[Embolization of splenic artery aneurysms: Treatment of choice. About a case and review of the literature]. / Embolisation des anévrysmes de l'artère splénique : traitement de choix. À propos d'un cas et revue de la littérature.

Splenic artery aneurysms constitute 60% of digestive artery aneurysms. They are often discovered incidentally and by imaging. Currently, endovascular treatment is considered the first-line treatment, as it is less invasive with less morbidity and mortality than surgery. An aggressive approach in their management is certainly justified because the overall mortality of ruptured splenic aneurysms is 25%. False splenic aneurysms have a greater potential for rupture than true aneurysms because they grow faster. Endovascular treatment is generally indicated for aneurysms larger than 2cm or with an increase in size of more than 0.5cm/year. Embolization is rarely associated with an infarction of the spleen due to the good supply of short gastric vessels. Embolization is performed using different materials including coils, which can be used alone or with other embolic agents. Post-embolization syndrome can be seen with persistent pain, fever and other systemic symptoms. Endovascular treatment compared to open surgery is associated with better quality of life and appears to be the most cost-effective strategy. Endovascular treatment and especially coil embolization are starting to be the standard treatment. Surgical and laparoscopic treatment are reserved for ruptured aneurysms which are burdened with significant mortality, especially in pregnant women. We report the case of a 66-year-old female patient in whom a splenic artery aneurysm was discovered incidentally during an ultrasound for an ovarian cyst.

Femoropopliteal In-stent Restenosis Repair: Midterm Outcomes After Paclitaxel Eluting Balloon Use (PLAISIR Trial).

OBJECTIVE: The aim was to assess 18 month outcomes of the paclitaxel eluting balloon (PEB) in patients with femoropopliteal (FP) in-stent restenosis (ISR). METHODS: In a national prospective and multicentre cohort study, symptomatic patients with femoropopliteal in-stent restenosis were included from January 2012 to June 2013. Patients were treated by paclitaxel eluting balloon angioplasty (In Pact Admiral, Medtronic, Santa Rosa, CA, USA). Clinical and duplex scan follow-up evaluations were performed at 1, 3, 6, 9, 12, and 18 months. The primary endpoint was freedom from target lesion revascularisation (TLR) at 12 months. Secondary endpoints were major adverse cardiovascular events (MACE), Target extremity revascularisation (TER), primary and secondary sustained clinical improvement, recurrent restenosis rate, primary and secondary patency, quality of life assessed by EQ-5D questionnaire, technical success, clinical success, and length of stay RESULTS: A total of 53 patients were enrolled. After a blinded review, 10 patients were defined as protocol violation because restenosis occurred more than 2 years after stent implantation. Procedures were performed in 55 limbs, 48 (87%) for claudication and 7 (13%) for critical limb ischaemia. The mean diameter and length of PEB were 6 ± 0.57 mm and 86 mm ± 32 mm, follow-up was 17 months (range 1-19). At 1 year, the survival rate was 96 ± 2.7% and freedom from TLR and TER were 90.2 ± 4.2% and 85 ± 5%, respectively. Sustained primary and secondary clinical improvements were 78.6 ± 5.7% and 92.0 ± 3.8%, respectively. At 1 year, the primary patency rate was 83.7 ± 5.0%. Prior to the procedure, the mean EQ-5D score was 66 ± 14 and 74 ± 16 at 1 year (p = .10). Two patients died during follow-up; one patient died 33 days after the procedure because of limb ischaemia. CONCLUSION: PEB for the treatment of FP ISR is associated with a low rate of re-interventions and restenosis. Clinical improvement is maintained at 18 months.

Bone Like Arterial Calcification in Femoral Atherosclerotic Lesions: Prevalence and Role of Osteoprotegerin and Pericytes.

