Obliterative Endoaneurysmorrhaphy with Stent Graft Preservation for Treatment of Type II Progressive Endoleak.

OBJECTIVE/BACKGROUND: Persistent type II endoleak (EL II) with sac enlargement after endovascular repair of abdominal aortic aneurysm requires treatment to prevent rupture. Embolization is not always effective. Conversion to open repair with stent graft (SG) explantation is a high risk option. The aim of this study was to evaluate the feasibility and immediate results of an alternative technique combining obliterative endoaneurysmorrhaphy (OEA) with SG preservation. METHODS: The open surgical technique combined sacotomy, ligation of all patent back-bleeding vessels and SG preservation. The aneurysmal shell was tightly closed over the SG to protect it from the intestines. An intra-aortic occlusion balloon was used when clamping was required. RESULTS: Twelve patients were treated with the OEA technique at Amiens University Hospital. All 12 procedures were successful. Four patients had previously undergone unsuccessful transarterial or translumbar embolization. Aortic clamping was performed in four cases. No SG migration or graft dislocation was observed. Follow up computed tomography scan at a median of 12 months showed shrinkage of the aneurysm sac with stable diameters and no recurrence of EL II in all cases. CONCLUSION: The OEA technique is an alternative option for the treatment of progressive EL II, which can be particularly useful after failure of embolization.

[Conservative treatment of an aortoduodenal fistula after paraaortic lymphadenectomy in hepatobiliary malignancy surgery with aortic endoprosthesis]. / Traitement conservateur d'une fistule aortoduodénale après curage interaorticocave dans le cadre d'une chirurgie hépatobiliaire carcinologique par endoprothèse aortique.

Lower gastrointestinal bleeding from a primary aortoduodenal fistula is unusual and usually fatal. Postoperative aortoduodenal fistula after biliary surgery is a very rare complication. We report hence a 69-year-old female patient who underwent a main bile duct resection with extended paraaortic lymphadenectomy for a cholangiocarcinoma. Acute melena with hemoglobin drop occurred on postoperative day 24. Initial CT-scan showed an aortic pseudoaneurysm with aortoduodenal fistula. An aortic endoprosthesis with endoscopic drainage of periaortic collections allowed successful treatment.

[Tuberculous aneurysm of abdominal aorta: case report and literature review]. / Anévrisme tuberculeux de l'aorte abdominale: cas clinique et revue de la littérature.

Tuberculous aneurysms of aorta are rare. They expose to a very high risk of unpredictable rupture with serious hemodynamic consequences. We report a 82-year-old male who presented with an tuberculous aortic aneurysm in a prerupture state. He underwent a surgical treatment and antibiotic therapy. Postoperative course was uneventful. Epidemiology, pathogenesis, presentation, management and mortality of this affection were reviewed and discussed. With appropriate medical and surgical management, the prognosis of this infection is very good.

Characterization and comparison of bone marrow and peripheral blood mononuclear cells used for cellular therapy in critical leg ischaemia: towards a new cellular product.

BACKGROUND AND OBJECTIVES: Autologous transplantation of either bone marrow (BM) or peripheral blood (PB) mononuclear cells (MNC) induces therapeutic angiogenesis in patients with peripheral arterial occlusive disease. Yet, the precise nature of the cellular product obtained from BM or PB and used in these therapeutic strategies remains unclear. MATERIALS AND METHODS: We have analysed the characteristics of BM-MNC and PB-MNC collected without mobilization and implanted in patients with critical limb ischaemia in a clinical trial of cellular therapy including 16 individuals treated by BM-MNC and eight by PB-MNC. These MNCs were characterized by cell counts, viability assessment and enumeration of leucocyte subsets, CD34 stem and endothelial progenitor cells (EPCs) (CD34+/CD133+/VEGF-R2+) by flow cytometry. Mean fluorescence intensity ratios were determined for CD34, CD133 and VEGF-R2 markers. All analyses were simultaneously performed in two laboratories. RESULTS: Accuracy and reliability between both laboratories were achieved. BM-MNCs and PB-MNCs were quantitatively and qualitatively heterogeneous and quite different from each other. Stem cells and EPCs were significantly more present in BM- compared to PB-cell products, but with similar mean fluorescence intensity ratios. A weakly positive correlation was observed between CD34+ cell counts and EPCs levels, confirming the specificity of cell identification. CONCLUSION: A great variability was observed in cell product characteristics according to their origin and also between individuals. These data stress the necessity of optimal characterization of cell products especially in multicentric clinical trials.

