Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study.

OBJECTIVE: During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. METHOD: From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75 ± 9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. RESULTS: The technical success rate was 97.6%. Failures were device migration (n = 1), navigation failure (n = 2), and release outside the target zone (n = 1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111 ± 51 mL and the radiation dose was 127,777 ± 89,528 mGy/cm(2). The total fluoroscopy time was 854 ± 538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n = 41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. CONCLUSION: This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

[Large-vessel granulomatous vasculitis during the course of sarcoidosis: Takayasu's arteritis?]. / Angéite granulomateuse au cours d'une sarcoïdose : maladie de Takayasu ?

BACKGROUND: Vascular involvement in sarcoidosis is very rare and is characterized by preferential involvement of large vessels similar to that observed in Takayasu's disease. Distinguishing between these two diseases is often difficult and constitutes a diagnostic pitfall. The association between sarcoidosis and Takayasu's arteritis is not coincidental and a common physiopathological factor may exist; it suggests a possible aetiopathogenetic relationship between sarcoidosis and Takayasu's arteritis and casts doubt on whether this form of vasculitis is a disease in its own right or simply a syndrome caused by other diseases. CASE REPORT: We report the case of a man with a 10-year history of cutaneous and pulmonary sarcoidosis who developed ischaemia of the right upper limb evocative of Takayasu's arteritis. The patient was successfully treated with oral steroids and methotrexate. DISCUSSION: This case prompts discussion about the relationship between Takayasu's disease and sarcoidosis. Physicians should be aware of the possible occurrence of granulomatous arteritis during the course of sarcoidosis which requires a special work-up.

Acute elbow dislocation with arterial rupture. Analysis of nine cases.

UNLABELLED: Elbow dislocations are the most frequently encountered dislocations after shoulder dislocations. In their vast majority these injuries involve only the joint and carry a good prognosis. Close anatomic proximity to the joint of neurovascular structures put them at risk of concomitant injury but this occurrence remains, actually very rare. The objective of this study is to retrospectively analyze the results of nine cases of elbow dislocations with brachial artery complications and to propose coherent therapeutic guidelines derived from this experience. MATERIALS AND METHODS: From 1999 to 2004, 357 elbow dislocations were treated by the traumatology team at the Purpan University Hospital and 340 at the Rangueil University Hospital in Toulouse, France. These two teaching institutions combined their series, contributing to seven dislocations associated with a brachial artery partial rupture, resulting in ischemia. Between 2001 and 2006 at the Le Mans Regional Hospital Center, 138 dislocations of the elbow were treated, and included two cases involving rupture of the brachial artery. In all these institutions' emergency departments, elbow dislocations were mainly treated on an outpatient basis: closed reduction under ultra short-acting products general anesthesia, with stability evaluation followed by cast immobilization. In the rare instances of ischemia, the artery was repaired in concert with the vascular surgery team. All the nine cases had a similar treatment protocol and were submitted to an identical outcome evaluation method. The patients were all males with a mean age of 37.3 years (range, 18-58 years). The combined injury occurred at sports in two cases, because of a fall in three cases and as a result of a traffic accident in four cases. Ischemia was complete in three cases (no radial or ulnar pulse and devascularized hand). In the six other cases, the clinical presentation was subacute. An arteriogram was obtained in five cases after reduction of the dislocation, confirming the brachial axis disruption. Median and/or ulnar nerve injury was suspected in six patients. Only five elbows remained stable after reduction allowing plaster cast immobilization. In the other cases, dislocation recurrence or consequential residual varus/valgus laxity required external fixation or a cross-pinning fixation. An autologous vein, brachial artery bypass was performed in eight cases and an end-to-end anastomosis was carried out in one case. Revascularization was reestablished between 4 and 19 h after injury (mean 10.5 h). RESULTS: All the patients were seen at a minimum of 2 years' follow-up (mean of 4.3 years). On the basis of Mayo Clinic score, the results were considered excellent in three cases, good in four cases, and poor in two cases. No patients complained of elbow instability. The X-rays showed a reduced elbow in all cases and heterotopic ossifications in three cases. No degenerative lesion was observed at the longest follow-up. DISCUSSION: The incidence of a combined vascular injury with dislocation remains difficult to establish because the literature reports sporadic short series of clinical cases. The prevalence of this association is estimated to be between 0.3 and 1.7% in hospitals. The vascular lesion risk is probably related to the displacement extent and this later as a consequence of the injury intensity. This context calls for a diagnostic warning signal of possibly associated vascular involvement. Assessment of arterial vascularization should be systematic and mandatory with any osteoarticular injury. The slightest vascular status clinical doubt after reducing any dislocation presses for vascular patency work-up: echo-Doppler, angio-scan, arteriography. The multi-parametric nature of these combined injuries explain why their sometimes disappointing outcome remains dependent on the ability to deal with contradictory healing concerns: skin condition, capsular, and ligaments damages, type of revascularization procedure used, joint stability after closed reduction. This last parameter, being a substantial determinant for the period of immobilization, appears crucial to the final functional outcome, particularly in terms of range of motion loss or residual flexion contracture. LEVEL OF EVIDENCE: Level IV. Therapeutic retrospective study.

