more effective than cDMARDs to improve arterial lesions in TAK.

Surgical management of sporadic and schwannomatosis-associated pelvic schwannomas.

Pelvic schwannomas are rare tumors that may occur either sporadically or in the context of schwannomatosis. We retrospectively reviewed the charts of patients harboring a pelvic schwannoma under conservative management or operated at our reference center between 2016 and 2023. All patients were operated by a multidisciplinary team, combining a vascular surgeon and a neurosurgeon. Twenty-four patients harboring 33 pelvic tumors were included in the cohort, including 12 patients with sporadic lesions, 2 patients with NF2-related schwannomatosis, and 10 patients with NF2-independent schwannomatosis. Multi-nodular tumors were more frequent in schwannomatosis compared to sporadic cases (p = 0.005). The mean age at diagnosis was 41 years old. Schwannomas were located on branches of the sciatic nerve (23/33, 70%), the femoral nerve (6/33, 18%), and the obturator nerve (4/33, 12%). Over the course of the study, 16 patients were operated, including 11 sporadic cases. The indication for surgery was pain (12/16, 75%) or tumor growth (4/16, 25%). Complete resection was achieved in 14 of 16 patients (87%). The mean post-operative follow-up was 37 months (range: 2-168 months). At last-follow-up, complete pain relief was achieved in all 12 patients with pre-operative pain. Post-operative morbidity included 3 long-term localized numbness and one MRC class 4 motor deficit in a multi-nodular tumor in a schwannomatosis patient. Despite its limited size, our series suggests that nerve-sparing resection of pelvic schwannomas offers satisfying rates of functional outcome both in sporadic and schwannomatosis cases, except for multi-nodular tumors.

Thrombosis of Medium-Sized and Large Arteries During Covid-19 Infection: Results of the COVIVASC Study.

BACKGROUND: COVID-19 infection is associated not only with venous thromboses but also with arterial thromboses (COV-ATs) in relation with an endothelial dysfunction, a coagulopathy and rhythm disorders. The incidence, the topography, and the prognosis of COV-ATs remain poorly known. The objective of this study was to report the overall experience of the Greater Paris University Hospitals (Assistance Publique - Hopitaux de Paris, AP-HP) during the first pandemic wave of COVID-19 infection. METHODS: After approval by the ethics committee, a study using the AP-HP clinical data warehouse was carried out between March and May 2020. Overall, 124,609 patients had a polymerase chain reaction for COVID-19 in our hospitals, of which 25,345 were positive. From 20,710 exploitable stays, patients tested positive for COVID who presented an episode of acute COV-AT (except coronary and intracranial arteries) were selected on the basis of the French medical classification for clinical procedures codes. The data are presented as absolute values with percentages and/or means with standard deviation. RESULTS: Over the studied period, 60 patients (aged 71±14 years, 42 men) presented a COV-AT at the time of their hospitalization, an incidence of 0.2%. The arterial complication occurred 3±7 days after the COVID infection and was inaugural in 30% of the cases (n = 18). The sites of COV-AT were the lower extremities (n = 35%, 58%), the abdominal aorta (n = 10%, 17%), the thoracic aorta (n = 7%, 12%), the upper limbs (n = 7%, 12%), the cerebral arteries (n = 7%, 12%), the digestive arteries (n = 6%, 10%), the renal arteries (n = 2%, 3%), and the ophthalmic artery (n = 1%, 2%). Multiple COV-ATs were observed in 13 patients (22%). At the time of diagnosis, 20 (33%) patients were in intensive care, including six (10%) patients who were intubated. On computed tomography angiography, COVID lesions were classified as moderate and severe in 25 (42%) and 21 (35%) cases, respectively. Revascularization was attempted in 27 patients (45%), by open surgery in 16 cases, using endovascular techniques in 8 cases and with a hybrid approach in three cases. Six patients (22%) required reinterventions. The duration of hospitalization was 12±9 days. Early mortality (in-hospital or at 30 days) was 30% (n = 18). Nine (15%) patients presented severe nonlethal ischemic complications. CONCLUSIONS: Arterial involvement is rare during COVID-19 infection. The aorta and the arteries of the limbs are the privileged sites. The morbi-mortality of these patients is high. Future studies will have to determine if the systematization of anticoagulation therapy decreases the incidence and the severity of the condition.

