Lessons learned in adopting endovascular techniques for treating abdominal aortic aneurysm.

HYPOTHESIS: Endovascular exclusion of abdominal aortic and common iliac aneurysms can be performed safely, and in the short term represents a feasible alternative to traditional, open aneurysm repair. PATIENTS AND METHODS: Forty-one patients were treated with endovascular grafts for 39 abdominal aortic and 2 common iliac artery aneurysms. RESULTS: All devices were successfully deployed. The size of the abdominal aortic aneurysms varied from 4.9 to 11.9 cm (average, 6.13 cm). The median procedure time was 195 minutes. There was one iliac artery rupture, which required celiotomy for repair. The hospital stay varied from 2 to 39 days (average, 6.7 days). The perioperative mortality rate was 2.4%. Sixteen patients (39%) had groin wound complications. Ten patients (24%) had evidence of contrast (endoleak) within the aneurysm sac on completion of the procedure. There were no obvious direct leaks from either the point of proximal or distal fixation. Seven of these endoleaks have resolved spontaneously. Two patients required additional procedures in the postoperative period to treat endoleak. The final patient has evidence of persistent endoleak on 3-month surveillance computed tomography scan. Major late problems occurred in 3 patients. CONCLUSION: Patients with large abdominal aortic aneurysms and considerable cardiac comorbidity can safely undergo endovascular aneurysm repair. Femoral groin wound complications resulting in prolonged hospitalization remain the major cause of perioperative morbidity. In contradistinction to open aneurysm repair, long-term surveillance is essential to detect migration of the device and identify flow within the residual aneurysm sac-complications that could lead to aneurysm rupture following endovascular repair.

Shear force regulates matrix metalloproteinase activity in human saphenous vein organ culture.

BACKGROUND: Development of vein graft intimal hyperplasia has been related both to shear force and to the activity of matrix metalloproteinases (MMPs). Little data are available regarding the effects of shear on MMP expression and activity. The aim of this study was to examine the relationship among shear force, metalloproteinase activity, and intimal thickening in human saphenous vein segments maintained in organ culture. MATERIALS AND METHODS: Segments of human saphenous vein were cultured under static conditions, or perfused under low-flow and high-flow conditions in a perfusion apparatus for 7 days. Metalloproteinase levels and activities were measured using ELISA and substrate gel zymography, respectively. Intimal thickening was determined by morphometric analysis. Results were compared with control vein tissue, which was not subjected to organ culture, using a one-way ANOVA. RESULTS: A 13% increase in proteolytic activity was noted on substrate gel zymography at 68-72 kDa in high-flow vein tissue. The protein content of MMP-2, MMP-9, tissue inhibitor of metalloproteinase-1 (TIMP-1), and TIMP-2 was increased in high-flow vein tissue by 21%, 126%, more than 100-fold, and 86%, respectively. In culture media bathing the outside of the vein, TIMP-2 was increased in high-flow specimens, while TIMP-1 was inversely related to flow rate. Intimal thickening was directly related to flow rates, and was progressively increased in the low-flow and high-flow groups by 3-fold and 4-fold, respectively. CONCLUSIONS: Metalloproteinase levels in human saphenous vein cultures are related to shear force. MMP levels and activity correlate with the degree of intimal thickening. This model may provide a valuable tool for the analysis of physical forces and their influence on intimal thickening in human saphenous vein.

All-trans-retinoic acid decreases cell proliferation and increases apoptosis in an animal model of vein bypass grafting.

BACKGROUND: We have previously demonstrated a decrease in intimal hyperplasia in vein bypass grafts from animals treated with all-trans-retinoic acid (atRA). The purpose of this study was to examine the effect of atRA on proliferation and apoptosis rates in healing vein bypass grafts. METHODS: Interposition jugular vein bypass grafts were placed in the carotid artery of 30 New Zealand white rabbits. Animals received either atRA (10 mg/kg/d) or vehicle (corn oil) for a period of 2 weeks. Animals were killed at 3, 7, or 28 days after graft placement after having received 3 doses of 5-bromo-2'-¿Deoxyuridine (BRDU, 35 Mg/KG). Animals Were Perfusion Fixed, And Vein Grafts Were Prepared For Immunohistochemistry By Using Antibodies To Brdu, Proliferating Cell Nuclear Antigen, And Bcl-XL. Apoptosis Was Measured By Using The Tunel Assay. Histologic Sections Were Analyzed By A Pathologist Blinded To The Study, And An Index Of Positively Stained Cells Was Generated For Each Layer Of The Vein Graft Wall. RESULTS: All-trans-retinoic acid reduced the proliferation index in the neointima of vein grafts during the first week after surgery. Apoptotic rates were higher in the intima of vein grafts from animals treated with atRA, which could not be explained by changes in bcl-xl expression. No differences were noted in the media or adventitia between the groups. CONCLUSIONS: atRA decreased cell proliferation and increased apoptosis in the intima of healing vein bypass grafts. These effects contribute to decreased intimal hyperplasia, which has been previously noted.

All-trans-retinoic acid decreases vein graft intimal hyperplasia and matrix metalloproteinase activity in vivo.