[Acute limb ischemia and fracture of the pelvic ring: a case report]. / Ischémie fémorale aiguë et fracture de l'anneau pelvien: à propos d'un cas.

We report the case of traffic accident victim who suffered multiple injuries after being ejected from the vehicle. The patient suffered blunt trauma of the pelvis followed by acute ischemia of the lower limb. The initial work-up revealed minimally displaced fractures of the right and left obturator rings and the left sacral wing, as well as a non-displaced fracture of the anterior wall of the acetabulum. Computed tomography eliminated a compressive retroperitoneal hematoma. The mechanism of the injury was direct blunt trauma rupturing an atheroma plaque which led to thrombosis of the left common femoral artery. Thrombectomy three hours 30 minutes after onset of ischemia enabled complete sensorial and motor recovery. Awareness of this unusual type of injury can be helpful in conducting a rigorous physical examination to ensure rapid diagnosis and treatment.

[Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 14 cases]. / Luxations traumatiques du genou associées à une interruption de l'artère poplitée: étude critique rétrospective d'une série de 14 cas.

PURPOSE OF THE STUDY: Complex femorotibial dislocation of the knee joint generally results from high-energy trauma caused by a traffic or a contact sport accident. Besides disruption of the cruciate ligaments, in 10-25% of patients present concomitant palsy of the common peroneal nerve and more rarely disruption of the popliteal artery. The purpose of this work was to assess outcome in a monocentric consecutive series of knee dislocations with ischemia due to disruption of the popliteal artery and to focus on specific aspects of management. MATERIAL AND METHODS: This retrospective series included eleven men and three women, aged 18 to 74 years (mean 47 years). The right knee was injured in five and the left knee in six. Trauma resulted from a farm accident in six patients, fall from a high level in two, a traffic accident in three and a skiing accident (fall) in one. Two other patients with morbid obesity were fall victims. Nine patients had a single injury, two presented an associated serious head injury, one a severe chest injury, and one multiple trauma with coma, chest contusion, and abdominal lesions. One patient had a fracture of the distal femur with associated ischemia. Five knee dislocations were open with a popliteal wound for three and a posteromedial wound for two. Four patients presented total sciatic nerve palsy and nine palsy of the common peroneal nerve. The dislocation was documented in ten cases: lateral (n=1), anterior (n=4), posterior (n=5). For four patients, the dislocation had been reduced during pre-hospital care. Preoperative arteriography was available for eight patients and confirmed the disruption of the popliteal artery; the diagnosis was obvious in six other patients who were directed immediately to the operative theatre without pre-operative imaging. Revascularization was achieved with a upper popliteal-lower popliteal bypass using an inverted saphenous graft. The graft was harvested from the homolateral greater saphenous vein in eight patients and the contralateral vein in six. On average, limb revascularization was achieved after 10.07 hours ischemia. Intravenous heparin was instituted for 810 days followed by low-molecular-weight heparin. The dislocation was stabilized by a femorotibial fixator in nine patients and a cruropedious cast in five. An incision was made in the anterolateral and posterior leg compartments in twelve patients. A revision procedure was necessary on day one in one patient because of recurrent ischemia; a second bypass using an autologous venous graft was successful. One other 75-year-old patient also presented recurrent ischemia on day five; the bypass was reconstructed but the patient died from multiple injuries. Seven thin skin grafts were used to cover the aponeurotomy surfaces. Mean duration of the external fixator was 3.4 months. The five patients treated with a plaster case were immobilized for 2.7 months on average. Ligament repair was performed in three patients (one lateral reconstruction and one double reconstruction of the central pivot for the two others). A