Single aortic branch device: the Mona LSA experience.

Endovascular treatment of aortic arch pathologies is challenging due to its complex anatomical architecture and the presence of vital collateral branches. This paper aims to provide an overview of the currently available and future endovascular options for these diseases, particularly regarding branched stent-grafts and the Mona LSA device. After discussing the indications for revascularization of supra-aortic trunks in endovascular aortic repair, we present the principles, benefits and drawbacks of the main modern methods to overcome an insufficient proximal landing zone, i.e. hybrid repair with associated surgical bypass, chimney or snorkel grafts, fenestrated stent-grafts and branched stent-grafts. Subsequently, we detail the technical specifications of the two main branched stent-graft devices under study: the Valiant Mona LSA (Medtronic, Santa Rosa, CA, USA) and the W.L. Gore (Flafstaff, AZ, USA) arch branch device. The steps of the deployment procedure are described from examples of branched stent-graft aortic repair of aortic dissection and aneurysm of the left subclavian artery. Finally, available results of the premarket trial on the Mona LSA branched stent-graft device are recalled. Branched stent grafts represent a promising therapeutic option for pathologies of the aortic arch with insufficient proximal landing zone or mandatory revascularization of supra-aortic trunks. Further studies are needed to specify their indications, long-term effectiveness and safety.

French multicenter experience with the GORE TIGRIS Vascular Stent in superficial femoral and popliteal arteries.

BACKGROUND: Preliminary results in small single-center studies after stenting with the GORE TIGRIS Vascular Stent (W. L. Gore & Associates, Flagstaff, Ariz) show promising short-term primary patency rates, but larger, multicenter studies are needed. This study therefore investigated the performance of the GORE TIGRIS Vascular Stent at three different centers in France in patients with symptomatic peripheral artery disease. METHODS: This retrospective, single-arm, multicenter cohort study included 215 patients with peripheral artery disease (Rutherford-Becker category 2-6) who were treated with the GORE TIGRIS Vascular Stent, a dual-component stent consisting of a nitinol wire frame combined with a fluoropolymer-interconnecting structure. The efficacy end point was primary patency defined by freedom from binary restenosis as derived by duplex ultrasound imaging until 2 years after the intervention. Primary, secondary, and primary assisted patency rates at 3, 6, 12, 18, and 24 months were estimated by Kaplan-Meier analysis. RESULTS: The GORE TIGRIS Vascular Stent was used to successfully treat 239 lesions, of which 141 lesions were located in the superficial femoral artery and 98 in the popliteal artery. Patients were a mean age of 74 ± 12 years. Mean lesion length was 86.8 ± 44.7 mm. After 12 and 24 months, the overall primary patency rates were 81.5% and 67.2%, respectively, and primary assisted patency was 94.9% and 84.8%. Secondary patency was achieved in 99.1% at 24 months. CONCLUSIONS: Our multicenter experience with the GORE TIGRIS Vascular Stent demonstrates continued good results at 2 years for endovascular treatment of challenging obstructive superficial femoral artery and popliteal artery disease.

Preliminary experimental study of a mechanical connector allowing vascular anastomosis.

BACKGROUND: Aortic clamping time needed to carry out anastomosis during aortic surgery is one of the major predictive factors of morbidity/mortality. Because of the difficulties inherent in this technique, the duration of aortic clamping can be increased significantly with laparoscopy, which may explain why this kind of surgery is not often undertaken. We designed an original connector that will help us perform automated end-to-end vascular anastomoses. This anastomotic device was tested on a cadaver, test benches, and finally on pigs. METHODS: The connector consists of a bare-metal stent with spikes covering its outer surface. Once the prosthesis has been introduced into the arterial lumen over a 15-mm length, the connector is placed into the prosthesis; then, upon inflating a balloon and employing stent spikes, the prosthesis can be anchored in the artery. A feasibility study was carried out, first on cadaveric arteries and then on bench tests. In vivo, using this connector, the infrarenal aorta of 7 pigs was replaced with a 6-8-mm-diameter prosthesis. One to 42 days after implantation, angiography was performed before explanting the prosthesis. Evaluation criteria included anastomosis performance time, leakproofing capacity, tensile strength, patency, and histologic changes induced by the device. RESULTS: On the cadavers, manual traction tests showed that the anastomoses were satisfactory. Median force needed to rupture an automated anastomosis was 15.85 N. No leakage was seen under a systolic/diastolic pressure of up to 250/180 mm Hg. All pigs benefited from automated anastomosis. Once the designed device had been assessed, the median connection time was 2 minutes. In 4 cases, aortic thrombosis was found, 1 of which was septic. The implanting ancillary was responsible for 2 posterior aortic wall perforations, which extended the clamping time; therefore, this device should be modified. Anastomosis patency and tensile strength tests were satisfactory. Histologic results showed the connector incorporation, integration of the spikes in the arterial wall, and the absence of inflammation in the aortic wall. CONCLUSIONS: These preliminary studies confirm that the connector is quick and reliable for performing in vivo arterioprosthetic anastomoses. Further studies are needed to improve the ancillary device, which will enable its use it in laparoscopic and conventional surgery.