[Inferior mesenteric arteriovenous fistulas. Report of a case]. / Les fistules artérioportales mésentériques inférieures. A propos d'un cas.

We report a case of postoperative inferior mesenteric arteriovenous fistula. Arteriovenous fistula represents a rare disease. Symptoms are due to portal hypertension and distal ischemy. Treatment of these fistulas is embolization. Surgery is possible by ligature or excision of the fistula because vascularisation is obtained by Riolan arcade and hypogastric artery.

[Aortobronchial fistulas]. / Fistules aorto-bronchiques.

INTRODUCTION: Aortobronchial fistulas are uncommon but generally fatal if not treated surgically. Haemoptysis is the main symptom of this pathology. STATES OF ART AND PERSPECTIVES: Aortobronchial fistulas occur most commonly in patients with thoracic aneurysms (atherosclerosis, mycotic, aortic surgery's complication...). Main investigation is CT angiography with 2 D and 3 D reconstructions. CONCLUSION: Endovascular exclusion can be efficient treatment option.

[Aortobronchial fistula developing from an infectious aneurysm of the thoracic aorta]. / Fistule aortobronchique à partir d'un anévrisme infectieux de l'aorte thoracique.

Aortobronchial fistula presenting as massive haemoptysis is a rapidly fatal process if not promptly diagnosed and repaired. It's an unusual complication of thoracic aneurysm. We report the case of a 61-year-old woman with rupture of a thoracic aortic infectious aneurysm secondary to an Escherichia coli infection. Aortobronchial fistula diagnosis should be considered in patients who have minor or major haemoptysis and correct diagnostic procedures should be performed early. An aggressive surgical approach is often necessary.

Aortic thrombosis and ulcerative colitis.

Arterial thrombotic accidents in the course of inflammatory bowel disease are rare. They generally affect young adults whose disease is active. We observed a case of aortic and renal arterial thrombosis in a 40-year-old woman who was suffering from ulcerative colitis. Surgical thrombectomy ensured good postoperative results, without any ischemic or renal sequelae. Six days later the patient presented with distal thrombosis of the splenic artery, which receded under anticoagulant treatment. The physiopathology of thromboembolic events in the course of inflammatory bowel disease is uncertain. Such events result from a state of hypercoagulability of various mechanisms, which can be observed in active inflammatory bowel disease. This possibility of serious arterial thrombosis argues in favor of long-term anticoagulant treatment when inflammatory bowel disease is active.

Traumatic subclavian artery pseudoaneurysm: periprocedural salvage of failed stent-graft exclusion using coil embolization.

PURPOSE: To report the exclusion of a subclavian pseudoaneurysm by a combination of covered stent implantation and coil embolization. CASE REPORT: A 30-year-old man presented with a posttraumatic pseudoaneurysm of the left subclavian artery. A covered Jostent was inserted via a percutaneous femoral approach and deployed in the injured subclavian artery. Because of tapering of the artery proximally, apposition of the covered stent to the arterial wall was insufficient, leading to persistent filling of the pseudoaneurysm. Exclusion of the pseudoaneurysm was achieved by coil embolization through a gap between the stent-graft and the arterial wall. CONCLUSIONS: This report illustrates that successful endovascular treatment of a left subclavian pseudoaneurysm may require a combination of catheter-based techniques.

[Spontaneous rupture of the esophagus or Boerhaave syndrome. Report of 3 cases and review of the literature]. / La rupture spontanée de l'oesophage ou syndrome de Boerhaave. A propos de trois cas et revue de la littérature.

