Role of bioresorbable stents in the superficial femoral artery.

Bioresorbable stents or scaffolds are a new technology in the treatment of coronary and peripheral vascular disease. Their goal is to provide adequate support to the dilated vessel segment for the time needed and to disappear through a controlled resorption process afterwards. Doing so they can offer the early advantages and avoid the late complications related to stent placement such as stent-induced restenosis, stent fracture and problems at reintervention. Although the first implantation dates from more than ten years ago, this technology is still in its infancy and experience is still being built up. Most studies till now have been performed in the coronary arteries although the superficial femoral artery is an equally appealing area of application. Bioresorbable scaffolds are made of resorbable polymers or metals with or without antiproliferative drug elution. Early experiences in coronary arteries as well as in other areas such as the superficial femoral artery (SFA) have shown the importance of the material that is used, the design of the device and the duration of the absorption process. They suggest that elution of an antiproliferative drug might be necessary to obtain clinically acceptable results. Although initial results are promising with some of the newer generation devices results of larger studies with longer follow-up are eagerly awaited to define the precise place of this new technology. This article gives an overview of the existing evidence, the available devices, the clinical studies that have been performed in different areas and the preliminary results of a large multicenter study with a bioresorbable stent in the SFA.

BRAVISSIMO: 12-month results from a large scale prospective trial.

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

The use of the cryoplasty technique in the treatment of infrapopliteal lesions for Critical Limb Ischemia patients in a routine hospital setting: one-year outcome of the Cryoplasty CLIMB Registry.

AIM: It was the objective of the Cryoplasty CLIMB to evaluate the effectiveness of the PolarCath device in a standard clinical practice in the treatment of infrapopliteal lesions in critical limb ischemia patients. METHODS: Between May 2007 and July 2008, 100 patients (72 years, 67%male) with CLI were enrolled in the trial for the treatment of 100 infrapopliteal stenoses or occlusions. The mean lesion length and diameter stenosis were 54.9+/-55.8 mm and 91.3+/-8.3%. Primary endpoint was defined as 12-month primary patency based on duplex. Secondary endopoints were immediate success and 12-month limb salvage and survival rate. RESULTS: Multiple cryoplasty cycles were performed in 56 cases (2.1 inflations per patient) and in 4 the use of a different size balloon was required. The immediate technical success rate was 95.0% and the stent rate was 17.0%. The 12 month primary patency, limb salvage and survival rates were 55.9+/-7.4%, 93.8+/-2.5% and 81.8+/-3.9%, respectively. Stratification for lesion length did not show significant outcome differences for lesions < or =50.0 mm and those >50.0 mm neither for primary patency (P=0.94), nor for limb salvage (P=0.32). CONCLUSION: The cryoplasty technique is effective for the treatment of infrapopliteal lesions in CLI patients. The results seem to be within the range of those of conventional PTA. Especially for shorter lesion (<50.0 mm), the wide-spread use of cryoplasty is not recommended. For lesions with a minimal length of 50.0 mm, the results are encouraging.

Fibromuscular dysplasia of the external iliac artery.

A 47-year-old female with fibromuscular dysplasia of both external iliac arteries was treated by percutaneous balloon catheter angioplasty. The immediate result was unsatisfactory. On discharge from hospital, the patient was only able to walk one kilometer, and had reduced ankle:arm blood pressure indices. Conservative treatment with anticoagulants for three months, followed by ticlopidine, and exercise for six months led to complete recovery.

The use of extracorporeal membrane oxygenation in postpneumonectomy pulmonary oedema.

A 59-year-old male developed a severe adult respiratory distress syndrome following a right pneumonectomy for pulmonary cancer. Extracorporeal membrane oxygenation for 11 days was life-saving. The operation was considered curative, but the patient died nine months later with multiple metastases. The pathogenesis and treatment for postpneumonectomy pulmonary oedema and an explanation for rapid dissemination of the cancer are stated.

Myasthenia gravis associated with thymolipoma: a case report.