OBJECTIVE/BACKGROUND: Arterial calcification, a process that mimics bone formation, is an independent risk factor of cardiovascular morbidity and mortality, and has a significant impact on surgical and endovascular procedures and outcomes. Research efforts have focused mainly on the coronary arteries, while data regarding the femoral territory remain scarce. METHODS: Femoral endarterectomy specimens, clinical data, and plasma from a cohort of patients were collected prospectively. Histological analysis was performed to characterize the cellular populations present in the atherosclerotic lesions, and that were potentially involved in the formation of bone like arterial calcification known as osteoid metaplasia (OM). Enzyme linked immunosorbent assays and cell culture assays were conducted in order to understand the cellular and molecular mechanisms underlying the formation of OM in the lesions. RESULTS: Twenty-eight of the 43 femoral plaques (65%) displayed OM. OM included osteoblast and osteoclast like cells, but very few of the latter exhibited the functional ability to resorb mineral tissue. As in bone, osteoprotegerin (OPG) was significantly associated with the presence of OM (p = .04). Likewise, a high plasma OPG/receptor activator for the nuclear factor kappa B ligand (RANKL) ratio was significantly associated with the presence of OM (p = .03). At the cellular level, there was a greater presence of pericytes in OM+ compared with OM- lesions (5.59 ± 1.09 vs. 2.42 ± 0.58, percentage of area staining [region of interest]; p = .04); in vitro, pericytes were able to inhibit the osteoblastic differentiation of human mesenchymal stem cells, suggesting that they are involved in regulating arterial calcification. CONCLUSION: These results suggest that bone like arterial calcification (OM) is highly prevalent at femoral level. Pericyte cells and the OPG/RANK/RANKL triad seem to be critical to the formation of this ectopic osteoid tissue and represent interesting potential therapeutic targets to reduce the clinical impact of arterial calcification.

Treatment of TASC C and D Femoropoliteal Lesions with Paclitaxel eluting Stents: 12 month Results of the STELLA-PTX Registry.

OBJECTIVE: The aim was to evaluate the safety and the efficacy of primary stenting with paclitaxel eluting stents for TASC C and D femoropopliteal lesions. METHODS: Patients with TASC C/D de novo femoropopliteal lesions were treated by implanting paclitaxel eluting stents. Patients were included in a single center registry and prospectively followed by clinical and ultrasound evaluation. X-ray of the stented zone was systematically performed 12 months after implantation. The primary endpoint was primary sustained clinical improvement after 12 months. RESULTS: A total of 45 patients (48 limbs) suffering from claudication (25 limbs) or CLI (23 limbs) were enrolled. Lesions were either TASC C (28 limbs) or TASC D (20 limbs). The mean length of the treated segment was 252 ± 90 mm. The mean number of stents was 2.9 ± 1 (2-5). Mean follow up was 12.7 months. No patient was lost to follow up. At 1 year post procedure, primary and secondary sustained clinical improvements were 56.3 ± 7.4% and 80.1 ± 5.9% respectively. Freedom from target lesion and target extremity revascularization were 63.6% and 90.1%, respectively. Primary and secondary patency rates were 52.5% and 79.6%. One year primary sustained clinical improvement rates for TASC C/D were 63.3 ± 9.2% and 45.6 ± 11.7%, respectively (p = .34). One year primary sustained clinical improvement rates for claudication/CLI patients were 68 ± 9.3% and 41.6 ± 11.1%, respectively (p = .13). The incidence of in stent re-stenosis and in stent thrombosis were 25% and 14%, respectively. The incidence of stent fracture was 12.5% on a limb basis and 9% on a per stent basis. CONCLUSIONS: The paclitaxel eluting stent did not achieve its goal in terms of prevention of in stent re-stenosis for TASC C/D femoropopliteal lesions. It requires frequent re-interventions during the first year to maintain satisfactory clinical results.

State-of-the-art treatment of common femoral artery disease.

Atherosclerotic common femoral artery (CFA) disease is a well-known and frequent cause of symptomatic peripheral artery disease (PAD). Not so long ago, surgical treatment was considered the gold standard and the main treatment option. Therapeutic advances have, however, provided a wide and suitable armamentarium. These advances concern medical treatment and the direct treatment of lesions by open surgery or endovascular treatment. The aim of this manuscript was to summarize therapeutic updates and to describe the current endovascular and open surgical procedures used to treat common femoral artery disease.

Incidence and the clinical impact of stent fractures after primary stenting for TASC C and D femoropopliteal lesions at 1 year.

