European Experience with a System for Bifurcated Stent-Graft Insertion

Purpose:

To test an endovascular aneurysm exclusion system in the presence of a wide range of challenging anatomic features.

Methods:

Bifurcated endovascular stent-grafts were inserted in 52 patients and followed with serial computed tomography for up to 3 years. The device underwent several modifications during this time, the most significant of which represent the difference between the homemade (n = 42) and industry-made (n = 10) versions.

Results:

The initial procedural success rate was 92% in the homemade group and 100% in the industry-made group. In the 3 years of follow-up, the long-term success rate was 64% in the homemade group and 90% in the industry-made group. The primary reasons for failure in the homemade group were graft thrombosis due to kinking early in the series and proximal stent migration later in our experience. All cases of migration occurred when the neck was < 15 mm in length, the neck was lined with thrombus, or the stent was implanted > 15 mm from the renal arteries. Kinking was subsequently overcome by implanting Wallstents throughout the graft limbs. The sole failure in the industry-made group was a case in which collateral perfusion reached the aneurysm through patent lumbar arteries.

Conclusions:

The fruits of this experience are a better technique, a better device, and, most importantly, a better understanding of the system's limits, as reflected in the current selection criteria.

Coronary and carotid artery occlusive disease: single center experience

BACKGROUND AND OBJECTIVE

Due to increased life expectancy, the risk profile of the patients undergoing cardiac surgery changed dramatically. This is especially important in case of concomitant coronary artery disease and carotid artery stenosis (CAS). Careful decision making and appropriate surgical strategy in these patients is critical for the success of the operation. Controversy about relationship between staged and concomitant carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) still exists. In the current study, we present our case lood in treating patients with concomitant carotid artery stenosis and coronary artery disease.

PATIENTS AND METHODS

CABG with additional CEA due to neurologic symptoms or high grade (>80%) CAS has been performed in 835 patients in the period of 1982-2010. Results of evaluation of perioperative mortality and morbidity in regard to the surgical approach have been discussed.

RESULTS

The average patient age was 62.6 +/- 8.7 years. Echocardiography revealed that 28% of the patients had poor left ventricle ejection fraction (<30%). Coronarography demonstrated that 21.4% of the operated patients had significant left main coronary artery stenosis (>60%). In terms of neurological status, majority of the patients (88.3%) were neurologically asymptomatic. The overall mortality regardless the sequence of procedures was 2.3% (19 patients). In the group of concomitantly treated patients 44.6% (50 patients) required triple coronary bypass while the mean number of coronary bypasses was 2.6. Postoperative neurologic complications were present in 102 patients (12.2%). Eighty-four patients (10.0%) have had TIA, while 18 patients (2.2%) have had permanent neurologic deficit while 4 patients (0.5%) died as a result of it.

CONCLUSIONS

It is imperative that every patient being considered for CABG should undergo ultrasonic evaluation of the carotid arteries regardless the neurological symptomatology. Concomitant surgery on patients with severe CAS and coronary disease carries a slightly higher operative risk and, therefore, should be avoided. Concomitant surgical treatment should only be considered in patients with unstable angina and significant CAS in whom we may expect higher morbidity and mortality.

Anévrysmes aortiques multiples au cours d’une polychondrite atrophiante

BACKGROUND

Although rare, cardiovascular involvement is the second most frequent cause of mortality in chronic relapsing polychondritis behind tracheobronchial tree chondritis. The most frequent cardiovascular complications are valvulopathy and aortic aneurysm.

CASE REPORT

We report a case of chronic relapsing polychondritis with multiple aortic aneurysms that were clinically silent but continued to progress despite systemic corticosteroids and immunosuppressive therapy.

DISCUSSION

Progression of aortic aneurysms and extravascular disease do not appear to be correlated. Although the disease may appear to be in remission, vascular lesions can continue to progress independently. This case shows that medical treatment has little effect on the progression of these aneurysms. Consequently, it is necessary to opt for surgical therapy at the opportune moment.

[Evolution of the treatment of chronic post-traumatic aneurysms of the descending thoracic aorta: 30 years experience]

The authors present the early and late results of a series of 40 patients treated for chronic post-traumatic aneurysms of the descending thoracic aorta from 1975 to 2005. With the exception of a patient who died of an intra-pleural rupture before surgery, the patients were treated by aortotomy and prosthetic graft (N=17), aortotomy and direct suture (N=17) or endoprosthesis (N=5). The use of distal aortic perfusion in 22 patients enabled 17 direct sutures (77.3%) thanks to extensive mobilisation of the aortic arch. Endoprostheses have been used since 1997 in high surgical risk patients with severe comorbid conditions. There were no deaths, one transient paraparesia after simple aortic clamping, one reoperation for a haemothorax and four cases of dysphonia due to paralysis of the recurrent laryngeal nerve. Thirty-five patients (90%) were followed up for an average of 119.7 +/- 16.4 months. There were no clinical complications and the late morphological results were good in all cases with the exception of one type 1 endoprosthetic leak. The treatment of chronic post-traumatic aneurysms of the descending thoracic aorta gives excellent early and late results, justifying wide operative indications. The wish to avoid use of a prosthesis in young patients with a long life expectancy should give preference to conventional surgical techniques which, providing distal aortic perfusion is employed, allow direct suture of three quarters of cases. Endovascular treatment is reserved only for "poor surgical risks".

[Surgical exposure of visceral arteries]

Surgery of visceral arteries is mainly indicated for ostial and juxtaostial atherosclerosis of the celiac axis and superior mesenteric arteries. Their surgical exposures are often difficult because of their deepness.

[Aortic dissections: recent endovascular therapeutic advances and current indications]

Dissection is one of the most serious diseases of the aorta if only because of its potential for rupture, but also for other complications which may be fatal. Replacement with a prosthesis remains the treatment of reference as an emergency for proximal dissection and as an elective procedure for selected cases of distal dissection with complications. Despite steady progress in ancillary management (distal perfusion, circulatory arrest, cardiac, neurological and visceral protection) the operation remains a very invasive procedure. Aortic endoprostheses represent the therapeutic innovation of the decade for the treatment of aortic aneurysms and their use could be extended to dissections, at least for the most distal forms and to patients at very high surgical risk.