total prosthesis with a rotating hinge was implanted in two patients aged 67 and 74 years after removal of the external fixator at six and seven months. Failure of the ligament repair also led to arthroplasty in a third patient. RESULTS: Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in 13 patients. Transient acute renal failure required dialysis in one patient. Four patients developed pin track discharges and there was one case of septic arthritis of the knee joint which was cured after arthrotomy for wash-out and adapted antibiotics. Outcome was assessed a minimum 18 months follow-up (average 22 months) for the 13 survivors. The three sciatic palsies recovered partially at five and six months in the tibial territory but with persistent paralysis in the territory of the common peroneal nerve. The nine cases of common peroneal nerve palsy noted initially regressed completely or nearly completely in three patients, partially in three and remained unchanged in three. The results were assessed as a function of the final knee procedure: outcome was satisfactory for the patients with a total knee arthroplasty. Outcome of the three ligamentoplasties was good in one, fair in one, and a failure in one (revision arthroplasty). Patients treated by immobilization without a second surgical procedure complained of joint instability with a variable clinical impact; their knee retained active flexion greater than 90 degrees and complete extension. DISCUSSION: An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma. The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation is between 4 and 20%. The rate is closely related to that of injury to nerves and soft tissue. Ischemia should be immediately suspected in all cases of knee dislocation. The pedious and tibial pulses must be carefully noted before and after reduction of the dislocation to determine whether or not there is an organic arterial lesion. If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction. Otherwise, arteriography should be performed. Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture. Repair requires a bypass between the upper popliteal artery and the tibioperoneal trunk using an inverted saphenous graft because the walls are torn over several centimeters. The traumatology and vascular surgical teams must work in concert from the beginning of the surgical work-up in order to establish a coherent operative strategy founded on primary reduction of the dislocation, installation of a fixator and then vascular repair and aponeurotomy incisions. It would be preferable to wait until the bypass is proven patent and wound healing is complete before proposing ligament repair. This should be done after a precise anatomic work-up to assess each ligament lesion. Bony avulsion or simple disinsertion can however be repaired in the emergency setting at the time of the bypass as well as any ligament rupture which is obvious and-or situated on the medial collateral approach. Secondarily, elements of the central pivot can be repaired in young patients with an important functional demand. Arthroplasty is not warranted except in the elderly patient. Dissection of the popliteal fossa or debridement of the wound enables a careful anatomic assessment of the nerve trunks. In the event of a peroneal nerve disruption, it is advisable to fix the nerve ends to avoid retraction. Beyond three months without clinical or electromyography recovery, surgical exploration is indicated. In the event more than 15 cm is lost, there is no hope for a successful graft. Complete knee dislocation is extremely rare. It can be caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy. Compression, contusion or disruption of the popliteal artery is very rarely caused by the displacement of the femur or the tibia. Limb survival may be compromised. Mandatory emergency restoration of blood supply will modify immediate and subsequent surgical strategies. There has not however been any study exclusively devoted to double joint and vascular involvement. Our objective was to present a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

[Management of visceral artery aneurysms. Retrospective study of 23 cases]. / Prise en charge des anévrismes des artères digestives. Etude rétrospective de 23 cas.