Results of cryopreserved arterial allograft replacement for thoracic and thoracoabdominal aortic infections.

BACKGROUND: Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts. METHODS: Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity. RESULTS: Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively. CONCLUSIONS: Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications.

Short and Mid Term Outcomes of Cryopreserved Abdominal Aortic Allografts Used as a Substitute for Infected Prosthetic Grafts in 200 Patients.

OBJECTIVE: To investigate the use of cryopreserved arterial allografts (CAA) as a substitute for infected infrarenal aortic prostheses, and its outcomes. METHODS: A single centre retrospective study of consecutive patients receiving an abdominal aortic CAA after removal of an infected graft was conducted between January 1997 and December 2013. The primary outcome was the rate of allograft related revision surgery. Secondary outcomes were the 30 day mortality rate, survival, primary patency, limb salvage, and infection recurrence. Allograft ruptures secondary to infection and risk factors for allograft failure were also investigated. RESULTS: Two hundred patients (mean age 64.2 ± 9.4 years) were included. In 56 (28%) cases, infection was related to an enteric fistula. The mean follow up duration was 4.1 years. The 30 day mortality rate was 11%. Early revision surgery was needed in 59 patients (29.5%). Among them, 15 (7.5%) were allograft related and led to the death of three patients (1.5%), corresponding to a 7.5% 30 day allograft related revision surgery rate. During the first six months, 17 (8.5%) patients experienced 21 events with complete or partial rupture (pseudo-aneurysm) of the allograft responsible for five (2.5%) deaths, corresponding to a re-infection rate of 8.5%. The multivariable analysis showed that diabetes and pseudo-aneurysm of the native aorta on presentation were predictive factors for short term allograft rupture. After six months, 25 (12.5%) patients experienced long term allograft complications (rupture, n = 2, 1%; pseudo-aneurysm, n = 6, 3%; aneurysm, n = 2, 1%; thrombosis, n = 11, 5.5%; stenosis, n = 4, 2%;) requiring revision surgery resulting in one death. The five year rates of survival, allograft related revision surgery, limb salvage, primary patency, and infection recurrence were 56%, 30%, 89%, 80%, and 12%, respectively. CONCLUSION: CAAs provide acceptable results to treat aortic graft infection with few early graft related fatal complications. Long term allograft related complications are quite common but are associated with low mortality and amputation rates.

Factors influencing the recurrence of arterial involvement after surgical repair in Behçet disease.

OBJECTIVE: Arterial involvement in Behçet disease (BD) is rare, and its surgical management is a major concern because of its high recurrence rate. This study evaluated the influence of the surgical technique, device, and immunosuppressive treatment used on the postoperative recurrence in patients with non-pulmonary arterial BD. METHODS: A single-center, retrospective study was conducted of 23 patients meeting the international criteria for BD who underwent surgery for arterial involvement between May 1996 and September 2015. Recurrence was defined as the occurrence of arterial aneurysm or thrombosis during follow-up. Perioperative medical treatment and surgical technique used were reported. RESULTS: There were 47 surgical procedures performed in 23 patients. Mean follow-up was 8.4 ± 7.5 years. Initial arterial lesions were aneurysms and thrombosis in 85% and 15% of cases, respectively. Arterial lesions were aortic and peripheral in 48% and 52% of cases. Recurrence rate was 51%. Recurrences developed within <1 year in 24% of cases and at the same anatomic site in 92% of cases. Among the 24 recurrences, 17 were false aneurysms, 6 were thrombosis, and 1 was a true aneurysm in a different arterial site. To treat the arterial lesion, direct anastomosis was performed in 6 cases; bypass using the saphenous vein, graft, or allograft was performed in 6, 27, and 5 cases, respectively; and stent graft was used in 3 cases. Vascular lesions involved the aorta in 19 cases and a peripheral artery in 28 cases. Preoperative medical treatments, including colchicine, steroids, and immunosuppressants, significantly decreased recurrence rate: 28% (7/25) vs 75% (15/20) in untreated patients (P = .002). The recurrence rate was 42.5% (17/40) in patients treated postoperatively vs 80% (4/5) in untreated patients. The nature of the device used (vein, prosthetic graft, allograft, stent graft, or direct anastomosis) did not change the risk of recurrence. When anastomoses were protected using the prosthetic sleeving technique, the recurrence rate was three times lower (P = .08). CONCLUSIONS: Relapse is a main concern after surgical repair of arterial BD. This study suggests the need for targeted perioperative medical management to reduce the risk of arterial recurrence in BD patients. To this end, a multidisciplinary approach is mandatory. The use of sleeve anastomosis is associated with a numerically lower risk of recurrence. However, further studies are needed to confirm this efficacy.