Experimental study of a novel mechanical connector for sutureless open arterial anastomosis.

OBJECTIVES: This study assessed the feasibility and efficacy of a new sutureless connector for end-to-end arterial anastomosis. METHODS: The anastomotic device is a connector consisting of a bare-metal stent with spikes covering its outer surface, which is introduced through the prosthesis. The seal of the anastomosis is obtained by inflating a balloon anchoring the stent with the spikes in the prosthesis and in the receiving artery. This experiment was conducted in three phases: (1) A feasibility study was done on four cadaveric femoral arteries using a polytetrafluoroethylene prosthesis, with measurement of the penetration of the spikes into the layers of the arterial wall. (2) Bench tests were conducted in seven automated and in seven sutured anastomoses. Anastomosis sealing was tested using a pump system (≤250 mm Hg) in a water-filled closed circuit. (3) The infrarenal aorta of seven pigs was replaced with a 6- to 8-mm diameter prosthesis, using this automated device for the proximal anastomosis. The distal anastomosis was handsewn on the aortic bifurcation. After completion angiography, animals were euthanized for macroscopic and histologic studies of the aorta, connector, and prosthesis. Explantations were done immediately (2 pigs), and at 15 (2 pigs), at 30 (2 pigs), and 42 days (1 pig). Study end points were the automated anastomosis time compared with manual suturing, leakage, mechanical strength, and patency of the anastomosis together with the histologic changes of the aortic wall in contact with the spiked stent. RESULTS: Tests performed on four cadaveric arteries showed complete penetration of the spikes into the arterial wall layers without metal fracture. Tests of traction showed that the median force needed to rupture the automated anastomosis was 18.3 N (interquartile range [IQR], 17.7-19.9 N), with no significant difference from the handmade anastomosis (19.5 N; IQR, 17.9-20.2 N, P = .33). No leakage was demonstrated in vitro with a pulsatile flow and a pressure up to 250 mm Hg. The median automated anastomosis time on pig aorta was 2.4 minutes (IQR, 1.4-3.3 min) vs 17.0 minutes (IQR, 15.1-17.2 minutes) for the handmade aortic anastomosis performed on the same animals (P = .002). There was no anastomotic leak. Histology showed incorporation of the connector spikes in the aortic wall, without intimal hyperplasia or false aneurysm. CONCLUSIONS: This preliminary study confirms the feasibility of this sutureless system, suggesting its usefulness for a faster and simpler anastomosis in hybrid arterial surgery.

Abdominal infectious aortitis caused by Streptococcus pneumoniae: a case report and literature review.

We report a case of a 75-year-old man who had been complaining of fever and pelvic pain for 3 weeks. First angio-computed tomography (CT) characteristics and blood culture led to suspicion of a pneumococcal-infected aortic aneurysm, which however was not confirmed by the surgeon. The abdominal infectious aortitis caused by Streptococcus pneumoniae was affirmed by a second angio-CT performed 7 days later. Without further delay, the patient underwent surgery for resection of mycotic aneurysm and in situ reconstruction with aortobiiliac homograft, in association with antibiotics. He died 10 days after the surgery as a result of severe sepsis in a polyvalent intensive care unit. This case report highlights the severity of this pathology. We reviewed the relevant literature related to Streptococcal pneumoniae mycotic aneurysm located in the abdominal aorta, including 29 more cases. Various microorganisms have already been associated with mycotic aneurysms, including S pneumoniae. Infectious aortitis remains a rare disease. It is extremely important to establish an early diagnosis but it may be delayed because clinical manifestations are usually nonspecific. However, if left untreated it is always lethal. Antibiotic in combination with complete surgical excision of the infected aorta is the treatment of reference. This therapeutic association dramatically improved patient survival.

Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial.