BACKGROUND: Development of vein graft intimal hyperplasia has been associated with increased activity of matrix metalloproteinases (MMPs). All-trans-retinoic acid (atRA) decreases expression and activity of MMPs in tissue culture and has decreased intimal hyperplasia following arterial balloon catheter injury. We examined the effect of oral administration of atRA on intimal hyperplasia and MMP expression in an animal model of vein bypass grafting. MATERIALS AND METHODS: Interposition jugular vein bypass grafts were placed in the carotid artery of New Zealand white rabbits. Animals received either atRA (10 mg/kg/day) or vehicle (corn oil) for a period of 2 weeks. Retinoic acid serum levels were determined by HPLC. Intimal and medial areas were measured using morphometric analysis of perfusion-fixed vein graft specimens, and intimal thickness was calculated using circumferential measurements. Expression of MMP-2, MMP-9, and TIMP-1 in vein grafts and unoperated control veins was determined using Northern analysis, and proteolytic activity was determined using substrate gel zymography. RESULTS: Animals treated with atRA had significantly elevated serum levels of this compound and its metabolites. A decrease in intimal to medial ratio was noted after 28 days in vein grafts from treated animals (0.63 vs 0.88, P < 0.01), and a decrease in calculated intimal thickness was noted at 7 and 28 days. Expression of MMP-2 was decreased in treated animals 7 days following surgery, and expression of both MMP-2 and MMP-9 was decreased at 28 days. A decrease in proteolytic activity was noted on zymography at 68 kDa, 7 and 28 days following surgery in vein grafts from animals treated with atRA, corresponding with a decrease in the active form of MMP-2. Increased expression of TIMP-1 was noted in vein grafts from both the treated and the control groups, 7 and 28 days following graft placement. CONCLUSIONS: Oral administration of all-trans-retinoic acid resulted in decreased intimal hyperplasia in an animal model of vein bypass grafting. This was associated with decreased expression and activity of MMP-2 in treated animals.

Pararenal aortic aneurysms: the future of open aortic aneurysm repair.

PURPOSE: As endovascular stent graft repair of infrarenal abdominal aortic aneurysms (AAAs) becomes more common, an increasing proportion of patients who undergo open operation will have juxtarenal aneurysms (JR-AAAs), which necessitate suprarenal crossclamping, suprarenal aneurysms (SR-AAAs), which necessitate renal artery reconstruction, or aneurysms with associated renal artery occlusive disease (RAOD), which necessitate repair. To determine the current results of the standard operative treatment of these patterns of pararenal aortic aneurysms, we reviewed the outcome of 257 consecutive patients who underwent operation for JR-AAAs (n = 122), SR-AAAs (n = 58), or RAOD (n = 77). METHODS: The patients with SR-AAAs and RAOD were younger (67.5 +/- 8.8 years) than were the patients with JR-AAAs (70.5 +/- 8.3 years), and more patients with RAOD were women (43% vs 21% for JR-AAAs and SR-AAAs). The patient groups were similar in the frequency of coronary artery and pulmonary disease and in most risk factors for atherosclerosis, except hypertension, which was more common in the RAOD group. Significantly more patients with RAOD had reduced renal function before surgery (51% vs 23%). Supravisceral aortic crossclamping (above the superior mesenteric artery or the celiac artery) was needed more often in patients with SR-AAAs (52% vs 39% for RAOD and 17% for JR-AAAs). Seventeen patients (7%) had undergone a prior aortic reconstruction. The most common renal reconstruction for SR-AAA was reimplantation (n = 37; 64%) or bypass grafting (n = 12; 21%) and for RAOD was transaortic renal endarterectomy (n = 71; 92%). Mean AAA diameter was 6.7 +/- 2.1 cm and was larger in the JR-AAA (7.1 +/- 2.1 cm) and SR-AAA (6.9 +/- 2.1 cm) groups as compared with the RAOD group (5.9 +/- 1.7 cm). RESULTS: The overall mortality rate was 5.8% (n = 15) and was the same for all the groups. The mortality rate correlated (P <.05) with hematologic complications (bleeding) and postoperative visceral ischemia or infarction but not with aneurysm group or cardiac, pulmonary, or renal complications. Renal ischemia duration averaged 31.6 +/- 21.6 minutes and was longer in the SR-AAA group (43.6 +/- 38.9 minutes). Some postoperative renal function loss occurred in 104 patients (40.5%), of whom 18 (7.0%) required dialysis. At discharge or death, 24 patients (9.3%) still had no improvement in renal function and 11 of those patients (4.3%) remained on dialysis. Postoperative loss of renal function correlated (P <.05) with preoperative abnormal renal function and duration of renal ischemia but not with aneurysm type, crossclamp level, or type of renal reconstruction. CONCLUSION: These results showed that pararenal AAA repair can be performed safely and effectively. The outcomes for all three aneurysm types were similar, but there was an increased risk of loss of renal function when preoperative renal function was abnormal. These data provide a benchmark for expected treatment outcomes in patients with these patterns of pararenal aortic aneurysmal disease that currently can only be managed with open repair.