Surgical repair of radiation-induced carotid stenosis.

OBJECTIVE: Carotid endarterectomy and carotid artery stenting are both valid therapeutic options for the treatment of radiation-induced carotid stenosis (RICS). The second has the advantage of being less invasive, although it seems to result in more restenosis than the first. Meanwhile, progress in radiation therapy and head and neck surgery has significantly increased the survival of these patients. As a result, treatment of RICS should be considered from a long-term perspective. This works presents perioperative and follow-up outcomes of surgical treatment of RICS. METHODS: This single-center retrospective study included all patients who underwent carotid endarterectomy for RICS from January 1998 to June 2017. Clinical and duplex ultrasound examination-based follow-up was performed postoperatively, at 1 month, 6 months, 12 months, and yearly thereafter. Kaplan-Meier curves were used for survival plots based on a log-rank test. Any abnormal finding led to angio-computed tomography scan and specialized neurovascular examination. RESULTS: Between 1998 and 2017, 128 patients (162 lesions) were treated. The median interval between radiation therapy and surgery was 16 years. Forty-five patients (35%) were symptomatic. The eversion technique was performed in 79 cases (49%), and the patch was favored in 24 cases (15%), prosthetic bypass graft in 51 cases (31%), and a venous bypass graft in 8 cases (5%). Two postoperative deaths (1.5%) (one secondary to massive stroke) were noted. The primary end point of early postoperative cerebrovascular event was 2.5%. Two cervical hematomas (1.2%) required surgical revision and seven cases of permanent cranial nerve injury were recorded. The median follow-up was 29 months (range, 2-199 months). There were no additional strokes. The 3-year primary patency rate was 96% and the 3-year freedom from neurologic event was 98%. CONCLUSIONS: Open surgical treatment of RICS lesions is a safe and durable option. Our results suggest that the outcomes of such treatment are good and in particular that rates of cerebrovascular event and restenosis are low and that cranial nerve injury should not be a concern. As a result, we consider that open surgery for RICS lesions should be offered as a first-line treatment. However, comparative data are mandated to address this issue.

Direct Distal Renal Artery Aneurysm Repair.

OBJECTIVE: Treatment of renal artery aneurysms (RAA) remains controversial. Endovascular treatment has increased for main trunk and for very distal aneurysms, whereas for lesions located at the bifurcation surgical treatment seems to be a valid option. The goal of this study was to describe the technique of direct reconstruction of RAA and to report on outcomes. METHODS: This study comprised single centre prospective collection of data with retrospective analysis (January 2015 to August 2018) of patients operated on for distal RAA using direct reconstruction. RESULTS: A total of 24 RAA in 21 patients (seven men and 14 women, mean age 59 ± 13 years) was included. History of hypertension was found in 15 patients and renal insufficiency was present in one. Mean pre-operative systolic and diastolic blood pressures were 134 ± 21 mmHg and 74 ± 10 mmHg, and mean pre-operative rates of creatinine and glomerular filtration rate were 67 ± 13 µmol/L and 93 ± 49 mL/min/1.73 m2, respectively. Indications for repair were a diameter >20 mm in seven cases (mean diameter = 25 ± 2 mm) or rapid growth in one case, symptomatic aneurysm in 12 cases (hypertension, haematuria, pain), and a concomitant lesion in four cases (splenic aneurysm, abdominal aortic aneurysm, occlusive visceral artery lesions). All lesions were distal, main artery bifurcation in 22 cases and hilar in two cases. The main aetiology was fibromuscular dysplasia (16 cases) followed by atherosclerosis (seven cases) and one case of Ehlers Danlos Syndrome. In situ reconstruction was possible for 22 RAA, while two cases required kidney autotransplantation. The mean renal ischaemia time was 18 ± 5 min. At two years, the patency rate was 100%, and mean systolic blood pressure decreased (134 mmHg-122 mmHg, p = .047). Renal function was stable from 93 ± 49 pre-operatively to 95 ± 35 mL/min/1.73 m2 in the post-operative course (p = .56). CONCLUSION: Direct reconstruction appears to be efficient for most RAA. This technique is complementary to ex vivo autotransplantation and endovascular treatment.