Hyperhomocysteinemia and arterial aneurysm

Hyperhomocysteinemia (HCY) is an independent risk factor for atherosclerosis. Arterial aneurysm has rarely been described in association with heterozygous HCY. Here we report two cases of this association. Case 1 was 32-Year-old man who presented with distal trophic manifestations of the lower extremities. Upon investigation, occlusive arterial disease with fusiform aneurysm of both popliteal arteries and occlusion of the left cubital artery were found. Laboratory findings indicated HCY due to homozygous methylene tetrahydrofolate reductase (MTHFR) deficiency. Case 2 was 38-year-old man with no history of trauma who presented with repeated ischemic events involving the right hand in association with isolated aneurysm of the right cubital artery. Histological study demonstrated extensive dystrophic changes in the aneurysmal vessel wall, including sclerohyalin deposits. The only abnormality was homozygous MTHFR deficiency. Pathologic changes induced by HCY in vessel walls may be implicated in early arterial aneurysm. The association of anatomic lesions, young age, and absence of other causes suggests that the relationship between HCY and arterial aneurysm observed in these two patients was not coincidental.

Psychosocial outcomes of urban African American adolescents born to teenage mothers

This is a study of psychosocial outcomes of adolescents born to teenage mothers. Adolescents'problem behaviors, psychological well-being, social support, school variables, and sexual behaviors are compared across three groups- those born to mothers 17 or younger, mothers 18-19 years old, and mothers 20 or older. Analyses from two samples of African American adolescents from Maryland (n = 205) and Michigan (n = 570) are reported. The results from both samples indicate that mother's age at birth is unrelated to adolescents' psychosocial outcomes. These two studies add to the limited number of analyses that examine adolescent outcomes for children of teen mothers. The results suggest that efforts to understand social structural determinants of healthy and problematic adolescent development may be more informative than examining the effects of mother's age. They also suggest that teen pregnancy prevention programs may be more effective if they are part of a larger prevention strategy that incorporates social structural change efforts and not only a focus on individual level change.

Aneurysms of the innominate artery: surgical treatment of 27 patients

PURPOSE

Aneurysms of the innominate artery (AIA) are widely considered to be a rare entity. We describe our experience with AIAs in the last three decades.

METHODS

From October 1973 to October 2000, we operated on 27 patients with an AIA. The underlying cause of aneurysm was Takayasu's disease in 7 patients, degenerative disease in 6 patients, syphilis in 5 patients, chronic dissection in 3 patients, trauma in 2 patients, infection in 2 patients, a postoperative complication in 1 patient, and Marfan syndrome in 1 patient. AIA was associated with an aortic aneurysm in 17 patients. Fourteen patients had no symptoms. The remaining patients had symptoms, with thromboembolic complications in 7 patients, pain without rupture in 3 patients, and a ruptured aneurysm in 3 patients. In two patients at high risk for surgery who had a small AIA with embolic complications, a cervical approach was used as a means of performing distal exclusion and crossover bypass. In the remaining 25 patients, a midline sternotomy was used. One patient with a ruptured AIA exsanguinated during sternotomy. Ten patients underwent a prosthetic replacement of the ascending aorta and/or aortic arch with a separate prosthetic branch to the innominate artery (IA). Thirteen patients underwent ascending aorta-to-IA prosthetic bypass in association with lateral suture (8 patients) or prosthetic patching (5 patients) of the aorta. One patient with an infected aneurysm was treated by means of resection of the aneurysm, proximal ligation of the IA, and transposition of the right into the left common carotid artery. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in 10 patients.

RESULTS

Three perioperative deaths occurred (2 of 4 in association with emergency treatment and 1 of 23 with elective treatment). Respiratory complications requiring prolonged artificial ventilation developed in five patients. Two patients had transient worsening of preoperative neurologic deficits. Late results, with a mean follow-up of 85 months, were good.

CONCLUSION

The etiology and presentation of AIAs are variable. Surgical management with current cardiovascular techniques achieves excellent results.

Endovascular treatment of abdominal aortic aneurysms: is there a benefit regarding postoperative outcome?

BACKGROUND AND OBJECTIVE

The endovascular treatment of abdominal aortic aneurysms has raised great interest amongst vascular surgeons. The aim of this study was to compare the postoperative morbidity and mortality rates of endovascular treatment with those of open surgery, from the anaesthesiologist's standpoint.

METHODS

From January 1997 to June 2000, 425 consecutive patients with abdominal aortic aneurysms were referred for regular surgery. Thirty-nine patients who needed a visceral or renal artery revascularization, or a nephrectomy were excluded. The remaining 386 patients were studied in a prospective manner. Aneurysms were evaluated with spiral computerized tomography scanning and calibrated aortography. After informed consent, only those patients with a suitable vascular anatomy underwent endovascular treatment (n = 193). All other patients underwent open surgery and are considered as a control group (n = 193). Endovascular treatment was performed by a femoral or an iliac retroperitoneal route. All stent-grafts were made to measure using auto-expandable stainless-steel stents covered with a standard polyester prosthetic graft.

RESULTS

Six patients in the endovascular treatment group needed to be converted to the open surgical technique (during the same operation) because of rupture of the iliac bifurcation (1 patient), a large endoleak (2 patients), or technical problems (3 patients).

CONCLUSION

The amount of bleeding and the need for blood products were significantly lower in the endovascular treatment group. Despite the absence of significant differences regarding cardiac complications and mortality, there was a lesser incidence of pneumonia, acute respiratory and renal failure. Patients in the endovascular treatment group spent less time in the intensive care unit and in the Hospital.

Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts

PURPOSE

Prosthetic graft infection is an uncommon but life-threatening complication of descending thoracic/thoracoabdominal aortic aneurysmectomy. The purpose of this study was to assess the value of in situ arterial allografts in the management of this complication.