STUDY AIM: To evaluate symptoms and results of the treatment of aneurysms of digestive arteries. PATIENTS AND METHOD: Retrospective study of 23 patients (14 male and 9 female, mean age = 51 years) treated in two departments of academic hospital. We studied the aneurysms characteristics (location, number, size, etiology) the type of treatment, and occurrence of post-operative complications. RESULTS: The aneurysms involved the splenic artery in 13 patients (56%), the superior mesenteric artery in 5 patients (22%), the hepatic artery in 3 patients (13%), the gastroepiploic artery in 2 patients (9%). There were thirty-one aneurysms (24 true aneurysms and 7 pseudo-aneurysms) in 23 patients. Diagnosis was mainly done by the CT-scan. An aneurysm rupture occurred in 7 patients (30%). Treatment was surgery for 26 aneurysms (84%) or a radiological embolization in 3; abstention was decided for 2 aneurysms (6%). No death was observed. CONCLUSION: The bad prognosis after rupture, the lack of predictive factors of rupture combined with the good results of surgical treatment suggest to prefer a surgical treatment at first. Embolization could be reserved for the contra-indication of surgery and when aneurysms are poorly accessible to surgery.

Comparison of first- and second-generation prostheses for endoluminal repair of abdominal aortic aneurysms: a 6-year study with life table analysis.

PURPOSE: The outcome of endoluminal repair of abdominal aortic aneurysms with two generations of prostheses was analyzed and compared. METHODS: Between May 1992 and December 1998, 266 patients underwent elective endoluminal repair of an AAA. First-generation prostheses were used in 118 patients (group I), and second-generation prostheses were used in 148 patients (group II). The two groups were similar in age, sex, and size of AAA. The proportion of patients with comorbidities was higher in group I than in group II, but not significantly. First-generation devices were characterized by large (24F internal diameter) delivery systems, one-piece construction, and a lack of metallic support throughout their length. Second-generation devices had smaller (21F or smaller internal diameter) delivery systems, modular construction, and a metallic frame throughout the length of the prostheses. The major end-point criteria were survival and successful endoluminal repair. Success was defined as the exclusion of the aneurysm sac from the circulation, with stability or the reduction in AAA maximum transverse diameter. Persistent endoleaks were classified as failures, irrespective of whether they were subsequently corrected by means of secondary endovascular intervention. The minimum follow-up period was 5 months for each of the 266 patients. Analysis was performed by means of the life-table method. RESULTS: Perioperative mortality was not significantly different between group I (4.2%) and group II (2.7%). There was a statistically significant difference between the survival curves of the two generations, which favored group II (P =.012). There was a significant (P <.001) difference between the two generations of patients in their conditional probability of graft failure when the competing risk of all-cause mortality was considered. Second-generation patients were at a lower risk of graft failure than first-generation patients. The probability of failure, expressed as a proportion of grafts failing at 2 years, was 0.15 for patients with second-generation prostheses and 0.33 for patients with first-generation prostheses. CONCLUSION: Endoluminal AAA repair is a safe procedure, whether first- or second-generation prostheses are used. Survival and probability of graft success were significantly higher with second-generation prostheses than with first-generation prostheses. This improvement in outcome resulted from a combination of increasing clinical experience and advances in technology. A more accurate evaluation of the role of the endoluminal method in AAA repair would be achieved by studying patients in whom second-generation devices were used, rather than longer term studies in which first- and second-generation devices were used.

Life-table analysis of primary and assisted success following endoluminal repair of abdominal aortic aneurysms: the role of supplementary endovascular intervention in improving outcome.

AIM: the aim of this study was to analyse the effect of supplementary endovascular intervention on the outcome of primary endoluminal repair of abdominal aortic aneurysm (AAA). METHODS: between May 1992 and December 1998, 266 patients underwent endoluminal repair of AAA. Minimum period of follow-up was 6 months. Those patients in whom the endoprosthesis could not be deployed were converted to open repair at the primary operation. Patients developing an early endoleak, within 31 days, were treated by a period of observation and secondary endovascular intervention in persistent cases. Patients developing a late endoleak were treated similarly, without a period of observation. Outcome was analysed by the life-table method. Primary success was defined as exclusion of the aneurysm from the circulation resulting from the original operation. Assisted success occurred when aneurysms with endoleaks became excluded from the circulation as a result of supplementary endovascular intervention. RESULTS: endoluminal repair failed in 17 patients requiring conversion to open repair at the original operation. Supplementary endovascular intervention was undertaken in 26 patients, with early endoleaks (n=6) and late endoleaks (n=20). Interventions involved deployment of secondary endoluminal grafts within the primary grafts (n=22), and coil embolisation (n=4). Successful exclusion of the aneurysm sac was achieved in 22 of 26 (85%) patients undergoing supplementary endovascular procedures. Conditional cumulative incidence of primary graft failure and secondary graft failure in the presence of all-cause mortality at 6 years was 47% and 25% respectively. CONCLUSIONS: supplementary endovascular intervention is an important adjunct to endoluminal AAA repair with the potential to improve outcome and avoid conversion to open repair. Successful supplementary endovascular intervention was achieved in 85% of patients in whom it was attempted. Life-table analysis showed these supplementary procedures to be durable in the long term.