Multicentre Experience with the Chimney Technique for Abdominal Aortic Aneurysms in French University Hospitals.

OBJECTIVE: The chimney technique (ChEVAR) allows for proximal landing zone extension for endovascular repair of complex aortic aneurysms. The aim of the present study was to assess ChEVAR national outcomes in French university hospital centres. METHODS: All centres were contacted and entered data into a computerised online database on a voluntary basis. Clinical and radiological data were collected on all consecutive ChEVAR patients operated on in 14 centres between 2008 and 2016. Patients were deemed unfit for open repair. Factors associated with early (30 day or in hospital) mortality and type 1 endoleak (Type I EL) were calculated using multivariable analysis. RESULTS: In total, 201 patients with 343 target vessels were treated. There were 94 juxtarenal (46.8%), 67 pararenal (33.3%), 10 Crawford type IV thoraco-abdominal (5%) aneurysms, and 30 (15.1%) proximal failures of prior repairs. The pre-operative diameter was 66.8 ± 16.7 mm and 28 (13.9%) ChEVAR were performed as an emergency, including six (2.9%) ruptures. There were 23 (11.7%) unplanned intra-operative procedures, mainly related to access issues. The rate of early deaths was 11.4% (n = 23). The elective mortality rate was 9.8% (n = 17). Nine patients (4.5%) presented with a stroke. The rate of early proximal Type I EL was 11.9%. Survival was 84.6%, 79.4%, 73.9%, 71.1% at 6, 12, 18, and 24 months, respectively. The primary patency of chimney stents was 97.4%, 96.7%, 95.2%, and 93.3% at 6, 12, 18, and 24 months, respectively. Performing unplanned intra-operative procedures (OR 3.7, 95% CI 1.3-10.9) was identified as the only independent predictor of post-operative death. A ChEVAR for juxtarenal aneurysm was independently associated with fewer post-operative Type I ELs (OR 0.17, 95% CI 0.05-0.58). CONCLUSION: In this large national ChEVAR series, early results were concerning. The reasons may lie in heterogeneous practices between centres and ChEVAR use outside of current recommendations regarding oversizing rates, endograft types, and sealing zones. Future research should focus on improvements in pre-operative planning and intra-operative technical aspects.

Endarterectomy for Isolated Atherosclerotic Lesions of the Popliteal Artery.

BACKGROUND: In the endovascular era, angioplasty has grown a large place in the treatment of peripheral artery disease. Few studies have been focused in short atherosclerotic lesions of the popliteal artery itself, which remain for many surgeons a critical zone for the technical approach decision. We herein describe simple techniques of popliteal endarterectomy for the treatment of short popliteal occlusive disease. METHODS: Between January 2011 and June 2019, patients with isolated popliteal artery atherosclerotic lesions were included in this retrospective study. Indication for intervention was either disabling lower limb claudication or critical limb ischemia. We performed either endarterectomy by eversion of the popliteal artery or a simple endarterectomy with a patch angioplasty. We then studied the procedural data, the thirty-day outcomes, and the mid-term follow-up. RESULTS: A total of 17 patients were included in the study, and 18 limbs were revascularized with the endarterectomy technique. Total duration of the procedure was 100 ± 46 min. Overall technical success was 100%. Median hospital stay was 4 days. Complete clinical success, that is, freedom from claudication or rest pain, was achieved in all cases. No early additional procedure was needed. After a mean follow-up of 34 ± 32 months with no patient lost to follow-up, all patients were alive, and a 100% primary patency and limb salvage was observed. CONCLUSIONS: At 3 years' follow-up, endarterectomy of the popliteal artery appears to be a valid option for isolated and short atherosclerotic lesions.

Effects of Cross-Clamping on Vascular Mechanics: Comparing Waveform Analysis With a Numerical Model.