METHODS

From 1992 to 2000 we treated 11 consecutive patients with prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy by replacing the prosthetic graft with an in situ arterial allograft. There were 10 men and one woman with a mean age of 50.8 years (range, 32-73 years). The primary aortic disease was degenerative aneurysm in 6 patients, chronic type B dissection in 2 patients, inflammatory aneurysm in 1 patient, Marfan's disease in 1 patient, and Behçet's disease in 1 patient. Replacement involved only the descending thoracic aorta in three patients and more or less extensive segments of the thoracoabdominal aorta in eight patients. Signs of severe infection were present in all patients, and false anastomotic aneurysms were noted in six patients. Aortoenteric fistula occurred in three patients and aortobronchial fistula in two patients. The causative organisms were identified in nine patients. The mean interval between the primary surgery and reoperation was 33.4 +/- 27.5 months. Reoperation was performed under emergency conditions because of hemorrhage in three patients. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in seven patients. Allograft replacement of the aorta was associated with reimplantation of intercostal and/or visceral arteries in all patients.

RESULTS

One patient died intraoperatively of heart failure during emergency surgery. Two patients died of persistent infection during the postoperative period at 19 and 58 days. Mean follow-up was 34 +/- 19 months. One patient died during the late follow-up period after surgery of the infrarenal aorta. Another patient underwent surgery for stenoses of one branch of a bifurcated allograft and a renal bypass graft to a solitary kidney.

CONCLUSIONS

The use of in situ arterial allografts is a significant advance in the management of prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy provided that reoperation is performed early.

Optimization of the resistance of arterial allografts to infection: comparative study with synthetic prostheses

Arterial allografts can be used for in situ treatment of prosthetic graft infection. The purpose of this in vitro study was to compare the resistance of allografts and synthetic prostheses to infection by five strains of bacteria and to study antibiotic treatments designed to reduce allograft infection. Fresh and cryopreserved allografts were compared with synthetic prostheses made of various biomaterials including PTFE, plain Dacron, gelatine-sealed Dacron, and gelatine-sealed, rifampicine-bonded Dacron. Allografts were used with or without treatment using an antibiotic containing gentamycine, lincomycine, and vancomycine. The bacterial strains tested were Escherichia coli, Staphylococcus aureus, slime-producing Staphylococcus epidermidis, non-slime-producing Staphylococcus epidermidis, and Pseudomonas aeruginosa. Infection was evaluated by counting the number of adherent bacteria on the allograft or synthetic material after rinsing and ultrasonication. Statistical analysis was achieved using nonparametric Mann-Whitney tests. Results showed that allografts not treated with antibiotics were highly susceptible to bacterial infection. Antibiotic treatment decreased infection. Application of antibiotic after thawing cryopreserved allografts led to a significant decrease. None of the biomaterials tested provided sufficient protection against bacteria resistant to the antibiotics used.

A new study demonstrates the efficacy of naftidrofuryl in the treatment of intermittent claudication. Findings of the Naftidrofuryl Clinical Ischemia Study (NCIS)

BACKGROUND

The efficacy and safety of naftidrofuryl were assessed in a double blind, placebo controlled, parallel group study, in patients presenting with intermittent claudication, according to the latest European guidelines.

METHODS

The outpatients selected were of both sexes, aged 35 to 85, with moderately severe chronic, stable intermittent claudication and a pain-free (PFWD) and maximum walking distance (MWD) on the treadmill of between 100 and 300 metres. They received naftidrofuryl 200 mg tid or placebo for six months and were then assessed during a six-month follow-up period without treatment. The primary outcome measures were the pain-free walking distance and maximum walking distance.

RESULTS

Of the 221 selected patients, 196 were randomised and 181 entered the intention-to-treat analysis. The two groups were well matched for demographic variables, risk factors and history of vascular disease. After six months of treatment, patients who received naftidrofuryl had a 92% im-provement of geometric pain-free walking distance versus 17% in the placebo group (p < 0.001) and an 83% improvement of geometric maximum walking distance versus 14% in the placebo group (p < 0.001). During the follow-up period without treatment, the walking distances of the patients in the naftidrofuryl group significantly decreased. The incidence of adverse events was similar in the two groups.

CONCLUSIONS

This study demonstrated the efficacy of naftidrofuryl versus placebo in patients with intermittent claudication with a highly significant and clinically relevant difference and confirmed its good safety profile.

Perioperative activation of hemostasis in vascular surgery patients

BACKGROUND

Perioperative activation of hemostasis could play an important role in the occurrence of postoperative cardiac events. The authors conducted a prospective study to assess platelet function, coagulation, and fibrinolysis status during and after infrarenal aortic surgery.

METHODS

Seventeen patients were studied. Excluded were patients with preoperative coagulopathies or liver disease, or cardiac or renal insufficiency; patients receiving anticoagulant treatment, antiplatelet agents, nonsteroidal antiinflammatory agents, fresh frozen plasma, or platelet concentrates; and patients undergoing reoperation and septic patients. Blood samples were drawn before induction (T1), 1 h after incision (T2), 1 h after extubation (T3), 24 h postoperatively (T4), 48 h postoperatively (T5), and at day 7 (T6). The following tests were performed: platelet count, platelet aggregation, platelet flow cytometry for CD62 and CD63, usual coagulation tests, thrombin--antithrombin complexes, plasminogen activator inhibitor 1.

RESULTS

A significant increase of adenosine diphosphate--induced platelet aggregation was observed postoperatively at T4 and T5. This was not associated with a change of flow cytometry profile. No increase of thrombin--antithrombin complex levels was observed. A higher fibrinogen rate was detected at T5 and T6. Greater amounts of plasminogen activator inhibitor 1 were detected at T3 and T4. Thus, thrombin generation was limited and fibrinolysis was impaired postoperatively. Platelets were not activated in the postoperative period, as shown by flow cytometry, but were prone to be activated, as shown by aggregation studies.

CONCLUSION

The association of more easily activated platelets with a higher fibrinogen rate and a temporary shut down of fibrinolysis during the early postoperative period may indicate an increased thrombotic risk in patients undergoing major vascular surgery.

