[Predictive factors of amputation after iliac angioplasty in patients with severe artery disease]. / Facteurs prédictifs d'amputation après angioplastie de l'artère iliaque chez les patients avec artériopathie sévère.

INTRODUCTION: Despite the success of angioplasty of the iliac artery, this technique remains associated with significant amputation rates. The purpose of this study was to identify predictive factors for lower limb amputation after iliac angioplasty in patients with critical ischemia. METHODS: We reported a retrospective study including patients who successfully underwent angioplasty of the iliac artery between 2014 and 2018. The primary endpoint was limb salvage at 1 month. The variables were studied in univariate and multivariate analysis. RESULTS: Our study included 86 patients. The median age was 57±10 and the sex ratio was 4.7. Cardiovascular risk factors were represented by smoking in 14 cases (16.3%), diabetes in 25 cases (29.1%), arterial hypertension in 2 cases (2.3%) and dyslipidemia in 2 cases (2.3%). Seventy patients (81.3%) were classified as stage 4 according to the Leriche and Fontaine classification and 16 patients (18.7%) were classified as stage 3. The lesions were stenosing in 48 cases (55.8%) and occlusive in 38 cases (44.2%). These lesions were classified according to the TASC classification "Trans-Atlantic-Society-Consensus" in TASC A-B in 61 cases (70.9%) and TASC C-D in 35 cases (29.1%). Distal arteritis was found in 8 cases (9.3%). Balloon angioplasty was performed in 36 cases (41.8%) and angioplasty stenting in 50 cases (58.2%). At 1 month, the amputation rate was 9.3%. Univariate analysis showed that diabetes and smoking were the most important factors associated with amputation (respectively P=0.007, OR=9.31, 95% CI=[1.73-50.07] and P=0.022; OR=6.8; 95% CI=[1.46 to 31.61]). Multivariate analysis showed that diabetes and distal arteritis were the predictive factors for amputation (respectively P=0.034, OR=21.06, 95% CI=[1.25 to 354.46] and P=0.008, OR=11,61, 95% CI=[1.88 to 71.69]). CONCLUSION: Diabetes and distal arteritis are the predictive factors for lower limb amputation after iliac angioplasty.

Crush stent technique: A bail out technique to manage occluded iliac stent.

Management of iliac stent thrombosis is challenging. Open surgical repair may be indicated when intraluminally stent catheterization is difficult to perform. The present review reports the crush stent recanalization technique illustrated with the management of a patient with critical limb ischemia associated to iliac stent thrombosis. Crush stent technique has been described in interventional cardiology but remains rarely performed. Few reported cases described this technique for peripheral arterial recanalization, that is stenting through the subintimal space around an occluded stent.

Endovascular repair of traumatic aortic isthmic rupture: Early and mid-term results.

INTRODUCTION: Conventional open repair of a traumatic aortic isthmic rupture is associated with a significantly high mortality and morbidity rates. Thoracic endovascular aortic repair (TEVAR) is currently often performed because it is a less invasive treatment than surgery. The aim of this study was to evaluate short and mid-term results of TEVAR in traumatic aortic isthmic rupture. METHODS: This is a retrospective study conducted between 2010 and 2018 including patients who underwent TEVAR for traumatic aortic isthmic rupture. RESULTS: Thirty-six consecutive patients were included. All patients had sustained a violent blunt chest trauma after a sudden deceleration with associated injuries. The injury severity score (ISS) was 40 (14-66). All patients were hemodynamically stable at admission. We deployed thoracic aorta stent grafts with a mean diameter of 26mm (18-36). The procedural success rate was 100%. We reported one intra-operative complication which was a distal migration of the graft, managed by an implantation of an aortic extension graft. On the first postoperative day, one patient presented an acute lower limb ischemia, probably due to the surgical femoral access, treated with an embolectomy with a Fogarty catheter with satisfactory results. The mean follow-up was 40.41 months (6.5-96). The mortality and paraplegia rates were 0% at one month and during the follow-up period. We reported a case of kinking of the graft that occurred at 6 months. No cases of endoleak neither re-intervention were reported. CONCLUSION: TEVAR is a safe and a reliable method for the treatment of sub-acute traumatic thoracic aortic injuries.

