Preoperative Sizing to Lower In-Stent Restenosis in Peripheral Arterial Occlusive Disease.

BACKGROUND: The primary treatment for lower-extremity peripheral arterial occlusive disease (PAOD) is angioplasty stenting. Its main complication is in-stent restenosis. Poor selection of stent dimensions has been identified as a factor contributing to early in-stent restenosis. The aim of this study is to determine whether the implantation of stents, selected based on arterial morphological reconstruction using a sizing software program, reduces the occurrence of in-stent restenosis. The study also aims to evaluate the potential benefits of routine preoperative sizing. METHODS: Between January 2016 and December 2020, all patients treated for PAOD through scheduled angioplasty stenting in our department were included in the study. Using systematic preoperative computed tomography angiography, precise reconstruction and sizing were performed to select the ideal length and diameter of stents, resulting in the selection of a so-called IDEAL stent. During the procedure, the surgeon implanted either the IDEAL stent or a different one, named the ACTUAL stent, based on intraoperative data and/or availability. We compared the in-stent restenosis rate between IDEAL and ACTUAL stents. RESULTS: There were no significant differences in the overall characteristics between the IDEAL and ACTUAL stent groups. The in-stent restenosis rate at 1 year was 13% (N = 28/212, P = 0.994) in the IDEAL group and 17% (N = 25/149, P = 0.994) in the ACTUAL group. Among the ACTUAL stents, a total of 19.6% of stents with a diameter mismatch when chosen based on arteriography showed a significantly higher restenosis rate during the first year of follow-up (P = 0.02). CONCLUSIONS: Our study did not demonstrate a significant difference in 1-year restenosis rate between the IDEAL and the ACTUAL stent groups. It specifically revealed the significant impact of diameter selection on the intrastent restenosis rate during the first year of follow-up. Stents chosen based on arteriographic criteria, which exhibited diameter discordance, compared to the IDEAL stents group selected using sizing reconstructions, could be either oversized or undersized. This led to a significantly higher restenosis rate at 1 year postoperatively.

Evaluation of the Effectiveness of Endovascular Treatment of Type 2 Endoleaks.

BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR) is a safe and minimally invasive alternative to open surgical repair for infra renal aortic aneuvrysm. EVAR requires lifelong post-procedural surveillance. Endoleaks represent the main complication. Type II endoleaks (EL2) are the most frequent and tend to be indolent. Most practitioners do not treat in EL2 as long as they are associated with stable aneurysm diameter. European guidelines recommend treatment in case of aneurysm growth. Several techniques can be offered, such as transarterial embolization and translumbar embolization. This study reports the experience and results of a single center for EL2 endovascular treatment. The aim of this study was to determine more precisely the efficacity of embolization for type 2 endoleaks treatment. METHODS: A single center cohort of patients treated for EL2 with endovascular technique between 1998 and 2018 was formed to perform a descriptive analysis. Preoperative sizing, risk factors of endoleaks and intraoperative data were collected. Computed topography (CT) scans were regularly performed after EVAR to detect endoleak recurrence. Clinical recurrence was defined as the persistence of aneurysm sac growth and radiological recurrence was defined as the occurrence of EL2 on a post-embolization CT scan. Data related to reintervention, overall mortality and aneurysm related mortality were also collected. Kaplan-Meier survival analyses were used to determine the rates of reoperation-free survival and recurrence-free survival. RESULTS: Six hundred seven patients underwent an endovascular treatment for abdominal aorta aneurysm between 1998 and 2018. One hundred forty-five type 2 endoleaks occurred during this period. Nineteen patients (median age 76 years), underwent endovascular treatment for EL2, with immediate success on 15 patients (8 transarterial embolization, 8 direct sac puncture and 3 combined procedures). During follow-up, 5 patients required a new translumbar embolization and 6 required an open surgery for recurrence of the EL2. Six patients died, 2 of them of causes related to the aneurysm. At 59,6 months median follow-up, 53% of the patients presented a radiologic recurrence, with a sac growth of more than 5 mm since last procedure in 4 patients (24%). CONCLUSIONS: Long term clinical recurrence of type 2 endoleaks treated by endovascular procedures appear to be frequent in our experience, leading to several deaths and requiring open surgical treatment.

Combined Pull through and Balloon Anchoring Bailout Technique to Repair a Failed Bifurcated Endovascular Aortic Repair.

BACKGROUND: To describe a bailout technique used to manage the left stump of a bifurcated endograft that was stuck above a narrowed distal aortic neck. METHODS: An 80-year-old man with a suprarenal aneurysm was treated with a custom-made 4-vessel fenestration endograft. During the procedure, the left stump of the distal bifurcated graft module was chased out of a narrow distal aortic neck and became stuck horizontally at the bottom of the aortic aneurysmal sac. Through a femoral to left subclavian artery through-and-through percutaneous access, a balloon-anchoring technique was successfully used to return the endograft stump into the narrowed aortic neck and exclude the aneurysm. CONCLUSIONS: The combined technique of a through-and-through and anchoring balloon was found to be suitable for introducing an endograft limb into a narrow distal aortic neck.

Lessons for the clinical nephrologist: a rare case of unfused renal ectopia.

Right crossed inferior unfused renal ectopia is a rare developmental anomaly in which both kidneys are located on the left side of the body. It's the result of a halt in migration of kidneys to their normal location during the embryonic period and in ureteral bud faulty that migrates to the opposite side and induces the metanephric blastema on the wrong side. In this article, we aim to review embryology and complete description of renal ectopia anatomy and describe a rare case of right crossed unfused inferior renal ectopia with a left lower kidney artery originated directly from an abdominal aortic aneurism (AAA). The treatment consisted in AAA's exclusion with a custom-made endograft device shaped on purpose with a dedicated branch allowing perfusion of the ectopic lower left kidney.