BACKGROUND: Immediate changes in vascular mechanics during aortic cross-clamping remain widely unknown. By using a numerical model of the arterial network, vascular compliance and resistance can be estimated and the time constant of pressure waves can be calculated and compared with results from the classic arterial waveform analysis. METHODS: Experimental data were registered from continuous invasive radial artery pressure measurements from 11 patients undergoing vascular surgery. A stable set of beats were chosen immediately before and after each clamping event. Through the arterial waveform analysis, the time constant was calculated for each individual beat and for a mean beat of each condition as to compare with numerical simulations. Overall proportional changes in resistance and compliance during clamping and unclamping were calculated using the numerical model. RESULTS: Arterial waveform analysis of individual beats indicated a significant 10% median reduction in the time constant after clamping, and a significant 17% median increase in the time constant after unclamping. There was a positive correlation between waveform analysis and numerical values of the time constant, which was moderate (ρ = 0.51; P = 0.01486) during clamping and strong (ρ = 0.77; P ≤ 0.0001) during unclamping. After clamping, there was a significant 16% increase in the mean resistance and a significant 23% decrease in the mean compliance. After unclamping, there was a significant 19% decrease in the mean resistance and a significant 56% increase in the mean compliance. CONCLUSIONS: There are significant hemodynamic changes in vascular compliance and resistance during aortic clamping and unclamping. Numerical computer models can add information on the mechanisms of injury due to aortic clamping.

Importance of Early Diagnosis and Care in Knee Dislocations Associated with Vascular Injuries.

BACKGROUND: Arterial injury secondary to acute knee dislocation (KD) is a rare but devastative complication. The aim of this study is to evaluate functional sequelae and factors of poor prognosis. METHODS: A retrospective monocentric series of consecutive KD with acute ischemia by popliteal artery injury was analyzed between 2005 and 2017. The main outcome was the amputation rate. RESULTS: Sixteen dislocations were included. Nine (56%) were due to public road accidents, 5 (31%) were due to falls from height, and 2 (13%) were due to sports injuries. Dislocation had occurred in the posterior location in 8 (50%) cases. Regarding arterial injury, there were 7 (44%) ruptures, 7 (44%) dissections, and 2 (13%) isolated thromboses. Eleven (69%) KDs with vascular trauma were associated with signs of acute ischemia. Revascularization was achieved by anatomical venous bypass in 14 (88%), resection and direct anastomosis in one (6%), and isolated thrombectomy in one (6%). Median time to surgery (time between trauma and vascular repair) was 7 hours (3.25-60.92 hours). Primary revascularization was performed in 12 (75%) cases. In three cases (19%), orthopedic reduction and stabilization were performed first. In one case, (6%) three-step management with vascular shunt at first, then with knee stabilization, and finally vascular bypass was carried out. Stabilization was achieved by using an external fixator in 13 (82%) cases, by open reduction and internal fixation in one case (6%), by ligamentoplasty in one (6%), and by using a long leg cast in one (6%). Fasciotomy was required in 12 (75%) cases. Two patients had early vascular complications, and 2 had early systemic complications. Three secondary transfemoral amputations were performed. Median follow-up duration was 23 months. No secondary amputation was recorded. At the end of follow-up, functional outcomes were evaluated using the Oxford Knee Score (OKS). The median OKS was 30 versus the pretrauma median OKS of 47 (P < 0.00028). No risk factor associated with limb amputation has been highlighted. CONCLUSIONS: Analysis of these results provided indications for therapeutic management of this condition. This study shows poor functional outcomes because of severity of vascular lesion in patients with orthopedic trauma but with healthy arteries.

2018 update of the EULAR recommendations for the management of Behçet's syndrome.

Several new treatment modalities with different mechanisms of action have been studied in patients with Behçet's syndrome (BS). The aim of the current effort was to update the recommendations in the light of these new data under the auspices of the European League Against Rheumatism (EULAR) Standing Committee for Clinical Affairs. A task force was formed that included BS experts from different specialties including internal medicine, rheumatology, ophthalmology, dermatology, neurology, gastroenterology, oral health medicine and vascular surgery, along with a methodologist, a health professional, two patients and two fellows in charge of the systematic literature search. Research questions were determined using a Delphi approach. EULAR standardised operating procedures was used as the framework. Results of the systematic literature review were presented to the task force during a meeting. The former recommendations were modified or new recommendations were formed after thorough discussions followed by voting. The recommendations on the medical management of mucocutaneous, joint, eye, vascular, neurological and gastrointestinal involvement of BS were modified; five overarching principles and a new recommendation about the surgical management of vascular involvement were added. These updated, evidence-based recommendations are intended to help physicians caring for patients with BS. They also attempt to highlight the shortcomings of the available clinical research with the aim of proposing an agenda for further research priorities.

