Secondary rupture of abdominal aortic aneurysm following endovascular repair.

AIM: The aim of this study was to analyze the Literature covering the characteristics of secondary ruptured abdominal aortic aneurysm (AAA) following endovascular repair with aortic stent graft (ASG). METHODS: The study based on a Pubmed search of articles describing the characteristics of secondary ruptured AAA after ASG between January 1995 and May 2008. A total of 105 articles were selected, including the following characteristics: aneurysm diameter evolution, delay between implantation and rupture, average follow-up time, mechanisms implicated, results following further repair. RESULTS: Out of a total of 23 002 ASG cases reported, of which 47.4% (10 911) were carried out by ASG suppliers themselves, 227 ruptures (1%) have been described. After exclusion of the perioperatory ruptures (occurring within the first month), the average duration of implantation at rupture was 27+/-16 months, with an average follow-up of 22.4+/-14 months. When the evolution of the sac was mentioned, AAA diameter decreased or remained stable before rupture in 55.7% of the cases. Mechanisms of rupture have been reported in 168 cases and consisted in a failure of the ASG in 76.1% of the cases. When patients were operated, the mortality rate was 39%. CONCLUSION: This study showed how little is actually known about rupture of stented AAA. The available data were provided by studies sponsored by companies in 47.4% of the cases, and had usually too short follow-up considering the average of duration of implantation at rupture. Rupture mechanisms were not reported in all cases, but a failure of the ASG was considered as responsible for the rupture in a majority of the cases. The absence of warning signs of rupture emphasizes the need of caution about the durability of ASG and also the need to undertake further studies with longer follow-ups.

[Paraplegia secondary to surgery of the abdominal aorta]. / Les paraplégies secondaires à la chirurgie de l'aorte abdominale.

We report the case of an 84 year-old man who suffered of paraplegia after surgery of an abdominal aortic aneurysm. The neurologic status did not improve during 5 years of follow-up. This complication is rare in light of the review of the literature. It is more frequent after emergency (1.4%) and redux (19%) surgery than after elective surgery (1.1%). Its mechanisms are anatomic (occlusion of the Adamkievitz artery and of the pelvic collateral arteries) and hemodynamic mechanisms (thromboembolism, low systemic tension, long supra-renal clamping). Since pre-operative aortography to detect anatomic variations is not realistic, its only prevention remains maintenance of intra-operative hemodynamic, systemic heparinization, and preservation of the pelvic collateral circulation.

Cardiac myxoma with glandular component: case report and review of the literature.

A 7 cm diameter tumor of the left atrium is reported in a 78 year-old woman with a past history of pT3N1M0 colonic adenocarcinoma. The histological examination of the atrial tumor disclosed areas of highly vascularized myxoid stroma with cells strongly reactive for vimentin. Multiple mucoid spaces lined by a single layer of goblet cells were scattered among those typical areas of myxoma. No nuclear atypia was observed. Cytoplasm of the glandular cells was immunoreactive for epithelial antisera (keratin, EMA), CEA and CA19.9. Two years later, the patient was doing well, with no local recurrence of the cardiac myxoma and no secondary location of the colonic adenocarcinoma. The histological characteristics, the absence of atypia, the absence of tumoral extension or neoplastic lymphatic vascular thrombi in the pedicle or in the interatrial septum, and the finding of typical myxomatous areas supported the diagnosis of cardiac myxoma with glandular component. To our knowledge, 21 cases of myxoma with glandular mucinous component, focal or prominent, have been previously published in the literature. These myxoma were generally sporadic cases with the same clinical features and prognosis as typical myxoma. Immunoreactivity of these glandular structures was constant for epithelial markers. The positive immunostaining by CEA, and by CA19.9 in our case, reflects the histogenetic endodermal origin.

Clinical presentation and treatment options for mitral valve myxoma.