[Short- and long-term outcomes of surgical treatment of popliteal aneurysms]. / Traitement chirurgical des anévrismes poplités : résultats à court et à long termes.

INTRODUCTION: The popliteal artery aneurysm (PAA) is a rare vascular disease, but represents the most common site of peripheral aneurysms. We report in this paper our experience in the surgical management of PAA. OBJECTIVES: The aim of this work was to clarify the indications and the results of the surgical management of PAA. METHODS: It was a retrospective study, extended over a period of 12years, going from 2007 to 2018, covering 26 patients operated on surgically for popliteal aneurysm. RESULTS: We have operated 26 patients for PAA. All patients were male. The average age was 59years [39-80years]. The aneurysm was symptomatic in 22 cases and asymptomatic in 4 cases. The mean aneurysm diameter was 37mm [26-70mm]. Twenty-two patients have received a planned surgery and we did emergency surgery for 4 patients because of a limb ischemia complication. The surgical treatment consisted in a surgical bypass after the aneurysm removing. The restoration of blood continuity was achieved by a vein graft in 23 cases and prosthetic in 3 cases. Three patients needed major amputation within 30days (11.53%) and no mortality was observed during this period. Mean follow-up was 24months [12-96months]. Two-years mortality, complication rate and limb salvage was respectively 7.69%, 15.38% and 84.62%. CONCLUSION: The PAA represents a serious disease that can affect the vitality of the lower limb. Surgical treatment is currently the gold standard because of its good results.

[Revascularization delay and complications in acute upper limb ischemia]. / Délai de revascularisation et complications dans l'ischémie aiguë du membre supérieur.

INTRODUCTION: Acute upper limb ischemia is a medical and surgical emergency. Studies that have reported revascularization results in acute upper limb ischemia are rare. For this reason, the revascularization delay has remained poorly defined. The purpose of this study was to evaluate surgery results of acute upper limb ischemia related to revascularization delay. METHODS: We report a retrospective study of patients operated for acute upper limb ischemia between 2008 and 2016. Patients with thrombotic, traumatic or iatrogenic ischemia were excluded from this study. Patients were divided into two groups (those operated before 12hours and those operated after 12hours). A statistical analysis was performed to compare surgery results between the two groups in terms of limb salvage rate and neurological sequelae rate. RESULTS: Our population consisted of 138 patients. The average age was 69 [31,92]. There were 90 women and 48 men. The mean revascularization delay was 20hours [2,240]. Seventy-six patients were operated on before 12hours and 62 patients after 12hours. At one month, the mortality was 1.4% and the morbidity was 5.7%. The overall limb salvage rate was 86.9% and the overall neurologic sequelae rate was 31.8%. Statistical analysis showed that there was no significant difference between patients operated before or after 12hours in terms of limb salvage (86.8% versus 87%, P=0.258). However, there was a statistically significant difference in terms of neurological sequelae in favor of patients operated after 12hours (15.7% versus 51.6%, P=0.012). CONCLUSION: Revascularization of acute embolic upper limb ischemia is often associated with good results even if performed late. Beyond 12hours of ischemia, amputation rate is not significantly higher, however, the rate of neurological sequelae can be high.

[A rare localization of angio-Behçet revealed by a false aneurism of a gluteal artery treated surgically]. / Une localisation rare de l'angio-Behçet révélée par un faux anévrisme d'une artère glutéale traité chirurgicalement.

Behçet's disease is a rare chronic systemic inflammatory disease. It is more common in Turkey, North Africa and Japan. The incidence of vascular involvement (angio-Behçet) is 7 to 38%. The gluteal localization of angio-Behçet is rarely reported and could be revealed late. Aside from aneurysmal rupture, nerve compression with pain and lower limb impotence could be the main clinical signs. Because of the deep location of the lesion, management of this disease can be difficult. The classic surgical treatment remains the gold-standard especially in case of extreme urgency, non-feasibility of endovascular treatment and especially in case of associated nerve compression. We report the case of a 45-year-old man with a history of pulmonary angio-Behcet, who underwent emergency surgery for a huge false aneurism of a collateral of the hypogastric artery treated via a double anterior and posterior approach with good outcome.