Management of major organ involvement of Behçet's syndrome: a systematic review for update of the EULAR recommendations.

Objective: To assess the efficacy and safety of treatment modalities for major organ involvement of Behçet's syndrome (BS), in order to inform the update of the EULAR recommendations for the management of BS. Methods: A systematic literature review of all randomized controlled trials, controlled clinical trials, or open label trials assessing eye, vascular, nervous system or gastrointestinal system involvement of BS was performed. If controlled trials were not available for answering a specific research question, uncontrolled studies or case series were also included. Results: We reviewed the titles and abstracts of 3927 references and 161 studies met our inclusion criteria. There were only nine randomized controlled trials. Observational studies with IFN-α and monoclonal anti-TNF antibodies showed beneficial results for refractory uveitis. Meta-analysis of case-control studies showed that immunosuppressives decreased the recurrence rate of deep vein thrombosis significantly whereas anticoagulants did not. CYC and high dose glucocorticoids decreased mortality in pulmonary arterial aneurysms and postoperative complications in peripheral artery aneurysms. Beneficial results for gastrointestinal involvement were obtained with 5-ASA derivatives and AZA as first line treatment and with thalidomide and/or monoclonal anti-TNF antibodies in refractory cases. Observational studies for nervous system involvement showed improved outcome with immunosuppressives and glucocorticoids. Meta-analysis of case-control studies showed an increased risk of developing nervous system involvement with ciclosporin-A. Conclusion: The majority of studies related to major organ involvement that informed the updated EULAR recommendations for the management of BS were observational studies.

Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysms.

OBJECTIVE: A suitable ipsilateral great saphenous vein (GSV) autograft is widely considered the best material for arterial reconstruction of a popliteal artery aneurysm (PAA). There are, however, cases in which such a GSV is absent, diseased, or of too small diameter for this use. Alternatives to GSV are synthetic conduits, but with a reduced long-term patency, in particular for infragenicular bypass; other venous autografts of marginal use; and stent grafts still in the first stages of their evaluation. However, a sufficiently long segment of the ipsilateral superficial femoral artery (SFA) is often preserved in patients with a PAA. Such a segment may be used as an autograft for popliteal reconstruction. Moreover, the morphometric characteristics of the SFA often optimally match those of the distal native popliteal bifurcation. SFA autografts (SFAAs) have therefore become our choice when the ipsilateral GSV is not suitable. We herein present the long-term results of SFAA for the treatment of PAA in the absence of a suitable GSV. METHODS: Within this single-center study, all cases during the last 26 years were retrospectively reviewed. Demographics, risk factors, comorbidities, morphometrics of the PAA, and preoperative and follow-up data were intentionally sought. RESULTS: From 1997 to 2017, there were 67 PAAs treated with an SFAA. The mean age of the patients was 67.67 ± 12 years, and 98% were male. Symptoms included intermittent claudication in 25% (17), critical limb ischemia in 7% (5), and acute ischemia in 10% (7) of the patients; 51% (34) of the patients were asymptomatic. The mean aneurysm diameter of the treated PAA was 29 ± 11 mm (12-61 mm). The mean operative time was 254.8 ± 65.6 minutes (140-480 minutes), with a mean cross-clamp time of 64.5 ± 39 minutes (19-240 minutes). The median length of stay was 9 ± 6.4 days (5-42 days). There were no early amputations or deaths in the series. During a mean follow-up of 47.91 ± 48.23 months, there were 2 anastomotic stenoses, 11 thromboses, 1 infection, and 1 aneurysmal degeneration of the graft; 6 patients died of unrelated causes. The 1-, 3-, 5-, and 10-year primary and secondary patency rates were 93% and 96%, 85% and 90%, 78% and 87%, and 56% and 87%, respectively. CONCLUSIONS: These data suggest that SFAA use to treat PAA is a safe and durable option. A prospective and comparative work is necessary to confirm these results and to determine the interest of this technique as a first-line strategy.

Surgical internal iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms to avoid buttock claudication and distal type I endoleaks.

