Health system barriers and enablers to early access to breast cancer screening, detection, and diagnosis: a global analysis applied to the MENA region.

OBJECTIVES: To identify barriers and enablers that impact access to early screening, detection, and diagnosis of breast cancer both globally and more specifically in the Middle East and North Africa (MENA) region (with a specific focus on Egypt, Jordan, Oman, Saudi Arabia, United Arab Emirates [UAE], and Kuwait) with a specific focus on the health system. STUDY DESIGN: A systematic review of literature. METHODS: We conducted a systematic reviewing using the PRISMA methodology. We searched PubMed, Global Index Medicus, and EMBASE for studies on 'breast cancer', 'breast neoplasm,' or 'screening, early detection, and early diagnosis' as well as key words related to the following barriers: religion, culture, health literacy, lack of knowledge/awareness/understanding, attitudes, fatalism/fear, shame/embarrassment, and physician gender from January 1, 2000 until September 1, 2016. Two independent reviewers screened both titles and abstracts. The application of inclusion and exclusion criteria yielded a final list of articles. A conceptual framework was used to guide the thematic analysis and examine health system barriers and enablers to breast cancer screening at the broader macro health system level, at the health provider level, and the individual level. The analysis was conducted globally and in the MENA region. RESULTS: A total of 11,936 references were identified through the initial search strategy, of which 55 were included in the final thematic analysis. The results found the following barriers and enablers to access to breast cancer screening at the health system level, the health provider level, and the individual level: health system structures such as health insurance and care coordination systems, costs, time concerns, provider characteristics including gender of the provider, quality of care issues, medical concerns, and fear. In addition, the following seven barriers and enablers were identified at the health system or provider level as significantly impacting screening for breast cancer: (1) access to insurance, (2) physician recommendation, (3) physician gender, (4) provider characteristics, (5) having a regular provider, (6) fear of the system or procedure, and (7) knowledge of the health system. More specifically, the largest increased odds for having a mammogram was from having insurance, having a physician recommendation, type of provider (mainly gynecologist), and having regular contact with a physician. Clinical breast examinations were increased by having insurance and having regular contact with a physician. The eight studies identified from the MENA region identified barriers to breast cancer screening related to service quality, fear of pain and of cancer itself, female versus male provider, having a physician recommend the screen, cost issues as well as time and convenience of the services. CONCLUSIONS: There are a number of system changes that can be made to remove barriers to breast cancer screening. Some of these system changes apply directly to MENA countries. A larger health system assessment of a country is warranted to determine which health system changes should be made to most efficiently and effectively improve access to breast cancer screening.

Selective microsurgical treatment of giant intracranial aneurysms.

Giant intracranial aneurysms are defined as greater than 25mm in diameter. They share the same surgical challenges and strategies as so-called complex aneurysms, sometimes smaller in size but presenting with similar complex anatomy. The surgical difficulties arise from the size of the sack, the presence of intraluminal thrombus, the thickness of the arterial wall, and the complexity of arterial branching on the neck. Preoperative imaging gathers complementary information from magnetic resonance imaging, computed tomographic angiography, and rotational catheter-based angiography with three-dimensional reconstruction including balloon-test occlusion. The therapeutic decision-making needs a multidisciplinary approach including endovascular, neurosurgical and anesthesiological expertises. The microsurgical treatment needs a step-by-step preoperative planning with anticipation of possible pitfalls and alternative strategies. Classical principles of aneurysm surgery have to be tailored to face the difficulties arising from the size of the sack and from the arterial wall calcifications.

[Aortic dissection in pregnancy]. / Dissection aortique et grossesse.

During pregnancy, the occurrence of aortic dissection is a rare event immediately threatening fetal and maternal prognosis. Its occurrence is more common in cases of connective tissue disease. But the absence risk factor shall not exclude or delay diagnosis. We must learn to think about it, because the prognosis is highly dependent on time management. The clinical presentation of this medical and surgical emergency varies, and pregnancy adds its own symptoms. We have to ask without hesitation that echocardiography or chest CT be performed since these diagnostic methods are both reliable and available.

Current and future perspectives in the repair of aneurysms involving the aortic arch.