A triad of signs constitutes Boerhaave syndrome: forceful vomiting, chest pain and subcutaneous emphysema. The syndrome results from spontaneous rupture of the oesophageal wall leading to an oeso-pleural or oeso-mediastinal fistula. Positive diagnosis is established with a water-soluble swallow, sometimes coupled with computed tomography of the thorax. Boerhaave syndrome is a surgical emergency. We report three cases of spontaneous rupture of the oesophagus and analyze the importance of emergency surgery as well as emergency treatment of the sepsis, an important prognosis factor.

Treatment of popliteal arterial aneurysm using a superficial femoral artery autograft.

The usefulness of aggressive surgical management of popliteal arterial aneurysm is now widely accepted. Reconstruction is usually performed using either prosthesis or saphenous vein autograft. Autografts are preferable but not always possible because of problems of availability and congruence. An alternative conduit for cases involving lesions spanning the articular midline of the knee is the superficial femoral artery. From 1993 to 1998, we used superficial femoral artery autografts to treat a total of 18 aneurysms in 12 patients. All patients were male with a mean age of 66 years (range, 42 to 75). Fourteen aneurysms were treated during elective procedures, including four in combination with aortic repair. The remaining four were treated on an emergency basis. Exposure was achieved via the internal medial route in all cases. Treatment consisted of exclusion or aneurysmorraphy. The mean length of the autograft harvested from the ipsilateral thigh was 10.2 cm (range, 6-18). The harvested graft was replaced by a PTFE prosthesis. Our results show that superficial femoral artery autografts are a suitable alternative for two indications: for patients with small aneurysms located in the middle of the popliteal artery, since autografts provide excellent congruence, and for patients with no other useable donor vein or concurrent deep venous thrombosis.

[Quantitative assessment of carotid stenosis: comparison between Doppler ultrasound, spiral computed tomography angiography, magnetic resonance angiography and digital angiography]. / Quantification du degré de sténose carotidienne. Comparaison entre l'échographie Doppler, le scanner hélicoïdal, l'imagerie par résonance magnétique et l'angiographie numérise.

BACKGROUND: The North American Symptomatic Carotid Endarterectomy Trial has confirmed the benefit of carotid endarterectomy in comparison to medical treatment in stroke prevention in symptomatic patients having a carotid stenosis of 70% or more. The Asymptomatic Carotid Atherosclerosis Study has concluded that the benefit of surgical treatment remains significant in asymptomatic patients with 60% (or more) stenosis of the ipsilateral internal carotid artery, when mortality rate remains inferior to 3%. In these two trials, angiography has been used to quantify the stenosis. Though this test is carrying some neurological and renal risks, replacing the angiography stenosis grading for a non or less invasive test, seems to be permissible. METHODS: In our retroprospective study, the assessments of the carotid stenosis by several non-invasive tests findings were compared to the angiography results. Nineteen carotid arteries of fifteen patients, both symptomatic and asymptomatic, having a carotid stenosis at least 60% or more and being detected by the Doppler ultrasound were explored either by magnetic resonance angiography (MRA), spiral computed tomography angiography (SCTA) and angiography. RESULTS: The ultrasonography and angiography findings were well correlated (r=0,88; p<0.002) according to the Spearman test. The assessments of the MRA were better correlated to the angiography than to the SCTA (respectively r=0.91, p<0.0001 and r=0,68, p<0.001). Using both ultrasonography and MRA as a confirmatory test, the rate of injustified carotid endarterectomy was 25%. And this rate rose up to 33% when the ultrasonography was used with the SCTA. It is noteworthy that negative predictive value of ARM was 100%. To reduce the mortality rate, several surgical teams managed the carotid stenosis without angiography. CONCLUSION: MRA could replace angiography, on condition that the rate of unjustified carotid endarterectomy lowers and becomes acceptable. Far reaching complementary studies are necessary to confirm the fiability of those non-invasive tests. In order to raise the benefit to carotid endarterectomy, the research studies should turn to the predictive score determination of a surgical international risk and towards the "High benefit" patients groups after endarterectomy.