Treatment of aortic arch dissection using the elephant trunk technique

The elephant trunk technique was developed to facilitate multiple-stage treatment of extensive aneurysm of the thoracic aorta. However, little information is available concerning its usefulness for aortic dissection. From April 1992 to July 1998, we used the elephant trunk technique for treatment of aortic arch dissection in 22 patients (including 19 men) with a mean age of 58.5 years (range 21 to 85 years). Twelve patients presented with type A dissection (acute in 3 and chronic in 9), 3 with type B acute dissection, and 7 with "non A/non B" dissections with retrograde extension to the aortic arch or entry site located in the aortic arch without involvement of the ascending aorta. All patients had aneurysms of the descending (n = 7) or thoracoabdominal (n = 15) aorta. Procedures were performed under hypothermic circulatory arrest at between 15 degrees and 20 degrees C. Antegrade cerebral perfusion was used in three cases. The procedure was associated with aortic valve replacement and/or coronary bypass in 6 cases and bypass of one or more supraaortic vessels in 13. In two patients the distal end of the elephant trunk was attached with an endovascular prosthesis during the same procedure. The ensuing results in these patients indicate that the elephant trunk technique can be highly effective for treatment of complex aortic arch dissection.

[Endovascular treatment of aorto-iliac aneurysms. Made-to-measure endoprotheses increase the feasibility]

The authors describe their experience of tailoring endoprostheses for endovascular treatment of aorto-iliac aneurysms with components available on the market. Between January 1996 and December 1999, 188 aorto-iliac aneurysms were treated by tailor-made endoprostheses using self-expanding Z stents made of stainless steel compiled with polyester ligatures and covered with standard commercially available polyester prostheses. These endoprostheses were implanted with an 18 to 24 Fr (usually 20 Fr) introducer and positioned by a surgical approach. This method allows construction of tubular, bifurcated, digressive or occlusive endoprostheses associated with an extra-anatomical bypass graft. It increased the number of endovascular procedures for aorto-iliac aneurysms in the authors' department. This number has been further increased by using endoprostheses with an uncovered proximal or distal stent for cases with particularly short or angled necks and by using hybrid endoprostheses with one or more extremities without a stent, allowing surgical suture of the anastomosis. The authors' results show that tailoring endoprostheses considerably increased the feasibility of endovascular treatment of aorto-iliac aneurysms, even in unselected patients whilst providing an effectiveness and safety to justify the continuation of this experience.

[Risk factors for mortality in abdominal aortic surgery]

OBJECTIVE

To analyse pre and peroperative variables for predicting mortality after abdominal aortic surgery.

STUDY DESIGN

Prospective study.

PATIENTS

We prospectively included 658 consecutive patients undergoing abdominal aortic surgery from January 1993 to July 1997.

METHODS

Age, gender, hypertension, history of myocardial infarction or coronary revascularization, angina pectoris, diabetes, arrhythmia, cardiac insufficiency, serum creatinine > 150 mumol.L-1, beta-blockers therapy, calcium channel inhibitors, angiotensin converting enzyme inhibitors were preoperative analysed variable. Type of aortic disease (anuerysms versus aortic occlusion), duration of surgery, blood loss, type of laparotomy (medium versus lombotomy) were peroperative analysed variables. Haemoglobinemia was monitored during surgery and patients were transfused if haemoglobinaemia < 80 g.L-1.

RESULTS

Thirty-three patients died after aortic surgery (5%). In multivariate analysis, angina pectoris (OR = 5.47, P < 0.001), chronic obstructive bronchopulmonary disease (OR = 2.27, P = 0.05) and duration of surgery (OR = 1.60, P < 0.001) were the independent predictive factors of mortality. Age, blood loss were predictive factors only in univariate analysis.

CONCLUSION

Angina pectoris and COBP were the two independent preoperative factors of mortality. The duration of surgery was the only peroperative factor. Well monitored blood loss was not a predictive factor.

Cardiac troponin I is reliable with immediate but not medium-term cardiac complications after abdominal aortic repair

BACKGROUND

The diagnosis of cardiac complications is particularly challenging in the postoperative course of non-cardiac surgery. Follow-up of patients suggests that silent or symptomatic postoperative myocardial infarction have similar short-term outcomes. Cardiac troponin I (cTnI) has been reported as being a sensitive and specific marker of these complications.

METHODS

We conducted a prospective study to determine the cut-off values of cTnI which may predict cardiac complications, i: in the postoperative period until discharge, and ii: during a 1-year period after aortic surgery. Three hundred and twenty-nine consecutive patients undergoing infrarenal aortic surgery were included over a 2-year period in a single center. cTnI was measured at recovery and on the 1st, 2nd and 3rd postoperative days. The presence or absence of cardiac complications was classified by reviewers who had no knowledge of cTnI. For evaluation of the ideal discrimination value of cTnI between the complicated and uncomplicated patient groups, we calculated receiver-operator characteristics for the mean values of the peak of cTnI.

RESULTS

Thirteen patients (4%) developed 19 postoperative cardiac complications. Thirteen patients (4%) died in the postoperative period. Nine patients (3%) developed 10 cardiac complications during the 1-year follow-up in 316 patients. In 280 patients, cTnI was below 0.5 ng/ml, in 22 patients between 0.5 and 1.5 ng/ml and the 27 remaining patients had a cTnI higher than 1.5 ng/ml. The area under the curve for postoperative cardiac complications was 0.84 (SD=0.21). A limit value of 0.54 ng/ml yielded a sensitivity of 75% and a specificity of 89%. The area under the curve for late cardiac complications was 0.45 (SD= 0.13).

CONCLUSION

A cTnI level greater than 0.54 ng/ml appears to be correlated with the occurrence of cardiac complications in the period until discharge, but no value of cTnI is predictive of late cardiac complications occurring in the 1st year after aortic surgery.

[Vascular manifestations of Behçet's syndrome associated with solitary ulcerations and resolved with immunosuppressants]

INTRODUCTION

Behçet's disease is a systemic inflammatory disorder characterized by vasculitis. Its typical features are recurrent oral and genital ulcerations with uveitis. Although vascular lesions are not listed among the criteria for diagnosis of Behçet's disease, up to 25-35% of the patients develop complications in arterial and venous large vessels.