Myxomas rarely are located on the mitral valve. We report the case of a 44-year-old man operated on successfully with mitral valve conservation, which is the 21st case of mitral valve myxoma reported in the western literature. Among the cases reported in the literature, the diagnosis was made at the time of autopsy in 6 cases, with premortem heart failure in 1 case. A clinical diagnosis was made in 15 cases on the basis of the following symptoms: peripheral embolism in 9 cases, cardiac signs in 4 cases, and constitutional manifestations in 2 cases. The clinical presentation of mitral valve myxoma differs slightly from that of other cardiac myxomas in that it has a lower incidence of constitutional manifestations. The gold standard for noninvasive diagnosis and localization of cardiac myxomas is transesophageal echocardiography. It allows for the detection of early, small valvular tumors and may help to characterize better their location and echostructure, facilitating the choice of an optimal surgical approach through preoperative study of the integrity and mobility of the valve. Conservative operative treatment by resection of the area of implantation of the myxoma followed by suture repair of the valve and annuloplasty may be recommended as the most appropriate treatment option for this rare condition.

[Carotid endarterectomy by eversion and reimplantation. Techniques and results]. / L'endartérectomie carotidienne par éversion et réimplantation. Techniques et résultats.

Endarterectomy of the carotid bifurcation through a longitudinal arteriotomy of the common and internal carotid arteries followed by a direct closure is still accepted as the main surgical technique for carotid stenoses. However, this technique is complicated in about 10% of the cases by a restenosis. Mechanisms of myointimal hyperplasia leading to restenosis are not completely explained. The technique of eversion endarterectomy of the internal carotid artery has been said to be an alternate technique which could decrease the incidence of restenosis. We described the three main techniques of eversion endarterectomy and their results. The technique of eversion endarterectomy after proximal section of the internal carotid artery is the most frequently used. It allows to treat easily length excess of the internal carotid artery. Its results are good in terms of neurologic morbidity and mortality. However, randomized comparative studies are still required in order to determine its role on the incidence of restenosis despite the first encouraging results of first non comparative studies. The technique of eversion endarterectomy after distal section of the internal carotid artery has been proposed by Chevalier who reported also good short term results and no delayed restenosis.

[Extra-popliteal localizations of adventitial cysts. Review of the literature]. / Les localisations extra-poplitées des kystes adventitiels. Revue de la littérature.

Cystic adventitial disease is an uncommon vascular anomaly first described in 1947 in the external iliac artery. The preferential localization is the popliteal artery although other arteries and veins may also be involved though not always recognized. There have been 45 extra-popliteal localizations of adventitial cysts reported in the literature. Thirty cases involved an artery an 15 a vein. The iliofemoral axis, with 33 reported cases, is the preferential localization of these extra-popliteal adventitial cysts (including 22 arteries and 11 veins). All the other cases also involved a vessel near an articulation (knee, ankle, elbow, wrist). Despite a preferential popliteal arterial localization only one case involved the popliteal vein. The diagnosis is rarely made before surgery, probably because of the nonspecific clinical presentation. Ultrasonography should allow better recognition of these adventitial cysts, eliminating an aneurysm or a synovial cyst, and evidencing the localization of the cyst within the vessel wall.

The impact of knee joint flexion on infrainguinal vascular grafts: an angiographic study.

OBJECTIVES: To characterise the morphologic behaviour of infrainguinal vascular grafts during flexion of the knee. DESIGN: A prospective angiographic study. MATERIALS AND METHODS: In 64 infrainguinal bypass grafts, intravenous digital subtraction angiography was performed within the first postoperative week. Frontal and lateral projection angiograms with the knee joint extended and with a 80-90 degrees flexion were taken. The distal anastomosis of the bypass was performed below-knee in 49 cases (18 in situ veins, 8 reversed veins with an anatomic course, 2 reversed veins with an extra-anatomic course, 4 composite grafts, 15 synthetic grafts with an anatomic course (14 polytetrafluoroethylene (ePTFE), 1 polyurethane), and two synthetic grafts with an extra-anatomic course. Fifteen ePTFE prostheses were implanted in the above-knee position. RESULTS: Out of 64 cases a total of 16 grafts showed stenotic kinking during flexion: two of the 18 in situ vein grafts, four of the 12 reversed vein grafts implanted with an anatomic course, one of the two reversed vein grafts implanted in an extra-anatomic site, eight of the 15 synthetic grafts crossing the knee, 0 of the two extra-anatomic ePTFE grafts, and one of the 15 cases of above-knee femoropopliteal ePTFE grafts. CONCLUSIONS: Stenotic kinking due to knee flexion can affect all kinds of bypass grafts including vein grafts placed anatomically and above-knee prostheses.