Apoptosis of vascular smooth muscle cells induced by cholesterol and its oxides in vitro and in vivo.

The ability of cholesterol and its oxides to induce apoptosis in vascular smooth muscle cells in tissue culture and in a rabbit model of atherosclerosis was evaluated. Apoptosis was detected using DNA laddering and in situ end-labelling of fragmented DNA. Cholesterol oxides, but not cholesterol, were found to inhibit proliferation and induce apoptosis of vascular smooth muscle cells in tissue culture. 7-ketocholesterol was found to be the most potent inhibitor of proliferation, while 25-hydroxycholesterol was found to be the most potent inducer of apoptosis. These data suggest that the inhibition of proliferation and the induction of apoptosis by cholesterol oxides within vascular smooth muscle cells use different pathways, suggesting a differential role for these cholesterol oxides within the arterial wall. Cholesterol feeding after balloon injury in a rabbit model of atherosclerosis is known to result in the accumulation of cholesterol oxides. However, we found that cholesterol feeding had no effect on the level of apoptosis in the rabbit aortic wall after balloon injury, suggesting that the major factor determining apoptosis in our model was the balloon injury.

Growth arrest-specific gene 6 expression in proliferating rabbit vascular smooth muscle cells in vitro and in vivo.

Proliferation and migration of vascular smooth muscle cells (VSMCs) are involved in the processes of atherosclerosis and restenosis. The protein product of the growth arrest-specific gene 6 (Gas-6) has recently been identified as a ligand for the Axl/Rse/Mer tyrosine kinase receptor family, which may be involved in proliferation and migration of VSMCs. Here we show that Gas-6 gene expression is increased in proliferating VSMCs in tissue culture (2.5-fold increase by Northern blot) and following neointimal proliferation in a rabbit balloon-injury model (3-fold increase by Western blot). Neither platelet-derived growth factor (PDGF) nor thrombin stimulate the expression of Gas-6 in cultured VSMCs despite the ability of the PDGF, but not thrombin, to stimulate proliferation in growth-arrested cells. These data suggest a role for the Gas-6 regulatory system in VSMC proliferation, which may be a target for therapeutic interventions in the atherosclerotic process and restenosis after angioplasty.

P2X (purinergic) receptor redistribution in rabbit aorta following injury to endothelial cells and cholesterol feeding.

The redistribution of purinergic P2X receptor subunits (P2X(1) to P2X(7)) within the rabbit aorta wall three weeks after endothelial balloon injury/cholesterol feeding was examined. P2X(1) receptor cluster density was elevated in the media following balloon injury/cholesterol feeding by about 30% and these clusters appeared on smooth muscle cells throughout the greatly expanded neointima but they did not change significantly on the endothelial cells following balloon injury. P2X(4) clusters were found in high density throughout the media and in very high density in the enlarged neointima following balloon injury, particularly on the endothelial cells where the density increased about 10-fold after balloon injury. P2X(5) clusters were found in high density in the media of normal aorta but with little change following balloon injury. P2X(3), P2X(6) and P2X(7) cluster density was low in normal aorta and remained unchanged following balloon injury. All receptor subunits were found on endothelial cells. It is suggested that the release of ATP from damaged endothelial cells and from smooth muscle cells sufficient to activate P2X(4) receptors may contribute to neointimal proliferation.