EXEGESIS

We describe the case of a 45-year-old French man with Behçet-type vasculopathy. Though only one sign of Behçet's disease, i.e., oral ulcerations, was present, the patient had to undergo emergency surgery three times. The postoperative treatment combined corticosteroids, azathioprine, and oral anticoagulants. Three years later no therapy failure was observed.

CONCLUSION

On the basis of 1) recurrent aortic aneurysms, 2) large arterial and venous occlusive lesions, 3) superficial phlebitis, and 4) ulcerations of the aorta in macro- and microscopic examination of resected aortic walls, we concluded that the patient's life threatening vasculopathy was of the Behçet's type, even if several of the diagnostic features of Behçet's disease were lacking. Variations in clinical features of Behçet's disease are observed that might be due to hereditary traits, particularly to the genetic expression of an incomplete phenotype that would lead to the lack of typical clinical features.

[Cardiovascular manifestations of Behçet's disease]

Vascular involvement in Behçet's disease, recognized since 1946, is peculiar since it occurs in young subjects with no vascular risk factor. Recurrent phlebitis, sometimes associated with fever and biological signs of inflammation, commonly involve the large vessels (superior and inferior vena cava, hepatic veins) and cerebral veins. Arterial involvement was more recently identified and is expressed by thrombosis, stenosis and/or aneurysms diversely associated. Aneurysms, true "arterial aphthae", may be multifocal and can involve all arterial territories with a clear preference for the abdominal aorta and the pulmonary arteries (Hughes-Stovin syndrome). Mortality is significant due to rupture and the risk of recurrence. Cardiac involvement includes coronary artery disease which merits attention since it affects young subjects and is often expressed by myocardial infarction or angina; all three tunics can be involved; mortality is high: 20% in the months or years following diagnosis. A few cases of recurrent pericarditis have been reported. Myocardiopathy can be of inflammatory nature or secondary to coronary artery disease. Endocardiac involvement may be limited to valve disease or spread to the ventricular wall. Endomyocardial fibrosis is exceptional and usually associated with intracavitary thrombus formation. Coagulation disorders have been reported but they cannot explain the different thrombotic manifestations which are probably the consequence of an abnormal response of the vascular endothelial cells.

Cardiac troponin I cutoff values to predict postoperative cardiac complications after circulatory arrest and profound hypothermia

OBJECTIVE

Cardiac failure and myocardial infarction are complications of thoracic aorta, thoracoabdominal aorta, or aortic arch surgery, especially when surgery is performed using profound hypothermia and circulatory arrest (PHCA). Moreover, the diagnosis of non-Q-wave postoperative myocardial infarction (PMI) is challenging because there is no gold standard. The aims of this study were to determine values for cardiac troponin I (cTnl) in patients undergoing aortic arch or thoracoabdominal aortic surgery with PHCA who were free of cardiac complications in the postoperative period, and to test the validity of cutoff values of cTnl to predict postoperative cardiac complications in such patients.

DESIGN

Prospective, nonrandomized study.

SETTING

Single university hospital; Departments of Anesthesiology, Biochemistry and Vascular Surgery.

PARTICIPANTS

Fifty-two consecutive patients were studied over a 2-year period. None was excluded, even patients who underwent emergency surgery.

INTERVENTIONS

Patients undergoing aortic arch or thoracoabdominal aortic surgery with PHCA were studied. Thirty patients undergoing coronary artery bypass grafting (CABG) in the same period constituted a control group.

MEASUREMENTS AND MAIN RESULTS

The cTnl concentrations were determined using an immunoenzymofluorometric assay on a Stratus analyzer (Dade, Massy, France) on blood samples obtained at recovery and on day 1 (D1) and D2. Seventeen patients developed a cardiac complication, which was lethal in 10 patients. In patients without cardiac complication, the peak level for cTnl was observed on D1. Cutoff values of cTnl were identical in both the CABG control group (11 .6 microg/mL) and the sternotomy group (12.2 microg/mL), but were significantly greater (20.5 microg/mL) in patients with a thoracotomy approach. Sensitivity and specificity of these cutoff values were high in both groups (control group, sensitivity = 100%, specificity = 100%; sternotomy group, sensitivity = 78%, specificity = 100%; thoracotomy group, sensitivity = 100%, specificity = 94%).

CONCLUSION

In patients who underwent surgery using PHCA for aortic arch or descending aorta repair, myocardial damage related to cardiac arrest, vents or fibrillation explains the increased cutoff value (12.2 microg/mL). This value is similar to patients undergoing CABG surgery through a sternotomy approach with cardioplegia administration. In contrast, and probably related to the absence of cardioplegia, patients undergoing surgery through a left thoracotomy approach had a greater cutoff value (20.5 microg/mL). Values of cTnl greater than these respective cutoff values were closely related to cardiac complications during the postoperative period.

Endovascular treatment of aortoiliac aneurysms: made-to-measure stent-grafts increase feasibility

We describe here our preliminary experience with use of a range of made-to-measure stent-grafts made from commercially available components. From January 1996 to June 1998, 94 aortoiliac aneurysms (AIA) were treated with stent-grafts that were made to measure using Z autoexpandable stainless steel stents connected with polyester sutures and covered with commercially available polyester vascular prostheses. These stent-grafts were implanted through 18 to 24 (typically 20) Fr commercially available introducers via a surgical remote access. Made-to-measure tubular, bifurcated, tapered, and/or blind stents combined with extraanatomic bypass designs increased the rate of endovascular treatment (ET) of AIA in this series. This rate was further increased through the use of uncovered proximal or distal stents when dealing with short or tortuous necks near major collaterals and through use of hybrid, partly surgical designs, one with stented and the other with stentless ends, the latter allowing for a surgically made anastomosis. The results of our experience with these techniques show that use of made to-measure stent-grafts greatly increases the feasibility of the ET of AIA among unselected patients while offering enough efficiency and safety to deserve further investigation.