BACKGROUND: The clinical impact of stent fractures is still controversial. This study analyzed the incidence and the clinical impact of stent fractures after stenting of long femoropopliteal lesions. METHODS: From November 2008 to October 2009, 58 patients (62 limbs) were treated in a single center with a primary nitinol self-expanding stent for Trans-Atlantic Inter-Consensus (TASC) C and D de novo femoropopliteal lesions. Patients were prospectively followed by medical and duplex scan examinations. Stent fractures were assessed by biplane X-rays at 12 months. Logistic regression analysis was performed. RESULTS: At 1 year a complete follow-up was obtained in 42 limbs/90 stents. The median length of the stented segment was 240 ± 180 cm with a mean of 2.1 (1-4) stents per patient. Sixteen stents (17.8%) were fractured: one type I (asymptomatic); seven type II (2 restenosis); five type III (asymptomatic), and three type IV stent fractures (1 restenosis). Stent diameter (p = .04) and stent implantation in the distal part of the superficial femoral artery (p = .05) were positively associated with stent fractures. Stent fracture had no influence on restenosis. CONCLUSION: This study suggests that the high stent fracture rate associated with endovascular treatment of long femoropopliteal lesions should be balanced with its low clinical impact.

[Arterial heterogeneity]. / Artériopathie et hétérogénéité artérielle.

More and more clinical observations and trials support the concept of heterogeneity of atheroma according to the arterial bed. In a pilot study named "Étude Comparative des Lésions Athéromateuses" (ECLA), we have shown that carotid and femoral plaques possess different characteristics. Carotid arteries display increased lipid content compared to femoral arteries whereas femoral arteries are more prone to calcify and to develop osteoid metaplasia. These observations should lead the researcher and the clinician to look at the cellular and molecular mechanisms governing the heterogeneity of atheromas. At last, a better understanding of the characteristics of plaques should help us to determine plaque stability, to prevent cardiovascular events and to choose the best medical, endovascular or surgical option.

One-year clinical outcome after primary stenting for Trans-Atlantic Inter-Society Consensus (TASC) C and D femoropopliteal lesions (the STELLA "STEnting Long de L'Artère fémorale superficielle" cohort).

OBJECTIVE: The study aims to evaluate the safety and the efficacy of primary stenting for Trans-Atlantic Inter-Society Consensus Document II on Management of Peripheral Arterial Disease (TASC) C and D femoropopliteal lesions. DESIGN: Prospective cohort study. METHODS: Patients with TASC C and D de novo femoropopliteal lesions were treated with the same endovascular technique by implanting a primary nitinol self-expanding stent (LifeStent(®), Bard Peripheral Vascular, Tempe, AZ, USA). Patients were included in a single-centre registry and prospectively followed up. The primary end point was primary sustained clinical improvement after 12 months. Secondary end points were secondary sustained clinical improvement, primary and secondary patency rates, freedom from target lesion revascularisation (TLR), freedom from target extremity revascularisation (TER) and stent fracture rate. RESULTS: We enrolled 58 patients (62 limbs) suffering from either claudication (40.3%) or critical limb ischaemia (59.7%). Lesions were either TASC C (62.9%) or TASC D (37.1%). Median length of the treated segment was 220 ± 160 mm. The mean number of stents was 2.2. Mean follow-up was 17 months, with one patient lost to follow-up. At 1 year, the primary end point was 68.6% while secondary sustained clinical improvement was 82.6%. Freedom from TLR and TER rates were 81.1% and 96.3%. Primary and secondary patencies were 66% and 80.9%. One-year primary and secondary sustained clinical improvement rates were 76.7% ± 7.2 for TASC C and 46.3% ± 11.1 for TASC D (p = 0.03) and 87.6% ± 5.9 for TASC C and 67.3% ± 11.3 for TASC D (p = 0.09), respectively. The ankle-brachial pressure index increased from 0.58 to 0.94 (p = 0.001) at 1 year and the incidence of in-stent restenosis (ISR) was 19.3%. Stent fracture and disconnection rate was 17.7%. CONCLUSIONS: Primary stenting of TASC C and D lesions appears to be safe and efficient given the high-sustained clinical improvement and the low rate of ISR observed in our study. Endovascular treatment of such long and severe lesions exposes to high rate of stent fractures, which should not be a concern given their low clinical impact.

