[Long-term patency of a popliteal venous aneurysm treated surgically]. / Perméabilité à long terme d'un anévrisme veineux poplité traité chirurgicalement.

Popliteal venous aneurysms are infrequent but should be screened for with venous ultrasound in patients with acute or chronic venous diseases because of the unpredictable high risk of thromboembolism and potential curability. Therapeutic alternatives are discussed: follow-up, anticoagulation, surgery with different techniques. To illustrate this, we report the case of a 51-year-old woman presenting pulmonary embolism and left popliteal venous aneurysm treated surgically. Anticoagulation was stopped 12 months after surgery and primary patency was maintained 40 months after surgery. In patients with thromboembolism disease, clinicians should search for popliteal venous aneurysms in order to prevent recurrent thrombosis and adapt follow-up and treatment.

Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke.

UNLABELLED: After intravenous thrombolysis (IVT) for acute ischaemic stroke (AIS), a severe cervical internal carotid artery (ICA) stenosis may remain and increase the risk of recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in reducing the risk of stroke. However, it is not well known whether CEA can be performed safely after thrombolysis, and, if so, when. We report a prospective study of CEA for residual high-grade cervical ICA stenosis performed within 15 days after IVT for AIS. METHODS: All the patients had a brain magnetic resonance imaging (MRI) within 3h of the stroke onset. One day after IVT in neurovascular unit, computed tomography (CT) angiography was performed to assess the brain and the patency of cervical arteries. CEA was performed on neurologically stable patients after full cerebral artery re-canalisation. Blood pressure was controlled with particular caution before and after CEA. RESULTS: Between January 2005 and January 2008, we operated consecutively on 12 patients. Their median National Institutes of Health Stroke Scale (NIHSS) score was 12 (range: 5-21). Combined intracranial (ICA)-middle cerebral artery (MCA) occlusion was present in 58.3% of the patients. The median time between onset of symptoms until CEA was 8 days (range: 1-16 days). Stroke and death rate at 30 days was 8.3% (one nonfatal haemorrhagic stroke). At 90 days, nine patients had a Rankin score of 0-1, one had a score of 2 and two had a score of 3. CONCLUSION: In patients with residual cervical ICA stenosis after IVT, we achieved full patency of the occluded artery and good functional prognosis at 3 months in all cases. We advocate for an extremely close monitoring of the blood pressure in the pre-, peri- and post-operative course and a close collaboration between neurologist and surgeon to determine the best timing for CEA.

Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study.

AIMS: The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high-risk patients using the ankle-brachial index (ABI). METHODS: The ABI was measured by general practitioners in France (May 2005-February 2006) in 5679 adults aged 55 years or older and considered at high risk. The primary outcome was prevalence of PAD (ABI strictly below 0.90). RESULTS: In all, 21.3% patients had signs or symptoms suggestive of PAD, 42.1% had previous history of atherothrombotic disease and 36.6% had two or more cardiovascular risk factors. Prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors only to approximately 38% in each other subgroup. Prevalence differed depending on the localization of atherothrombotic events: it was 57.1-75.0% in patients with past history of symptomatic PAD; 24.6-31.1% in those who had experienced cerebrovascular and/or coronary events. Regarding the classical cardiovascular risk factors, PAD was more frequent when smoking and hypercholesterolemia history were reported. PAD prevalence was also higher in patients with history of abdominal aortic aneurysm, renal hypertension or atherothrombotic event. Intermittent claudication, lack of one pulse in the lower limbs, smoking, diabetes and renovascular hypertension were the main factors predictive of low ABI. CONCLUSIONS: Given the elevated prevalence of PAD in high-risk patients and easiness of diagnosis using ABI in primary care, undoubtedly better awareness would help preserve individual cardiovascular health and achieve public health goals.

[Endovascular aneurysm repair follow-up by unenhanced and contrast-enhanced duplex ultrasound]. / Surveillance des endoprothèses aortiques abdominales : intérêt de l'échographie-doppler standard et avec contraste.