OBJECTIVE: The objective of this study was to assess outcomes of a hybrid technique for treatment of abdominal aortic aneurysm (AAA) associated with iliac aneurysm without distal neck by combining an AAA endovascular repair approach with open surgery for preservation of the internal iliac artery (IIA). METHODS: The files of 51 patients operated on between 1998 and 2017 in a single vascular surgery department were retrospectively analyzed. Inclusion criteria were patients with AAA associated with uni-iliac or bi-iliac aneurysm without suitable distal sealing zone. Surgery consisted of deployment of an aortouni-iliac stent graft combined with an extra-anatomic crossover prosthetic bypass. With use of a limited retroperitoneal approach, the contralateral proximal common iliac aneurysm was surgically excluded and the IIA revascularized by direct ilioiliac anastomosis or terminal common iliac suture, preserving the iliac bifurcation. RESULTS: The patients' mean age was 74 years (58-88 years), and 92% were men. The mean follow-up was 5.8 years (0.1-18 years). Twenty-nine patients (57%) had one or more high-risk criteria for open surgery. Nineteen patients (37.3%) had aortouni-iliac aneurysms, 19 (37.3%) aortobi-iliac aneurysms, 5 (10%) isolated iliac aneurysms, and 8 (15.7%) bi-iliac aneurysms without aortic location. Four patients (7.8%) also had IIA aneurysms. Surgery was successful in all cases. Two patients (4%) died during the 30 days after surgery. One surgically preserved IIA occluded within the first month, resulting in buttock claudication. The 5-year IIA primary patency rate was 96%. Type I proximal endoleaks occurred in two patients, requiring additional surgery 3 years and 13 years after the initial surgery, respectively. CONCLUSIONS: This hybrid technique, consisting of AAA endovascular exclusion combined with open IIA revascularization, is safe and effective for preservation of pelvic vascularization. It is associated with long-term patency and low morbidity rates. We have been using this technique since before the advent of branched dedicated devices, allowing preservation of the IIA with good results. This technique should continue to be proposed, especially in patients not eligible for endovascular iliac branch repair because of anatomic contraindications, to avoid pelvic ischemia if the IIA has to be sacrificed.

Large-vessel vasculitis in human immunodeficiency virus-infected patients.

OBJECTIVE: The objective of this study was to describe large-vessel vasculitis (LVV) in patients with human immunodeficiency virus (HIV) infection. It is a retrospective single-center study conducted between 2000 and 2015 through a university hospital of 11 HIV-infected patients with LVV. METHODS: The characteristics and outcome of 11 HIV-infected patients with LVV (7 patients fulfilled international criteria for Takayasu arteritis, 5 patients had histologic findings of vasculitis, and 5 patients had imaging features of aortitis) were analyzed and compared with those of 82 patients with LVV but without HIV infection. RESULTS: Concerning the HIV-infected patients with LVV (n = 11), the mean age was 40 years (range, 36-56 years), and 55% of patients were female. At diagnosis of LLV, the mean initial CD4 cell count was 455 cells/mm3 (range, 166-837 cells/mm3), and the median HIV viral load was 9241 copies. Vascular lesions were located in the aorta (n = 7), in supra-aortic trunks (n = 7), and in digestive arteries (n = 3). Inflammatory aorta infiltrates showed a strong expression of interferon-γ and interleukin 6. In HIV-negative LVV patients (n = 82), the median age was 42 years, and 88% of the patients were women. Thirty patients had an inflammatory syndrome. Seventy patients had been treated with glucocorticosteroids and 57 with immunosuppressive treatments. Compared with their negative counterparts, HIV-positive patients with LVV were more frequently male (P = .014), had more vascular complications (ie, Ishikawa score; P = .017), and had more frequent revascularization (P = .047). After a mean follow-up of 96 months, four relapses of vasculitis were reported, and one patient died. Regardless of the HIV virologic response, antiretroviral therapy improved LVV in only one case. CONCLUSIONS: LVV in HIV-infected patients is a rare and severe entity.

Postmortem Retrieval of Arterial Allografts: Preliminary Results.

