Uretero-iliac fistula: modern treatment via the endovascular route.

We report three cases of ureteral-iliac fistula (UIF) in patients referred for treatment of macroscopic haematuria. Though it is a classic aetiology of haematuria, it is often difficult to diagnose and the treatment is not yet standardized. A diagnostic evaluation in combination with multidisciplinary approach improves the prognosis of the patients. Curative treatment via the endovascular route is effective and safe, and has a rapidly favourable course in all of our patients. The use of covered stents combined with the Amplatzer™ vascular plug makes the procedure easy and safe.

Radiocephalic fistula complicated by distal ischemia: treatment by ulnar artery dilatation.

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. However, its frequency is increasing with the rise in numbers of elderly and diabetic patients. This complication, which is more common for proximal than for distal accesses, can be very severe and may cause loss of hand function, damage to fingers, and even amputation of fingers or the hand. Its treatment is difficult and often leads to access loss. We report here a case of severe hand ischemia related to a radiocephalic fistula successfully treated by ulnar artery dilatation.

[Carotid Stenting in France after the EVA 3S and SPACE publications]. / Stenting carotidien en France après les publications d'EVA 3S et de SPACE?

Angioplasty of stenoses of the carotid bifurcation is a revascularization procedure that is used successfully in many patients. With more than 10 years of experience now, the feasibility of carotid stenting has been demonstrated. Its distribution is highly variable depending on the country, with a mean penetration rate in Europe of 15% of the number of carotid revascularizations. However, the complication rate is highly variable from one series to another and depends on the type of patient treated and the operator's learning curve. The results of the first two randomized studies comparing endarterectomy and carotid stenting, EVA 3S in France and SPACE in Germany, have just been published. The conclusions of these studies only relate to symptomatic patients, who make up a small proportion of revascularized patients. At 30 days, the French study concluded that surgery was better, and the German study showed no advantage to stenting. The analysis of these results compared to other publications should make it possible to best define the current indications for carotid stenting.

[Imaging of the extracranial carotid arteries: when, how and why?]. / Quand, comment et pourquoi réaliser une imagerie des carotides extracrâniennes?

The indications for treating carotid artery stenosis are related to the symptomatic nature of the lesion and the degree of stenosis. Duplex sonography is adequate for screening. While some groups believe that Duplex US alone or in combination with transcranial Doppler imaging may be sufficient for presurgical evaluation, it often is recommended to complete the evaluation with either MRA or CTA. Both techniques are advantageous since they allow evaluation of the cervical and intracranial arteries as well as cerebral parenchyma hence providing valuable information prior to definitive management. Catheter angiography remains indicated in patients with multi-vessel disease and ischemic cardiomyopathy, when results at non-invasive evaluation are discordant or in an emergency setting. Duplex US is used for routine follow-up of non-surgical lesions and after endarterectomy. Transcranial Doppler as well as advances in MRA and CTA techniques will be reviewed. Even though the treatment of atherosclerotic carotid artery stenoses remains primarily surgical, specific considerations related to angioplasty will be reviewed. Finally, diseases of the intracranial carotid artery and non-atherosclerotic diseases (dissection...) will also be discussed.

Carotid angioplasty and stenting with and without cerebral protection: clinical alert from the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) trial.

BACKGROUND AND PURPOSE: Whether cerebral protection during carotid angioplasty and stenting (CAS) is associated with a lower risk of periprocedural stroke or death remains to be established. We report on 80 patients randomized in the CAS arm of the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis trial comparing CAS (with or without cerebral protection) with carotid surgery in patients with recently symptomatic, severe carotid stenosis. SUMMARY OF REPORT: The Safety Committee recommended stopping unprotected CAS, because the 30-day rate of stroke was 3.9 (0.9 to 16.7) times higher than that of CAS with cerebral protection (4/15 versus 5/58). CONCLUSIONS: Although this result was not based on a randomized comparison of unprotected versus protected CAS, it suggests that the use of cerebral protection devices during CAS reduces periprocedural strokes.

[Critical limb ischaemia: endovascular treatment in diabetic patients?]. / Approche interventionnelle des artériopathies périphériques. Existe-t'il des spécificités chez le diabétique?

Endovascular treatment has an increasing role in the treatment of patients with critical limb ischemia, particularly in diabetic patients with a majority of infrapopliteal lesions. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses and short occlusions that impair distal vascularization. Stents are indicated when there is a suboptimal results following balloon angioplasty (recoil or dissection). Restenosis rate after primary stenting for long lesion is high. Angioplasty is a safe and effective procedure, allowing limb salvage rate in a majority of the cases with a low mortality and morbidity rate.

[Lower limb arterial disease: Doppler sonography follow-up after revascularization]. / Artériopathie des membres inférieurs: suivi par échographie-Doppler après revascularisation.