The repair of aneurysms involving the aortic arch is technically and physiologically demanding. Historically, these aneurysms have been treated using open surgical techniques that require cardiopulmonary bypass and deep hypothermic circulatory arrest. Many patients have been deemed "untreatable" and among those selected for surgery there are reported risks of death in 2% to 16.5% and stroke rates ranging from 2% to 18%. "Hybrid arch repair" combines one of a number of open surgical procedures (to secure a proximal landing zone for an endograft) with subsequent or immediate placement of an endograft in the arch and descending aorta. Although this concept is described as "minimally invasive" because it avoids aortic cross-clamping and hypothermic circulatory arrest, the morbidity and mortality rates remain considerable (mortality 0% to 15%, stroke 0% to 11%). Ongoing development of endograft technology has enabled total endovascular repair of complex aortic aneurysms involving the visceral segment, using fenestrated and branched endografts. Encouraging early results in this anatomy have inspired extension of the concept to include the aortic arch and great vessels. These strategies can be considered in patients generally at high-risk for the conventional procedures. However, the endeavour is at an early stage of its development and the arch poses unique challenges including the potential for stroke, angulation of the arch and the great vessel ostia to the arch, extremely high volume flow, three-dimensional pulsation and rotation with the cardiac cycle and the proximity of the aortic valve and coronary arteries.

Transcutaneous aortic valve implantation using the axillary/subclavian access with patent left internal thoracic artery to left anterior descending artery: feasibility and early clinical outcomes.

OBJECTIVE: Both retrograde femoral and subclavian artery catheterization techniques have been described as the most common methods for the implantation of the Medtronic CoreValve percutaneous aortic valve (Medtronic Inc, Minneapolis, Minn). The subclavian artery has been shown to be a safe and effective alternative access route in patients with unfavorable femoral access. Of the patients who are identified as candidates for subclavian artery access, a subset possess a patent left internal thoracic artery to left anterior descending artery. This patent left internal thoracic artery presents an additional anatomic and clinical variable that must be taken into consideration to ensure procedural safety and efficacy. We describe the Medtronic CoreValve percutaneous aortic valve implantation using the subclavian arterial approach in patients with a patent left internal thoracic artery and report our study's findings. METHODS: The CoreValve percutaneous aortic valve is a self-expandable nitinol-based frame with a porcine pericardial valve. The subclavian access was created by a small infraclavicular surgical incision to expose the artery. Rapid ventricular pacing was used to reduce cardiac output to perform the balloon aortic valvuloplasty via a 12F sheath inserted into the subclavian artery. An 18F sheath was then inserted into the artery down into the ascending aorta and used for introduction of the delivery catheter and implantation of the percutaneous aortic valve. RESULTS: With the use of this method, 19 patients (76 ± 13 years) whose surgical risk was deemed excessive because of severe comorbidity and in whom transfemoral catheterization was considered unfeasible or at risk of severe complications have received implants. Subclavian artery or left internal thoracic artery injury did not occur in any patient. Two deaths occurred. One patient died of right coronary artery occlusion during the procedure, and one patient died 48 hours after the procedure as the result of a tamponade after the temporary pacemaker wire ablation. CONCLUSIONS: This initial experience suggests that subclavian transarterial aortic valve implantation in patients with a patent left internal thoracic artery to left anterior descending artery is feasible and safe with satisfactory short-term outcomes.

Endovascular approaches to acute aortic type A dissection: a CT-based feasibility study.

BACKGROUND: Open graft replacement of the ascending aorta is the current treatment of choice for Stanford acute type A dissections. However, approximately 20% of patients are deemed unfit for open surgery. To determine if an endovascular option exists for this latter group of patients, we performed a computed tomography (CT)-based feasibility study. METHODS: A cohort of consecutive patients presenting to the cardiovascular care unit (CVCU) for an acute Stanford type A aortic dissection between 2006 and 2009 was retrospectively analysed. Inclusion criterion was a high-quality preoperative angio-CT scan that could be analysed on a three-dimensional (3D) workstation. Numerous anatomical parameters of the dissection were studied, including the location and the length of the primary proximal entry tear. Finally, we determined which of the patients would have been potential candidates for an endovascular repair (stentgraft implantation). RESULTS: A total of 102 patients were included in our study. The median distance of the primary entry tear to the closest coronary artery was 23 mm (range 0-128). The median true lumen and true + false lumen (total) diameters at the level of the entry tear was 38 mm (range 22-78) and 46 mm (range 28-93), respectively. The median length of the ascending aorta was 84 mm (range 40-130). An endovascular repair with a tubular stentgraft was deemed feasible in 37 patients. An additional eight patients were also candidates for a tubular endovascular repair but would have required a carotidecarotid cross over bypass. Finally, an arch-branched stentgraft could have been used in 13 patients to exclude an entry tear located in the arch. CONCLUSION: Open repair of acute type A dissection is and remains the 'gold standard' of care. Our study demonstrates that approximately half the patients undergoing an open repair could potentially benefit from an endovascular repair. This new treatment option has not been evaluated to date.