[Percutaneous angioplasty of renal artery stenosis: Short- and long-term results]. / Angioplastie des sténoses de l'artère rénale : résultats à court et à long termes.

INTRODUCTION: Renal artery stenosis (RAS) may be symptomatic. The treatment of these lesions is primarily medical but may sometimes require surgical or endovascular revascularization. RAS angioplasty is well controlled but its results are discussed. The objective of this work was to report the short- and long-term results of the endovascular treatment of renal arteries in our center. METHODS: We report a retrospective study between 2013 and 2018, including patients who received endovascular treatment for severe symptomatic RAS (≥75%). RESULTS: Our population consisted of 17 patients. Mean age was 51.1 years [18-76], sex ratio 2.4. RAS was discovered during work-up for severe renovascular hypertension resistant to medical treatment for 16 patients and rapidly progressive renal failure for one patient. The etiology retained was: atherosclerosis (9 cases), fibromuscular dysplasia (6 cases) and Takayasu's disease (2 cases). The average stenosis rate was 85.9% [75-97%]. We performed simple angioplasty in 47% of the cases and stenting in 53%. The technical success rate was 100%. At 1 month, morbidity-mortality rates were zero. Mean follow-up was 12 months [6-36 months]. Patients with renovascular hypertension experienced a decrease in blood pressure, with discontinuation of antihypertensive therapy in 62.5% of cases and reduction of doses in 37.5% of cases. The permeability rate was 100% at 1 year, 94% at 2 years and 94% at 3 years. One patient had asymptomatic stent thrombosis at the 18th month. The restenosis rate was zero. CONCLUSION: Angioplasty of symptomatic RAS may be indicated as first-line treatment. It is associated with satisfactory results in the short and long terms.

[Endovascular treatment of chronic mesenteric ischemia]. / Traitement endovasculaire des angors mésentériques.

INTRODUCTION: Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries. METHODS: We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018. RESULTS: Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day. CONCLUSION: Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

[Femoral pseudoaneurysms in drug addicts: About 4 cases]. / Faux anévrisme de l'artère fémorale chez le toxicomane: à propos de 4 cas.

PURPOSE: To describe the therapeutic management of false aneurysms of the femoral artery in drug addicts. PATIENTS AND METHODS: We report the cases of four drug addicts with pseudoaneurysms of the femoral artery. RESULTS: All patients were male with a mean age of 36 years. Emergency surgical treatment involved removal of the pseudoaneurysm followed by a venous graft (n=3) or patch (n=1). The post-operative period was uneventful for three patients. One patient required early revision with a second venous bypass after bleeding from the first then later a second revision for resection of infected tissue and sartorius muscle plasty to cover the groin area. Late outcome was favorable for all patients after an average 12-month follow-up. CONCLUSION: No consensus has been reached concerning the appropriate treatment for false aneurysms of the femoral artery in drug addicts. Analyses of larger series with longer follow-ups are needed to elucidate the best emergency surgical methods capable of reducing the risk of rupture.

[Staff knowledge of radiation protection in endovascular surgery]. / Connaissances du personnel de chirurgie endovasculaire en radioprotection.