Primary malignant tumors of the venous system in the lower extremities.

Malignant tumors arising from venous walls in the lower extremity are uncommon. Histologically they are divided into two groups: hemangioendotheliomas of intermediate malignancy and leiomyosarcomas. This report describes a retrospective series of seven primary venous tumors observed in four men and three women with a mean age of 49.8 years (range: 18 to 64 years) who underwent surgical treatment between 1985 and 1995. The tumor was located in the superficial femoral vein in four patients, common femoral vein in two patients, and greater saphenous vein in one patient. A palpable tumor was present in five patients, localized pain in two patients, and metastasis in two patients. The histological diagnosis was leiomyosarcoma in six patients and hemangioendothelioma in one patient. Surgical treatment consisted of complete resection in six patients and partial excision in one patient. Venous reconstruction was performed in two patients and adjuvant radiation therapy in four patients. There was no operative morbidity/mortality. Median survival was 31 months. Four patients with leiomyosarcoma died from metastasis. Two patients with leiomyosarcoma and one with hemangioendothelioma are alive at 9 years, 16 months, and 9 months, respectively. Local recurrence was never observed after complete resection. The prognosis of venous leiomyosarcoma of the lower extremities is poor due to early occurrence of metastasis. Doppler ultrasound and MRI are useful to establish early diagnosis at the nontumoral stage. Improvement in the prognosis of leiomyosarcoma may justify perioperative chemotherapy before and after radical surgical excision.

[Value of imaging in early diagnosis of peripheral vein tumors]. / Apport de l'imagerie dans le diagnostic précoce des tumeurs veineuses périphériques.

Peripheral venous tumors are uncommon and their delayed clinical expression leads to poor prognosis. We report a series of 7 cases including 6 leiomyosacromas and 1 hemangioendothelioma. Duplex Doppler and MR imaging appeared to be best suited for diagnosis, allowing an evaluation of extension and an analysis of associated endoluminal thrombi. These imaging techniques help guide surgery and improve prognosis.

[Echo-Doppler and stenosis of the renal arteries. Report of 86 cases]. / Echo-Doppler et sténose des artères rénales. Etude a propos de 86 patients.

Duplex-scan is widely used for arterial stenosis diagnosis. Its role in detection of renal artery stenosis remains controversial (2, 17, 19, 28). The aim of this study was to determine retrospectively if duplex-scan is accurate for diagnosis of renal artery stenosis. During 36 months, 764 patients had a renal artery examination with duplex-scan: 90 patients had also renal arteriography. Duplex-scan was feasible in 95% of cases (excess bowel gas or major obesity gave to duplex-scan incomplete results in four patients upon 90). Ninety-three per cent of patients had hypertension; 20% had renal failure; 61% had obstruction of coronary, carotid artery or lower limb arteries. Nineteen patients among 86 had also an intravenous renal arteriography. We compared duplex-scan with venous angiography and intra-arterial arteriography. Duplex-scan criteria for stenoses were: a maximal systolic velocity (MSV) above 180 cm/s for detection of 60% to 79% stenoses and a MSV superior to 300 cm/s for detection of 80% to 99% stenoses. Global results showed a good sensitivity 59/64 (92%) and specificity 112/117 (96%) for duplex-scan. Duplex-scan is accurate for diagnosis of renal artery stenosis in a selected population.

Recanalization of occluded superficial femoral arteries using the rotational transluminal angioplasty catheter system (ROTACS).