[Ankle brachial index measurement at the first visit for hypertension: a safe and very useful tool for aortic coarctation screening. A case report]. / L'index de pression systolique dans un premier bilan d'hypertension: outil diagnostique de choix de la coarctation aortique. Un cas rapporté.

A 24-year-old African who had been living in France for few years first consulted at our institution for severe systemic hypertension. He had no prior medical or surgical history. The patient was strictly asymptomatic. Except for systemic hypertension at both arms, the basic physical examination was normal with no cardiac murmur and no pulse deficit. A 24-hour ambulatory blood pressure monitoring performed before the consultation confirmed the presence of systemic hypertension with a mean blood pressure at 155/90mmHg during the day and also during the night under anti-hypertensive treatment. Ankle-brachial index measurement was low at 0.8 at both legs. Subsequently, a trans-thoracic echocardiography (TTE) and an aortic CT-scanner were performed. The TTE did not find any abnormalities including no aortic dilatation or no ventricular hypertrophy. The CT-scanner revealed a partial aortic coarctation. The patient underwent aortic surgery and recovered in few days with quite normal blood pressure under medical treatment. In conclusion, systematic ankle-brachial index is useful and recommended in every patient at first visit for systemic hypertension. Its safety and simplicity make it an essential tool in the management of systemic hypertension especially in populations with no systematic screening of aortic coarctation in childhood. It was in the present case very useful for the final diagnosis and treatment. In addition, it is an efficient tool to screen patients with asymptomatic peripheral artery disease and it can help for stratification of cardiovascular risk.

Endovascular repair of thoracoabdominal aortic aneurysms.

OBJECTIVES: To evaluate the early outcomes following thoracoabdominal aortic aneurysm (TAAA) repair utilising fenestrated and branched endografts. DESIGN AND MATERIALS AND METHODS: A prospective analysis of all patients undergoing endovascular repair of TAAA in a single academic centre. All patients were deemed unfit for open surgical repair. Customised endografts were designed using CT data reconstructed on 3D workstations. Post-operatively all patients were evaluated radiologically at hospital discharge, at 6, 12, 18 and 24 months, and annually thereafter. RESULTS: Thirty-three consecutive patients (30 males) were treated over 33 months (August 2006 to April 2009). Median age and aneurysm size were 70 years (range 50-83 years) and 64 mm (range 55-100 mm) respectively. 114/116 (98%) of the targeted visceral vessels were successfully catheterised and perfused. The in-hospital mortality rate was 9% (3/33). Transient spinal cord ischaemia was diagnosed in 4/33 (12%) patients, and permanent paraplegia in one (3%). The median follow-up period was 11 months (range 1-33 months). Endoleaks were identified in 5/33 (15%) patients: type II in four patients and a type III endoleak in one patient which required the only secondary intervention. During follow-up, two patients died: one from stroke and the other from myocardial infarction 9 and 29 months respectively after the procedure. CONCLUSION: This preliminary study, which includes our learning curve, confirms the feasibility and safety of the endovascular repair of TAAA in high-risk patients. Meticulous follow-up to assess sac behaviour and visceral perfusion is critical in order to ensure optimal results of these complex endovascular repairs requiring numerous mating components.

Endovascular thoracoabdominal aortic aneurysm repair: a literature review of early and mid-term results.