Follow-up color duplex sonography after arterial surgery or angioplasty for lower limb arterial disease evaluates the outcome of the procedure and searches for lesions compromising patency. The various types of lesions are described. After surgical bypass, lesions include stenosis, anastomotic abnormality (enlargement, false-aneurysm), arterio-venous fistula, intrinsic bypass abnormalities, and collections. After endoluminal treatment, the main lesions include residual stenosis, restenosis, and in-stent hyperplasia. Local complications related to arterial puncture are described. The frequency and the type of lesions encountered depend on the interval between the date of the revascularization and the follow-up examination.

Manual catheter-directed aspiration and other thrombectomy techniques for declotting native fistulas for hemodialysis.

Recent articles reported excellent results in the percutaneous declotting of native fistulas for hemodialysis with use of thromboaspiration, mechanical devices, or thrombolytic drugs, with success rates ranging from 76% to 100%. These results challenge the surgical approach, the effectiveness of which is not supported by comparable publications. Although it is more difficult to declot forearm native fistulas than grafts, declotting of fistulas is more rewarding because it achieves better long-term patency (1-year primary rates as high as 50% and secondary rates of 80%). The results reported from declotting of fistulas in the upper arm are not as good. The unmasking of stenoses in close to 100% of cases warrants stenosis detection programs similar to those used for grafts.

[Current role of angioplasty in lower limb arteriopathy obliterans]. / Aspect actuel de l'angioplastie dans l'artériopathie oblitérante des membres inférieurs.

For intermittent claudication caused by aorto iliac artery occlusive disease, percutaneous transluminal angioplasty is a safe and successful treatment. The introduction of vascular stents has been helpful in case of insufficient luminal gain (recoil or local dissection) or complications (extensive dissection). The results of angioplasty of femoropopliteal lesions must be compared with those obtained with medical or surgical treatment. In case of significant stenosis or short occlusions, conventional angioplasty alone is employed most of the time. Interventional radiology has an increasing role in the treatment of patients with critical ischemia. The majority of the culprit lesions are infra-inguinal. The goal of endovascular treatment is limb salvage (obtained in more than 80%) of the cases, not long-term patency. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses/short occlusions.

[Diagnosis of cardiac tumor by percutaneous thromboaspiration. A case report]. / Diagnostic d'une tumeur cardiaque par thromboaspiration percutanée. A propos d'un cas.

Percutaneous endovascular thromboaspiration is a valuable tool as illustrated by the case of a patient suffering from a large intracardiac tumour. Histological and immuno-histochemical analysis of the tumour fragments provided the diagnosis of a cardiac angiosarcoma. The patient was a 44 year old man admitted for a large sero-sanguinous pericardial effusion which recurred after drainage. The case was complicated by a haemorrhagic cerebrovascular accident unrelated to a secondary deposit. Initially suspected after transthoracic echocardiography, the diagnosis of a tumour invading the right atrium was confirmed by transoesophageal echocardiography and cardiac CT scan. Surgery was declined and as the diagnosis of lymphoma could not be excluded, the patient underwent biopsy by an original method of percutaneous thromboaspiration. This minimally invasive, low cost technique would appear to be a valuable alternative to other endovascular biopsy techniques (saber, biotome) and to surgical biopsy, and could be proposed as the technique of first intent in an a priori non-operable intra-cardiac tumour or when lymphoma is suspected.

Multiparametric attenuation and backscatter images for characterization of carotid plaque.

The goal of this study was to develop methods for quantitative ultrasound imagery suitable for noninvasive assessment of carotid plaque composition prior to the selection of the technique for revascularization. Using two broadband transducers (5-12 MHz and 12-28 MHz), backscattered radio frequency signals were acquired from entire lengths of 15 carotid endarterectomy specimens. Spectral analysis methods with correction for system response and beam diffraction were applied to radio frequency signals from local volumes of plaque having a 2 mm slice thickness, 1 mm width and axial depth of 480 microm and 240 microm at 10 MHz and 20 MHz, respectively. From these spectra, local values of four ultrasound parameters (integrated backscatter, frequency dependence of backscatter, integrated attenuation and slope of attenuation) were estimated and used to construct quantitative images. To combine information from these different parameter images, a two-step approach was followed. First, in 59 independent quantitative images of highly stenotic plaque, the average parameter values in a central five-by-three pixel region were correlated with plaque composition as assessed by histology to investigate the relationship between parameter values, frequency bandwidth and plaque composition. Discriminant analysis of parameter values vs. plaque composition was made to find a set of predictive equations to classify sets of measurements. Correct classification was obtained for 100% of calcified, 75% of intraplaque hemorrhage and 71% of lipidic plaques of the input data set. Second, each set of pixels from different parameter images was classified using the predictive equations, and a single, local tissue composition image was constructed. Examples of tissue composition images are presented in comparison with corresponding histologic sections. Both agreement and disagreement between image pairs are discussed.