BACKGROUND: Carotid stenting is a potential alternative to carotid endarterectomy but whether this technique is as safe as surgery and whether the long-term protection against stroke is similar to that of surgery are unclear. We previously reported that in patients in the Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the rate of any stroke or death within 30 days after the procedure was higher with stenting than with endarterectomy. We now report the results up to 4 years. METHODS: In this follow-up study of a multicentre, randomised, open, assessor-blinded, non-inferiority trial, we compared outcome after stenting with outcome after endarterectomy in 527 patients who had carotid stenosis of at least 60% that had recently become symptomatic. The primary endpoint of the EVA-3S trial was the rate of any periprocedural stroke or death (ie, within 30 days after the procedure). The prespecified main secondary endpoint was a composite of any periprocedural stroke or death and any non-procedural ipsilateral stroke during up to 4 years of follow-up. Other trial outcomes were any stroke or periprocedural death, any stroke or death, and the above endpoints restricted to disabling or fatal strokes. This trial is registered with ClinicalTrials.gov, number NCT00190398. FINDINGS: 262 patients were randomly assigned to endarterectomy and 265 to stenting. The cumulative probability of periprocedural stroke or death and non-procedural ipsilateral stroke after 4 years of follow-up was higher with stenting than with endarterectomy (11.1%vs 6.2%, hazard ratio [HR] 1.97, 95% CI 1.06-3.67; p=0.03). The HR for periprocedural disabling stroke or death and non-procedural fatal or disabling ipsilateral stroke was 2.00 (0.75-5.33; p=0.17). A hazard function analysis showed the 4-year differences in the cumulative probabilities of outcomes between stenting and endarterectomy were largely accounted for by the higher periprocedural (within 30 days of the procedure) risk of stenting compared with endarterectomy. After the periprocedural period, the risk of ipsilateral stroke was low and similar in both treatment groups. For any stroke or periprocedural death, the HR was 1.77 (1.03-3.02; p=0.04). For any stroke or death, the HR was 1.39 (0.96-2.00; p=0.08). INTERPRETATION: The results of this study suggest that carotid stenting is as effective as carotid endarterectomy for middle-term prevention of ipsilateral stroke, but the safety of carotid stenting needs to be improved before it can be used as an alternative to carotid endarterectomy in patients with symptomatic carotid stenosis.

Transection of the brachial artery after closed posterior elbow dislocation.

Although elbow dislocations are common orthopaedic lesions, vascular complications remain rare. We report the cases of three patients who presented with a rupture of the brachial artery after closed posterior dislocation, which is even more uncommon. Arteriograms were performed in all cases because of the persistent absence of pulses at the wrist after emergency reduction. In each patient, the treatment consisted of the insertion of reversed end-to-end saphenous bridges. None of them presented mid-term vascular complications (mean follow-up, 17 months). Brachial artery disruption can result from closed posterior elbow dislocation and responds well to vascular repair.

Totally laparoscopic aortic repair: a new device for direct transperitoneal approach.

On the basis of our experience with more than 71 cases of totally laparoscopic aortic surgery by the retrocolic approach, we have developed a new technique by a simple transperitoneal approach. The purpose of this report is to describe that technique and the novel laparoscopic bowel retractor used to ensure stable exposure of the aorta.

Post-traumatic thoracic outlet syndromes.

This retrospective study aims to clarify the mechanisms, frequency, symptoms, treatment, and outcome of post-traumatic thoracic outlet syndromes. A total of 13 patients (7 men and 6 women) with a mean age of 41 +/- 16 years were studied. Underlying injuries resulted from sports, road, and household accidents. Bone lesions were pseudarthrosis, hypertrophic callus, and luxations. Congenital anomalies were observed in five patients (38%). Vascular lesions included aneurysm of the subclavian artery or vein, acute ischemia, and subclavian vein thrombosis. Operative treatment involving orthopedic and/or vascular surgery was indicated in all patients. Post-traumatic thoracic outlet syndrome occurs in young subjects after violent trauma. Vascular complications are frequent and severe. Treatment achieves good results but benefits may be diminished by bone or nerve involvement.

Laparoscopic exclusion of a splenic artery aneurysm--a case report.

Splenic artery aneurysm is a rare but serious vascular disease. The mortality risk is 36% when one is ruptured. Surgical therapy has traditionally consisted in resection through a laparotomy. The authors' experience of a case of laparoscopic exclusion of a splenic artery aneurysm is reported. This surgical approach is simple, safe, and minimally invasive. This procedure should increase the indication for surgical treatment of a splenic artery aneurysm.