INTRODUCTION: Image intensification exposes the endovascular surgery staff to ionizing radiation. The aim of this study was to determine awareness of ionizing radiation risks among personnel working in the endovascular surgery environment and the availability of radiation protection clothes and to propose appropriate corrective measures. METHODS: This descriptive study was performed in the endovascular operating theatre equipped with a mobile image intensifier unit in La Rabta vascular department in September 2017. We visited the endovascular theatre to identify the availability of radiation protection clothes. We used a questionnaire to identify personnel knowledge about ionizing radiation. We established a global score of knowledge to classify our population. RESULTS: We identified 85 professionals exposed to ionizing radiation. Sixty-four of them (75%) responded to our questionnaire; 65% were male; median age was 34 years (range: 25-61). Endovascular theatre personnel were surgeons (35%), nurses (34%), qualified technicians (18%) and other department employees (13%). The mean global score of knowledge was 8.15/20 (2-18). This score increased significantly with grade and seniority (Kruskal-Wallis test). CONCLUSION: In the present study, the results indicate insufficiency knowledge about radiation exposure among the endovascular staff and in radioprotection tools availability. In order to minimize all unnecessary radiation, attempts should be made to increase vascular theatre staff knowledge about radiation protection. Safety culture is a referral method to reduce radiation exposure as low as possible.

[Femoropopliteal angioplasty: Short- and mid-term results]. / Angioplastie de l'axe fémoro-poplité : résultats à court et à moyen terme.

BACKGROUND: Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease. METHODS: Femoropopliteal percutaneous transluminal angioplasty was performed on 162 consecutive limbs (160 patients) from January 2006 to January 2016. RESULTS: In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included angioplasty only in 70 cases (43.2%), and the remaining 92 (56.8%) received at least one stent. Technical success was achieved in 98.7% of patients, with three deaths and a major morbidity rate of 15%. The actuarial primary patency at 12 and 36 month was 65.4% and 40.2%, respectively, 33 peripheral reinterventions were performed after femoropopliteal axis occlusion, resulting in an actuarial primary limb preservation rate of 94.4 at 12 months. Comparison between angioplasty only and the use of stent show no difference in primary patency (P=0.832) and limb salvage (P=0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P<0.001) and TASC D (P<0.001). However, diabetes mellitus (P=0.001) and poor run off (P<0.001) were the principal predictive factors of limb loss. CONCLUSION: Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization.

[Traumatic dissection of the innominate artery. A case report]. / Dissection traumatique du tronc artériel brachiocéphalique. À propos d'un cas.

INTRODUCTION: Lesions affecting the supra-aortic arterial trunks often occur in a contest of severe chest trauma. They are rarely isolated and can be life-threatening. We report a case of surgery for an isolated traumatic dissection of the innominate artery. CASE REPORT: A 48-year-old patient had a road accident causing head injury, trauma of the left lower limb and blunt chest trauma. At the physical exam, the pulse at the upper right limb was weak compared to the contralateral member. A pressure gradient of 50mm Hg was recorded between the two upper limbs. A whole body scan revealed a dissection of the innominate artery sparing its origin and bifurcation. Cervicotomy and sternotomy was necessary to achieve control. After heparinization and clamping, a prosthetic bypass was inserted to replace the innominate artery. The postoperative course was uneventful and the pressure gradient between the two upper limbs disappeared. CONCLUSION: Lesions of the brachiocephalic arterial trunk are not frequent but they are serious. A careful physical exam at admission helps detect them. Prognosis is directly linked to early diagnosis and management. Conventional surgery provides good results and remains the standard treatment for these lesions.

[Aortic stent migration: a rare complication after endovascular repair]. / Migration d'endoprothèse aortique : une complication rare après traitement endovasculaire.

Migration of an aortic stent is one of the most serious complications that can occur during follow-up after endovascular repair of an abdominal aortic aneurysm. We report the case of a 75-year-old man who underwent endovascular treatment for an infra-renal aortic aneurysm using an aorto-mono-iliac stent associated to a femoro-femoral bypass. The angiography performed at the end of procedure showed complete exclusion of the aneurysm. The postoperative course was uneventful. CT scans at 1, 6 and 12 months were normal. The CT scan at the 18th month showed a proximal migration of the stent, which was complicated by a type 1 endoleak and a stent disjunction with a type 3 endoleak. Revision surgery was indicated but the patient died from aneurismal rupture pending treatment. The migration of an aortic stent is a rare but serious complication of endovascular aneurysmal repair. Prevention requires a precise anatomical selection and adequate deployment of the stent graft.