Successful endovascular repair of abdominal aortic aneurysms (AAA) requires undilated proximal (infrarenal neck) and distal landing zones (common or external iliac arteries). A range of approved endografts are available to exclude such aneurysms. Recent multicentric prospective randomized trials have demonstrated a short and midterm decrease in aneurysm-related deaths of the endovascular technique compared to open surgery. These results have induced an overall increase in the rate of endovascular repair of AAA. Patients with more complex aortic aneurysms, involving the visceral vessels (juxta, para and thoraco-abdominal aneurysms (TAAA), have increased perioperative morbidity and mortality after open repair compared to AAA. These patients could potentially benefit from an endovascular approach. Branched and fenestrated endografts have been developed to address this endovascular challenge. This review was carried out on the current literature evaluating these new endovascular complex procedures. Spinal cord ischemia, 30-day mortality and branch patency rates after endovascular exclusion of TAAA ranged from 2.7% to 20%, 0% to 9.1% and 96% to 100% respectively. Mid-term results of endovascular complex aortic repairs are favourable compared to open surgery in high risk patients. Long-term results will be necessary to evaluate specific complications such as migration, material fatigue and component separation that can result in loss of visceral branches.

A comparison of the mid-term results following the use of bifurcated and aorto-uni-iliac devices in the treatment of abdominal aortic aneurysms.

PURPOSE: To compare the mid-term results following the use of bifurcated (ABIS) and aorto-uniiliac (AUIS) endovascular devices in the treatment of abdominal aortic aneurysms (AAA) in a population of patients deemed to be at high risk for open surgery. MATERIAL AND METHODS: Over a 4 year period (January 2003 to December 2007), 447 underwent elective endovascular aneurysm repair (EVAR) using ZENITH) stent-grafts. Group I comprised patients treated using the AUIS (n=124), and group II those receiving ABIS (n=323). Outcome measures included the assisted technical success rate, perioperative mortality, major complications, freedom from reintervention, and primary and secondary patencies. Factors associated with mid-term clinical failures were determined using univariate and multivariate analyses. RESULTS: The assisted primary technical success rate was 94% and 99% in groups I and II respectively (p=.002). Major perioperative complications occurred in 13 group I patients (10%) vs. 12 group II patients (4%) (p=.005). The 30-day mortality rate was 3.2% vs.1.5% (p=0.2). TASC C and D iliac lesions significantly increased the risk of major perioperative complications (35% vs. 3%; OR=14.94; 95% CI: 5.75 to 38.78; p<.0001). During the follow-up period (median 24 months), secondary procedures were required in 11% and 5% of group I and group II patients respectively (p=.01). Freedom from reintervention at 12, 24 and 36 months was 98%, 90%, and 85% in group I vs. 96%, 92%, and 92% in group II (P<0.005). The primary and secondary patency rates at 3 years were 92% vs. 98% (p=.003) and 97% vs. 99% (p=.04) for groups I and II respectively. In group I, the Crossover Femoro-Femoral Bypass (CFFB) was responsible for 3 major complications (2.4%) which occurred at 7, 12 and 57 months of follow-up. However, the use of AUIS with CFFB did not independently increase the risk of major complications during follow-up (HR=0.108; 95% CI: 0.007 to 1.637; p=.11, Cox proportion model). In both univariate and multivariate analysis, concomitant iliac arterial occlusive disease (IAOD) was the only significant predictor of clinical failure in study population as a whole (OR=3.996; 95% CI: 1.996 to 7.921; p<.0001). CONCLUSION: This study demonstrates that ABIS is associated with better results than AUIS in the management of patients with AAA. Iliac artery occlusive disease was more frequently diagnosed in the AUIS group and this was significantly associated with a higher risk of complications, while the crossover graft itself was not. Nevertheless, the outcomes for both groups are encouraging in this high risk population.

Zenith abdominal aortic aneurysm endovascular graft: a literature review.

The early experience of endovascular aneurysm repair (EVAR) using ''first generation'' devices was disappointing. There was an appreciable incidence of delayed, post-EVAR, aneurysm rupture. This was primarily a consequence of structural device failure. These failures provided important lessons for re-design and the modern ''second generation'' devices, including the Zenith (Cook Inc, Bloomington, IN, USA) endograft, are thought to be more reliable, particularly providing better fixation and sealing and also a more durable stent/fabric structure. This article comprises a review of the English literature detailing the endovascular treatment of abdominal aortic aneurysms using the Zenith endograft. It focuses on clinical studies or trials with intermediate to long-term follow-up, and related the literature to our own experience. In the series examined (N.=2 017 patients) the early mortality rate ranged from 0% to 4.1% and the technical success rate from 97.7% to 100%. The re-intervention rate was related to the length of follow-up (6.8% to 14%). Conversion rates were consistently <1%. There was a low incidence of device migration, limb thrombosis, component separation and stent fracture. These data support the ongoing use of the Zenith endovascular graft in patients with abdominal aortic aneurysms suitable for EVAR.

