Novel risk factors for premature peripheral arterial occlusive disease in non-diabetic patients: a case-control study.

BACKGROUND: This study aimed to determine the prevalence of genetic and environmental vascular risk factors in non diabetic patients with premature peripheral arterial disease, either peripheral arterial occlusive disease or thromboangiitis obliterans, the two main entities of peripheral arterial disease, and to established whether some of them are specifically associated with one or another of the premature peripheral arterial disease subgroups. METHODS AND RESULTS: This study included 113 non diabetic patients with premature peripheral arterial disease (diagnosis <45-year old) presenting either a peripheral arterial occlusive disease (N = 64) or a thromboangiitis obliterans (N = 49), and 241 controls matched for age and gender. Both patient groups demonstrated common traits including cigarette smoking, low physical activity, decreased levels of HDL-cholesterol, apolipoprotein A-I, pyridoxal 5'-phosphate (active form of B6 vitamin) and zinc. Premature peripheral arterial occlusive disease was characterized by the presence of a family history of peripheral arterial and carotid artery diseases (OR 2.3 and 5.8 respectively, 95% CI), high lipoprotein (a) levels above 300 mg/L (OR 2.3, 95% CI), the presence of the factor V Leiden (OR 5.1, 95% CI) and the glycoprotein Ia(807T,837T,873A) allele (OR 2.3, 95% CI). In thromboangiitis obliterans group, more patients were regular consumers of cannabis (OR 3.5, 95% CI) and higher levels in plasma copper has been shown (OR 6.5, 95% CI). CONCLUSIONS: According to our results from a non exhaustive list of study parameters, we might hypothesize for 1) a genetic basis for premature peripheral arterial occlusive disease development and 2) the prevalence of environmental factors in the development of thromboangiitis obliterans (tobacco and cannabis). Moreover, for the first time, we demonstrated that the 807T/837T/873A allele of platelet glycoprotein Ia may confer an additional risk for development of peripheral atherosclerosis in premature peripheral arterial occlusive disease.

Femorofemoral bypass as an alternative to a direct aortic approach in daily practice: appraisal of its current indications and midterm results.

BACKGROUND: To assess our current practice concerning the indications and the immediate and midterm results of femorofemoral bypass. METHODS: We retrospectively included all patients, from 1997 to 2008, operated on for aortoiliac occlusive disease using an extra-anatomical bypass from a donor iliac artery or a femoral artery to the contralateral femoral artery (common or profunda artery). Demographic data, initial clinical status, characteristics of the interventions, and short- and midterm results were collected. Elective surgery was distinguished from urgent surgery (critical limb ischemia, acute ischemia, vascular infection). RESULTS: One hundred twenty-four femorofemoral bypasses were performed (103 male), mean age 68 (±12) years. Indications were critical limb ischemia (47.1%), intermittent claudication (38.8%), acute ischemia (12.1%), and vascular infections (1.7%). Perioperative outcomes were 5.6% mortality (elective surgery 0.0%, urgent surgery 9.7%, P = 0.02) and 27.4% morbidity without any secondary graft infections (elective surgery 22.5%, urgent surgery 31.9%, P = 0.17). Mean follow-up period was 3 years, and overall survival was 69.4% (elective surgery 88.7%, urgent surgery 56.7%, P = 0.08). At 3 years, primary patency was 81.8% and secondary patency was 89.3% (elective surgery 96.4%, urgent surgery 84.2%, P = 0.68). No significant risk factors for immediate and secondary thromboses were found. CONCLUSION: In our current practice, femorofemoral bypasses are applied mainly for urgent procedures when avoiding a direct aortic approach is mandatory, with good midterm results. Although indications are limited for good-fit patients, femorofemoral bypass has confirmed safety (no perioperative deaths, no infections) and high durability (good secondary patency).

Prehospital treatment of infrarenal ruptured abdominal aortic aneurysms: a multicentric analysis.

BACKGROUND: The aim of this study was to evaluate the quality of the current treatment of patients presenting with ruptured abdominal aortic aneurysms (RAAAs), from the first symptoms to the operating room with an analysis of preoperative mortality risk factors. METHODS: For 3 years, in four vascular surgery departments, we have collected all the consecutive cases of patients operated on for RAAA. We analyzed the initial clinical situation, the means of transportation, the time elapsed before treatment, and the mortality rate at 3 days. Sixty-six RAAAs were operated on. Mean patient age was 76 years (range, 52-93 years). RESULTS: The initial symptoms were a precisely located pain either abdominal (45.3%), lumbar (17.2%), or both (14.1%) or feeling faint (10.9%). In 22.7% of the cases, an initial hemodynamic instability was observed. In 46.8% of the cases, patients first went to a peripheral hospital before being admitted into a referral centre. In 84.5% of the cases, medical mean of transportation was used. The mean distance covered was 59.8 kilometers (range, <5 km to 213 km). The initial diagnosis was accurate in 67.3% of the cases. The mean intrahospital waiting period between the arrival at a reference center and the admission into an operating room was 127 minutes. Global mortality rate was 44.2%. The main preoperative mortality factor to be noticed was the initial hemodynamic instability (p=0.0031). Among stable patients, only two of them (5.4%) worsened during the preoperative treatment. CONCLUSION: In our study, hemodynamic instability corresponds to the main prognosis factor of mortality. In most cases, the initial stability persisted and allowed additional evaluation. However, the intrahospital waiting periods appeared to be too long. To be optimal, the adequate treatment should be specifically designed as soon as a diagnosis has been established.