OBJECTIVE: Long-term surveillance is needed after endovascular aneurysm repair to monitor the aneurysm and search for persistent endoleaks. Our aim was to compare follow-up with duplex ultrasound, with and without a new contrast agent to track endoleaks, versus computed tomography angiography taken as the gold standard. MATERIAL AND METHOD: Patients treated with endograft were included prospectively from December 2005 to July 2006. Aortic duplex ultrasound and computed tomography were used to measure maximal aneurysm diameter and detect endoleaks. Patients with a high risk of endoleaks had a contrast-enhanced ultrasound with Sonovue (Bracco, Milan, Italy). We compared echographic and tomographic diameter and studied the sensitivity of ultrasound endoleak diagnosis. RESULTS: Sixty-seven patients were included. There was a good correlation between maximum anteroposterior diameters (CCI=0.98) measured by ultrasound and tomography, as well as mean maximum cross section diameters (CCI=0.96). Compared to tomography, the sensitivity of ultrasound endoleaks diagnosis was 44% (kappa=0.58). Contrast injection improved this sensitivity significantly (p<0.001) (sensitivity=88%; kappa=0.72). CONCLUSION: These findings confirmed the performance of our ultrasound method for endograft surveillance. Contrast-enhanced ultrasound significantly improves the sensitivity of detection of endoleaks. We suggest alternating ultrasound and tomographic exams. A unique report chart for use nationwide would be useful for standardizing follow-up.

The haemodynamics of the distal arterial Y-shaped autograft bypass-flap in a porcine experimental model.

BACKGROUND: The haemodynamic effects of revascularisation with combined bypass and free-muscle flap remain controversial. In a porcine experimental model, we investigated the transplantation-induced changes in the haemodynamics of a Y-shaped combined arterial autograft bypass-muscle flap (AABF). METHODS: Anatomy of AABF was identified in eight dissections in four porcine cadavers. In five animals, AABF served as a superficial femoral artery (SFA) defect replacement. Modelled, triggered pulsatile pressure (P) and flow (Q) waves delivered mean haemodynamics and PQ hysteresis loops before and after transplantation at days 0 and 10. RESULTS: Anatomically, AABF combined subscapular and circumflex-scapular arteries, and thoracodorsal artery as latissimus dorsi flap pedicle. Surgical feasibility and AABF patency were confirmed in each case. At day 0, the proximal flow was increased in the grafted Y-shaped AABF, which also adopted the specific SFA pulsatile haemodynamics. Regulatory mechanisms of AABF vasomotricity were preserved and AABF-flow-dependence amplified the flow in the distal segment, which otherwise preserved its own flow dependence. At 10 days, the AABF flow was unchanged in the distal segment, and remained elevated in the proximal and pedicle segments. CONCLUSIONS: Combined AABF, as a single one-piece arterial autograft, was shown highly adaptive to the receiving arteries. The transplantation-induced changes in AABF pulsatile flow profile and vascular reactivity improve the overall graft flow, and strongly advocate for beneficial effects on the blood propelling capacity of the grafted circulation.

Coxiella burnetii infection of aortic aneurysms or vascular grafts: report of 30 new cases and evaluation of outcome.

Q fever is a zoonotic disease caused by Coxiella burnetii. Polymorphic, the disease may present as an acute or chronic infection. Vascular infections are the second most common form of chronic Q fever, following endocarditis. Herein, we studied the outcome of 30 new cases of aortic infection caused by C. burnetii using uni- and multivariate analyses. The outcome of ten cases previously reported by our team was also updated. Of these 40 patients, 32 had a follow-up of >or=3 years. Among them, the overall mortality was of 25% (8/32). Vascular rupture was significantly and independently (multivariate P=0.03) associated with a lethal issue, whereas vascular surgery was significantly associated with recovery (uni- and multivariate P<0.01). Our findings demonstrate the critical importance of surgery in the management of C. burnetii vascular infections.

Management of small asymptomatic abdominal aortic aneurysms - a review.