Endovascular approaches to acute aortic type A dissection: a CT-based feasibility study.

BACKGROUND: Open graft replacement of the ascending aorta is the current treatment of choice for Stanford acute type A dissections. However, approximately 20% of patients are deemed unfit for open surgery. To determine if an endovascular option exists for this latter group of patients, we performed a computed tomography (CT)-based feasibility study. METHODS: A cohort of consecutive patients presenting to the cardiovascular care unit (CVCU) for an acute Stanford type A aortic dissection between 2006 and 2009 was retrospectively analysed. Inclusion criterion was a high-quality preoperative angio-CT scan that could be analysed on a three-dimensional (3D) workstation. Numerous anatomical parameters of the dissection were studied, including the location and the length of the primary proximal entry tear. Finally, we determined which of the patients would have been potential candidates for an endovascular repair (stentgraft implantation). RESULTS: A total of 102 patients were included in our study. The median distance of the primary entry tear to the closest coronary artery was 23 mm (range 0-128). The median true lumen and true + false lumen (total) diameters at the level of the entry tear was 38 mm (range 22-78) and 46 mm (range 28-93), respectively. The median length of the ascending aorta was 84 mm (range 40-130). An endovascular repair with a tubular stentgraft was deemed feasible in 37 patients. An additional eight patients were also candidates for a tubular endovascular repair but would have required a carotidecarotid cross over bypass. Finally, an arch-branched stentgraft could have been used in 13 patients to exclude an entry tear located in the arch. CONCLUSION: Open repair of acute type A dissection is and remains the 'gold standard' of care. Our study demonstrates that approximately half the patients undergoing an open repair could potentially benefit from an endovascular repair. This new treatment option has not been evaluated to date.

Endovascular repair of common femoral artery and concomitant arterial lesions.

OBJECTIVE: The common femoral artery (CFA) is an unusual location for endovascular repair (ER). We report the early results after ER of the CFA in a single centre. DESIGN: This is a cohort study. MATERIALS/METHODS: From 2006 to 2008, ER of the CFA was proposed to 36 patients (mean age 67.9, range 51-92). CFA lesions were classified into four types: in type I, lesions were located at the iliac external artery and were extended to the CFA; in type II, lesions were limited to the CFA; in type III, lesions were located at the CFA and its bifurcation; type IV represents restenosis bypass anastomosis. All patients were treated by stenting. RESULTS: Indications for ER of the CFA included 25 patients (70%) for claudication and 11 patients (30%) for critical limb ischaemia. Forty-three stents were implanted. The mean follow-up was 22 months (range, 12-42). At 1 year, primary and secondary sustained clinical improvements were 80% and 90%; target lesion revascularisation and target extremity revascularisation free cumulative survival were 85% and 80%, respectively, and in-stent restenosis rate was 20%. One stent fracture was noted. CONCLUSIONS: ER of CFA and concomitant arterial lesions seems to be a safe technique with acceptable clinical outcome at 1 year.

Fenestrated endovascular grafting: the French multicentre experience.

