Management of a Mobile Floating Carotid Plaque Responsible for Calcified Cerebral Emboli: A Double Sword of Damocles.

INTRODUCTION: The management of a rare case of calcified cerebral emboli associated with a mobile carotid plaque (MCP) is reported and discussed. REPORT: A 76 year old patient presented with sudden weakness of the left lower limb one month ago, which resolved spontaneously. A cerebral magnetic resonance imaging showed recent multiple infarcts in the right middle cerebral artery (MCA) territory. Computed tomography cerebral angiogram (CTA) revealed calcified cerebral emboli (CCE) in the right MCA territory and an isolated calcified embolus in the M3 segment of the right MCA. No calcification was observed in the aorta. The echocardiogram findings were normal. Trans-oesophageal echocardiography did not show aortic or mitral valve calcifications. A cervical duplex ultrasound (DUS) was performed and demonstrated a highly mobile carotid plaque located in the right carotid bifurcation, contrasting with static CTA imaging showing a common calcified plaque, probably because the plaque appeared against the carotid wall during image acquisition. Antiplatelet and anticoagulation therapy were initiated, and carotid endarterectomy was performed on day two to prevent further embolisation. One month follow up including carotid DUS was satisfactory. DISCUSSION: A case of mobile carotid plaque responsible for CCE which was diagnosed with DUS dynamic imaging is described, emphasizing the importance of multimodal imaging in such settings. Though the treatment of MCP remains controversial because of the paucity of published cases, carotid endarterectomy was considered to be the safest option to prevent recurrent stroke. Additional clinical data including large series and controlled trials are required to determine the best management of mobile carotid plaques with less than 50% diameter carotid stenosis.

A Very Unlucky Intraoperative Event During a Chimney Technique for Juxtarenal Aneurysm Exclusion.

A two-vessel Ch-EVAR procedure was scheduled within the instructions for use of the devices. After deploying, it appeared that the long sheath inserted through an arm access was discovered to be trapped behind the aortic stentgraft barbs. Trying to remove the sheath, the graft was displaced upward and the procedure was converted for a three-vessel Ch-EVAR incorporating the superior mesenteric artery. Simultaneous ballooning of the target vessels and the stentgraft permitted to exert a strong pullback traction on the blocked sheath, allowing its removal. A segment of the sheath distal end was left trapped in the aortic stentgraft. At 12 months follow-up, the patient is free of any complications and there are no occlusions of the abdominal visceral branches or embolic events in peripheral arteries.

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.