Surgical treatment of renal cell carcinoma with right atrial thrombus: early experience and description of a simplified technique.

Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.

Branched grafting for aortoiliac aneurysms.

PURPOSE: To evaluate a novel approach to preserve pelvic perfusion during endovascular AAA repair in patients with common iliac aneurysms extending to the iliac bifurcation. MATERIALS AND METHODS: A multicenter prospective analysis of patients undergoing implantation of a branched endograft designed to perfuse the internal iliac artery was conducted. All patients enrolled were considered high risk for open surgical repair and presented with common iliac artery aneurysms greater than 20mm and anatomy amenable to implant the branched device. Preoperative high resolution spiral CT, and follow-up CT studies in addition to abdominal radiographs were obtained at discharge, 1, 6, 12, and 24 months. RESULTS: Between 2003 and 2006, 52 patients (53 internal iliacs) were implanted with an investigational device. Mean common iliac aneurysm maximal diameter was 38 mm. The branch graft was combined with a proximal standard bifurcated component (61%), a fenestrated or a visceral branch component (33%), an aortouni-iliac component (2%), and alone in 2 patients (4%, following prior aortobi-iliac repair). Technical success was achieved in 94% of patients. Within the first month, 6 (11%) internal iliac branches occluded. No occlusions were noted after 1 month. The mean follow-up was 14.2 months. Common iliac aneurysm shrinkage was noted in 42% and 81% of patients at 6 and 12 months. There were no rupture, aneurysm related deaths or conversions, but there were 7 deaths during follow-up. CONCLUSIONS: The placement of endovascular prostheses that maintain antegrade perfusion of one or both internal iliac arteries is feasible, and early results provide evidence for optimism with regard to safety and efficacy.

Clinical outcome in patients with high-grade internal carotid artery stenosis after irradiation.

The authors followed up 41 consecutive patients (21 symptomatic) with internal carotid artery stenosis > or =70% and previous neck irradiation. After 28 months, 15 patients (36.6%) had died, five (12.2%) had had an ischemic stroke, and 15 (36.6%) had a new malignancy. Having a new malignancy was the only independent predictor of death. The major risk for patients with ICA stenosis > or =70% and previous neck irradiation is malignancy, not stroke.

[Hypertension revealing aneurysmal renal fibrodysplasia]. / Hypertension artérielle révélatrice d'une fibrodysplasie rénale anévrismale.

A 20-year-old woman consulted for severe hypertension which revealed aneurismal stenosing fibrodysplasia of the renal arteries. The diagnosis was established by duplex Doppler which visualized tight stenosis of the distal portion of the right renal artery and the proximal portion of the left, associated with aneurismal lesions downstream from the strictures (1.8 cm on the right and 1.3 cm on the left). The lesions were highly suggestive of fibrodysplasia and were confirmed by magnetic resonance angiography. Endoluminal revascularization was undertaken because of the severe hypertension and the presence of arterial lesions. Revascularization was unsuccessful and severe hypertension persisted. Surgery was performed in two stages. The first procedure consisted in resection of the left aneurismal lesion with aortorenal internal saphene bypass. Secondarily, exclusion of the right aneurysm was performed with cure of the stricture by extracorporal renal surgery with anastomosis of the renal artery to the aorta and the renal vein to the vena cava. Clinical outcome was favorable. Angioscan and duplex Doppler controls at three and six months confirmed the anatomic success of the revascularization. Aneurysm of the renal artery, like renal artery stenotic dysplasia, is a rare but probably underestimated condition due to insufficient screening. This diagnosis should be entertained in hypertensive young women. There is risk of rupture of the aneurysm. Aneurysmal lesions can be associated with renal artery stenosis which usually involves a short segment of the artery, as in our case. Renal aneurysms should be treated when one of the following elements is present: aneurysm measuring more than 20 mm, progressing aneurysm, dissection, discovery in a patient with a renal risk (single kidney, renal insufficiency), desire for pregnancy, severe hypertension recently discovered in a young subject associated with dysplastic stenosis, isolated aneurysm associated with recent severe hypertension, as reported here.

Angioplasty and stenting for high-grade internal carotid artery stenosis: safety study in 39 selected patients.