PURPOSE: This study aims to evaluate the medium-term outcomes following aortic aneurysm repair using fenestrated endografts performed in 16 French academic centres. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data was carried out. This study included all patients treated with fenestrated endografts in France between May 2004 and January 2009. Patients were judged to be at high risk for open surgical repair. Fenestrated endografts were designed using computed tomography (CT) reconstructions performed on three-dimensional (3D) workstations. All patients were evaluated with CT, duplex ultrasound and plain film radiograph at discharge, 6, 12, 18 and 24 months, and annually thereafter. RESULTS: A total of 134 patients (129 males) were treated over the study period. Median age and aneurysm size were 73 years (range 48-91 years) and 56 mm (range 45-91 mm), respectively. A total of 403 visceral vessels were perfused through a fabric fenestration, including 265 renal arteries. One early conversion to open surgery was required. Completion angiography and discharge CT scan showed that 398/403 (99%) and 389/394 (99%) respective target vessels were patent. The 30-day mortality rate was 2% (3/134). Pre-discharge imaging identified 16 (12%) endoleaks: three type I, 12 type II and one type III. After the procedure, transient or permanent dialysis was required in four (3%) and two (1%) patients, respectively. The median duration of follow-up was 15 months (range 2-53 months). No aneurysms ruptured or required open conversion during the follow-up period. Twelve of 131 patients (9%) died during follow-up (actuarial survival at 12 and 24 months: 93% and 86%, respectively). Median time from procedure to death was 15 months. None of these deaths were aneurysm related. Aneurysm sac size decreased by more than 5 mm in 52%, 65.6% and 75% of patients at 1, 2 and 3 years, respectively. Three (4%) patients had sac enlargement within the first year, associated with a persistent endoleak. During follow-up, four renal artery occlusions were detected. A total of 12 procedure-related re-interventions were performed in 12 patients during follow-up, including six to correct endoleaks, and five to correct threatened visceral vessels. CONCLUSIONS: The use of endovascular prostheses with graft material incorporating the visceral arteries is safe and effective in preventing rupture in the medium term. A predictable high mortality rate was depicted during follow-up in this high-risk cohort. Meticulous follow-up to assess sac behaviour and visceral ostia is critical to ensure optimal results.

Acute leriche syndrome due to paradoxical embolism.

Paradoxical embolism, describing the passage of venous or right-sided cardiac thrombus into the arterial or systemic circulation through patent foramen ovale, is an uncommon cause of acute arterial occlusion. Here, we report acute Leriche syndrome in a young woman attributable to paradoxical embolism. Ischaemia, patent foramen ovale, and venous thrombosis were the triad of evidence for paradoxical embolism.

[Hemoperitoneum due to rupture of an omental arterial aneurysm]. / Hémopéritoine par rupture spontanée d'un anévrisme de l'arcade vasculaire omentale.

We report a case of spontaneous hemoperitoneum due to rupture of an omental arterial aneurysm. This source of bleeding is unusual (2 cases published); the diagnosis was made preoperatively by doppler ultrasound and CT scan with IV contrast. Omental resection was performed and histological analysis confirmed the diagnosis. A literature review of the rare cases of hemoperitoneum due to rupture of a digestive arterial aneurysm is done.

Infected aneurysms of neck and limb arteries: a retrospective multicenter study.

Infected aneurysms (IA) of neck and limb arteries are uncommon. This report describes the results of a retrospective study undertaken by the University Association for Surgical Research (AURC) to evaluate etiology, bacteriology, location, diagnostic features, and therapeutic methods associated with IA. A total of 58 IA in 52 patients were reviewed. The lesion was located in a lower extremity artery in 47 patients (81%), internal carotid artery in 7 (12%), and upper extremity artery in 4 (6%). Eleven patients had multilocular aneurysm (21%). Symptoms of local infection were observed in 43 patients (82.6%). Rupture or splitting was the presenting manifestation in 13 patients (25%). Primary IA following bacteremia or septicemia without endocarditis was the most common type of IA observed in 34 patients (65.3%). Twelve patients (23%) presented mycotic IA secondary to bacterial endocarditis. In the remaining six patients (11.5%), IA resulted from direct contamination or spreading from a contiguous infection site. Surgical treatment included ligation of the artery without reconstruction in 19 patients and exclusion bypass in 33 patients. The duration of antibiotic treatment ranged from 15 days to 3 months. No recurrence of aneurysm was observed but three patients developed bypass infection. Primary IA was associated with high mortality due to severe septicemia.

Popliteal artery thrombosis secondary to exostosis of the tibia.

This report describes an exceptional case of popliteal artery thrombosis secondary to exostosis of the superior extremity of the superior tibia in a young adult. Correct diagnosis was made during re-operation for recurrent thrombosis. Surgical treatment consisted of resection of the bony tumor and venous bypass to reestablish arterial continuity. Femoropopliteal vascular complications of exostosis are rare, with most cases involving arterial aneurysms or false aneurysms. Differential diagnosis in our young patient took into account the other causes of popliteal thrombosis: entrapped popliteal artery, adventitious cyst, fibrodysplasia, and juvenile arteriopathy. In patients with major functional disability, operative treatment is recommended to remove the bony abnormality and repair the arterial lesion.