Successful endoluminal thrombo-aspiration of renal graft venous thrombosis.

Renal transplant vein thrombosis is an unusual event occurring in 0.3-3% of renal transplantations. Prognosis is uniformly poor with graft loss in nearly every case. We report here the first three cases of renal graft vein thrombosis successfully treated by percutaneous endoluminal thromboaspiration. After an initially uneventful course all recipients developed anuria and required hemodialysis. In two cases, an ultrasound examination suggested a diagnosis of venous thrombosis. Emergency arteriography and phlebography were performed, confirming the complete thrombosis of the graft veins. Thromboaspiration was carried out with full heparinization and led to renal function improvement in all cases. Grafts are still functioning 6 months after the procedure, with serum creatinine levels of 176 mumol/l, 120 mumol/l and 184 mumol/l, respectively. Thus, this procedure avoids surgical and anaesthetic risks and allows, if performed at an early stage, restoration of graft function. Great care must be taken to avoid vein wall damage, vascular suture line rupture, or pulmonary embolism.

Preoperative assessment of the efficacy of distal radial artery ligation in treatment of steal syndrome complicating access for hemodialysis.

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. We report here a case in which we applied a new diagnostic method to assess the efficacy of distal radial ligation to treat this syndrome. A favorable comparison of distal radial artery pressure measurements before and after temporary occlusion of the artery with a balloon catheter indicated that perfusion of the hand would be dramatically improved after surgical artery ligation.

[Immediate results and 2-year follow-up of percutaneous transluminal angioplasty in intermittent claudication in patients over 70 years of age]. / Résultats immédiats et à 2 ans de l'angioplastie transluminale percutanée dans la claudication intermittente du sujet âgé de plus de 70 ans.

PURPOSE: This retrospective study was aimed at assessing immediate and mid-term results of percutaneous transluminal angioplasty for intermittent claudication in patients over 70 years of age, and the overall morbidity and mortality during follow-up. METHODS: Fifty-one percutaneous transluminal angioplasties were performed between 1993 and 1997 in 30 men and eight women (mean age: 78 +/- 5.2; range 71-91) for intermittent claudication (walking distance < 250 m). RESULTS: Angioplasties were supra-inguinal in 24 cases (47%) and infra-inguinal in 27 cases (53%). Clinical success (walking distance > 500 m) was obtained in 92% of the patients. Significant complications (5.9%) were inguinal hematoma requiring subsequent surgery in one patient and common femoral false aneurysms in two patients. Mean duration of hospitalization was 3 days and a half. After a mean follow-up of 25 months (range: 4-51 months), improvement in the walking distance was still present in 31 patients (82%). The condition of seven (18%) patients did not improve. No patient presented with critical ischemia. As well, no patient underwent surgical revascularization or amputation. However, the condition of eight (21%) patients required subsequent percutaneous transluminal angioplasty. Four (10.5%) patients died. Following percutaneous transluminal angioplasty, six (18%) patients presented with a major non-fatal clinical event. All the patients lived at home. CONCLUSION: Percutaneous transluminal angioplasty has little immediate risk when lesions are accessible and leads to positive mid-term clinical results in the treatment of intermittent claudication in patients over 70 years of age.

Treatment of recurrent transplant renal artery stenosis with metallic stents.

PURPOSE: To evaluate the efficacy of stent deployment in the treatment of recurrent stenosis of transplant renal arteries (TRAs). PATIENTS AND METHODS: This retrospective study includes six consecutive patients who underwent a mean of 3.66 previous treatments of TRA stenosis per patient before stent implantation (20 angioplasties and two surgical procedures). The endoprostheses were a Wallstent in four patients and a Palmaz stent in two patients. Clinical, laboratory, and duplex scanning follow-up was performed every 6 months after stent placement in all patients. RESULTS: The procedure was a technical success in all patients. At 6 months, mean systolic blood pressure decreased from 179 to 152 mm Hg (P = .018) and mean diastolic blood pressure decreased from 102 to 90 mm Hg (P = .09). Mean serum creatinine level dropped from 269 to 182 mmol/L (P = .03) and the number of antihypertensive drugs per patient decreased from 2.5 to 1.6. At a mean follow-up of 34 months (range, 7-60 months), all TRAs were patent, with a stenosis less than 50% without clinical consequences in one patient. No secondary procedure was necessary. CONCLUSION: Stent placement seems to be an effective treatment of TRA recurrent stenosis. Midterm follow-up shows satisfactory clinical results and TRA patency rates. This technique might be considered as a valuable therapeutic option for the treatment of TRA recurrent stenosis.