[An unknown cause of prolonged fever: apropos of 6 cases of chronic aortic dissection]

PURPOSE

Aortic arch dissection may be sometimes misdiagnosed due to the lack of mild to moderate chest pain. Definite diagnosis is often made while dissection has already occurred more than 15 days ago, being thereafter considered as chronic. Aortic dissection may then present as a prolonged febrile illness with fever and/or inflammation as main symptoms, with little or no pain.

METHODS

We retrospectively reviewed cases of chronic aortic dissections seen in a department of internal medicine and a department of neurology between 1975 and 1992.

RESULTS

We report six cases of patients presenting with aortic dissection and describe their outcome and treatments after the diagnosis was made based on either thoracic computerized tomography or trans-esophageal echocardiography evidence. Four patients had surgical aortic arch repair while one patient was treated with beta-blockers.

CONCLUSION

Chronic aortic dissection has rarely been reported to cause fever or increased sedimentation rate. Treatment has to be discussed between medical and surgical teams involved in the therapeutical management of these unusual patients.

[Infectious aneurysm due to Listeria monocytogenes: a new case and review of the literature]

INTRODUCTION

Infections due to Listeria monocytogenes usually occur in pregnant women, in the elderly and in immunocompromised patients. Arterial aneurysms due to this germ are rare. Only 16 cases have been previously described in the literature.

EXEGESIS

We report the case of a patient who had been hospitalized for recurrent fever over the past 3 months. Aortic mycotic aneurysm was diagnosed; blood and aneurysm cultures revealed Gram-positive bacilli consistent with the presence of Listeria monocytogenes. We also review previous reports focusing on infections due to Listeria monocytogenes. Mycotic aneurysms due to this germ are mainly observed in elderly male patients and occur on large arteries. In the present study, only one patient was immunocompromised. Furthermore, all patients who were not operated on died.

CONCLUSION

Arterial aneurysm due to Listeria moncytogenes is best managed via surgical resection in combination with antimicrobial therapy. Immunosuppression is not necessary for the development of arterial aneurysm due to Listeria. Bacteriological and histological examinations should be done systematically when surgical resection of an aneurysm is required.

Computerized tomographic angiography scan following carotid endarterectomy

The purpose of this study was to evaluate the role of computed tomographic angiography (CTA) for postoperative assessment of carotid endarterectomy (CE). Twenty carotid endarterectomies were performed and controlled by using (1) intraoperative angiography, (2) postoperative duplex scanning and CTA with multiprojection volume reconstruction (MPVR). Intraoperative angiographic controls were deemed satisfactory for all patients. In 12 patients, the postoperative morphological aspect was satisfactory with CTA and duplex scanning. In the eight remaining patients, CTA and/or duplex scanning revealed 12 abnormalities: 3 were equally visualized on CTA and duplex scanning, 6 only on CTA and 3 only on duplex scanning. CTA is a rapid and noninvasive technique allowing the surgeon to get informative and comparative data. It might be an interesting alternative to postoperative angiography.

Treatment of vascular graft infection by in situ replacement with cryopreserved aortic allografts: an experimental study

PURPOSE

The purposes of this study were to prove the efficacy of cryopreserved aortic allografts to treat an established vascular graft infection by in situ replacement in an animal model and to evaluate the role of the antibiotics normally used to decontaminate the allografts.

METHODS

Twenty-three dogs underwent infrarenal aortic replacement with a gelatin-sealed knitted polyester graft contaminated in vitro by Staphylococcus epidermidis RP-62. One week later, the 18 surviving animals underwent reoperation for graft removal and were randomized into three groups for in situ replacement: group I (control, n = 6) received a new gelatin-sealed graft; group II (n = 6) received a non-antibiotic-treated cryopreserved allograft; and group III (n = 6) received an antibiotic-treated cryopreserved allograft. Control grafts and allografts were removed 4 weeks after the initial intervention for quantitative bacteriologic analysis and histologic analysis. Bacteriologic results were expressed as colony-forming units per square centimeter of graft material. Qualitative bacteriologic analysis was also obtained from perigraft fluid and tissue.

RESULTS

All of the initially implanted grafts and all of the control grafts (group I) were infected at the time of removal. In group II, three out of six allografts were not totally incorporated, whereas in group III incorporation was always complete, with a significantly decreased inflammatory reaction. All of the antibiotic-treated allografts were sterile, whereas three untreated allografts grew bacteria.

CONCLUSIONS

In this model, cryopreserved aortic allografts were more resistant to reinfection than synthetic grafts after in situ replacement of an infected prosthetic graft. However, the antibiotic loading of the cryopreserved aortic allograft appears to be essential to obtain optimal therapeutic effects.

Risk factors for acute postoperative renal failure in thoracic or thoracoabdominal aortic surgery: a prospective study

Acute postoperative renal failure is a common complication of thoracic aorta, thoracoabdominal aorta, or aortic arch surgery. To identify variables associated with acute postoperative renal failure, we prospectively studied 475 consecutive patients undergoing thoracoabdominal aortic surgery over a 12-yr period, including those requiring emergent surgery. One hundred twenty-one (25%) patients developed acute postoperative renal failure, and 39 (8%) required hemodialysis. Using multivariate analysis, acute postoperative renal failure was significantly associated with the following variables: age >50 yr (odds ratio [OR] 2.90 [95% confidence interval 1.52-5.53]), preoperative serum creatinine >120 micromol/L (OR 2.76 [1.70-4.48]), duration of left kidney ischemia >30 min (OR 2.01 [1.27-3.17]), packed red cells administration >5 units (OR 2.04 [1.24-3.37]), and Cell-Saver administration >5 units (OR 2.31 [1.34-1.96]). Reimplantation of visceral, renal arteries and the Adamkievicz artery; duration of visceral, spinal, and right kidney ischemia; requirement for fresh frozen plasma; administration of aprotinin; extracorporeal circulation; and procedures with circulatory arrest and profound hypothermia were not predictive of postoperative renal failure. In addition, age >50 yr (OR 5.59 [1.31-23.91]), requirement for packed red blood cells >5 unit (OR 3.91 [1.58-9.67]), and preoperative serum creatinine concentration >120 micromol/L (OR 2.26 [1.13-4.53]) were independent factors for acute renal failure requiring hemodialysis. In conclusion, acute renal failure is often observed after thoracic aortic surgery. Numerous predictive factors must be considered when evaluating the etiology of this complication.