A total of 85 occluded superficial femoral arteries were treated using the rotational transluminal angioplasty catheter system (ROTACS). The mean length of the occlusions was 7cm; 76% were uncalcified or only slightly calcified whereas 24% were calcified or highly calcified. The mean preoperative ankle:brachial index was 0.51. Primary success was achieved in 62 of 85 cases (73%). The mean length of reperfused occlusions was 6.2 cm: 26% of these lesions were calcified. The mean ankle:brachial index was 0.91. There were 23 primary failures (27%): reperfusion was impossible in 11 cases (including one complicated by perforation) and there were eight dissections, three cases where residual stenosis exceeded 50%, and one other unspecified failure. The mean length of these occlusions was 10.5 cm; 17% were calcified. Two patients developed a distal embolus and one died 10 days after reperfusion. The probability of primary patency of a reperfused artery was 44% at 1 year. Forty-two of the 62 patients who achieved primary success remained symptom free; the mean length of the original occlusion was 4.5 cm. Fifteen patients developed a new area of stenosis whereas five others exhibited new occlusion after a mean interval of 6 months. The mean length of these reperfused arteries was 9 cm. The probability of secondary patency at 1 year was 58%. Arterial calcification did not appear to influence the feasibility of reperfusion using the catheter. The main factor determining successful reperfusion was the length of the occlusal defect (P < 0.05). Reperfusion using the ROTACS did not improve the feasibility of reperfusion by conventional transluminal angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulmonary embolism in adolescents]. / Embolie pulmonaire chez l'adolescente.

BACKGROUND: Pulmonary embolism is rare in children, but its incidence is probably underestimated. While its causes are the same as in adults, the role of clotting factor deficiency and oral contraceptive agents has recently been stressed. CASE REPORTS: Case n. 1: A 15 year-old girl was immobilized for an ankle strain. She developed thrombophlebitis of the deep veins of the right leg. The condition was confirmed by Doppler. A phlebogram showed a clot floating in the inferior vena cava. This required the insertion of a clip around it and further thrombectomy. Despite immediate intravenous heparin therapy, the adolescent died of a massive pulmonary embolization. The girl had a congenital antithrombin III deficiency; she was also taking an oral contraceptive. Case n. 2: A 15 year-old suffered from left thoracic pain radiating to the shoulder. Perfusion scintiphotography showed evidence of pulmonary embolism of the left inferior lobe and a phlebogram showed thrombosis of the hypogastric veins. This adolescent was 4 months pregnant. A filter was placed inside the inferior vena cava to permit therapeutic interruption of the pregnancy. The girl was treated with intravenous heparin, followed by antivitamin K with an uneventful course. She suffered from no clotting factor deficiency. CONCLUSION: Pulmonary embolism remains a severe complication of thrombi in the femoral and pelvic veins. It can occur in adolescents, especially those with a congenital clotting factor deficiency, those on oral contraceptives or those who are pregnant.

Subclavian artery revascularization for myocardial ischemia.

A 54-year-old woman had a secondary occlusion of the subclavian artery proximal to the internal mammary artery, which had been used for an anterior interventricular artery bypass, and was the source of recurrent angina. A left carotid-to-subclavian bypass was performed with success. This rare complication underscores the need for careful selection and surveillance of candidates for myocardial revascularization using the internal mammary artery.

Arterioportal fistulas: twelve cases.

During the last 20 years, we encountered 14 arterioportal fistulas in 12 patients. Gastrointestinal hemorrhage or mesenteric artery insufficiency were the most frequent conditions found after the diagnosis. Arterioportal arterial fistulas were congenital in two cases and acquired in 10; seven of these 10 were iatrogenic. One patient had three successive and different sites of arterioportal fistula. The fistula originated from a branch of the celiac axis in nine cases, the superior mesenteric artery in three, and the inferior mesenteric artery in two. One patient died of massive anal bleeding before any treatment was possible. Eight fistulas were treated surgically and five by arterial embolization. After treatment there was no early mortality, while hemorrhagic and ischemic complications regressed in all cases. Three hemorrhagic recurrences were observed in patients with preexisting cirrhosis (two cases) or by recurrence of a congenital arteriovenous fistula (one case). Closure of symptomatic arterioportal fistula is justified. The choice of the most appropriate method for each patient should be discussed between the surgeon and interventional radiologist on a case by case basis.