Rupture of abdominal aortic aneurysms: A concurrent comparison of outcome of those occurring after endoluminal repair versus those occurring de novo.

AIM: to compare the outcome of patients whose abdominal aortic aneurysm (AAA) ruptured following endoluminal repair with those whose AAA ruptured prior to treatment. PATIENTS: over a 4-year period 434 patients underwent treatment for AAA with conventional open (n=253) and endoluminal repair (n=181). Of those having open repair, 216 patients had elective operations while 41 had operations for ruptured AAA. Four patients with ruptured AAA had undergone endoluminal repair previously (Group I) while the remaining 37 patients ruptured de novo (Group II). The patients in both groups were similar in age and sex but differed clinically. All four patients in Group I had major medical co-morbidities versus 56% in Group II (p<0.05). All patients in group I had a known endoleak following endoluminal repair. All patients underwent open repair. RESULTS: the proportion of patients presenting with hypotension in Group I (1/4) was significantly less than in Group II (30/37). The difference in 30-day mortality for Group I (0%) compared with that for Group II (43%) was significant. The four patients in Group I remain alive and well at follow-up 22 months after operation. The outcome for Group I was better than Group II despite the higher incidence of medical co-morbidities. CONCLUSION: endoluminal AAA repair complicated by a persistent endoleak does not protect from rupture, which may not be accompanied by such major haemodynamic changes and high mortality as rupture de novo. Further long-term results in more patients are required to confirm this intermediate level of protection.

Delay in opening the infarct related coronary artery increases plasma atrial natriuretic peptide levels.

Plasma atrial natriuretic peptide (ANP) levels were measured in rabbits during the late healing phase of myocardial infarcts. Significant differences in plasma ANP levels (P < 0.02) were found between rabbits that had undergone very late (6 h) or early reperfusion (20 and 45 min of ischemia) of the infarct related coronary artery. Differences in ANP levels were independent of infarct size, ventricular remodeling and infarct expansion. We conclude late reperfusion of infarct related artery, independent of myocardial salvage, is associated with increased circulating ANP plasma levels.

Evaluation of disinfection and sterilization of reusable angioscopes with the duck hepatitis B model.

PURPOSE: Nosocomial transmission of viral hepatitis and retrovirus infection has been reported. The expected risk is greatest for the hepatitis B virus (HBV). The duck HBV (DHBV) has similar biologic and structural characteristics to HBV and has been adopted as a suitable model for disinfectant testing. METHODS: Angioscopic examination of the external jugular vein was performed on DHBV-infected ducks. After use, the instrument was air dried for 3 minutes. Samples were obtained by flushing the channel with 5 mL of phosphate buffered saline solution. The samples were collected immediately after drying (control), after flushing with 5 mL of water, after glutaraldehyde disinfection for 5, 10, and 20 minutes, and after ethylene oxide gas sterilization. Angioscopes were either precleaned or uncleaned before disinfection/sterilization. Residual infectivity was assessed with inoculation of samples into the peritoneal cavity of day-old ducks (n = 231). RESULTS: DNA analysis results of liver samples showed that all 38 control ducks became infected. The frequency of DHBV infection was reduced to 93% (14 of 15) by flushing the angioscope with 5 mL of sterile water. No transmission occurred after the use of any of the properly precleaned and disinfected/sterilized angioscopes. However, after the use of the uncleaned angioscopes, the transmission rate was 90% (9 of 10) and 70% (7 of 10) after 5 and 10 minutes of contact time, respectively, in 2% glutaraldehyde. Even after the recommended 20 minutes of contact time, there was still 6% (2 of 35) transmission. After ethylene oxide sterilization, two of the recipient ducklings (2 of 35) were infected with DHBV. CONCLUSION: There was no disease transmission after reuse of disposable angioscopes adequately cleaned before disinfection or sterilization. However, if the angioscopes are inadequately cleaned, DHBV can survive despite glutaraldehyde disinfection or ethylene oxide sterilization. This contrasts with previous in vitro and in vivo data with solid surgical instruments. It is postulated that the presence of a narrow lumen or residual protein shielding within the lumen may compromise effective inactivation of hepadnaviruses on angioscopes, with the potential risk for patient-to-patient transmission.