IMPLICATIONS

Acute postoperative renal insufficiency is a common complication of thoracic aortic surgery. This study found that age >50 yr, preoperative renal dysfunction, duration of renal ischemia, and amount of blood transfusion are significant predictors of this complication.

[Inflammatory aneurysms of the thoracic aorta. Surgical aspects]

In the Western world, inflammatory aneurysms account for only 1 to 5%, of all operated thoracic aorta aneurysms. Takayasu's disease is by far the commonest cause although all forms of aortitis may result in aneurysm formation. Usually observed in young patients, these aneurysms are suitable for often major surgery with results that are globally better than in degenerative or dissecting aneurysms. However, they pose, two specific problems: the progression of the inflammatory disease which may require pre- and/or post-operative steroid therapy and that of the risk, at least in theory, of a late pseudo-aneurysm, which justifies regular long-term follow-up after surgery.

Occlusive fibromuscular disease of arteries supplying the brain: results of surgical treatment

Occlusive fibromuscular disease (FMD) of arteries supplying the brain is a documented cause of neurologic complications. From September 1976 to December 1994, 70 patients underwent surgery for occlusive FMD involving arteries supplying the brain. Isolated dysplastic aneurysms and coilings or kinkings were not included in this series. Twenty-two patients had experienced previous nonlethal ischemic stroke, 25 patients had experienced transient ischemic attacks, and 32 patients had vertebrobasilar insufficiency with or without associated carotid symptoms. Lesions involved one (n = 36) or two (n = 29) internal carotid arteries, and one (n = 18) or two (n = 14) vertebral arteries. Twenty-seven patients had simultaneous involvement of both carotid and vertebral arteries. Ten patients had FMD at another site, four had intracranial aneurysm, and four had an aberrant right subclavian artery. Seventy-seven carotid procedures including 67 graduated intraluminal dilatations were performed and 18 vertebral arteries were revascularized. One patient (1.4%) died postoperatively from hemorrhagic stroke and two patients (2.8%) presented nonlethal stroke. Sixty-two patients were followed postoperatively from 2 to 184 months (mean 86.2 +/- 54.4). Actuarial survival rates at 5 and 10 years were 96.4 +/- 5.0% and 82.1 +/- 14.9%, respectively. Actuarial primary patency rate at 5 and 10 years was 94.3 +/- 5.5%. Actuarial probability of stroke-free survival rates at 5 and 10 years were 94.2 +/- 5.6% and 88.6% +/- 10.3%, respectively. We conclude that improvement of symptoms, prevention of stroke, and stable long-term results justify surgical treatment in symptomatic patients with FMD of arteries supplying the brain.

Long-term survival after elective repair of infrarenal abdominal aortic aneurysm: results of a prospective multicentric study. Association for Academic Research in Vascular Surgery (AURC)

During 1989, 28 centers of the Association for Academic Research in Vascular Surgery (AURC) reported all cases involving patients with infrarenal abdominal aortic aneurysm (AAA) who reached the operating room alive. In a total series of 1107 procedures, 834 were performed electively. During 1993 and 1994, an effort was made to contact and, if possible re-examine the 794 (95.2%) patients who survived these elective procedures in order to establish survival curves, determine the causes of late death, and ascertain the predictive value for long-term survival of 628 perioperative variables recorded in 1989. Survival curves were calculated using the actuarial and Kaplan-Meier methods and compared with those obtained from national statistical records in a control population matched for age and sex. Variables with potential predictive value for late death were selected by univariate statistical analysis using either the chi2 or student t-test. In the group of 794 (92.5%) patients who survived elective AAA repair in 1989, survival rates were 93.9 +/- 1.8% at 1 year, 89.5 +/- 3.2% at 2 years, 83.5 +/- 3.2% at 3 years, 77.6 +/- 3.9% at 4 years, and 66.9 +/- 10.6% at 5 years. These rates were significantly lower than those observed in the control population. The mean annual death rate from cardiovascular disease was 1.8%, which was higher than in the control population matched for age and sex. Analysis using the Cox proportional risk model showed that the following variables were significant, independent predictors of late death: diameter of aneurysm (p < 0.02), choice of surgical approach in function of general status (p < 0.02), left ventricular insufficiency (p < 0.02), age (p < 0.02), carotid artery occlusion (p < 0.03), use of a surgical approach other than lobotomy (p < 0.04), cardiac arrhythmia (p < 0.04), duration of aortic clamping (p < 0.05), ECG evidence of myocardial ischemia (p < 0.05), abnormality at the upper limit of the aneurysm (p < 0.05), and advanced renal insufficiency (p < 0.05). Life expectancy in patients that undergo successful AAA repair is lower than in the general population. Although death is often unrelated to AAA or the repair procedure, the incidence of morbidity due to cardiovascular disease is higher than in a control population matched for age and sex. These findings suggest that better management of concurrent cardiovascular disease during the perioperative period and long-term follow-up holds the key to improving life expectancy in patients undergoing AAA repair.