The approach for abdominal aortic aneurysms (AAAs) larger than 55 mm is well defined due to the risk of rupture being higher than 10% per year, and a 30-day perioperative mortality rate between 2.5% and 5%. However, the approach for small asymptomatic AAAs is less well defined.There are different definitions given to describe a small AAA. The one the authors accepted and applied is "a localized, permanent and irreversible dilation of the aorta of at least 50% in relation to the normal adjacent infrarenal or suprarenal aorta, with a maximum diameter between 30-55 mm".The investigators of the largest study on small AAAs (United Kingdom Small Aneurysm Trial [UK-SAT]) concluded, in brief, that ultrasound monitoring is the most appropriate solution because the results do not support a policy of surgical restoration for AAAs with a diameter of between 40 mm and 55 mm.The aim of the present review article is to highlight several challenges that could change the limits or create a more flexible deciding factor in the management of AAAs. There are multiple factors that influence surgical decision-making, and the limit on aneurysm diameter that indicates surgery should depend on the patient's age, life expectancy, general status, associated diseases, diameter in relation to body mass, risk factors, sex, anxiety and compliance during the follow-up period. Monitoring is an acceptable alternative for AAAs between 40 mm and 55 mm, and is probably the best solution for high-risk patients. Surgery is the most reasonable solution for patients who are at moderate risk, have a significant life expectancy, are less than 70 to 75 years of age, and/or have aortic aneurysms larger than 50 mm.

'Pole test' measurements in critical leg ischaemia.

BACKGROUND: For the quantification of critical limb ischaemia (CLI) most vascular surgery units use sphygmo-manometric and transcutaneous oxygen pressure (TcPO2) measurements. However, measurements obtained by cuff-manometry can be overestimated especially in diabetic patients because of medial calcification that makes leg arteries less compressible. TcPO2 measurements present a considerable overlap in the values obtained for patients with different degrees of ischaemia and its reproducibility has been questioned. Arterial wall stiffness has less influence on the pole test, based on hydrostatic pressure derived by leg elevation, and this test seems to provide a reliable index of CLI. OBJECTIVE: The objective of this study was to evaluate the pole pressure test for detection of critical lower limb ischaemia, correlating results with cuff-manometry and transcutaneous oxygen pressure. DESIGN: University hospital-prospective study. MATERIALS AND METHODS: Seventy-four patients (83 legs) with rest pain or gangrene were evaluated by four methods: pole test, cuff-manometry, TcPO2 and arteriography. CLI was present if the following criteria were met: (a) important arteriographic lesions+rest pain with an ankle systolic pressure (ASP) < or = 40 mmHg and/or a TcPO2 < or = 30 mmHg, or (b) important arteriographic lesions+tissue loss with an ASP < or = 60 mmHg and/or a TcPO2 < or = 40 mmHg. Fifty-seven lower limbs met the criteria for CLI. RESULTS: Measurements obtained by cuff-manometry were significantly higher to those obtained by pole test (mean pressure difference: 40 mmHg, p<0.001). The difference between the two methods remained statistically significant for both diabetics (50.73, p<0.001) and non-diabetics (31.46, p<0.001). Mean TcPO2 value was 15.51 mmHg and there was no important difference between patients with and without diabetes. Overall, there was a correlation between sphygmomanometry and pole test (r = 0.481). The correlation persisted for patients without diabetes (r = 0.581), but was not evident in patients with diabetes. Correlation between pole test and TcPO2 was observed only for patients with diabetes (r = 0.444). There was no correlation between cuff-manometry and TcPO2. The pole test offered an accuracy of 88% for the detection of CLI. The sensitivity of this test was 95% and the specificity 73%.

Endovascular treatment of anastomotic false aneurysms of the abdominal aorta.

