Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease.

BACKGROUND: The goal of this article is to present clinical and patency results of endovascular treatment of nonmalignant, iliocaval venous obstructive disease and to discuss the evolution of technical details. METHODS: From November 1995 to June 2004, 44 patients (female-male ratio, 3.9:1; left-right lower limb ratio, 8.6:1; median age, 42 years; range, 21-80 years) had treatment for chronic disabling obstructive venous insufficiency with iliocaval stenosis or occlusion. The clinical class of CEAP was 2 in 11 limbs, 3 in 31, 4 in 4, 5 in 1, and 6 in 1; etiology was primary in 32 patients, secondary in 10, and congenital in 2. Anatomic involvement included superficial veins in 16 patients and perforator veins in 11. Obstruction was associated with superficial reflux in 4 patients, deep reflux in 13, and both in 13. Ten patients had occlusion. All procedures were performed in the operating room with perioperative angiography and angioplasty with or without self-expanding stent implantation. Venous clinical severity and disability scores were obtained before and after treatment. Patency and restenosis were evaluated by duplex Doppler ultrasonography. RESULTS: No perioperative death or pulmonary embolism occurred. The technical success rate was 95.5% (two recanalization failures), and two (4.5%) perioperative stent migrations occurred. One early thrombosis (2.4%) was treated by thrombectomy and creation of an arteriovenous fistula. One late death and one thrombosis occurred. Restenoses were found in five patients and were all treated successfully (four needed iterative stenting). Median follow-up was 27 months (range, 2-103 months). Median venous clinical severity score improved from 8.5 to 2, and median venous disability score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 36 months were 73%, 88%, and 90%, respectively, in intention to treat. The survival rate was 100% at 12 months and 97.3% at 60 months. CONCLUSIONS: Endovascular treatment of benign iliocaval occlusive disease is a safe and efficient minimally invasive technique with good mid-term patency rates. Moreover, it improves cases with obstruction only, as well as cases with associated reflux and obstruction. Primary stenting should always be performed by using self-expanding stents deployed under general anesthesia to avoid lumbar pain. In case of failure, the endovascular procedure does not preclude further surgical reconstruction.

Extensive arterial aneurysm developing after surgical closure of long-standing post-traumatic popliteal arteriovenous fistula.

Long-standing arteriovenous fistula (AVF) can lead after closure to late arterial aneurysm formation. We report the case of an extensive iliofemoral aneurysm extending from the aorta to a left venous above-knee to below-knee popliteal bypass occurring 14 years after closure of a post-traumatic popliteal AVF. While the arterial axis, which was not dilated at closure, became aneurysmal, it is remarkable that the vein bypass performed at the same time was not altered. The pathophysiologic mechanism of such a complication could be morphologic modification of the arterial wall while the AVF is open and hemodynamic change after its closure.

Tinnitus resulting from tandem lesions of the internal carotid artery: combined extracranial endarterectomy and intrapetrous primary stenting.

Lesions of the internal carotid artery involving the bifurcation and the intrapetrous portion represent a challenging therapeutic situation. We herein report the first case of a patient suffering from tinnitus which was treated by simultaneous carotid endarterectomy of the bifurcation and transluminal angioplasty and stenting of the intrapetrous portion with a good mid-term angiographic result.

Laparoscopy-assisted abdominal aortic aneurysm endoaneurysmorraphy: early and mid-term results.

OBJECTIVES: This study was undertaken to evaluate the consequences on patient selection and on early and mid-term results during the learning curve of a surgical team performing laparoscopy-assisted surgery to treat abdominal aortic aneurysm (AAA). PATIENTS AND METHODS: Between December 1998 and January 2002, 24 patients (22 men, 2 women; mean age, 68.2 years [range, 57-82 years]) were included in a prospective study and underwent laparoscopic transperitoneal AAA dissection followed by graft implantation through a 6 to 9 cm minilaparotomy. Perioperative data for the first 10 patients, obtained during the first 25 months of the study (group 1), were compared with data for the last 14 patients, obtained during the last 13 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomographic scanning before discharge and yearly thereafter. RESULTS: One patient (4.3%) died in the immediate postoperative period. In this patient and two others (12.5%), the minilaparotomy was extended intraoperatively, from 12 cm to 16 cm. With experience, initial contraindications such as obesity and short proximal or calcified aortic neck were eliminated, enabling increase in rate of patients included, from 27.7% during the first 25 first months to 56% during the last 13 months (P =.063). Mean duration of operative clamping decreased from 275 minutes in group 1 to 195 minutes in group 2 (P <.0001), and mean duration of aortic clamping decreased from 101 minutes in group 1 to 52 minutes in group 2 (P <.0001). The number of early repeat interventions was reduced from 3 (30%) in group 1 to 2 (14.3%) in group 2 (P =.61), and clinical recovery period decreased from 6.8 days to 4.3 days (P <.005). During mean follow-up of 17.1 months (range, 3-38 months), no late aortoiliac procedures were necessary and no prosthetic abnormality was detected. CONCLUSION: This minimally invasive video-assisted technique provides good postoperative comfort and excellent mid-term results. Developments in experience and instrumentation have enabled us to include a growing number of patients and to reduce the duration of the procedure.