A 31-year-old patient with a 2-year history of myasthenia gravis underwent resection of a mass in the anterior mediastinum. On histological examination, the tumour proved to be a thymolipoma. The association of thymolipoma with myasthenia gravis is rare. To our knowledge this is the 12th case reported. It is however the first in which histological examination revealed the presence of germinal centres. The tumour measured 28 x 14 x 2 cm and weighted 340 gr. This is by far the largest thymolipoma associated with myasthenia gravis reported. As in all previously published cases, the myasthenia associated symptoms improved significantly after surgery. In this case improvement occurred within weeks. In general, benefit after thymectomy is delayed until months to years.

High frequency jet ventilation for severe haemoptysis during extracorporeal circulation.

Two patients are described in whom fulminant haemoptysis occurred during extracorporeal circulation. The use of high frequency jet ventilation resulted in a dramatic decrease of blood loss from the tracheal tube, avoiding the need for more aggressive management.

Extra-anatomical grafting for aorto-occlusive disease: the outcome in 133 procedures.

Between 1978 and 1988 133 extra-anatomical grafts were performed in patients presenting with aorto-iliac occlusive disease. These series include 50 cross-over grafts, 46 axillofemoral and 37 axillobifemoral grafts. The indication for operation was acute ischemia in 26.4%, claudication in 9.7% and limb salvage in 63.9% of cases. Perioperative mortality rate was 10.4%. The early patency rate decreased from 92% after cross-over grafting to 86% in the axillofemoral series and 8% of the patients needed a major amputation in the immediate postoperative period. With a mean follow-up of 32 months, 62% of the patients died within 5 years of the operation, 54% of deaths being due to cardiovascular complications. The 3-years patency rate decreased to 78% after cross-over grafting and 49% after axillofemoral grafting. The 3-year limb salvage rate decreased to 89% and 75% respectively. Although our results are definitely less favourable than those of direct aortofemoral grafting, they seem to support the further use of the cross-over graft in patients with unilateral occlusive disease. Axillofemoral grafting on the other hand should be preserved for limb saving reconstructions in high risk conditions.

Carotid artery endarterectomy in patients over seventy years-of-age.

Carotid artery endarterectomy in the elderly patient has been considered to be a high risk procedure. Recent reevaluation, however, showed that advanced age alone doesn't seem to increase the perioperative surgical risk. We retrospectively reviewed the records for 222 carotid artery endarterectomies, not combined with any other type of surgery, in 195 patients over 70 years-of-age. Twenty-eight patients (14.3%) were asymptomatic, 43% were seen after transient ischemic attacks, 5.1% after reversible ischemic neurologic defects, and 37.4% after stroke. A standard operative protocol was followed. We used a shunt in 45.5% of patients, a standard endarterectomy was performed in 93% of patients, using a patch in 68%. There were three perioperative deaths and seven perioperative strokes in the series; total combined morbidity and mortality was 5.1%. In the 73 patients operated after previous stroke, three died and five suffered a perioperative stroke; total combined morbidity and mortality was 10.9%. In the 122 patients operated after previous transient ischemic attack or asymptomatic, two suffered a perioperative stroke; total combined morbidity and mortality was 1.6%. Late survival was identical to the survival of a normal Belgian control population, and stroke and death-free ratio at five years was 65%, 52% for patients operated after previous stroke and 69% for asymptomatic patients or patients operated after transient ischemic attack. Carotid artery endarterectomy can be performed in patients over 70 years-of-age with perioperative results equal to those of younger patients.

Baker's cyst connected to popliteal artery cyst.

A patient with compression of the left popliteal artery by cystic adventitial disease is presented. The adventitial cyst was connected to a Baker's cyst. The patient suffered severe ischemia only after heavy exercise, because the mucous fluid of the Baker's cyst shifted into the popliteal artery cyst when the Baker's cyst was compressed. The etiology of cystic adventitial disease of the popliteal artery in this patient is discussed.

Single-dose prophylaxis with cefotetan in elective abdominal surgery. A controlled trial.

Single dose cefotetan was compared with either a combination of metronidazole and cefazolin given for 24 hours or 3 doses of cefuroxime as prophylaxis in elective abdominal surgery. Wound infections and infections at remote sites (UTI and RTI) were similar in all groups. In a third group prophylaxis of abdominal surgery using a single 2g dose of cefotetan was compared to 2 doses of the same drug, given 12 hours apart. There was no demonstrable advantage to giving 2 doses. The low incidence of post-operative infections seen in all groups indicates the efficacy of cefotetan in the surgical prophylaxis of elective abdominal surgery.