Conventional surgical treatment of anastomotic false abdominal aortic aneurysms (AFAA) is technically difficult. Morbidity-mortality rates are higher than those for surgery of infrarenal abdominal aortic aneurysm (AAA). Endovascular management without laparotomy or aortic clamping represents an attractive alternative. The purpose of this study was to determine the immediate and middle-term outcome of endovascular management of AFAA. Between 1998 and 2001, 10 patients were treated for AFAA by placement of an endograft. The initial procedure was aortobifemoral bypass for occlusive artery disease in eight cases and resection and grafting for AAA in two cases. Mean age was 70 years. Seven patients were classified ASA 3 or 4. Three patients presented cardiac insufficiency with left ventricular ejection fraction <40%. Eight patients were treated using an aortounilateral iliac artery endograft in association with crossover femorofemoral bypass (3 AneuRx, 2 Endologix, 1 Talent, 1 Zenith, 1 surgeon-made stent). Two patients were treated with an aortoaortic endograft (1 Talent, 1 surgeon-made stent). In two patients extraperitoneal exposure of the common iliac artery was required for introduction of the stent in one case and for surgical closure of the iliac artery in the other case. A total of nine patients underwent another surgical procedure in association with stenting. Four endografts were custom-made. Endograft deployment was successful in all cases. No patient died during the postoperative period. Postoperative computed tomography (CT) scan confirmed exclusion of the aneurysmal sac in all cases. The mean duration of hospitalization was 13 days (range, 5-28 days). During follow-up (mean duration, 17.7 months; range, 5-42 months), one patient died from heart-related causes. No direct or indirect endoleak was detected by CT scan follow-up and a significant reduction in AFAA diameter was noted in the eight patients with follow-up periods lasting 6 months or more. One patient developed occlusion of an aortounilateral iliac artery endograft and was treated by axillobifemoral bypass. In one patient stenosis of the distal end of an aortounilateral iliac endograft was discovered by duplex scan and successfully treated by dilatation. Endovascular treatment of AFAA is technically feasible but requires more complex procedures involving associated surgical procedures and use of custom-made endografts. The morbidity-mortality rate in this small series of high-risk patients was low. Immediate and middleterm exclusion of AFAA was good.

Sural flap vascularization in arteritic patients: an anatomic study of 24 amputation specimens.

Obliterating arteriopathy of the lower limbs is a classic contraindication for neurocutaneous islands flaps, particularly the sural flap. But recent literature reports examples of its successful application in arteritic patients. The aim of this work was to study the vascular anatomy of the sural flap in patients suffering from arteriopathy and its possible clinical application. Twenty-four specimens of leg amputation were studied. The mean age of the amputated patients was 68.5 years. The clinical signs of arteriopathy had been present for 3-16 years. In 10 cases amputation was carried out directly, in 14 cases after failed revascularization. The results of the dissection showed the theoretical possibility of a sural flap in almost all the cases (23 of 24) despite certain anatomical peculiarities. In the upper part of the leg the arterial network of the sural communicating nerve dominates that of the sural nerve; this should allow the use of a sural flap centered on this vascular axis. In the lower part, the arterial network of the sural communicating nerve is sustained by the perforators of the peroneal artery, then by the branches of the calcaneal artery, and finally by the lateral tarsal artery, which should allow the use of a sural flap with a very distal pedicle. The authors propose a theory which suggests that the progressive evolution of arteriopathy and the concomitant development of a supply network involving the vascularization of the sensory nerves induces the "anticipation" of a sural flap.

Surgical anatomy of the lateral supramalleolar flap in arteritic patients: an anatomic study of 24 amputation specimens.