BACKGROUND: Carotid angioplasty and stenting (CAS) is sometimes used as an alternative to surgery, despite the lack of evidence for its safety and efficacy. METHOD: Over a 33-month period, 39 consecutive patients with a stenosis >/=70% underwent CAS (4 in a randomized trial and 35 because of contra-indications for surgery). RESULTS: In 5 patients (13%; 95% CI: 3-23), a major complication occurred (3 disabling ischaemic strokes, 1 myocardial infarction, 1 acute interstitial nephropathy). In 7 patients (18%; 95% CI: 6-30), a minor complication occurred (5 transient ischaemic attacks, 1 transient confusional state, 1 non-disabling ischaemic stroke). CONCLUSION: CAS cannot be considered as a routine procedure and should be restricted to high-risk patients unfit for surgery.

Percutaneous transluminal angioplasty of proximal vertebral artery stenosis: long-term clinical follow-up of 16 consecutive patients.

We report long-term (average 30 months) clinical and radiological follow-up of 16 consecutive patients with uni- or bilateral proximal vertebral artery stenosis who underwent percutaneous transluminal angioplasty (PTA), without stenting, between 1995 and 1998. Assessment was performed by an independent neurologist. All patients but one remained asymptomatic during follow-up; moderate restenosis was observed in four. PTA of the proximal vertebral artery is safe but in the absence of knowledge of the natural history of atherosclerotic vertebral artery stenosis, whether it is beneficial or not remains unproven. The decision as to whether to perform this procedure is individual.

Shot-noise detection of ultrasound-tagged photons in ultrasound-modulated optical imaging.

We propose a new detection method for ultrasound-modulated optical tomography that allows us to perform parallel speckle detection with optimum shot-noise sensitivity, using a CCD camera. Moreover, we show that making use of a spatial filter system allows us to fully filter out speckle decorrelation noise. This method is confirmed by a test experiment.

Risk factors of early and late complications in patients undergoing endovascular aneurysm repair.

OBJECTIVES: to identify pre-operative factors that could predict complications following from transluminal repair of abdominal aortic aneurysms (AAA). METHODS: during a 5-year period, 96 consecutive patients underwent elective endovascular treatment of a AAA. In all patients, helical CT and/or Magnetic Resonance Imaging (MRI), and plain abdominal roentgenogram were performed at 1, 3, 6, 12, 18, and 24 months and yearly thereafter. Angiography was performed systematically 1 year after the stent-graft implantation, or earlier if helical CT or MRI diagnosed an increase in the maximal transverse diameter or a high flow endoleak. RESULTS: early (<30 days) morbidity (12%) was significantly increased by pre-operative renal insufficiency (p < 0.01). Early mortality (2%) correlated with ASA score (p = 0.01). Median follow-up was 27 months (range 3-66). Mortality (12%) during follow-up was correlated to the pre-operative coronary status (p = 0.01). A type I endoleak was diagnosed in 18 patients (19%). Common iliac artery diameter was correlated with the presence of type I endoleak (p < 0.001). A type II endoleak was diagnosed in 47 (49%) patients. The diagnostic of type II endoleak was significantly increased (p = 0.001) in patients with pre-operative patent IMA associated with more than four patent lumbar arteries. The anatomic characteristics of the aneurysm were correlated to the additional endovascular procedures during stentgraft implantation (p = 0.01), and to the implantation of a complementary iliac limb extension during follow-up (p = 0.01). CONCLUSIONS: the risk factors determined by this statistical analysis could help surgeons to select more accurately patients suitable for endovascular treatment.

Stent-graft repair of the thoracic aorta: short-term results.

The purpose of this study was to evaluate clinical feasibility and immediate outcome of stent-graft repair of the thoracic aorta. From December 1999 to January 2001, a total of 14 patients underwent stent-graft repair of the thoracic aorta. The underlying etiologies were traumatic rupture of the aortic isthmus in four cases, Stanford type B dissection in four, thoracic aortic aneurysm in three, penetrating atherosclerotic ulcer in two cases, and postoperative aortoesophageal fistula in one case. Stent-graft placement was performed under angiographic control in all cases in association with transesophageal echography in seven cases. The procedure was performed under emergency conditions in five cases. Thirteen patients presented contraindications for surgery. Stent-graft placement was successful in all cases. No further surgery has been performed in any case. Thus we conclude that endovascular treatment of the thoracic aorta using stent grafts is a promising therapeutic modality in patients with contraindications for conventional surgical treatment.