A fully-automated environmental chamber for examination of long-term effects of intermittent hypoxia on medium-size animals.

We describe the design and construction of a fully-automated environmental chamber for the simultaneous exposure of up to four medium-size laboratory animals to long-term intermittent hypoxia. The air-sealed automated environmental chamber consists of a box equipped with a ventilation fan and three electrically-activated solenoid valves. Our system was used to expose four rabbits to 12 h of repetitive episodes of hypoxia (environmental O2 concentration 12-13%) lasting 45 min followed by breathing room air for 15 min. During environmental hypoxia, the mean arterial PaO2 and PaCO2 were 41 +/- 3.0 and 24 +/- 0.7 mmHg (mean +/- SEM), respectively. In this system, opening and closing of the solenoid valves is fully computerized to allow different settings of the duration and severity of hypoxia. The chamber is safe and fully automated and cost-effective for studying the effects of long-term intermittent hypoxemia in medium-size animals.

Shortening of endografts during deployment in endovascular AAA repair.

PURPOSE: To evaluate the incidence and extent of length changes during implantation of endovascular grafts in a prospective study of patients undergoing endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Data regarding the occurrence of intraoperative technical difficulties and device complications were recorded prospectively for the Vanguard or AneuRx self-expanding, bifurcated endovascular grafts in 64 patients (56 males; mean age 75 years). Graft length was measured in the sheath system before deployment and again immediately after deployment by fluoroscopic comparison to a graduated marking catheter. RESULTS: Graft shortening > or = 15 mm was documented in 22 (56%) of 39 Vanguard cases and 11 (44%) of 25 AneuRx endografts. Additional extension grafts were required to correct endoleak caused by inadequate graft length in 9 (14%) patients, but no conversion to open repair was necessary. CONCLUSIONS: There appears to be a high incidence of intraprocedural graft shortening with 2 current designs of self-expanding endoluminal grafts.

Adverse events after endoluminal repair of abdominal aortic aneurysms: a comparison during two successive periods of time.

PURPOSE: The aim of this study was to document the incidence rate of adverse events after endoluminal repair of abdominal aortic aneurysms (AAAs) during two successive periods of time. METHODS: One hundred ninety patients (175 men, 15 women; mean age, 72 years) underwent endoluminal repair of AAAs in a 5(1/2)-year period. Adverse events were documented prospectively for all the patients throughout this interval. An adverse event was defined as any of the following events: a death within 30 days, a conversion to open repair, the need for further intervention (either open or endovascular), the need for hemodialysis, a failure to cure the AAA, and wound complications. The patients were divided into two groups those who underwent operation in the initial 3-year period (group I; n = 75) and those who underwent operation in the subsequent 2(1/2)-year period (group II; n = 115). The results were analyzed for total adverse events for both periods of time and for difference in incidence rates within categories of adverse events between the two groups. RESULTS: Eight patients (4.2%) died in the perioperative period. The endoluminal repair failed in 17 patients (8.9%), which necessitated a primary conversion to open repair at the original operation. In 88 patients, 110 adverse events occurred. There was no significant difference in the incidence rates of adverse events in patients in group I (37/75) and group II (51/115). Apart from primary conversion (P =.007), there was no significant difference in the incidence rates of adverse events between group I and group II within the following categories: perioperative (within 30 days) deaths, primary conversion, secondary conversion, supplementary endoluminal repair, intervention for lower limb ischemia, hemodialysis necessitated, failure to cure the AAA as a result of persistent endoleak, and wound complications. CONCLUSION: Despite improvements in technology and increasing experience, adverse events continue to occur in a relatively high proportion of patients (45%) who undergo endoluminal repair of AAA. Reporting the incidence rates of adverse events provides a more accurate picture of the morbidity rates of the endoluminal method rather than simply listing the procedures as successes or failures. The similarity in the incidence rates of adverse events in patients in group I and group II suggests that there are inherent risks in the endoluminal method rather than iatrogenic complications that occur during the learning curve with a new technique.