The lateral supramalleolar flap (LSMF) is frequently used for covering major tissue defects of the foot and ankle but usually, in case of arteriopathy of the lower limbs, this device is contra-indicated. Twenty-four specimens of amputated limbs of patients suffering from arteriopathy of the lower limbs allowed us to study the vascular anatomy of this flap after intra-arterial injection of colored latex. At the time of the amputation the average age of the patients was 68.5 years. The clinical signs of arteriopathy had been present for 3-16 years. In 10 cases the amputation was performed directly, in 14 cases after an unsuccessful attempt at revascularization. The dissection results revealed certain specificities in the vascularization of the LSMF with arteriopathy. The perforating branch of the peroneal artery was found in all cases. The descending branch of this perforating artery was found to be patent in 22 cases but slim in five cases. It was absent in two cases. The superficial peroneal nerve and its vascular network always participated in the vascularization of the flap. Thus, its preservation in the distal part of the flap offers a second vascular flow to the pedicle of the LSMF. This specificity increases the theoretical feasibility of the LSMF from 17 to 22 cases out of 24 in our dissections. The authors suggest a theory according to which the evolution of arteriopathy and the gradual concomitant development of a supply network, which effects the vascularization of the sensory nerves too, induces the "anticipation" of a flap. The preliminary distal revascularization by bypass grafts or by some kind of endovascular treatment should guarantee the good vascularization of a limb and the reliable use of this neurocutaneous arterial network.

Critical review of non- or minimally invasive methods (duplex ultrasonography, MR- and CT-angiography) for evaluating stenosis of the proximal internal carotid artery.

OBJECTIVE: to assess the performance of non- or minimally invasive methods (duplex ultrasonography, MR- and CT-angiography) in measuring stenosis of the proximal internal carotid prior to endarterectomy without preoperative intra-arterial digital subtraction angiography (DSA). METHODS: systematic review of the literature (five databases, 1990 to February 2001). The value of each imaging technique was studied through its reproducibility and its sensitivity/specificity compared to DSA. RESULTS: sensitivity exceeded 80% and specificity 90% in over two-thirds of the methodologically sound studies, regardless of technique, although direct comparisons between results had to be avoided since the findings originated from different populations. The main drawback of duplex ultrasonography is its levels of reproducibility. In contrast, only a few studies have addressed the reproducibility of MR- and CT-angiography. When the results of duplex and MR-angiography agree, the combination use of these two techniques provides a better diagnosis than either technique taken alone. CONCLUSIONS: all three techniques appear suitable for measuring stenosis of the proximal internal carotid when compared to DSA.

Mortality and morbidity following endovascular repair of abdominal aortic aneurysms: analysis of two single centre experiences.

OBJECTIVE: to show how differences in anatomical and physiological risk factors can affect the outcome of endovascular repair of AAA by describing the experience of two centres with different selection policies. METHODS: one hundred and thirty-five patients (group I) were treated at Queen's Medical Centre (Nottingham, U.K.) using 101 in-house made and 34 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 26 mm, 27 mm, 40 degrees, respectively. Seventy-six patients had ischaemic heart disease, 47 had left ventricular failure, median forced expiratory volume in one second (FEV1) was 83%, median creatinine was 100 micromol/l and median age was 72 years. Fifty patients (group II) were treated at Timone Hospital (Marseilles, France) using seven in-house made and 43 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 25 mm, 34 mm, 33 degrees, respectively. Thirteen patients had ischaemic heart disease, two had left ventricular failure, median forced expiratory volume in one second was 101%, median creatinine was 108 micromol/l and mean age was 72 years. RESULTS: anatomical characteristics of the proximal neck were significantly worse in group I (p=0.02 for the three variables). Cardiac comorbidities were more frequent and mean FEV1 was lower in group I (p<0.0001 and p=0.001, respectively. Median aneurysm diameter was significantly greater in group I (65 mm) than in group II (53 mm) (p<0.001). Postoperative mortality was 9% and 0% in groups I and II respectively (p=0.03). The incidence of technical complications (groin wound complications and side branches endoleaks being excluded) was 20% and 0% in groups I and II, respectively (p=0.0006). CONCLUSION: postoperative mortality and technical complication rates were significantly greater in group I than in group II, readily explained by poorer general condition and worse anatomical characteristics of the proximal neck in group I.

Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification.