Lumbar muscle rhabdomyolysis after abdominal aortic surgery

Lumbar muscle rhabdomyolysis has been very rarely reported after surgery. The aim of this study was to determine its incidence and main characteristics in a large population undergoing abdominal aortic surgery. Over a 21-mo period, 224 consecutive patients, 209 male and 15 female, mean age 65 +/- 10 yr, underwent abdominal aortic surgery (aortic aneurysm in 142 patients and occlusive aortic degenerative disease in 82 patients). Surgical incision was a midline incision with exaggerated hyperlordosis in 173 patients and a flank incision with a retroperitoneal approach in 51 patients. Postoperative rhabdomyolysis was diagnosed in 20 patients. In these patients, 9 (4%) experienced severe low back pain, and lumbar muscle rhabdomyolysis was confirmed by tomodensitometry (n = 6) or muscle biopsy (n = 3). The remaining 11 patients had lower limb muscle rhabdomyolysis. Rhabdomyolysis occurred after surgery of longer duration, which involved more frequent visceral artery reimplantation, with longer duration of aortic clamping and greater intraoperative bleeding. Lumbar rhabdomyolysis occurred in younger patients who were more frequently obese. On first postoperative day, the mean creatine kinase (CK) value was greater in lumbar rhabdomyolysis than in lower limb rhabdomyolysis (17,082 +/- 15,003 vs 3,313 +/- 3,120 IU/L, P < 0.05). Acute renal failure and postoperative death did not occur in patients with lumbar muscle rhabdomyolysis. Lumbar rhabdomyolysis was not a rare event after abdominal aortic surgery (4%). This syndrome was characterized by postoperative low back pain of unusual severity, which required analgesic therapy, and induced a very high increase in CK with typical findings at tomodensitometry or muscle biopsy but was not associated with postoperative renal failure.

European experience with a system for bifurcated stent-graft insertion

PURPOSE

To test an endovascular aneurysm exclusion system in the presence of a wide range of challenging anatomic features.

METHODS

Bifurcated endovascular stent-grafts were inserted in 52 patients and followed with serial computed tomography for up to 3 years. The device underwent several modifications during this time, the most significant of which represent the difference between the homemade (n = 42) and industry-made (n = 10) versions.

RESULTS

The initial procedural success rate was 92% in the homemade group and 100% in the industry-made group. In the 3 years of follow-up, the long-term success rate was 64% in the homemade group and 90% in the industry-made group. The primary reasons for failure in the homemade group were graft thrombosis due to kinking early in the series and proximal stent migration later in our experience. All cases of migration occurred when the neck was < 15 mm in length, the neck was lined with thrombus, or the stent was implanted > 15 mm from the renal arteries. Kinking was subsequently overcome by implanting Wallstents throughout the graft limbs. The sole failure in the industry-made group was a case in which collateral perfusion reached the aneurysm through patent lumbar arteries.

CONCLUSIONS

The fruits of this experience are a better technique, a better device, and, most importantly, a better understanding of the system's limits, as reflected in the current selection criteria.

[Abdominal aortic aneurysms: contribution of genetics. From atheromatous theory to parietal theory]

Abdominal aortic aneurysms have usually been characterized as atheroslcerotic, but this view of their pathogenesis is a restricted one. As yet, no unified concept of pathogenesis has emerged, bat several factors appear to have an important role, including familial clustering, genetically determined and acquired biochemical alterations in the structural matrix of the aortic wall and bemodynamic mechanical factors. We review literature data concerning new pathogenic concepts of abdominal aortic aneurysms and particularly familial predisposition. Ultrasonographic screening is recommended in brothers (50 years) of patients with aneurysms of the abdominal aorta.

Surgery for ruptured abdominal aortic aneurysm: early and late results of a prospective study by the AURC in 1989

This study determines the early and late survival rates, the causes of death, and prognostic variables that are associated with early and late survival after for ruptured abdominal aortic aneurysm (AAA). These are based on the prospective analysis of 628 variables of data on 158 consecutive patients in 24 centers of our association in 1989. Patients were followed up for a mean of 42.1 +/- 21.0 months. Six patients were lost to follow-up. To identify the variables that were associated with early and late survival, statistical methods included logistic regression analysis, Kaplan-Meier analysis, and Cox regression analysis. The survival rate was 52.9% +/- 14.4% at 1 month, 48.8% +/- 15.8% at 1 year, 48.1% +/- 16.0 at 2 years, 40.3 +/- 19.2% at 3 years, and 35.0 +/- 21.8 at 4 years. The cause of the 73 (46.2%) early deaths were cardiac (33), hemorrhage (29), colonic necrosis (5), stroke (2), graft infection (2), pneumonia (1), and kidney failure (1). Significant predictors of early death were the presence of a common iliac aneurysm (p < 0.02), the age of the patient (p < 0.02), a previous history of stroke or transient ischemic attack (TIA) (p < 0.04), a bifurcated graft (p < 0.04), a saccular aneurysm (p < 0.06), the blood creatinine level (p < 0.06), and hypotension on admission (p < 0.06). The causes of the 28 (17.7%) late deaths were heart disease (11), cancer (8), stroke (3), another operation (3), graft infection (1), pneumonia (1), and Alzheimer disease (1). Significant predictors of late death were heavy smoking (p < 0.03) and chronic obstructive pulmonary disease (p < 0.07). Rupture of an abdominal aortic aneurysm remains a catastrophic event. Even after a successful cure of a ruptured AAA, cardiovascular causes of death are responsible for survival rates that are significantly lower than that in a matched nonaneurysmal population.

Popliteal aneurysm due to fibromuscular dysplasia

We report herein the case of an asymptomatic popliteal aneurysm due to fibromuscular dysplasia in a 39-year-old woman. The aneurysm was resected and arterial continuity restored by direct end-to-end anastomosis. Pathologic findings were consistent with fibromuscular dysplasia of the media. To the best of our knowledge, this is the fourth case documented by pathologic findings in the literature.

[Technical advances in the surgical management of thoracoabdominal aortic aneurysms]

Thoracoabdominal aortic aneurysmectomy ranks among the major cardiovascular surgical procedures. During the last two decades perioperative results have improved to the point that surgery should be discussed in the vast majority of patients seen with a thoracoabdominal aortic aneurysm. This progress is largely attributable to a variety of technical improvements including: aortic reconstruction using the graft inclusion technique, usually with direct reattachment of aortic branches to the prosthetic graft; distal aortic perfusion; selective use of deep hypothermic circulatory arrest in anatomically complex situations; preoperative visualization of arterial blood supply to the spinal cord using selective arteriography of intercostal and lumbar arteries. Current perioperative mortality is around 10% whereas the spinal cord complication rate is between 5% and 20% according to clinical and anatomical conditions. Future efforts should concentrate on the prevention of spinal cord complications.