BACKGROUND: Cryopreserved arterial allografts are vascular substitutes used for arterial reconstructions in a septic field. Their use remains however limited by the shortage of donors. One of the possibilities to address this lack of grafts is to multiply the sources of retrieval. The objective of this preliminary study was the evaluation of the early clinical results and the microbiological safety of arterial grafts retrieved after death. METHODS: In addition to the standard conditions of arterial sampling, the criteria of inclusion for postmortem retrieval comprised the refrigeration of the body of the donor within 4 hr following the death, a 24-hr time limit from the death, and the availability of an adapted place for retrieval (surgical unit or death chamber respecting the required aseptic conditions). We only retrieved the femoral axes (FAs) and the aortoiliac bifurcation. The conditions of retrieval, transportation, preparation, and conservation were identical to those of cryopreserved arterial allografts harvested during standard multiple organs retrieval. We evaluated the bacteriological risk of contamination and the patency of the grafts in the short and medium term. RESULTS: In 2015 and 2016, 6 donors were included. Eleven FAs and 2 aortic bifurcations were harvested. The bacteriological samples done on arrival in bank and after thawing were negative in the 6 donors, but one of the 6 donors presented a bacterial contamination of other removed tissues, and the arterial grafts obtained from this donor were destroyed as a precaution (3 grafts). The quality of the grafts evaluated by the surgeon during harvesting was good in all the cases. The indications of allografts were arterial reconstruction in a septic field (n = 8) and aorto-hepatic bypass during hepatic transplantation (n = 1). One graft was unhopefully thawed without being used. At the end of the follow-up, 8 out of 9 grafts were patent. Two ruptures occurred in a context of locally persistent sepsis (crural abscess due to Salmonella typhi and persistent groin wound disunion with a polymicrobial flora). One allograft thrombosis was observed (aorto-hepatic bypass for transplantation). These complications were unrelated to the mode of graft harvesting. No aneurysmal evolution was observed. CONCLUSIONS: The preliminary results of this protocol are encouraging because the immediate quality of the grafts was good with a risk of microbiological contamination identical with that of the usual harvesting mode. This mode of harvesting looks promising to reduce the shortage in arterial allografts and could be extended to harvest thoracic aortic allografts. However, results at a larger scale are necessary to confirm these data.

A multicenter experience with infected abdominal aortic endograft explantation.

OBJECTIVE: Endovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome. METHODS: We have reviewed all consecutive endograft explants for infection at 11 French university centers following EVAR, defined as index EVAR, from 1998 to 2015. Diagnosis of infected aortic endograft was made on the basis of clinical findings, cultures, imaging studies, and intraoperative findings. RESULTS: Thirty-three patients with an infected aortic endograft were identified. In this group, at index EVAR, six patients (18%) presented with a groin or psoas infection and six patients (18%) presented with a general infection, including catheter-related infection (n = 3), prostatitis (n = 1), cholecystitis (n = 1), and pneumonia (n = 1). After index EVAR, eight patients underwent successful inferior mesenteric artery embolization for a type II endoleak within 6 months of index EVAR and one patient received an additional stent for a type Ib endoleak 1 week after index EVAR. Median time between the first clinical signs of infection and endograft explantation was 30 days (range, 1 day to 2.2 years). The most common presenting characteristics were pain and fever in 21 patients (64%) and fever alone in 8 patients (24%). Suprarenal fixation was present in 20 of 33 endografts (60%). All patients underwent endograft explantation, with bowel resection in 12 patients (36%) presenting with an endograft-enteric fistula. Methods of reconstruction were graft placement in situ in 30 patients and extra-anatomic bypass in 3 patients. In situ conduits were aortic cryopreserved allografts in 23, polyester silver graft in 5, and autogenous femoral vein in 2. Microbiology specimens obtained from the endograft and the aneurysm were positive in 24 patients (74%). Gram-positive organisms were the most commonly found in 18 patients (55%). Early mortality (30 days or in the hospital) was 39% (n = 13) in relation to graft blowout (n = 3), multiple organ failure (n = 6), colon necrosis (n = 3), and peripheral embolism (n = 1). At 1 year, the rates of patient survival, graft-related complications, and reinfection were 44%, 10%, and 5%, respectively. CONCLUSIONS: Abdominal aortic endograft explantation for infection is high risk and associated with graft-enteric fistula in one-third of the cases. Larger multicenter studies are needed to better understand the risk factors and to improve preventive measures at index EVAR and during follow-up.