OBJECTIVE: to propose an anatomical classification of juxtarenal aortic aneurysm (JRA) that relates to their epidemiology and the result of surgical repair. MATERIAL AND METHODS: retrospective study of 53 JRA and 376 infrarenal aortic aneurysm (AAA) operated between January 1989 and August 1999. RESULTS: perioperative mortality after JRA repair was 19% for type A (interrenal), 13% for type B (aneurysm of one or two renal origins) and 4% for type C (no infrarenal neck). These differences were not significant. The overall perioperative mortality after JRA repair (11%) was significantly higher than mortality of AAA (3%p<0.01). Postoperative morbidity after JRA repair was 62% for type A, 75% for type B and 33% for type C. Postoperative morbidity after type B repair was significantly more frequent than after type C (p<0.001). The overall postoperative morbidity (51%) was significantly more frequent than after AAA repair (26%p<0.01). Preoperative ischaemic heart disease, aortic clamping above the coeliac axis and aortic proximal clamping longer than 30 min were significant risk factors for death after JRA repair. Survival by life-table analysis at five years after JRA repair and AAA repair were respectively 73%+/-7% and 76%+/-3%. CONCLUSION: there is a less favourable outcome after JRA repair as compared to AAA repair. The complexity of the surgical procedure requires accurate preoperative morphological assessment. The proposed classification of juxtarenal aneurysms may be helpful in guiding surgical access.

Endovascular treatment of occlusive lesions in the distal aorta: mid-term results in a series of 31 consecutive patients.

The purpose of this study was to evaluate the early and mid-term results of endovascular treatment of occlusive lesions in the distal aorta in a consecutive series of patients. Between February 1996 and March 1999, a total of 31 patients underwent transluminal procedures for treatment of occlusive atherosclerotic lesions located at the lower end of the aorta. Thirty patients presented with intermittent claudication and one had critical ischemia. Manifestations were bilateral in 26 cases and unilateral in 5. The lesion was confined to the lower aorta in 3 patients and extended to the common iliac arteries in 19, with predominant proximal lesions of the common iliac artery occurring in 9 patients. Fourteen patients had concurrent infracrural occlusive lesions. All patients underwent exclusive endovascular treatment without any associated open surgical procedure. The three patients with isolated aortic lesions were treated by angioplasty, followed by stent placement in two cases. The 19 patients with aortobiiliac lesions were treated by bilateral common iliac artery angioplasty according to the "kissing-balloon" technique; 7 of these patients also underwent aortic angioplasty. In these 19 patients, aortic stenting was performed in 3 cases and bilateral iliac stenting in 10 cases, including 3 in association with aortic stenting. The nine patients with a proximal lesion of the common iliac arteries were treated by angioplasty, followed by bilateral stenting in three cases and unilateral stenting in three cases. The findings of this study show that the mid-term anatomical and functional results of endovascular treatment for atherosclerotic lesions of the distal aorta are satisfactory. We recommend it as the initial treatment modality.

Compromised hemodynamics associated with multipedicular lesions of cerebral arteries.

The purpose of this study was to demonstrate that severe multipedicular lesions involving supraaortic trunks cause compromised cerebral hemodynamics with nonhemispheric symptoms (NHS) that can be relieved by surgical treatment. A total of 11 patients were prospectively included in the study. Regional cerebral blood flow (rCBF) and cerebral blood flow reactivity (CBFR) were measured by acetazolamide single photon emission computed tomoscintigraphy scans (SPECT) before and after surgery. Seven patients presented with isolated NHS and four presented with NHS associated with hemispheric symptoms. Lesions consisted of either high-grade (>75%) bilateral carotid artery stenosis associated with vertebral or subclavian artery lesions or high-grade (>75%) bilateral vertebral or subclavian artery stenosis associated with medium-grade (>50%) carotid lesions. All patients presented with a functional circle of Willis with no significant intracranial arterial lesions and no corticosubcortical atrophy. A total of 15 procedures were performed for revascularization of 19 arteries. The cumulative morbidity/mortality rate was nil. All revascularizations were patent on postoperative controls. Results from this study show that multipedicular lesions lead to hemodynamic changes affecting hemispheric and vertebrobasilar territories. Surgical treatment can improve or normalize cerebral hemodynamic abnormalities and relieve NHS.