[Prostatic or urethral rectal fistulas]. / Fistules prostato-ou uréthro-rectales.

Reporting 7 new observations of prostatic or urethro-rectal fistulas, the authors insist on their etiological modalities specially of traumatical, inflammatory, post-irradiation, cancerous and congenital origin. The diagnosis methods and surgical techniques are also mentioned.

[Internal urethrotomy. Resection of urethral stricture (over 5 years follow-up)]. / L'urétrotomie interne. Résection des rétrécissements urétraux (greater than 5 ans de recul).

Since 1980, in addition to internal urethrotomy, the authors have used urethrotomy combined with endoscopic resection of the stricture. This method consists of a classical first stage of section of the stricture, but only at 11 o'clock and at 1 o'clock to leave a rail of midline fibrosis. The second stage consists of resection of this rail. The value of this approach consists of more effective excision of the fibro-inflammatory callus. Thirty-four patients treated by this method have a follow-up exceeding 5 years. This series was compared with a series of patients treated by internal urethrotomy alone (39 patients with a follow-up greater than 5 years). Very good results were obtained in 55% of cases versus 28% with internal urethrotomy alone. Poor results were obtained in 32% of cases versus 43%. Internal urethrotomy therefore appears to be more rapidly and more completely effective.

[Voided urinary cytodiagnosis. Cyto-histologic comparison]. / Le cytodiagnostic urinaire mictionnel. Confrontation cyto-histologique.

The authors report the results of a 4 year study of voided urinary cytology by cytocentrifugation. The findings were compared with those of histology. The sensitivity of the cytological diagnosis varies with the histological grade of the tumor. Grade 1 papillary tumors are not detectable with classical cytological criteria of malignancy. However they may be evoked if finer criteria are considered. Voided urinary cytology is efficient in the detection of grade 2 and grade 3 papillary tumors as well as dysplasia and in situ carcinoma in flat mucosa. The sensitivity of urinary voided cytology is remarkably improved by repeating the examination 3 successive times. This method detects tumors of the urinary bladder as well as those of the upper urinary tract. False positive results are possible, but may be avoided by knowing the clinical history and by repeated urinary cytology. Protocols are proposed for the diagnosis and follow-up of transitional cell tumors. Systematic screening of high risk subjects is also an important indication for voided urinary cytology, but we lack experience in this domain.

[Rigid ureteroscopy: a reliable, non-aggressive technic. Apropos of 51 cases treated for ureteral lithiasis]. / Urétéroscopie rigide: une technique fiable et peu agressive. A propos de cinquante et une observations de traitement de lithiases urétérales.

The authors obtained 82% good results by using rigid ureteroscopy to treat a total of 55 calculi in a series of 51 patients and they propose the following therapeutic approach: calculi in the lumbar ureter are frequently difficult to reach (54% failures). There is no harm in gently trying to remove the stone by ureteroscopy which, in the event of failure, can be followed by percutaneous surgery or posterolumbar incision. Rigid ureteroscopy is easier and more reliable in the case of calculi in the iliac or pelvic ureter (7% failures) and the indications can be extended.

[Total prostatocystectomy followed by enterocystoplasty in the treatment of bladder neoplasms]. / Prostato-cystectomie totale suivie d'entérocystoplastie dans le traitement des tumeurs de vessie.

Bladder replacement enterocystoplasty in the treatment of bladder tumors provides the patient with maximum mictional comfort, and better protection of the kidneys than in the case of cutaneous urinary diversion. The remote carcinological results are satisfactory at over 60% nowadays at three years, against only 20%, seventeen years ago. The functional impact on continence is very good during the day but not yet satisfactory at night, but a sometimes lengthy re-education can help. The result on the upper urinary tract is still the delicate point in this technique, with the hope of an attenuation of the renal insufficiency thanks to the setting up of an antireflux process. However, the indications for this brilliant technique may be limited by the extension of the tumor and the fragility of the diasthesis.

[Value of an ostomy club for patient followup after total cystectomy]. / Intérêt d'un club d'urostomisés pour le suivi des malades après cystectomies totales.

Patients using stoma appliances after a total cystectomy undergo a considerable psychological shock. The creation of groups of ostomates helps in the dissemination of information concerning the use of stomal appliances and in the building up of user confidence, thereby facilitating a return to a normal everyday life. Our main aim is to organize regular meetings of stoma appliance users, with frequent visits from former cystectomy patients. The usefulness of these clubs has been amply demonstrated by the introduction of the training of enterostomal therapists, the collaboration offered by the appliance manufacturers and the interest manifested by surgeons and urologists.

Renoureteral bypass in obstructions and losses of substance of the initial ureter.

When the renal pelvis and the proximal ureter are destroyed, surgical repair is always difficult. In case of a loss of substance of the upper ureter, it is possible to replace the obstructed (or destroyed) segment and to preserve the healthy iliopelvic ureter. The 'renoureteric bypass' consists of the insertion of an intermediate segment between the lower calyx of the kidney and the lumboiliac ureter. A prosthesis or an intestinal loop may be used to restore the continuity of the urinary tract. The results obtained in dogs being excellent, the technique was applied successfully in man in 2 cases.